, Cosmetic Bonding


Medway Smile – Consent Form

    Cosmetic Bonding

    Informed Consent For Composite Cosmetic Bonding

    I understand that cosmetic bonding treatment may entail certain risks and possible unsuccessful results, with even the possibility of failure to achieve the results which may be desired or expected. I agree to assume those risks, possible unsuccessful results, and/or failure associate with, but not limited to the following: (Even though care and diligence is exercised in this subject treatment, there are neither guarantees of anticipated or desired results nor the longevity of the treatment).

    I confirm that I am happy with the colour of my current teeth and do not wish for further whitening treatment to go any lighter. I understand that composite bonding is irreversible, once it is attached to the tooth it is very difficult to establish the junction between the filling and the tooth. If you have been recommended straightening prior to bonding, the bonding will need to be removed and then completed again post straightening which will not be included in the cost.

    1. Reduction or roughening of tooth structure: In making preparation of teeth for the reception of composite bonding, it is necessary to slightly reduce or roughen the surface of the tooth to which the material may be bonded. This preparation will be done as conservatively as possible. If the veneer/bonding covering breaks or comes off, the uncovered tooth may become more susceptible to tooth decay. The tooth may require replacement with a porcelain veneer or porcelain crown.

    2. The sensitivity of teeth: Even though there is usually no appreciable sensitivity, this type of treatment may cause teeth to become sensitive. Should sensitivity occur and persist for any length of time, please contact this office for an examination. After being complete the tooth may develop a condition known as pulpitis or pulpal degeneration. It is often necessary to do root canal treatments in these teeth.

    3. Chipping, breaking or loosening of the composite: No matter how well done, this could occur. Many factors may contribute to this happening such as: chewing of hard materials; changes in occlusal (biting) forces; traumatic blows to the mouth; break down of the bonding agents; and other such conditions over which a doctor has no control.

    4. Aesthetics and appearance: Every effort possible will be made to match and coordinate both the form and shade of the bonding which will be placed in order to be cosmetically pleasing to the patient. However, there are some differences that may exist between the natural dentition and the materials which are artificial, making it impossible to have the shade and/or form perfectly match your natural dentition.

    5. Longevity: it is impossible to place any specific time criteria on the length of time that bonding should last for. These time periods may vary from a very short time to a very long time depending upon many conditions existing from patient to patient, and/or upon each patient’s individual habits or circumstances, which may be either internal, external or both. Additionally, general health, good oral hygiene, regular dental check-ups, diet, etc, can affect longevity. I understand that cosmetic composite bonding discolours, and this is dependent on aftercare (e.g. diet, hygiene, and the rate of staining of my teeth

    It is the patient’s responsibility to immediately inform the dentist and seek attention from him/her should any under or unexpected problems occur, or if the patient is dissatisfied. Also, all instructions must be diligently followed, including scheduling and attending all appointments.

    1 Year Guarantee includes any fracture of composite veneers/ bonding but does not include, failure due to underlying tooth fracture, secondary decay, trauma or accidental damage or fracture caused by inappropriate use (opening bottles) or de bonding (loosening) or subsequent need for root canal treatment. The guarantee is only valid for patients who attend March Dental Surgery bi-annually for examination and hygiene appointments, to ensure there are no aggravating factors, gum disease, excessive force or plaque, and food trapping. You also have followed our recommended preventative dental treatments and maintenance, including if advised wearing a bite splint/guard at night where the dentist detects a history of grinding and/or clenching.


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