Informed Consent for Orthognathic (Corrective Jaw) Surgery

Procedure Name

Form Sections

Section 1info grid

Surgical Facility Name

Attending Oral and Maxillofacial Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Orthognathic Procedure

Planned Fixation Method

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Section 12signature block

Patient / Authorized Representative Signature

Witness Signature (If Required)

Attending Oral Surgeon Signature

Informed Consent for Orthognathic (Corrective Jaw) Surgery

Patient and Facility Information

Surgical Facility Name

Attending Oral and Maxillofacial Surgeon

Patient Full Legal Name

Date of Birth

Medical Record Number (MRN)

Planned Orthognathic Procedure

Planned Fixation Method

Nature and Purpose of the Procedure

Orthognathic surgery is performed to correct major skeletal and dental irregularities, including the misalignment of the jaws and teeth. The surgical procedure, which is coordinated with orthodontic treatment, is performed under general anesthesia. The surgeon cuts and repositions the upper jaw (maxilla), lower jaw (mandible), or both to restore normal skeletal relationships, bite function, and facial balance. Specialized surgical plates, screws, or wires are placed to secure the bones in their new positions. The bones will fuse in these new positions over several months. The procedure typically takes 2 to 5 hours.

Material Risks and Potential Complications

Bleeding or hematoma formation, which can be significant in jaw surgeries and may require blood transfusion or surgical drainage.

Nerve damage: injury to the sensory nerves of the face (inferior alveolar or infraorbital nerves) causing temporary or permanent numbness, altered sensation, or tingling in the lower lip, chin, gums, teeth, or cheeks.

Infection of the surgical incisions or around the internal plates and screws, potentially requiring antibiotic therapy or hardware removal after healing.

Relapse: shifting of the jaws or teeth back toward their original positions over time, requiring additional orthodontic treatment or secondary surgery.

Injury to adjacent teeth, tooth loss, or damage to supporting bone structures.

Temporomandibular joint (TMJ) dysfunction, which may cause pain, clicking, or limited jaw opening.

Expected Benefits

Expected benefits include correction of skeletal bite mismatch, improvement in chewing and swallowing function, reduction in abnormal tooth wear, improvement in speech, and alignment of facial skeletal balance.

Reasonable Alternatives

Orthodontic treatment alone (camouflaging the bite discrepancy without correcting the skeletal position).

Non-surgical management using orthopedic appliances or orthodontic splints.

Choosing not to undergo corrective jaw surgery and maintaining the current skeletal bite.

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

Witness Signature (If Required)

Attending Oral Surgeon Signature

Document ID: CC-PENDING

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