SOFT TISSUE GRAFTING INFORMATION AND CONSENT Date: Patient name: I, have been informed of the nature of soft tissue, soft tissue surgery, risks, treatment alternatives and the maintenance prior to commencement of treatment. DOB: Treatment planned: SOFT TISSUE PROCEDURE The pre-planning for soft tissue surgery requires a comprehensive examination with a full medical history, relevant diagnostic tests and radiographs for thorough discussion and planning. Certain medical conditions, nutritional implications or those that smoke or drink alcohol have high risks of limiting the successful outcome of the procedure and may adversely affect gum healing. The procedure with soft tissues will vary depending on individual cases such as utilising natural or de-cellularised artificial tissue and we will discuss with you which one is relevant to your procedure. Natural tissue is usually harvested off the roof of your mouth and best for coverage of smaller areas. Natural tissue is often preferred as it has expansion capabilities overtime which gives better coverage. The outcome of soft tissue grafting is to either cover areas of recession, prevent recession, aesthetics, maintaining gum health and adding gingival thickness. Soft tissue grafting may not necessarily result in full coverage and this is dependent on the severity Prosthesis planned (if applicable): of the recession. After surgery, the site of the procedure will be tender and sore in the initial days and require gentle home maintenance over the following weeks. The soft tissues will be reviewed and re-evaluated up to 3-6 months for optimal healing and stabilization prior to further restorative or prosthetic work if required. The costs for soft tissue grafting is approximately from $1,500-$6,500 depending on the level of coverage required.
RISKS Soft tissue grafting may not be successful in all cases. There is no method that will accurately predict or evaluate how the gums or bone will heal and a second procedure may be required if the results are not satisfactory and a full fee will be incurred. Complications that may result from soft tissue grafting procedures include but are not limited to: (the ones which are marked are applicable to your treatment) Post-surgery infection, bleeding, pain, swelling, bruising, discomfort Burning, Tingling, Numbness to affected areas. Tooth or gum sensitivity/injury /mobility Transient or on rare occasion permanent numbness of the lip, tongue, chin, gum, palate Facial discolouration Allergic reactions Delayed healing Accidental swallowing of foreign matter SURGICAL RISKS Adverse reactions to the anaesthetic, drugs, medications: On some rare occasions, patients may have an adverse reaction to the anaesthetic or medications that are used or prescribed. These reactions usually take place within the first two hours and can include pallor, palpitations, diaphoresis, dizziness, nausea and a more serious anaphylactic reaction can occur. It is important to disclose all medical history including list of allergies, medications, natural remedies, herbal or any non-prescription medications in order to avoid and prevent these adverse outcomes and appropriately manage the procedure. Accidental swallowing of foreign matter: Soft tissue surgery requires fine and small componentry during placement, removal, adjustments and fitting of the graft. The upmost care will be taken to prevent complications such as this however; there is always a risk that the fine componentry can be accidentally swallowed during the procedure. If this occurs, there is a requirement to have appropriate x-rays and surgical treatment to have it removed.
POST-SURGICAL RISKS Post-surgical care (bleeding, swellings, pain, bruising, joint pain, prolonged numbness): After soft tissue surgery, patients may feel quite sore and tender over the next couple days and may notice minor bruising and swelling as with most surgical procedures. The swelling, tenderness, pain, bruising and prolonged numbness from the anaesthetic should settle over the next couple of days and weeks but the exact duration of these complications may not be determinable. There is a slight chance they may be become permanent and irreversible. It is important attend follow-up appointments in order to provide and manage the healing and to let the dentist know if the pain, tenderness or prolonged numbness is still present or has increased over time. Delayed healing: The ability to heal after surgery varies between individuals so do not be alarmed if the area is healing quickly or slower than expected. During the follow-up visits, the healing of the graft will be assessed and managed appropriately if the healing process is not going as expected. The level of recession coverage will vary depending on how well the area heals, the pre-existing recession and underlying tissue thickness and the type of graft used. On some occasions, an additional soft tissue graft surgery may need to be performed for adequate coverage and this will be discussed with you and the costs involved. Oral hygiene care: It is important to exercise delicate brushing techniques after the graft has been placed. This will be demonstrated and discussed with you by the dentist. If you traumatize the healing site and graft from vigorous brushing, this can damage the graft and affect the overall healing process. Adjunctive oral hygiene instructions or mouth-rinses may also be recommended whilst the graft is healing and will be discussed with you. MAINTENANCE In order to improve the chances of success, there is a requirement to attend follow-up appointments so that healing can be monitored and assessed. Following treatment, there is a need for ongoing and lifelong maintenance daily at home and with regular check-ups every 3-6 months which is not included in the costs of the soft tissue grafting procedure. This ensures the optimum care for the teeth, implants, prosthesis and gums. In essence, for long term success of implant treatment you have the following responsibilities: 1) Follow all the instructions regarding a soft diet, denture wear, gum and teeth management during the healing after each phase of surgery. 2) Clean the teeth, denture or implant/crown and thoroughly as instructed. 3) Appear for periodic examinations and cleans every 3-6 months as advised by your dentist. There is an additional fee for these services.
