Ronak Patel, D.D.S.

355 E. Westchester Pkwy, Suite 200 Grand Prairie, TX 75052


Consent for Crown & Bridge Prosthetic's

Patients Name:
Phone Number:
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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, 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/teeth so that crowns and/or bridges may be placed upon them. Tooth preparation will be done as conservatively a 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 Anesthesia: In order to reduce tooth structure without causing pain during the procedure, it will be necessary to administer local anesthetic. 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, 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 ascertained.
  5. 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.
  6. Breakage: 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 placement.
  7. Uncomfortable or strange feeling: This may occur because of the differences between natural teeth and the 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. Esthetics 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 where indicated.
  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.

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