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Clinical Notes



Patients seen at the request of the office general dentist for evaluation of dental implants to support a denture . Discussed in length various available option including but not limited to conventional denture, overdenture (removal) vs Fixed with implants. After patient demonstrated complete understanding of the proposed options decided to proceed with placement of 4 implant in XXXX jaw and use of removal prosthesis. Reviewed all steps with patient from placement to over denture. Risks /Benefits / Complications discussed including all steps with patient from placement to final restoration. Risks, benefits, complications in particular to their case were also discussed.​

Past Medical History
Refer to patient history form

Past Surgical History
Refer to patient history form

Refer to patient history form

Refer to patient history form

Social History
Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form

Extraoral, Head and Neck exam: 

Constitutional: general appearance of patient  
No extraoral swelling or erythema 
Parotid and submandibular glands soft, nonpainful to palpation bilaterally 
No lesion noted on facial skin
Facial palpitation exam reviews no swelling or no lymphadenopathy 
CN V1, V2, V3, CN VII intact bilaterally 
No neck masses noted
Thyroid midline with no evidence of any swelling
Musculoskeletal: TMJ joint seems to be normal. No poping upon opening
Maximum mouth opening within normal range

Intraoral Soft Tissues: 

Clear saliva extruded from bilateral Wharton’s and Stenson’s ducts 
Tongue soft and non-tender with no apparent lesions 
Buccal mucosa without lesions bilaterally 
Hard palate, soft palate, and pharynx are within normal limits no pathology visualized 
Floor of mouth without an evidence of pathology


Refer to dental chart for detail dental caries evaluation

Radiographic examination: 
Panorex reviewed demonstrates
No bony pathology. 

Extraction of teeth #xxxxxxx with Local under General Anesthesia

Placement of 4 Bone Graft, membrane and 4 Dental Implants

Position 20,23,26,29


Discussed risk, benefits, complication of surgery including but not limited to bleeding swelling, infection, pain, retained root tip, numbness of lower lip, chin, tongue. Patient understood risks informed, verbalized understanding and consented accordingly.

Local Anesthesia
___ 2% lido w/ 1:100,000 epi Carpules (1.7 cc)
___ 4% sepocaine Carpules (1.7 cc)
___ 3% Carbocaine w/o epi Carpules (1.7 cc)

Procedure Performed
SURGEON 1:  Joseph Krajekian, D.M.D., M.D.

   Simple extraction :
   Surgical Extraction :
   Alveoplasty :

    Placement of 4 Bone Graft, membrane and 4 Dental Implants

    Position 20,23,26,29 (Implant placement x 4 (mandible) :

                  ABDE position according to Misch protocol)

After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.

Simple Exo: were performed with use of elevator, and appropriate forcepts.

Surgical extractions and root tip were performed in standard oral and maxillofacial surgery fashion with use 15 blade intra-suclular incision, periosteol elevator to reflect full thickness mucoperiosteol flap, straight elevator,  drill used with copious irrigation to section the tooth and create a purchase point. All attempts were made to preserve the buccal wall.  Tooth was then removed by elevators/crane picks and rongeur.

Following extraction rongeur was used to smooth the bone (alveoplasty)  after full the mucoperiosteol flap was reflected and remove any sharp edges that may protrude through the gingiva.  Bone file was used to smoothen any rough edges. 

With use of sequential drilling sequence per Straumann guidelines 800/600 RPM with chilled saline Round bur was then used to create the bone osteotomy holes x4 (A/B/D/E position) and they were place in canine and 1/2 premolar position bilaterally. The mental nerve was identified during the dissection and avoided during sequential drilling. Careful attention was make to protect and not to stretch the nerve.


Next the pilot drill was placed at 8mm  depth in 4 osteotomies and Panorex was taken to confirm placement, angulation. Appropriate adjustment were made and the osteotomies were completed with copious irrigation.  Angulation and position was confirmed again prior to placement of implant via panorex. Which seemed satisfactory. Implant were then placed in following sequence below

After implant placement bone graft placed followed with membrane and 3.0 vycril suture to obtained primary closure tension free.

Implant Position


Canine Positions B/C implant Position
4.1  x 10 mm Straumann BL with Cover screw @ 35 N

PreMolar Positions   A/D  

4.1  x 10 mm Straumann BL with Cover screw @ 35 N

Areas was then closed with 3.0 gut suture and patient discharged in stable condition after showing the patient picture of panorex demonstrating the implants placements. 

All patient and escort questions were answered prior to discharge




Pen VK 500mg    PO q6 hrs Disp 7 days                     refill 0
Tylenol #3          1 tabs PO q6 hrs prn Disp 5 days    refill 0
Peridex                Provided from the office                  refill 0
Motrin 800mg      1 tablet every 8 hrs prn x 28 pills    refill 0

next day with general dentist. 2 weeks with me if needed. Patient was provided post-op instruction/medication sheets in writing and they were also review with patient escort. Pt and escort were also provided with my 24 hour direct contact number and was also instructed to contact the office with any questions

DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD


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