FILL OUT THE FORM BELOW Informed Consent for Gingivectomy Surgery This letter is meant to review the recommended gingivectomy surgical procedure. Please review this letter. Should you have any further questions before starting treatment, please do not hesitate to have these clarified with myself. Gingivectomy is a procedure intended to increase the amount of tooth exposed above the gums. Dentists often need more tooth exposed above the gumline in order to prepare the tooth for a veneer of a crown (or cap as some call it, fillings which are at and or below gumline). Following freezing by local anesthesia, this procedure will be carried out using laser and or scalpel and or electro surgery is made around the tooth and the gum tissue is gently resected/ repositioned/ recontouring. A periodontal bandage or dressing may be placed as needed over the surgically-treated area. The purpose of the gingivectomy procedure is to provide the specialists more access as well as more tooth structure to work with when the tooth is restored thereby increasing the retention of the restoration to be placed. It will also help create a biologic width which will reduce post-operative inflammation. Following any intra-oral surgical procedure, a patient can typically expect some pain, discomfort, mild swelling, bruising or discoloration. You will receive post-operative instructions on how to minimize these effects, following the surgical procedure. Other risks associated with the proposed procedure involve infection of the surgical site, damage to adjacent teeth, and disturbance of the sensory nerve which provides that area of the lower jaw with sensation to the skin of the chin, cheeks, and lips. Please note that these complications are possible, not probable, and with proper planning they are largely avoidable. The estimated fee for gingivectomy surgery has already been provided to you. Payment is due in full on the day of the procedure. Please sign below if you have read and understood the proposed surgical treatment as it indicates your acceptance of the terms and information provided.First Name* Last Name* Email* Date* Enter the patient and witness signature in the box below.
