Consent For Soft Tissue Graft Augmentation Surgery

Diagnosis

After a careful oral examination and study of my dental condition, my periodontist has advised me that I have gum recession and/or associated problems. I understand that with this condition, further recession may occur. In addition, for fillings at the gumline or crowns with edges under the gumline, it is important to have sufficient width of attached gum to withstand the irritation caused by the fillings or edges. Gum tissue may also be placed to improve the appearance and to protect the roots of the teeth.

Recommended Treatment

In order to treat this condition, my periodontist has recommended that gingival augmentation (gum grafting) procedures be performed. I understand that sedation may be utilized and that a local anesthetic will be administered to me as part of the treatment. The surgical procedure involves the transplanting of gum from elsewhere in my mouth and/or using donated tissue from a tissue bank.

Expected Benefits

1. The purpose of gingival augmentation is to create an amount of attached gum tissue adequate to reduce the likelihood of further gum recession.
2. Another purpose may be to cover exposed root surfaces, to enhance the appearance of the teeth and gum line, or to prevent or treat root sensitivity or root decay.

Principle Risks and Complications

I understand that complications may result from gingival augmentation or from anesthetics. These complications include, but are not limited to:

1. Swelling, bleeding, bruising or discomfort in the surgical and surrounding areas.
2. Post-operative infection requiring additional treatment or medication.
3. Temporary or on occasion permanent tooth sensitivity to hot, cold, sweet or acidic foods.
4. Gum recession/shrinkage creating open spaces between the teeth.
5. Incomplete root coverage.
6. Unaesthetic exposure of crown (cap) margins.
7. Numbness or altered sensations in the teeth, gums, lip, tongue or chin, around the surgical area following the procedure. Almost always the sensation returns to normal, but in rare cases, the loss may be permanent.
8. Limited jaw opening due to the inflammation or swelling. Sometimes it is a result of jaw joint discomfort (TMJ), especially when TMJ disease already exists.

I hereby certify that I clearly comprehend the nature, purpose, benefits, risks and alternatives to (including no treatment), the proposed procedure(s). I have been given the opportunity to ask questions and they have been answered to my complete satisfaction. I also consent to the performance of such additional or alternative procedures as may be deemed necessary in the best judgement of my periodontist.

I authorize photos, slides, x-rays or any other viewings of my care and treatment during or after its completion to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public, however, without my permission.

I have read and understand the above.