These pages wil l provide you with the fol lowing information: 1 . Understanding the surgical phase of t reatment 2 . Explanat ion of r isks and complicat ions. 3 . Expectat ions af ter implant surgery. 4 . Post operat ive instruct ions. Please read careful ly. Cal l the off ice or make an appointment with the doctor (before your implant appointment) i f there are any quest ions regarding this consent form.

A minimum of 48 hours not ice is required for cancel ing an implant appointment . There is a $200.00 missed appointment fee . This fee is for ordered implant suppl ies and disposable products set up for your surgery.

IMPLANT SURGERY INFORMATION AND CONSENT FORM

Diagnosis: After a careful oral examinat ion, a review of radiographs, and a s tudy of my dental condi t ion, my dent is t advised me that my missing tooth or teeth might be replaced with ar t i f ic ia l teeth supported by an implant or implants .

Recommended Treatment: I have been presented with the fol lowing opt ions for t reatment:

1 . No t reatment . 2 . Limited use of a new part ia l denture for eat ing and publ ic appearance. 3 . Crown and br idge-work ( i f possible) . 4 . Placement of a t i tanium implant f ixture into the exis t ing bone of the jaw, which wil l be used to support new restorat ions, f ixed br idgework, or a removable denture .

I have selected the opt ion of the placement of a t i tanium f ixture into the exis t ing bone of the jaw. I am aware of the benefi ts and r isks involved, and have been informed of the surgical and prosthodont ic procedures involved.

Surgical Phase: I understand that sedat ion may be ut i l ized and that a local anesthet ic wil l be adminis tered to me as par t of the t reatment . My gum t issue wil l be opened to expose the bone. Implants wil l be placed by tapping or threading them into the holes that

Central New Jersey999 Palmer Avenue Suite #1 Holmdel, NJ 07733732.671.7100

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Nutley, NJ 07110973.661.2992

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www.advancedperiodontist.com

Advanced Periodontics & Implant Dentistry

Wayne Aldredge, D.M.D. *R ichard Nejat , D.D.S .*Daniel Nejat , D.M.D.*

*Diplomate, American Board of Periodontology

have been dr i l led into the jawbone. The implants wil l have a snugly f i t and wil l be held t ight ly in place during the heal ing phase. I f I am a candidate , a minimally invasive approach may be used to place the implant . Depending upon the densi ty of the bone, s tabi l i ty of the implants , and the doctor ’s c l inical judgment , teeth may be anchored immediately via the Smile In A DayTM or Teeth in an Hour TM procedure or the implants may be loaded at a future date . Later vis i ts wil l involve the prosthodont ic phase of my t reatment which may involve several appointments .

The gum and sof t t issue wil l be s t i tched closed over or around the implants . Heal ing wil l ensue for a per iod of two to s ix months. I understand that dentures usual ly cannot be worn during the f i rs t two weeks of the heal ing phase. I fur ther understand that i f c l inical condi t ions turn out to be unfavorable for the use of this implant system, or prevent the placement of implants , my dent is t wil l use professional judgment as to the management of the s i tuat ion. The procedures a lso may involve a supplemental bone graf t or other types of graf t mater ia ls to bui ld up the r idge of my jaw, and thereby assis t the placement , c losure, and securi ty of my implants . This may also include the placement of bone graf ts into the maxil lary s inuses to increase the height and width of bone for the appropriate inser t ion of implants for use as “back” teeth.

After the surgery, there may be temporary pain, swel l ing, discolorat ion of the skin, and numbness or a l tered sensat ion. I f s inus graf ts are used, there may be nosebleeds.

Post-Operative Exam: A post-operat ive examinat ion wil l be required at regular intervals .

For example:

1 . Firs t or second week af ter surgery;

2 . Every four to e ight weeks af ter surgery for three months.

*Certain s i tuat ions may require more/ less f requent vis i ts .

Post-Operative Sequelae: Typical ly, post operat ive heal ing is uneventful . However, cer ta in s i tuat ions may occur: pain around the implant f ixture , infect ion, phobia , or change of mind by the pat ient . In addi t ion, some t ingl ing and loss of sensat ion in the area may occur when the implants are placed in the back of the lower jaw. In rare s i tuat ions, this a l tered or loss of sensat ion may be permanent .

Prognosis: While the prognosis is favorable a t this t ime, the resul ts cannot be guaranteed s ince unforeseen changes in the bone and sof t t issue may occur which may require removal of the implant f ixture . I f an implant f ixture does not join properly with the bone, i t wi l l be necessary to remove the implant in quest ion. No problems are usual ly foreseen as a resul t of this removal .

Second Surgical Procedure: For implants requir ing a second surgical procedure, the overlaying t issues wil l be opened at the appropriate t ime, and the s tabi l i ty of the implant wil l be ver i f ied. I f the implant appears sat isfactory, an at tachment wil l be connected to the implants . Plans and procedures to create an implant crown or appl iance (by your general dent is t or res torat ive dent is t ) can then begin af ter the gum t issue has healed.

