John Doe Medical History

This is a sample surgical report to test the Virtual Patient System.

Surgical Report 13-06-2023

Surgical Report

Patient ID: [TMJ] Date of Procedure: [13-06-2023] Surgeon: [Michael Truppe, MD] Assistant: [Dina, Katarina]

ImplantID: IMPL23ABC

Preoperative Diagnosis: Single missing tooth, #46 lower right first molar Postoperative Diagnosis: Single missing tooth, #46 lower right first molar Procedure Performed: Placement of dental implant using image-guided surgery

Indications: The patient presented with a missing lower right first molar (#46), with sufficient bone height and width. It was determined that the patient was an ideal candidate for a dental implant.

Procedure Details:

Preoperative Preparation: The patient was given oral hygiene instructions and premedication consisting of antibiotics (Amoxicillin 500mg) and anti-inflammatory medication (Ibuprofen 400mg). Written informed consent was obtained.

Anesthesia: Local anesthesia was administered with 2% lidocaine with 1:100,000 epinephrine. Profound anesthesia was achieved, and the surgical site was isolated with sterile drapes.

Incision and Flap Reflection: A crestal incision was made on the edentulous ridge at site #46. Full-thickness mucoperiosteal flap was reflected using a periosteal elevator to expose the underlying alveolar bone.

Image-Guided Surgery: Using CBCT images that were acquired prior to the surgery, the implant site was marked. The image guidance system, which was previously calibrated, was used to precisely place the pilot drill.

Osteotomy Preparation: Following the pre-planned path, sequential osteotomies were performed using increasing diameter drills as per the manufacturer’s guidelines. Irrigation with sterile saline was done throughout the process to prevent overheating. The final osteotomy matched the diameter and length of the chosen implant.

Implant Placement: A sterile packaged [ASTRA Prime Taper] implant of [4,2 mm] x [11 mm] was selected. The implant was placed into the osteotomy site using a torque wrench until the implant platform was flush with the alveolar bone crest. A torque of 35 Ncm was achieved indicating good primary stability.

Closure: A healing abutment was connected to the implant. The mucoperiosteal flap was repositioned and sutured using resorbable sutures. A sterile dressing was placed over the surgical site.

Postoperative Imaging: Postoperative radiographs were taken to confirm the correct placement of the implant in relation to neighboring structures and to serve as a baseline for future evaluations.

Postoperative Instructions and Follow-Up: The patient was given postoperative instructions, a prescription for antibiotics, and analgesics, and an appointment was set for suture removal and follow-up in one week.

Surgeon’s Comments: The patient tolerated the procedure well. The surgical site will be allowed to heal for 3-6 months before a final prosthetic restoration will be placed.

This report is a true and accurate record of the procedure performed.

Surgeon Signature: [Michael Truppe, MD] Date and Time: [13-06-2023 5 PM]

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