Removal of impacted tooth - partially boney
Removal of impacted tooth - Partially boney
PMH, Meds, and Allergies reviewed.
Risks and benefits of procedure reviewed.
Patient accepts risks.
Consent read, signed, and understood.
Patient was prepped and draped in a normal oral surgical manner. Monitors (EKG, Pulse Oximeter, Pretracheal Stethoscope, and Blood Pressure) were placed on the patient.
An IV of D5W / D5W ½ NS / LR was started in the patient's Right / Left arm / hand. Supplemental Oxygen 6L/min via nasal hood was administered.
The patient was then given ___mg Versed ____mg Fentanyl _____mg Propofol ____mg Ketamine IV _____mg Brevital IV
Attention was turned to tooth / teeth number / numbers ____.
_____ Carpules of Xylocaine 2% with 1:100,000 Epi. / Carbocaine 3% plain / Marcaine 0.5% with 1:200,000 Epi. was / were used to anesthetize the Right / Left PSA MSA IAN Long Buccal, Lingual, Greater Palatine Nasopalatine Nerve / Nerves. After adequate anesthesia was obtained a full thickness mucoperisteal envelop / disto-buccal releasing / hockey stick incision was developed. A Hall drill with adequate irrigation was used to remove bone superior / buccal / distal to the tooth crown. The crown and tooth roots were sectioned and removed. All remaining tooth follicle and debris were curetted free of the extraction site, the bone edges were smoothed with a bone file, and the wound was irrigated with normal saline. All irrigant and debris were suctioned free of the wound site. The flap was replaced in its normal anatomic position and held in place with ___ (3-0) chromic sutures. A hemostatic pack was placed over the extraction site.
There were no intraoperative complications and the patient tolerated the procedure well. Good hemostasis was obtained and the patient was transferred to the recovery room in stable condition. After an appropriate recovery time the patient was evaluated and discharged home with their escort. Prior to discharge, the patient and patient's escort were given verbal and written post-operative instructions.
Follow-up 1 / 2 weeks for post-op check.
Prescriptions: None Tylenol #3 (# ) Vicodin 500/5 # Percocet # Pen VK 500mg 1PO q6h x 7 days Clindamycin 300mg 1PO q6h x 7 days.