Consent for the surgical exposure of teeth

Stateline Oral & Maxillofacial Surgery, PC


Note to patients:  this is a synopsis of the consent form used in our office.  The actual form may differ in small details from this text.  The doctor will review the risks and benefits associated with this surgery before you are given the opportunity to sign the actual consent form.


You have the right to be informed about your condition and the various treatment alternatives that might be available.  Once you have been given the risks and benefits associated with various treatment options you have the right and responsibility to make an educated decision as to whether or not to pursue such treatment.  You present to our office today for the surgical procedure named below; it is important for you to understand why this treatment has been recommended and what risks and benefits are associated with this procedure.

The following surgery is to be accomplished today:


Surgery is an irreversible process; there are some risks and they include, but are not limited to the following.

-  post-operative swelling, bruising and discomfort in the surgical area which may require additional treatment.

-  stretching of the corners of the mouth which may cause cracking or bruising, and may be slow to heal.

-  post operative  infection which may require  medical and / or surgical treatment.

-  jaw pain beginning a few days after surgery.  This condition may require care to reduce discomfort; otherwise the condition is self limiting.

-  post operative restricted mouth opening; this is normal for many patients, but may require active physical therapy is some cases.  This is especially common when pre existing TMJ conditions exist.

- bleeding; significant bleeding is not common but persistent oozing can be expected for several hours and, in some cases,  up to 24 hours after surgery.

-  sharp ridges or bone splinters may form in the areas of bone surgery.  These sharp areas usually smooth out with time without treatment, but may, in some cases, require further surgery.  Small pieces of bone may work through the gum tissues for 2 weeks or more after surgery.

-  because of the exposure required to gain access to certain teeth buried beneath the gum, areas around the uncovering may feel numb for days, weeks or months after surgery.  In rare cases this feeling may be permanent.

-  certain teeth to be uncovered often are very close to roots of adjacent teeth.  There is a slight chance that those roots may be injured, requiring later root canal treatment or, in rare instances, may result in the loss of those teeth.

-  although usually only one incision is needed to expose the buried tooth, sometimes the approach is complicated enough to require two or more incisions.

-  when uncovering upper back teeth, there is a chance that the sinus may be entered, requiring antibiotic therapy, or possibly resulting in an opening between mouth and sinus that may require further care.  Rarely, the same complication may effect the nasal cavity.

-  often an orthodontic bracket and/or a wire or fine chain is attached to the uncovered tooth; then to your orthodontic appliances to gain the force to try to move the tooth. This may cause irritation to your tongue and interfere somewhat with eating. You will usually adjust to this problem fairly quickly.  Occasionally the bracket will become detached and must be re-attached.

-  although it cannot be easily determined beforehand, sometimes the planned orthodontic movement of the uncovered tooth cannot be accomplished.  If so, the tooth may be left in place or, if conditions require, be removed.

-  the orthodontic backet bonded to the tooth to be exposed is not meant to be permanent and may become dislodged during orthodontic treatment.  Occasionally, a new bracket must be placed to complete the appropriate eruption of the impacted tooth.  If the bracket becomes dislodged within 3 months of surgery, it is customary for the braket to be reattached without charge to the patient.

No guaranteed or warranted results have been offered or promised.  I realize my doctor may discover conditions which may require different surgery from that which was planned and I give my permission for those other procedures that are advisable in the exercise of professional judgment to complete my surgery.

During the course of treatment, unforeseen conditions may be revealed that may require minor changes to the surgical treatment plan.  In this instance, I authorize my surgeon to use professional judgment to perform these surgical modifications they deem necessary and desirable to complete my surgery.

The anesthetic I have chosen for my surgery is: (Please check one)

  1.        local anesthetic
  2.        local anesthetic with nitrous oxide sedation
  3.        local anesthetic with oral sedation
  4.        local anesthetic with IV sedation and / or general anesthesia

For those patients undergoing surgery with local anesthetic with or without nitrous oxide, there are some risks.  These include, but are not limited to:  discomfort, swelling, bruising, infection, prolonged numbness, dizziness, nausea and allergic reactions.

For those patients undergoing IV sedation and / or general anesthesia, there are some additional risks.  These include, but are not limited to the following:  inflammation at the site of an intravenous injection, which may cause prolonged discomfort and / or disability, which may require special care.  Nausea and vomiting, although uncommon, may be unfortunate side effects of IV anesthesia.  Intravenous anesthesia is a serious medical procedure, and although considered safe, does carry with it the very rare risks of significant medical morbidity.

Your obligations if IV anesthesia is used:

- Since anesthetic medications cause prolonged drowsiness, you must be accompanied by a responsible adult who can drive you home and stay with you until you have sufficiently recovered to care for yourself.

-  During your recovery time, which may take up to 24 hours, you should not drive, operate complicated machinery or devices, or make important decisions.

-  It is important for you to have an empty stomach prior to being sedated.  It is your responsibility to make a truthful disclosure of all food and liquid taken prior to surgery.  It is important that your stomach be completely empty at the time of surgery; failure to do so may lead to life threatening complications.

-  Advise the doctor as to whether or not your daily (if any) medications were taken in the usual manner.


I understand that individual reactions to treatment cannot be predicted, and that if I experience any unanticipated reactions during or following treatment, I agree to report them to the doctor as soon as possible.  I also agree to report any numbness that persists into the day after surgery.

I realize that no guarantees or assurances have been given by anyone regarding treatment results that may be obtained.  I also understand that if I have any questions regarding my treatment, I am to ask the doctor prior to signing this consent.

I certify that I speak, read and write English and have read and fully understand this consent for surgery.  Any questions that I had were answered by my doctor or his staff before this consent was signed.

I hereby acknowledge that I have read the foregoing and have discussed any questions or concerns I may have regarding my proposed treatment before signing this document.