Free Implant Crown Delivery Note Template (D6058/D6065)
This implant crown note template covers the restorative visit after the implant has integrated: the site, implant system and platform, abutment, screw torque, retention method, contacts and occlusion, and the baseline radiograph and probing that every future peri-implant comparison depends on.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Implant crown delivery, site #[30]. Implant: [Straumann BLT 4.1 x 10mm, RC platform]; integration confirmed: no mobility, no pain on percussion. Healing abutment removed; peri-implant tissues [healthy, no bleeding or suppuration]. [Custom titanium] abutment seated and torqued to [35] Ncm per manufacturer specification; seating verified radiographically. [Zirconia] crown tried in: margins verified, contacts verified with floss, occlusion checked with articulating paper and shim stock and adjusted to [light centric contact, no excursive contact]. Crown [cemented with RelyX Unicem; excess cement removed, no residual cement on radiograph] / [screw-retained; access sealed with PTFE tape and composite]. Baseline PA radiograph taken. Baseline probing: [3, 2, 3, 3, 2, 3] mm, no bleeding on probing. Patient instructed on implant home care: [floss, interdental brush, water flosser]. Patient tolerated procedure well. Next visit: [recall 6 months with peri-implant evaluation].
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When to use this template
Use this implant crown delivery note when you seat a single crown on an integrated implant. It is the restorative visit, not the surgery: surgical placement (D6010) is documented in its own surgical note with the implant dimensions, insertion torque, and grafting. How the crown attaches decides the code. A crown cemented or screwed onto a separate abutment is an abutment-supported crown (for example D6058, porcelain/ceramic) reported with the abutment, D6056 if prefabricated or D6057 if custom. A crown that attaches directly to the implant is an implant-supported crown (for example D6065, porcelain/ceramic), with no separate abutment code. Material picks the exact code within each family, so the note should name both.
Record the implant system and platform, the abutment type, and the torque you applied in Ncm, following the manufacturer's specification. That line is what the next clinician needs when a screw loosens years later. For a cement-retained crown, name the cement and how you managed the excess: residual cement below the margin is associated with peri-implant inflammation, so a radiograph confirming no retained cement is worth documenting. For a screw-retained crown, record how the access channel was sealed so it can be retrieved.
Close with the baseline. The 2017 World Workshop consensus on peri-implant diseases recommends a baseline radiograph and probing measurements once the implant prosthesis is completed, because later bone loss is judged against that starting point rather than an absolute number. Document contacts (floss), occlusion and how it was checked, implant home-care instruction, and the recall interval for peri-implant monitoring.
Step by step: how to document this implant crown delivery
- 1
Confirm integration
Remove the healing abutment and confirm no mobility, no pain, and healthy peri-implant tissues without bleeding or suppuration.
- 2
Seat the abutment
Seat the abutment, verify seating radiographically, and torque to the manufacturer's specification, recording the value in Ncm.
- 3
Try in the crown
Verify margins, contacts with floss, and occlusion with articulating paper and shim stock; adjust and polish.
- 4
Retain
Cement-retained: cement, remove all excess, and confirm radiographically. Screw-retained: torque the screw and seal the access channel.
- 5
Record the baseline
Take the baseline periapical radiograph and record baseline probing depths around the implant.
- 6
Educate and recall
Give implant home-care instructions and set the recall interval for peri-implant monitoring.
Tips for using this template
- check_circleName the attachment and the material: abutment-supported (D6058 family, plus D6056 or D6057 for the abutment) versus implant-supported (D6065 family, no separate abutment). Those two words decide the claim.
- check_circleRecord the implant system, platform, and size. Years from now, that line is how a colleague orders the right screwdriver and components.
- check_circleDocument torque as a number in Ncm, per the manufacturer specification. "Torqued per manufacturer" leaves the next clinician guessing.
- check_circleFor cement-retained crowns, name the cement and document excess removal with a radiograph. Retained subgingival cement is a recognized contributor to peri-implant inflammation.
- check_circleFor screw-retained crowns, record the access seal (PTFE tape, composite shade) so the crown can be retrieved cleanly.
- check_circleTake the baseline radiograph and record baseline probing at delivery, per the 2017 World Workshop consensus. Without a baseline, later bone loss cannot be measured.
- check_circleRecord how occlusion was checked (articulating paper, shim stock) and where you left it. Implants have no periodontal ligament, so many clinicians leave lighter contact on a single implant crown than on the adjacent teeth.
- check_circleGive implant-specific home care and a recall interval: peri-implant mucositis is reversible when it is caught at recall.
Standards & references
- ADA Code on Dental Procedures (CDT): Implant services: abutment-supported crowns (D6058 family), implant-supported crowns (D6065 family), abutments D6056/D6057, and surgical placement D6010.
- AAP: 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions: AAP/EFP World Workshop classification, including the peri-implant health, mucositis, and peri-implantitis definitions.
- Berglundh et al. Peri-implant diseases and conditions: Workgroup 4 consensus report (J Periodontol 2018): Recommends baseline radiographic and probing measurements after delivery of the implant-supported prosthesis.
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