Consent for Composite or Porcelain Veneers Form

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Patient Information

Name*

Date*

Consent for Composite or Porcelain Veneers

Composite veneer

Teeth #s*

Porcelain veneer

Teeth #s*

Veneers are thin layers of porcelain or composite resin that are placed on the front surfaces of teeth in order to change the appearance of your smile. Teeth that are discolored. chipped, rotated, or spaced can be transformed with veneers. Porcelain veneers are fabricated at a laboratory by expert ceramists from an impression of the prepared teeth. Composite veneers are placed directly on the teeth in your dentist's once. Porcelain veneers tend to resist staining more readily than composite veneers.

The procedure for placing Porcelain Veneers involves a series of appointments in which your input is essential in producing a desirable outcome. First your dentist will perform a consultation discussing costs. esthetic desires, and treatment sequence. At this initial visit impressions may be taken in order to fabricate a model with the veneers in wax to better discuss esthetic goals and to show you what your new smile will look like. the tooth structure and gums Should be in Stable condition prior to placement of veneers. Defective fillings should be replaced, gums contoured and should be free of periodontal disease before proceeding. The next step is to remove a small amount of enamel from the fronts of the teeth to have adequate space for the veneers so they will not appear bulky or over contoured. The teeth will be temporized if needed at this appointment. The Veneers will be cemented into place on the third visit. A fourth appointment of short duration is needed for final finishing and polishing of your veneers.

The goal of composite veneers is the same as porcelain veneers but the materials, techniques, and timeline are a bit different. These usually take two appointments. During the first appointment, the teeth are prepared, and tooth colored filling material is placed on the front of the teeth and shaped to the desired form. The material is finished and polished to a life-like shine. A second polishing appointment may be necessary.

Potential Risks and Complications:

1- In preparing the teeth for the reception of cosmetic veneers. either made of porcelain or composite resin, it may be necessary to reduce or roughen the surface of the tooth to which the veneer(s) may be bonded. This preparation will be done as conservatively as possible. but once this is done, the patient is committed to veneers or crowns for the duration of life. If the veneer covering breaks or comes off. the uncovered tooth may become susceptible to decay if the veneer is not replaced in a timely manner.

2- Sensitivity of teeth: Through the process of modifying teeth to accept veneers, there is the possibility of the development of tooth sensitivity which may last for days or months following tooth preparation. In most cases. this sensitivity will alleviate over time but in rare instances is permanent.

3- Chipping, breaking or loosening of the veneer may occur any time following placement. Many factors may contribute to this happening such as: chewing of excessively hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; failure of the bond between the veneer and tooth: and Other such conditions over which the dentist has no control, once the patient has confirmed the Shade of the cosmetic and has had it installed, they are unable to change 'it without a full payment for a new installation.
Chips, breaks ,or any damage that may occur .After the procedure is done is not covered under the initial cost. Payment will be required-

4- Alteration in speech: Since the veneers may be wider and/or longer than the natural teeth they are covering, a difference in speech may be evident. Many times the patient will adapt to the change and speech returns to normal very shortly after placement. The veneers may need to be adjusted in order to alleviate problems with speech.

5- Sensitive or allergic reactions to anesthetics or materials used in the procedure.

6- Esthetics/Appearance: Every attempt possible will be made to match and coordinate both the form and shade of veneers, which will be placed to be cosmetically pleasing to the patient. However, there are some differences, which may exist between that which is natural and that which is artificial making it impossible to have the shade and/or form perfectly match your natural dentition. Once veneers are bonded to place on the teeth, should the patient desire any changes later a fee may be assessed to cover any extensive adjustments or remakes.

7- Longevity: It is impossible to place any specific time criteria on the length of time that veneers should last. Once the tooth structure is prepared for veneer placement, the patient is committed to veneers for life. Should the veneers become damaged, leaky, or stained, they will need to be replaced.

8- Veneers are susceptible to staining just like natural teeth. Composite resin veneers tend to stain more readily than porcelain. The veneers may need to be replaced if excessive staining, marginal leakage, or chipping occurs. Every attempt to avoid stain inducing foods and drinks should be avoided.

9- An acrylic lab fabricated night guard may be indicated to help protect your veneers from damage due to night time clenching and grinding.

I certify that I have read the above and fully understand this consent for treatment. I understand that a perfect result cannot be guaranteed. J am aware of the fee(s) associated with this treatment and am responsible for any and all payments not covered by my insurance.

Doctor Signature*

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Patient Signature*

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