Dental Education Lecture: Informed Consent for Micro-implant

I                       accept the treatment plan proposed by Dr. Wei, which includes the use of microimplants (mini-implants) as aid to position my teeth.

I understand that Dr. Wei will use these microimplants as anchorage units because number, position or state of my teeth do not allow their use as anchorage to achieve an effective movement of the teeth that should be repositioned.  It is explained to me that      microimplants will be inserted into my mouth in appropriate position in my palate or between my upper or lower teeth.

Dr. Wei explains to me that microimplants will be inserted with local anesthesia.  He also explains to me the insertion procedure, and I understand that absolute success of microimplants cannot be guaranteed.

 Some risks that can occur are:

1. Discomfort or mild pain in the area
2. Infection or inflammation of the insertion site
3. Mobility or loss of microimplants during the treatment
4. Fracture of microimplants
5. Damage of the dental roots or other structures adjacent to microimplant insertion site

Signature of the patient                                      Date        /           /201                                                    

Xin Wei, DDS, PhD, MS 1st edition 04/11/2010, last revision 09/28/2012