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Consent Form

Our consent forms play a vital role in ensuring transparency and empowering you in your dental journey. These forms outline the procedures, risks, and benefits associated with your dental treatments, allowing you to make informed decisions and provide your consent.

Understanding Your Dental Treatment

Please take a moment to review and complete the consent forms relevant to your specific treatments. Your well-being and satisfaction are our top priorities, and these consent forms enable us to deliver the highest standard of care while respecting your rights and preferences.

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Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile you should also be aware that 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. Orthodontic treatment usually proceeds as planned; however, like all areas of the healing arts results cannot be guaranteed.
You are encouraged to discuss any questions you may have or alternatives to treatment with the doctor prior to beginning treatment.
The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances and following the orthodontics instructions carefully.


Orthodontics plays an important role in improving overall oral health, and in achieving balance and harmony between the teeth and face for a beautiful, healthy smile. An attractive smile enhances one's self-esteem, which may 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 response of the patient to the orthodontic treatment.


All forms of medical and dental treatment, including 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:
1. Decalcification and dental caries:
Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in tooth decay, gum disease, and permanent marking (decalcification) on the teeth. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient consumes sweetened beverages or foods. Our professional recommendation is a dental exam and cleaning every 4-6 months during orthodontic treatment. This is a patient's personal responsibility due to the above reasons listed in this paragraph.
2. Root Resorption:
In some patients the length of the roots of the teeth may become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption; however, some patients are prone to this happening and 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. If resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the completion of your orthodontic treatment.
3. Periodontal Disease:
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitors your periodontal health during orthodontic treatment every three to six months. If periodontal treatment cannot be controlled, orthodontic treatment may have to be discontinued prior to completion. In general, orthodontic treatment lessens the possibility of tooth loss or gum infection due to misalignment of the teeth or jaws.
Occasionally, gingival recession of one or more teeth can occur during orthodontic treatment. Poor oral hygiene increases the risk of gingival recession. Gingival graft might be needed in moderate to severe case. This procedure is performed by the general dentist or a periodontist.
4. Relapse:
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift. Regular retainer wear is recommended for the rest of your lifetime. However, changes after time can still occur due to natural causes, including habits such as tongue thrusting mouth breathing, and growth and maturation. Some changes may require additional orthodontic treatment or, in some cases, surgery.
5. Temporomandibular (Jaw) joint dysfunction:
Occasionally problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing joint pain, headaches, or ear problems. Many factors can affect the health of the jaw joints, including past trauma, arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, a poorly balanced bite and many medical conditions. These problems may occur with or without orthodontic treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening and closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.
6. Nerve Damage:
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 and in rare instances may aggravate this condition. In some cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.
7. Injury or damage from Orthodontic Appliances:
Appliances are designed to have a maximum amount of strength and a minimum amount of injury potential. Nevertheless, accidents can occur. It is also possible for a patient to swallow or inhale parts of the appliance or our instruments. The gums, cheeks and lips may be scratched or irritated by braces, wires or the aligner occasionally. Tender teeth should be expected after switching to the next aligner in the series. The period of tenderness or sensitivity varies with each patient.
When clear and tooth-colored brackets have been utilized, incidents of patients experiencing bracket breakage and/or damage to teeth, including attrition and enamel flaking or fracturing upon debonding have been reported. Fractured brackets may result in remnants that might be harmful to the patient especially if swallowed or aspirated.
8. Discomfort:
Since the mouth is sensitive to changes, the introduction or adjustment of any appliance may result in discomfort or sensitivity that varies with each patient and the procedure performed (typical post-adjustment tenderness may last 24-48 hours). This discomfort can usually be resolved by using over-the-counter non-aspirin pain medication. Inform your orthodontist of any unusual symptoms when noticed. Also, on rare occasions, when dental instruments are used in the mouth, the patient may inadvertently get scratched, poked or receive a blow to a tooth with potential damage to or soreness of oral structures.
9. Orthognathic Surgery:
Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you should discuss with your maxillofacial surgeon. Please be aware that orthodontic treatment prior to surgery only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without the planned surgical procedures may have a malocclusion(bite) that is worse than when treatment began. Our office does not do the surgical procedures and there will be a separate fee charged by the surgeon.
10. Extractions:
Some cases will require the removal of teeth. There will be risks associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the procedure. There will be a separate fee involved for this procedure.
11. Length of Treatment:
The length of treatment depends on a number of issues, including the severity of the problem, the patient's growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are some habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if a patient's cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond the original estimate, additional fees may be assessed.
12. Impacted, Ankylosed, Unerupted Teeth:
Teeth may become impacted (trapped below the bone or gum), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circumstance and the overall importance of the involved tooth and may require extraction, surgical exposure, surgical transplantation or prosthetic replacement.
13. Non-Ideal Results:
Due to the wide variation in the size and shape of the teeth, missing teeth, etc.., achievement of an ideal result (complete closure of space) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges, or periodontal therapy, may be indicated.
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, or a tooth forms very late, the bite may change, requiring additional treatment, or in some cases, oral surgery. Growth disharmony and unusual tooth formation are biological processes beyond the orthodontist’s control. Growth changes that occur after active orthodontic treatment may alter the final treatment result.
14. Wisdom Teeth:
As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them to determine when and if the third molars should be removed.
15. Allergies:
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discontinuance of treatment prior to completion.
16. General Health Problems:
General medical problems such as bone, blood or endocrine disorders, and many prescription and nonprescription drugs (including bisphosphonates) can affect orthodontic treatment. It is imperative that you inform your orthodontist to any changes in your medical health.
17. Use of Tobacco Products:
Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with the healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.
18. Temporary anchorage Devices:
Your treatment may include the use of a temporary anchorage device (metal screw attached to bone). There are specific risks associated with them. It is possible that the screw could become loose which would require removal and possibly relocation or replacement. The screw and related material may be accidentally swallowed. If the device cannot be stabilized for an adequate length of time, an alternative treatment plan may be necessary. Tissue around the device could become inflamed and infected, or the soft tissue could grow over the device, which could also require its removal. When inserting the device it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary. Local anesthetic may be used when these devices are placed, which also has risks.


