Diagnosis: After careful oral examination and study of my dental condition my dentist has advised me that I need a crown lengthening.

Recommended Treatment: Crown lengthening is a procedure that removes a small amount of gum and bone to uncover more tooth structure to allow for a crown.

Principal Risks and Complications: These complications include, but are not limited to post-surgical infection, bleeding, swelling and pain, transient but on occasion permanent numbness of the jaw, lip, tongue, teeth, chin or gum, jaw joint injuries or associated muscle spasm, increased tooth looseness, tooth sensitivity to hot, cold or sweet, or acidic foods, shrinkage of the gum upon healing resulting in elongation of adjacent teeth and greater spaces between some teeth. The exact duration of any complications cannot be determined, and they may be irreversible.

Alternates to Suggested Treatment: I understand that alternatives to crown lengthening include no treatment resulting inability to predictably restore the tooth with a crown.

I will need to come for appointments following surgery so that my healing may be monitored and so that my dentist can evaluate and report on the outcome of surgery upon completion of healing. Smoking or alcohol intake may adversely affect gum healing and may limit the successful outcome of my surgery. I know that it is important 1.) To abide by the specific prescriptions and instructions given to me by the dentist and 2.) To see my dentist for periodic examination and prevention treatment.

I have been fully informed of the nature of periodontal surgery, the procedure to be utilized, the risks and benefits, the alternative treatments available, and the necessity for the follow up and self care. I have had the opportunity to ask any questions I may have in connections with the treatment and to discuss my concerns with my dentist. After thorough deliberation, I hereby consent to the performance of periodontal surgery as presented to me during consultation and in the treatment plan presentation.

I CERTIFY I HAVE READ AND FULLY UNDERSTAND THIS DOCUMENT.