Free Implant Placement Note Template (D6010)
An implant placement note is the record every later visit leans on: which implant went in, how big, how tight, and how it was left to heal. This D6010 template documents the planning, consent, flap and osteotomy, the implant system and dimensions, insertion torque and stability, any graft, and whether you left a cover screw or a healing abutment.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
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Cover screw for two-stage (submerged) healing; healing abutment for one-stage healing.
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Implant placement #[30] (D6010). Medical history reviewed; [no changes; non-smoker; not taking anticoagulant, antiresorptive, or antiangiogenic medications]. Restorative plan: [single implant-supported crown]. Pre-operative [CBCT]: [bone width and height adequate for the planned implant; adequate clearance to the inferior alveolar canal]. Risks discussed, including [pain, swelling, bleeding, infection, failure to integrate, need for additional grafting, damage to adjacent teeth, and altered sensation of the lip, chin, or tongue]; alternatives reviewed, including [a fixed bridge, a removable partial denture, and no treatment]; [written] consent obtained. Topical anesthetic applied. Local anesthesia: [2] carpules of [4% Septocaine 1:100k epi] via [IANB and long buccal]; profound anesthesia confirmed. [Crestal incision with sulcular extensions; full-thickness mucoperiosteal flap reflected] / [Flapless approach]. [Surgical guide seated and fit verified.] Osteotomy prepared with sequential drills under copious sterile saline irrigation [per the manufacturer's drilling protocol]. Implant placed: [Nobel Biocare NobelActive 4.3 x 10 mm], lot [number]; insertion torque [35] Ncm; [ISQ 74]. Primary stability achieved. [Simultaneous bone graft placed with xenograft at a buccal dehiscence (D6104).] [Cover screw placed for submerged (two-stage) healing] / [Healing abutment (4.5 x 3 mm) placed for one-stage healing]. Closed with [4-0 PTFE, 3 interrupted sutures]; hemostasis achieved. Post-operative PA radiograph: [implant in the planned position, clear of the canal]. Post-operative instructions given verbally and in writing. Analgesics: [ibuprofen 600 mg with or without acetaminophen as directed]. [Chlorhexidine 0.12% rinse twice daily.] Next visit: [suture removal and post-op check in 10 to 14 days]; [uncovery or restoration after integration].
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When to use this template
Use this implant placement note template when you surgically place an endosteal implant. CDT D6010 is surgical placement of implant body: endosteal implant, and it is reported per implant. Interim implants placed to support a transitional prosthesis (D6012) and mini implants (D6013) have their own codes. Start the note with the plan the surgery serves: the planned restoration, the imaging you planned from (usually a CBCT), and what it showed about bone width and height and the distance to the inferior alveolar canal, mental foramen, maxillary sinus, and adjacent roots. Record the medical history that changes implant surgery: smoking, diabetes control, anticoagulants, and antiresorptive or antiangiogenic medications, which carry a risk of medication-related osteonecrosis of the jaw (MRONJ). The consent line should name the risks that are real for this site, such as altered sensation for a lower posterior implant or sinus involvement for an upper posterior one, along with failure to integrate and the possible need for more grafting, and the alternatives you offered.
The surgical part of the note is where detail pays off later. Record the anesthesia, the flap design or a flapless approach, whether the osteotomy was guided or freehand, and irrigation. Then record the implant itself: system, line, diameter and length, and the lot or reference number from the packaging. Give the insertion torque in Ncm and the ISQ if you measured it, and state whether primary stability was achieved. A graft placed at the time of implant placement is reported as D6104 (bone graft at time of implant placement), and a barrier membrane over it is reported separately. Finish with how the implant was left: a cover screw for submerged, two-stage healing, which means a second-stage uncovery (D6011) later, or a healing abutment for one-stage healing.
Close with sutures, hemostasis, and a post-operative radiograph confirming the implant position. That film is a position check, not the peri-implant baseline: the 2017 World Workshop places the baseline radiograph and probing at delivery of the prosthesis. Record post-operative instructions, analgesics, and the next visits, usually suture removal and then uncovery or restoration once the implant has integrated. For post-operative pain, the 2024 ADA-endorsed guideline makes an NSAID, alone or with acetaminophen, the first-line choice.
Step by step: how to document this implant placement
- 1
Plan and consent
Record the restorative plan, imaging findings, relevant medical history and medications, site-specific risks, alternatives, and consent.
- 2
Anesthetize and access
Record the anesthetic, volume, and technique, then the incision and flap design or a flapless approach, and whether a surgical guide was used.
- 3
Prepare the osteotomy
Record sequential drilling under sterile saline irrigation, guided or freehand.
- 4
Place the implant
Record system, diameter and length, lot number, insertion torque in Ncm, ISQ if measured, and primary stability.
- 5
Graft and close
Record any graft and membrane, the cover screw or healing abutment, the sutures, and hemostasis.
- 6
Confirm and follow up
Take the post-operative radiograph, give written instructions and analgesic advice, and book suture removal and the next stage.
Tips for using this template
- check_circleRecord the implant system, line, diameter and length, and the lot or reference number from the packaging. Years from now, that line is how a colleague identifies the implant and orders the right parts.
- check_circleGive insertion torque as a number in Ncm, and ISQ if you measured it. "Good primary stability" on its own does not let anyone judge whether one-stage healing or an immediate provisional was a reasonable call.
- check_circleSay how you left the implant: cover screw for two-stage healing, which sets up a second-stage uncovery (D6011), or healing abutment for one-stage healing, which does not.
- check_circleReport a graft placed with the implant as D6104 and name the material and where it went, such as a buccal dehiscence. A barrier membrane is reported separately.
- check_circleName the anatomy-specific risks in the consent line: altered sensation for lower posterior sites, sinus involvement for upper posterior sites.
- check_circleRecord the medical factors that change implant surgery: smoking, diabetes control, anticoagulants, and antiresorptive or antiangiogenic drugs (MRONJ risk).
- check_circleFor an immediate implant, document the extraction separately, then state that the implant went into the fresh socket and how the gap between implant and socket wall was managed.
- check_circleThe post-operative film confirms position. The baseline radiograph and probing that later bone levels are judged against are taken when the prosthesis is delivered.
Standards & references
- ADA Code on Dental Procedures (CDT): D6010 (surgical placement of implant body: endosteal implant), D6011, D6012, D6013, D6104 (bone graft at time of implant placement), and D6106/D6107.
- AAOMS Parameters of Care: American Association of Oral and Maxillofacial Surgeons clinical guidelines, including dentoalveolar and implant surgery.
- AAOMS Position Paper on Medication-Related Osteonecrosis of the Jaws, 2022 Update (J Oral Maxillofac Surg 2022): Risk assessment for patients taking antiresorptive or antiangiogenic medications before dentoalveolar and implant surgery.
- Tonetti et al. Management of the extraction socket and timing of implant placement (J Clin Periodontol 2019): XV European Workshop in Periodontology consensus on ridge preservation and immediate, early, and delayed implant placement.
- 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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