IMPLANT SURGERY INFORMATION AND CONSENT FORM. Diagnosis: After a
... with artificial teeth supported by an implant or implants. ... For example: 1.
Advanced Periodontics & Implant Dentistry
Wayne Aldredge, D.M.D. * R ichard Nejat, D.D.S.* Daniel Nejat, D.M.D.* *Diplomate, American Board of Periodontology
Th es e p a g e s w i ll provide you w ith th e f ollowing inf or ma tion: 1. 2. 3. 4.
U n derstanding the surgic a l pha se of tr e a tme nt E x p lanation of risks and c omplic a tions. E x p ectations after implan t surge r y. P o s t operative instructions.
Pl ease re a d c a refully. C all the office or ma ke a n a ppointme nt with the doc tor ( b e f o r e y o u r i m p l a n t a p pointment) if there are a ny que stions r e ga r ding this c onse nt f or m. A m i n i m u m o f 4 8 hours notice is req uir e d f or c a nc e ling a n impla nt a ppointme nt . T h e r e is a $ 2 0 0 . 0 0 m i sse d appointment fee. This f e e is f or or de r e d impla nt supplie s a nd d is p o s a b le p ro d u c t s se t u p for your surgery. IMP L A N T S U R GE RY INFORM ATION AND CONSENT FORM Di ag n o si s: A f ter a careful oral examina tion, a r e vie w of r a diogr a phs, a nd a stu d y o f my d ent a l c o n d i t i o n , my dentist advised me tha t my missing tooth or te e th might be r e p la c e d wi t h a r t i f i c i a l teeth supported by an impla nt or impla nts. Reco m m e n d e d Treatment: I have b e e n pr e se nte d with the f ollowing options f o r t reat m e n t : 1. 2. 3. 4.
N o t r e atm ent. L i m i t ed use of a new partial de ntur e f or e a ting a nd public a ppe a r a nc e . Cr o w n and bridge-w ork (if possible ) . P l a c e ment of a titanium im p la nt f ixtur e into the e xisting bone of the jaw, w h i c h will be used to suppor t ne w r e stor a tions, f ixe d br idge wor k, or a r e m o v able denture.
I h av e se l e c t e d the option of the plac e me nt of a tita nium f ixtur e into the e xistin g b o n e o f t h e j a w. I a m a w are of the benefits and r isks involve d, a nd ha ve be e n inf or me d o f th e s urgi c a l a n d p r osthodontic procedures involve d. S u rg i c a l P h a se : I understand that seda tion ma y be utiliz e d a nd tha t a loc a l a ne s th e tic wi l l b e a d m i n i stered to m e as part of the tr e a tme nt. My gum tissue will be ope n e d to exp o se t h e b o n e . Im plants w ill be pla c e d by ta pping or thr e a ding the m into the h o le s th a t
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h ave b e e n d r i l l ed into the jaw bone. The impla nts will ha ve a snugly f it a nd will b e h e ld t i g h t l y i n p l a c e during the healing pha se . I f I a m a c a ndida te , a minima lly invas iv e app ro a c h m a y be used to place the impla nt. De pe nding upon the de nsity of the b o n e , s t ab i l i t y o f t h e im plants, and the doc tor ’s c linic a l judgme nt, te e th ma y be a nc ho r e d i m m e d i a t e l y v i a the Smile In A D ay TM or Te e th in a n Hour TM pr oc e dur e or the imp la n ts m ay b e l o a d e d a t a future date. L ater visits will involve the pr osthodontic pha s e o f my t reat m e n t w h i c h m ay involve several a ppointme nts. Th e g u m a n d soft tissue w ill be stitche d c lose d ove r or a r ound the impla nts. Hea lin g w ill ens ue f o r a p e r iod of tw o to six months. I unde r sta nd tha t de ntur e s usua lly c a nn o t b e worn d u r i n g t h e first tw o w eeks of th e he a ling pha se . I f ur the r unde r sta nd tha t if c lin ic a l con d i t i o n s t u r n out to be unfavorable f or the use of this impla nt syste m, or pr e v e n t th e p l ace m e n t o f i m plants, my dentist w ill use pr of e ssiona l judgme nt a s to the ma nag e me n t o f t h e si t u a t i o n . T he procedures also ma y involve a supple me nta l bone gr a f t or oth e r ty p e s o f g r a f t m a t e r i a ls to build up the ridge of my ja w, a nd the r e by a ssist the pla c e m e n t, cl os u r e , a n d se curity of m y im plants. This ma y a lso inc lude the pla c e me nt of bo n e g r a f ts i n t o t h e m a x i l l ary sinuses to increase the he ight a nd width of bone f or the a ppr o p r ia te i n s er t i o n o f i m p lants for use as “back ” te e th. Aft er t h e su rg e ry, there may be tem p or a r y pa in, swe lling, disc olor a tion of the sk in , a n d n u m b n e ss o r a l tered sensation. If sinus gr a f ts a r e use d, the r e ma y be nose ble e d s . Initial and Date _________________ Po s t- O p e r a t i v e E xam: A post-operative e xa mina tion will be r e quir e d a t r e gula r in te r v a ls . For example: 1 . F i r st or second w eek after surge r y; 2 . E v e ry four to eight w eeks a f te r surge r y f or thr e e months. * Cert a i n si t u a t ions m ay require more/le ss f r e que nt visits. Po s t- O p e r a t i v e Sequ elae: Typically, post ope r a tive he a ling is une ve ntf ul. Howe v e r, cert a i n si t u a t i o n s m ay occur: pain around the impla nt f ixtur e , inf e c tion, phobia , o r c h a n g e o f m i n d b y t h e patient. In addition, s ome tingling a nd loss of se nsa tion in the ar e a ma y o ccu r w h e n t h e im plants are placed in the ba c k of the lowe r ja w. I n r a r e situa tio n s , th is al t ere d o r l o ss of sensation may be pe r ma ne nt. Pro g n o si s: W hile the prognosis is favor a ble a t this time , the r e sults c a nnot be g u ara n t e e d si n c e unforeseen changes in the bone a nd sof t tissue ma y oc c ur whic h ma y requ i r e r e m o v a l of the im plant fixture . I f a n impla nt f ixtur e doe s not join pr oper ly w ith t h e b o n e , i t w i ll be necessary to rem o ve the impla nt in que stion. No pr oble ms ar e u s u a lly fo res e e n a s a r esult of this rem oval. S eco n d S u r g i c a l P rocedu re: For impla nts r e quir ing a se c ond surgic a l pr oc e dur e , th e o v erla y i n g t i ssu es w ill be opened at the a ppr opr ia te time , a nd the sta bility of th e imp la n t wi l l b e v e r i f i e d. If the implant appear s sa tisf a c tor y, a n a tta c hme nt will be c onn e c te d to t h e i m p l a n t s. P lans and procedures to c r e a te a n impla nt c r own or a pplia nc e ( by y o u r g ene r a l d e n t i st or restorative dentist) c a n the n be gin a f te r the gum tissue ha s hea le d .
Pro st h e t i c P h a se of P roced u re: I unde r sta nd tha t a t this point I will be r e f e r r e d b a c k to m y d e n t i st o r t o a prosthodontist. T h is pha se is just a s impor ta nt a s the surgic al p h a s e fo r t h e l o n g - t e r m success of the oral r e c onstr uc tion. Dur ing this pha se , a n impla n t p ro s th e t i c d e v i c e or crow n w ill be atta c he d to the impla nt. This pr oc e dur e shou ld b e p erfo r m e d b y a person trained in pro sthe tic pr otoc ol f or the r oot f or m impla nt s y s te m. Initial and Date _________________ Exp e c t e d B e n efits: T he purpose of de nta l impla nts a llows me to ha ve mor e f un c tio n a l art i fic i a l t e e t h . T he im plants provide suppor t, a nc hor a ge , a nd r e te ntion f or the s e te e th and a c t a s n e w roots w ithin the jaw bone . Pri nc i p a l R i sk s an d C omp lication s: I unde r sta nd tha t some pa tie nts do not r e s p o n d s ucce ssf u l l y t o dental implants, and, in suc h c a se s, the impla nts ma y be lost. I mp la n t s urge r y m a y n o t be successful in prov iding a r tif ic ia l te e th. Be c a use e a c h pa tie n t’s con d i t i o n i s u n ique, long-term success c a nnot be pr e dic te d. I u n d e r st a n d t h at com plications m ay r e sult f r om the impla nt surge r y, dr ugs, a nd anes t h e t i c s u se d. T hese com plication s inc lude , but a r e not limite d to, post surg ic a l i n fec t i o n , b l e e d ing, sw elling and pain, f a c ia l disc olor a tion, tr a nsie nt but on oc ca s io n p erm a n e n t n u m bness of the lip, tongu e , te e th, c hin or gum, ja w joint injur ie s, or as s oc i a t e d m u scle spasm , transient, but on oc c a sion pe r ma ne nt inc r e a se d tooth l o o s e n e s s , t o o t h se n si t i v i t y to hot, cold, sw eet o r a c idic f oods, shr inka ge of the gum tissue u p o n h eal i n g r e su l t i n g in elongation of some te e th a nd gr e a te r spa c e s be twe e n some t e e th , crack i n g o r b r uising of the corners of the mouth, r e str ic te d a bility to ope n the m o u th f o r s ev er a l d a y s o r w