Free Sinus Lift Note Template (D7951/D7952)
A sinus lift note has to show why the bone was not enough, how you got under the sinus floor, and what state you left the Schneiderian membrane in. This template covers lateral window (D7951) and crestal (D7952) approaches: residual bone height, technique, membrane status and any perforation repair, the graft, a window membrane, a simultaneous implant if you placed one, and sinus precautions.
By Yasmin Byott, DDS, MS · Founder, ButterNote · Updated
Customize your note
Fill in the fields below and we'll generate a complete clinical note for you in seconds.
Lateral window only.
Copy-paste template
Replace each [bracketed field] with your specific clinical detail. Brackets are placeholders. They don't get saved into the chart.
Sinus lift, [lateral window approach (D7951)] / [crestal approach (D7952)], #[3][, with simultaneous implant placement]. Medical history reviewed; [no changes; no current sinus symptoms; non-smoker]. Pre-operative CBCT: [residual bone height about 3 mm below the sinus floor at #3; sinus clear, no mucosal thickening; no septum at the site]. Risks discussed, including [pain, swelling, bruising, bleeding, nosebleed, sinus membrane perforation, sinus infection, graft loss, oroantral communication, and failure of the implant to integrate]; alternatives reviewed, including [a shorter implant, a staged approach, a removable partial denture, and no treatment]; [written] consent obtained. Local anesthesia: [3] carpules of [4% Septocaine 1:100k epi] via [PSA block with buccal and palatal infiltration]. Residual bone height [3] mm. [Crestal incision with a mesial releasing incision; full-thickness mucoperiosteal flap reflected. Lateral window osteotomy prepared in the lateral sinus wall with a [round diamond bur / piezoelectric insert] under copious sterile saline irrigation. Schneiderian membrane elevated from the sinus floor and medial wall.] / [Osteotomy prepared short of the sinus floor; sinus floor infractured with osteotomes and the membrane elevated through the osteotomy.] Schneiderian membrane [intact; Valsalva negative] / [perforation of about [3] mm noted and repaired with a resorbable collagen membrane]. [Xenograft] placed into the subantral space. [Resorbable collagen membrane placed over the lateral window (D7956).] [Implant placed: Straumann BLT 4.1 x 10 mm, lot [number]; insertion torque [30] Ncm (D6010).] Closed with [4-0 PTFE, interrupted and horizontal mattress sutures]; hemostasis achieved. Post-operative [PA / CBCT]: [graft above the original sinus floor; implant in position]. Sinus precautions reviewed: [no nose blowing, sneeze with the mouth open, and no straws, smoking, flying, or scuba diving until cleared]. Post-operative instructions given verbally and in writing. Analgesics: [ibuprofen 600 mg with or without acetaminophen as directed]. Next visit: [post-op check and suture removal in 10 to 14 days].
Customize this note in seconds, no typing. Get your hours back.
Templates for practically every clinical scenario, with instant custom note generation.
Tap through any clinical scenario
Tap chips for any clinical scenario, get a complete custom note instantly, paste into your EHR.
Or skip clicks entirely
Ambient listening records the appointment in the background. AI writes the note from the conversation itself.
“I'm Dr. Yasmin, a dentist who got tired of staying late writing notes. I used to search the internet for note templates that actually worked, and I could never find good ones. So I built ButterNote to make note writing feel as smooth as butter.
If the click-build flow above just saved you time, you'll love what's behind a free account: templates for practically every clinical scenario you'll see this week, with instant custom note generation. And if you want zero clicks at all, the iOS app handles that too. Ambient listening on your iPhone or Apple Watch turns each appointment into a finished note.
Take whatever's useful here for free.”
Yasmin Byott, DDS, MS
Founder, ButterNote
When to use this template
Use this sinus lift note template when you augment the maxillary sinus floor to gain bone height for implants in the posterior maxilla. The code follows the approach. D7951 is sinus augmentation with bone or bone substitutes via a lateral open approach. D7952 is sinus augmentation via a vertical approach: access through the ridge crest, raising the floor of the sinus and grafting as necessary. Both descriptors say the procedure includes obtaining the bone or bone substitutes, so the sinus graft is part of the code rather than a separate D7953 or D6104. The D7951 descriptor says a barrier membrane, if used, is reported separately; for an edentulous site that means D7956 (resorbable) or D7957 (non-resorbable). An implant placed at the same visit is reported as D6010. Coverage of sinus augmentation varies, payers may question a crestal lift reported with an implant in the same site, and a narrative with the radiographs is usually expected.
Before surgery, record what the CBCT showed: the residual bone height (and width) below the sinus floor at each site, the health of the sinus (mucosal thickening or signs of active sinusitis), septa, and vessels in the lateral wall where a window is planned. Record the medical history and any current sinus symptoms. The consent should name the sinus-specific risks: membrane perforation, sinus infection, graft loss, oroantral communication, bleeding, and failure of the implant to integrate, along with alternatives such as a shorter implant, a staged approach, or a removable prosthesis. The residual height also explains the approach: crestal elevation is generally used when there is more residual bone and a smaller gain is needed, and a lateral window when the residual height is low or a larger gain is needed.
