Consent Form for Bone Graft Surgery

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I have been informed and afforded the time to fully understand the purpose and the nature of the bone graft surgery procedure. I understand what is necessary to accomplish the placement of the bone graft under the gum on/or in the bone.

My doctor has carefully examined my mouth. Alternatives to this treatment have been explained. I have tried or considered these methods, but I desire a bone graft to help secure the replaced missing teeth

I have further been informed of the possible risks and complications involved with surgery, drugs, and anesthesia. Such complications include pain, swelling, infection and discoloration. Numbness of the lip, tongue, chin, cheek, or teeth may occur. The exact duration may not be determinable and may be irreversible. Also possible are thrombophlehitis (inflammation of the vein), injury to teeth present, bone fractures, sinus penetration, delayed healing, allergic reactions to drugs or medications used,etc.

I understand that if nothing is done any of the following may occur: bone disease, loss of bone, gum tissue inflammation, infection, sensitivity, looseness of teeth followed by necessity of extraction. Also possible are temporomandibular joint(jaw) problems, headaches, referred pains to back of the neck and facial muscles, and tired muscles when chewing. In addition, I am aware that if nothing is done an inability to place a bone graft or implants at a later date due to changes in oral or medical conditions could exist.

My doctor has explained that there is no method to predict accurately the gum and bone healing capabilities in each patient following the placement of a bone graft. It has been explained that bone in its healing process remodels and there is no method to predict the final volume of bone, thus additional grafting may be necessary.

It has been explained that in some instances bone grafts fail (mal-union, delayed union, or non-union of the donor bone graft to the recipient bone site) and must be removed. Lack of adequate bone growth in the bone graft replacement material could result in failure I have been informed and understand that the practice of dentistry is not an exact science; no guarantees or assurances as to the outcome of the results of treatment or surgery can be made. I am aware that there is a risk that the bone graft surgery may fail, which might require further corrective surgery or the removal of the bone graft with possible corrective surgery associated with the removal. If the bone graft surgery fails I understand that alternative prosthetic measures may have to be considered.

I understand that excessive smoking, alcohol, or blood sugar may effect gum healing and may limit the success of the bone graft. I agree to follow the doctor's home care instructions. I agree to report to my doctor for regular examinations as instructed.

I agree to the following procedure:

Autogenous Graft

Autogenous Graft

Chin (mental symphysis)Edentulous areaMaxillary tuberosity siteAscending ramusIliac crestTibiaOther
Upper ArchLower ArchEdentulous AreaSinus


Demineralized free-dried bone (DFDB)Freeze-dried bone (Puros Cancellous Particulate Allograft
Upper ArchLower ArchEdentulous AreaSinus
Alloplast Graft


Dense HA RecipentResorabable HA SiteCollagen membranesOther
Upper ArchLower ArchEdentulous AreaSinus

I agree to the type of anesthesia, depending on the choice of the doctor. I agree not to operate a motor vehicle or hazardous device for at least 24 hours or more or until fully recovered from the effects of the anesthesia or drugs given for my care.

To my knowledge, I have given an accurate report of my physical and mental health history. I have also reported any prior allergic or unusuual reactions to drugs, food, insect bites, anesthetics, pollens, dust, blood, or body diseases, gum or skin reactions, abnormal bleeding or any other conditions related to my health.

I consent to photography, filming, recording, x-rays and additional professional staff observing the procedure to be performed for the advancement of implant dentistry, provided my identity is not revealed.

I agree to notify the doctor's office of any and all changes to my address and/or telephone number within a reasonable time frame (two to four weeks).

With clear knowledge of all of these possible complications, have requested that the procedure be perfomed in the:

Office environmentHospital environment

I request and authorize medical/dental services for myself, including bone grafts and other surgery. I fully understand the contemplated procedure, surgery, or treatment conditions that may become apparent which warrant, in the judgement of the doctor, additional or alternative treatment pertinent to the sucess of comprehensive treatment. I also approve any modifications in design, materials, or care, if it is felt this is for my best interest. If an unforeseen condition arises in the course of treatment which calls for the performance of procedurs in addition to or different from that now contemplated I further authorize and direct my doctor, associate or assistant, to do whatever they deem necessary and advisable under the circumstances, includes the decision not to proceed with the bone graft procedure.