Consent of orthodontic treatment provided by Dr Mohammed Almuzian

INFORMED CONSENT FOR THE ORTHODONTIC

PATIENT

A. Overview of the treatment plan

B. Risks and limitations of orthodontic treatment
C. Acknowledgement

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, as with all healing
arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to
indicate that you should not have treatment; however, all patients should seriously consider the option of
no orthodontic treatment at all by accepting their present oral condition.
Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions
or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with
the doctor prior to beginning treatment.
Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention,
interception and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the
developing or mature orofacial structures.
An orthodontist is a dental specialist who has completed at least two additional years of graduate training
in orthodontics at an accredited program after graduation from dental school.

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A. OVERVIEW OF THE TREATMENT PLAN

Before active orthodontic treatment (if any):

Payment Plan: NHS Private as per the provided estimate

Extractions: No Review Yes
Appliance/Arch: Upper & lower Upper Lower
Appliance Type: Removable Functional Invisalign
Metal fixed appliance Clear fixed appliance Other

Other auxiliary appliances:

Treatment Time (Approximate):

Additional treatment (if any):

Potential risk of the treatment (if any):

Acceptable compromised results (if any):

Retainers (FREE for the first set of Removable Fixed Both

retainer (s) and for the treated arch
only)

Others:

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B. Risks and Limitations of orthodontic treatment

1. BENEFITS OF TREATMENT
Orthodontic treatment mainly aims to straighten teeth and provide a more pleasing smile. 

2. RESULTS OF TREATMENT
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve
the best results for every patient. However, we cannot guarantee that you will be completely satisfied
with your results, nor can all complications or consequences be anticipated. The success of treatment
depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or
broken appliances, and following the orthodontist’s instructions carefully.

3. NON-IDEAL RESULTS
Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal
result (for example, complete closure of a space) may not be possible. Restorative dental treatment, such
as aesthetic bonding, crowns or bridges or periodontal therapy, may be indicated. You are encouraged to
ask your orthodontist and family dentist about adjunctive care.

4. TYPES OF TREATMENT
Treatment may involve fixed braces which are attached to the teeth or removable types of appliances
which can be taken out for cleaning. The orthodontist already advised what is appropriate for your case.
Sometimes a combination of appliances is used or additional components are recommended.  

5. 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 habits affecting the dentofacial structures, if periodontal or other dental problems
occur, or if patient 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.

6. FREQUENCY OF APPOINTMENTS
It is necessary to check appliances on a regular basis in order to monitor progress and make adjustments.
This obviously necessitates taking time away from school or work for treatment to be carried out
successfully. Normally, you need to visit us every 4-6 weeks, it could be more or less depending on your
case and the orthodontist recommendation.

7. FAILED AND CANCELLED APPOINTMENTS

Failure to attend regularly will result in prolonged or unsuccessful treatment, if this is deemed to be a
problem the treatment will be stopped prior to completion. We have a failed and cancelled appointment
policy to help reduce waiting times, if you fail to attend an appointment you will be charged as per the
practice policy. We ask wherever possible that you provide us with 48hrs notice if cancelling an
appointment, if this is not provided then a charge as per the practice policy may be applied. 

8. DECALCIFICATION AND DENTAL CARIES

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Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family
dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease
and/ or decalcification. 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 has not had the benefit of fluoridated water or its substitute, or if the patient consumes
sweetened beverages or foods.

9. DISCOMFORT
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the
introduction of orthodontic appliances. Non- prescription pain medication can be used during this
adjustment period.

10. ROOT SHORTENING

The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not
known exactly what causes root resorption, nor is it possible to predict which patients will experience it.
However, many patients have retained teeth through- out life with severely shortened roots. 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 orthodontic treatment.

11. NERVE DAMAGE

A tooth that has been traumatized by an accident or deep decay may have experienced damage to the
nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some
cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.

12. PERIODONTAL DISEASE

Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many
factors, but most often due to the 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 problems cannot be controlled, orthodontic treatment may have to be
discontinued prior to completion.

13. INJURY FROM ORTHODONTIC APPLIANCES

Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided.
Loosened or damaged orthodontic appliances can be inhaled or swallowed or could cause other damage
to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken
appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown,
bonding, veneer, etc.) is possible when orthodontic appliances are removed. This problem may be more
likely when aesthetic (clear or tooth coloured) appliances have been selected. If damage to a tooth or
restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

14. TEMPOROMANDIBULAR (JAW) JOINT DYSFUNCTION

Problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches or
ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the
head or face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching,
poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without
orthodontic treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or

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closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists
may be necessary.

15. IMPACTED, ANKYLOSED, UNERUPTED TEETH

Teeth may become impacted (trapped below the bone or gums), 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.

16. OCCLUSAL ADJUSTMENT

You can expect minimal imperfections in the way your teeth meet following the end of treatment. An
occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the
occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby
“flattening” surfaces in order to reduce the possibility of a relapse.

17. STABILITY OF TREATMENT RESULTS

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, in addition to other adverse
effects. Regular retainer wear is often necessary for several years following orthodontic treatment.
However, changes after that time can occur due to natural causes, including habits such as tongue
thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most
people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be
accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some
situations may require non-removable retainers or other dental appliances made by your family dentist.

18. EXTRACTIONS
Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional
risks associated with the removal of teeth which you should discuss with your family dentist or oral
surgeon prior to the procedure.

19. THIRD MOLARS

As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or
orthodontist should monitor them in order to determine when and if the third molars need to be
removed.

20. HEADGEARS
Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes. In
the event of injury or especially an eye injury, however minor, immediate medical help should be sought.
Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or
pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.

21. 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 oral and/or maxillofacial surgeon prior to beginning orthodontic treatment.

