Nicoweb
Name: Email:
Name:
Sex: MF
Age:
Has the patient been smoking for the last 5 years: YesNo
How many cigarettes per day?:
Has the patient undergone antibiotic treatment before the surgery?: YesNo
Has the patient systemic disease?: YesNo
Which type?:
Has the patient taken drugs for osteoporosis?: YesNo
PART NUMBER:
BATCH NUMBER – LOT:
Date of placement: (dd/mm/yyyy)
Date of removal: (dd/mm/yyyy)
Description:
Position in the mouth:
Reason for removal:
Immediate placement Delayed placement (at least 3 months after extraction) Placement in healed bone
If so, what was the cause of tooth loss?:
Distance from the contiguous tooth/implant in mm:
Regenerative procedure:YesNo
If you have performed a regenerative procedure, can you please indicate the type/name of the regenerative material (bone and/or membrane) you have used:
Complications during surgery?: YesNoOther
If yes, which type?: FenestrationFracture of the alveolar boneLack of primary stabilityOther
If other, please describe:
Quality of the bone:
Immediate loading Loaded within 48 hours after surgery Loaded between 48 hours and 7 days after surgery Other
Or else please specify the time of loading:
Single crown:Yes
Please shortly describe the type of restoration (PFM, zirconia, cement retained, screw retained etc.):
Bridge:Yes
Please shortly describe the type of restoration (PFM, zirconia, cement retained, screw retained etc.) and the number of implants supporting the restoration:
Full arch, fixed: Yes
Please shortly describe the type of restoration (resin, metal reinforced etc.) and the number of implants supporting the restoration:
Full arch, removable:Yes
Please shortly describe the type of restoration (resin, metal reinforced, on ball attachments, on Locators etc.) and the number of implants supporting the restoration:
Please describe the level of hygiene of the patient:
Has the patient regularly undergone controls after surgery and loading? How frequently?:
Assumptions about possible reasons of failure:
Reason for complain:
Assumptions about possible reasons of complain:
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