Sinus Lift Consent

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Sinus Lift Consent

CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS-LIFT/BONE GRAFTING PROCEDURE
Patient's Name*
First Name Last Name
Date*
MM slash DD slash YYYY
Please check each paragraph after reading. If you have any questions, please ask your doctor before initialing.
You have the right to be given information about your proposed implant placement so that you are able to make the decision as to whether to proceed with surgery. What you are being asked to sign is confirmation that you have been given information on the nature of your proposed treatment, the known risks associated with it and the possible alternative treatments.
Dr. has informed me of my diagnosis (condition) which is described as:
The surgical procedure proposed to treat the above condition has been explained to me and I understand it to be:
- 1. I understand that incisions will be placed inside my mouth in the upper jaw for the purpose of placing one or more endosteal root form structures (implants) in my jaw to serve as anchors for a missing tooth or teeth replacement or to stabilize a crown (cap), bridge or denture. I acknowledge that the doctor has explained the procedure, including the number and location of incisions and the type of implant to be used. I also understand that the crown, bridge or denture that will later be attached to this implant(s) will be made and attached by Dr. and that a separate charge will be made by that office.
- 2. In my case, I further understand that there is not enough natural jawbone in which to place the proposed implant and that a procedure called “sinus lift” is planned. This procedure is more complicated than usual implant placement and involves opening the sinus cavity in my upper jaw and placing a bone graft in order to provide support for the implant. I have been told that this graft could come from specially-prepared donated bone, or may be taken from my jaw, chin, skull or hip, any of which might be supplemented with specially-prepared donated bone or bone substitute.
- 3. I understand the implant(s) must remain covered by gum tissue (2 piece) or remain untouched (1 piece) for at least six months or longer before it can be used, and that a second surgical procedure is required to uncover the top of the implant(s) (two piece). No guarantee can be or has been given that the implant(s) will last for a specific time period. It has been explained to me that once the implant(s) is/are inserted, the entire treatment plan must be followed and completed on schedule. If this is not done, the implant(s) may fail.
CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS- LIFT/BONE GRAFTING PROCEDURE
- 4. I have been informed of possible alternative forms of treatment (if any), including: doing nothing, full sinus lift, crestal sinus lift, removable partial denture, fixed partial denture (if possible). I understand that other forms of treatment or no treatment at all are choices that I have and the risks of those choices have been presented to me.
- 5. My doctor has explained to me that there are certain inherent and potential risks and side effects in any surgical procedure and in this specific instance such risks include, but are not limited to, the following:
Risks of Implant Surgery
A. Post-operative discomfort and swelling that may require several days of at-homerecuperation.
B. Prolonged or heavy bleeding that may require additional treatment. Because the sinus isinvolved, some bleeding may be from the nose.
C. Injury or damage to adjacent teeth or roots of adjacent teeth, possibly requiring further rootcanal therapy, and occasionally the loss of an injured tooth.
D. Post-operative infection, including sinus infection, which may require additional treatment. Inrare instances an opening may develop between mouth and sinus, again requiring additional treatment.
E. Stretching of the corners of the mouth that may cause cracking and bruising.
F. Restricted mouth opening for several days; sometimes related to swelling and musclesoreness, and sometimes related to stress on the jaw joints (TMJ).
G. Possible prolonged symptoms of sinusitis requiring certain medications and longer recoverytime, resulting from intentional entry into the sinus. H. Fracture of the jaw.
I. Possible injury to nerve branches in the bone resulting in numbness, pain
or tingling of the lips, cheek, gums or teeth. If implants are placed in the lower jaw, there may be numbness or pain of the chin or tongue also. These symptoms may persist for several weeks, months or, in rare instances, may be permanent.
General Risks of Bone Grafting:
A. Bleeding, swelling or infection at the donor site requiring further treatment.
B. Allergic or other adverse reaction to drugs used during or after the procedure.
C. The need for additional or more extensive procedures in order to obtain sufficient bone forgrafting.
CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS LIFT/BONE GRAFTING PROCEDURE
Risks and Complicatins of Grafting from Within a Mouth Area
A. Damage to adjacent teeth, which may require future root canal procedures, or may cause lossof those teeth.
B. Removal of adult teeth in order to obtain sufficient bone material.
C. Numbness or pain in the area of the donor or recipient site, or moreextensive areas, which may be temporary or permanent.
D. Penetration of the sinus or nasal cavity in the upper jaw which could result in infection or othercomplication requiring additional drug or surgical treatment.
Risks of Freeze-Dried, Demineralized or Other Banked Bone
On occasion, additional donated bone is used to supplement the patient’s bone, or to spare an extensive donor site surgical procedure. Use of such bone may involve separate risks including, but not limited to:
- 6. I understand that in my grafting procedure, the use of (autogenous, demineralized, etc.) bone is expected to be taken from (note anatomic area), plus(other area)
- 7. ANESTHESIA
- The anesthesia I have chosen for my surgery is:
- Local Anesthesia
- Local Anesthesia with Nitrous Oxide/Oxygen Analgesia Local Anesthesia with Oral
- Premedication
- Local Anesthesia with Intravenous Sedation
- 8. ANESTHETIC RISKS include: discomfort, swelling, bruising, infection, prolonged numbness and allergic reactions. There may be inflammation at the site of an intravenous injection (phlebitis) which may cause prolonged discomfort and/or disability, and may require special care. Nausea and vomiting, although rare, may be unfortunate side effects of IV anesthesia. Intravenous anesthesia is a serious medical procedure and, although considered safe, carries with it the risk of heart irregularities, heart attack, stroke, brain damage or death.
CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS LIFT/BONE GRAFTING PROCEDURE
- 9. YOUR OBLIGATIONS IF IV ANESTHESIA IS USED. Because anesthetic medications cause prolonged drowsiness, you MUST be accompanied by a responsible adult to drive you home and stay with you until you are recovered sufficiently to care for yourself. This may be up to 24 hours. During recovery time (24 hours) you should not drive, operate complicated machinery or devices, or make important decisions such as signing documents, etc. You must have a completely empty stomach. IT IS VITAL THAT YOU HAVE NOTHING TO EAT
- OR DRINK FOR EIGHT (8) HOURS PRIOR TO YOUR ANESTHETIC. TO DO OTHERWISE MAY BE LIFE-THREATENING! However, it is important that you take any regular medications (high blood pressure, antibiotics, etc.) or any medications provided by this office, using only a small sip of water.
- 10. Conditions may be revealed which will necessitate extension of the original procedure, a different procedure from those set forth above, or abandonment of the procedure entirely. In such an event, I authorize my doctor and his staff to perform such procedures as are necessary and desirable in the exercise of professional judgment to complete my surgery.
- 11. I understand that my doctor is not a seller of the implant device itself and makes no warranty or guarantee regarding success or failure of the implant or its attachments used in the procedure.
- 12. I understand smoking is extremely detrimental to the success of implant surgery. I agree to cease all use of tobacco for 2-3 weeks prior to and after surgery, including the later uncovering procedure, and to make strong efforts to give up smoking entirely.
- 13. It has been explained to me and I understand that a perfect result is not, and cannot be guaranteed or warranted.
Consent:
I certify that I speak, read and write English and have read and fully understand this consent for surgery, and that all blanks were filled in prior to my initialing and signing this form and that all my questions were answered to my satisfaction.
Patient, Parent/Guardian*
Witness
Date
MM slash DD slash YYYY
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After submitting, feel free to return to the Patient Forms page. Please note, there are multiple forms for each section.

