Case history
General illnesses:
Current medication:
COMPLAINT form
BEGO Implant Systems
Neurological disorders:
Smoker:  Yes  No
Angle class
I
Other:
Occlusion:  IIa  IIb  III
Occlusal interference:
Elongated teeth:
Intercuspidation:  Canine guidance
 Occlusion
Cusp inclination:  Steep
 Moderate  Flat Parafunctions:  Bruxism  Tongue thrust
It is only possible to process a complaint properly if the complaint form is filled out correctly.
All of the items listed below must be submitted together with this form.
 None
• Product forming subject of complaint
• Goods return form
• All x-rays from this case
• Prosthetic constructions (e.g. bridge or bar)
Suspected cause of failure (implant failure / complications)
• Planning and working models if applicable
 Insufficient available bone
• Photo if applicable
 Trauma during placement
 Primary instability  Buccal bone lamellae fractured
 Extremely hard bone  Simultaneous implantation and augmentation
Goods returned as part of a complaint are only accepted if they are sent to BEGO Implant Systems GmbH & Co. KG accompanied by
the corresponding goods return form.
Surgeon / implantologist:
 Healing phase too short
 Infection during
 the healing phase  the prosthetic treatment  the recall phase
Name
 Occlusal trauma
 Other trauma
Address
 Other cause
Tel. / Fax
Prosthodontist:
To be completed by BEGO Implant Systems.
Complaint no.:
Date received:
(Place, date, signature, stamp)
Processed by:
BEGO Implant Systems GmbH & Co. KG · Wilhelm-Herbst-Str. 1 · 28359 Bremen · Germany
Tel. +49 421 2028-268 · Fax +49 421 2028-265 · www.bego-implantology.com · E-mail: info@bego-implantology.com
REF 15150/03 · adwork · © 2012 by BEGO Implant Systems · 2012-09
Description of the complication (with treatment data)
Name
Address
Tel. / Fax
Patient:
Name / date of birth
Partners in Progress
Treatment data
Implant-borne prosthesis
Extraction of the replaced tooth (weeks before implantation):
Implant position: Width of the crestal alveolar process at the implantation site: Bone quality: Single crown(s) on implant:
Date of implantation:
Crown block
 D1  D2  D3 (mm)
Bridge from  D4
Bar with removable prosthesis on
as abutments
as abutments
over Speed used: (rpm)
Bar with limited prosthesis removal on
Pretapped thread:  Yes  No
Extension bar(s) region
Countersink used:  Yes  No
Ball attachment anchor on implant
Torque used during insertion: (N/cm)
Magnetic inserts on implants Tool used:  Handpiece  Handwheel
Telescopic crowns:
 Ratchet No tool, rather:
 Parallel-walled Cone angle  6°  8°  10° Torque used during fixation Simultaneous osteoplasty with:
to
(cylinder / stepped cone)
 > 10°
(N/cm)
Other:
Materials used:
 Chips and membrane
 Titanium mesh / film
 Lateral onlay (pressure screw)*
Overview diagram
 Vertical onlay (pressure screw)*
 Sinus floor elevation (chips)
 Same, with block implant*
MAXILLA
 Same, with mixture*
*Harvest site:
Augmentation with alloplastic materials:
 Granules
17
47
 Granules + membrane
16
46
15
14
13
12
11
45
44
43
42 41
21
22
23
24
25
31 32 33
34
35
26
36
27
37
 Alloplastic blocks
Healing phase
Healing:  Covered  Insecurely covered  Open
 Not loaded  Partially loaded  With final prosthesis
Healing period not loaded: days
Period between exposure and insertion of final prosthesis: days
Product forming subject of complaint (implants / prosthetic components):
Implant position
Article
Recall phase
Article no.
Recall interval/dates:
Level of hygiene (1 = excellent to 6 = inadequate):
Batch no.
