This form explains the risks, benefits, consequences, and alternatives to a Crown Lengthening procedure; a procedure that is performed during which gum and bone tissue is reshaped to expose more of the natural tooth. The form also obtains the patient's consent to perform the procedure.

 

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Informed Consent for Crown Lengthening Procedure

Facts for Consideration

Crown lengthening is a procedure during which gum and bone tissue are reshaped to expose more of the natural tooth. It may be recommended if your tooth has decayed or broken below the gum line and/or has insufficient tooth structure for a restoration, such as a crown or a bridge.  It may also be recommended for cosmetic reasons when crowns and veneers are placed. The success of the treatment depends in part on your efforts to brush and keeping the area clean while it is healing. You need to schedule an appointment in 6 to 8 weeks to have the tooth restored properly. Also, you should brush and floss daily, receive regular cleaning as directed, follow a healthy diet, avoid tobacco products and follow proper home care.

Benefits of Crown Lengthening Procedure, NOT Limited to the Following:

Surgical crown lengthening of the tooth allows you to keep your tooth by enabling your dentist to place a restoration such as a filling, onlay or a crown that could not be possible otherwise since the tooth destruction has advanced below the gum and/or the bone. It can help to reduce the chance of further gum irritation or infection. It can decrease the cost of replacing teeth lost due to gum disease or decay or fracture.

Risks of Crown Lengthening Procedure, NOT Limited to the Following:

I have been informed and understand that my gums may bleed or swell and I may experience moderate discomfort for several hours after the anesthesia wears off and there may be a 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 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.

I understand that because cleanings involve contact with bacteria and infected tissue in my mouth, I may also experience an infection, which would be treated with antibiotics. I will immediately contact the office if I experience fever, chills, sweats or numbness.

I understand that as my gum tissue heals, it may shrink somewhat, exposing some of the root surfaces. This could make my teeth more sensitive to hot and cold. I also understand that following treatment, I may have spaces between my teeth at the gumline, which could trap food particles and requires special maintenance. I understand additional surgical procedures are available to protect the sensitive areas.

I understand that depending on my current dental condition, existing medical problems, or medications I may be taking, these methods alone may not completely reverse the effects of gum disease or prevent further problems. Teeth that become loose as a result of periodontal disease may be extracted, which may require replacing the teeth with fixed or removable bridge, denture, or artificial teeth called implants.

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 given my condition, there are no effective alternative treatments available to treat my condition and keep affected teeth and I risk losing the tooth/teeth involved. Further decay, toothache, gum irritation may also arise.

Alternatives to Surgical Periodontal Treatment

I elected the treatment listed above even though the alternatives have been explained to me 

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 crown lengthening procedure 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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