Diagnosis: After a thorough oral examination, my dentist has advised me that the revision of a frenum in my mouth may help to restore anatomy, function, and/or prevent commonly associated future problems (ie: continued recession due to frenum pull).

Recommended Treatment: In order to treat this condition, my dentist has recommended that a frenectomy be performed at the selected site or sites.

Principle Complications: I understand that a smooth recovery is expected, however, there are always associated risks that cannot be eliminated and may occur in a minority of cases. These complications include but are not limited to post-surgical bleeding, infection, swelling, discomfort, damage to adjacent structures such as salivary glands, nerve, muscle, or skin. A more common complication is re-attachment of the frenum. Genetics also plays a strong role in healing, such as formation of scar, keloid, or overt fibrous tissue formation.

Follow Up: I am advised to return for a 1-week check, and a 3 week check to follow up on the proposed care. There may be a referral to a myofunctional therapist or another professional for follow up care. Photos may be taken, but not of the face without permission.

Alternatives to Suggested Treatment: I understand that alternatives to a frenectomy include: no frenectomy, with the expectation that the frenum does not normally improve but may aggravate the surrounding tissues including the gums and teeth. Also, an alterative to a frenectomy by my dentist is to seek the care of another health care professional, including but not limited to doctors of periodontics, oral surgery, ENT, and plastic surgery. The procedure can be performed with a scalpel, scissors, or a laser.

No Warranty or Guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. I do expect however that the doctor perform the surgery to the best of her ability.

I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT AND ALL MY QUESTIONS REGARDING THIS DOCUMENT AND THE PROCEDURE WERE ANSWERED.