The Implant Placement Notes Template

MDR 2017 makes implant batch / lot number traceability mandatory — and missing lot numbers are an audit failure waiting to happen. Below is a template for UK clinicians to paste into their PMS for every implant placement.

Why this implant placement template wins

• Implant batch / lot number recorded — MDR 2017 traceability is legally mandatory.
• Pre-op CBCT review documented at surgery — defends planning decisions.
• Insertion torque value AND ISQ — quantifies primary stability for any future failure investigation.
• Bone quality classified (Lekholm & Zarb) — drives healing timeline and crown loading decisions.
• Written consent re-confirmed and post-op leaflet given — closes the consent loop and protects against post-op claims.

The template (paste into your PMS notes field)

Paste the implant placement template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

PROCEDURE: Implant placement
SITE: [Tooth position FDI]
SURGICAL DATE: [Confirmed from PMS]

PRE-OP CHECKS:
- Written consent: [Re-confirmed today — patient signed at consultation, copy on file]
- Pre-op CBCT/OPG reviewed: [Date — findings reviewed: bone dimensions, IAN/sinus distance, planned implant position]
- Surgical guide: [Used Y/N — type]
- Antibiotic prophylaxis: [None / 2g amoxicillin 1h pre-op — clinical justification (e.g. graft case, immunocompromised, large procedure)]
- CHX 0.2% mouthwash pre-op: [Used Y/N]
- MHx update: [Reviewed, no changes since consultation]

ANAESTHESIA: [Agent + volume + technique]. Profound. [If sedation — cross-reference]

SURGICAL APPROACH:
- Flap: [Full-thickness mucoperiosteal / mini-flap / flapless]
- Incision design: [Sulcular / paramarginal / palatal-shifted for aesthetic zone]
- Reflection: [Atraumatic, conservative]

OSTEOTOMY:
- Surgical kit: [System brand]
- Drill sequence: [Per manufacturer protocol — pilot → progressive widening]
- Cooling: [Copious sterile saline]
- Depth: [__ mm matching implant length]
- Final drill: [Size and depth]

IMPLANT PLACED (MDR-MANDATORY DETAILS):
- System: [Brand — e.g. Straumann BLT / Nobel Active / Astra OsseoSpeed / specify]
- Diameter: [__ mm]
- Length: [__ mm]
- Batch / Lot number: [RECORDED — MDR 2017 mandatory]
- Reference: [Catalogue number]
- Insertion torque: [Ncm — typically 25-45Ncm for adequate primary stability]

BONE QUALITY (Lekholm & Zarb): [Type I (dense cortical) / II / III / IV (low quality)]

PRIMARY STABILITY: [Achieved — ISQ if measured / Ncm value]

ADJUNCTIVE PROCEDURES:
- Membrane: [None / brand + batch number]
- Bone graft: [None / autograft / xenograft (brand + batch) / allograft (brand + batch) / alloplast]
- Soft tissue graft: [None / CTG from palate / acellular dermal matrix]

CLOSURE:
- Sutures: [Material — Vicryl 5-0 / nylon / silk — number — sites]
- Healing protocol: [Immediate temporisation / submerged / non-submerged with healing abutment]

POST-OP RADIOGRAPH: [Periapical — confirms implant position, depth, no perforation. IR(ME)R justification.]

POST-OP INSTRUCTIONS (verbal + WRITTEN COPY given):
- Ice intermittently 24h
- Soft diet 1 week
- No spitting, smoking, alcohol 24-48h
- CHX 0.2% mouthwash from day 2 (rinse only, not site)
- Analgesia (ibuprofen + paracetamol PRN)
- Antibiotic post-op if indicated (clinical justification)
- Contact urgently for uncontrolled bleeding, severe swelling, persistent paraesthesia

REVIEW:
- 1-week soft tissue check / suture removal
- Osseointegration period: typically 8-12 weeks (mandible) / 12-16 weeks (maxilla, graft cases)
- Crown impression timing: [Date]

Try the implant placement note in the live demo → No account needed.

What good looks like — a worked example

The same implant placement template, completed for a realistic case.

