This form explains the risks, benefits, consequences, and alternatives to Sinus Graft or Augmentation surgery; A procedure that is performed for the purpose of placing dental implants in the future. It involves making an opening into the sinus(es) and placing sterile cone constituents or minerals into the sinus(es) after its lining is pushed in. The form also obtains the patient's consent to perform the procedure.

 

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Informed Consent for Sinus Graft or Augmentation Surgery

Facts for Consideration

I have been informed and afforded the time to fully understand the purpose and the nature of the bone graft surgery procedure. I understand what is necessary to accomplish the placement of the bone graft under gum on/or in the bone. My doctor has examined my mouth and x-rays have been taken. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire a bone graft to help secure the replaced missing teeth.

Sinus graft (augmentation) procedure is performed for the purpose of placing dental implants in the future. The procedure involves making an opening into my sinus(es) and placing sterile bone constituents/or minerals originated from either human donors, bovine, synthetic or my own bone into the sinus(es) after its lining is pushed up. Then the area is closed by placing stitches and appropriate dressings. 

I understand that the dentist providing treatment is a general practitioner with advanced training in this field and not an oral surgeon or periodontist. I also understand that this procedure may not be covered by my dental insurance and I may be responsible for the entire fee. I had the opportunity to discuss fees and my financial responsibility with the office before the procedure was performed.

Risks of Sinus Augmentation and Bone Graft Procedure, NOT Limited to the Following:

I understand my gums may bleed or swell and I may experience moderate discomfort for several hours after the anesthesia wears off and there may be slight soreness for a few days which may be treated with pain medications. I will notify the office if this condition persists beyond a few days.

I understand that smoking, alcohol, oral hygiene and blood sugar may affect gum healing and may limit the success of the bone graft. I agree to follow my doctor's home care instructions and report back for regular examinations and follow up appointments.

I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include numbness of the lip, tongue, chin, cheek, or teeth. The exact duration may not be determinable and may be irreversible. Also, possible risks are thrombophlebitis (inflammation of the vein), injury to the teeth present, bone fractures, sinus penetration, and delayed healing. The surgery may need to be terminated and rescheduled if complications such as, but not limited to, a tear of the sinus membrane or sinus infection is noted. Excessive bleeding may occur for which the procedure may need to be terminated prematurely and rescheduled for the future. I may need to be hospitalized due to complications that may arise during or after surgery.

I understand that I will be responsible for any or all additional medical costs that may arise during or after surgery.

I understand that I will receive a local anesthetic and/or other medications. In rare instances, patients have a reaction to the anesthetic, which may require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the chance of swallowing foreign objects during treatment. In case of swallowing or aspiration of a foreign object, a chest x-ray and examination by my medical doctor may be necessary to determine the location of the object and proper treatment. Depending on the anesthesia and medications administered, I may need a designated driver to take me home.

Rarely, temporary or permanent nerve injury can result from an injection.

I understand that all medications have the potential for accompanying risks, side effects, and drug interactions and that it's critical that I tell my dentist about all medications I am currently taking.

I understand that holding my mouth open during treatment may temporarily leave my jaw feeling stiff and sore and may make it more difficult for me to open wide for several days. However, this can occasionally be an indication of a further problem. I will notify the office if this or other concerns arise.

My doctor has explained to me that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a bone graft. It has been explained that bone in its healing process remodels and there is no method to predict the final volume of bone, thus additional grafting may be necessary. 

It has been explained that in some instances bone grafts fail (mal-union, delayed union, or non-union of the donor bone graft to the recipient bone site) and must be removed. It also has been explained to me that lack of adequate bone growth into the bone graft replacement material could result in failure. I am aware that there is a risk that the bone graft surgery may fail, which might require further corrective surgery or the removal of the bone graft with possible corrective surgery associated with the removal. If the bone graft surgery fails, alternative prosthetic measures may have to be considered.

I understand that every reasonable effort will be made to ensure that my condition is treated properly, although it's not possible to guarantee perfect results. By signing below, I acknowledge that I have received adequate information about the proposed treatment, that I understand this information and that all of my questions have been answered to my satisfaction.

Consequences if NO Treatment is Administered, NOT Limited to the Following:

I understand that if no treatment were administered or ongoing treatment was interrupted or discontinued, my condition would continue and probably worsen. I understand that without performing this procedure it may not be possible to place implant restorations into the area at this time.

Alternatives to Surgical Periodontal Treatment

I understand that given my condition, there are no effective alternative treatments available.

No guarantee or assurance has been given to me by anyone that the proposed treatment or surgery will cure or improve the condition(s) listed above.

 

[x] I consent to the sinus graft/augmentation surgery as described above.

x_______________________________                    Date:____________________________

Please Sign Here (Patient)

 

[x] I attest that I have discussed the risks, benefits, consequences, and alternatives to this treatment with the patient who had the opportunity to ask questions, and I believe my patient understands what has been explained.

x_______________________________                    Date:____________________________

Please Sign Here (Dentist) 

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