After a careful oral examination and study of my dental condition, Dr.______________
has advised me that my missing tooth/teeth may be replaced with artificial teeth
supported by dental implants as follows:
Anesthesia: 1) __ Local Anesthetic, 2) __ Oral Sedation, 3) __ Conscious Sedation.
All risks/benefits and instructions pertaining to sedation and surgical complications
appear on the “Surgical Consent” sheet. I have selected the above treatment and
have read and understand all items pertaining to the “Surgical Consent” sheet.
In order to treat this condition, Dr._______has recommended that my treatment include
dental implant(s) to be implanted into the jawbone. I understand that this surgical
phase is followed by a prosthetic phase where artificial dentures, bridges or crowns
are placed by the dentist/prosthodontist.
I understand that sedation may be utilized and that a local anesthetic will be administered
to me as part of the treatment. My gum tissue will be opened to expose the bone,
implants will be placed and the gum tissue will be sutured during the healing phase.
I understand that the healing phase of surgery varies from patient to patient and
case to case, but typically last between 2-6 months. I understand that dentures
or partial dentures that place pressure on the surgical site are to be avoided for
1-2 weeks following surgery.
I further understand that if during surgery the clinical situations turn out to
be unfavorable for the implant, Dr. _____will make a professional judgment to manage
this. This includes canceling the procedure, supplemental bone and soft tissue grafting
to allow placement, gum closure and security of the dental implants. These procedures
might be done in conjunction or separately from the implant placement.
I understand that some implants require second stage surgeries. Overlying tissues
will be opened at the appropriate time and the stability of the implant will be
verified. If the implant appears satisfactory, an attachment will be connected to
the implant. The artificial crown fabrication may begin after healing of this soft
tissue. I understand that I will be referred back to my dentist/prosthodontist to
have this artificial crown/denture treatment.
Expected benefits: The purpose of dental implants is to allow me to have more functional
artificial teeth and an improved appearance. The implants provide support, anchorage
and retention for the artificial replacement.
Principal risks and complications: I understand that a small number of patients
do not respond successfully to implant placement. In such cases, implants may have
to be removed and replaced. Because each patient’s conditions are unique, long-term
success may not occur. I understand that complications may result from the implant
surgery, drugs or anesthetics.
There is no method that will accurately predict or evaluate how my gum and bone
will heal. I understand that there may be a need for a revision procedure if the
initial results are not satisfactory. In addition, the success of dental implant
procedures can be affected by medical conditions, dietary and nutritional problems,
smoking, alcohol consumption, clenching and grinding of teeth, inadequate oral hygiene
and medications that I may be taking.
To my knowledge, I have reported to Dr.______any prior drug reactions, allergies,
diseases, symptoms, habits or conditions which might in any way relate to this surgical
procedure. I understand that my diligence in providing the personal daily care recommended
by Dr. _____and taking all medications as prescribed are important to the ultimate
success of the procedure.
Alternatives to suggested treatment: I understand that alternatives to dental implant
surgery include: No treatment, removable appliances and other procedures depending
Necessary follow-up and self-care: I understand that it is important for me to continue
regular visits to dentist. Implants, natural teeth and appliances must be maintained
in a clean, hygienic manner. Implants and appliances should be examined by the dentist
or Dr.______ periodically.
I have been fully informed of the nature of implant surgery, the procedure to be
utilized, the risks and benefits of implant surgery and the selected anesthesia,
the alternative treatments available and the necessity for follow-up and self-care.
I have had an opportunity to ask any questions I may have in connection with the
treatment and to discuss my concerns with Dr. ______
I hereby consent to the performance of dental implant surgery as presented to me
during consultation and the treatment plan as described in this document.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS CONSENT DOCUMENT: DENTAL IMPLANT SURGERY
Patient Name:____________________________________________ Date: ______________
Parent/Legal Guardian (if applicable):___________________________