I have been fully informed of the nature of implants and implant surgery, therapeutic risks, and treatment alternatives to dental, and I hereby consent to their surgical placement in my jaws (mouth). I agree to maintain these implants as prescribed by my dentist.
Nature of Procedure
The initial surgical phase consists of the surgical reflection of the gum tissue followed by precision drilling of holes into the underlying jawbone which depth and width are somewhat smaller than the roots of your natural teeth. These holes are immediately filled with metal cylindrical posts (implants), which are designed to remain in the jawbone indefinitely. In some
Situations, where inadequate bone is present, a regenerative procedure might be utilized in which a freeze-dried bone graft is placed and the site is then covered with a regenerative membrane. All surgery is performed under local anesthesia and may be supplemented with sedative drugs or I.V. Conscious Sedation (if requested by the patient or if deemed necessary).
During the first two (2) weeks following the initial surgery, no dentures or partial dentures should be worn over the surgical sites without consent of the surgeon.
The second surgical procedure usually occurs three-to-eight months after the initial surgery. At this time the implant is evaluated for proper healing and a post is placed into the implant, which extends through the gum tissue into your mouth. Additionally, a minor surgical correction of tissue may later be necessary to modify any tissue overgrowths or discrepancies.
In the final prosthetic phase, a metal sleeve is threaded into the previously surgically imbedded implant, which is then attached (anchored) to the overlying denture, crown, or bridge.
Alternative Treatments to Implants
1. If no treatment is elected to replace existing dentures or missing teeth, the non-treatment risk includes maintenance of the existing full or partial denture with relines or remakes every three-to-five years for shifting of teeth, or as otherwise may be necessary due to the slow but progressive resorption (dissolution) of the underlying (supporting) jawbone.
2. Construction of new full or partial dentures or bridges, which may provide better fit and function than your present situation.
3. Surgical treatment to provide a better base or foundation for a new denture. Associated risk and benefits of alternative surgical procedures may be explained in greater detail by consulting an oral surgeon.
Risks
1. Surgical risks include, but are not limited to: post-surgical infection; bleeding; swelling; pain; facial discoloration; sinus or nasal perforation during surgery; TMJ (aw joint) injuries or spasms, bone fractures; slow healing; and, transient, but on occasion, permanent numbness of the lip, chin, and tongue.
2. Prosthetic implant risks include, but are not limited to: unsuccessful union of the implant to the jawbone and/or stress metal fractures of the implant. After one (1) year of stable implant retention, it is probable that the implant is permanently joined to the underlying jawbone. A separate surgical procedure for removal of the implant is necessary if implant failure or fracture occurs or requires replacement for changed prosthetic needs. If the implant fails, there will be fees charged for their removal and/or replacement.
No Warranty or Guarantee
I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed implant will be completely successful in function or appearance (to my complete satisfaction). It is anticipated that the implant will be permanently retained, but because of the uniqueness of every case, and since the practice of dentistry is not an exact science, long-term success cannot be promised.
Consent to Unforeseen Surgical Conditions
During treatment, unknown oral conditions may modify or change the original treatment plan such as discovery of changed prognosis for adjacent teeth or insufficient bone support for the implant. I therefore consent to the performance of such additional or alternative procedures as may be required by proper dental care in the best judgment of the treating doctor.
Patient Aqreement to Daily Home Care
In order to improve chances for success, I have been informed that the implant and adjacent teeth must be maintained dally in a clean and hygienic manner, and I agree to perform the home care in accordance with instructions provided, as well as keep periodic professional maintenance visits.
I understand Dr. Mia Anne V Perez is my oral surgeon, and that she will be responsible to assist me during the post-operative phase. It is my responsibility to inform Dr. Perez: of any problems that occur following the surgery. I understand how to get in touch with Dr. Perez. In rare cases, it may be necessary to refer some post-operative patients to another doctor. The costs associated with any consultation or treatment with other doctors will be the patient’s responsibility.
I certify that I have read and fully understand the above authorization and information consent to implant insertion and surgery and that all of my questions, if any, have been answered.
* Selecting I agree means giving full consent and is equivalent to patient’s signature.
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