Dental implants are devices that are surgically placed in the jaw that become attached to the bone as substitutes for natural tooth roots. Implants permit missing teeth to be replaced through the use of crowns, fixed bridges, or dentures, which attach to the top(s) of the implant(s).

This recommendation is based on visual examination(s), on any X-rays, models, photos and other diagnostic tests taken, and on my doctor’s knowledge of my medical and dental history. My needs and desires have also been considered.

Implant placement surgery involves opening the gums and creating a hole in the jawbone for each dental implant. The dental implant is placed snugly in the custom hole created for it. In some cases, an implant may be placed into a tooth socket at the time a tooth is extracted. The gums are then stitched closed over the implant. Follow-up visits are required. Following placement, implants require time to heal and attach to the surrounding bone before replacement teeth can be made to fasten on top of the. During this time, I may be without replacement teeth.

A second surgery is then necessary to uncover the implant and prepare it for use. The prognosis, or likelihood of success, of this procedure is . However, I understand that no guarantee, warranty, or assurance has been given to me that this treatment will be successful, or for how long.

Alternatives to Implant Placement Surgery

Depending on the condition of my mouth and my current diagnosis, there may be other treatment alternatives to implant placement and implant-supported tooth replacement. I understand that possible alternatives to an implant-supported restoration may be:

– Replacement of the missing tooth or teeth by a tooth-supported fixed bridge. Natural teeth next to the toothless space are used to support a bridge, which is cemented into place and is non-removable. This procedure requires drilling the natural teeth to properly shape them to support the fixed bridge. – Replacement of the missing tooth or teeth by a removable partial denture or full denture. Partial and full dentures are removed from the mouth for cleaning. No treatment. I may decide not to replace the missing tooth or teeth. If I decide upon no treatment, my teeth may shift over time, causing chewing or gum problems.

Risks of Implant Placement Surgery

I have been informed and fully understand that there are certain inherent and potential risks associated with any type of surgical procedure, including surgical implant placement. I understand that during and following treatment, I may experience pain or discomfort, bleeding, swelling, and/or bruising, all of which may last for several days. I understand that it is possible for an infection to occur in or around the implant site and that I may need antibiotics and/or other procedures to treat the infection.

I understand that less common complications include: injury to adjacent teeth and soft tissues; jaw fractures; sinus exposure and sinus infection (upper arch); limited ability to fully open your mouth; soreness in the jaw joints (TMJs). I understand that the implant(s) may fail to properly attach to the surrounding bone and may require removal. I understand that this may occur for unknown reasons. I understand that the use of tobacco products (smoking or chewing), and certain medical conditions, such as diabetes, increase the risk that the implant(s) will fail and will require removal. I understand that poor eating habits and poor oral hygiene may negatively affect how long my implants last. I understand that the design and construction of my replacement tooth or teeth may contribute to implant failure.

I understand that following implant placement surgery, I may have nerve disturbances such as temporary or permanent numbness, itching, burning, or tingling of the lip, tongue, chin, teeth, and/or mouth tissues. I understand this risk is greater in the lower jaw. I understand that additional surgical procedures may be necessary based on findings and observations revealed during surgery that are not now known.

I understand that I will be given a local anaesthetic injection and that in rare situations, patients have had an allergic reaction to the anaesthetic, an adverse medication reaction to the anaesthetic, or temporary or permanent injury to nerves and/or blood vessels from the injection. I understand that the injection area(s) may be uncomfortable following treatment and that my jaw may be stiff and sore from the injection or from holding my mouth open during treatment.

Patient Consent
I, the undersigned, do hereby state and confirm as follows:

I have been explained the following in terms and language that I understand. I have been explained the following in {{LANGUAGE}} (Language) that is spoken and understood by me.
I have been provided with the requisite information; I have understood; and thereafter I consent, authorize and direct the above named doctor-in-charge and his / her team with associates or assistants of his / her choice to perform the proposed treatment mentioned herein above
I have been explained and have understood that due to unforeseen circumstances during the course of the proposed treatment something more or different than what has been originally planned and for which I am giving this consent may have to be performed or attempted. In all such eventualities, I authorize and give my consent to the medical team to perform such other and further acts that they may deem fit and proper using their professional judgment.
I have been explained and have understood the alternative methods and therapies of the proposed treatment, their respective benefits, material risks and disadvantages.
I state that the doctor-in-charge has answered all my questions to my satisfaction regarding the proposed treatment .
I have been explained and have understood that despite the best efforts there can be no assurance about the result of the proposed treatment. I further state and confirm that I have not been given any guarantee or warranty about the results of the proposed treatment.
I have been explained and have understood that despite all precautions complications may occur that may even result in death or serious disability.
I have been advised of the option to take a second opinion from another doctor regarding the proposed treatment.
I state that after explaining, counseling and disclosures I had been given enough time to take decision for giving consent.
I have signed this consent voluntarily out of my free will and without any kind of pressure or coercion.