Dental Implant Surgical Consent Form

I have been informed and understand that transitional or ?mini? dental implants are available to certain dental patients. These mini implants are small diameter (1.88mm) titanium alloy dental implant screws that are placed in a patient?s jaw to provide immediate and ongoing stabilization of teeth. I am aware that these implants are being placed for the immediate and ongoing stabilization of my dental prosthesis, and the long-term function cannot be predicted. I wish to undergo this procedure as a patient of Bristol Dental Group. I have requested my dentist to place one or more transitional or mini-dental implants into my jaw.

I have also been fully informed by my dentist that the purpose of this dental implant procedure is to provide support for my lower jaw and to enhance function, and I hereby consent to the surgical insertion of transitional or mini-dental implants in my jaw by my clinician. I understand that in the vent the mini-dental implants implanted by my dentist fail, they will be removed through a subsequent surgical procedure. I further understand that it is possible that one or more of the implants may fracture during insertion, or during the implant?s life cycle, and in the event a fracture were to occur, I give My dentist permission and consent to leave the fractured implant in my jaw or remove it, under professional conditions and using professional judgment. It has also been explained to me that once the mini-dental implants are inserted or implanted, a recommended dental treatment plan, including a program of personal oral hygiene, must be strictly followed by me and completed on schedule. I have been informed that if this schedule and plan are not carried out, the implants may fail.

I am further aware that the surgical procedure includes the insertion of the mini-dental implants in my jaw, and possibly the construction of a prosthetic device. I am aware that I must return for appropriate post-operative care and evaluation on a timely basis, which will include evaluation of oral hygiene and plaque removal.

I also understand that function and comfort will be the primary goals of this dental procedure, but that success rates of each patient vary. With that in mind, no guarantees of success have been give me by my dentist or any member of his staff. He has also informed me that use of tobacco, including cigarette smoking, as well as excessive alcohol consumption, can cause failure of dental implants.

I have further been advised that swelling, infection, bleeding and/or pain may be associated with any surgical procedure, including the one recommended to me by My dentist, and that said conditions may occur during the life of the implants. I have also been advised that temporary or permanent numbness may occur in my tongue, lip(s), chin, gum or jaw as a result of this procedure, as well as the possibility of sinus involvement in the upper jaw. My dentist has discussed the possibility of alternative procedures for my individual needs and has offered to answer any of my questions concerning those procedures.

Having been fully informed of the above, I hereby knowingly consent to the recommended surgical procedures outlined to me by My dentist, and request him to place one or more transitional or mini-dental implants in my jaw for the purpose of dental reconstruction and function enhancement.

I further state that I have carefully read the surgical consent for and understand the contents.