Implant Procedure Note:

Pre-operative Diagnosis:

Missing #***

Post-operative Diagnosis:

Missing #***

Procedure Performed:

Endosteal implant placement at site #***

Anesthesia:

IV Sedation

Procedure in Detail:

Patient presents today for implant placement at site #***.  Consent obtained after discussing benefits/risks/alternatives with patient and inviting all questions. Written and verbal post op instructions given to patient and escort prior to procedure. H&P and imaging reviewed, NPO/escort verified. IV started in R arm antecubital fossa with 22 ga catheter.  All appropriate monitors were placed and working properly. Sedative medications were then administered and titrated to effect.

2% Lido w/ 1:100k epi x *** carpules delivered via infiltration. Adequate anesthesia confirmed. A papilla-sparing incision was designed and a full thickness mucoperiosteal flap was developed and reflected buccally.  A round bur was used at the site of the proposed osteotomy site. The recommended osteotomy sequence was completed for soft bone according to the manufacturer’s recommendations using copious chilled saline irrigation throughout. A Zimmer 4.7mm x 10mm TSV implant was placed in the osteotomy site with excellent primary stability. A cover screw was placed on the implant. The flap was then repositioned and sutured with interrupted 3-0 chromic gut suture.

Thickness of gingival tissue over implant site: 2mm

Implant

Date placed:

Make and size:

Ref#

Lot #

Complications: None

Blood Loss:

5mL

IV Fluids:

500mL

Total meds administered:

Ancef 2g

Decadron 8mg

Toradol 30mg

Zofran 4mg

Versed 5mg

Fentanyl 50mcg

Propofol 60mg

Ketamine none

2% lidocaine with 1:100,000 epinephrine x 6 carpules

0.5% marcaine with 1:200,000 epinephrine x 2 carpules

See anesthesia record for details.

Recovery for over 30min without incident

Vital signs at baseline

Mental status at baseline

Patient discharged with escort who accepts responsibility for patient

RTC:  1 week for post-op eval

Rx: amoxicillin 500mg tid x 10 days, hydrocodone-acetaminophen 7.5-325mg 1 tab q4h prn pain, Zofran 4mg ODT prn nausea and Medrol dose pack

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