PROCEDURE: Implant placement
SITE: UR1
SURGICAL DATE: Today

PRE-OP CHECKS:
- Written consent: Re-confirmed. Patient signed at consultation 2 weeks ago. Copy on file.
- Pre-op CBCT: Reviewed (taken 2 weeks ago). Bone width 7mm at planned implant site (adequate without grafting). Bone height 14mm (adequate). Labial plate 1.5mm thick.
- Surgical guide: Not used (single tooth in stable anterior position).
- Antibiotic prophylaxis: NONE — not indicated for straightforward case in healthy patient (per ADI guidance).
- CHX 0.2% mouthwash: Used pre-op as oral rinse.
- MHx update: Reviewed — no changes since consultation. Patient well.

ANAESTHESIA: Articaine 4% w/ adrenaline 1:100,000, 2.5ml — buccal infiltration UR1 + palatal infiltration. Profound anaesthesia.

SURGICAL APPROACH:
- Flap: Mini-flap (papilla-sparing, minimally invasive)
- Incision: Crestal incision with no relieving incisions (preserves blood supply for anterior aesthetics)
- Reflection: Atraumatic, just enough to expose crestal bone

OSTEOTOMY:
- Surgical kit: Straumann SLActive
- Drill sequence: Pilot 2.2mm → 2.8mm → 3.5mm
- Cooling: Copious sterile saline
- Depth: 10mm matching planned implant length
- Final drill: 3.5mm × 10mm

IMPLANT PLACED:
- System: Straumann BLT (Bone Level Tapered) Roxolid SLActive
- Diameter: 4.1mm
- Length: 10mm
- Batch / Lot number: [STR-2026-04-12345] (recorded from box label)
- Reference: 021.2310
- Insertion torque: 35Ncm

BONE QUALITY: Type II (good cortical bone with cancellous core).

PRIMARY STABILITY: Achieved — 35Ncm insertion torque, ISQ measurement 75 (excellent).

ADJUNCTIVE PROCEDURES:
- Membrane: None.
- Bone graft: None — adequate bone width per CBCT confirmed clinically.
- Soft tissue graft: None today. May be considered later if aesthetic outcome requires CTG.

CLOSURE:
- Sutures: Vicryl 6-0, 4 sutures (interrupted) — preserving papillae.
- Healing protocol: Submerged with cover screw placed (anterior aesthetic zone — 2-stage approach for better soft tissue management).

POST-OP RADIOGRAPH: PA taken. Implant positioned axially, depth at planned level (~2mm subcrestal), no apparent perforation of labial plate. Adjacent root anatomy normal. Quality A.

POST-OP INSTRUCTIONS (verbal + written leaflet given):
- Ice intermittently 24h, swelling expected to peak 48-72h
- Soft diet 1 week
- No spitting, smoking (life-long non-smoker), alcohol 48h
- CHX 0.2% mouthwash from day 2 (rinse only, not site)
- Analgesia: ibuprofen 400mg + paracetamol 1g PRN, alternate
- No antibiotic post-op (not indicated — healthy non-smoker, straightforward case)
- Contact urgently for uncontrolled bleeding, severe swelling, persistent paraesthesia (none anticipated — anterior maxillary, no IAN involvement)

REVIEW:
- 1-week soft tissue check
- Osseointegration: 12-16 weeks (anterior maxilla submerged)
- 2nd-stage surgery for healing abutment + impression at 16 weeks
- Crown delivery at ~20 weeks total

Compliance: the medico-legal angle

• MDR 2017 — implant batch / lot number mandatory for 10-year traceability.
• ADI UK Guidelines — surgical placement documentation standards.
• ITI Consensus 2023 — current evidence-based protocols.
• IR(ME)R 2017 — post-placement radiograph requires justification documented.
• GDC Principle 4 — surgical record sufficient for continuation and audit.

Common documentation mistakes

• Implant batch / lot number not recorded — MDR breach, audit fail, cannot trace if device recall.
• No insertion torque value — cannot defend immediate vs delayed loading decision.
• Routine post-op antibiotic without justification — antimicrobial stewardship issue.
• No post-op radiograph documented — depth and position not verified.
• Written post-op instructions not given — GDC Principle 4 weakness.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) (accessed 18 October 2026)

Frequently asked questions

Patient leaflets for this treatment

• After Your Dental Implant Surgery
• Caring for Stitches After Dental Surgery
• Soft Food Guide After Dental Surgery

Related dental note templates

Browse the full set of free dental notes templates.