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Patients seen at the request of the office general dentist for evaluation of dental for dental implant placement on #XXXXXX. Discusses in details need for sinus lift due to pneumatization of the sinus. Had long over ½ hr consultation on previous visit.  Reviewed risk and discussed with patients.

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Past Medical History
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Refer to patient history form

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Past Surgical History
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Refer to patient history form

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Medications
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Refer to patient history form

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Allergies
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Refer to patient history form

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Social History
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Smoking – Refer to patient history form
Alcohol - Refer to patient history form
Drugs - Refer to patient history form

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CLINICAL EXAMINATION: 
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Extraoral, Head and Neck exam: 

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Constitutional: general appearance of patient  
No extraoral swelling or erythema 
Parotid and submandibular glands soft, nonpainful to palpation bilaterally 
No lesion noted on facial skin
Facial palpitation exam reviews no swelling or no lymphadenopathy 
CN V1, V2, V3, CN VII intact bilaterally 
No neck masses noted
Thyroid midline with no evidence of any swelling
Musculoskeletal: TMJ joint seems to be normal. No poping upon opening
Maximum mouth opening within normal range

Intraoral Soft Tissues: 

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Clear saliva extruded from bilateral Wharton’s and Stenson’s ducts 
Tongue soft and non-tender with no apparent lesions 
Buccal mucosa without lesions bilaterally 
Hard palate, soft palate, and pharynx are within normal limits no pathology visualized 
Floor of mouth without an evidence of pathology

Dentition: 

Refer to dental chart for detail dental caries evaluation

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Radiographic examination: 
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Panorex reviewed demonstrates
No bony pathology. 

Pneumatized sinus @ previously extracted site #3,4

ASSESSMENT / PLAN / RECOMMENDATION
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Direct open sinus lift with PRP and possible immediate implant placement.

 

CONSENT
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Discussed risk, benefits, complication of surgery including but not limited to bleeding swelling, infection, pain, retained root tip, numbness of lower lip, chin, tongue. Patient understood risks informed, verbalized understanding and consented accordingly.

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Local Anesthesia
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___ 2% lido w/ 1:100,000 epi Carpules (1.7 cc)
___ 4% sepocaine Carpules (1.7 cc)
___ 3% Carbocaine w/o epi Carpules (1.7 cc)

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Procedure Performed
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SURGEON 1:  Joseph Krajekian, D.M.D., M.D.
DENTAL ASSISTANT :  Rae / Shawna

OPERATION/PROCEDURE : 
    Direct open sinus lift with PRP and possible immediate implant placement.

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​    60 CC of Blood taken from and provided for arteriocyte for PRP

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After proper time for local anesthesia to work.
Mouth prop utilized, throat pack used followed by sweetheart.

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Attention  mid ridge incision made and extended mesially to mesial of #13 with anterior release and posteriorly to #15 with release Tissue was then reflected 1cm and 0.6cm window made 4 mm above the ridge with copius irrigation via high speed drill until membrane was visualized. And then with use of hand instrumentation the sinus was then elevated about 1 cm in all direction without any evidence of preformation.

 

MX grafter was then use to obtained autogenous bone which was later mixed with 1cc of allograft and PRP. Membrane was placed at floor of sinus membrane and implant drill was used for sequential drilling and straumann implant placed and following placement PRP and bone was added carefully into the sinus lift area and areas was then closed after placing membrane (socked with PRP) on facial bone. Areas was closed tension free with 3.0 Vycril suture.
 

Straumann SLA Tapered implant 4.1 x10mm was placed.

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Quality of bone was :      __ D1    _X_D2   __D3   __ D4

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Expected stage II : 4 months

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ESTIMATED BLOOD LOSS:  minimal

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DISPOSITION : Home 

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PRISCRIPTION DISPENSED:
Augemtin 875mg  1 tabs PO q6 hrs Disp 7 days                            refill 0
Tylenol #3        1 po q 6 hr prn x 5 pill for 3 days
Peridex                 Provided from the office                          refill 0
Motrin 800mg      1 tablet every 8 hrs prn x 28 pills            refill 0

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FOLLOWUP : 
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next day with general dentist. 2 weeks with me if needed. Patient was provided post-op instruction/medication sheets in writing and they were also review with patient escort. Pt and escort were also provided with my 24 hour direct contact number and was also instructed to contact the office with any questions

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DICTATED BY :                    
Dr. Joseph Krajekian DMD, MD