Consent for Dental Implants

1. I request and authorize my doctor to perform the surgical placement of dental implants upon me. This procedure has been recommended to me by my dentist as an option to replace my natural teeth. Dental implants are metal anchors put inside the jawbone underneath the gum line. Small posts are attached to the implants and artificial teeth or dentures are fastened to the posts. Most implants are installed in two stages. The first procedure involves drilling small holes into the jawbone and placing the anchors. A temporary denture may be worn for a few months while the anchors bond with the jawbone and the gums and bone heal. The second procedure will uncover the implants to allow for attachment of the posts. After the posts are in place, the replacement teeth, in the form of fixed or removable bridgework or a denture, are fastened to the posts. Depending on the condition of the mouth, bone grafting or guided tissue regeneration also might be necessary to install the anchors and posts.
   
   
2. I have chosen to undergo this procedure after considering the alternative forms of treatment for my condition, which include no treatment at all, complete or partial dentures, or fixed or removable bridges. Each of these alternative forms of treatment has its own potential benefits, risks and complications.
   
   
3. I consent to the administration of local anesthetic before, during or after the procedure. I understand that all anesthetics involve the very rare potential of risks or complications such as damage to the nerves.
   
   
4. I understand that there are potential risks, complications and side effects associated with any dental procedure. Although it is impossible to list every potential risk, complication and side effect, I have been informed of some of the possible risks, complications and side effects of dental implant surgery. These could include but may not be limited to the following:
   
   a.) Postoperative discomfort and swelling
   
   b.) Bleeding
   
   c.) Postoperative infection
   
   d.) Injury or damage to adjacent teeth or roots of the teeth
   
   e.) Injury or damage to nerves in the lower jaw, causing temporary or permanent numbness and tingling of the chin, lips, cheek, gums or tongue
   
   f.) Restricted ability to open the mouth because of swelling and muscle soreness or stress on the joints in the jaw — temporomandibular joint (TMJ) syndrome
   
   g.) Fracture of the jaw
   
   h.) Bone loss of the jaw
   
   i.) Penetration into the sinus cavity
   
   j.) Mechanical failure of the anchor, posts or attached teeth
   
   k.) Failure to implant itself
   
   l.) Allergic or adverse reaction to any medications
   
   m.) When issues do arise with implants, they occur at a faster rate compared with natural teeth
   
   n.) Implant do not have the ability to move or modify their position, unlike natural teeth. As you age, your body continues to grow and change. Gaps between implants and teeth can occur as a result. Because of this you may require modifications to the crowns or bridges, as well as additions to adjacent teeth.
   
   Most of these risks, complications and side effects are not serious or do not happen frequently. Although these risks, complications and side effects occur very rarely, they do sometimes occur and cannot be predicted or prevented. I acknowledge that no guarantee has been made to me about the results of this procedure or the occurrence of any risks, complications or side effects. These potential risks and complications could result in the need to repeat the procedures; remove the implants; or undergo additional dental procedures. I recognize that during the course of treatment, unforeseeable conditions may require additional treatment or procedures.
   
   
5. I understand after implant maintenance is also very important for long-term success of my therapy. This includes and may not be limited to annual implant evaluation and follow-up. My failure to arrange annual follow-up may cause the loss of my implant. More frequent visits to the Hygienist may be required as oral plaque can negatively affect them. To avoid damage to your implants and porcelain crowns, we recommend you wear a night guard and have it checked frequently.
   
   
6. Unless you are being treated by our prosthodontists, please note our office will not be fabricating the final implant restoration (crown, bridge, denture). Please contact your general dentist for a breakdown of all related restorative costs associated with the restoration of your implant.

I certify that I have read or had read to me the contents of this form. I understand the potential risks, complications and side effects involved with any dental treatment or procedure and have decided to proceed with this procedure after considering the possibility of both known and unknown risks, complications, side effects and alternatives to the procedure. I declare that I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I have read and understand this document before I signed it: