Surgical Extraction Notes Template for UK Dentists

Surgical extractions are a frequent source of UK GP dental indemnity claims — and nerve damage without documented consent is a recurring issue. Below is a template for UK clinicians to paste into their PMS for any extraction requiring flap or sectioning. For third-molar (wisdom tooth) surgery, use the wisdom tooth extraction template instead.

Why this surgical extraction template wins

• Reason for surgical (vs forceps) recorded explicitly — defends against NHSBSA audit (if NHS) and indemnity scrutiny.
• Written consent specifically referenced — for surgical extractions, written consent is best practice and indemnity-strongly preferred.
• Sectioning approach documented — critical if a sectioned root tip is left behind, or if patient queries the extent of bone removal.
• No-lingual-flap line for lower 8s — preserves lingual nerve, defensible against lingual paraesthesia claims.
• Written post-op leaflet confirmed — a key defensive line if a complication follows.

The template (paste into your PMS notes field)

Paste the surgical extraction template below into your PMS notes field. Patient demographics are left out because your PMS already holds them.

TOOTH: [FDI]
INDICATION: [Retained root / impacted / surgical complexity (curved roots, ankylosis, hypercementosis) / extensive caries below bone level]
REASON SURGICAL (vs FORCEPS): [Specific clinical reason — bullet point]

PRE-OP ASSESSMENT:
- Pre-op radiograph: [Type — date — quality — report: roots, IAN distance, sinus proximity, pathology, bone density]
- MHx: [Anticoagulants / bisphosphonates (MRONJ risk per SDCEP 2024) / immunosuppression / bleeding disorder / diabetes (HbA1c if known) / radiotherapy history]
- BP: [If indicated]
- Patient fitness for procedure: [ASA grade]

CONSENT (Montgomery, written for surgical procedures): Risks specific to this tooth —
- Common: pain (manageable), swelling (peaks 48-72h), bruising, trismus, sutures
- Uncommon: dry socket (~10% surgical extractions, higher in smokers), bleeding requiring return
- Rare: IAN paraesthesia (specify likelihood per radiograph), lingual nerve injury (lower 8s, lingual flap), mental nerve injury (premolar region), sinus communication (upper molars/premolars), root displacement, jaw fracture (rare, document if elderly/atrophic mandible)
Alternative: refer to oral surgery (NHS waiting time / private cost), leave as is. Patient understands and consents in writing.

LA: [Agent + total volume — IDB / infiltration / long buccal / supplemental]. Profound anaesthesia confirmed.

SURGICAL PROCEDURE:
- Incision design: [Sulcular / sulcular + relieving distal-distal / envelope flap]
- Flap: [Full-thickness mucoperiosteal / mucogingival]
- Bone removal: [Bur — round / fissure — water-cooled / piezosurgery]
- Volume removed: [Conservative — buccal cortex only / extensive]
- Sectioning: [Single section (vertical) / multiple sections / crown removed first / each root delivered separately]
- Delivery: [Elevation with luxator / forceps / piecemeal]
- Root tip retrieval: [N/A / retained — decision documented]

INTRA-OP FINDINGS: [Complications — fracture, IAN exposure, sinus communication / smooth — none]

SOCKET MANAGEMENT: [Inspected, irrigated with saline, sharp bony edges smoothed, debris removed]

CLOSURE:
- Sutures: [Vicryl 3-0 / silk 3-0 / chromic gut — number — sites — interrupted/continuous]
- Haemostatic adjunct: [Pressure pack / collagen / tranexamic acid mouthwash if anticoagulated]

POST-OP INSTRUCTIONS (verbal + written leaflet — given confirmed):
Bite gauze 30min. No vigorous rinsing 24h. Salt-water rinses from 24h. Soft diet. Avoid smoking + alcohol 48h. Analgesia — ibuprofen 400mg + paracetamol 1g PRN. Contact immediately if uncontrolled bleeding. Dry socket symptoms discussed (onset 2-4 days, dull aching, radiating). Suture removal date provided.

PRESCRIPTIONS: [Antibiotic — only if indicated (systemic signs / immunocompromised / significant tissue loss). Indication documented. SDCEP-compliant.]

REVIEW: [Suture removal at __ days. Earlier review if complications.]

Try the surgical extraction note in the live demo → No account needed.

What good looks like — a worked example

The same surgical extraction template, completed for a realistic case.

TOOTH: LR8
INDICATION: Failed forceps extraction attempt by previous clinician — crown fractured, retained roots remain. Complex retrieval required.
REASON SURGICAL: Retained roots subgingival, no clinical crown to grip with forceps. Surgical flap + bone removal + sectioning required.

PRE-OP ASSESSMENT:
- Pre-op radiograph: OPG taken today (quality A). Two roots (mesial + distal), parallel, no curvature. IAN canal inferior to roots with apparent separation (~2mm). No sinus involvement (lower).
- MHx: Fit and well. No anticoagulants. No bisphosphonates. No bleeding disorder. Non-smoker.
- BP: 122/78. Normal.
- ASA I.

