Surgery Consent Forms

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Kindly select the type of surgery you will be undergoing and complete the online consent form

Dental Implant / Zygomatic Implants & Pre-prosthodontic Surgery

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Dental Implant / Zygomatic Implants & Pre-prosthodontic Surgery

(Diagnosis: ICD-10: K08.1)

Tooth loss results in numerous unwanted effects like unwanted tooth movement (due to lack of side to side and vertical contacts), poor chewing function and esthetic compromise. Dental implants and other forms of pre-prosthodontic surgery can prepare the mouth for dentures or other forms of dental prosthesis.

Dental implants are bio-inert screws that are placed in the jawbone to replace a tooth root. A dentist can use these screws to secure a tooth crown onto it. Dental implants are just one of many ways of replacing a missing tooth. It is, however, not without its limitations. Remember that your Oral Surgeon only insert the implant and your Dentist needs to make the crown that fits onto the implant.

Pre-prosthodontic surgery can increase the bone height, increase the amount of thick gum tissue or remove soft flabby tissue, all that make denture wear just a little more comfortable.

I have:*

read the description of the surgery/procedure.

Complications

Dental Implant / Zygomatic Implants & Pre-prosthodontic Surgery

Below complications does not constitute an exhaustive list but does highlight some of the most common complications. If you require more information, please ask your Maxillofacial and Oral Surgeon directly. Implant related complications can largely be categorized as biological vs. mechanical or early vs late.

EARLY BIOLOGICAL COMPLICATIONS

1. Infection (1%)
Infections result in pain and swelling, mostly >7-days after surgery but it may develop weeks / months after surgery. We follow the American College of Surgeons Antibiotic prophylaxis protocol. Infections can be local and result in systemic infection with fever. Infections may lead to implant loss.

2. Failure of osteointegration (1%)
Implants may not fuse to the surrounding bone. Failure of osteointegration is more common among smokers, poorly controlled diabetics, bone disease of very thin osteoporotic bone. In some cases, no clear cause can be identified. Multiple failures may necessitate your surgeon doing an allergy test to some of the most common metals in implants.

3. Nerve injury (<1%)
The inferior alveolar nerve is at risk of injury during lower jaw implant placement of sulcus deepening surgery. Modern 3D-imaging hugely reduces the risk as correct implant length can more accurately be planned. Such injury may result in loss of feeling of half the lip and chin on the affected side. This could be temporary but in some cases it may be permanent.

4. Sinus complications (5%)
Implant placed in the upper jaw are close to the maxillary sinus. Implants that involve the sinus may result in sinusitis or may even result in implant loosening and subsequent loss.

LATE BIOLOGICAL COMPLICATIONS

1. Periimplantitis
Periimplantitis is a form of gum disease that results in progressive bone loss around dental implants. Patients that have active or previous gum disease are at higher risk than others. Poorly made dental crowns or bridges may contribute to periimplantitis. Poor oral hygiene is a common cause of periimplantitis.

MECHANICAL COMPLICATIONS

1. Screw loosening
The screws that hold the crown onto the implant may occasionally become loose. This can easily be treated by your dentist / prosthodontist that can re-tighten the screw. Untreated screw loosening may lead to screw fracture or periimplantitis as the loose crown will irritate the surrounding gum.

2. Hardware failure / implant fractures (Rare)
Very high biting forces, poor crown design or poor implant placement may all contribute to implant fractures. Implants that have fractured need to be removed and replaced.

3. Crown / bride or denture fracture.

HOW TO CARE FOR YOUR DENTAL IMPLANT(S):

• Floss around your implant daily • Brush your teeth twice daily • Rinse your mouth with a chlorhexidine mouth rinse weekly. • Biannual dental checkup visits with your Dentist • Annual recall with your Oral Surgeon

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Dental Implant / Zygomatic Implants & Pre-prosthodontic Surgery

1. Dentures

These are removable plastic teeth, aka “false teeth”. They are made to rest on your gums and can improve your chewing and aesthetics. Other metal base dentures are also available. Please discuss this with your Dentist.

2. Dental bridges

Dental bridges are a type of fixed denture that are stuck onto neighbouring teeth (called anchors teeth). For these bridges, the anchor teeth need to be drilled into a particular shape to accommodate the support of the bridge. This is good if the affected teeth have large fillings or tooth decay. If one of the anchor teeth is lost due to tooth decay, infection, or gum disease the whole or part of the bridge will be lost. Please discuss this with your Dentist.

