Dental Implants Consent and Warranty

An explanation of your need for dental implants, their purpose and benefits, the surgeries related to their placement and exposure, and the possible complications as well as alternatives to their use were discussed with you at your consultation. We obtained your verbal consent to undergo the implant surgical treatment planned for you. Please read this document which restates issues we discussed and provide the appropriate signature on the last page. Please ask for clarification of anything you do not understand.

PURPOSE OF IMPLANTS: I have been informed that the purpose of an implant is to provide support for a crown (artificial tooth) or a fixed or removable denture or bridge.

ALTERNATIVE TREATMENT: Reasonable alternatives to implants have been explained to me. I have tried or considered these methods, but I desire an implant to help secure the replaced missing teeth.

TYPE OF IMPLANT: I am aware that the type of implant to be used on me is one which is placed into the jaw bone; that this is done by first reflecting a flap of gum, preparing a site in the bone, inserting the implant into the bone, and covering the bone and implant with the gum flap.

SURGICAL PROCEDURES: I understand that multiple surgeries are necessary: one to insert the implant(s) as described above, and one to uncover the top of the implant(s) so that it is exposed and can be used for attachment of a tooth, bridge, or denture. I also understand that sometimes it is beneficial to add gum tissue to the implant site either prior to implant placement or after the implant(s) has healed. I also understand that sometimes the implant(s) is covered with a bone graft material or a membrane to further enhance healing and that this may necessitate an additional procedure to remove the membrane.

NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed implant(s) will be completely successful in function or appearance (to my complete satisfaction). It is anticipated that the implant(s) 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 UNFORSEEN CONDITIONS: During treatment, unknown 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(s). I therefore consent to such additional or alternative procedures as may be required in the best judgment of the treating doctor.

COMPLIANCE WITH SELF‐CARE INSTRUCTIONS: I understand that excessive smoking and/or alcohol intake may affect healing and may limit the successful outcome of my surgery. I agree to follow instructions related to the daily care of my mouth. I agree to report for appointments following my surgery as suggested so that my healing may be monitored and the doctor can evaluate and report on the outcome of surgery upon completion of healing.

SUPPLEMENTAL RECORDS AND THEIR USE: I consent to photography, filming, recording, and x‐rays of my oral structures as related to these procedures, and for their educational use in lectures or publications, provided my identity is not revealed.

RISKS: Risks related to this surgery include, but are not limited to, post‐surgical infection, bleeding, swelling, pain, facial discoloring, perforation of the upper jaw sinus or nasal cavity during the surgery, transient but on occasion permanent numbness of the lip, tongue, teeth, or chin, jaw joint injuries or associated muscle spasms, bone fractures, and slow healing. Prosthetic risks include, but are not limited to, unsuccessful union of the implant(s) to the jaw bone, and/or stress metal fracture of the implant(s). Risks related to the anesthetics include, but are not limited to, allergic reactions, accidental swallowing of foreign matter, facial swelling, bruising, pain, inflammation, soreness and/or discoloration or blockage along a vein at the injection site.

Consent for the Placement of Dental Implants

PATIENT’S ENDORSEMENT: My endorsement (signature) to this form indicates that I have read and fully understand the terms and words within this document and the explanations referred to or implied, and that after thorough deliberation, I give my consent for the performance of any and all procedures related to the placement of dental implant(s) as presented to me during the consultation and treatment plan presentation by the doctor or as described in this document.

CONSENT TO UNFORSEEN CONDITIONS: During surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, extraction of additional teeth or termination of the procedure prior to the completion of all of the extraction/surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the treating doctor.

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

How long will my dental implant last?

Dental implant treatment is one of the most predictable treatment options we have available to you. With a success rate of well above 90% and the ability to allow your dentist to restore your mouth without preparing {grinding down) other teeth, there is really no other option like it.

When properly cared for, your implant can last a very long time. However, just like a natural tooth, it is possible for a dental implant to fail. We certainly want all of our patients to be happy and prefer not to have implant failures but implants can fail for a variety of reasons. These include but are not limited to:

-Poor oral hygiene

-Trauma to the tooth or jaw

-A poorly aligned bite or grinding and clenching teeth

-Your lifestyle and overall health {diabetes, smoking, etc.)

-Attending all scheduled appointments to include 2 week, 4 week, 3 month post operative and then annual implant appointment.

-The skill level of the dentist placing or restoring {placing abutment or crown) on your implant.

The other component to your implant restoration, the dental crown, may not last forever and may require replacement at some point. This would be done by your regular dentist and any associated charges with the abutment and/or crown replacement would be between the patient and their regular dentist.

Treat your dental implant just as you would any other natural tooth, proper maintenance is essential to the longevity of your dental implant:

Daily brushing and flossing, seeing a dentist every four months or more often if necessary for cleanings and exams and x-rays. Seeing DC Perio & Implants at least once a year for the first five years.

DC Perio and Implants’ replacement policy is fairly simple and we believe fair to you:

As long as you continue proper maintenance with your regular dentist: If the implant does not osseointegrate {not become solid enough in your jaw to place an abutment and/or crown on it) or in the rare case the implant fails within the first year after initial placement, we will replace the dental implant at no cost to you. {This does not include the replacement charge, if any, from your regular dentist for an abutment and/ or crown.)

Once the implant integrates {becomes solid enough in your jaw to place an abutment and crown on it) and is restored, we will replace the implant at no charge within the first 2 years. At times when an implant fails bone grafting and other materials may be necessary. If bone grafting or other materials becomes necessary, our regular fee for the bone graft will apply.

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I have read and fully understood the terms within this document and refuse to give my consent for the proposed treatment plan as described above. I have also been informed of and accept the consequences if no treatment is administered.

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Patient’s Signature

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Signature of Witness

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Dental Implants Consent and Warranty