Free Implant Uncovery Note Template (D6011 Second Stage)
Second-stage surgery is short, and the note often is too. This D6011 template documents the submerged implant you uncovered, the radiograph and integration check, how you exposed it, the soft tissue around it, the healing abutment you placed, and when the patient comes back for the restoration.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
Customize your note
Fill in the fields below and we'll generate a complete clinical note for you in seconds.
Copy-paste template
Replace each [bracketed field] with your specific clinical detail. Brackets are placeholders. They don't get saved into the chart.
Implant uncovery #[19] (D6011, second-stage surgery). Implant placed [date]: [Straumann BLT 4.1 x 10 mm, RC platform], submerged under a cover screw. Medical history reviewed; [no changes]. Pre-operative PA radiograph: [crestal bone stable around the implant; no peri-implant radiolucency]. Soft tissue: [healed; about 4 mm of keratinized tissue over the site]. Risks and alternatives discussed; consent obtained. Local anesthesia: [0.5] carpule of [2% Lidocaine 1:100k epi] via [buccal infiltration]. [Tissue punch used to expose the implant] / [Incision made slightly lingual of the crest and a small flap reflected to keep keratinized tissue on the buccal] / [Overlying soft tissue removed with a laser]. [Bone over the cover screw removed with a hand instrument.] Cover screw removed; implant [immobile, no pain]; platform [clean]. Healing abutment [4.5 x 4 mm] placed and hand-tightened [per the manufacturer]. [PA radiograph: healing abutment fully seated.] [Tissue adapted around the healing abutment with 4-0 chromic gut, 2 interrupted sutures.] Hemostasis achieved. Post-operative instructions given, including [gentle soft-brush cleaning around the healing abutment]. Next visit: [post-op check in 7 to 14 days]; [impression or scan for the implant crown after soft tissue healing].
Customize this note in seconds, no typing. Get your hours back.
Templates for practically every clinical scenario, with instant custom note generation.
Tap through any clinical scenario
Tap chips for any clinical scenario, get a complete custom note instantly, paste into your EHR.
Or skip clicks entirely
Ambient listening records the appointment in the background. AI writes the note from the conversation itself.
“I'm Dr. Yasmin, a dentist who got tired of staying late writing notes. I used to search the internet for note templates that actually worked, and I could never find good ones. So I built ButterNote to make note writing feel as smooth as butter.
If the click-build flow above just saved you time, you'll love what's behind a free account: templates for practically every clinical scenario you'll see this week, with instant custom note generation. And if you want zero clicks at all, the iOS app handles that too. Ambient listening on your iPhone or Apple Watch turns each appointment into a finished note.
Take whatever's useful here for free.”
Yasmin Byott, DDS, MS
Founder, ButterNote
When to use this template
Use this implant uncovery note template when you surgically expose an implant that was left submerged under a cover screw at placement, so that a healing abutment or another component can be placed. CDT D6011 is surgical access to an implant body (second stage implant surgery). Its descriptor, revised for CDT 2025, describes the procedure as removal of the tissue that covers the implant body so that a fixture of any type can be placed. An implant placed with a healing abutment at surgery (one-stage) has no second stage, and a visit where the implant is already exposed does not fit that description either.
Carry the implant details forward from the placement note: placement date, system, platform, and size. Then record what you found before you started: a radiograph showing crestal bone around the implant and no peri-implant radiolucency, and the soft tissue over the site, including the band of keratinized tissue. That tissue decides the technique. A tissue punch is quick when there is plenty of keratinized tissue and you know exactly where the implant is. A crestal or slightly lingual incision with a small flap lets you keep keratinized tissue and move it to the buccal, and lets you see and remove bone grown over the cover screw. A laser is another option for removing the overlying tissue. Say which you used.
After exposure, record the cover screw removal, the integration check (no mobility, no pain), the healing abutment diameter and height and how it was tightened, and a radiograph confirming the abutment is fully seated where that is your practice. Record any sutures, home care around the healing abutment, and the restorative timeline: soft tissue healing, then the impression or scan for the implant crown. If the implant is mobile or painful at uncovery, it has not integrated; document the finding and the plan rather than proceeding.
Step by step: how to document this implant uncovery
- 1
Review the implant
Record the placement date, system, platform, and size from the placement note.
- 2
Check before exposing
Record the pre-operative radiograph and the soft tissue over the site, including keratinized tissue.
- 3
Anesthetize and expose
Record the anesthetic and the technique used to expose the implant: tissue punch, flap, or laser.
- 4
Confirm integration
Remove the cover screw and confirm no mobility and no pain; remove any bone over the platform.
- 5
Place the healing abutment
Record its diameter and height, how it was tightened, and any seating radiograph and sutures.
- 6
Plan the restoration
Give home-care instructions and book the post-op check and the impression or scan for the crown.
Tips for using this template
- check_circleCarry the implant forward from the placement note: placement date, system, platform, and size. The restoring dentist needs all four.
- check_circleCheck integration before you commit: a radiograph with no peri-implant radiolucency, and no mobility or pain once the cover screw is off.
- check_circleName the technique (tissue punch, flap, or laser) and record the keratinized tissue you found and kept.
- check_circleRecord the healing abutment diameter and height, chosen for the emergence profile and tissue thickness, and how it was tightened.
- check_circleWhere it is your practice, take a radiograph to confirm the healing abutment is fully seated on the implant platform.
- check_circleD6011 is the second stage of a two-stage implant. An implant placed with a healing abutment at surgery has no second stage to report.
- check_circleIf the implant is mobile or painful, do not uncover and hope. Document the finding and the plan.
- check_circleEnd with the restorative timeline, so the next visit is booked for the right thing.
Standards & references
- ADA Code on Dental Procedures (CDT): D6011 (surgical access to an implant body, second stage implant surgery) and D6010.
- AAP: Ask the Coding Coach (CDT 2025 changes): American Academy of Periodontology summary of CDT 2025 revisions, including the revised D6011 descriptor.
- AAP: 2017 Classification of Periodontal and Peri-Implant Diseases and Conditions: AAP/EFP World Workshop definitions of peri-implant health, mucositis, and peri-implantitis.
Frequently asked questions
Get your hours back.
Click-build any implant uncovery note in seconds, or let ambient listening turn your appointments into finished notes.
Built by a dentist who's been in your chair.
Free to start. HIPAA-aware.
Want all 6 templates as a printable PDF?
Other dental note templates
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.
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.
Socket Graft Note Template (D7953 Ridge Preservation)
A socket graft note has to show that the graft went into a fresh extraction site, at the extraction, for a reason.
Sinus Lift Note Template (D7951/D7952)
A sinus lift note has to show why the bone was not enough, how you got under the sinus floor, and what state you left the Schneiderian membrane in.
Clear Aligner (Invisalign) Start Note Template (D8080/D8090)
The aligner start visit sets the record every later check is measured against.
Clear Aligner Check Note Template (D8670)
An aligner check note answers one question for the next visit: is the case doing what the plan says? This D8670 template documents the aligner the patient is in, reported wear, tracking, attachments, IPR, any refinement decision, and the aligners and instructions you sent home.