eeks, impact on spe e c h, a lle rgic r e a c tion, injur y to te e th, bone f r a c tu r e s , n as al si n u s p ene t r a t i o n s, d e layed healing, and ac c ide nta l swa llowing of f or e ign ma tte r. The e x a c t d u rati o n o f a n y complications cannot be de te r mine d, a nd ma y be ir r e ve r sible . I u n d e r st a n d t h at the design and struc tur e of the pr osthe tic a pplia nc e c a n be a su b s ta n tia l fact o r i n t h e su c cess or failure of the impla nt. I f ur the r unde r sta nd tha t a lte r a ti o n s ma d e o n t h e a r t i f i c i a l appliance or the impla nt c a n le a d to loss of the a pplia nc e or imp la n t. Th i s l o ss w o u l d be the sole responsibility of the pe r son ma king suc h a lte r a tions . I a m adv i se d t h a t t h e connection betw een the impla nt a nd the tissue ma y f a il a nd that it ma y b eco m e n e c e ssa ry to rem ove the im pla nt. This c a n ha ppe n in the pr e limina r y ph a s e , d u ri n g t h e i n i t i a l integration of the impla nt to the bone , or a t a ny time the r e a f te r. Nece ssa r y F o l low -u p C are and S elf Care : I unde r sta nd tha t it is impor ta nt f or me to con t i n u e t o se e m y dentist or prosthodontist. I mpla nts, na tur a l te e th, a nd a pplia n c e s h a v e t o b e m a i n t a i n e d daily in a clean, hygie nic ma nne r. I mpla nts a nd a pplia nc e s mu s t a ls o b e exam i n e d p e r i o dically and may need to be a djuste d. I unde r sta nd tha t it is impo r ta n t f o r m e t o a b i d e b y the specific prescriptions give n by my Pe r iodontist. No w a r r a n t y o r Gu arantee: E ven though de nta l impla nts ha ve a ve r y high suc c e s s r a te , I h ea r b y a c k n o w ledge that no 100% wa r r a nty or a ssur a nc e ha s be e n give n to me th a t th e p ro p o se d t r e a t ment w ill be successful. Due to individua l pa tie nt diff e r e nc e s, a P eri o d o n t i st c a nnot predict certainty of suc c e ss. The r e e xists the r isk of f a ilur e, r e la p s e , add i t i o n a l t r e a t m ent, or w orsening of my pr e se nt c ondition, inc luding the possib le lo s s o r d evi t a l i z a t i o n of certain teeth, despite the be st of c a r e . Initial and Date _________________
Pu b l i c a t i o n s o f R ecords: I authorize photos, slide s, a nd x- r a ys of my c a r e a nd tr e a tme n t d u ri n g o r a f t e r its completion to be use d f or the a dva nc e me nt of de ntistr y a nd f o r rei m b u r se m e n t purposes. My identity will not be r e ve a le d to the ge ne r a l public w ith o u t m y p e r m i ssi o n . PATI ENT CONSENT I h av e b e e n f u l ly inform ed of the natur e of de nta l impla nt surge r y, the pr oc e dur e to b e u t i l i z e d , t h e r i s ks and benefits of the surge r y, the a lte r na tive tr e a tme nts a va ila b le , a n d th e n eces si t y f o r f o llow -up care and self c a r e . I ha ve the oppor tunity to a sk que stio n s o r v o i ce c o n c e r n s I may have in connection with the tr e a tme nt. I he r e by c onse nt to p erfo r m a n c e o f dental implant surgery a s pr e se nte d to me dur ing my con s u l t a t i o n / t r eatment planning visit( s) . If cl in i c a l c o n ditions prevent the place me nt of de nta l impla nts, I de f e r to my den tis t’s j u d g m e n t o n t h e surgical managem ent of tha t situa tion. I a lso give pe r mission to r e c e iv e s up p l e m e n t a l b o ne grafts or other typ e s of gr a f ts to build up the r idge of my ja w a n d t h ere b y a ssi st i n the placement, closur e , a nd se c ur ity of my impla nts. I u n d e r st a n d t h at the fee for my dental impla nt( s) a nd surge r y doe s not inc lude t h e f e e f o r t h e re st o r a t i v e w ork (crow ns or dentur e s) . I h er e b y g i v e c onsent to D r. N ejat to pe r f or m the ne c e ssa r y tr e a tme nt.
Date _____________________________________________ Patient Signature __________________________________________________ Witness Signature __________________________________________________ Dentist Signature __________________________________________________ Location and Type of Implants ___________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
