CONSENT FOR EXPOSURE OF IMPACTED TOOTH and/or Extraction

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BENEFITS and DESCRIPTION of PROCEDURES: Exposure of an impacted tooth (teeth) and extraction of a retained primary tooth (teeth) will allow me to continue with my orthodontic treatment. Local anesthetic will be used to numb the area(s) to be treated. If my dentist has requested extraction of my retained primary tooth, this tooth will be removed. For the impacted tooth exposed from the palatal side (roof of my mouth), the gum tissue and bone covering the tooth will be removed and a soft tissue graft will be placed around the crown of the exposed tooth to minimize the chance of tissue growing back. For impacted teeth that are exposed from the cheek side, the gum tissue is moved downward on the tooth and any surrounding bone removed. A periodontal dressing and stitches may be used to keep the gum tissue away from the exposed crown.

OTHER CONSIDERATIONS: We may recommend additional diagnostic studies (special x-rays) to help determine the exact position of the impacted tooth and surrounding teeth. Once uncovered, the tooth may require a button or chain to be attached to the tooth, either at our office or at your dentist's office.

RISKS RELATED TO THE PROCEDURE: Possible risk or complications of a tooth uncovering may include, but are not limited to, allergy or adverse reaction to any medications used, pain, infection, bleeding, numbness, swelling and exposure of root surfaces in adjacent teeth. If a tooth is extracted other possible risks include dry socket. It is also possible that the tissue may grow back over the crown(s and a second procedure may be required to remove additional tissue. If a temporary attachment is placed on the exposed tooth it may detach and require a second procedure to replace it. In rare cases, an impacted tooth may be ankylosed (fused to the surrounding bone) and may not move with orthodontics. If so, tooth removal may be necessary. In some cases, the space may be closed with orthodontic treatment or the tooth is removed. An impacted tooth may have caused damage to adjacent teeth that is not evident until the teeth are moved during orthodontics. When alignment of the impacted tooth is complete, the gum line may be uneven. Impacted teeth often experience some gum recession during alignment. If the appearance of the gum line is uneven, a secondary separate procedure (not described in this document) may be needed.

ALTERNATIVE to the PROCEDURE: No treatment, which may result in difficulty proceeding with your orthodontic treatment.

CONSENT FOR EXPOSURE OF IMPACTED TOOTH and/or Extraction

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NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed surgery will be completely successful in eradicating all pre-existing symptoms or complaints. It is anticipated that the surgery will provide benefit in reducing the cause of this condition and produce healing which will enhance the possibility of longer retention of my teeth by reducing the problems associated with this tooth/ these teeth. However, due to individual patient differences, one cannot predict the absolute certainty of success. Therefore, there exists the risk of failure, relapse, selective retreatment, or worsening of my present condition including the possible loss of certain teeth with advanced involvement, despite the best of care.

CONSENT TO UNFORSEEN CONDITIONS: During surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, extraction of hopeless teeth to enhance healing of adjacent teeth, the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or termination of the procedure prior to completion of all of the surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the treating doctor.

COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or alcohol intake may affect healing and may limit the successful outcome of my surgery. I agree to follow instructions related to the daily care of my mouth. I agree to report for appointments as needed following my surgery as suggested so that my healing may be monitored and the doctor can evaluate and report on the outcome of surgery upon completion of healing.

SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, video recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures or publications, provided my identity is not revealed.

PATIENT'S ENDORSEMENT: My endorsement (signature) to this form indicates that I have read and fully understand the terms and words within this document and the explanations referred to or implied, and after thorough deliberation, I give my consent for the performance of any and all procedures related to tooth extraction as presented to me during the consultation and treatment plan presentation by Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga or Dr. Farzan Ghannad; or as described in this document.

I hereby state that I read, speak and understand English.