The system consists of a series of clear polymer, removable appliances (aligners) that move your teeth in small increments from their original position to a more ideal position. Some patients require bonded aesthetic attachments (small, tooth-colored dental composites) and/or elastics on their teeth to facilitate specific dental movements. The total number of aligners varies depending on the complexity of your orthodontic problem. The only times you remove your aligners are to eat, drink and clean your teeth. Your orthodontist will monitor your progress and direct the timing/transition of aligner wear.


Interproximal enamel reduction or thinning the width of teeth is often part of clear aligner treatment. It is a procedure to remove a slight amount of enamel between the teeth to create space for the correction of crowded teeth or to enable the teeth in each jaw to come together more efficiently. The enamel is removed in our clinic and does not require anesthesia. We would recommend fluoride rinses for 3 days after each of these appointments without wearing the aligners.


Little bumps of tooth colored acrylic called attachments may be bonded\glued to the front or back side of specific teeth to give your aligners more grip on your teeth for moving them. You must remind personnel at your family dentist's office that these bumps are part of your treatment and should only be removed by your orthodontist when your clear aligner treatment is complete.


For most patients, orthodontic treatment is an elective procedure/improvement. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present oral condition and decide not to have orthodontic correction or improvement. The specific alternatives to orthodontic treatment for any particular patient depend on the nature of the individual’s teeth, supporting structures and appearance.


I have read, understood, and have had all my questions answered regarding the risks and limitations of orthodontic treatment. I have also been alerted to conditions that do or may exist. I also understand that if conditions change and risk factors of continuing orthodontic treatment outweigh the benefits, then orthodontic treatment may be terminated. I understand that orthodontics is not an exact science and acknowledge that no guarantees have been made to me regarding the results of orthodontic treatment.
Pertinent information necessary to aid in the decision-making process has been presented to me and I have been given the opportunity to ask all questions I have about the proposed orthodontic treatment and information contained in this form. I hereby consent to orthodontic treatment.
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I realize, and it has been explained to me, that it is my responsibility to keep my orthodontic appliances (braces) clean. It is also my responsibility to maintain regular visits to my family dentist at least every six months. If I do NOT maintain proper oral hygiene throughout my orthodontic treatment, I understand that any or all of the following negative conditions may occur: permanent discoloration of my teeth, cavities or periodontal disease (gum infection). If any of the above conditions occur as a result of my poor oral hygiene, I realize that I may need procedures to be performed by my family dentist or a dental specialist.
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If you are unable to keep an appointment, 48 hours’ notice of cancellation is required; this allows us to schedule another patient in your place. If you cancel an appointment less than 48 hours in advance or fail to show for an appointment, it will be considered a no-show. After 3 no-shows, you will be considered non-compliant and your continued treatment in this clinic will be reevaluated.
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I hereby consent to the making of diagnostic records, including, but not limited to x-rays, before, during and following orthodontic treatment, to the treating doctor and where appropriate, staff providing orthodontic treatment prescribed by the treating orthodontist or dentist.
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I hereby authorize my orthodontist or dentist at this office to provide other health care providers with information regarding the above individual's orthodontic care as appropriate. I understand once released, my treating doctor at this office and staff have no responsibility for any further release by the individual receiving this information.
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I hereby give my permission for the use of orthodontic records, including radiographs, photos and models for the purpose of professional consultations, research education, or publications in professional journals.
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I decline surgery on behalf of myself or my child and accept the results. I understand the risks/benefits of declining a jaw surgery treatment plan.
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This field is for validation purposes and should be left unchanged.
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