OT notes · OMFS

Surgical removal of impacted mandibular third molar

Usual anaesthesia
Local anaesthesia (inferior alveolar nerve block with buccal infiltration); GA only when surgery under LA is not possible
Position
Semi-reclined in the dental chair, or supine with head turned if under GA
Setting
elective

Operative note template for surgical removal of an impacted lower third molar, with a filled example for a mesioangular 48 removed under local anaesthesia for recurrent pericoronitis.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • numbness or tingling of the lower lip and chin (inferior alveolar nerve), temporary or permanent
  • numbness or altered taste of the tongue (lingual nerve), temporary or permanent
  • dry socket (alveolar osteitis)
  • pain, swelling and limited mouth opening for a few days
  • bleeding
  • infection
  • damage to the adjacent second molar or its filling
  • part of the root left behind, or coronectomy as a planned alternative when the root is close to the nerve

Pre-operative details for this operation

  1. Tooth3848
  2. Indicatione.g. recurrent pericoronitis (number of episodes), caries in 38/48 or distal of second molar, cyst, orthodontic, before radiotherapy
  3. EruptionUneruptedPartially eruptedFully erupted
  4. Winter classification (angulation)MesioangularVerticalDistoangularHorizontalInverted
  5. Pell and Gregory class (space to ramus)Class IClass IIClass III
  6. Pell and Gregory position (depth)Position APosition BPosition C
  7. Relation to inferior alveolar canal on OPG / CBCTdarkening of root, interruption of canal white lines, diversion of canal, or none
  8. Pre-op sensationlower lip, chin and tongue sensation on the operated side
  9. Mouth opening and second molarinter-incisal opening in mm; caries or restoration in the second molar
  10. Options discussedComplete removalCoronectomyReview only

Anaesthesia and position

  1. AnaesthesiaLALA with conscious sedationGA with LA infiltration
  2. Local anaestheticblock and infiltration given; drug, strength, volume (write the volume actually used)
  3. Pre-op mouth rinseChlorhexidineNot given

Operative findings

  1. Tooth position at surgeryas expected on X-ray or different
  2. Follicle / pericoronal tissuenormal, inflamed, cystic
  3. Rootsnumber, curved, fused, hooked
  4. Inferior alveolar canalNot seenSeen, nerve intactNerve exposed or injured
  5. Lingual plateIntactPerforated
  6. Tooth removedComplete with all rootsRoot tip retained (reason)Coronectomy, roots left

Procedure (steps)

  1. Local anaesthesia giveninferior alveolar block and buccal infiltration; test for numbness
  2. FlapEnvelope flapTriangular flap with anterior relieving incisionincision kept buccal, not lingual; full-thickness mucoperiosteal flap raised
  3. Lingual tissuesLingual retractor usedNo lingual retraction
  4. Bone removalSurgical handpiece and bur with saline irrigationChiselsite: buccal and distal; bur type
  5. Tooth sectioningNot neededCrown sectionedRoots separatedCoronectomy
  6. Elevation and deliveryelevator used; tooth and roots checked for completeness
  7. Socket toiletfollicle removed, sharp bone smoothed, irrigated with saline
  8. Haemostasispressure, sutures, other measures

Closure, drains and dressing

  1. Wound closurePrimary closureSecondary (partial) closure
  2. Suturematerial, size, number of sutures
  3. DrainNoneDrain placed
  4. Gauze packbite on pack, time

Specimens and implants

  1. Extracted toothDiscarded as anatomical wasteSent for HPEGiven to patient on request (documented)
  2. Follicle / soft tissueSent for HPENot sentsend if cystic or abnormal

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Packbite on gauze; time advised
  2. Analgesiadrug, dose, frequency, duration
  3. Antibioticsnot routine; if given, the reason
  4. Mouth rinseschlorhexidine or warm saline, from when
  5. Dietsoft diet on the day of surgery
  6. Warning signsbleeding, fever, increasing pain after day 3, numbness that does not go
  7. Suture removal / reviewdate, unless resorbable
  8. Nerve check at reviewlip, chin and tongue sensation; if altered, map it and arrange follow-up

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. V.S., 24 years, three episodes of pericoronitis around a partially erupted 48 in the past year. OPG: mesioangular 48, Pell and Gregory class II position B, roots close to but not crossing the canal, no darkening or interruption of the canal lines.

Case details

Date: 09/07/2026. Elective. Minor OT, OMFS.

Start 10:20. End 11:05.

Surgeon: Dr A. (MDS OMFS, 2nd year). Assistant: Dr B. Consultant: Dr C., available.

Nurse: Sr E.

Indication and pre-op

Indication: recurrent pericoronitis 48, three episodes, now quiet.

48 partially erupted, mesioangular (Winter), class II position B (Pell and Gregory). 47 sound.

Lower lip, chin and tongue sensation normal both sides. Mouth opening 42 mm.

Options explained: removal, coronectomy, review. Patient chose removal. Consent for surgical removal of 48 under LA taken in Hindi, including nerve injury, dry socket and damage to 47.

Pre-op chlorhexidine mouth rinse.

Anaesthesia and position

Semi-reclined in dental chair. Face painted and draped.

