1. My doctor has explained the various types of implants used in dentistry and I have been informed of the alternatives to implant surgery for replacement of my missing teeth. I have also been informed of the foreseeable risks of those alternatives. I understand what procedures are necessary to accomplish the placement of the implant (s) either on, in, or through the bone, and I understand that the most common types of implants available are subperiosteal (on), endosteal (in), and transosteal (through). The implant type recommended for my specific condition is circled above. I also understand that endosteal implants (more commonly known as root form) generally have the most predictable prog 19519t1910t nosis. I further understand that subperiosteal implants, if an option for me, are not as widely used as root form implants but will negate the necessity of my having the bone grafting and other surgical procedures which would be necessary for the placement of root form implants. I understand that the risk associated with the use of a subperiosteal implant is the failure and loss of the implant which could further reduce the minimal amount of existing bone which I now have, requiring more extensive bone grafting and other surgical procedures at some future time. I also understand that other dental practitioners may not be familiar or experienced in the use of subperiosteal implants, including their placement, maintenance, and treating any problems which might arise involving the subperiosteal implant. I promise to, and accept responsibility for failing to, return to this office for examinations and any recommended treatment, at least every 6 months. My failure to do so, for whatever reason, can jeopardize the clinical success of the implant system. Accordingly, I agree to release and hold my dentist harmless if my implant(s) fail as a result of my not maintaining an ongoing examination and preventive maintenance routine as stated above.
2. 1 have further been informed that if no treatment is elected to replace the missing teeth or existing dentures, the non-treatment risks include, but are not limited to:
(a) maintenance of the existing full or partial denture(s) with relines or remakes every three to five years, or as otherwise may be necessary due to slow, but likely, progressive dissolution of the underlying denture-supporting jaw bone;[/font]
,___________________ , hereby authorize Dr. ___________, and any other agents and such assistants as may be selected by him, to perform surgery upon me (or upon the person identified above as the patient, for whom I am empowered to consent), to insert a two-stage endosteal osseointegrated implant(s) in my upper and/or lower jaw.[/font]
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I understand incision(s) will be made inside my mouth for the purpose of placing one or more endosteal titanium root form structures in my jaw(s) to serve as anchor(s) for a missing tooth or teeth or to stabilize a crown(cap), denture or bridge. I acknowledge that Dr. _____________ has explained the procedure, including the number and location of the incisions to be made, in detail. I understand that the crown(cap), denture or bridge will later be attached to this implant by Dr. ___________ and the cost for that work is not included in the charge for this procedure. I also understand that this implant should last for many years, but that no guarantee that it will last for any specific period of time can be or has been given. I have been informed that the implant will remain covered under the gum tissue for at least four months before it can be used and that a second surgical procedure is required to uncover the top of the implant. I also understand that there will be no refund of the fees in the event of failure. It has also been explained to me that once the implant is inserted, the entire dental treatment plan, including my personal oral hygiene, must be followed and completed on schedule. If this schedule is not carried out, the implant may fail /font]
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I understand that excessive smoking, alcohol or sugar may effect gum healing and may limit the success of the implant. I agree to follow my doctor's homecare instructions. I agree to report to my doctor for regular examinations as instructed /font]
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To my knowledge I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, dust, pollens, anesthetics, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health /font]
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I consent to photography, filming, recording and x-rays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed /font]
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I have been informed of the alternatives to use of an osseointegrated implant which may include no treatment at all; construction of a new ridge of my upper or lower jaw by means of vestibuloplasty (plastic surgery on gums), skin and bone grafting with synthetic materials; and implantation of another type of device. The advantages of each of the above procedures, if appropriate, have been explained to me and I choose to proceed with insertion of the osseointegrated implant(s) /font]
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I also authorize and direct Dr. ___________ to provide such additional services as he may deem reasonable and necessary, including, but not limited to, the administration of anesthetic agents; the performance of necessary laboratory, radiological (x-ray), and other diagnostic procedures; the administration of medications orally, by[/font]
I hereby authorize Dr. _____ _______ ______ ______ to perform periodontal surgery upon _____ _______ ______ ______ (name of patient) I have been informed that the purpose of the operation is to surgically treat and possibly correct my diseased gum tissues, implant, and supporting jawbones.
In the event that extraction of an implant is deemed advisable by Dr. _____ _______ ______ ______ due to conditions visualized and determined at the time of surgery, I hereby consent to all such extraction's.[/font]
[FONT='Verdana','sans-serif']If any unforeseen condition should arise in the course of the operation, calling for Dr. _____ _______ ______ ______'s judgment or for procedures in addition to or different from those now contemplated, I further request and authorize the Doctor to do whatever he may deem advisable. Further, I have been informed of other possible alternative and/or supplemental methods of treatment, if any /font]
[FONT='Verdana','sans-serif']Post-operative risks of the proposed surgery include, but are not limited to; pain, restricted mouth opening for several days, weeks, or longer; parasthesia (numbness) of the jaw or gum nerves which may persist for several weeks, months, or in remote instances permanently, gum recession (shrinkage): temporary, or, in rare instances, permanent interference with phonetics (speech sounds); clicking or pain of the temporomandibular joints (jaw joints) tooth sensitivity to hot or cold for days, weeks, or on occasion, several months; transient or in some instances permanent tooth mobility (looseness) in selected areas; food lodging between the teeth after meals, requiring cleaning devices such as floss for removal; and unesthetic exposure of crown margins of teeth in the surgery area.
I further understand that if no treatment is rendered, my present periodontal condition will probably worsen in time, which may result in premature implant loss.
No guarantee, warranty, or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. Due to individual patient differences there exists a risk of failure, relapse, selective re-treatment, or worsening of my present condition despite the best of care. However, it is Dr. _____ _______ ______ ______'s opinion that therapy will be helpful, and that any further loss of supporting tissues or bone would occur sooner without the recommended treatment.
I understand that long-term success requires my long-term continued performance of mechanical plaque removal (daily home care) and my availability for periodic periodontal maintenance visits (recall professional care).
I consent to photographs of my oral and facial structures and their publication for educational and scientific purposes.
I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT AND THE EXPLANATION REFERRED TO OR MADE, AND THAT ALL BLANKS OR STATEMENTS REQUIRING INSERTION OR COMPLETION WERE FILLED IN AND INAPPLICABLE PARAGRAPHS, IF ANY, WERE STRICKEN BEFORE I SIGNED. I ALSO STATE I READ AND WRITE ENGLISH.
Dentist Signature Patient Signature[/font]
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Witness Signature Witness Signature[/font]
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Parent or Guardian, if Patient is a Minor[/font]
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