Diagnosis:  After careful oral and radiographic examination, my surgeon has advised me that the extraction of my tooth/teeth has been recommended and my tooth or teeth may be replaced by a dental implant/s and bone grafting.

Recommended treatment:  In order to treat my condition, the removal of my tooth/teeth has been recommended and then to place dental implant(s) under the gum and into the jawbone.

Alternatives to suggested treatment: I understand that non-treatment may result in, but not be limited to: infection, swelling, pain, periodontal disease, malocclusion (damage to the way the teeth bite together) and systemic disease/infection. I understand that alternatives to dental implant(s)/ bone grafting surgery may include: 1) no treatment, 2) dental bridgework (if there are good adjacent teeth for supporting a fixed bridge), 3) removable dentures.

Surgical phase:  The procedure will be performed under local anesthetic . You also have the option of being sedated In order to treat my condition. My surgeon has recommended the removal of my tooth/teeth and use of dental implants placed into the jawbone. I understand that when there is insufficient bone, a bone graft will be placed using either my own bone harvested from my jaw and/or certified bone mineral of bovine origin (Bio-Oss or allograft origin ( human donor bone) We also may draw blood and use the growth factors in your blood to help build up the missing bone. 

There may be the need to replace deficiencies in the soft tissue ( gingiva) with your own soft tissue from the palate or donor tissue is used from human (allograft) or bovine origin. The soft tissue will be sutured over or around the implants.

In certain circumstances, a temporary removable denture is fabricated and will be fitted on the day of the procedure. If there are issues with fitting the denture then you may be required to return to the restoring dentist to have the prosthesis fitted . I understand that dentures may not be able to be worn for a few days / weeks depending on the specific procedure undertaken. You must expect to have possible swelling and discomfort for approximately a week post surgery. This can vary from patient to patient and type of procedure performed. We will then wait usually between 2- 6 months before you will be able to proceed to the next phase which is the restorative phase with your dentist where the final prosthesis is made and fitted.

I understand that during surgery, if clinical conditions are unfavorable for the placement of implants, my surgeon will make a professional judgment to manage the situation. The procedure may require supplemental bone grafts or other types of grafts to build up the ridge to allow for implant placement. 

Your surgeon will discuss with you the different techniques which may include extraction(s) and implant(s) placed as either a delayed or immediate placement approach.

Expected benefits:  The purpose of extraction(s) and dental implant surgery is to allow me to replace my missing tooth or teeth for improved function and/or to improve my appearance. The implants provide support, anchorage and retention for a fixed or removable prosthesis. This procedure has a surgical phase followed by a prosthetic phase (implant crown/bridge/denture) which is performed by your restorative dentist.

Restorative phase:   I understand that at this point, I will be referred back to my restorative dentist/prosthodontist for the fabrication of the implant crown(s) or prosthesis. This part of the process will involve additional costs with your restoring provider.

Primary risks and complications:  I understand that some patients do not respond successfully to dental implants/bone grafting, and in such cases, the implant/bone graft may need to be removed. 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 anaesthetics. These complications include, but are not limited to:

• Post surgical infection 

• Delayed healing (dry socket) necessitating several post operative visits
  

• Restricted ability to open mouth

• Pain, swelling and post-operative discoloration of the face, neck and mouth
  

• Impact on speech

• Allergic reactions

• Injury to teeth

• Accidental swallowing of foreign objects

• Jaw bone fracture
  

• Mal-union, delayed union, or non-union of the bone graft material to normal bone
  

• Lack of adequate bone growth into the bone graft replacement material

• Limitation of jaw function and stiffness of jaw and facial muscles

• Referred pain to the ear, neck or head.

• Post-operative, unfavorable reactions to drugs, such as nausea, vomiting and allergies

• Unfavourable conditions for the placement of the implant(s) which may require a bone graft, or a soft tissue graft. This may delay the placement of the implant and the healing process.

• Damage to sinuses requiring additional treatment or surgical repair at a later date.

• Transient or permanent numbness of the lip, tongue, teeth, chin or gum

• Bleeding which might require more advanced techniques to contro

• Failure of implant(s) integrating resulting in implant removal

I understand that if I smoke I have an increased risk of the above complications. The exact duration of any complication(s) can not be determined, and they may be irreversible.

No warranty or guarantee:  It is understood that although good results are expected, they cannot be and are not implied, guaranteed, or warrantable. There is also no guarantee against unsatisfactory or failed results. In the unforeseen circumstance an implant does fail, I understand that an implant may be replaced. The components will be replaced free of charge, however there will be a fee to cover the costs of the surgery and materials. 

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

Sedation:  Please speak to your treatment coordinator if this is something you wish to discuss further as this requires to be arranged prior to your procedure date, with a minumum of 24 hours notice.

I understand that if I take oral sedation, I will need a driver to and from my appointment and that I should not operate any heavy equipment/machinery for 24 hours following the use of oral sedation.

Payment Terms: I understand the proposed treatment plan estimation which has been presented to me as a written treatment plan outlining the required appointments, time frames, item codes and the fees associated with my treatment.

I understand all appointments are to be paid in full on the day of the procedure, and I will be mindful of any daily bank card limits I may have, thus ensuring full payment can be made. 

I understand that if I wish to make payment via direct deposit that I will contact my treatment coordinator at least two days prior to my appointment, ensuring the funds have cleared before the commencement of my appointment. 

I am aware that a HICAPS terminal is not available on site and I will claim any benefits that I may be entitled to directly from my health fund.

Patient Consent:

I have been fully informed of the nature of the extraction(s) implant (s) and bone grafting placement surgery, the risks and benefits, the alternative treatments available and the necessity for follow up care. I have had an opportunity to ask any questions I may have in connection with the treatment and discuss my concerns with my surgeon. I hereby consent to the extraction(s) implant(s) and bone grafting placement surgery as presented to me during consultation and in the treatment plan presented. I understand that during the procedure, conditions may become apparent which warrant additional or alternative treatment for my best interest, which I will be informed of. This may involve additional costs that may not have been outlined in the provided treatment plan.

The success of surgical procedures can be affected by medical conditions, dietary and nutritional problems, smoking, alcohol consumption, clenching and grinding of teeth, adequate oral hygiene, and medications that I may be taking. To my knowledge I have reported to my periodontist any prior drug reactions, allergies, diseases, symptoms, habits or conditions that in any way relate to this surgical procedure.

I have agreed to follow the post-operative instructions and to report to all follow up appointments.

Please note, due to the sterile environment, no family or friends are permitted chairside at the time of the procedure.

By providing my signature, I certify that I have read and fully understand this document and that all my questions have been answered to my satisfaction.