All-on-X Implant Surgery (AOX) Template

All-on-X implant surgery.

RMH: Medical history reviewed/updates
BP/Pulse: BP/Pulse

Arch: Arch
Number of implants: Number of implants
Implant positions: Implant positions

All-on-X code support: Extraction dates/teeth removed, reason for tooth loss, arch/PDI status
CBCT/guide support: CBCT/radiographs/photos; surgical guide/key/drill sequence
Implant records: Implant systems, sizes, lot/serial numbers, insertion torque by implant
Graft/biologic/membrane: Materials used or none
Provisional prosthesis details: Material, multi-unit abutment type/torque, occlusion, hygiene access

Consent: Consent/PARQ reviewed; signed/verbally obtained

Anesthesia: Anesthetic used
Carps: Carpules/amount

Procedure:
Remaining teeth extracted.
Alveoloplasty performed.
Implant osteotomies prepared.
Implants placed.
Primary stability achieved on all implants.
Torque values: Torque values
Multi-unit abutments placed.
Impression taken for provisional.
Provisional prosthesis delivered.
Occlusion adjusted.
Hemostasis achieved.

Complications: None or describe.

Patient tolerance: Tolerance/response.

Post-op instructions: Instructions reviewed.
Soft diet only.
No chewing directly on prosthesis.
Rx: Prescription or none

NV: Next visit

Documentation requirements

An AOX surgical visit is a multi-hour, multi-component procedure with a four-figure to five-figure case fee. The chart needs to prove (1) the patient was a documented candidate (medical clearance, terminal dentition or edentulism, adequate bone for the planned implant positions, restorative-space adequacy after planned alveoloplasty), (2) comprehensive informed consent covered the surgical, prosthetic, and immediate-load risks plus alternatives (conventional bridge / removable / no treatment), (3) each implant was placed under guideline-concordant conditions (CBCT-confirmed bone, primary stability, recorded torque, brand / lot / size traceability per fixture), (4) the immediate-load decision is justified by the cumulative primary-stability data, and (5) the post-op plan, definitive restorative timeline, and hygiene access are explicit.

A defensible AOX surgical record includes:

