SINUS LIFT (SINUS BONE GRAFTING) INFORMATION AND CONSENT FORM

1. I have been informed and I understand the purpose and the nature of the Sinus bone grafting surgery, that will be performed to place a bone graft material into the floor of the sinus to build up adequate bone height for the placement of implants.

2. The bone graft will consist of a bone substitute material, tissue bank bone, animal bone or a combination of them.

3. In approximately 6-9 months after the bone graft has partially healed and integrated, a second procedure will be done to insert the implants into the upper jaw and the grafted material. In some cases it is possible to insert the implants and graft the floor of the sinus simultaneously at the same operation.

4. Although the success rate of this procedure is extremely high, Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad has explained to me that if the bone graft does not incorporate with my own bone alternative prosthetic measures will have to be considered, including but not limited to, dentures and or bridges and or no treatment.

5. The likelihood for success of the suggested treatment plan is very high. However, there are risks involved. Bone grafting of the sinus has consistently been shown in the research literature to enjoy very high success with a low chance of rejection or infection. However, there is no guarantee that your graft will not become infected or rejected.

6. It is understood that although good results are expected, they cannot be and or not implied guaranteed or warrantable. There is also no guarantee against unsatisfactory or failed results.

7.I have been informed and I understand that occasionally there are complications of surgery, drugs and anesthesia including but not limited to: Pain, swelling, discoloration of the face, neck and mouth. Numbness and tingling of the upper lip, chin, gums, teeth, cheek, and palate, which may be temporary or, rarely permanent. Infection of the bone, that might require further treatment including hospitalization & surgery Mal-union, delayed union or non-union of the bone graft material to normal bone Lack of adequate bone growth into the bone graft replacement material Bleeding which may require extraordinary means to control hemorrhage Limitation of jaw function; stiffness of facial and jaw muscles Injury to teeth and or loss of teeth and bone segments Referred pain to the ear, neck and head Postoperative complications involving the sinuses, nose, nasal cavity, sense of smell, infraorbital regions, and altered sensations of the upper cheek and eyes. Postoperative unfavorable reactions to drugs, such as nausea, vomiting and allergy.

8. I understand that I am not to use alcohol or non-prescribed drugs during the treatment period. Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad has discussed with me that smoking is particularly harmful to the success of this operation. I have been requested to stop smoking .

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9. I have been informed that I should avoid flying for the first 2 weeks after my sinus surgery (Pressure changes experienced during flying may cause bleeding and discomfort) and to avoid any strenuous activity for the first week.

10. I have also been informed that it is of paramount importance that I follow the postoperative instructions sheet and take all the prescribed medications as they are crucial to the success of this sinus grafting surgery. Failure to follow these instructions could increase chances of infection or rejection of the graft.

11. I understand that Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad will give his best professional care toward the accomplishment of the desired results.I understand that I can withdraw from treatment at any time.

12. I give permission to photography and/or video recording of this procedure for treatment planning, documentation of my ongoing care, teaching and research. My anonymity is guaranteed.

13. I authorize and request that Dr. Farzin Ghannad, Dr. Hannu Larjava, Dr. Nabil Nadji, Dr. Robert Straga, Dr. Farzan Ghannad to perform this sinus grafting surgery on my upper jaw (maxilla) and such additional procedures as may be found necessary in the judgment of my doctor during the course of this treatment.I understand unforeseen circumstances may necessitate a change in the desired procedure or in the rare cases, prevent completion of the planned procedure.

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

15. I consent to photographic recording/documentation of any aspect of my treatment or follow-up care and i understand that these records will be used to document the progress of my care along with other purposes as stated above.