Bone Grafting/Sinus Lift Operative Note

Date of Procedure: [Procedure date]

Patient Name: [Patient full name]

Patient ID/DOB: [Medical record number and/or date of birth]

Surgeon: [Primary surgeon name and credentials]

Assistant(s): [Assistant names and roles] (Omit if none)

Location/Setting: [Facility name and operating room or suite identifier]

Procedure Summary

Preoperative Diagnosis: [Clinical diagnosis prompting augmentation]

Postoperative Diagnosis: [Updated diagnosis if changed intraoperatively / Same as preoperative]

Procedure(s) Performed:

• [Procedure with laterality and site] (List each procedure on a separate line)
• [Autogenous bone harvest with donor site] (Only include if performed)

Indication: [Reason for augmentation] (1–2 sentences)

Anesthesia: [Local / IV sedation / General] [Anesthesia provider if applicable]

Estimated Blood Loss: [mL / Minimal]

Implants/Devices/Materials: [High-level list of grafts, membranes, fixation hardware, and implants placed] (Detailed specifications documented under Operative Details)

Complications: [None / Brief description of intraoperative events]

Preoperative Context

• Edentulous sites and implant plan: [Sites by numbering system; staged vs simultaneous implant placement]
• Imaging reviewed: [Modality and date] – [Key measurements: residual ridge height and width in mm at planned sites]
• Sinus anatomy: [Septa location; membrane thickness if assessed; pathology such as mucosal thickening or retention cyst] (Only include for sinus procedures)
• Pertinent risk factors: [Relevant factors present, e.g., smoking status, prior grafts, bisphosphonate exposure, glycemic control] (Omit if none present)
• Consent and time-out: Informed consent obtained; surgical time-out performed.

Operative Details

(Document with specific measurements in mm for dimensions and mL/cc for volumes. Omit subsections that do not apply.)

Anesthesia and Preparation

[Patient position]. [Local anesthetic agent, concentration, vasoconstrictor, total volume, and injection sites]. [Reference to anesthesia record if IV sedation or general anesthesia used].

Surgical Approach

[Incision design: crestal, sulcular, vertical releases]. [Flap elevation: full-thickness / partial-thickness; extent of exposure]. [Periosteal release or scoring if performed for tension-free closure]. [Baseline defect characteristics: location, type (horizontal / vertical / combined), and dimensions in mm].

Sinus Augmentation

(Only include if a sinus lift was performed)

Approach: [Lateral window / Transcrestal], [Left / Right / Bilateral].

Lateral window details: [Osteotomy method], [Window location relative to sinus floor], [Schneiderian membrane elevation technique]. Membrane integrity: [Intact / Perforated]. [Management of septa or intraoperative bleeding if encountered]. (Only include if lateral approach used)

Membrane perforation management: [Location and size in mm], [Repair method, e.g., collagen membrane, PRF], [Modification to grafting if any]. (Only include if perforation occurred)

Transcrestal details: [Osteotomy preparation and sinus floor elevation technique], [Elevation depth and bone gain in mm], [Membrane integrity and management]. (Only include if transcrestal approach used)

Ridge Augmentation/GBR

(Only include if performed)

Technique: [Particulate GBR with membrane / Titanium mesh / Tenting screws / Block graft / Ridge split].

Recipient site preparation: [Surface preparation and decortication if performed]. [Space maintenance method]. [Fixation: number and location of screws, tacks, or pins].

Graft Materials

• [Material type (autograft / allograft / xenograft / alloplast)], [Form (particulate / block / putty)], [Volume in mL or cc], [Mixing ratio if combined], [Additives if used: PRF / PRP / growth factors / antibiotics]
• [Autogenous harvest site and technique, e.g., mandibular ramus, chin, trephine cores] (Only include if autograft harvested)

(Reference implant/graft log for manufacturer details and lot numbers)

Barrier Membrane

[Membrane type: resorbable collagen / PTFE / Titanium-reinforced]. [Configuration: single-layer / double-layer]. [Fixation method: tacks / screws / sutures]. [Planned removal timeline for non-resorbable membranes].

Simultaneous Implants

(Only include if implants were placed)

• [Site designation]: [Implant system], [Diameter × length], [Insertion torque in Ncm and/or ISQ], [Healing protocol: submerged with cover screw / healing abutment], [Osteotomy modifications if relevant]

Closure

[Irrigation and hemostasis]. [Primary tension-free closure: achieved / not achieved]. [Suture material, size, and technique, e.g., 4-0 PTFE horizontal mattress and interrupted sutures].

Complications

[No intraoperative complications] (If none occurred)

[Description of complication: event, severity, immediate management, procedure modifications, and patient condition at case completion. Summarize membrane perforation details here if occurred.] (If complications occurred)

Postoperative Plan

Condition and Disposition: [Patient condition at end of procedure]; [Disposition: discharged home / to recovery].

Medications:

• [Antibiotic: drug, dose, frequency, duration]
• [Analgesic: drug, dose, frequency, duration]
• [Antimicrobial rinse: agent, frequency, duration]
• [Nasal medications: agent, dose, frequency, duration] (Only include for sinus procedures if prescribed)

Sinus Precautions: [No nose blowing × duration], [Sneeze with mouth open], [Avoid straws and forceful spitting], [Avoid heavy lifting/straining], [No flying/diving × duration], [Smoking cessation counseling]. (Only include for sinus procedures)

Graft Protection: [Diet restrictions], [Oral hygiene instructions for surgical site], [Removable prosthesis guidance: timing for reinsertion and adjustment to avoid graft pressure]. (Include for ridge augmentation/GBR)

Return Precautions: Persistent bleeding, purulent drainage, fever, increasing pain or swelling, or signs of infection.

Follow-up: [Follow-up interval for suture removal] and [Anticipated timing for re-entry or staged implant placement if applicable].