The Implant Placement Notes Template
An implant placement notes template captures the surgical placement visit — pre-op consent re-confirmation and CBCT review, surgical approach (flap or flapless), implant system with diameter / length / batch / lot number (MDR mandatory), insertion torque value, bone quality (Lekholm & Zarb), primary stability, membrane / graft used with batch numbers, closure, healing abutment placement, and post-op review — meeting ADI UK Guidelines, ITI Consensus 2023, and MDR 2017 traceability.
MDR 2017 makes implant batch / lot number traceability mandatory — and missing lot numbers are an audit failure waiting to happen. Below is the template UK clinicians paste into their PMS for every implant placement.
Download the free Implant Placement template — plain text, GDC/FGDP(UK)-aligned.
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.
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.
- IRMER 2017 — post-placement radiograph requires justification documented.
- GDC Principle 4 — surgical record sufficient for continuation and audit.
Common mistakes UK dentists make
- 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.
Frequently asked questions
Do I always need to record the implant batch number?
Yes — MDR 2017 mandatory. Without it, if there's a device recall, you cannot identify which patients received affected implants, AND you cannot demonstrate compliance at audit. Record at placement: capture from the box label.
What insertion torque should I aim for?
25-45Ncm typical. Higher torque (>50Ncm) may cause bone compression/necrosis. Lower (<15Ncm) inadequate for primary stability and delayed protocols are safer. ISQ ≥60 confirms primary stability. Document the value.
When do I need a bone graft at placement?
CBCT-identified inadequate bone width or height. Common indications: posterior maxilla (sinus lift simultaneous), narrow ridges (lateral augmentation), peri-implant defects. Choose graft material and document batch number. Membrane usually combined.
Submerged or non-submerged healing?
Submerged (2-stage): aesthetic zone, grafted cases, soft tissue concerns. Healing abutment placed at 2nd-stage surgery 4-6 months later. Non-submerged (1-stage): posterior, no graft, good soft tissue. Healing abutment at placement. Document the choice.
When should I prescribe antibiotics post-implant?
Routine straightforward placement in healthy non-smoker: usually no. ADI / ITI: antibiotic prophylaxis (2g amoxicillin 1h pre-op) for: graft cases with biomaterials, immunocompromised patients, long surgical times, complex sites. Document the indication.
Healing period before crown?
Mandible: 8-12 weeks. Maxilla: 12-16 weeks. Anterior aesthetic zone or graft cases: longer (16-24 weeks). Document the planned timeline based on bone quality and site.