I UNDERSTAND that treatment of dental conditions requiring CROWNS and/or FIXED
BRIDGEWORK includes certain risks and possible unsuccessful results, including the possibility of
failure. Even though care and diligence is exercised in the treatment of conditions requiring crowns
and bridgework and fabrication of the same, there are no promises or guarantees of anticipated
results or the longevity of the treatment.
Nevertheless, I agree to assume the risks, possible unsuccessful results and/or failure associated
with, but not limited to the following:
1. Reduction of tooth structure: In order to replace decayed or otherwise traumatized teeth it is
necessary to modify the existing tooth or teeth so that crowns (caps) and/or bridges may be placed
upon them. Tooth preparation will be done as conservatively as possible.
2. Injury : During the reduction of tooth structure or adjustments done to temporary restorations, it is
possible for the tongue, cheek or other oral tissues to be inadvertently abraded or lacerated (cut). In
some cases, sutures or additional treatment may be required.
3. Local Anaesthesia:
In order to reduce tooth structure without causing undue pain during the
procedure, it will be necessary to administer local anaesthetic. Such administration may cause
reactions or side effects which include, but are not limited to, bruising, hematoma, cardiac
stimulation, temporary or, rarely permanent numbness of the tongue, lips, teeth, jaws and/or facial
tissues, and muscle soreness.
4. Sensitivity of teeth :
Often, after the preparation of teeth for the reception of either crowns or
bridges, the teeth may exhibit sensitivity, which can range from mild to severe. This sensitivity may
last only for a short period of time or may last for much longer periods. If sensitivity is persistent, this
office should be notified immediately such that all possible causes of the sensitivity may be
5. Risk of Further Treatment:
Following crown preparation and placement for either individual teeth
or bridge abutments, the involved tooth or teeth may require root canal treatment. Teeth, after being
crowned, may develop a condition known as pulpitis or pulpal degeneration. Usually this cannot be
predetermined. The tooth or teeth may have been traumatized from an accident, deep decay,
extensive preparation, or other causes. It is often necessary to do root canal treatments in these
teeth, particularly if teeth remain appreciably sensitive for a long period of time following crowning.
Infrequently, the tooth (teeth) may abscess or otherwise not heal completely. In this event, periapical
surgery or even extraction may be necessary.
Crowns and bridges may possibly chip or break. Many factors can contribute to this
situation such as chewing excessively hard materials, changes in biting forces exerted, traumatic
blows to the mouth, etc. Unobservable cracks may develop in crowns from these causes, but
crowns/bridges may not actually break until chewing soft foods, or for no apparent reason. Breakage
or chipping seldom occurs due to defective materials or construction unless it occurs soon after
7. Uncomfortable or strange feeling:
This may occur because of the differences between natural
teeth and artificial replacements. Most patients usually become accustomed to this feeling in time. In
limited situations, muscle soreness or tenderness of the jaw joints (TMJ) may persist for
indeterminable periods of time following placement of the crown or bridgework.
8. Aesthetics or appearance:
Patients will be given the opportunity to observe the appearance of
crowns or bridges in their mouths prior to final cementation. If satisfactory, this fact will be
acknowledged by the patient's signature (or signature of legal guardian) on the back of this form
9. Longevity of crowns and bridges :
There are many variables that determine "how long" crowns
and bridges can be expected to last. Among these are some of the factors mentioned in preceding
paragraphs. In addition, general health, good oral hygiene, regular dental checkups, diet, etc., can
affect longevity. Because of this, no guarantees can be made or assumed to be made concerning
how long crown and bridgework will last.
10. Opening the Bite:
In some cases, years of wear on the teeth will create a situation where the
patient over closes or loses length of the face. A full mouth reconstruction where all existing teeth
are crowned will enable the dentist to reopen the bite to the proper length. As a result the patient
may experience some temporary discomfort and the crowns will be more subject to wear and
breakage. If a night-guard is recommended or made but not worn by the patient, there will be an
increased risk of breakage or fracture of the porcelain.
