fbpx
REQUEST FOR TREATMENT AND CONSENT
SINUS LIFT PROCEDURE WITH BONE
REPLACEMENT GRAFTING AN
PLACEMENT OF IMPLANTS

I authorize and request Dr. Allen Aptekar to perform surgery on my upper jaw (maxilla).

Site

I understand that surgery will be performed to place a bone graft material into the floor of the sinus to build up adequate bone height for the placement of implants. The bone graft will consist of a bone from tissue bone bank, my own bone or a combination of both. In approximately five to six months after the graft has partially healed, a second procedure will be done to insert the implants into the upper jaw and the grafted material. In some cases, it is possible to insert the implants and graft the floor of the sinus in the same operation. It is expected that the implants will become stable and act as anchors for the fixed or fixed detachable bridges or dentures.

Dr. Aptekar has explained that if new bone does not incorporate into the bone graft material, alternative prosthetic measures will have to be considered. Dr. Aptekar has explained and described the procedures to my satisfaction and understanding. The likelihood of success of the suggested treatment plan is good. However, there are risks involved. The bone graft material has produced good results when placed on top of the upper and lower jaw ridge. However, there are sufficient long term studies to evaluate placement of this material on the sinus floor. This bone graft replacement material has previously been shown to be free from rejection or infection. There is no guarantee that your graft will not become infected or be rejected.

There have been some cases of failure of this graft to incorporate new bone or to sustain implants. Rarely, implants have failed and require removal. Occasionally, the area can be regrafted and implants reinserted.

It is understood that although good results are expected, they cannot be and are not implied, guaranteed, or warrantable. There is also no guarantee against unsatisfactory or failed results.

I have been informed and understand that occasionally there are complications of surgery, drugs and anesthesia including, but not limited to:

1. Pain, swelling and postoperative discoloration of face, neck and mouth

2. Numbness and tingling of the upper lip, gums, teeth, cheek and palate which may be temporary or, rarely, permanent.

3. Infection of the bone, that might require further treatment including hospitalization and surgery.

4. Mal-union, delayed union, or non-union of the bone graft replacement material to normal bone.

5. Lack of adequate bone growth into the bone graft replacement material.

6. Bleeding which might require extraordinary means to control.

7. Limitation of jaw function and stiffness of jaw and facial muscles.

8. Injury to the teeth, with loss of teeth or bone segments.

9. Referred pain to the ear, neck or head.

10. Postoperative complications involving the sinuses, nose, nasal cavity, sense of smell, infraorbital regions, and altered sensations of the upper cheek and eyes.

11. Postoperative unfavourable reactions to drugs, such as nausea, vomiting = allergy.

There have been recent studies that may link bisphosponate medications with severe bone infections following dental surgery. Examples of this class of medication include Fosomax, Zometa, Didronel, Aredia, Actonel and Boniva. If you are taking any of these medications please bring this to our attention so that we may discuss how this may impact on the proposed surgery.

I understand that I am not to use alcohol or nonprescribed medication during the treatment period. Dr. Aptekar has discussed with me that smoking is particularly harmful to the success of this operation. If a smoker, I have been requested to stop. I understand that Dr. Aptekar will give his best professional care toward the accomplishment of the desired results. I understand that I can request a full recital of risks attendant to all phases of my care.

I
certify that I have read and fully understand this consent form, I request Dr. Aptekar to perform the surgery discussed. I also state that I read, speak, and understand English, and by signing below I consent to the surgery.

PATIENT SIGNATURE:

К сожалению, ваш браузер не поддерживает данную функцию.
Мы рекомендуем вам обновить ваш браузер или установить другой.

DATE:

______________

DENTIST SIGNATURE:

К сожалению, ваш браузер не поддерживает данную функцию.
Мы рекомендуем вам обновить ваш браузер или установить другой.

DATE:

______________

WITNESS SIGNATURE:

К сожалению, ваш браузер не поддерживает данную функцию.
Мы рекомендуем вам обновить ваш браузер или установить другой.

DATE:

______________

Submit

Attention!
You need fill all fields marked in red

has been added to the cart. View Cart