The purpose of this informed consent form is to provide an opportunity for patients (and/or their parents or
guardians) to understand and give permission for bone grafting and/or barrier membrane treatment. Each item should
be initialed after the patients (and/or their patients or guardians) have the opportunity for discussion and
I understand that bone grafting and barrier membrane procedures include inherent risks include but is not exclusive of:
Pain. Some discomfort is inherent to any oral surgery procedure. Grafting with
materials that do not have to be harvested from your body are less painful because they do not require a
donor site surgery. If the necessary bone is taken from your chin or wisdom tooth area in the back of
your mouth, there will be more pain, it can be largely controlled with pain medications.
Infection. No matter how carefully surgical sterility is maintained it is possible,
because of the existing non-sterile oral environment, for infections to occur postoperatively. At times,
this may be of serious nature. Should severe swelling occur, particularly accompanied with fever or
malaise, professional attention should be received as soon as possible.
Bleeding, Bruising or Swelling. Some moderate bleeding may last several hours. If
profuse, you may contact us as soon as possible. Some swelling is normal, but if severe, you should
notify us. Swelling usually starts to subside after about 48 hours. Bruises may persist for a week or
Loss of all or part of the graft. Success with bone and membrane grafting is high.
Nevertheless, it is possible that the graft could fail. A block bone graft taken from somewhere else in
your mouth may not adhere or become infected. Despite meticulous surgery, particulate bone graft
material can migrate out of the surgery site and be lost. A membrane graft could start to dislodge. If
so, the doctor should be notified as soon as possible. Your compliance is essential to assure success.
Types of graft material. Some bone graft and membrane material commonly used are
derived from humans or other mammals’ sources. These grafts are thoroughly purified by different means
to be free of contaminants. Signing this consent form gives your approval for the doctor to use such
materials according to her knowledge and clinical judgment for your situation.
Injury to nerves. This would include injuries causing numbness of the lips, the tongue,
any tissues of the mouth, and cheeks or face. This numbness, which could occur, may be of a temporary
nature, lasting a few days, a few weeks, a few months, or could possibly be permanent and could result
of surgical procedures or anesthetic administration.
Sinus involvement. In some cases, the root tips of upper teeth lie in proximity to the
maxillary sinus. Occasionally, with extractions and/or grafting near the sinus, the sinus can become
involved. If this happens, you will need to take special medications. Should sinus penetration occur, it
may be necessary to later have the sinus surgically closed.
It is my responsibility to seek attention should any undue circumstances occur post operatively, and I will diligently follow any preoperative and postoperative instructions.
We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.