Diagnosis: After a careful oral examination and study of my dental condition, I have been advised that
my missing tooth or teeth may be replaced with an artificial tooth or teeth supported by an implant.
However, there is insufficient bone between the oral cavity and the maxillary sinus to allow placement
of dental implants, and a sinus lift procedure with bone replacement graft is necessary before, or during
In order to treat this condition, Dr. Safari has recommended that my
treatment include a sinus lift procedure with a bone replacement graft. I understand that sedation may
be utilized and that a local anesthetic will be administered to me as part of the treatment. My gum
tissue will be opened to expose the bone above my missing tooth or teeth and a small portion of bone
will be removed to access the floor of the sinus.
I understand that surgery will be performed to place a bone graft material onto the floor of the
maxillary sinus to build up adequate bone height and volume for the placement of implants. Various
types of graft material may be used. These materials may include my bone, synthetic bone substitutes,
or bone obtained from tissue banks (allografts). Membranes may also be used. The soft tissue will be
stitched closed and healing will be allowed to proceed for four to eight months. After the graft has
partially healed, a second procedure will be done to insert the implants into the upper jaw and grafted
I understand that dentures usually cannot be worn during the first one to two weeks of the healing
phase. I understand, in some circumstances, Dr. Safari may place the dental implants at the same time
as the sinus lift procedure. I further understand that unforeseen conditions may call for modification
or change from the anticipated treatment plan. These may include but are not limited to, (1) placing
the bone replacement graft or dental implants at a later date (2) termination of the procedure before
completion of all the surgery originally outlined.
Expected Benefits: The purpose of the sinus lift procedure is to add bone height and volume to the
floor of the maxillary sinus to allow the placement of dental implants. It is expected that the implants
will become stable and act as anchors for the fixed or fixed-detachable bridge or dentures in the grafted
Principal Risks and Complications: I understand that some patients do not respond successfully to the
sinus lift procedure, and in such cases, the bone graft material may need to be removed. The sinus lift
procedure may not be successful in providing adequate bone for dental implants. Because each
patient’s condition is unique, long-term success may not occur. I understand that complications may
result from the sinus lift procedure, drugs, and anesthetics. These complications include but are not
limited to, post-surgical infection or bleeding that might require further treatment including
hospitalization and surgery, swelling and pain, discoloration of the face, neck, and mouth, transient but
on occasion permanent numbness or tingling of the upper lip, gums, teeth, cheek, or palate, which may
be temporary or, rarely, permanent, injuries or associated muscle spasm, cracking or bruising of the
corners of the mouth, restricted ability to open the mouth for several days or weeks, impact on speech,
allergic reactions, altered sense of smell, injury to teeth, bone fracture, sinus penetrations, bloody
nose, congestion or post-nasal drip, sinus leakage or sinus exposure, delayed healing, and accidental
swallowing of foreign matter.
Other complications may include trauma to the nerve tissue or blood vessels that may lead to loss of
sensation of lip tongue check or other tissues in the mouth or altered sensation or pain.
The exact duration of any complications cannot be determined, and they may be irreversible.
Dr. Safari has discussed with me that smoking is particularly harmful to the success of the operation. It
has been requested that I stop smoking.
Dr. Safari has explained that if the new bone does not incorporate into the bone graft material,
alternative tooth replacement measures will have to be considered.
Alternatives to Suggested Treatment:
Alternative treatments for the sinus lift procedure include no
treatment, new removable or fixed appliances, and other procedures – depending on the
Necessary Pre-Surgical, Follow-up, and Self-Care: I understand that it is important for me to see Dr.
Safari for follow-up care, to follow home-care instructions, and to abide by the specific pre-and postoperative
prescriptions and instructions given by Dr. Safari and his staff. I understand that the failure
to follow such recommendations could lead to ill effects, which would become my sole responsibility.
No Warranty or Guarantee:
I hereby acknowledge that no guarantee, warranty, or assurance has been
given to me that the proposed treatment will be successful. Due to individual patient differences. Dr.
Safari cannot predict the certainty of success. There exists the risk of failure, relapse, additional
treatment, or worsening of my present condition, including the possible loss of bone replacement
grafts, certain teeth, or implants despite the best care.
Publication of Records:
I authorize photos, slides, x-rays, videos, or any other viewings of my care and
treatment during or after its completion to be used for the advancement of dentistry and/or
reimbursement purposes. My identity will not be revealed to the general public, however, without my
I have been fully informed of the nature of the sinus lift surgery, the procedure to be utilized, the risks
and benefits of my treatment, the alternative treatments available, and the necessity for pre-, followup,
and self-care. I have had an opportunity to ask any questions I may have in connection with the
treatment and to discuss my concerns with Dr. Safari. After thorough deliberation, I hereby consent to
the performance of the sinus lift procedure as presented to me during the consultation and in the
treatment plan presentation as described in the document. I also consent to the performance of such
additional or alternative procedures as may be deemed necessary in the best judgment of Dr. Safari.
I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENTS
Once fully read and reviewed, please make sure that the above document is filled out appropriately.
By signing below and submitting this document, we are assuming that it has been read in its entirety.
All patient signatures will be verified for authenticity in the office.