In the procedure itself, record the anesthesia; for a lateral window, the flap, the window osteotomy, and membrane elevation; for a crestal lift, the osteotomy short of the sinus floor, the infracture, and the elevation. Then record the membrane outcome: intact and how you confirmed it (Valsalva test or direct inspection), or the perforation and how it was repaired. Name the graft, any membrane over the window, and the implant if one went in, with its size and torque. Close with sutures, the post-operative radiograph, sinus precautions, analgesics, and follow-up. Systematic reviews from 2008 found high implant survival with both lateral and transalveolar sinus floor elevation, with the best lateral-approach results when the window was covered with a membrane.
Step by step: how to document this sinus lift
- 1
Assess and consent
Record the CBCT findings (residual bone height, sinus health, septa), sinus symptoms, sinus-specific risks, alternatives, and consent.
- 2
Anesthetize and access
Record the anesthetic, then the flap and lateral window osteotomy, or the crestal osteotomy short of the sinus floor.
- 3
Elevate the membrane
Record the Schneiderian membrane elevation and its outcome: intact and how confirmed, or perforated and how repaired.
- 4
Graft
Record the graft material placed into the subantral space and any membrane over the lateral window.
- 5
Place the implant if planned
Record the implant system, size, lot, and insertion torque, or the plan for staged placement.
- 6
Close and protect
Record sutures and hemostasis, the post-operative radiograph, sinus precautions, analgesics, and follow-up.
Tips for using this template
- check_circleRecord the residual bone height in mm from the CBCT. It is the reason for the lift and the reason for the approach you chose.
- check_circleName the approach. A lateral window is D7951; a crestal lift through the ridge crest is D7952.
- check_circleRecord the membrane outcome every time: intact and how you confirmed it, or the perforation, its size, and what you repaired it with.
- check_circleThe graft is part of D7951 and D7952, which include obtaining the bone or bone substitutes. Name the material, but do not add D7953 for the sinus graft.
- check_circleA membrane over the lateral window is reported separately. For an edentulous site that is D7956 (resorbable) or D7957 (non-resorbable).
- check_circleWith a simultaneous implant, record it as fully as in a placement note: system, size, lot, and torque. If you staged the implant, record the plan and timing.
- check_circleRecord the sinus health you checked before surgery, both symptoms and the CBCT appearance of the sinus lining.
- check_circleWrite the sinus precautions you gave, and for how long, in the note.
Standards & references
- ADA Code on Dental Procedures (CDT): D7951 (sinus augmentation via a lateral open approach), D7952 (via a vertical approach), D7956/D7957 (barrier, edentulous area), and D6010.
- Pjetursson et al. Success of sinus floor elevation and survival of implants: lateral approach (J Clin Periodontol 2008): Systematic review: high implant survival with lateral sinus floor elevation; best results with rough-surface implants and membrane coverage of the window.
- Tan et al. Success of sinus floor elevation and survival of implants, Part II: transalveolar technique (J Clin Periodontol 2008): Systematic review: implant survival in transalveolar (crestal) sites comparable to non-augmented sites, with a low complication rate.
- AAOMS Parameters of Care: American Association of Oral and Maxillofacial Surgeons clinical guidelines, including preprosthetic and implant surgery.
Frequently asked questions
Get your hours back.
Click-build any sinus lift note in seconds, or let ambient listening turn your appointments into finished notes.
Built by a dentist who's been in your chair.
Free to start. HIPAA-aware.
Want all 6 templates as a printable PDF?
Other dental note templates
Implant Placement Note Template (D6010)
An implant placement note is the record every later visit leans on: which implant went in, how big, how tight, and how it was left to heal.
Socket Graft Note Template (D7953 Ridge Preservation)
A socket graft note has to show that the graft went into a fresh extraction site, at the extraction, for a reason.
Implant Uncovery Note Template (D6011 Second Stage)
Second-stage surgery is short, and the note often is too.
Implant Crown Delivery Note Template (D6058/D6065)
This implant crown note template covers the restorative visit after the implant has integrated: the site, implant system and platform, abutment, screw torque, retention method, contacts and occlusion, and the baseline radiograph and probing that every future peri-implant comparison depends on.
Clear Aligner (Invisalign) Start Note Template (D8080/D8090)
The aligner start visit sets the record every later check is measured against.
Clear Aligner Check Note Template (D8670)
An aligner check note answers one question for the next visit: is the case doing what the plan says? This D8670 template documents the aligner the patient is in, reported wear, tracking, attachments, IPR, any refinement decision, and the aligners and instructions you sent home.