DENTAL IMPLANT CONSENT FORM FOR SURGICAL AND PROSTHETIC PHASES

You have the right to be informed about the recommended treatment plan so that you may make an educated decision as to whether or not to undergo this procedure. This disclosure is not meant to alarm you, but is an effort to provide information so that you may give or withhold your consent.

Dental Implants have been around for many years, but the success has become more predictable since the use of the pure titanium cylindrical osseointegrated implant. I understand that the purpose of the dental implant is to provide support for dental prosthetic reconstruction in the form of a single tooth, bridge, or denture, or to provide orthodontic anchorage.The purpose of dental implant(s) is to provide stability, support and/or retention for a crown, fixed bridge, fixed denture or removable denture in the absence of natural teeth.

The first procedure involves drilling small holes into the jawbone and placing the anchors. Depending on the condition of the mouth, bone grafting or guided tissue regeneration also may be necessary to install the implants. If you need extensive bone grafting, your implant procedure may be done at a later date once the bone is built up properly so that it can accommodate an implant.

Sometimes bone grafting can be done at the same time of your implant surgery. The Dentist will determine your specific case.

At times, the course of treatment can be altered depending upon the clinical situation of the area. Sometimes the Dentist will place implants right away; however, when the Dentist opens up the surgical site, there may be cases where the clinician finds it in the patient’s best interest to change the planned procedure from the original planned treatment. It is possible that he may just place bone graft at the 1st surgery instead of the implants and change his plan based on his clinical judgement.

You will be given an anesthetic to numb the pain. You may also be put on antibiotics and be given pain medication if needed. A temporary denture or flipper may be worn for a few months while the anchors bond with the jawbone and the gums and bone heal. At the end of the surgery, depending upon the condition of the bone and gum, the dentist will either seal the implant with a cover screw and bury it in the gum or a healing abutment will be placed on the implant to form the gum tissue around the implant. Both techniques will protect the implant during healing, but the Dentist will decide which method is best for your case.

After 3-6 months following the implant surgery, The patient will come back to test the implant area(s). During this visit, the Dentist will test and torque the implants to see if the implants are ready to be restored with the implant crowns, bridge or implant integrated denture. If the implant was buried, he will make a small incision and remove the cover screw, placing a healing abutment. The patient will return 4-6 weeks later to take impressions or scans for the final prosthesis.If the implant is unburied and just covered with a healing abutment, the healing abutment will be removed and the implant tested by torquing it. An impression or scan will be taken of the area and sent to the lab to fabricate the prosthesis. Fabrication of an implant prosthesis will be designed by the laboratory based on the Dentist’s measurements and approval . The final insertion will take place about 2 weeks later.

At present, we cannot predict the length of time dental implants will provide service in the oral cavity, nor can we guarantee if this procedure will succeed. I know that smoking lowers the chances of implant success in direct proportion to the amount smoked. I also understand the risks involved in this procedure. I understand that the implant surgery and prosthetics will be done in the established way and that the risks in the front of the mouth consist of the usual ones associated with simple gum surgery including, but not limited to:

• Post-operative pain and discomfort, swelling and bruising
• Infection that may require further treatment. and bleeding.
• Injury or damage to adjacent fillings or teeth
• Restricted mouth opening during healing sometimes related to swelling or muscle soreness
• Other complications may include trauma to the nerve tissue or blood vessels that may lead to loss of /or an altered sensation of the tongue, cheeks, gums, chin, lip or other tissues in the mouth specifically on the treated side in the lower jaw, and the creation of a communication between the sinus and the mouth on the treated side in the upper jaw (opening of the sinus). Such risks can also include a chance of fracture to the bone or jaw. These complications would require further surgery for correction.
• Poor bone quality, requiring either no implants to be placed or proceed with surgery with a lesser rate of success, possible grafting.

It has been explained that in some instances implant(s) fail and must be removed.I understand that in the event the implant fails to integrate, it must be removed through a second surgical procedure, and there can be no refund of all or part of the fee for the lost implant. I have been informed and understand that the practice of dentistry is not an exact science; therefore, I understand there are no guarantees or assurances as to the outcome of treatment results. I acknowledge that there is a chance that the implant(s) placed can fail and I am taking a risk by agreeing to this surgical procedure.

To my knowledge, I have given an accurate report of my physical and mental health history. understand that excessive smoking, alcohol, or blood sugar may affect gum healing and may limit the success of the implant(s) and restoration. I will report any significant change in my health should it occur.

Excessive forces, as grinding or clenching my teeth, on the implant(s) may lead to loosening and/or fracture of the retaining screws or cement; fracture of the porcelain, metal or acrylic on the prosthesis; loosening and/or fracture of the implant(s); and/or loss of bone around the implant(s). Any of these may cause loss of this implant(s). Additional treatment and associated costs will be involved should this occur, including, but not limited to occlusal guards.
The possible risks and complications for fixed prostheses include:

• compromised appearance and/or lack of support of the lip(s) and cheek(s) as a result of inadequate bone
• air escaping underneath the prosthesis while talking which may adversely affect speech and/or food entrapment underneath the prosthesis since space is necessary for homecare of the implant(s).
• sore gums, food entrapment, wearing of attachments, replacement of attachment components, and initial problems with speech.

The potential benefits of this procedure include the replacement of missing natural teeth or supporting dentures.

Alternatives to this treatment have been explained. I understand the alternative conventional dental treatment options and I am aware of the consequences of receiving no treatment. I desire an implant prosthesis to help secure the replacement of my missing teeth. The entire procedure has been fully explained, including the benefits and possible risks. I have been given the opportunity to ask questions regarding the procedure and they have been answered to my satisfaction. I have not asked for, nor have I received from anyone, a guarantee of the outcome of this procedure.

INFORMED CONSENT

It has been explained to me that once implants are inserted or implanted, a recommended program of personal oral hygiene must be strictly followed by me and completed on schedule. I have been informed that if this schedule and plan are not carried out, the implants may fail.

I agree to make every effort to return for follow-up visits for hygiene and exams after the surgery in order to have any necessary x-rays taken but I am aware that this is entirely voluntary on my part. Follow-up care for the implants and prosthesis is extremely important to the success of the implants or Bone graft. It will be necessary to return to the office at regular intervals for examination and service. Keeping your gums and teeth healthy by coming for hygiene visits every 3-4 months is one of the best ways to take care of your implants. It has been made clear that failure on my part to keep my mouth, implant(s) and prosthesis thoroughly clean may jeopardize the success of my implant(s). I realize that unforeseen long term factors may necessitate additional surgery, modification of the implant(s) or even surgical removal of the implant(s). I also understand that I will be financially responsible for long term maintenance and/or any modifications required, including but not limited to cleanings, attachment replacements, x rays, and examinations.

• Photographs and clinical data might be used in scientific papers and presentations and the confidentiality of the patient will be respected.
• I consent to the administration of anesthesia or other medications before, during or after the procedure by qualified personnel.
• There is a chance that during the course of the treatment unforeseen conditions may be revealed that may require changes in the procedure noted above.I authorize the Dentist to use professional judgement to perform such additional procedures that are necessary and desirable to complete my surgery.
• I certify that I have read or had read to me the contents of this form. I will follow any patient instructions related to this procedure. I confirm that the proposed treatment and potential risks and/or complications associated with the procedure have been explained to me. I understand the potential risks, complications and side effects involved with any dental treatment or procedure and have decided to proceed with this procedure after considering the possibility of both known and unknown risks, complications, side effects and alternatives to the procedure. I declare that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.