AMERICAN ACADEMY OF IMPLANT DENTISTRY
211 East Chicago Ave, Suite 750, Chicago IL 60611-2616 312/335-1550 FAX. 312/335-9090
CHECKLIST FOR ELECTRONIC CASE REPORTS FOR THE ASSOCIATE FELLOW EXAMINATION
Instructions: Place an "x" before each item that is included in the case report.
To verify that you have PERSONALLY reviewed this report and checklist for accuracy, write your Examination
Number in the space provided at the end of the checklist.
This case meets the ONE of following required cases for Associate Fellowship:
Single Tooth
Edentulous Segment of Two or More Adjacent Teeth with a minimum of two implants
Candidates’ Choice of:
Edentulous arch
Immediate Placement of one or more Implants in the Maxillary Segment
Horizontal Onlay Graft
Vertical Onlay Graft
This case report includes ALL of the following as specified in the Guidelines for Case Reports for Associate
Fellow Membership and Instructions for Submission of Electronic Case Reports:
A narrative (prose) report checked for spelling errors
My report includes the following sections:
Patient Examination
Development of the Treatment Plan
Surgical and Prosthetic Report
Clinical Resume
A health history with the patient's signature and (if applicable) an English translation
Treatment consent form with the patient’s signature
My NAME, OFFICE NAME, and OFFICE ADDRESS (including city, state, and country) do not appear
ANYWHERE in the written report.
Four (4) required radiographs (Grafting cases: six (6) required radiographs)
Each radiograph is labeled with 1) candidate number, 2) patient initials, 3) date taken, and 4)
required view, and 4) patient initials.
The required post-completion photographs (number varies based on case type)
Each photograph is labeled with 1) candidate number, 2) patient initials, 3) date taken, and 4)
required view, and 4) patient initials.
A signed patient release form for the case is submitted with my case report (the ONLY place where my
name appears.
My candidate number is
case report is complete.
.
I have PERSONALLY reviewed this checklist and verified that my
Candidate number:
Patient:
Case Type:
MEDICAL HISTORY
if the health history is not in the English language, an English translation must also be submitted.
Insert a scanned copy medical history with patient’s signature. Click on the sample history below, go to
INSERT picture and choose a scanned copy of the medical history.
If you need to add a second page, click on the dot at the bottom of this page. Go to the Insert menu,
insert a blank page and then INSERT picture and choose a scanned copy of the medical history.
BE SURE SCAN is LEGIBLE
•
TREATMENT CONSENT FORM
Insert a scanned copy treatment consent form with patient’s signature. Click on the sample treatment
consent, go to INSERT picture and choose a scanned copy of the treatment consent.
If you need to add a second page, click on the dot at the bottom of this page. Go to the Insert menu,
insert a blank page and then INSERT picture and choose a scanned copy of the treatment consent
BE SURE SCAN is LEGIBLE.
•
PATIENT EXAMINATION
History
[Describe the chief complaint and secondary complaints. Be sure to describe the patient’s medical
history as well as any laboratory findings (e.g. CBC, SMA, PTT, INR) and current medications, as
applicable.]
Clinical Examination
[Describe the existing dentition, adjacent soft tissues, periodontal charting, lip line,
temporomandibular joint function, parafunctional habits, hard and soft tissue anatomy of edentulous
areas and other findings.]
Radiographic Examination
[Describe the findings and limitations.]
Preoperative diagnosis
[Describe the preoperative diagnosis.]
DEVELOPMENT OF TREATMENT PLAN
Treatment goals
[Describe the patient desires and functional, esthetic, hygiene, and limitations, e.g. medical
conditions, physical, psychological.]
Evaluation of existing natural dentition
[Evaluate the existing natural dention focusing on crown-root ratio, periodontal condition, abutment
suitability, alignment, and resorative needs.]
Interarch relationships
[Describe the occlusion, jaw relation and temporomandibular joint function.]
Evaluation of endentulous ridge
[Evaluate the amount of resorption, soft and hard tissue anatomy (dificiencies and limitations) and
suitablility for implants.]
Prosthetic restoration selection
[What are the advantages and disadvantages of, and alternatives for the prosthetic restoration that
you selected? Explain your rationale.]
Hard and soft tissue modifications
[Describe any tissue modifications, e.g. grafts, osteoplasties, and gingivoplasties. ]
Implant selection rationale
[Explain the rationale for the implant selected, e.g. type, number and placement positions. ]
SURGICAL AND PROSTHETIC REPORT
Surgical procedures
[In a written, detailed operative report, describe the type and amount of anesthesia, instruments and
materials used, suture type and techniques, surgical and postoperative complications.]
Prosthetic procedures
[In a written, detailed operative report, describe step-by-step, how each of the following (as applicable)
was used and why.
Materials used
Techniques used
Prosthetic deliver
 Impression
 Preparation
 Evaluation of fit
 Die
 Impression
 Occlusion/adjustment
 Model
 Bite registration
 Placement
 Transfer
 Temporization
 Abutment
 Articulation (e.g.
 Restorative
hinge, face bow,
 Cementation
semi-adjustable)
]
CLINICAL RESUME
Comparison of preoperative and postoperative diagnoses
[Compare the preoperative and postoperative diagnoses.]
Type of patient instructions
[Describe any instruction (e.g. preoperative, postoperative, diet, temporization, prosthetic) given to
the patient.]
Complications
[Describe any complication with the procedure. ]
.
Patient acceptance and prognosis
[Describe the patient's acceptance of the treatement. What is the prognosis for this case?]
RELEASE OF INFORMATION
Submit the release of information form for this case that the patient signed. Send the original form.
Scanned copy will not be accepted.
PHOTOGRAPHS AND RADIOGRAPHS
Submit photographs and radiographs, as appropriated, for this case using the Photograph and
Radiograph templates.