DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

CASE SHEET

SL. NO.

OP. NO.

1. NAME

2. AGE & SEX

3. ADDRESS

4. OCCUPATION

5. CHIEF COMPLAINT

6. HISTORY OF PRESENT ILLNESS:

7. PAST MEDICAL HISTORY :

Bleeding disorders
Hypertension
Diabetes
Asthma
Allergy
Thyroid diseases [hyperthyroidism]
Heart diseases [valvular, open heart, angiogram etc]
Stroke
Kidney diseases

DATE:

Organ transplant
Cancer
Radiation/chemotherapy
HIV/hepatitis
Tuberculosis

8. PAST DENTAL HISTORY

9. PERSONAL HISTORY

10. FAMILY HISTORY

11. DRUG ALLERGY

:
:

11. GENERAL EXAMINATION:

General state of the health:

Past hospitalizations:
Vitals:
o BP
o RR
o Pulse rate
o Temp
Skin
Head and neck
Eyes, nose, ears
CVS
GIT

 RS
CNS
Extremeties

12. Local examination

Extra-oral examination:
Swelling:
o Site
o Size
o Shape
o Extensions
o Colour
o Consistency: soft/firm/hard
o Tenderness:
o Borders: well defined/diffused
Extra-oral sinus: yes/no
o Site
o Discharge
Paresthesia/anesthesia:
o Lower lip/chin: yes/no
o Infra-orbital area: yes/no
TMJ:
o Mouth opening
Deviation
Clicking
Tenderness
Lymph nodes:
o Palpable
o Not palpable
Mandible:
o Prognathic/retrognathic/normognathic

INTRA-ORAL EXAMINATION:
a) Soft tissues
1) Lip
2) Buccal Mucosa
3) Vestibule
4) Retro molar area
5) Floor of mouth
6) Tongue
7) Hard & Soft palate
8) Oral Hygiene
9) Mouth Opening

b) Hard Tissue Examination

1) No. of Teeth Presented
2) Missing Teeth
3) Vitality
4) Caries
5) Mobility
6) TMJ
7) Occlusion

8) State of eruption: partially erupted/unerupted

9) Position of teeth: labial/buccal/palatal/lingual
10)

Condition: caries/pericoronitis/periodontitis

11)

Intra-oral sinus: present/absent

12)

Adjacent teeth: caries/periodontitis

13)

Opposing teeth: present/absent/other

c) ON PALPATION:
1) External oblique ridge
2) Internal oblique ridge
3) Angle of mandible
4)
13) Classification & Type Of Impaction

14) Investigation
a) Radiograph and Radiographic Interpretation
a. IOPA
b. OPG
c. Other
d. ROOT PATTERN OF IMPACTED TOOTH;
i. NUMBER OF ROOTS
ii. Shape: dilacerations/others
iii. Convergent/divergent
iv. Small/short/long
v. Follicular space: large/thin
vi. Fused or separate roots
vii. Hypercementosis
viii. Others
e. Texture of investing bone

f. Pathology around impacted tooth

g. External oblique ridge inclination:
i. Vertical
ii. Horizontal
iii. Behind the tooth
iv. In front of the tooth
h. Crown shape
b) Blood
c) Urine
d) Biopsy
e) Other investigations
5) Classification:
i. Winters classification:
vertical/horizontal/mesioangular/distoangular others
ii. Pell and Gregory classification: class-1/class-2/class-3
iii. Position: A/B/C
iv. WHARFE assessment
6) Pederson difficulty index
7) Periodontal pocket depth
8) Diagnosis:

16) Treatment

plan

Pre-operative steroids or medication

Anesthesia
Type:
Bone cutting technique:

Method:
Flap design
Tooth sectioning:
Combination:
Elevation:
Trephination:
Socket Toilet:
Suturing:
Drugs:
Antibiotics:
Anti-inflammatory/Steroids:
Post-operative instructions:

OPERATIVE NOTES: [duration and amount of blood loss also]

POST OP MEDICATION
23) Follow up
first day
seventh day

after one month

after three months

complications:

Pain on 3rd day

Trismus
Febrile episode
Maximum interincisal distance
Swelling
Wound dehiscence/purulence
lymphadenopathy