Informed Consent For Dental Implant Surgery printable pdf download

Informed Consent for Dental Implant Surgery

This is my consent for Dr. Robert Solomon to place dental implants in my jaw bone(s) for the

purpose of giving support either fixed or removable artificial teeth or appliances. For protection

from pain and discomfort during the procedure(s), I further consent Dr. Solomon to request the

administration of local anesthesia and sedation anesthetics and/or sedative agents as he may deem

advisable.

Description: I understand that dental implants are titanium posts placed into the jaw bone(s) to

support replacement teeth. These posts are just as susceptible to disease and bone loss as natural

teeth. Thus, daily care and frequent visits to the dentist are necessary for the longevity of your

dental implants. I understand that in most instances, dental implants require two surgical

procedures. The first surgical procedure (phase 1) will be to place the implant into the jaw bone.

At this time, in most instances, the gum tissue will be closed over the top of the implant. After a

healing period of between 4 and 6 months, a second surgical procedure (phase 2) will be

necessary to remove the gum tissue overlying the top of the implant. A metal post will then be

inserted into the top of the implant. This post will then extend up through the gum and into the

mouth. Following healing of the gum tissue around this metal post, a prosthetic phase will be

started. During this phase of the dental implant treatment, the prosthesis (crown, bridge, denture,

artificial teeth and/or appliance) will be made and attached to the implant(s). Occasionally, in

conjunction with the making of the prosthesis, additional surgery may be necessary to establish a

more ideal contour of the bone and/or gum surrounding the dental implant(s). The surgical phases

will be performed by Dr. Solomon and the prosthetic phase will be performed by Dr. Berty and

Dr. Ryan.

1. I understand that dental implants are most desirable in my case, but when teeth are missing,

one or more of the following treatment options are currently available:

a. Do nothing to replace the missing teeth.

b. Have a removable partial denture to replace the missing teeth. This partial denture or “partial

plate” is an appliance or prosthesis which can be removed and replaced by the patient. If all

of the teeth in one or both jaws are missing, a conventional complete (full) denture(s) can be

made. This complete denture(s) can be removed and replaced by the patient.

c. Have a fixed partial denture or fixed bridge. This appliance or prosthesis is cemented to

adjacent teeth and is not removed.

d. Replace the missing teeth with one or more dental implants. Dental implants are attached to

the bone and can not be removed. However, there are several options for attaching

manufactured teeth to implants, by the way of an appliance or prosthesis. This prosthesis can

either be: “removable” (can be removed and replaced by the patient); “fixed removable” (can

be removed only by a dentist), or “fixed” (can not routinely be removed).

2. While a period of between 4 to 6 months is usually needed for proper healing of the implants,

the exact time will be determined by the operating surgeon.

3. It has been explained to me that there are certain inherent and potential risks in any treatment

or procedure, and that in this specific instance such operative risks include, but are not limited

to: swelling; pain; bruising; fracture of the jaw; stretching the corners of the mouth which

may result in cracking and brushing of the mouth and facial tissues; restricted mouth opening

or discomfort in the jaw muscles or joint(s); possible nerve injury with resulting change in

sensation and/or numbness to the lip, chin, gum, teeth and/or tongue which may be

temporarily or permanent; infection; damage to adjacent teeth, nasal cavity, sinuses; and

failure of the implants to heal (integrate) with the surrounding bone; medical emergencies

that may require life saving procedures and/or admission to a designated hospital.

4. If any unforeseen condition(s) should arise in the course of the operation which calls for the

doctor’s judgment or for procedures in addition to or different from those now planned, I

Informed Consent For Dental Implant Surgery

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