Tooth Extraction and/or Ridge Augmentation Consent Consent for Tooth Extraction and/or The Use of Bone Grafting for Ridge Augmentation Prior to Dental Implant Placement Patient Name: The need for extraction and ridge augmentation by the use of demineralized freeze-dried allograft and guided tissue regeneration, their purpose and benefits, the surgery related to this procedure, and the possible complications as well as alternatives were discussed with you at your consultation. We obtained your verbal consent to undergo this procedure. Please read this document which relates to these issues and provide the appropriate signature on the last page. Please ask for clarification of anything you do not understand. SUGGESTED TREATMENT: I have been informed of the need for dental extraction (the removal of a tooth or several teeth). The reasons for this extraction have been explained to me. The tooth/teeth to be removed are checked below. Upper (right -> left) 8765432112345678 Lower (right -> left) 8765432112345678 I have been informed that in areas of my jaw, where I will be having teeth removed, there would be benefit to the support of conventional dental prosthetics, and for the anchorage of dental implants, if simultaneous bone augmentation is performed. DESCRIPTION OF THE PROCEDURE: After anesthetics have numbed the area to be operated on, the gum is reflected, the teeth are removed, the extraction sites are cleansed of any infection, the graft material placed on the surface of the bone, then a Guided Tissue Barrier Membrane may be placed over the graft to prevent gum cells from entering the wound and stopping interference with bone regeneration, and, to aid in the retention of the bone graft. Finally, the gum is sutured back around the teeth and/or together. DESCRIPTION OF THE GRAFT MATERIAL: Bone tissue harvested from other areas of your mouth. Demineralized Bone Allograft- this is human bone tissue. All donors are screened by physicians and other health care workers to prevent the transmission of disease to the person receiving the graft. They are tested for hepatitis, syphilis, blood and tissue infections, and AIDS virus. Tissue is recovered and processed under sterile conditions. Processing includes demineralization of the bone and its preservation by the process of freeze-drying. In addition, bone processed similar to the above descriptions after harvesting from bovine sources can be used as well as artificial bone-like substances. RISKS RELATED TO THE PROCEDURE: Risks related to surgery with extraction and ridge bony regeneration by the use of bone grafts might include, but are not limited to: fracture of the tooth/teeth during extraction, retention of part of a root or roots, dislodging of a tooth or part of a tooth into the upper jaw sinus, post-surgical infection, bleeding, swelling, pain, facial discoloration, transient but on occasion permanent numbness of the lip, tongue, teeth, chin, or gum, jaw joint injuries or associated muscle spasms, transient or on occasion permanent increased tooth looseness, tooth sensitivity to hot or cold or sweets or acidic foods, shrinkage of the gum upon healing (which could result in the elongation of an/or greater spaces between some teeth). Risks related to the anesthetics might include, but are not limited to, allergic reactions, accidental swallowing of foreign matter, facial swelling, bruising, pain or soreness or discoloration at the anesthetic injection site. ALTERNATIVES TO THE PROCEDURE: These may include: (1) No treatment, with the expectation of the advancement of my condition resulting in greater risk or complications including, but not limited to, bone loss, pain, infection, and possible damage to the support of adjacent teeth, a less than satisfactory dental prosthetic result. (2) Building up the ridge with soft tissue grafting which would not increase the possibility of using dental implants. (3) Extending the depth of the cheek pouch by surgery with or without the use of a soft tissue graft which would not increase the possibility of using dental implants or using the esthetics or phonetics related to design of a fixed bridge. NO WARRANTY OR GUARANTEE: I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed surgery will be completely successful in eradicating pockets, infection, or further bone loss or gum recession. It is anticipated that the surgery will provide benefit in reducing the cause of this condition and produce healing which will enhance the possibility of longer certainty of success. Therefore, there exists the risk of failure, relapse, selective treatment, or worsening of my present condition, including the possible loss of certain teeth with advanced involvement, despite the best of care. CONSENT TO UNFORSEEN CONDITIONS: During surgery, unforeseen conditions could be discovered which would call for a modification or change from the anticipated surgical plan. These may include, but are not limited to, extraction of hopeless teeth to enhance healing of adjacent teeth, the removal of a hopeless root of a multi-rooted tooth so as to preserve the tooth, or termination of the procedure prior to the completion of all the surgery originally scheduled. I therefore consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgment of the treating doctor. COMPLIANCE WITH SELF-CARE INSTRUCTIONS: I understand that excessive smoking and/or alcohol intake may affect gum healing and may limit the successful outcome of my surgery. I agree to follow instructions related to the daily care of my mouth and the use of prescribed medications. I agree to report for appointments as needed following my surgery so that healing may be monitored and the doctor can evaluate and report on the success of the surgery. SUPPLEMENTAL RECORDS AND THEIR USE: I consent to the photography, video recording, and x-rays of my oral structures as related to these procedures, and for their educational use in lectures, or publications, provided my identity is not revealed. PATIENT’S ENDORSMENT: My endorsement (signature) to this form indicated that I have read and fully understand the terms used within this document and the explanations referred to or implied. After thorough consideration, I give my consent for the performance of any and all procedures related to tooth extraction and the simultaneous use of bone grafting to attempt ridge augmentation as presented to me during the consultation and treatment plan presentation by the doctor or as described in this document. Signature of Patient (or parent or legal guaridan): Relationship to Patient: Date: Press the button below to submit the completed consent form.