After a thorough oral examination, Dr. Schalk 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.
In order to treat this condition, Dr. Schalk has
recommended that a frenectomy be performed at the selected site(s):
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. I understand all of the previous are
for my child's safety.
I understa nd 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 reattach want of
the frenum. Genetics also plays a strong role in healing, such as formation of scar,
keloid, or overt fibrous formation.
Post-op care and follow up:
I understand that I must follow the daily therapy
exercise instructions for 10-14 days to lessen the risk of frenum re attachment. I am
advised to return for 1 week check, and a 3 week check to evaluate healing of the
Pre-op and post-op photos may be taken for documentation and
insurance purposes, but not of 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.
No warranty or guarantee:
I hereby acknowledge that no guarantee, warranty or
assurance as been given to me that the proposed treatment will be successful. I
do expect however that Dr. Schalk will perform the surgery to the best of his
I certify that I have read and fully understand this document and all my
questions were answered.