Contact information:
3Shape Implant Studio
Surgical Report
Order Details APPROVED
Patient Name: Rita Matos
Client Order Reference: 0_20220825_2003_57_350
Creation Date: 25/08/2022 20:36:30
Approved by Dr. Tiago Oliveira
(a67792e8-75ca-4717-905e-c3acdefaa5f8)
Lower Jaw Upper Jaw
Implant information
Implant position (FDI) 12
Manufacturer Straumann
Type BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®, Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Implant information
Implant position (FDI) 22
Manufacturer Straumann
Type BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®, Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Limitation of Liability: Page 1
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant information
Implant position (FDI) 24
Manufacturer Straumann
Type BLT, Ø 3.3 mm NC, SLActive® 12 mm, Roxolid®, Loxim®, guided
Order number 021.3312G
Length, mm 12
Diameter (Ø), mm 3,3
Color Yellow
Implant information
Implant position (FDI) 26
Manufacturer Straumann
Type BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®, Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Implant information
Implant position (FDI) 36
Manufacturer Straumann
Type BLT, Ø 4.1 mm RC, SLActive® 8 mm, Roxolid®, Loxim®, guided
Order number 021.5308G
Length, mm 8
Diameter (Ø), mm 4,1
Color Red
Implant information
Implant position (FDI) 46
Manufacturer Straumann
Type BLT, Ø 4.1 mm RC, SLActive® 8 mm, Roxolid®, Loxim®, guided
Order number 021.5308G
Length, mm 8
Diameter (Ø), mm 4,1
Color Red
Limitation of Liability: Page 2
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 12
Manufacturer Straumann
BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®,
Type
Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 3
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 22
Manufacturer Straumann
BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®,
Type
Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 4
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 24
Manufacturer Straumann
BLT, Ø 3.3 mm NC, SLActive® 12 mm, Roxolid®,
Type
Loxim®, guided
Order number 021.3312G
Length, mm 12
Diameter (Ø), mm 3,3
Color Yellow
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 5
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 26
Manufacturer Straumann
BLT, Ø 3.3 mm NC, SLActive® 10 mm, Roxolid®,
Type
Loxim®, guided
Order number 021.3310G
Length, mm 10
Diameter (Ø), mm 3,3
Color Yellow
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 6
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 36
Manufacturer Straumann
BLT, Ø 4.1 mm RC, SLActive® 8 mm, Roxolid®, Loxim®,
Type
guided
Order number 021.5308G
Length, mm 8
Diameter (Ø), mm 4,1
Color Red
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 7
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
Implant Information
Implant position (FDI) 46
Manufacturer Straumann
BLT, Ø 4.1 mm RC, SLActive® 8 mm, Roxolid®, Loxim®,
Type
guided
Order number 021.5308G
Length, mm 8
Diameter (Ø), mm 4,1
Color Red
Safety zone - apical distance 2,0
Safety zone - radial distance 1,5
Buccal Mesial Lingual Distal
M D
Limitation of Liability: Page 8
This instruction incorporates a custom document that is based on a surgical plan proposed by the surgeon before operation. The surgeon,
therefore, takes full medical responsibility for the design and the application of the surgical guide, the intended used surgical tray kit, implants and
sleeves – all as specified on the order form received by the supplier. The custom document shall be considered as an addition to all other
documents sent with and pertaining to the case, and it does not replace any of those other documents.