3. No treatment

Patients are entitled to deny any treatment.

I have:*

read through the available alternative treatments.

Consent

Dental Implant / Zygomatic Implants & Pre-prosthodontic Surgery

I have been informed of the potential complications, treatment alternatives and benefits of dental, zygomatic implant or pre-prosthodontic surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:*

Witness signature:*

Head and Neck Cancer Surgery

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Head and Neck Cancer Surgery

(Diagnosis: ICD-10: C02-07/ C44)

Head and neck cancer is the sixth most common cancer worldwide. It carries a poor prognosis if not treated. It is associated with tobacco smoking, alcohol use and HPV infections but can develop in the absence of these risk factors.

Treatment of oral cancer is largely surgical with post operative radiation with / without chemotherapy for high-risk patients. Surgery may include a combination of the following: excision of the tumor, excision of the lymph glands in the neck, removal of affected nerves and/ or blood vessels, repair of cancer defect with skin-bone and/or muscle from arm, leg or chest, tracheostomy, stomach feeding tube and drips placed in large blood vessels in neck / chest or groin.

Most patient will require extended surgery followed by ICU care and rehabilitation of speech and/ or eating.

Patients with stage III and IV head and neck cancer will require radiotherapy with/ without chemotherapy. This normally starts 6-weeks after surgery.

Head and neck cancers are complex conditions and require the expertise of many specialists working together in a team. This team is called a multi-disciplinary team (MDT).

I have:*

read the description of the surgery/procedure.

Complications

Head and Neck Cancer Surgery

1. Nerve injuries 10%

Removal of a cancerous tumour and affected lymph glands may injure the following nerves. Most injuries are temporary, but some injuries may result in long term dysfunction: • Facial nerve (Movement of same side of face) • Lingual nerve (Numbness of same side of tongue) • Hypoglossal nerve (Movement of same side of tongue) • Accessory (Weakness in shrugging shoulders / shoulder pain) • Phrenic nerve (Irregular breathing) • Other sensory nerves (Loss of feeling over neck / chin and lips / cheek and / or earlobe)

2. Major bleeding or Seroma (<1%)

Major bleeding is defined as bleeding that either requires blood transfusion or surgery to stop the bleeding. Seroma is an abnormal collection of tissue fluid that causes a swelling and may require surgical drainage.

3. Surgical Site Infection (3-5%)

Infections results in pain and swelling, mostly >7-days after surgery but it may develop weeks / months after surgery. We follow the American College of Surgeons Antibiotic prophylaxis protocol. Infections can be local and result in systemic infection with fever.

4. Chyle leak (Lymph duct leak) (<1%)

The lymph system of the human body drains via two ducts into large veins in the neck. Due to their thin walls, they are at risk of injury during neck dissection. Most chyle leaks are treated conservatively with local pressure or medicine. Approximately 10% of chyle leaks require further surgical exploration.

5. Dysphagia / Difficulty swallowing (Common)

The jaw does not always break (split) where we would like it to. This may result in a poor occlusion / bite that could be corrected with further orthodontics or surgery.

6. Scaring (Common)

Scaring from head and neck cancer surgery is more common when patients develop infection after surgery, repeat surgery or receive radiotherapy after surgery.

7. Positive margins / marginal resections (Common)

Head and neck cancers are not symmetrical or linear tumours. They are complex 3D tumours and are hence at risk of incomplete excision. We attempt to limit this by asking pathologists to test tumour margins for cancer which allows us to remove more tissue until we are fairly certain all tumour has been removed.

8. Hardware failure (1-2%)

Plate, screws, or implants may all fail due to infection or radiotherapy.

9. Non-surgical complications (Common)

Hospital acquired infections, lung or other organ injuries from central lines, drips, or ancillary procedures.

10. Death(Rare)

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Head and Neck Cancer Surgery

1. Chemoradiotherapy

Some head and neck cancers are sensitive to chemotherapy and or radiotherapy. Oral cavity and salivary gland cancers are however not very sensitive to either chemotherapy or radiotherapy. Speak to your surgeon and oncologist about your type of cancer.

2. Immunotherapy

This is a type of chemotherapy that is reserved for advanced stage cancers that are to large to operate on, or for cancers that return.

