Smile Cliniq Lingual Orthodontic Treatment Consent

Information and Informed Consent form

This information serves to help you come to an informed decision in regards to your dental treatment.

Please note side effects and complications are uncommon to rare and we at Smile Cliniq would hope our rate is even less than the norm, due to the techniques and materials we use. Also bear in mind the complications are no different to any orthodontic treatment currently available or you may have had previously, it’s just you are now aware of them, weather you wanted to know or not is an interesting debate!

As a general rule, positive orthodontic results can be achieved by informed and cooperative patients. Thus, the following information is routinely supplied to all who are considering lingual orthodontic treatment in our practice.
Whilst recognising the benefits of healthy teeth and a pleasing smile, you should also be aware that lingual orthodontic treatment has limitations and potential risks. These are seldom enough to avoid treatment, but should be considered in making the decision to undergo orthodontic treatment. Lingual orthodontic treatment usually proceeds as planned; however, response to treatment and results cannot be guaranteed.
Benefits
Lingual orthodontics plays an important role in improving overall oral health. Lingual orthodontics also helps create balance and harmony between the teeth and face for a beautiful, healthy smile. An attractive smile enhances one’s self esteem, which may actually improve the quality of life itself. Properly aligned teeth are easier to brush, and thereby may decrease the tendency to decay, or to develop diseases of the gum and supporting bone.
Because of the individual conditions present and the limitations of treatment imposed by nature, each specific benefit may not be attainable for every patient. The unknown factor in any orthodontic correction is the treatment response and cooperation of the patient during orthodontic treatment.
Risks
All forms of medical and dental treatment, including lingual orthodontics, have some risks and limitations. Fortunately, in orthodontics complications are infrequent and when they do occur they are usually of minor consequence. Nevertheless, they should be considered when making the decision to undergo orthodontic treatment. The major risks involved in orthodontic treatment may include, but are not limited to:
1. Decalcification: (Permanent enamel markings) Tooth decay, gum disease, and permanent markings (decalcification) on the teeth can occur if orthodontic patients consume foods or drinks containing excessive sugar and/or acid (eg, sweets, fizzy drinks, diluting juice, etc). This tooth scarring also occurs if patients do not brush their teeth frequently and properly. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces.
2. Root shortening: In some patients the length of the roots may be shortened during orthodontic treatment. Some patients are prone to this happening, some are not. Usually this does not have significant consequences, but on occasion it may become a threat to the longevity of the teeth involved. Previous trauma to teeth, nail biting or even pen chewing may exacerbate root shortening.
3. Good oral hygiene: Periodontal health (health of the bone and gums which support the teeth) may be affected by orthodontic tooth movement if there is already a pre-existing condition, but also may occur in some rare cases where a condition does not appear to exist. In general, orthodontic treatment lessens the possibility of tooth loss or gum infection due to misalignment of the teeth or jaws. Periodontal disease (inflammation of the gums and loss of supporting bone) can occur if plaque is not removed daily with good oral hygiene.
4. Relapse tendency: Teeth may have a tendency to change their positions after orthodontic treatment. This usually is only a minor change and faithful wearing of retainers as instructed should help reduce this tendency. Throughout life the bite can change adversely from various causes, such as: eruption of wisdom teeth, growth and/or maturational changes, mouth breathing, playing of musical instruments and other oral habits, all of which may be out of the control of the orthodontist.
5. Jaw joint problems: Rarely problems may occur in the jaw joints, i.e. temporomandibular joints (TMJ), causing joint pain, headaches or ear problems. These problems may occur with or without orthodontic treatment and may worsen, improve, or stay the same during orthodontic treatment.
6. Loss of tooth vitality: Sometimes a tooth may have been traumatized by a previous accident or a tooth may have large fillings, which can cause damage to the nerve of the tooth. Orthodontic tooth movement may in some cases aggravate this condition and in rare instances may lead to loss of vitality and possible root canal treatment.
7. Post-adjustment pain: After adjustment of your brace, tenderness should be expected, and the period of tenderness or sensitivity varies with each patient and the procedure performed. Typical post-adjustment tenderness may last 24 to 48 hours. You should inform the clinic of any unusual symptoms, broken or loose appliances, as soon as they are noted.
8. Unfavourable growth (if under 21): Atypical formation of teeth, or insufficient or abnormal changes in the growth of the jaws may limit our ability to achieve the desired result. If growth becomes disproportionate during or after treatment the bite may change, requiring additional treatments or, in some cases, surgery. Growth disharmony and unusual tooth formations are biological processes beyond the orthodontist’s control. Growth changes that occur after orthodontic treatment may alter the quality of treatment results.
9. Treatment time: The total time required to complete treatment may exceed the original estimate. Excessive or deficient bone growth, poor cooperation, poor oral hygiene, broken appliances and missed appointments can lengthen the treatment time and affect the quality of the end results.
10. Adjunctive dental care: Due to the wide variation in the size and shape of teeth, achievement of the most ideal result (for example, complete closure of excessive space) may require restorative dental treatment (in addition to orthodontic care). The most common types of treatment are cosmetic bonding (white fillings as “build ups”), crown and bridge restorative dental care and/or periodontal therapy.
11. Perfection is our goal: In dealing with human beings and problems of growth and development, genetics and patient cooperation, achieving perfection is not always possible. Lingual orthodontics is an art, not an exact science; therefore, a functionally and aesthetically adequate result, not 100% perfection, must be acceptable. Your comments in regard to your expectations prior to, during and after lingual orthodontic treatment will help us understand your concerns. Please keep us regularly informed of your feelings, concerns and results that do not meet your expectations.
Patient Responsibility: It is the patients responsibility to follow the brushing and oral hygiene instruction that are given, so that no harm will come to the teeth and surrounding tissues, to come to all appointments at the recommended intervals, to adhere to the food restrictions in order not to damage the teeth and orthodontic appliance; to wear the elastics and retainers, if they are necessary, so that the treatment time will be as short as possible and so we can achieve the best results; and to visit the general dentist at least every six months for an examination and cleaning. There may be an additional charges for replacement of appliances (such as retainers or braces) that are lost or damaged due to repeated patient neglect, or any excessive extension of treatment due to lack of patient co-operation. 100% patient cooperation is very important.

Termination of treatment: it is understood that treatment can be terminated for failure to cooperate, missing appointment, not wearing appliances, excessive breakage, failure to keep financial commitments, relocation, personal conflicts or for any other reason the doctor feels necessary. If termination is necessary, the patient will be given ample time to locate another orthodontist to continue treatment or the braces will be removed.

Relapse: teeth have tendency to return to their original position after orthodontics treatment. This is called a relapse. Very severe problems have a higher tendency to relapse and the most common area to relapse is the lower front teeth. After removal of the appliance, retainers are placed to minimise relapse. Full cooperation in wearing these appliances is vital.

I consent to the taking of photographs, study models and x-rays before, during and after orthodontic treatment to assist in the planning and progress of the treatment objectives.

I certify that I have read or had read to me the content of this form and do realise the risks and limitations involved, and consent to orthodontic treatment.