Informed Consent:  Corrective Jaw Surgery

This is my consent for Corrective Jaw Surgery, as previously explained to me, or other procedures deemed necessary or advisable to complete the planned operation. I also agree to the use of a general anesthetic and hypotensive anesthesia, depending on the oral and maxillofacial surgeon(s) and anesthesiologist involved in my care.

I have been informed and understand that there are symptoms (sequelae) from surgery including: pain; infection; swelling; bleeding that may be heavy or prolonged; late postoperative bleeding; bruising; numbness; the possibility that facial muscles may not function following the surgical procedure for an indefinite time; temporomandibular (jaw) joint difficulty, such as pain, clicking or decreased mouth opening; injury to adjacent teeth or dental restorations, or possible future loss of adjacent teeth, or injury to adjacent soft tissues; and/or referred pain to the ear, neck and head.

I accept that due to the deformity and/or surgery, numbness, tingling, and/or a painful altered sensation of the lip, tongue, chin, gums, cheeks and teeth may result and that this may be temporary or permanent.

Other potential complications could include nausea, vomiting, allergic reaction, unfavorable bone fractures, delayed healing or non-healing of bony segments, sinus complications, loss of bone and the invested teeth, devitalization (nerve damage which may require root canal treatment) of teeth, relapse and prolonged depression from the anesthesia/surgery.

I understand that although the use of rigid fixation (i.e. plates, and/or screws) is planned, there is the possibility that I may waken with my jaws wired, even though that was not the original surgical intent. Rigid fixation (plates and/or screws) may also fail, thus requiring replacement or removal at a later date.

I acknowledge that the surgeon may require additional bone to be placed either at the time of surgery or in the future. Additional bone may either be harvested directly from the patient (autograft) and/or substituted with a commercially available human bone graft product (allograft). I understand that any type of bone graft may increase the risk of infection, may require further diagnostic tests, and may require further treatment.

I understand that this surgery is being performed to optimize my skeletal and bite relationship. I acknowledge the possibility that untoward aesthetic changes may occur, resulting in an altered facial appearance. I understand that no final decisions regarding my facial appearance can be made for at least 12 months post-surgery.

I agree to cooperate completely with the recommendations of the Doctors of South Calgary Oral & Maxillofacial Surgery while I am under their care, realizing that any lack of cooperation could result in a less than optimum result.

The fee for service has been explained to me and is satisfactory. I will be responsible financially for any additional procedures and/or treatment if needed, following my initial surgical treatment.

I understand that there is no warranty or guarantee as to the result and that my condition may return or become worse. I have been advised that repeat surgery may be necessary, in the event of an unsatisfactory result, and accept this possibility.