3. Palliative Therapy

Palliative care refers to a set of treatments that does not intend to cure the cancer but to rather improve a patient’s overall quality of life. The focus is on quality rather than quantity of life. 4. No treatment Patients are entitled to deny any treatment.

I have:*

read through the available alternative treatments.

Consent

Head and Neck Cancer Surgery

I have been informed of the potential complications, treatment alternatives and benefits of head and neck cancer surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:*

Witness signature:*

Orthognathic Surgery

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Orthognathic Surgery

(Diagnosis: Skeletal Malocclusion K07.0)

Orthognathic surgery involves surgically repositioning either upper or lower jaw to facilitate a good functional occlusion (bite), improve facial esthetics, improve upper airway airflow (in obstructive sleep apnea) and other functional jaw abnormalities.

I have:*

read the description of the surgery/procedure.

Complications

Orthognathic Surgery

1. 5-8% % Inferior alveolar nerve injury

This may lead to numbness of the same half of the lower teeth, lip and chin. Numbness could be temporary or may lead to some degree of persistent numbness. The affected lip moves normally.

2. Major bleeding

Major bleeding is defined as bleeding that either requires blood transfusion or surgery to stop the bleeding.

3. 3-5% Infection

4. Unfavourable splits with malocclusion

The jaw does not always break (split) where we would like it to. This may result in a poor occlusion / bite that could be corrected with further orthodontics or surgery.

5. Surgical relapse

Surgical relapse mostly occurs because of continued growth but could be the result of resorption of temporomandibular joint bone and/or other bony growths or abnormalities.

6. Less common complications (<0.1%)

• Avascular necrosis of the jaw • Plate fracture or loosening (requiring removal) • Injury to tooth roots resulting in tooth infection or loss • Temporomandibular joint problems

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Orthognathic Surgery

1. Orthodontic Camouflage

OC can result in an acceptable occlusion / bite but may result in an unacceptable long-term stability (hence increased risk of teeth becoming skew again) or poor facial aesthetics / profile.

2. Growth Modification

GM can be used during a child pre- pubertal growth spurt (6-8). It is largely not an option for post-pubertal patients. The body of evidence to support GM is limited.

3. No treatment

I have:*

read through the available alternative treatments.

Consent

Orthognathic Surgery

I have been informed of the potential complications, treatment alternatives and benefits of orthognathic surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:

Witness signature:*

Parotidectomy and Salivary Gland Surgery

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Parotidectomy and Salivary Gland Surgery

(Diagnosis: ICD-10: K11.2; D11.0, C07)

Salivary gland diseases that may require surgical intervention includes a wide range of conditions from infections, salivary stones, non-cancerous tumors and salivary gland cancers.

Humans have three sets (six in total) of major salivary glands. The paired parotid. submandibular and sublingual salivary glands.

All three glands are anatomically closely related to important nerves in the mouth and check areas.

Loss of one or two of these glands rarely result in clinically significant dry mouth leading to difficulty in eating or speaking.

I have:*

read the description of the surgery/procedure.

Complications

Parotidectomy and Salivary Gland Surgery

Below complications does not constitute an exhaustive list but does highlight some of the most common surgical complications. If you require more information, please ask your Maxillofacial and Oral Surgeon directly.

1. Nerve injuries (Approximately 5%)

Removal of a salivary gland may injure the following nerves. Most injuries are temporary, but some injuries may result in long term dysfunction:

• Facial nerve (Movement of same side of face)
• Lingual nerve (Numbness of same side of tongue)
• Hypoglossal nerve (Movement of same side of tongue)
• Other sensory nerves (Loss of feeling over neck / chin and lips / cheek and / or earlobe)

Facial nerve injury is most common with parotid gland surgery. This is because the main trunk of the facial nerve needs to be identified and carefully dissected out during parotid surgery.

The lingual, hypoglossal and one branch of the facial nerve (marginal mandibular) are at risk during submandibular gland surgery. This is particularly true for patients with longstanding infection of the gland or previous radiation therapy to the neck.

The lingual nerve is the only nerve at risk during sublingual gland removal.

2. Major bleeding or Seroma (<1%)

3. Surgical Site Infection (3-5%)

Infections result in pain and swelling, mostly >7-days after surgery but it may develop weeks / months after surgery. We follow the American College of Surgeons Antibiotic prophylaxis protocol. Infections can be local and result in systemic infection with fever.