CONSENT (Montgomery, written): Risks specific to LR8 retained roots —
- Common: pain (manageable with analgesia), swelling (peaks 48-72h), bruising, trismus 3-5 days, sutures (resorbable)
- Uncommon: dry socket (~10% surgical, lower in non-smokers)
- Rare: IAN paraesthesia of lip/chin (~1-2% based on OPG proximity), lingual nerve injury (lingual flap not planned), root displacement into IAN canal (rare, OPG suggests separation), jaw fracture (very rare, patient is 28F with normal mandible)
Alternative: refer to oral surgery (4-month NHS waiting list, patient prefers same-day resolution given pain). Patient understands all risks. WRITTEN CONSENT signed and dated.

LA: IDB articaine 4% w/ adrenaline 1:100,000 — 1.7ml (1 cartridge). Long buccal — articaine 4% 1:100,000 — 0.5ml. Mental nerve infiltration — 0.5ml. Total 2.7ml. Profound anaesthesia confirmed.

SURGICAL PROCEDURE:
- Incision design: Sulcular LR8 + relieving incision distal to LR7
- Flap: Full-thickness mucoperiosteal, buccal only (no lingual flap — preserves lingual nerve)
- Bone removal: Round bur (#6) — buccal cortex removed to expose roots. Water cooled.
- Volume removed: Conservative — buccal cortex only over root surfaces
- Sectioning: Vertical section between mesial and distal roots with fissure bur. Each root then elevated separately.
- Delivery: Mesial root — Coupland's elevator. Distal root — Cryers elevator + Read root forceps.
- Root tip retrieval: All root fragments retrieved. Visual + tactile check.

INTRA-OP FINDINGS: No complications. IAN not exposed. Socket walls intact. No sinus involvement.

SOCKET MANAGEMENT: Inspected — no retained roots. Irrigated with saline. Sharp bony edges smoothed with bone file. Debris removed.

CLOSURE:
- Sutures: Vicryl 3-0, 3 sutures — 2 along sulcular incision (interrupted), 1 closing relieving incision
- Haemostatic adjunct: Pressure pack with gauze 5min — haemostasis achieved

POST-OP INSTRUCTIONS (verbal + written leaflet given): Bite gauze 30min. No vigorous rinsing 24h. Salt-water rinses from 24h. Soft diet. Avoid smoking + alcohol 48h. Ibuprofen 400mg + paracetamol 1g PRN. Contact immediately if uncontrolled bleeding, swelling closing eye, dysphagia. Dry socket symptoms discussed. Sutures will dissolve in 2-3 weeks.

PRESCRIPTIONS: NONE — patient immunocompetent, no systemic signs, minimal contamination. SDCEP-compliant.

REVIEW: No routine review (resorbable sutures). Contact if dry socket symptoms or other complications.

Compliance: the medico-legal angle

• BAOS Standards and Guidance — surgical extraction documentation expectations.
• BAOMS 2020 lower third molar guidelines — for wisdom-related surgical extractions.
• SDCEP Oral Health Management of Patients at Risk of MRONJ (2017, reviewed and extant March 2024) + Anticoagulants (2nd edition, March 2022) — pre-op assessment of bisphosphonate and anticoagulant status mandatory.
• NICE TA1 — for prophylactic third molar removal; pathology must be present and documented.
• Montgomery — surgical-specific risks (paraesthesia, sinus, jaw fracture in atrophic mandibles) require explicit consent.
• GDC Principle 4 + 6 — refer when beyond competence; if surgical extraction is within your competence, document that and the case complexity.

Common documentation mistakes

• No documented reason for surgical (vs simple forceps) — flags NHSBSA audit and indemnity review.
• IAN paraesthesia not discussed in consent for lower 8s / lower premolars — Montgomery breach.
• Lingual flap raised for lower 8 — unnecessary risk to lingual nerve. Document why if you do.
• Antibiotic prescribed routinely post-surgical extraction — over-prescription audit issue.
• No written post-op leaflet given (or not documented as given) — GDC Principle 4 breach.

Sources

• GDC Standards for the Dental Team, Principle 4: Maintain and protect patients’ information (accessed 18 October 2026)
• Montgomery v Lanarkshire Health Board (UK Supreme Court, 2015, UKSC 11) (accessed 18 October 2026)
• NICE TA1: Guidance on the extraction of wisdom teeth (accessed 18 October 2026)
• SDCEP: Oral Health Management of Patients at Risk of Medication-related Osteonecrosis of the Jaw (March 2017) (accessed 18 October 2026)

Frequently asked questions

Guides that cover this

• Local Anaesthetic Maximum Doses in Dentistry: A UK Reference
• Dental Drug Interactions: A UK Reference

Patient leaflets for this treatment

• After Your Tooth Extraction
• Your Guide to Tooth Extraction
• Caring for Stitches After Dental Surgery
• Soft Food Guide After Dental Surgery

Related dental note templates

Browse the full set of free dental notes templates.