MANDIBLE
Treatment data
Implant-borne prosthesis
Extraction of the replaced tooth (weeks before implantation):
Implant position: Width of the crestal alveolar process at the implantation site: Bone quality: Single crown(s) on implant:
Date of implantation:
Crown block
 D1  D2  D3 (mm)
Bridge from  D4
Bar with removable prosthesis on
as abutments
as abutments
over Speed used: (rpm)
Bar with limited prosthesis removal on
Pretapped thread:  Yes  No
Extension bar(s) region
Countersink used:  Yes  No
Ball attachment anchor on implant
Torque used during insertion: (N/cm)
Magnetic inserts on implants Tool used:  Handpiece  Handwheel
Telescopic crowns:
 Ratchet No tool, rather:
 Parallel-walled Cone angle  6°  8°  10° Torque used during fixation Simultaneous osteoplasty with:
to
(cylinder / stepped cone)
 > 10°
(N/cm)
Other:
Materials used:
 Chips and membrane
 Titanium mesh / film
 Lateral onlay (pressure screw)*
Overview diagram
 Vertical onlay (pressure screw)*
 Sinus floor elevation (chips)
 Same, with block implant*
MAXILLA
 Same, with mixture*
*Harvest site:
Augmentation with alloplastic materials:
 Granules
17
47
 Granules + membrane
16
46
15
14
13
12
11
45
44
43
42 41
21
22
23
24
25
31 32 33
34
35
26
36
27
37
 Alloplastic blocks
Healing phase
Healing:  Covered  Insecurely covered  Open
 Not loaded  Partially loaded  With final prosthesis
Healing period not loaded: days
Period between exposure and insertion of final prosthesis: days
Product forming subject of complaint (implants / prosthetic components):
Implant position
Article
Recall phase
Article no.
Recall interval/dates:
Level of hygiene (1 = excellent to 6 = inadequate):
Batch no.
MANDIBLE
Case history
General illnesses:
Current medication:
COMPLAINT form
BEGO Implant Systems
Neurological disorders:
Smoker:  Yes  No
Angle class
I
Other:
Occlusion:  IIa  IIb  III
Occlusal interference:
Elongated teeth:
Intercuspidation:  Canine guidance
 Occlusion
Cusp inclination:  Steep
 Moderate  Flat Parafunctions:  Bruxism  Tongue thrust
It is only possible to process a complaint properly if the complaint form is filled out correctly.
All of the items listed below must be submitted together with this form.
 None
• Product forming subject of complaint
• Goods return form
• All x-rays from this case
• Prosthetic constructions (e.g. bridge or bar)
Suspected cause of failure (implant failure / complications)
• Planning and working models if applicable
 Insufficient available bone
• Photo if applicable
 Trauma during placement
 Primary instability  Buccal bone lamellae fractured
 Extremely hard bone  Simultaneous implantation and augmentation
Goods returned as part of a complaint are only accepted if they are sent to BEGO Implant Systems GmbH & Co. KG accompanied by
the corresponding goods return form.
Surgeon / implantologist:
 Healing phase too short
 Infection during
 the healing phase  the prosthetic treatment  the recall phase
Name
 Occlusal trauma
 Other trauma
Address
 Other cause
Tel. / Fax
Prosthodontist:
To be completed by BEGO Implant Systems.
Complaint no.:
Date received:
(Place, date, signature, stamp)
Processed by:
DentMerk Benelux B.V. | Antwoordnummer 592 | 1270 VB Huizen
BEGO Implant Systems GmbH & Co. KG · Wilhelm-Herbst-Str. 1 · 28359 Bremen · Germany
Tel. +49 421 2028-268 · Fax +49 421 2028-265 · www.bego-implantology.com · E-mail: info@bego-implantology.com
REF 15150/03 · adwork · © 2012 by BEGO Implant Systems · 2012-09
Description of the complication (with treatment data)
Name
Address
Tel. / Fax
Patient:
Name / date of birth
Partners in Progress