Stateline Oral & Maxillofacial Surgery, PC


Note to patients:  this is a synopsis of the consent form used in our office.  The actual form may differ in small details from this text.  The doctor will review the risks and benefits associated with this surgery before you are given the opportunity to sign the actual consent form.


You have the right to be informed about your condition and the various treatment alternatives that might be available.  Once you have been given the risks and benefits associated with various treatment options you have the right and responsibility to make an educated decision as to whether or not to pursue such treatment.  You present to our office today for the surgical procedure named below; it is important for you to understand why this treatment has been recommended and what risks and benefits are associated with this procedure.

The following surgery is to be accomplished today:


Surgery is an irreversible process; there are some risks and they include, but are not limited to the following.

-  post-operative swelling, bruising and discomfort in the surgical area which may require additional treatment.

-  stretching of the corners of the mouth which may cause cracking or bruising, and may be slow to heal.

-  post operative  infection which may require  medical and / or surgical treatment.

-  jaw pain beginning a few days after surgery.  This condition may require care to reduce discomfort; otherwise the condition is self limiting.

-  injury or damage to adjacent teeth, fillings and / or crowns.  Teeth with extensive fillings and teeth with crowns next to the tooth to be extracted are most susceptible to damage.

-  post operative restricted mouth opening; this is normal for many patients, but may require active physical therapy is some cases.  This is especially common when pre existing TMJ conditions exist.

- bleeding; significant bleeding is not common but persistent oozing can be expected for several hours and, in some cases,  up to 24 hours after surgery.

- surgery, injury or trauma in the vicinity of a nerve underlying this area may result in pain, numbness, tingling, or other sensory disturbances in the chin, lip, cheek, gums or tongue which may persist for several weeks, months, or in rare instances, permanently.  Should you experience numbness in one or more of these areas the day after surgery, it is very important that you return to our office for a thorough evaluation.  Further treatment and / or surgery may be required in some cases.

-  with surgery in the area of the back upper teeth, opening of the sinus which may require additional treatment.

-  sharp ridges or bone splinters may form in the areas of bone surgery.  These sharp areas usually smooth out with time without treatment, but may, in some cases, require further surgery.  Small pieces of bone may work through the gum tissues for 2 weeks or more after surgery.

-  allergic reactions to any medications or anesthetics used in treatment.


During the course of treatment, unforeseen conditions may be revealed that may require minor changes to the surgical treatment plan.  In this instance, I authorize my surgeon to use professional judgment to perform these surgical modifications they deem necessary and desirable to complete my surgery.

The anesthetic I have chosen for my surgery is: (Please check one)

  1.        local anesthetic
  2.        local anesthetic with nitrous oxide sedation
  3.        local anesthetic with oral oxide sedation
  4.        local anesthetic with IV sedation and / or general anesthesia

For those patients undergoing surgery with local anesthetic with or without nitrous oxide, there are some risks.  These include, but are not limited to:  discomfort, swelling, bruising, infection, prolonged numbness, dizziness, nausea and allergic reactions.

For those patients undergoing IV sedation and / or general anesthesia, there are some additional risks.  These include, but are not limited to the following:  inflammation at the site of an intravenous injection, which may cause prolonged discomfort and / or disability, which may require special care.  Nausea and vomiting, although uncommon, may be unfortunate side effects of IV anesthesia.  Intravenous anesthesia is a serious medical procedure, and although considered safe, does carry with it the very rare risks of significant medical morbidity.


Your obligations if IV anesthesia is used:

- Since anesthetic medications cause prolonged drowsiness, you must be accompanied by a responsible adult who can drive you home and stay with you until you have sufficiently recovered to care for yourself.

-  During your recovery time, which may take up to 24 hours, you should not drive, operate complicated machinery or devices, or make important decisions.

-  It is important for you to have an empty stomach prior to being sedated.  It is your responsibility to make a truthful disclosure of all food and liquid taken prior to surgery.  It is important that your stomach be completely empty at the time of surgery; failure to do so may lead to life threatening complications.

-  Advise the doctor as to whether or not your daily (if any) medications were taken in the usual manner.


I understand that individual reactions to treatment cannot be predicted, and that if I experience any unanticipated reactions during or following treatment, I agree to report them to the doctor as soon as possible.  I also agree to report any numbness that persists into the day after surgery.

I realize that no guarantees or assurances have been given by anyone regarding treatment results that may be obtained.  I also understand that if I have any questions regarding my treatment, I am to ask the doctor prior to signing this consent.

I certify that I speak, read and write English and have read and fully understand this consent for surgery.  Any questions that I had were answered by my doctor or his staff before this consent was signed.

I hereby acknowledge that I have read the foregoing and have discussed any questions or concerns I may have regarding my proposed treatment before signing this document.