Implant Patient Surgery Information and Consent Form
Recommended Treatment. I have been presented with the following options for treatment.
- No treatment.
- Limited use of a new partial or full denture for eating and public appearance.
- Crown and bridge-work (if possible).
- Placement of titanium implant fixtures into the existing bone of the jaw, which will be used to support new restorations, fixed bridgework, or a removable denture.
I have selected the option of placement of titanium fixtures into the existing bone of the jaw.
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. Implants will be placed, by tapping or threading them, into the holes that have been drilled into my jawbone. The implants will have a snugly fit and will be held tightly in place during the healing phase.
The gum and soft tissue will be stitched closed over or around the implants. Alternatively, a temporary tooth will be connected to my implant. A periodontal bandage or dressing may be placed. Healing will be allowed to proceed for a period of two to nine months. I understand that dentures usually cannot be worn during the first two weeks of the healing phase.
I further understand that if clinical conditions turn out to be unfavorable for the use of this implant system, or prevent the placement of implants, my dentist will make a professional judgment of the management of the situation. The procedures also may involve supplemental bone graft or other types of grafts to build up the ridge of my jaw, and thereby to assist the placement, closure, and security of my implants. This may also include the placement of bone grafts into the maxillary sinuses to increase the height and width of bone for the appropriate insertion of implants for use as “back” teeth.
After the surgery, there may be temporary pain, swelling, discoloration of the skin, and numbness or altered sensation. If sinus grafts are used, there may be nosebleeds.
Post-Operative Exam. Post-operative examination will be required at regular intervals.
- For example:*
- Seven Days after Surgery
- Two Weeks after Surgery
- Every six to eight weeks after surgery until surgical exposure of the implants.
Prognosis. While the prognosis is favorable now, the results cannot be guaranteed since unforeseen changes in the bone and soft tissue may occur which may require removal of the implant fixture. If an implant fixture does not join properly with the bone, it will be necessary to remove the implant in question. No problems are usually foreseen because of this removal. If, on the remote possibility, the entire group of implant fixtures should fail to integrate into the bone, a new attempt if possible can be made on a later date.
PATIENTS WHO SMOKE DURING THE HEALING PERIOD WILL HAVE A DECREASE OF A SUCCESS RATE. THE PATIENT WILL BE RESPONSIBLE FOR COST OF NEW REPLACEMENT.
Second Surgical Procedure. For implants requiring a second surgical procedure, the overlaying tissues will be opened at the appropriate time, and the stability of the implant will be verified. If the implant appears satisfactory, an attachment will be connected to the implants. Plans and procedures to create an implant crown or appliance can then begin after the gum tissue has healed.
Principal Risks and Complications. 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, transient, but on occasion permanent increased tooth looseness, tooth sensitivity to hot, cold, sweet or acidic foods, shrinkage of the gum tissue upon healing resulting in elongation of some teeth and greater spaces between some teeth, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech, allergic reaction, injury to teeth, bone fractures, nasal sinus penetrations, delayed healing, and accidental swallowing of foreign matter. The exact duration of any complications cannot be determined, and may be irreversible.
No warranty or Guarantee. Even though dental implant have a very high success rate (92-97% in Healthy no smoking adults), I hear by acknowledge that no guarantee, warranty, refund or assurance has been given to me that the proposed treatment will be successful. Due to individual patient differences, a Dentist cannot predict certainty of success. There exists the risk of failure, relapse, additional treatment, or worsening of my present condition, including the possible loss or devitalization of certain teeth, despite the best of care.
Monday8:00 am - 4:00 pm
Tuesday8:00 am - 5:00 pm
Wednesday8:00 am - 5:00 pm
Thursday 8:00 am - 5:00 pm
Friday 8:00 am - 5:00 pm
507 Dwight Street, Coudersport, PA 16915