315 Westheimer Road, Houston, Texas. 77006
P 713.807.9877 F 713.807.0501
Consent for Dental Implant Surgery
(One Stage, Two Stage, Immediate Load and Temporary)
Patient Name Date Friday, November 25, 2016
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE signing.
You have the right to be given information about your proposed implant placement so that you are able to make the decision as to whether to proceed with surgery. What you are being asked to sign is your acknowledgment that you fully understand the nature of the proposed treatment, the known risks associated with it, and the possible alternative treatments.
My planned procedure will involve placement of (#) _____ to _____ implant(s) in the
_______________________________________________________________ area(s) of my
(circle) UPPER and/or LOWER jaw.
____ I understand that dental implants may be placed by either a one-stage technique or two-stage technique. One stage means the implant will be surgically positioned with a portion of the implant protruding through your gum tissue at the completion of surgery. Two-stage surgery requires one surgery to place the implant, followed by a healing time, then a second surgery to uncover the implant and place a healing cap that protrudes through the gum tissue. Both the one-stage and two-stage implant placement techniques usually require a healing period before your restorative dentist will be able to place a dental restoration. Your surgeon and restorative dentist will utilize the technique that is best suited for your condition.
____ In certain unusual circumstances, and with very specific criteria, your surgeon and restoring dentist may elect to restore some or all of the implants immediately or shortly after the placement procedure. This technique is called “Immediate Load” and it carries some increased concerns about bone and implant healing.
____ In certain unusual circumstances, “Temporary Implants” may be placed to temporarily anchor a provisional dental restoration while the other implants heal. This technique carries some increased concerns about the longevity of the “temporary” implants. “Temporary” implants are usually removed in the final treatment phase.
_____In certain cases, the surgery may involve additional materials and procedures (grafting with bone or artificial bone substitutes, use of healing membranes and associated fixation devices, impressions or indexing the implants, etc.). The need for those procedures may not be apparent until after the surgery has begun.
Your procedure is intended to be: One Stage Two Stage
Immediate Load Temporary Implants
Additional methods may include: Grafting (with separate consent form)
Bone substitutes or Locally Available Bone Particles
Healing membrane Fixation screws
Sinus-Lift Procedure (with separate consent form)
Consent for Dental Implant Surgery
The pros and cons of possible alternative methods (if any) of replacing my missing teeth have been explained to me, including:
Keeping, or attempting to improve, my present denture or bridge
Restoring missing teeth with “conventional” methods, such as:
_____ I understand that incisions will be made inside my mouth for the purpose of placing one or more root-form structures (dental implants) in my jaw to serve as anchors to replace a missing tooth or teeth, upon which a crown (cap), bridge or denture will be secured. I acknowledge that the procedure has been explained to my full understanding, including the number and location of incisions and the type of implant(s) that will be used.
____ I understand that the dental restoration (such as crown, bridge or denture) will be made and placed by Dr. _______________________________, and that a separate charge for such services will be made by that office. That office will also monitor those restorations in the future.
____ I understand that if a two-stage procedure is planned, the implant will probably remain covered by gum tissue for the initial healing period, and that a second surgical procedure will be required to uncover the top of the implant to prepare for dental restoration. (In a one-stage procedure, the implant will usually remain accessible.)
Risks and Complications of Dental Implant Surgery include, but are not limited to:
____ A. Post-operative discomfort and swelling that may require several days of at-home recuperation.
____ B. Prolonged or heavy bleeding that may require additional treatment.
____ C. Damage to adjacent teeth or roots of adjacent teeth.
____ D. Post-operative infection that may require additional treatment.
____ E. Stretching of the corners of the mouth that may cause cracking and bruising, and may heal
____ F. Restricted mouth opening for several days; sometimes related to swelling and muscle
soreness and sometimes related to stress on the jaw joints (TMJ).
____ G. Injury to nerve branches in the jaw or soft tissue resulting in tingling, numbness, or pain in the
chin, lips, cheek, gums, tongue (including possible loss of taste sensation) or teeth on the
operated side(s). These symptoms may persist for several weeks or months, and in some
cases may be permanent.
____ H. Opening into the sinus (a normal hollow chamber in the bone above the roots of back upper
teeth) requiring additional treatment. If the sinus is entered there may be symptoms of
sinusitis for several weeks that may require certain medications and additional recovery time.