11. Damage or trauma to teeth during the Replacement of old crowns or bridges:
If you have an existing crown or bridge already and the Dentist recommended that it is in your best
interest to change the current crown or bridge, please note the following if this is applies to you:
There are three primary reasons to remove an individual crown or bridge that has been
previously cemented into place:
- To attempt to fix or redo crowns and/or bridges that have broke or fractured while in the mouth
- To render some type of necessary treatment to a tooth that is difficult or impossible to perform or render treatment without removing the existing crown or bridge.
- To confirm the presence of dental decay or other pathology that may be difficult to
detect or may be obscured while the crown/bridgework is in place.
I UNDERSTAND that REMOVAL OF CROWNS AND OR BRIDGES include possible inherent
risks such as, but not limited to the following; and also understand that no promises or
guarantees have been made or implied that the results of such treatment will be successful:
a. Fracture or breakage of the existing crown or bridge: Many crowns and bridges are
fabricated either entirely in porcelain or with porcelain fused to an underlying metal structure. In
the attempt to remove these types of crowns there is a distinct possibility that they may fracture
(break) even though the attempt to remove them is done as carefully as possible.
b. Fracture or breakage of the actual tooth from which the crown or bridge is removed: Because
of the leverage of torque pressures necessary in removing a crown from a tooth, there is a
possibility of fracturing or chipping the tooth. At times these fractures are extensive enough to
necessitate extracting the tooth.
c. Trauma to the tooth: Because of the pressure and/or torque necessary in some cases to
remove a crown, these pressures or torque may result in the tooth being traumatized and the
nerve (pulp) injured which may necessitate a root canal treatment in order to preserve the tooth.
Instruments used to remove crowns and bridges may inadvertently lacerate the gums, other
tissues within the mouth, and tongue.
d. Failure of conventional methods in removing crowns: There are certain methods and
instruments which are utilized in conventional attempts to remove crowns from teeth. In some
instances, none of these methods or instruments will effectively remove the crown from a tooth
and may result in the tooth being inadvertently extracted. This may necessitate a new bridge or
an addition and extension of the existing bridge if the tooth is an abutment tooth for a bridge; or
construction of a bridge if this is an individual tooth within an existing arch or teeth.
e. Inadvertent extraction of the crowned tooth: In extremely rare cases, the amount of pressure
or torque necessary to remove the crown from a tooth may result in the tooth being
inadvertently extracted. This may necessitate a new bridge or an addition and extension of the
existing bridge if the tooth is an abutment tooth for a bridge; or construction of a bridge if this is
an individual tooth within an existing arch of teeth.
***It is the patient's responsibility to seek attention from the dentist should any undue or
unexpected problems occur. The patient must diligently follow any and all instructions,
including the scheduling and attending all appointments. Failure to keep the cementation
appointment can result in ultimate failure of the crown/bridge to fit properly and an additional
fee may be assessed.
INFORMED CONSENT FOR CROWN & BRIDGE PROSTHETICS AND FOR FINAL CEMENTATION:
I have been given the opportunity to ask any questions regarding the nature and purpose of crown
and/or bridge treatment and have received answers to my satisfaction. I voluntarily assume any and
all possible risks, including risk of substantial harm, if any, which may be associated with any phase
of this treatment in hopes of obtaining the desired results, which may or may not be achieved. No
guarantees or promises have been made to me concerning the results. The fee(s) for this service
have been explained to me and are satisfactory. The nature and type of material used in my
crown(s) or bridgework, for example porcelain-fused-to- metal, all porcelain, etc. has been explained
By signing this form, I am freely giving my consent to allow and authorize Dr._______________(please write the name of the doctor below)
to render treatment pertaining to crown and bridge prosthetics considered necessary and/or
advisable to my dental conditions, including the prescribing and administering of any
medications and/or anaesthetics deemed necessary for my treatment.