Yes! Oral Surgery Requires An Operative Report

Note Blocked font must be listed into the Report!

Operative Report Sample Patient Name: Jane Doe Date: 3.18.20

Indications: The patient presented with pain and mobility in the maxillary right quadrant. She had a history of periodontal disease and has been undergoing maintenance therapy. Tooth #4 has recently become more mobile and has been declared unrestorable by the periodontist.

Preoperative diagnosis: Advanced adult periodontitis

Postoperative diagnosis: Same

Anesthesia/Sedation: Local with IV conscious sedation

Procedure in Detail: The patient was taken to the operatory and placed supine in the dental chair. Vital sign monitors were placed consisting of an EKG, blood pressure monitor, pulse oximeter and capnograph. An IV line was established in dorsum of the right hand. A D5W drip was started. Versed was given by slow titration until conscious sedation was achieved. A betadine prep was done of the facial skin, and the oral cavity.

The surgical team was then scrubbed and gloved and a sterile drape was placed across the patient. Local anesthesia was administered by infiltration, slowly and with good aspiration. Following adequate local anesthesia, a full thickness incision was made in the sulcus of tooth #4 and a full thickness flap was elevated. The tooth was removed with luxation with a 301 elevatore and removal with a #150 forcep. Sharp curettage was used to remove all soft tissue remnants in the socket. Using the implant kit, a 4.3 x 13 mm osteotomy was created in the apex of the socket, extending 2.0 mm beyond the socket apex. A 4.3 mm x 13 mm endosseous implant was placed and found to be stable. A digital radiograph indicated that the implant was in good position relative to the maxillary sinus floor. Mineralized allograft bone was hydrated with sterile saline and was applied to the gap between the socket walls and the implant and then a dense PTFE membrane was placed over the socket, extending 3 mm beyond the socket margins on the palatal and facial. The soft tissue was secured in its native position with PTFE suture x 2. Good hemostasis was achieved. Sterile 4×4 gauze packs were uses throughout the procedure to protect the airway. The patient was allowed to recover spontaneously in the operatory.

Postoperative instructions were reviewed with the patient and their caregiver, and then given to them in writing. They both voiced their understanding & signed home care form. They were was instructed to call with any questions or problems that might arise. Postoperative medications were discussed.

Complications: none EBL: less than 10 cc Plan: Return to the clinic in one week for suture removal and postoperative evaluation.

______________ John Doe, DDS 3.18.20

Leave a Reply