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June 2, 2021.

Dr. Wall is a living legend in our family! He has helped me recover from poorly done root canals, fixed years worth of incorrect orthodontics, and solved my TMJ problems. I struggled with chronic vertigo during and after my pregnancy that was passed off as “normal” hormonal changes. I saw multiple doctors and neurologists before visiting Dr. Wall. He discovered 4 cavitations that needed addressing and once he worked his dental magic, the vertigo I had struggled with daily for 2 years disappeared! The importance of proper dental care for overall health cannot be overlooked. Dr. Wall is the best in his field and it’s an honor to have him on my healthcare team!

Missy Beavers

May 26, 2021.

I highly recommend Dr. Wall to anybody with tooth aches or pains. He is so caring and understanding. He has genuine concern for my well being. His staff is very nice and professional. I can't say enough good things about the care I received from Dr. Judson Wall and his team. Thank-you!

Tyler Heath

May 26, 2021.

I had so much discomfort for years and Dr Wall took out teeth that were gangrene that I did not know were that bad. He is amazing....

Beatrice Ireland

May 24, 2021.

Hands down the most amazing dentist I've ever been to. From the expertise of care and heartfelt communication from Dr. Wall and his staff to the lush jungle of plants throughout the office, this is a dental experience like no other. For 15 years I had been struggling with a phantom disease causing chronic fatigue, brain fog, anxiety, depression, etc...it was hell. A woman (who I now feel is certainly a guardian angel) brought to my attention that my story was almost identical to the man who produced the film "Root Cause". I was taken aback that my issues could actually be caused by an old root canal I had and felt compelled to watch it...it made me cry and I knew this was it. She then referred me to Dr. Wall and the rest is history. I spent about 4 hours at Dental Solutions my first visit where I received a level of care you wouldn't expect from a dentist, let alone your family doctor. Being a biological practice, Dental Solutions has your whole body in mind and I was tested from head to toe to figure out what was going wrong. Sure enough, I had a failed root canal that had eaten a 1 cm diameter hole in my jaw above that tooth...it was slowly killing me. Dr. Wall pulled the decayed tooth which was gangrenous, cleaned everything out, stuffed the decayed hole with platelet rich fiber (PRF) and put a zirconia implant in. He also cleaned out my wisdom tooth cavitations and did TMJ injections to help the jaw issues I didn't realize I had. Over one year later and I feel better than ever, I have my vitality back!!!! So very thankful for Dr. Wall, he saved my life. No other dentist had any idea what was going on. This is the place to go, I travel from Colorado to come here...highly recommend this practice. Thank you Dental Solutions for changing my life!

Alex Curry

May 13, 2021.

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Sinus Lift Consent

CONSENT FOR TWO-STAGE OSSEOUSINTEGRATED IMPLANT WITH SINUS-LIFT/BONE GRAFTING PROCEDURE