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Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth
within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without
completing the planned surgical procedures may have a malocclusion that is worse than when they began
treatment!

22. GENERAL DENTAL CARE

It is recommended that routine dental care is well looked after by your own dentist throughout
orthodontic treatment. Dr Mohammed Almuzian mostly provides orthodontic treatment. Please note that
general dental work such as fillings, checkups and cleans are not performed by Dr Almuzian and therefore,
it is recommended that appointments with your regular dentist are made every 3-6 months.

23. GENERAL HEALTH PROBLEMS

General health problems such as bone, blood or endocrine disorders, and many prescription and non-
prescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that
you inform your orthodontist of any changes in your general health status.

24. 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. Although very uncommon, medical management of dental material allergies may be
necessary.

25. USE OF TOBACCO PRODUCTS

Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with
healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed
tooth movement during orthodontic treat- care providers. If you use tobacco, you must carefully consider
the possibility of a compromised orthodontic result

26. TEMPORARY ANCHORAGE DEVICES

Your treatment may include the use of a temporary anchorage device(s) (i.e. metal screw or plate
attached to the bone.) There are specific risks associated with them. It is possible that the screw(s) could
become loose which would require its/their removal and possibly relocation or replacement with a larger
screw. The screw and related material may be accidentally swallowed. If the device cannot be stabilized
for an adequate length of time, an alternate treatment plan may be necessary. It is possible that the
tissue around the device could become inflamed or infected, or the soft tissue could grow over the device,
which could also require its removal, surgical excision of the tissue and/or the use of antibiotics or
antimicrobial rinses. It is possible that the screws could break (i.e. upon insertion or removal.) If this
occurs, the broken piece may be left in your mouth or may be surgically removed. This may require
referral to another dental specialist. When inserting the device(s), 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 inserted or removed, which also has risks. Please advise the doctor placing the device if you
have had any difficulties with dental anesthetics in the past.

27. TRANSFERRING PATIENT

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Orthodontic treatments vary widely. Transfer will likely increase treatment fees, may involve changes in
payment policies, and may change your treatment and/or appliances. When you transfer to a new
orthodontist, your treatment time is often extended by the process of transfer.
If any of the complications mentioned above do occur, a referral may be necessary to your family dentist
or another dental or medical specialist for further treatment. Fees for these services are not included in
the cost for orthodontic treatment.

28. ABOUT CLEAR ALIGNERS

Clear aligner therapy is a form of orthodontic treatment in which the patient wears a series of clear,
removable aligners that gradually move the teeth to improve their position and bite.
-It may be necessary to temporarily affix attachments (small bumps of tooth coloured filling material your
teeth to assist with tooth movements.
- Poor compliance in wearing aligners less than 22 hours per day, missing appointments, unpredicted
bone growth, poor oral hygiene and lost aligners can lengthen treatment time, increase cost, and affect
the quality o the end results.
-In cases of crowding, IPR, also known as inter-proximal reduction (reducing the thickness of a tooth’s
enamel), will be required to create enough space to allow teeth movement. IRP will be across U/L incisors.
-Black triangles can develop after aligning the crooked teeth. Their occurrence can sometimes be
minimized by additional IPR, however the outcome cannot be guaranteed or predictable.
-Tooth sensitivity and tenderness of the mouth may occur during treatment - especially when advancing
from one aligner to the next.
-Sometimes elastics wear will be required and this may be needed for 12-18 hours per day for several
months.
-A successful treatment outcome cannot be guaranteed. After the final planned aligners have shipped,
some cases may require refinement with additional clear aligners, traditional orthodontic techniques,
and/or cosmetic procedures like crowns or veneers to achieve ideal results
-For Invisalign Full and Teen cases we offer five years of no re-treatment fee from the date you start
treatment. However for this to be valid, you must attend 4-6 monthly retainer check appointments with
us and wear retainers as prescribed.

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C. ACKNOWLEDGEMENT

 I hereby acknowledge that I have read and fully understand the treatment considerations and
risks presented in this form.
 I also understand that there may be other problems that occur less frequently than those
presented, and that actual results may differ from the anticipated results.
 I also acknowledge that I have discussed this form with the undersigned orthodontist( s) and have
been given the opportunity to ask any questions.
 I have been asked to make a choice about my treatment.
 I hereby consent to the treatment proposed and authorize the orthodontist(s) indicated below to
provide the treatment.
 I also authorize the orthodontist(s) to provide my health care information to my other health care
providers.
 I understand that my treatment fee covers only treatment provided by the orthodontist(s), and
that treatment provided by other dental or medical professionals is not included in the fee for my
orthodontic treatment.
 I acknowledge that all treatment options have been offered including no treatment in addition to
the advantages and disadvantages of each, I have chosen the above-mentioned treatment option.
 I have read the information leaflet titled "Orthodontic treatment. What are the risks ",
“Retainers”, “Teeth and brace-friendly food and drink” as well as
……………………………………………………………………… that has been provided to me.
 I hereby consent to the making of diagnostic records, including x-rays, before, during and
following orthodontic treatment, and to the above doctor(s) and, where appropriate, staff
providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully
understand all of the risks associated with the treatment.
 I hereby authorize the above doctor(s) to provide other health care providers with information
regarding the above individual’s orthodontic care as deemed appropriate. I understand that once
released, the above doctor(s) and staff has(have) no responsibility for any further release by the
individual receiving this information.
 I hereby give my permission for the use of orthodontic records, including photographs, made in
the process of examinations, treatment, and retention for purposes of professional
consultations, research, education, or publication in professional journals.

Patient (or Parent/Guardian + Patient) Dr Mohammed Almuzian

Signed Signed
Date Date

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