Clinic Note

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Third Molar Extraction Procedure Note:

Pre-operative Diagnosis:

impacted #1, #16, #17 and #32

Post-operative Diagnosis:

same as above

Procedure Performed:

EXT of impacted #1, #16, #17 and #32.

Anesthesia:

IV General Anesthesia

Procedure in Detail:

Consent reviewed after discussing benefits/risks/alternatives with patient and/or family member and inviting all questions. H&P and imaging reviewed, NPO/escort verified. All appropriate monitors were placed and working properly. IV started with 22 ga catheter. Sedative medications were then administered and titrated to effect per anesthesia record.

2% Lido w/ 1:100k epi x 6 carpules administered. Adequate anesthesia confirmed.

Attention directed at tooth #1, where a sulcular incision with a distobuccal release was made, followed by subperiosteal reflection. The tooth was then extracted using elevators without complication, site was irrigated with normal saline.

Attention was then directed at tooth #32, where a sulcular incision with a distobuccal release was made, followed by subperiosteal reflection and removal of buccal bone using a fissure bur in surgical handpiece. The tooth was then sectioned and removed with elevators and forceps. Site was irrigated with normal saline and flap was reapproximated.

Attention was then directed at tooth #16, where a sulcular incision with a distobuccal release was made, followed by subperiosteal reflection. The tooth was then extracted using elevators without complication, site was irrigated with normal saline.

Attention was then directed at tooth #17, where a sulcular incision with a distobuccal release was made, followed by subperiosteal reflection and removal of buccal bone using round bur in surgical handpiece. The tooth was then sectioned using a round bur and removed with elevators and forceps, site was copiously irrigated with normal saline and flap was reapproximated. Bilateral gauze packs placed, hemostasis noted.

Complications: None

Blood Loss: 10mL

Recovery for over 30min without incident

Vital signs at baseline

Mental status at baseline

Patient discharged with escort who accepts responsibility for patient

Written and verbal post op instructions given to patient and escort

RTC:  1 week for post-op eval if needed

Rx: amoxicillin, Norco, ibuprofen, Zofran prn, medrol dose pack

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OR Note

Surgeon(s): ***

‍Assistant Surgeon(s):  ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts:  Correct x2

‍Indications: ​***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

Local anesthesia was administered using [Name and dosage of local anesthetic agent] with vasoconstrictor at the surgical sites to provide profound anesthesia and hemostasis. Incision: Anesthetic infiltration was followed by a crevicular incision and mucoperiosteal flap reflection to expose the impacted third molars and surrounding bone. Bone Removal: Utilizing a surgical handpiece and appropriate burs, bone removal was performed to gain access to the impacted teeth and facilitate their extraction. The tooth was sectioned using a high speed handpiece and with the aid of elevators and extraction forceps, the impacted third molars were carefully luxated and extracted from their respective sockets. Socket Inspection: Following tooth removal, thorough irrigation with sterile saline was performed to clean the extraction sockets, and the sites were inspected for any remaining bony irregularities or fragments. Hemostasis and Closure: Hemostasis was achieved using gentle pressure and the application of hemostatic agents as necessary. The mucoperiosteal flaps were repositioned and approximated using resorbable sutures.

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

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