Diagnosis: After careful oral examination, my periodontist has advised me that my implant needs to be removed. 

Recommended treatment: In order to treat my condition, the removal of my dental implant(s) has been recommended. I understand the procedure involves removing the implant from the jawbone. 

Surgical phase: I understand that local anaesthetic will be administered to me as part of the treatment and there is the option of sedation. My gum tissue will be retracted to expose the bone and the implant(s) will be removed from my jawbone. The soft tissue will be sutured closed. There will be a healing period of 4-6 months or more before planning for replacement options.

I understand that during surgery, if clinical conditions are unfavourable for the placement of implants [in the future], my periodontist will make a professional judgement to manage the situation. The procedure may require supplemental bone grafts or other types of grafts to build up the ridge to allow for future implant placement.

Primary risks and complications: I understand there can be complications of the implant removal surgery, drugs and anaesthesia including, but not limited to:

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

• Bleeding which might require more advanced techniques to control

• Post surgical infectionTransient or permanent numbness of the lip, tongue, teeth, chin or gum

• Restricted ability to open mouthImpact on speech

• Allergic reactionsInjury to teeth

• Accidental swallowing of foreign objects

• Delayed healing

• Jaw bone fracture

• 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

I understand that if I smoke I have a higher 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: 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 periodontist 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.

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.

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PATIENT CONSENT:

I have been fully informed of the nature of the implant removal 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 periodontist. I hereby consent to the implant removal 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.

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.

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.