4) Exercise extreme care in not abusing the graft and advise your dentist immediately if any problems are noticed. If you fail to maintain the work that has been done and do not attend regular appointments, complications can arise and become untreatable, difficult and costly to manage. You will be liable to incur the total costs for treatment to correct implications or failures if you do not attend follow up appointments and maintain regular appointments. ACKNOWLEDGEMENT & CONSENT 1. I certify that I have been fully informed by my dentist and have carefully read all the information provided on this form and that the proposed treatment and the alternatives have been explained to me by the dentist to my satisfaction. I understand the purpose and the nature of the soft tissue grafting procedure. I understand what is necessary to accomplish the placement of the graft. I understand the implications and consent to the proposed treatment. I agree to the fees and accept the general and special conditions. 2. The dentist has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire to have a graft in order to assist with recession and add gum thickness. 3. I have further been informed of the possible risks and complications involved with surgery, drugs, and anaesthesia. I understand that such complications include pain, swelling, infection, discoloration, and acute or chronic pain or dysfunction associated with my jaw joint/s or muscles. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration of these complications may not be determinable and I am aware that there is a slight chance they may be become permanent and irreversible. Also possible are inflammation of a vein, injury to existing or surrounding teeth, delayed healing, allergic reactions to drugs or medications used. 4. I understand that if I do not proceed with the proposed treatment, any of the following could occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth, necessity of extraction. 5. The dentist has explained that there is no method to accurately predict gum and bone healing capabilities in each individual following the placement of a soft tissue graft. 6. It has been explained that in some instances the soft tissue graft may not work optimally. I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurance as to the outcome of results of treatment or surgery can be made. 7. I understand that excessive smoking, alcohol, or sugar may affect gum healing and may limit the success of the graft. 8. I agree to follow the home care instructions. I agree to report to the dentist for regular examinations and cleans as instructed.
9. I agree to the type of anaesthesia, depending on the choice of the dentist. I understand that I must not operate a motor vehicle or hazardous device for at least 24 hours or more until fully recovered from the effects of the anaesthesia or drugs administered for my care depending on the proposed anaesthesia. 10. To my knowledge I have given an accurate report of my physical, mental health and medical history. I have also reported any prior allergic or unusual reactions to drugs, food, insect bites, anaesthetics, pollens, dust, blood or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health. 11. I consent to photography, filming, recording, and x-rays of the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed. 12. I request and authorize medical/dental services for me. I fully understand that during and following the contemplated procedure, surgery, or treatment, conditions may become apparent which warrant, in the judgment of the dentist, additional or alternative treatment pertinent to the success of comprehensive treatment. I also approve any modification in design, materials, or care, if it is felt this is in my best interest. I understand that regardless of what had been explained to me or my expectations, results and experiences vary from patient to patient. No Warranty or Guarantee? I hereby acknowledge that no guarantee, warranty, or assurance has been given to me that the proposed implant will be completely successful to my complete satisfaction in function or appearance. Each individual and their conditions are unique, thereby it is anticipated that the long-term success cannot be promised. Disclaimer: The practice of dentistry is not an exact science and therefore, reputable practitioners cannot guarantee results. Please understand that no one can promise that any treatment or dental procedure will be successful or that any risk, complication or injury will not occur. I have been explained the contents of this document and understood all the information provided in regards to Soft tissue grafting and associated risks and benefits, complications, costs, alternative treatments and maintenance. I certify I have had every opportunity to ask questions and discuss these and consent to the procedure presented to me during consultation. Patient Name and Signature Harris Dental Boutique Team Member Name Date Date