Oral and Maxillofacial Surgery Consult & Procedure
05/08/25
HPI:
presents for evaluation of impacted/malpositioned #1,16,17,32. Referred by general dentist. NPO>8 hours.
PMH: Denies
PSH: Denies. Denies difficulty with anesthesia
Meds: Denies
Allergies: NKDA
SH: Denies
FH: Denies family history of bleeding or anesthesia problems
ROS: good exercise tolerance, no chest pain, shortness of breath, coughing, wheezing, or palpitations
Physical Examination
Vitals WNL
Gen: NAD
Head: NC AT
Eyes: EOMI b, sclera white
Ears: normal external appearance
Nose: nares patent
Throat: normal oropharyngeal tone, tonsillar pillars symmetric, Mallampati
Mouth: MIO 40mm. No intraoral mucosal lesions. impacted/malpositioned#1,16,17,32
Neck: neck supple, >6cm thyromental distance. Normal cervical range of motion.
Cardiac: RRR
Resp: non-labored breathing on room air, CTAB
Extremities: moves all extremities, warm and well-perfused
Body Habitus: wnl
Imaging:
Panoramic radiograph with impacted/malpositioned#1,16,17,32. Remaining exam grossly within normal limits.
Assessment/ Plan:
with impacted/malpositioned#1,16,17,32
Plan:
- Recommend extraction. Discussed option of retaining teeth with periodic monitoring. Using radiograph as a visual aid, I reviewed the risks of removal including but not limited to pain, swelling, bleeding, infection, temporary/permanent neurosensory deficit of lower lip/chin/teeth/gums/tongue including dysesthesia, retained root tips, damage to adjacent teeth, oroantral communication/fistula, alveolar osteitis, jaw fracture, periodontal defect, TM pain/trismus, need for additional procedures. Usual recuperation discussed, as well. Anesthesia options reviewed including local anesthesia alone or with either nitrous oxide or IV sedation. Reviewed risks of sedation including but not limited to recall, PONV, respiratory or cardiovascular compromise, allergic reactions, need for additional interventions. All questions answered.
- Shared decision to proceed with extraction of #1,16,17,32 under local anesthesia & IV sedation
Procedure Note
Pre-operative Diagnosis:
impacted/malpositioned#1,16,17,32
Post-operative Diagnosis:
same as above
Procedure Performed:
Extraction of #1,16,17,32
Anesthesia:
Local anesthesia & IV Sedation
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. Pre procedure vitals noted to be within a safe range. A surgical timeout was performed with patient participation in order to confirm patient, procedure, and laterality.
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.
4% septocaine w/ 1:100k epi x 4 carpules administered via local infiltration and 2% Lido w/ 1:100k epi x 4 carpules administered via bilateral PSA, IAN, lingual nerve blocks. 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 fissure bur in surgical handpiece. The tooth was then sectioned and removed with elevators and forceps. The site was copiously irrigated with normal saline and flap was reapproximated. Collagen plugs placed into all extraction sites. Bilateral gauze packs placed, hemostasis noted.
Complications: None
Blood Loss: Minimal
Monitored recovery without incident. Vital signs and mental status at baseline
Patient discharged in stable condition with verbal & written postoperative instructions.
Rx:
Amoxicillin, percocet, ibuprofen
Return to Clinic:
1 week for post-op eval if needed
