Louvre Dental in Paris & Brantford | Your Paris & Brantford Dentist

Informed Consent for the Orthodontic Patient
Father/Mother/ Husband’s Name:

As a rule, excellent orthodontic results can be achieved with informed and co-operative patients. Thus, the following information is routinely supplied to anyone considering orthodontic treatment in our center. While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has some inherent risks and limitations. These are seldom enough to contra-indicate treatment, but should be considered in making a decision to start orthodontics. Please feel free to ask any questions during the treatment.

  1. The patient’s responsibility:
  2. It is the patient’s responsibility to follow the brushing and oral hygiene instructions that are given, so that no harm will come to the teeth and surrounding tissues; to come to all appointments on the proper day and time; to adhere to the list of food restrictions in order to keep from damaging the teeth and orthodontic appliance; to wear headgear, elastics and retainers, if they are necessary, so that treatment time will be as short as possible and so we can achieve the best results; and to visit the our center at least every six months for an examination and cleaning. There will be additional orthodontic charges for replacement of appliances (such as retainers or braces) that are lost or damaged due to repeated patient neglect, or any excessive extension of treatment due to lack of patient co-operation. 100% patient co-operation is very, very important.

  3. Oral hygiene:
  4. Decalcification (permanent markings), decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly during treatment period. Excellent oral hygiene and plaque removal is a must. Sugars and between meal snacks should be reduced as much as possible. Visit our center or any general dentist regularly or as and when required for general examination.

  5. A non-vital or dead tooth is a possibility:
  6. A tooth that has been traumatized from a deep filling or even a minor blow can die over a long period of time with or without orthodontic treatment. An undetected non-vital tooth may flare up during orthodontic movement, requiring endodontic (root canal) treatment to maintain it.

  7. Root resorption:
  8. In some cases, the root ends of the teeth are shortened during treatment. This is called root resorption. Under healthy circumstances the shortened roots are no disadvantage. However, in the event of gum disease in later life the root resorption may reduce the longevity of the affected teeth. It should be noted that not all root resorption arises from orthodontic treatment. Trauma, cuts, impaction, endocrine disorders, idiopathic reasons can also cause root resorption.

  9. Growth issues:
  10. Occasionally a person who has grown normally and in average proportions may not continue to do so. If growth becomes disproportionate, the jaw relation can be affected and original treatment objectives may have to be compromised. Skeletal growth disharmony is a biologic process beyond the Dentist’s control. Some orthodontic patients will require oral surgery to obtain a reasonable treatment result to complete their case. Most patients we can inform ahead of time prior to starting any treatment that this is necessary. Some patients with poor growth, poor response to treatment, or poor co-operation may also require oral surgery to complete their cases.

  11. Gum tissues:
  12. The bone-gum relationship around teeth is always dependent upon whether there is enough bone to support the gum tissue properly. Many times when very crowded teeth are straightened there is a lack of bone and supporting gum tissues surrounding the teeth. Therefore, the gum tissue contour and support may not be adequate and require periodontal intervention.

  13. Treatment time:
  14. The total time for treatment can be delayed beyond our estimate. Lack of, or poorly directed facial growth, poor elastic wear, or headgear co-operation, broken appliances and missed appointments are all important factors that could lengthen treatment time and affect the quality of the result.

  15. Extra-oral appliances:
  16. Instructions must be followed very carefully. A Facebow or Headgear that is pulled outward while elastic force is attached can cause damage to the face or eyes. However, we use appliances with a safety feature to reduce this possibility. Always remember to release the forces before removing the facebow from your teeth. To reduce the possibility of injury, contact sports and similar activities should not be performed while a headgear is worn.

  17. TMJ:
  18. There is a risk that problems may occur in the temporomandibular joints (TMJ). Although this is rare, it is a possibility. Tooth alignment or bite correction sometimes can improve tooth related causes of TMJ pain, but this is not in all cases. Tension appears to play a role in the frequency and severity of joint pains, and there are many other causes of TMJ dysfunction.

