A crown/bridge may separate from tooth

• If the cement is old or lost  
• Poor retention & resistant form of tooth prepared   
• Extensive decay on tooth 
• Fracture of tooth or its component eg. post                                       

Not all loose crowns/bridges can be recemented especially if the tooth suffers from extensive decay or extensive tooth fracture which renders the tooth to become unrestorable or needs additional preparation for a new crown/bridges. 

Since your crown/bridge is not treated at our clinic, we offer no guarantee concerning the result and longevity of re-cementation of your old crown/bridges. In addition, our dentist is not responsible for any future issues that arise with this tooth. Future issues may include but not limited to: 

• Breakage/chip - crown/bridge may break during or after re-cementation procedure. If this happens, new crowns/bridges will be made at additional cost. 
• Dislodgement: Crown/bridge may separate from tooth again due to poor retention/resistance from initial tooth preparation. 
• Occlusion: we will try our best to re-cement the crown to its original position but we can not guarantee it will be fitted exactly the same as before. Therefore, your occlusion may feel different from before and we will try to adjust it if possible. 
• Tooth decay: tooth decay may still occur after recementation due to poor oral hygiene/diet. 
• Tooth fracture: tooth fracture can occur depending on the amount of remaining underlying tooth structure and occlusal force. 
• Damage of old crown/bridge may occur during polishing/handling. If this happens, new crowns/bridges will be made at additional cost. 

If tooth was not root canal treated

Tooth may become sensitive after re-cementation which can not be predicted and may require root canal treatment or extraction after re-cementation of crown/bridges. If root canal treatment or extraction is needed, extra charges will apply.

If tooth was root canal treated 

Root canal re-infection: with dislodged crown/bridges, saliva/bacteria contamination of root canal treated teeth may occur which may result in re-infection of this tooth in the future. Our dentist has recommended you to have root canal retreatment first but you declined and fully aware that tooth re-infection may occur and re-treatment may be indicated at additional cost in the future.

Your explicit consent: 

I understand that the recementation of crowns and bridges includes certain risks and possible unsuccessful results. 

I agree to assume the above mentioned risks, and acknowledge that the dentist has explained the various options, including the options of no treatment at all. and the option of removing the broken tooth/teeth.

I had the opportunity to ask any questions regarding the nature and purpose of this procedure and have received answers to my satisfaction. I was also given the opportunity to seek a second opinion with another dentist. 

I agree to the dentist at HEARTS DENTAL to recement the tooth   eg. tooth   . At the same time, I also agree that the doctor will take X-rays, give injection and use medication when she thinks it is necessary.

I understand that the total cost of treatment is $   total cost  . 

The above fee includes all filling materials, but does not include potential root canal treatment, new crowns/bridges or extraction.