I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED BRIDGEWORK includes certain risks and possible unsuccessful results, including the possibility of failure. Even though care and diligence is exercised in the treatment of conditions requiring crowns and bridgework and fabrication of same, there are no promises or guarantees of anticipated results or the longevity of the treatment. Nevertheless, I agree to assume the risks, possible unsuccessful results and/or failure associated with, but not limited to the following:

1. Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth it is necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed upon them. Tooth preparation will be done as conservatively as possible.
   
   
2. Injury: During the reduction of tooth structure or adjustments done to temporary restorations, it is possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut). In some cases, sutures or additional treatment may be required.
   
   
3. Local Anesthesia: In order to reduce tooth structure without causing undue pain during the procedure, it will be necessary to administer local anesthetic. Such administration may cause reactions or side effects which include, but are not limited to, bruising, hematoma, cardiac stimulation, temporary or, rarely permanent numbness of the tongue, lips, teeth, jaws and/or facial tissues, and muscle soreness.
   
   
4. Sensitivity of teeth: Often, after the preparation of teeth for the reception of either crowns or bridges, the teeth may exhibit sensitivity, which can range from mild to severe. This sensitivity may last only for a short period of time or may last for much longer periods. If sensitivity is persistent, this office should be notified immediately such that all possible causes of the sensitivity may be ascertained.
   
   
5. Following crown preparation and placement for either individual teeth or bridge abutments, the involved tooth or teeth may require root canal treatment: Teeth, after being crowned, may develop a condition known as pulpitis or pulpal degeneration. Usually, this cannot be predetermined. The tooth or teeth may have been traumatized from an accident, deep decay, extensive preparation, or other causes. It is often necessary to do root canal treatments in these teeth, particularly if teeth remain appreciably sensitive for a long period of time following crowning. Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical surgery or even extraction may be necessary.
   
   
6. Breakage: Crowns and bridges may possibly chip or break. Many factors can contribute to this situation such as chewing excessively hard materials, changes in biting forces exerted, traumatic blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes, but crowns/bridges may not actually break until chewing soft foods, or for no apparent reason. Breakage or chipping seldom occurs due to defective materials or construction unless it occurs soon after placement.
   
   
7. Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the artificial replacements. Most patients usually become accustomed to this feeling in time. In limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for indeterminable periods of time following placement of the crown or bridgework.
   
   
8. Esthetics or appearance: Patients will be given the opportunity to observe the appearance of crowns or bridges in their mouths prior to final cementation. If satisfactory, this fact will be acknowledged by the patient's signature (or signature of legal guardian) on the back of this form where indicated.
   
   
9. Longevity of crowns and bridges: There are many variables that determine "how long" crowns and bridges can be expected to last. Among these are some of the factors mentioned in preceding paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can affect longevity. Because of this, no guarantees can be made or assumed to be made concerning how long crown and bridgework will last.
   
   
10. Opening the Bite: In some cases, years of wear on the teeth will create a situation where the patient overcloses or loses length of the face. A full mouth reconstruction where all existing teeth are crowned will enable the dentist to reopen the bite to the proper length. As a result the patient may experience some temporary discomfort and the crowns will be more subject to wear and breakage. If a nightguard is recommended or made but not worn by the patient, there will be an increased risk of breakage or fracture of the porcelain.
    
    
11. It is the patient's responsibility to seek attention from the dentist should any undue or unexpected problems occur. The patient must diligently follow any and all instructions, including the scheduling and attending all appointments. Failure to keep the cementation appointment can result in ultimate failure of the crown/bridge to fit properly and an additional fee may be assessed.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of crown and/or bridge treatment and have received answers to my satisfaction. I do voluntarily assume any and all reasonable medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of standard crown and bridge prosthetics treatment procedures in hopes of obtaining the potential desired results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results.

1. The nature and type of material used in my crown(s) or bridgework, for example porcelain-fused-to-metal, all porcelain, etc. has been explained to me and it is my understanding that the material to be used is:

By signing below I acknowledge and authorize the above listed material to be used in my mouth.

2. I have been given the opportunity to view my crown(s) and/or fixed bridgework in place prior to final cementation. I approve the color, shape, feel and overall appearance of my crown(s) or fixed bridgework. I understand that once the crown/fixed bridgework is placed in my mouth, the factors of color, shape, feel and overall appearance cannot be changed without additional and possibly significant time being taken and fees assessed. I further understand that removing cemented crowns or fixed bridgework may create the risk of injury or breakage to the underlying teeth.