• Medical history reviewed and updated today — meds, conditions, allergies, ASA status. AOX patients skew older with comorbidities; high-yield items: anticoagulants / antiplatelets (warfarin INR, apixaban, rivaroxaban, dabigatran, clopidogrel), antiresorptive / antiangiogenic medications (oral and IV bisphosphonates, denosumab, romosozumab — duration of therapy and MRONJ risk; AOX cases involve significant alveoloplasty and are higher-MRONJ-risk than single-tooth implants), uncontrolled diabetes (recent A1C; full-arch cases generally deferred above ~A1C 8.0), active smoking (quantified pack-years; smoking-cessation counseling documented; smoking dramatically increases AOX failure rates), immunosuppression / chemotherapy / head-and-neck radiation history, psychiatric / neurologic conditions that affect post-op compliance with soft diet and hygiene, and bruxism / parafunction (a major cause of AOX prosthetic failure).
• Vitals (BP, pulse, SpO2) — with sedation, also continuous monitoring records (pulse ox, capnography, BP intervals). AOX is typically performed under IV moderate or deep sedation; the sedation record is its own document and should reference the sedation provider, agents, doses, and times.
• Pre-op CBCT and treatment plan — explicit reference to the CBCT (D0367 typically) read pre-op for bone volume in each planned implant position (anterior axial sites: width and height; posterior tilted sites: trajectory engaging anterior bone, distance to mental foramen on mandible, distance to maxillary sinus on maxilla), bone quality (Lekholm & Zarb / Misch), proximity to vital structures (IAN canal, mental foramen on the mandible; maxillary sinus floor, incisive canal, nasal floor on the maxilla), and pathology screen. The AP spread (anteroposterior distance from the most anterior to most posterior implant) and the planned cantilever length are documented from the CBCT-merged digital plan.
• Arch-level decisions — which arch (maxillary, mandibular, both); number of implants planned (4 vs 6 vs other); planned axial vs tilted positions (e.g., All-on-4: #6, #11 axial + #3, #14 tilted ~30 degrees); planned MUA angulations.
• Extraction list — every tooth being extracted today, with extraction code (D7140 erupted / D7210 surgical) per tooth. Document atraumatic extraction technique to preserve buccal plate; document any complications (root fracture, retained tip).
• Alveoloplasty — planned vs achieved ridge reduction in mm; quadrants treated (D7310 in conjunction with extractions, D7320 without). Restorative space target — typically minimum 15 mm vertical from the planned occlusal plane to the ridge for a hybrid prosthesis; document the measurement.
• Per-implant records (one row per implant) — site / position descriptor (e.g., "right posterior tilted, ~30 degrees mesial-to-distal"), implant brand / system (Nobel Biocare NobelActive, Straumann BLT, BioHorizons Tapered Internal, Megagen AnyRidge, Neodent GM, etc.), diameter and length (e.g., 4.0 x 13 mm), lot or serial number from the package label, insertion torque in Ncm at final seating, ISQ value if RFA / Osstell measured. Every implant needs this complete row — gaps are audit risks. Most practices use a structured table or the EHR's implant-record module rather than narrative prose.
• Multi-unit abutment (MUA) records (one row per MUA) — abutment brand / system (matched to the implant brand), angulation (straight, 17, 30 degrees), collar height (e.g., 1, 2, 3, 4 mm), lot number, and torque value (typically 15-20 Ncm per manufacturer IFU; over-torquing damages the platform).
• Surgical guide details — static guide vs stack guide vs dynamic navigation vs free-hand. Note the guide system (Nobel NobelGuide, Straumann coDiagnostiX, Blue Sky Bio, X-Guide dynamic navigation, Yomi robotic, etc.), key sleeve diameter, and any deviation from planned position. Free-hand placement after extraction-driven anatomy change is documented with rationale.
• Drill sequence per implant — sequential drills (pilot → intermediate → final) and confirmation that the sequence followed the manufacturer's IFU for the specific implant system. With copious sterile saline irrigation.
• Bone graft / biologic / membrane — when grafting buccal-plate gaps or extraction sockets concurrently (D6104), document material (autograft, allograft brand, xenograft brand, alloplast brand), volume in cc, lot number, membrane type if used (resorbable collagen, PTFE), and fixation. Write "none placed" explicitly when not grafting.
• Immediate-load decision and primary-stability summary — explicit calculation: minimum, mean, and median insertion torque across all implants. Most AOX protocols require ≥35 Ncm on a minimum number of implants (typically all 4 in All-on-4, or at least 4 of 6 in All-on-6) to justify immediate provisional loading. When primary stability is inadequate, the chart documents the decision to bury the implants and place a removable interim prosthesis instead — a delayed-load conversion. This decision is the single most important medico-legal pivot of the AOX visit.
• Provisional prosthesis details — material (PMMA milled, 3D-printed nano-ceramic, monolithic zirconia interim, denture-tooth-and-acrylic conversion), prefab vs same-day milled / printed, screw-retained on MUAs, occlusion (group function vs canine guidance, bilateral simultaneous contact, no anterior guidance during integration, no protrusive / lateral excursive contacts), cantilever length (typically limited to 1.5x AP spread; document the actual cantilever distalmost MUA to distalmost prosthetic tooth), hygiene access (intaglio surface convex and accessible to a Waterpik / superfloss; no concave traps), and occlusal screw-access channels sealed with PTFE tape and temporary composite.
• Anesthesia and sedation — local anesthetic agent, concentration, technique, total carpules. Sedation type (D9230 nitrous, D9239 / D9243 IV moderate, D9222 / D9223 deep, etc.) cross-referenced to the sedation record.
• Informed consent (PARQ) — Procedure, Alternatives, Risks, and Questions. AOX consent must specifically include: failure of immediate load requiring conversion to removable interim, single or multiple implant failure (cumulative AOX implant survival is high but per-implant failure does occur, especially in posterior tilted sites), prosthetic complications (screw loosening, prosthesis fracture in PMMA provisional, acrylic-tooth fracture), nerve injury (mental nerve / IAN paresthesia for mandibular cases — quantified per AAOMS), maxillary sinus communication / sinusitis for maxillary cases, infection / peri-implantitis, need for additional procedures (graft revision, implant replacement), bone or fixture fracture during placement, MRONJ in antiresorptive users, smile-line and lip-support outcome limitations, phonetic adaptation to a hybrid prosthesis (S, F, V sounds), need for prosthesis remake at definitive phase (typically 4-6 months later — final hybrid in zirconia, titanium-acrylic, or PFM), and the option to decline AOX in favor of conventional removable complete denture, segmental implant-supported overdenture, or no treatment. Signed written consent is the AOX standard.
• Procedure narrative — sequential, time-stamped where possible: time-out and surgical-pause checklist, extraction sequence, alveoloplasty execution, surgical-guide seating (or guide-pin reference markers if guide is removed for flap access), implant-by-implant osteotomy and placement with torque values, MUA placement and torque, soft-tissue management around MUAs (any tissue trim or apically positioned flap), impression / scan for the provisional, provisional try-in, occlusal adjustment, screw-access seal, and final post-op imaging.
• Pre-op and post-op imaging — pre-op CBCT findings recorded above; post-op pano (D0330) or post-op CBCT confirming all implants in planned position, no encroachment on vital structures, and provisional fully seated on MUAs without gaps.
• Definitive restoration plan and timeline — typical AOX timeline: provisional in place ~4-6 months for osseointegration → soft-tissue maturation → definitive impressions → definitive hybrid (zirconia full-arch monolithic, titanium-bar acrylic with denture teeth, or zirconia / PFM hybrid). Document the planned definitive material and the planned timeline.
• Complications — per-implant any failures of primary stability, perforations, fractures, sinus communications; arch-level any flap-management issues, intraoperative hypertensive episodes, sedation-recovery delays. Write "none" explicitly when no complications.
• Post-op instructions and prescriptions — soft / liquid diet 7-14 days; no chewing directly on the prosthesis for 8-12 weeks (the immediate-load provisional is for esthetics and phonetics, not function); ice protocol; head elevation while sleeping; chlorhexidine 0.12% rinse 2x/day starting 24 hrs post-op for 2-4 weeks; no smoking; suture management instructions; emergency contact protocol. Antibiotics: amoxicillin 500 mg TID x 7 days standard; clindamycin or azithromycin for PCN allergy; some protocols extend to 10 days for AOX given the surgical magnitude. Analgesic guidance NSAID-first (ibuprofen 600 mg q6h scheduled x 48 hrs then PRN); short-course opioid is occasionally used given AOX surgical magnitude — when prescribed, document indication and PDMP check.
• Patient tolerance, sedation recovery, and dismissal — Aldrete or modified Aldrete score on dismissal if sedation used; ride-home documentation; written / verbal post-op instructions reviewed with patient and accompanying adult; emergency-contact provided.
• Provider signatures — surgeon, sedation provider (if separate), restorative dentist (if co-treating), and any auxiliary operator initials.