  19. Very unusual occurrences:
  20. Swallowed appliances, chipped teeth, dislodged restorations and allergies to latex or nickel rarely occur but are possible.

  21. Termination of treatment:
  22. It is understood that treatment can be terminated for failure to cooperate, missing appointments, not wearing appliances, excessive breakage, failure to keep financial commitments, relocation, personal conflicts or for any other reason the doctor feels necessary. If termination is necessary, the patient will be given ample time to locate another dentist to continue treatment or the braces will be removed.

  23. Expectations:
  24. All orthodontic patients can expect improvement with their particular problem, but, in many cases, absolute perfection is impossible due to lack of muscle balance, tooth shapes and sizes and varying degrees of co-operation during treatment, along with heredity aspects that affects everyone’s specific treatment results.

  25. Relapse:
  26. Teeth have a tendency to return to their original position after orthodontic treatment. This is called relapse. Very severe problems have a higher tendency to relapse and the most common area for relapse is the lower front teeth. After band removal, a positioner or retainers are placed to minimize relapse. Full co-operation in wearing these appliances is vital. We will make our correction to the highest standards and in many cases over correct in order to accommodate the rebound tendencies. When retention is discontinued some relapse is still possible.

  27. Discomfort
  28. 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.

  29. Extractions
  30. 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 us prior to the procedure. The treatment plan could start with or without extraction ,but during treatment we should reassess and we might decide to extract one or more than one tooth; the patient will be informed about the possibility of this point ASAP.

  31. Orthognathic Surgery:
  32. 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. 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.

  33. Nerve Damage
  34. 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.

  35. Injury From Orthodontic Appliances:
  36. 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 us 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 esthetic (clear or tooth coloured) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by us may be necessary.

  37. Non-Ideal Results:
  38. 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 esthetic bonding, crowns or bridges or periodontal therapy, may be indicated. 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, or typical teeth and jaw midline without deviation or shifting) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges or periodontal therapy, maybe indicated.

  39. Allergies
  40. 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 maybe necessary.

  41. General Health Problems:
  42. 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 dentist of any changes in your general health status.

  43. Use of Tobacco Products:
  44. 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 treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

  45. General:

We shall not be responsible if during treatment you opt for or takes any other opinion with another clinic about the treatment as we have our own treatment plan and can differ from other treatment plans. In such case, we will not be able to refund any of the fees duly paid. Further, the cost of treatment can differ from another clinics and this could be related to the complicity of the case, the appliance used, the treatment plan and needed time, also we will be not able to refund if another clinic pretends that the cost of our treatment is high. This is pure organisational policies and you, by signing the present consent form, duly acknowledge the aforesaid averments.

Further, if the patient decides to travel or to continue his/her treatment in another clinic, we will provide him a report, the treatment plan should be followed and the appliance used will stay, and it will be the patient responsibility if the other clinic decides to change the treatment plan or the orthodontic appliance. In any case, there shall not be any provision for refund of any fees duly paid against the treatment done.

Further, it will be the patient responsibility if he/ she decide to get removed part of the orthodontic appliance (for example removing lower appliance and keep the upper or the opposite) in such cases, we cannot ensure that the treatment plan and the results expected will be the same and hence, there shall not be any provision for refund of any fees duly paid against the treatment done.


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 dentist(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 dentist(s) indicated below to provide the treatment. I also authorize the dentist(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 dentist(s), and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment. I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment and I fully understand all of the risks associated with the treatment.

Dr Kifah Alyassin Alyassin ,General dentist DDS ,doctor of dental surgery/university of Alberta

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Guardian (in case of minor patient)
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Possible extraction of 4 permanent teeth during or before the orthodontic treatment starts, sometimes needed to improve the upper and lower teeth relation or their angulation which is related to the soft tissue profile (face from side view)
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