You have the right to be given pertinent information about your proposed sinus lift surgery so that you have sufficient information to make the decision as to whether or not to proceed with
surgery. What you are being asked to sign is a confirmation that we have discussed the nature
of the proposed treatment, the known risks associated with it and the feasible alternate
treatments.
PLEASE READ THIS DOCUMENT CAREFULLY. IF YOU HAVE ANY QUESTIONS, PLEASE ASK
YOUR DOCTOR BEFORE SIGNING.
1) I hereby authorize the dentists at Parkway Smiles to perform a sinus lift/elevation procedure. A procedure being done to allow for sufficient bone volume, in the posterior maxilla, in order to place root form implants that will provide support for the planned restoration.
2) I am satisfied that I fully understand the nature and purpose of the treatment.
3) I understand that the graft material must be in place for at least 4 to 6 months before it can
be exposed for placement of implants. I understand that subsequent surgery will be
required to uncover the top of the implants that will be placed in this graft.
4) No guarantee can be or has been given that the graft will consolidate and this be adequate
for implant placement. It has also been explained to me that once implants are inserted, the
entire treatment plan must be followed and completed on schedule. If this schedule is not
carried out, the implants and even grafts may fail.
5) I understand that other forms of treatment or no treatment at all are choices that I have and
the risks of those choices have been presented to me.
6) My dentist has explained to me that there are certain inherent and potential risks and
side effects in any surgical procedure and in this specific instance, such risks include, but are not
limited to, the following:
- (a) Prolonged or heavy bleeding that may require additional treatment.
- (b) Postoperative discomfort and swelling that may require several days of at-home
recuperation.
- (c) Injury or damage to adjacent teeth or roots of adjacent teeth if present.
- (d) Postoperative infection that may require additional treatment including removal of the
graft.
- (e) Stretching of the corners of the mouth may cause cracking and bruising and may heal
slowly.
- (f) Restricted mouth opening for several days; sometimes related to swelling and muscle
soreness and sometimes related to stress on the jaw joints (TMJ). Pre-existing TMJ
symptoms may be worsened.
- (g) Injury to the nerve branches of the upper jaw resulting in numbness or tingling of the
lower eyelid, side of the nose and upper lip/cheek area along with the gums on the operated side. This may persist for several weeks, months, or, in rare instances, permanently.
- (h) Some bleeding through the nostril on the side of the surgery may occur which usually will
last one to two days.
- (i) I understand that if I am a smoker, I should not smoke one day prior to surgery, the day of
surgery and one day following surgery.
- (j) Swelling around the eye of the surgical side may even result in the closing of the eye for a day
or two.
- (k) Opening into the sinus after surgery can occur and would require additional treatment.
- (l) Infection of the graft, possibly necessitating its total removal. The removal of grafted bone from any donor site has its own potential risks and complications, which also have been explained to me.
7) It has been explained to me that during the course of this procedure, unforeseen conditions
may be revealed that will necessitate an extension of the original procedure or a procedure
different from the one that was planned. In rare cases, it may not be possible to continue with
the procedure. I authorize my doctor and his staff to perform such different procedure(s) as
necessary and desirable in the exercise of professional judgment.
8) I consent to the administration of local anesthesia in connection with the procedure referred to above. If intravenous sedation is used, there may be soreness at the injection site or along the being, as well as some bruising around the injection site. In rare cases, the vein irritation
may cause restricted mobility of the arm or hand and may require additional treatment.
9) I have been made aware that certain medications, drugs, anesthetics and prescriptions,
which I may be given, can cause drowsiness, incoordination, and lack of awareness which also
may be increased by the use of alcohol and other drugs. I have been advised not to operate any
vehicle or hazardous machinery and not to return to work which taking such medications, or
until fully recovered from their effects. I understand this recovery may take up to 24 hours or more after I have taken the last dose of medication. If I am to be given sedative medication
during my surgery, I agree not to drive myself home and will have a responsible adult drive me
home and accompany me until I am fully recovered from the effects of the sedation.
10) I understand that I am not to have anything (or have not had anything) by mouth for at least
six hours before my surgery. TO DO OTHERWISE MAY BE LIFE-THREATENING!
11) It has been explained to me, and I understand, that a perfect result is not, and cannot be guaranteed or warranted.
12)I authorize photos, slides, x-rays or any other viewing of my care and treatment during or
after its completion to be used for the advancement of dentistry and for reimbursement
purposes. However, my identify will not be revealed to the general public without my
permission.
