PATIENT #2

 

NAME: Patient #2
DATE: 6/91

CIS
PROSTHETIC DESIGN
COMMENTS FEE
1 MULTIPLE UNIT - FREESTANDING _ _
3 SINGLE TOOTH _ _
5 UTILIZING NATURAL TOOTH ABUTMENTS 4 Copings/11 Units C&B $10,000.00
IMPLANT LOCATION
1 ANTERIOR MANDIBLE _ _
2 ANTERIOR MAXILLA 3 Fixtures $2,250.00
4 POSTERIOR MANDIBLE _ _
5 POSTERIOR MAXILLA 2 Fixtures $2,000.00
SURGICAL TYPE (0-4) *
3 AVAILABLE BONE VOLUME Post. Max = 7mm _
_ BONE DENSITY _ _
2 ANATOMICAL LANDMARKS Max Sinus _
_ GENERAL MEDICAL CONDITION _ _
_ IMMEDIATE IMPLANTS _ _
PHYSIOLOGICAL TYPE
_ _
1 AGE _ _
1 OCCLUSAL FACTORS _ _
1 ORAL HYGIENE _ _
1 PSYCHOLOGICAL TYPE _ _

* A 0 grade indicates no impact on surgical success of implant placement. A 4 grade indicates no chance of successful implant placement.

COMPLEXITY INDEX: 18