Informed Consent for Crown Lengthening Surgery

Procedure Name

Form Sections

Section 1info grid

Dental Practice Name

Attending Periodontist / Dentist

Patient Full Legal Name

Date of Birth

Patient ID / Chart Number

Teeth Undergoing Treatment

Anesthesia Method

Section 2text block

Section 3list block

Section 4text block

Section 5list block

Section 6text block

Section 7text block

Section 8text block

Section 9text block

Section 10text block

Section 11text block

Section 12signature block

Patient / Authorized Representative Signature

Attending Periodontist / Dentist Signature

Informed Consent for Crown Lengthening Surgery

Patient and Clinic Information

Dental Practice Name

Attending Periodontist / Dentist

Patient Full Legal Name

Date of Birth

Patient ID / Chart Number

Teeth Undergoing Treatment

Anesthesia Method

Nature and Purpose of the Procedure

Crown lengthening is a surgical periodontal procedure designed to expose more of the natural tooth structure. Under local anesthesia, the clinician gently reshapes the gum tissue and sometimes the underlying bone around the treatment teeth. This is performed to prepare the tooth for restorative procedures (such as placing a crown, bridge, or filling when the tooth is broken or decayed close to the gumline) or to improve cosmetic appearance. The procedure typically takes 30 to 60 minutes.

Material Risks and Potential Complications

Postoperative bleeding, swelling, or pain, which is typically managed with medication and cold compresses.

Infection at the surgical site, which may require antibiotic rinses or systemic antibiotics.

Increased tooth sensitivity: temporary or permanent sensitivity to hot, cold, or sweet foods due to root exposure.

Aesthetic changes: the treated tooth may appear longer, and the gumline may appear uneven compared to adjacent teeth.

Mobility: transient looseness of the treated tooth or adjacent teeth during the healing phase.

Root resorption or gum recession over adjacent teeth.

Expected Benefits

Expected benefits include exposing adequate tooth structure to secure a durable dental crown or filling, preventing chronic gum irritation caused by deep restorations, and improving the cosmetic appearance of the gumline.

Reasonable Alternatives

Tooth extraction followed by a dental implant, bridge, or partial denture (if insufficient tooth structure exists).

Forced orthodontic eruption to pull the tooth structure above the gumline.

Declining treatment, which may lead to restorative failure, recurrent decay, chronic gum inflammation, or tooth loss.

Consent for Anesthesia Services

I understand that anesthesia services are needed for this procedure. The anesthesia provider will separately explain the risks, benefits, and alternatives of the specific anesthesia plan (e.g., general, regional, or local sedation) and obtain separate consent.

Consent for Blood Transfusion

I understand that during this procedure, significant blood loss may occur. If my physician determines it is medically necessary to preserve my life or health, I consent to the administration of blood or blood products.

Tissue Disposal and Pathology

I authorize the medical facility to retain, preserve, use for educational purposes, or dispose of any tissue, fluid, or body parts removed during the procedure in accordance with standard medical practices and legal requirements.

Photography and Observer Consent

I consent to the photographing or video recording of the procedure for medical, scientific, or educational purposes, provided my identity is not revealed. I also consent to the presence of medical students, residents, or device manufacturer representatives as approved by my surgeon.

No Guarantees

I acknowledge that the practice of medicine and surgery is not an exact science. I understand that no guarantees or assurances have been made to me regarding the outcomes or results of this procedure.

Patient Acknowledgment and Consent

I certify that I have read and fully understand this consent form. My physician has explained the procedure, its risks, benefits, and alternatives. I have had all my questions answered to my satisfaction, and I voluntarily consent to the proposed treatment.

Signatures and Verification

Patient / Authorized Representative Signature

Attending Periodontist / Dentist Signature

Document ID: CC-PENDING

CONSENTCOLLECT