4. Frey Syndrome (5%) or Salivary Fistula (Rare)

Frey Syndrome results from abnormal healing of injured nerve ends overlying the skin of the parotid gland. It is related to parotid surgery only. The symptoms are cheek sweating when hungry and flushed skin over cheek. Salivary fistula results in salivary draining from pinpoint of skin where cut was made.

5. Scaring (<5%)

Scaring from head and neck cancer surgery is more common when patients develop infection after surgery, repeat surgery or receive radiotherapy after surgery.

6. Death (Rare)

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Parotidectomy and Salivary Gland Surgery

1. Specific salivary gland diseases

Salivary duct surgery to remove accessible stones is possible in some patients. Sialo-endoscopy to break up and remove stones is possible in some patients. Extracorporeal lithotripsy is possible to break up some stones. Antibiotic therapy is possible for acute gland infections but not an effective cure for longstanding infections.

2. No treatment

Patients are entitled to deny any treatment.

I have:*

read through the available alternative treatments.

Consent

Parotidectomy and Salivary Gland Surgery

I have been informed of the potential complications, treatment alternatives and benefits of parotidectomy and salivary gland surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:*

Witness Signature:*

Temporomandibular Joint Surgery

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Temporomandibular Joint Surgery

(Diagnosis: ICD-10: K07.6/ M19.99/ M25.58)

Temporomandibular joint disorders (TMD) constitute a complex set of symptoms that results in pain and poor joint movement. It includes muscle pain, joint clicks / noises, joint pain and limited mobility and atypical symptoms such as vertigo, tinnitus, or ear fullness.

The causes of TMDs are poorly understood. It is thought to be associated with teeth grinding, psycho-emotional stress and some medicines. Trauma to the TM-joints may result in TMD symptoms in some patients.

Most patients respond well to a set of conservative treatments such as jaw rest, bite plates, pain / anti-inflammatory medications, muscle relaxant medications, physiotherapy, psychotherapy, Botox injections or joints rinses (arthrocentesis).

Less than 10% of patient will require open joint surgery during their lifetime.

I have:*

read the description of the surgery/procedure.

Complications

Temporomandibular Joint Surgery

1. Facial Nerve injuries (2-3%)

The facial nerve passes over the temporomandibular joint and are at risk of injury. Injuries will result in weakness of frowning, blinking, pouting, smiling and grimacing. Most injuries are temporary, but some injuries may result in long term dysfunction.

2. Auriculotemporal nerve injury (Common)

The auriculotemporal nerve passes behind and over the temporomandibular joint. It provides sensation to the earlobe and area of skin in front of the ear. Injury will result in numbness of the skin in these areas. Numbness largely resolves after 6-months but could be permanent and related with a burning pain (neuralgia).

3. Major bleeding or Seroma (<1%)

Major bleeding is defined as bleeding that either requires blood transfusion or surgery to stop the bleeding. Seroma is an abnormal collection of tissue fluid that causes swelling and may require surgical drainage.

4. Surgical Site Infection / prosthesis injection (<1%)

5. Malocclusion (<1%)

Changing the structure of the joint may directly change the way teeth bite on top of each other. Careful planning largely limits this risk, but inaccuracies in planning or operation execution may result in malocclusion. This could be corrected via fillings, orthodontic treatment, jaw movement surgery or joint reoperation.

6. Perforation of the ear canal (<1%)

The external ear canal is situated behind and above the temporomandibular joint. The front wall of the canal can be injured during the operation, or the prosthesis could “migrate” into the ear canal over time.

7. Continued joint noises (>10%)

The jaw does not always break (split) where we would like it to. This may result in a poor occlusion / bite that could be corrected with further orthodontics or surgery.

8. Frey Syndrome or salivary fistulae (Rare)

Frey Syndrome results from abnormal healing of injured nerve ends. The symptoms are cheek sweating when hungry and flushed skin over cheek. Salivary fistula results in salivary draining from pinpoint of skin where cut was made.

9. Scaring (Rare)

Scaring from TM-joint surgery is uncommon due to the anatomical location of the incisions / cuts. They are placed in natural skin creases. Scaring is more common after infection, patients with previous surgical scaring or re-operations.

10. Hardware failure (Rare)

Plate, screws, or implants may all fail due to infection or mechanical breakage. This will require re-operation.

