Third Molar Extraction Operative Note

Date: [Date]

Start/End Time: [Start time] – [End time]

Location: [Procedure location]

Surgeon: [Surgeon name, credentials]

Assistant(s): [Assistant names and roles]

Anesthesia Provider: [Name, credentials] (Include only if sedation or general anesthesia provided; otherwise omit this line.)

Pre-Operative Diagnosis and Indication

[Diagnosis with tooth numbers using Universal Numbering System] (Include specific indication such as impaction, pericoronitis, caries, orthodontic requirement, or periodontal defect. If imaging was reviewed—panoramic, periapical, CBCT—summarize key findings affecting surgical approach, such as inferior alveolar nerve proximity for mandibular teeth or sinus relationship for maxillary teeth.)

Informed Consent and Time-Out

[Informed consent discussion] (Document that risks, benefits, and alternatives were discussed. For third molars, include material risks discussed: bleeding, infection, dry socket, damage to adjacent teeth, inferior alveolar and lingual nerve injury for mandibular teeth, oroantral communication for maxillary teeth, retained root fragments, and medication-related risks. Note that patient questions were answered and consent obtained.)

[Time-out confirmation] (Document that a time-out was performed immediately prior to procedure confirming correct patient, correct teeth, and correct imaging available. If time-out was not performed, document the reason.)

Anesthesia

Type: [local only / local with nitrous oxide sedation / IV sedation / general anesthesia]

Local anesthetic: [Agent(s), concentration, vasoconstrictor, and volume] (e.g., articaine 4% with epinephrine 1:100,000, 3.4 mL)

Blocks/infiltrations: [Techniques used] (e.g., inferior alveolar nerve block, long buccal, posterior superior alveolar; include only if specified.)

(If sedation or general anesthesia used, reference anesthesia record: "See anesthesia record for monitoring and medication details.")

Procedure Performed

Teeth extracted: [Tooth numbers using Universal Numbering System]

Planned but not extracted: [Tooth numbers and reason] (Include only if applicable; otherwise omit this line.)

Operative Technique

(Repeat the following subsection for each extracted tooth. Maintain tooth-specific organization; do not merge findings across teeth.)

Tooth #[number] ([maxillary / mandibular] [right / left])

• Pre-extraction status: [erupted / soft tissue impacted / partial bony impacted / complete bony impacted]
• Flap and incision: [Incision design and flap type] (Include only if a flap was raised; specify design such as envelope, triangular, or distal wedge.)
• Ostectomy: [Location and method] (Include only if bone removal performed.)
• Tooth sectioning: [What was sectioned and rationale] (Include only if performed.)
• Tooth delivery: [Delivery method and any notable difficulty]
• Socket management: [Curettage, irrigation, hemostatic agents, grafting materials] (List measures performed.)
• Nerve considerations: [IAN canal visualization and protective measures] (For mandibular teeth only; include only if nerve canal was visualized or exposed. Do not state nerve was intact unless specifically assessed.)
• Sinus considerations: [Oroantral communication status and management] (For maxillary teeth only; if communication occurred or suspected, describe management and confirm sinus precautions provided.)
• Closure: [Suture material, size, and technique] (If socket intentionally left open, document rationale.)
• Retained root tip: [Reason for retention, estimated size, location, patient informed, follow-up plan] (Include only if a root tip was intentionally retained.)
• Coronectomy: [Decision rationale] (Include only if extraction was converted to coronectomy.)

Estimated Blood Loss

[Estimated blood loss in mL or "minimal"]

Specimens

[Specimens submitted with source and destination] (State "None" if no specimens submitted.)

Complications

[Complications and management] (Must be explicitly addressed. State "None" only if clinician confirms no complications occurred. Do not auto-populate.)

Post-Procedure Condition

[Patient tolerance and condition at completion] (If sedation or general anesthesia was used, document that discharge criteria were met and responsible escort was present.)

Discharge Medications

• Pain management: [NSAID and/or acetaminophen with dose, directions, quantity] (First-line unless contraindicated.)
• Opioid: [Medication, dose, directions, quantity, justification, risk counseling documented] (Include only if prescribed.)
• Antibiotic: [Medication, dose, directions, quantity, indication] (Include only if prescribed; document rationale such as active infection or specific prophylaxis indication.)
• Other: [Medication, dose, directions, quantity, indication] (Include chlorhexidine rinse, steroid, antiemetic, etc., only if prescribed.)

(If no medications prescribed, state "No medications prescribed.")

Post-Operative Instructions

[Written and verbal instructions provided] (Note patient-specific instructions beyond standard care: sinus precautions if maxillary extraction with suspected communication, modified bleeding precautions if on anticoagulation, return precautions for uncontrolled bleeding, fever, worsening swelling, difficulty breathing or swallowing, or persistent numbness.)

Follow-Up

[Planned follow-up timing and specific return triggers]