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TMJ Disorder -TemporoMandibular Joint Message Board

TMJ Disorder -TemporoMandibular Joint Board Index

1. I authorize Dr. ______and his staff to treat the condition diagnosed as:_____________
2. The procedure planned to treat the condition noted above has been explained to me and I understand it to be:_______________
3. I understand that the TMJ Concepts Temporomandibular Joint (TMJ) Reconstruction Prosthesis is fabricated with the aid of CT scan generated model of the patient's actual anatomy. The fossa (cup) is made of ultra-high-molecular-weight polyethylene (plastic) attached to a commercially pure titanium metal backing which is secured to the zygomatic arch (cheek bone) with titanium alloy screws. The condyle (ball), which moves against the fossa (cup) during jaw function, is made of cobalt-chromium-molybdenum metal alloy attached to a titanium alloy plate which is secured to the ramus of the mandible (lower jaw bone) with titanium alloy screws.
4. I have been informed to my satisfaction of possible alternative forms of treatment (if any), including,
5. Dr. __ has explained that the chronic, badly deteriorated condition of my TMJ(s) has made it necessary to perform this complex surgical procedure and, because of the seriousness of my condition, the TMJ reconstruction procedure cannot be considered an absolute solution to my TMJ problems. Although the TMJ Concepts device has undergone preliminary in vivo tests and improved results are anticipated, I have been informed that this procedure may not allow me to regain full or even better function of my jaws and that it may not reduce my pain and discomfort. This may be especially true because it may not be entirely possible to eliminate or adequately reduce underlying causes of my TMJ problems, such as clenching and grinding of my teeth, muscle spasms, and my individual reaction to stress. I am aware that the results also depend upon how well I follow the post-operative rehabilitation and exercise program, recommended change in diet, etDr. ___ has explained to me that the potential for success of my joint surgery depends upon many factors, including my overall physical condition at the time of treatment, the condition and degree of disease/damage to my TMJ(s) at the time of implantation of any reconstruction prosthesis, my body's acceptance of the implant(s), and possible tissue reactions sometimes referred to as "foreign body reactions" around the implant and in the associated lymph nodes. Other significant factors are: the degree to which underlying causes of my disease may respond to pre-operative treatment or continue after surgery (i.e., clenching and grinding of teeth, jaw muscle spasm), how well I follow post-operative rehabilitation and exercise programs and otherwise cooperate with my surgeon's instructions, and whether or not I deal effectively with other contributing factors such as stress, diet, etc.
6. Dr. ___ has informed me that patients who have already undergone prior TMJ surgeries have a higher risk of complications and less than ideal results.
7. I understand all of my treatment options, including the risks and benefits of each. I wish to proceed with the treatment recommended in item #2. I am aware that my current condition is serious, that there can be no promise or warrantee of cure, and that my condition may return or worsen after this procedure.
8. It has been explained to me in layman's terms where and how the required surgical incisions will be made and what steps are involved in reconstructing my TMJ with the TMJ Concepts Patient-Fitted TMJ Reconstruction Prosthesis. All questions have been answered to my satisfaction.
9. I understand that Dr. __ may find other or different conditions during the surgery which were not evident during clinical or radiographic examination or other diagnostic studies performed before surgery. These discovered conditions may require additional or different procedures that were not anticipated prior to surgery. Therefore, I consent to and authorize Dr. __to perform those procedures which are necessary and advisable in his/her professional judgement.
10. It has been explained to me that there are certain potential risks and side effects of this surgery, some of which may be serious. They include, but are not limited to:
A. Facial and jaw swelling after surgery usually lasting several days.
B. Temporary or permanent facial muscle weakness resulting from motor nerve injury during surgery. The most common problem resulting is an inability to wrinkle the brow, raise the eyebrow, or gain tight closure of the eyelids.
C. Allergic reaction to any of the medications given during or after the surgery.
D. Numbness (temporary or permanent) of certain areas of the skin in the region of the joint and sometimes in more remote areas of the face and scalp.
E. Objectionable scarring of the incision line, possibly requiring later revision.
F. Bruising and discoloration of the skin around the eyes, jaw, and ear.
G. Ear problems, including inflammation of the canal, middle or inner ear infections, perforation of the ear drum, temporary or permanent hearing loss, ringing in the ears, or equilibrium problems.
H. Malocclusion (change in bite) after surgery requiring treatment.
I. Post-operative development of adhesions or ankylosis within the joint space which may cause continued jaw dysfunction, decreased range of jaw movement, difficulty chewing, and pain requiring further treatment.
J. Worsening of present TMJ symptoms which may require further treatment.
K. Post-operative infection requiring additional treatment.
L. Further degenerative joint changes and development of adhesions (scar tissue), joint arthritis (opposite joint in unilateral cases), or osteomyelitis of the jaw. (bone infection)
M. Foreign body reaction or allergic reaction and rejection of the implant, wear, displacement, breakage, or loosening of the implant parts.
N. The formation of heterotopic bone (reactive bone) resulting in joint pain and/or mobility limitations requiring further surgical intervention.
O. Post-operative and/or future treatments are not limited to, but may include: physical therapy, bite splint therapy, restorative or reconstructive dentistry, orthodontia, orthognathic surgery (jaw repositioning surgery), further reconstructive TMJ surgery.
11. General anesthesia will be used for this surgery and I have been told of the risks, including bronchitis, pneumonia, hoarseness or voice changes, irregularities of heart beat, heart attack, or death. I am aware of the importance of not having anything by mouth (including clear liquids unless specifically authorized by the surgeon or anesthesiologist) after midnight on the day before surgery.
12. I realize the importance of providing true and accurate information about my health, especially concerning possible pregnancy, allergies, medications, and history of drug and/or alcohol abuse. If I misinform my doctor, I understand the consequences may be life threatening or otherwise adversely affect the result of the surgery. I have given a truthful medical and dental history, including all problems, drug and/or alcohol use, and any other information that may affect this surgery.
13. I agree to fully comply with the recommendations of my surgeon, realizing that lack of cooperation may result in less than an optimal result.
14. I agree to use only those medications approved by my surgeon and not to participate in contact sports, water sports, and strenuous physical activity for six weeks following surgery.
15. As with any joint reconstruction, it is not possible to guarantee how long the implant will last in any particular patient. I realize that I should not consider any TMJ implant to be a lifetime replacement and that it may require removal and/or replacement at any time or another form of TMJ reconstructive therapy may have to be performed.
16. I certify that I speak, read and write English, that I fully understand this consent form for surgery, and that all the blanks were filled in prior to my initialing and signing this form. I have been given the opportunity to obtain a second opinion from a qualified professional regarding this proposed procedure.

By signing this consent form, I acknowledge that I have read it completely and understand the procedure to be performed, the risks, and the alternatives to surgery. I have had all of my questions answered to my satisfaction.
I was under no pressure to sign this form and have made a voluntary choice to proceed with surgery.

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