I hereby consent to the surgical insertion of one or more mini dental implants,
which will be performed by Dr. Mark Safari, General Dental Surgeon.
I have been informed and understand that transitional or mini implants are
available to those dental patients who meet specific criteria. These mini implants are
smaller in diameter than traditional implants. They are placed in a patient’s jaw to
provide immediate stabilization of teeth and enhance function. I am aware that the longterm
function cannot be predicted.
I understand that in the event that the mini dental implants fail they will be
removed through a subsequent surgical procedure. I further understand that it is possible
that one or more of the implants may fracture during insertion, or during the implant’s life
cycle. In the event that such a fracture occurs, I give permission to leave the fractured
implant in my jaw if indicated by my dentist’s clinical judgment. It has also been
explained to me that once the mini implants are inserted or implanted, a recommended
dental treatment plan, including a of personal oral hygiene must be strictly
followed by me and completed on schedule. I have been informed that if this
schedule and plan are not carried out, the implants may fail.
I have been advised that swelling, infection, bleeding, and or pain may be
associated with any surgical procedure. I have also been advised that temporary or
permanent numbness may occur in my tongue, lips, chin, gum or jaw.
I hereby consent to the surgical placement of dental implants as well as the
denture prosthetic portion of the mini implants which will be inserted once healing is
fully successful and ready for integration of the denture.
I understand that the purpose of the mini implants is to provide support for dental
prosthetic reconstruction in the form of denture, or to provide orthodontic anchorage.
Most patients need two surgical procedures to install the implants. The first procedure
involves drilling small holes into the jawbone and placing the anchors. You will be given
anesthetic to numb the pain. You will also be put on antibiotics and be given pain
medication. A temporary denture or flipper may be worn for a few months while the
anchors bond with the jawbone and the gums and bone heal. The second procedure which
usually will occur 3-6 months after mini implant placement, will uncover the implants to
allow for attachment of the posts. After the posts are in place, the denture(s), are fastened
to the posts. Depending on the condition of the mouth, bone grafting or guided tissue
regeneration also may be necessary to install the anchors and posts.
At present, we cannot predict the length of time dental implants will provide
service in the oral cavity. I know that smoking lowers the chances of implant success in
direct proportion to the amount smoked. I understand that in the event the implant fails to
integrate, it must be removed through a second surgical procedure, and there can be no
refund of all or part of the fee for the lost implant.I understand the alternative
conventional dental treatment options and I am aware of the consequences of receiving no
The potential benefits of this procedure include the replacement of missing natural
teeth or supporting dentures. I have chosen to undergo this procedure after considering the
alternative forms of treatment for my condition, which include no treatment at all,
complete or partial dentures, or fixed or removable bridges. Each of these alternative
forms of treatment has its own potential benefits, risks and complications.
I consent to the administration of anesthesia or other medications before, during or
after the procedure by qualified personnel. I understand that all anesthetics or sedation
medications involve the very rare potential of risks or complications such as damage to
vital organs including the brain, heart, lungs, liver and kidneys; paralysis; cardiac arrest;
and/or death from both known and unknown causes.
I understand that the implant surgery and prosthetics will be done in the
established way and that the risks in the front of the mouth consist of the usual ones
associated with simple gum surgery including, but not limited to pain, swelling, bruising,
infection and bleeding. Additional complications have been reported for implant surgery
in the back of the mouth; they consist of loss of sensation to the tongue, cheeks or lip on
the treated side in the lower jaw, and the creation of a communication between the sinus
and the mouth on the treated side in the upper jaw. Other complications may include
trauma to the nerve tissue or blood vessels that may lead to loss of sensation of lip
tongue check or other tissues in the mouth or altered sensation or pain. These
complications would require further surgery for correction.
I agree to make every effort to return for follow-up visits for hygiene and exams
three months, six months, one year, eighteen months and two years after the surgery and
to have the needed x-rays taken as well as any cleaning and adjustment procedures needed
to keep my mouth healthy at the usual and customary fees, but I am aware that this is
entirely voluntary on my part. Keeping your gums and teeth healthy by coming for
hygiene visits every 3-4 months is one of the best ways to take care of your implants.
Photographs and clinical data might be used in scientific papers and presentations
and the confidentiality of the patient will be respected.
certify Ithat I have read or had read to me the contents of this form. I will follow
any patient instructions related to this procedure. I confirm that the proposed treatment
and potential risks and/or complications associated with the procedure have been
explained to me. I understand the potential risks, complications and side effects involved
with any dental treatment or procedure and have decided to proceed with this procedure
after considering the possibility of both known and unknown risks, complications, side
effects and alternatives to the procedure. I declare that I have had the opportunity to ask
questions and all of my questions have been answered to my satisfaction.
I am aware that I must return for appropriate postoperative care and evaluation,
which will include evaluation of oral hygiene and plaque removal. I also understand that
function and comfort will be the primary goals of this dental procedure but that success
rates for each patient vary. With that in mind, no guarantees of success have been given to
me. I have also been informed that use of tobacco, including cigarette smoking, as well as
excessive alcohol consumption can cause failure of dental implants.
I confirm that I have explained the proposed treatment and potential risks and/or
complications associated with the procedure.
I certify that I have read and fully understand the above consent of treatment, and I
am fully satisfied with the explanations given to me by Dr. Mark Safari
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and submitting this document, we are assuming that it has been read in its entirety.
All patient signatures will be verified for authenticity in the office.