Initial and Date _________________

Prosthetic Phase of Procedure: I understand that a t this point I wil l be referred back to my dent is t or to a prosthodont is t . This phase is just as important as the surgical phase for the long-term success of the oral reconstruct ion. During this phase, an implant prosthet ic device or crown wil l be at tached to the implant . This procedure should be performed by a person t ra ined in prosthet ic protocol for the root form implant system.

Expected Benefits: The purpose of dental implants a l lows me to have more funct ional ar t i f ic ia l teeth. The implants provide support , anchorage, and retent ion for these teeth and act as new roots within the jawbone.

Principal Risks and Complications: I understand that some pat ients do not respond successful ly to dental implants , and, in such cases , the implants may be lost . Implantsurgery may not be successful in providing ar t i f ic ia l teeth. Because each pat ient’s condi t ion is unique, long-term success cannot be predicted.

I understand that complicat ions may resul t f rom the implant surgery, drugs, and anesthet ics used. These complicat ions include, but are not l imited to , post surgical infect ion, bleeding, swel l ing and pain, facial discolorat ion, t ransient but on occasion permanent numbness of the l ip , tongue, teeth, chin or gum, jaw joint injur ies , or associated muscle spasm, t ransient , but on occasion permanent increased tooth looseness , tooth sensi t ivi ty to hot , cold, sweet or acidic foods, shr inkage of the gum t issue upon heal ing resul t ing in e longat ion of some teeth and greater spaces between some teeth, cracking or bruis ing of the corners of the mouth, res t r ic ted abi l i ty to open the mouth for several days or weeks, impact on speech, a l lergic react ion, injury to teeth, bone fractures , nasal s inus penetrat ions, delayed heal ing, and accidental swal lowing of foreign matter. The exact durat ion of any complicat ions cannot be determined, and may be i r revers ible .

I understand that the design and s t ructure of the prosthet ic appl iance can be a substant ia l factor in the success or fa i lure of the implant . I fur ther understand that a l terat ions made on the ar t i f ic ia l appl iance or the implant can lead to loss of the appl iance or implant . This loss would be the sole responsibi l i ty of the person making such al terat ions. I am advised that the connect ion between the implant and the t issue may fai l and that i t may become necessary to remove the implant . This can happen in the prel iminary phase, during the ini t ia l integrat ion of the implant to the bone, or a t any t ime thereaf ter.

Necessary Fol low-up Care and Self Care: I understand that i t i s important for me to cont inue to see my dent is t or prosthodont is t . Implants , natural teeth, and appl iances have to be maintained dai ly in a c lean, hygienic manner. Implants and appl iances must a lso be examined per iodical ly and may need to be adjusted. I understand that i t i s important for me to abide by the specif ic prescr ipt ions given by my Periodont is t .

No warranty or Guarantee: Even though dental implants have a very high success ra te , I hear by acknowledge that no 100% warranty or assurance has been given to me that the proposed t reatment wil l be successful . Due to individual pat ient differences, a Per iodont is t cannot predict cer ta inty of success . There exis ts the r isk of fa i lure , re lapse, addi t ional t reatment , or worsening of my present condi t ion, including the possible loss or devi ta l izat ion of cer ta in teeth, despi te the best of care .

Initial and Date _________________

Initial and Date _________________

Publications of Records: I authorize photos , s l ides , and x-rays of my care and t reatment during or af ter i ts complet ion to be used for the advancement of dent is t ry and for re imbursement purposes . My ident i ty wil l not be revealed to the general publ ic without my permission.

PATIENT CONSENT

I have been ful ly informed of the nature of dental implant surgery, the procedure to be ut i l ized, the r isks and benefi ts of the surgery, the al ternat ive t reatments avai lable , and the necessi ty for fol low-up care and self care . I have the opportuni ty to ask quest ions or voice concerns I may have in connect ion with the t reatment . I hereby consent to performance of dental implant surgery as presented to me during my consul ta t ion/ t reatment planning vis i t (s) .

I f c l inical condi t ions prevent the placement of dental implants , I defer to my dent is t ’s judgment on the surgical management of that s i tuat ion. I a lso give permission to receive supplemental bone graf ts or other types of graf ts to bui ld up the r idge of my jaw and thereby assis t in the placement , c losure, and securi ty of my implants .

I understand that the fee for my dental implant(s) and surgery does not include the fee for the restorat ive work (crowns or dentures) .

I hereby give consent to Dr. Nejat to perform the necessary t reatment .

Date _____________________________________________

Patient Signature __________________________________________________

Witness Signature __________________________________________________

Dentist Signature __________________________________________________

Location and Type of Implants ___________________________________________________________

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