CONSENT FORM FOR ROOT FORM DENTAL IMPLANTS
Diagnosis: After a careful oral examination and study of my dental condition, my oral surgeon,
Dr. Alibhai, has advised me that my missing tooth or teeth may be replaced with an artificial tooth or teeth suppofied by an implant.
Recommended Treatment: ln order to treat my condition, my periodontist has recommended the use of root form dental implants. I understand that the procedure for root form implants involves placing implants into the jawbone. This procedure has a surgical phase followed by a prosthetic phase where the artificial teeth or tooth crowns are placed.
Surgical Phase of Procedure: I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the treatment. My gum tissue will be opened to expose the bone. lmplants will be placed into holes that have been drilled in my jawbone. The implants will have to be snugly fitted and held tightly in place during the healing phase. The soft tissue will be stitched closed over or around the implants. A periodontal bandage or dressing may be placed. Healing will be allowed to proceed for a period of four to six months. I understand that dentures usually cannot be worn during the first one to two weeks of the healing phase.
I further understand that if during surgery, clinical conditions turn out to be unfavorable for the use of this Implant system or prevent the placement of implant, my periodontists will make a professional judgement
on the management of the situation. The procedure may need to be cancelled or may involve supplemental bone grafts or other types of grafts to build up the ridge of my jaw to allow placement, gum closure, and security of my implants.
For implants requiring a second surgical procedure, the overlying tissues will be opened at the appropriate time, and the stability of the implant will be verified. lf the implant appears satisfactory, an attachment will be connected to the implant. Plans and procedures to create an implant prosthetic appliance or artificial crown can then begin.
Prosthetic Phase of Procedure: I understand that at this point I will be referred back to my dentist This phase is just as important as the surgical phase for the long-term success of the oral reconstruction. During this phase, an implant prosthetic device will be attached to the implant. This procedure should be performed by a person trained in the prosthetic protocol for the root form implant system.
Expected Benefits: The purpose of dental implants is to allow me to have more functional artificial teeth or improved appearance. The implants provide support, anchorage, and retention for artificial teeth or crowns. Principal Risks and Complications: I understand that some patients do not respond successfully to dental implants, and in such cases, the implant may need to be removed. lmplant surgery may not be successful in providing artificial teeth. Because each patient’s condition is unique, longterm success may not occur. I understand that complications may result from the implant surgery, drugs, and anesthetics. These complications include, but are not limited to, post-surgical infection, bleeding, swelling and pain, facial discoloration, transient but on occasion permanent numbness of the lip, tongue, teeth, chin or gum, jaw joint injuries or associated muscle spasm, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech, allergic reactions, injury to teeth, bone fracture, nasal sinus penetrations, delayed healing, and accidental swallowing of foreign matter. The exact duration of any complication cannot be determined and may be irreversible.
I understand that the design and structure of the artificial tooth appliance can be a substantial factor in the success or failure of the implant. I further understand that alterations made on this appliance or the implant can lead to loss of the appliance or implant. This loss would be the sole responsibility of the person making such alterations. I am advised that the tight adaptation between the implant and the surrounding bone may fail and that it may become necessary to remove the implant. This can happen in the preliminary phase, during the initial integration of the implant to the bone, or at any time thereafter.
Alternatives to Suggested Treatment: Alternative treatments for missing teeth include no treatment, new removable appliances, and other procedures – depending on the circumstances. However, continued wearing of ill fitting appliances can result in further damage to the bone and soft tissue of my mouth
Necessary Follow-up and Self’Care: I understand that it is important for me to continue to see my general dentist or prosthodontist. lmplants, naturalteeth, and appliances must be maintained daily in a clean, hygienic manner. lmplants and appliances must also be examined periodically and may need to be adjusted. I understand that it is important for me to abide by the specific prescriptions and instructions given by my periodontist.
No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. Due to individual patient differences, a therapist cannot predict certainty of success. There exists the risk of failure, relapse, additional treatment, or worsening of my present condition, including the possible loss of certain teeth or implants, despite the best of care.
Use of Records for Reimbursement Purposes: I authorize photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for reimbursement purposes.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.
I have been fully informed of the nature of ridge augmentation surgery, the procedure to be utilized, the risks and benefits of periodontal surgery, the alternative treatments available, and the necessity for follow-up and self-care. I have had an opportunity to ask any questions I may have in connection with the treatment and to discuss my concerns with my periodontist. After thorough deliberation, I hereby consent to the performance of dental implant surgery as presented to me during consultation and in the treatment plan presentation as described in the document. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of my periodontist.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.
Consent
