Apicoectomy/Root-End Surgery Procedure Note

Date of Service: [Date]

Location: [Clinic/Facility name and address]

Operator: [Name, credentials]

Assistant(s): [Name(s) and role(s)] (Omit if not applicable)

Tooth/Teeth Treated: [Tooth number(s) and specific root(s) treated] (Required field—flag as INCOMPLETE if not documented)

Procedure(s) Performed: [Plain-language procedure description]

Pre-Procedure Assessment

[Indication for surgery linked to symptoms and/or evidence of persistent periapical disease] [Pre-operative endodontic diagnosis: pulpal status and periradicular status] [Pertinent medical history: allergies, anticoagulant/antiplatelet use, bisphosphonates, relevant systemic risk factors] [Imaging reviewed: PA and/or CBCT with key anatomic risks noted] (Include patient's own words for symptom description when provided. If a separate pre-op H&P exists, include a brief interval update and reference rather than duplicating.)

Informed Consent and Time-Out

[Consent process documented: diagnosis, nature of procedure, material risks, prognosis, and alternatives discussed including nonsurgical retreatment, extraction, and no treatment; patient questions addressed; written consent confirmed]

[Time-out verification: patient identity confirmed, tooth number/site confirmed, procedure and anesthesia plan confirmed, special precautions noted]

Anesthesia

[Local anesthetic agent(s), concentration, vasoconstrictor] [Total volume] [Injection type(s) and site(s)] [Adverse reaction: none / describe]

[Sedation/anxiolysis: intended level, route, monitoring performed, reference to anesthesia record] (Include only if sedation was used; omit entirely for local anesthesia only)

Procedure

(Document all subsections. If a step was not performed, state "not performed" with rationale. Do not infer specific details—prompt for clarification if not dictated.)

Flap Design and Reflection

[Flap type/design] [Incision location] [Full-thickness mucoperiosteal reflection confirmed] [Complications or need to extend: none / describe]

Osteotomy

[Method/instrumentation] [Osteotomy size in mm] [Irrigation used] [Management of nearby anatomic structures]

Root-End Management

[Apex identification method] [Periapical curettage performed: yes / no] [Description of periapical tissue removed] [Sinus membrane exposure or nerve proximity issues: none / describe]

Root-End Resection

[Length resected in mm] [Bevel angle if measured] [Instrument used] [Root-end surface inspection findings: cracks, isthmus, additional portals of exit]

Root-End Preparation

[Technique] [Preparation depth in mm] [Isthmus management] [Irrigation used]

Retrograde Filling

[Material used] [Placement technique] [Verification method] (If root repair/perforation repair performed, specify defect type and location. If retrofill deferred, document reason.)

Hemostasis

[Approach used] [Adequacy prior to retrofill placement: adequate / describe management]

Regenerative Adjuncts

[Bone graft type and amount] [Membrane type and fixation] [Indication] (Include only if regenerative adjuncts were used; omit entire subsection otherwise)

Closure

[Surgical site irrigation solution] [Flap repositioning and tension status] [Passive primary closure achieved: yes / no] [Suture type, size, technique, number] [Periodontal dressing: none / type used]

Specimen

[Specimen type] [Source/site] [Fixative used] [Clinical history provided to pathology] (Include only if tissue submitted for pathology. If periapical tissue obtained but not submitted, document rationale here instead.)

Findings

• [Root-end anatomy findings: isthmus, multiple portals of exit, calcification]
• [Evidence of fracture/crack: present / absent / indeterminate]
• [Lesion characterization]
• [Anatomic structure considerations]

(Document "no unexpected findings" if applicable)

Complications and Blood Loss

EBL: [Estimated blood loss]

Complications: [None / describe with management]

Deviations from Planned Procedure: [None / describe with rationale]

Post-Operative Care

Patient Condition: [Tolerance of procedure, immediate status, discharge disposition]

Medications Prescribed:

• [Drug name, strength, dose, route, frequency, duration, quantity, indication]

(Add additional medications as separate items)

Post-Op Instructions: [Written and verbal instructions confirmed] [Key instructions given: bleeding control, swelling management, diet, oral hygiene, activity limits, smoking avoidance, red flags, emergency contact] [Special instructions if applicable]

Follow-Up Plan: [Suture removal timing] [Post-op check timing] [Radiographic follow-up plan] [Communication plan with referring dentist]

Post-Op Imaging: [Post-op PA obtained: yes / no—if no, document reason]