Frenectomy Consent Form

  • After a thorough oral examination, Dr. Mason has advised me that the reduction of a frenum(s) attachment in my child’s mouth may help to restore anatomy, function, and/or possibly prevent commonly associated future problems.

    Recommended Treatment: In order to treat this condition, Dr. Mason has recommended that a frenectomy be performed at the selected site(s):

  • A soft tissue laser will be utilized and is FDA approved for soft tissue surgery. Soft tissue lasers tend to lessen discomfort during treatment and recovery.

    Patient safety: I understand that a swaddle blanket may be used to gently ensure my child’s safety during the frenectomy procedure (applies to infants only). Nitrous oxide and mouth props will likely be utilized for older children. Protective eyewear must be worn by all people present in the treatment room, including my child. I understand all of the previous are for my child’s safety.

    Principle complications: I understand that a smooth recovery is expected, however, there are always associated risks that cannot be eliminated and may occur in a small number of cases. These complications include but are not limited to post-surgical bleeding, infection, swelling, pain, damage to adjacent structures such as salivary glands, nerve, muscle, and skin. Such complications may require care from an additional healthcare provider such as an oral surgeon. A common complication is re-attachment of the frenum. Genetics also plays a strong role in healing, such as the formation of a scar, keloid, or overt fibrous tissue formation.

    Post- op care and follow up: I understand that I must follow the daily therapy exercises instructions for up to 21 days to lessen the risk of frenum reattachment. I am advised to return for a one-week post-op to evaluate healing of the frenum area.

    Photos: Pre-op and post-op photos may be taken for documentation and insurance purposes, but not of the face without permission.

    Alternatives to suggested treatment: I understand that alternatives to a frenectomy include: no treatment, with the expectation that the frenum does not normally improve with age but may aggravate the surrounding tissues including the gums and teeth. Also, an alternative to a frenectomy by my dentist is to seek the care of another healthcare professional, including but not limited to doctors of general dentistry, periodontics, oral surgery, ENT, and plastic surgery. The use of the laser itself can be deferred to more traditional instruments of care.

    No warranty or guarantee: I hereby acknowledge that no guarantee, warranty or assurance has been given to me that the proposed treatment will be successful. I do expect however that Dr. Mason will perform the surgery to the best of her ability.

    I certify that I have read and fully understand this document and all my questions were answered.

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