Right inferior alveolar nerve block with 2% lignocaine with adrenaline and buccal infiltration. Volume as on the LA record. Lip and tongue numb before incision.

Procedure

Triangular flap: incision from the distobuccal line of 47 along the ramus, kept buccal, with an anterior relieving incision at the mesial of 47. Full-thickness mucoperiosteal flap raised.

Buccal and distal bone removed with round bur in a surgical handpiece under saline irrigation. Lingual plate not touched.

Crown sectioned with bur. Crown removed, then the root mass elevated with a straight elevator.

Findings: two roots, mildly curved, removed complete. Follicle mildly inflamed, removed. Inferior alveolar canal not seen. Lingual plate intact.

Sharp bone edges smoothed. Socket irrigated with saline. Haemostasis by pressure.

Closure

Primary closure with 3 interrupted 4-0 chromic catgut sutures. No drain. Gauze pack placed, patient biting on it.

Specimens and implants

48 with follicle discarded as human anatomical waste (yellow bag). No HPE. No implants.

End of procedure

Blood loss minimal, about 20 ml.

Instrument and needle count correct.

No intra-operative complications. 47 intact.

Patient walked out of minor OT in stable condition.

Post-op orders

Bite on pack as instructed. Soft diet today.

Analgesic as prescribed. No antibiotic prescribed.

Chlorhexidine mouth rinse from the next day.

Return if bleeding does not stop with pressure, fever, or numbness of lip or tongue that persists.

Review with nerve check on day 7. Sutures are resorbable.

Signature

Dr A., MDS resident, OMFS. Reg. no. ________. 09/07/2026, 11:15.

Must document for this operation

  • Winter angulation and Pell and Gregory class and position, and the X-ray signs of nerve proximity. This shows the difficulty was assessed before surgery and explains why a nerve risk was quoted to the patient.
  • Lip, chin and tongue sensation before surgery and at review. Nerve injury is the main medicolegal complaint after third molar surgery, and a baseline is needed to judge it.
  • Options discussed, including coronectomy and leaving the tooth. Consent is valid only if the patient knew the reasonable alternatives and the material risks.
  • Flap design, bone removal method, sectioning, and whether the lingual plate stayed intact. If a lingual nerve deficit appears, the record shows how the lingual side was handled.
  • Whether the tooth came out complete, or a root was left, and why. A retained root seen on a later X-ray looks like a mistake unless it was recorded as a decision.
  • Any nerve seen or injured at surgery, and the plan. An observed nerve injury needs early referral, and the timing of repair affects the result.

Common mistakes in these notes

  • Writing 'disimpaction of 48 done' with no classification or X-ray findings.
  • No record of pre-op lip and tongue sensation.
  • Not writing that coronectomy or review was offered.
  • Leaving out whether sectioning was done and whether all roots were removed.
  • Not recording the local anaesthetic drug and volume.
  • Writing antibiotics by habit without a reason.

Indian practice and paperwork

  • An extracted tooth is human anatomical waste and goes in the yellow bag if it is not sent for HPE. (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines, Yellow (a))
  • Consent must explain the procedure, risks, benefits, alternatives and who will operate, in a language the patient understands, and must be taken by the person doing the procedure. (NABH 5th ed., PRE.4(c) and (e))
  • In a study of 1,200 Indian patients quoted by the RCS guideline, mesioangular impaction was the most common, followed by distoangular, and half the teeth were close to the inferior alveolar nerve. (FDS RCS England, Parameters of care for patients undergoing mandibular third molar surgery, 2020, Background)

Sources

  • Haggerty CJ, Laughlin RM, eds. Atlas of Operative Oral and Maxillofacial Surgery. 2nd ed. Wiley; 2023, Ch 1, Anatomic and Legal Considerations in Dentoalveolar Surgery (Gangwani P, Kolokythas A, Miloro M), pp. 3-11.
  • Haggerty CJ, Laughlin RM, eds. Atlas of Operative Oral and Maxillofacial Surgery. 2nd ed. Wiley; 2023, Ch 2, Exposure and Bonding of an Impacted Tooth (flap, bone removal and closure technique for impacted teeth), pp. 12-14.
  • Faculty of Dental Surgery, Royal College of Surgeons of England. Parameters of care for patients undergoing mandibular third molar surgery. 2020 (published April 2021). Flap design, lingual retractor, bur vs chisel, irrigation, primary vs secondary closure, drain; LA with 2% lignocaine with adrenaline IDB plus buccal infiltration; antibiotics not routine; pre-op chlorhexidine rinse; radiographic signs of IAN risk; coronectomy. www.rcseng.ac.uk/-/media/files/rcs/fds/guidelines/3rd-molar-guidelines--april-2021.pdf
  • Santos KK, Lages FS, Maciel CAB, Gloria JCR, Douglas-de-Oliveira DW. Prevalence of mandibular third molars according to the Pell & Gregory and Winter classifications. J Maxillofac Oral Surg. 2022;21(2):627-633. Definitions of Pell and Gregory classes I-III, positions A-C, and Winter angulations. pmc.ncbi.nlm.nih.gov/articles/PMC9192858/

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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