INFORMED CONSENT FOR ORTHOGNATHIC SURGERY

You are hereby informed that you have the right to know the details of the procedure you are about to undergo, the benefits it offers and the most frequent complications that may occur. I have been informed by Dr. Hugo Martinez and understand the purpose and nature of orthognathic surgery. I have been explained and consent to undergo such surgical procedure in which a correction of the position of my maxillary bones and not the individual teeth will be made, with the consequent improvement of the aesthetic and/or functional aspect at the time of chewing and speaking. I understand that the procedure is performed by osteotomies (cuts) in the bones of the face and their subsequent repositioning, often fixation with osteosynthesis, which is the use of metallic or non-metallic materials that remain in place indefinitely and usually do not need to be removed, or materials that are reabsorbed over time. I understand that orthodontic treatment is usually required before and after surgery. Additionally, dental restorations, periodontics (gum treatment), and endodontic treatment may be required post-operatively. I fully understand that, during and following the planned procedure, surgery or treatment, conditions may arise that, in professional judgment, require a complementary/alternative treatment plan, directly related to the success of the treatment. This surgery is performed under general anesthesia (with the risks inherent to it, which will be informed by an anesthesiologist) and the use of transfusions may be necessary, and may result in specific reactions and infections. Among the most frequent complications of this surgery are: postoperative hematoma and swelling, intraoperative or postoperative bleeding, postoperative infection and even osteomyelitis, postoperative pain, allergic reactions to medication, drugs or materials used in the surgical technique, lack of sensitivity of the lips, chin, cheek, nose, gums, tongue, teeth or palate (partial or total, temporary or permanent), lack of mobility of the facial nerve, transient or permanent, teeth close to the surgery may be damaged and require treatment or even extraction, poor union of bone fragments, total or partial recurrence (relapse) of the deformity, sinusitis, communication between the mouth and nose or maxillary sinuses, deformity of the nasal septum or nose, failure to meet aesthetic and/or emotional changes reactive to facial changes; in case of extra oral incisions anesthetic scarring, instrument breakage may occur. Stated that my mouth has been properly examined and alternatives to this treatment have been explained and that these methods have been studied and considered and I have made a final decision to have orthognathic surgery. I have been informed of the inconvenience of smoking, drinking alcohol or taking too much sugar, for the healing of the gums and that such habits compromise the success of the treatment. I fully agree with the instructions given to me by the surgeon about the care I must follow and the indications regarding the hygiene of my mouth and I understand how to do it. I agree to go to my dentist’s office to be examined and instructed as he/she instructs me to do so. Having received the above information, I consider that I have understood the nature and purpose of the procedure; furthermore, I have been informed, in terms that I have understood, of the scope of such treatment. In the interview I have had the opportunity to propose and resolve my possible doubts and to obtain as much complementary information as I have deemed necessary. Therefore, I consider myself in a position to duly accept both its possible risks and the usefulness and benefits that I can obtain from it. I approve any modification in design, materials or maintenance, if it is considered to be for my benefit. I declare that my mouth has been properly examined and alternatives to this treatment have been explained to me and that these methods informed to me have been studied and considered, my decision being final. I am satisfied with the information provided to me and, therefore,

I GIVE MY CONSENT to undergo Orthognathic Surgery.

I confirm that I have read and understood all of the above. I agree to take all the necessary care and follow the necessary indications; to comply with the stipulated medication, without any modification; to attend the stipulated controls and to immediately inform my dentist in charge of any symptomatology that appears, in order to take care of it in an early manner.