Diagnosis: After a careful oral examination and study of my dental condition, my Periodontist has advised that my missing tooth or teeth may be replaced with artificial teeth supported by an implant.

Recommended Treatment: In order to treat my condition, my Periodontist has recommended the use of root form dental implants.  I understand that the procedure for root form implants involves placing implants into the jawbone.  This procedure has a surgical phase followed by prosthetic phase where the artificial teeth or tooth crowns are placed.

Surgical Phase of Procedure:  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.  The implants will be placed by threading them into holes that have been drilled in my jawbone.  The implants will have to be snugly fitted and held tightly in place during the healing phase.

In a one-stage implant procedure, a small round section of gum tissue is removed from the site where the implant is planned.  A series of holes will then be drilled into the jawbone and the implant screwed into place.  A titanium-healing collar is then threaded into the implant.  This allows the gum tissue to heal in preparation for restoration.  One-stage implants do not normally require a second surgery in order to complete the restoration.

In the two-stage procedure, the soft tissue will be stitched closed over or around the implants.  A periodontal bandage or dressing may be placed.  Healing will be allowed to proceed for a period of three to six months.  I understand that dentures usually cannot be worn during the first one to two weeks of the healing phase.

I further understand that if during surgery, clinical conditions turn out to be unfavorable for the use of this implant system, or prevent the placement of implants; my Periodontist will make a professional judgment on the management of the situation.  The procedure may need to be canceled or may involve supplemental bone grafts, sinus lift or augmentation, or other type of grafts to build up the ridge of my jaw to allow placement, gum closure, and security of my implants. There will be additional fees for procedures as needed. 

For implants requiring a second surgical procedure, the 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.  Plans and procedures to create an implant prosthetic appliance or artificial crown can then begin.

Prosthetic Phase of Procedure:  I understand that at this point I will be referred back to my dentist or to a Prosthodontist.  This phase is just as important as the surgical phase for the long-term success of the oral reconstruction. During this phase, an implant prosthetic device will be attached to the implant.  A person trained in the prosthetic protocol for the root form implant system should perform this procedure.   

Expected Benefits:  The purpose of dental implants is to allow me to have more functional artificial teeth or improved appearance.  The implants provide support, anchorage, and retention for artificial teeth or crowns.

Principal Risks and Complications: I understand that some patients do not respond successfully to dental implants, and in such cases, the implant may need to be removed.  Implant surgery may not be successful in providing artificial teeth.  Because each patient’s condition is unique, long-term success may not occur.                                                                          

I understand that complications may result from the implant surgery, drugs and anesthetics.  These complications include, but are not limited to: post-surgical infection, bleeding, swelling and pain, facial discoloration, transient but on occasion permanent numbness of the lip, tongue, teeth chin or gum, jaw joint injuries or associated muscle spasm, cracking or bruising of the corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech, allergic reactions, injury to teeth, bone fractures, nasal sinus penetrations, delayed healing, and accidental swallowing of foreign matter.  The exact duration of any complications cannot be determined, and they may be irreversible.   

Alternatives to Suggested Treatment:  Alternative treatments for missing teeth include: no treatment, new removable appliances, and other procedures – depending on the circumstances.  However, continued wearing of ill-fitting appliances can result in further damage to the teeth, bone and soft tissue of my mouth.

Necessary Follow-Up Care and Self-Care:  I understand that it is important for me to continue to see my general dentist or Prosthodontist.  Implants, natural teeth and appliances must be maintained daily in a clean, hygienic manner; Implants and appliances must also be examined periodically and may need to be adjusted.  I understand that it is important for me to abide by the specific prescriptions and instructions given by my Periodontist.   

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.  Due to individual patient differences, a surgeon cannot predict certainty of success.  There exists the risk of: failure relapse, additional treatment or worsening of my present condition, including the possible loss of certain teeth or implants, despite the best care.  

IMPLANT WARRANTY 5 YEARS

If an implant that was placed in our office fails, we will replace it at no cost (within 5 years from date of placement), one time only. If an implant requires a repair procedure, it will be billed according to the warranty, one time only. In the event that the implant fails a second time, the patient will be responsible for the complete procedure fees including implant and final restoration.  Additional grafting, if needed, will be charged at the standard fee. An annual implant examination including x-rays and regular dental cleanings are an absolute requirement for this warranty to apply. This warranty does not apply to smokers or to persons who have, or who develop, an uncontrolled systemic health problem, such as, but not limited to, diabetes, autoimmune disorders, severe osteoporosis, or any condition requiring long term steroid use. If smoking or a medical condition is suspected as the cause of implant failure or other complication that requires treatment, a medical examination and appropriate blood tests will be required for this warranty to apply.

Publication of Records:  I authorize photos, slides, x-rays, or any other viewings of my care or treatment during or after its completion to be used for the advancement of dentistry and for reimbursement purposes.  My identity will not be revealed to the general public, however, without my permission. 

Patient Consent:  I have been fully informed of the nature of root form implant surgery, the procedure to be utilized, the risks and benefits of this surgery, the alternative treatments available, and the necessity for follow-up care 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 my Periodontist.  After a thorough deliberation, I hereby consent to the performances of dental implant surgery as presented to me during consultation and in the treatment plan presented to me.

I also consent to the use of alternative implant system(s) or method(s) if clinical conditions are found to be unfavorable for the use of the implant system that has been described to me.  If clinical conditions prevent the placement of implants, I defer to my Periodontist’s judgment on the grafts of other types of grafts to build up the ridge of my jaw and thereby to assist in placement and security of my implants.

                   ***I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT***