Oral and Maxillofacial Surgery Consult & Procedure

Date: 

‍

HPI: 

presents for evaluation of non-restorable ___ and exostoses and tori requiring reduction for prosthetic rehabilitation. 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. Mandibular posterior buccal exostoes and lingual tori bilaterally. Non-restorable and carious ___.

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 carious ____.

‍

Assessment/ Plan:

__  with non-restorable and carious __  and mandibular bilateral buccal exostoses and lingual tori

Plan:

- Recommend extraction of carious dentition and bl alveoplasties in preparation of prosthetic rehabilitation.. Discussed option of just extraction without alveoplasty but will likely result in tissue irritation and poor retention of future prosthetic. 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, alveolar osteitis, jaw fracture,  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 carious dentition and biateal mandibular alveoplasty

‍

Procedure Note

‍

Pre-operative Diagnosis:

Carious ___

Bilateral mandibular buccal exostoses and bilateal lingual tori

‍

Post-operative Diagnosis:

same as above

‍

Procedure Performed:

Extraction of #___

Bilateral mandibulr alveoplasties

‍

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 IAN, lingual nerve blocks, and local infiltaration. Adequate anesthesia confirmed.

A 15 blade was used to make a mid-crestal incision from the posterior mandibular ridges bilaterally with distobuccal releasing incisions being mindful of the location of the mental nerve. A sulcular incision was made where teeth were present. A #9 periostea elevator was used to develop a full thickness mucoperiosteal flap exposing the buccal and lingual of the alveolar ridge and being mindful of the local of the mental nerve.

Elevators and forceps were used to extract carious ____. After the extractions were completed a rongeur was used to remove prominent exostoses and remove sharp bony contours. A pineapple bur under copious irrigation was used to smooth the alveolar ridge and remove any prominent buccal exostoses or lingual tori. A bone file was then used to smooth any remaining sharp bony contours. The surgical site was copiously irrigated with normal saline irrigation. The ridge was noted to be smooth to palpation with no shap bony contours or prominences.

The surgical site was closed in a tension-free fashion with 3-0 chromic gut in a continuous fashion. 3-0 Chromic gut single interrupted sutures were used to reinforce the closure.

‍

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

‍

‍