The "amnesia test" applies hardest to AOX: a third party reading the chart — and any auditor — must be able to reconstruct why the case was indicated, which teeth were extracted, how much ridge was reduced, which implants (brand / lot / size) went where with what torque, which MUAs were used at what angles and torques, why immediate loading was justified by the primary-stability data, what the provisional looks like and how the occlusion is set, and what the definitive restorative timeline is. Generic "AOX placed, sutured, provisional delivered" without per-implant traceability is the single biggest audit risk on this workflow.

Common denial reasons

The most common reasons AOX component codes are denied, downgraded, or recouped:

• No pre-authorization on file for the AOX plan — by far the most common denial. AOX is universally pre-auth-default. The pre-auth must enumerate every component code (extractions, alveoloplasty, each D6010, D6190 if used, D6104 if grafting, D6118 / D6119 for the interim prosthesis, sedation) — not just "AOX" or a case-fee summary.
• Missing-tooth clause denial for the arch — the carrier finds the arch was already partially or fully edentulous when the patient's current plan started, and the policy excludes pre-existing missing teeth. Remedy: extraction-history narrative for every tooth in the arch and any prior coverage history.
• No implant benefit on the plan — the plan pays only an alternate benefit equal to a complete denture. The patient and front desk should know this before the case is scheduled.
• Insufficient per-implant documentation — chart silent on brand / size / lot / torque for one or more implants. AOX cases have 4-6 implants and every implant must have a complete record. A single missing lot number can trigger a chart-pull on the whole case.
• No CBCT or radiographic support submitted — AOX pre-auth and claim require CBCT showing bone volume at every planned implant position. Pano + PA is generally inadequate for AOX pre-auth review.
• Inadequate informed-consent documentation — chart silent on alternatives (conventional denture, segmental overdenture, no treatment), risks specific to AOX (immediate-load failure, prosthetic complications, phonetic adaptation), and the patient's choice. Generic implant-consent language is increasingly cited as inadequate for AOX given the case magnitude.
• Same-arch prior AOX components in claim history — frequency violation. The carrier's history shows prior D6010s, D7310, or D6118 / D6119 at the same arch within plan lookback, so new AOX components are denied as duplicative without a removal-and-replacement narrative.
• Active periodontitis or uncontrolled medical condition documented — auditors flag full-arch implant placement performed in the presence of documented active perio in the contralateral arch, uncontrolled diabetes (recent A1C above plan or guideline thresholds), or active osteomyelitis as deviating from accepted practice.
• Bone-graft codes billed but rejected as bundled — D6104 billed concurrently with D6010s and denied as inclusive on specific plans. Verify at pre-auth.
• Tooth numbers / quadrants missing on extraction lines — every D7140 / D7210 line needs the specific tooth number; every D7310 / D7320 needs the specific quadrant.
• Mismatch between the AOX plan and a previously paid bridge or partial — the carrier's history shows the same span was previously restored under coverage; AOX is denied for redundancy without narrative establishing prior prosthesis failure.
• Default-normal templating across multiple AOX cases — every AOX chart in the practice reads identically with the same brand, the same torques, the same MUA angles. Auditors flag pattern-matched templates as evidence of fabricated documentation. Vary the chart with the actual case data.
• Inadequate immediate-load justification — chart fails to document the cumulative primary-stability data justifying same-day provisionalization. Auditors reviewing AOX cases specifically look for the per-implant torque table and the immediate-load decision rationale.
• Smoker without documented cessation counseling — some plans assess increased liability or deny coverage outright on tobacco-using patients for full-arch surgery.
• Sedation record missing or inadequate — when D9243 or other sedation codes are billed, the sedation record must be a separately documented entry with vitals at intervals, drug log, and recovery / dismissal data. Missing sedation records trigger denials of the sedation code and sometimes recoupment of the surgical components.

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