HTML Preview Dental Operative Report page number 1.
Operative Report Sample
Patient Name: Jane Doe
Date: 3.18.05
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 4x4 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. 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
3.18.05