Dental Implant Consent Form

Varboncoeur & Caldemeyer Oral & Maxillofacial Surgery

CONSENT FOR DENTAL IMPLANT SURGERY

Please initial each paragraph after reading.  If you have any questions, please ask your doctor BEFORE initialing.

You have the right to be informed about your diagnosis and planned surgery so that you can decide whether or not to have a procedure after being told the risks and benefits.

_____1. My condition has been explained to me as a Missing Tooth or Missing Teeth.

______________________________________________________________

_____2. The procedure proposed to treat this condition is Surgically Placing a Dental Implant or Implants into my jaw bones and gums in these positions:  ____________________________________________________________________________________________________________________________

_____3. I have been informed of possible alternative methods of treatment 

I understand that these other forms of treatment, or no treatment at all, are choices.  The risks of those choices have been presented to me.

_____4. My doctor has explained to me that there are risks and side effects of any surgical procedure.  For this procedure, the main risks include:

_____A. Post-operative discomfort, bruising and swelling needing several days of at-home recovery.

______B. Bleeding that is heavy or lasts for a long time that might need more treatment.

_____C. Injury or damage to teeth or roots of teeth that are near the implant. This may need root canal treatment of the injured tooth, or even result in tooth loss.

_____D. An infection after the procedure that might need more treatment or cause loss of the implant.

_____E. Stretching of the corners of the mouth that might cause cracking and bruising and might heal slowly.

______F.   It might be hard to open my mouth for several days.  This might be from swelling and muscle soreness, or from stress on the jaw joints (TMJ).  This could last several weeks or months, or it could be permanent.

_____G. During the surgery, pieces of bone, synthetic bone, or synthetic membranes may be placed.  These pieces of bone or membranes may also become infected or devitalized and require antibiotics and/or more surgical treatment.

_____H. Allergic reactions (previously unknown) to any medications or materials used in treatment.

______I. Implants placed in lower jaw might injure the nerve that gives sensitivity to the face.   After the surgery, there might be pain or a numb feeling in my chin, lip, cheek, gums, teeth or tongue.  It is 

  possible that I might lose my sense of taste.  This might last for weeks or months.  It can be permanent, but this rarely happens.  

_____J. Opening into the sinus (a normal bony area above the upper back teeth) that might need additional treatment.  If the doctor goes into the sinus on purpose to do another procedure (sinus-lift procedure with grafting), I might have several weeks of sinusitis symptoms that will need medicine and more recovery time.

_____K. The jaw may break and need more surgical treatment for repair.

_____L.  Use of other materials, synthetic bone-like materials or membranes, that might have to be removed at a later date.

_____M.  Bone loss around implants and/or adjacent teeth.

_____N.  Fracture or the Implant or the restorative parts.

_____O.  Loss of an implant or implants.

_____P.  Other: ________________________________________________

_____5. I understand that cuts (incisions) will be made inside my mouth in the gums to put one or more dental implants into my jaw bone.  The implants will be the support for one or more missing tooth replacements to hold a crown, cap, bridge, partial denture, complete denture or plate.  The doctor has explained the procedure, and told me how many incisions will be made, where they will be, and what kind of implants will be used.  If a crown, bridge or denture is attached to this implant(s), this will be done by your general dentist or prosthodontist, and  that office will bill me for this procedure.

_____6. Sometimes dental implants remain covered by gum tissue during the initial healing period.  If the implant is covered by gum tissue, it will have to be surgically uncovered before it can be restored by the dentist.  Sometimes dental implants are left exposed through the gum tissue when placed.  Gum tissue grafting or trimming may be necessary before or after restoration by the dentist.

_____7.  No one has promised how long the implants will last.  I have been told that once the implant is put in, I need to follow through with the whole treatment plan and finish it in the time period that is set by my doctors.  If this is not done, the implants may fail.

_____8. If my doctor finds a different condition than expected and feels that a different surgery or more surgery needs to be done, I agree to have it done.