____ I. Fracture of the jaw or of thin bony plates.
____ J. Bone loss around the implants.
____ K. Certain other fixation devices may be used (screws, plates, membranes, etc.) that may either
stay in place permanently or require later removal by another surgery. There may be
unexpected exposure of these devices through the gum, causing their premature loss or
removal, and possible loss of the implant.
____ L. Implant or prosthesis failure. Rarely, the implant or parts of the structure holding the
replacement tooth, or the replacement tooth itself, may fail due to chewing stresses.
Page 3 of 4, Consent for Dental Implant Surgery
____M. Rejection of the implant by natural body defenses. (If the implant is lost, it is usually possible
to replace it in a later surgery after the bony defect has healed or been bone grafted to achieve
adequate bone volume for another implant placement procedure)
____ N. Other:
____It has been explained to me that during the course of surgery unforeseen conditions may be revealed that will necessitate extension of the original procedure or a different procedure from that which was planned (for example, changing from a one-stage to a two-stage process, use of bone grafting techniques involving substitute material or locally available bone particles, etc.). I give my permission for such additional procedures that may be indicated in my doctor’s professional judgment.
____ No guarantee can be or has been given that the implant(s) will last for a specific time period.
It is anticipated that the proposed treatment will offer measurable relief for my condition, or
otherwise enhance my dental health. Nonetheless, it is not possible to predict the absolute
certainty of success. I hereby acknowledge that no guarantee, warranty or assurance has been
given to me that the proposed surgery will be completely successful in eliminating all pre-treatment
symptoms or complaints. I acknowledge that there is the risk of failure, relapse, selective re-
treatment, or worsening of my present condition, despite efforts at optimal care.
____ I understand that once the implant is inserted, the entire treatment plan must be followed and completed on schedule. If the planned schedule is not carried out, the implant(s) may fail.
____ I understand that my doctor is not a seller of the implant device itself and makes no warranty or guarantee regarding success or failure of the implant or its attachments used in this procedure.
The anesthesia I have chosen for my surgery is:
Local anesthesia (numbness)
Local anesthesia with Nitrous Oxide/Oxygen (Laughing Gas)
Local anesthesia with Oral Sedation (Relaxing Pill)
Local Anesthesia with Intravenous Sedation
Local Anesthesia with General Anesthesia
Anesthetic Risks include: discomfort, swelling, bruising, infection, prolonged numbness and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) that may cause prolonged discomfort and/or disability, and may require special care. Nausea and vomiting, although rare, may be a side effect of IV anesthesia. Intravenous sedation and/or anesthesia is a serious procedure and, although considered safe, carries with it the risk of heart irregularities, heart attack, stroke, brain damage or death.
Your Obligation if IV Anesthesia is used:
Because anesthetic medications cause prolonged drowsiness, you MUST be accompanied by a responsible adult to drive you home and stay with you until you are recovered sufficiently to care for yourself. This may be up to 24 hours.
During recovery time (24 hours) you should not drive, exercise, or operate devices that may harm you, or make important decisions that demand full comprehension.
Page 4 of 4, Consent for Dental Implant surgery
You must have a completely empty stomach. IT IS VITAL THAT YOU HAVE NOTHING TO EAT OR DRINK FOR SIX (6) HOURS PRIOR TO YOUR ANESTHETIC. TO DO OTHERWISE MAY BE LIFE THREATENING!
However, it is important that you take any regular medications (high blood pressure, antibiotics, etc.) or any medications provided by this office, using only a small sip of water.
____ I understand tobacco use is extremely detrimental to the success of implant surgery. I agree to cease all use of tobacco for 2-3 weeks prior to and after surgery, including the later uncovering procedure, and to make strong efforts to give up smoking entirely.
My signature below signifies that all questions regarding this consent have been answered to my satisfaction, and I fully understand the risks involved with the proposed procedures and anesthetic. I certify that I read, write, and understand English. I hereby give my consent for the planned surgery.
Signature of Patient or Guardian Date Friday, November 25, 2016 Guardian’s Relationship to Patient
Doctor’s Signature Date Friday, November 25, 2016
Witness’ Signature Date Friday, November 25, 2016