11. Death (Rare)

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Temporomandibular Joint Surgery

1. Continued non-surgical treatments

Continued non-surgical treatments include jaw rest, bite plates, pain / anti- inflammatory medications, muscle relaxant medications, physiotherapy, psychotherapy, Botox injections or joints rinses (arthrocentesis).

2. Arthrocentesis / Arthroscopy

This is a minimally invasive treatment option that aims to rinse out the joint, tear any abnormal scar tissue in the joint and allow for injection of medications directly into the joint. Arthroscopy additionally help surgeon to directly visualize any obvious joint abnormalities. Minor joint procedures can be performed via the arthroscope.

3. Medical treatments

Where temporomandibular joint symptoms are a result of other systemic conditions such as Rheumatoid Arthritis, Systemic Sclerosis or Ankylosing Spondylitis, these conditions should first be well controlled by your Physician / Rheumatologist.

4. No treatment

Patients are entitled to deny any treatment.

I have:*

read through the available alternative treatments.

Consent

Temporomandibular Joint Surgery

I have been informed of the potential complications, treatment alternatives and benefits of temporomandibular joint surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:*

Witness signature:*

Third Molar Surgery

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Third Molar Surgery

(Diagnosis: Impacted teeth ICD-10: K01.1)

Wisdom teeth are the last teeth to erupt into the mouth and often does not have sufficient space to erupt. They are more prone to dental pathologies such as tooth decay, gum disease, tumours, or cysts. They may also preclude orthodontic treatment to straighten teeth. Not all wisdom needs surgical removal, but indiscriminate retention of wisdom teeth may also not be in patients’ be interests.

I have:*

read the description of the surgery/procedure.

Complications

Third Molar Surgery

1. 1% Inferior alveolar nerve injury

This may lead to numbness of the same half of the lower teeth, lip and chin. Numbness could be temporary or may lead to some degree of persistent numbness. The affected lip moves normally.

2. 0.1-0.3% Lingual nerve injury

This may lead to numbness of the same half of the tongue. Numbness could be temporary or may lead to some degree of persistent numbness. The tongue moves normally.

3. 2-3% Dry Socket (Alveolar Osteitis)

Dry socket (alveolar osteitis) is a condition where the blood clot inside the socket is lost resulting is exposed bone and severe pain not resolved by OTC painkillers. It becomes apparent during day 2-3 after surgery. More common is smokers and female patients. The condition is self-limiting and resolves within 10-14 days and treated with strong anti-inflammatories.

4. 3-5% Infection

5. Uncommon complications:

• Jaw fracture
• Tooth displacement
• Persistent sinus opening
• Gum defects / recession

I have:*

read through the possible complications associated with this surgery/procedure.

Treatment Alternatives

Third Molar Surgery

1. Active Surveillance

AS involved annual clinical and radiological examinations to identify any disease process early before it becomes difficult and/or risky to treat.

2. Coronectomy

This procedure involves removal of the crown of the wisdom tooth only and keeping the roots. Root removal may become necessary 6-10% of patients.

3. No treatment

I have:*

read through the available alternative treatments.

Consent

Third Molar Surgery

I have been informed of the potential complications, treatment alternatives and benefits of third molar surgery. My rights as a patient are contained (not limited to) in: South African Constitution (1996) The National Health Act 61 of 2003 Childrens Act 2010. I acknowledge that I remain ultimately responsible for the cost of the above treatment as contained in the T&C of this practice billing policy.

With my details & signature below:*

I give my consent.

I am:*

the patient

the parent / legal guardian

Name:*

ID number:*

Email:*

Signature:*

Date:*

Witness name:*

Witness signature:*

General Pre-Operative Consent

Form Submission is restricted

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PATIENT DETAILS

Planned procedure date:*

Procedure details:

Patient Name:*

ID-Number:*

I am:*

the patient

the parent / legal guardian

Name (complete if you are the parent/legal guardian):

ID number (applicable to parent/legal guardian):

Email:*

CONSENT

I/We the undersigned:*

confirm that DR PETRIE VAN DER MERWE discussed the nature of the planned operation/procedure.

I/We the undersigned:*

understand that as with any form of surgery/procedure, complications can occur.

I/We the undersigned:*

were given the opportunity to ask questions. The possible complications relevant to this surgery/procedure were discussed with me/us.

With my details & signature below:*

I give my cosent.

Date:*

Signature:*

Witness name:*

Witness signature:*

TO BE COMPLETED BY THE DOCTOR:

Doctor's Signature:

Date: