RESTORATIVE DRIVEN IMPLANTS

Pre-Surgical Case Review Checklist | Series 3 Live Patient Event

Reviewing Doctors: Dr. Jan Bublik | Dr. Brad Millard | Dr. Wes Mullins

SECTION 1 — CASE IDENTIFICATION

Patient Name*

Date of Review*

Treatment Site (Tooth #)*

Click a tooth to select the implant site. Selected teeth fill in. Click again to unselect.

Patient Source*

Peter Christensen Patient Referred Patient

Referring Doctor (if applicable)

Materials Received*

Other

SECTION 2 — MEDICAL & DENTAL HISTORY

2A. Medical History

ASA Classification*

I II III IV+ (NO-GO)

ASA IV or above is an automatic NO-GO — return case to referring doctor with explanation.

Yes No

Medications reviewed (incl. bisphosphonate / anticoagulant / immunosuppressive)?*

Relevant medications

Yes No

Diabetic patient with A1C of 7 or below?*

A1C value / notes

Yes No

Tobacco / nicotine use?*

Type / frequency

Yes No

Alcohol use?*

Frequency

Yes No

Does medical history change the treatment plan?*

How treatment changes

Yes No

Case rejected due to medical history?*

Reason

2B. Dental History

Periodontal Status*

Healthy Gingivitis Mild–Mod Perio Severe Perio

Caries Status*

Controlled Active Caries Present

Occlusion Status*

Normal Malocclusion Bruxism Noted

Oral Hygiene*

Good Fair Poor

Medical / Dental History Notes

SECTION 3 — SOFT TISSUE EVALUATION

Minimum required: 3 mm of bound-down keratinized tissue circumferentially around the planned implant site. Free gingival tissue only = automatic NO-GO.

Yes No N/A

Adequate bound-down keratinized tissue present (≥3 mm circumferentially)?

Yes No N/A

If insufficient — is a modified flap technique feasible?

Yes No N/A

Site presents with free gingival tissue ONLY (no bound-down tissue)?

If Yes above → NO-GO. Tissue grafting is outside RDI protocol.

Soft Tissue Outcome

Pass Pass w/ Modified Flap NO-GO

Soft Tissue Notes

SECTIONS 4–7 — PER IMPLANT SITE*

Complete Sections 4 through 7 for each tooth selected in Section 1. Switch between sites using the tabs below; a check mark (✓) appears on a tab once that site's required fields (Sections 4 & 6) are complete.

Select at least one treatment site (tooth #) in Section 1 to begin.

SECTION 8 — CASE COMPLEXITY RATING

Assign a complexity level so RDI can match the case to a mentor of appropriate skill. Select one.*

Level 1 — Foundational

Single implant, healed site with abundant bone and keratinized tissue. No augmentation needed. Straightforward guided or freehand placement. Suitable for any RDI mentor.

Level 2 — Intermediate

Modified flap to reposition tissue, or minor / localized grafting. Bone at or near minimum, or D4 requiring an altered protocol. Tight inter-root or MD spacing, or vital-structure proximity needing precision guidance. Out-of-the-ordinary steps that call for closer attention. Experienced mentor.

Level 3 — Advanced

Ridge augmentation or ridge split concurrent with placement, or soft-tissue grafting (e.g., AlloDerm) to increase tissue thickness. Multiple implants in one session, sinus involvement, or edentulous / full-arch case requiring edentulous surgical-guide management. Highest-level mentor only.

Complexity Notes / Justification

SECTION 9 — CASE OUTCOME & SIGN-OFF

Overall Case Decision*

Approved Conditional Rejected

Conditional Requirements / Rejection Rationale (communicate to referring doctor)

Referring Doctor Notification*

Not Needed (Approved) Conditional — Notify Requirements Rejected — Notify w/ Rationale

Reviewing Doctor Sign-Off*

Dr. Jan Bublik — Reviewed

Dr. Brad Millard — Reviewed

Dr. Wes Mullins — Reviewed

Date of Review Sign-Off*

Additional Clinical Notes

RDI Series 3 | Dental Crafters Confidential — Internal Clinical Use Only

Tip: click the microphone in any text box to dictate instead of typing (Chrome or Edge). When finished, click Save completed PDF to generate a flattened, branded PDF for the patient record. The form works offline; dictation needs internet.