Case study: Bone loss

BACKGROUND

A 58-year-old HR manager – Mr F – attends his local dental surgery complaining of a loose crown at UL1. The dentist re-cements the post crown without incident, noting that there is no evidence of root fracture.

Six months later Mr F moves for work and registers with a new practice. He makes an appointment with Dr W who undertakes a dental examination with bitewing and periapical radiographs. The dentist notes: Poor crown in situ UL1, recommend extraction and partial denture. Patient agrees.

An impression is taken for an immediate partial denture and two months later Mr F attends to have UL1 extracted. The post crown is removed but Dr W notes that the root is at gum level and difficult to grip with forceps. He drills a gutter around the root and elevators are applied. A sizable fragment of labial bone comes away with the root, leaving a large cavity. The partial denture is applied.

Mr F returns the next day for review and Dr W notes that the denture is sitting well but the aesthetics are poor with insufficient gum remaining to close the wound. He arranges for a further review in a month’s time when further healing has taken place.

Mr F attends the practice twice more, unhappy with the denture fit and the labial bony defect left by the extraction. Another dentist at the practice refers the patient to the maxillofacial unit at the local hospital trust. Mr F later undergoes bone augmentation at the dental hospital and is fitted with an implant by a specialist oral surgeon.

A claim for damages – including the implant cost – is lodged against Dr W alleging that he neglected to secure informed consent for the procedure and failed to provide an adequate standard of surgical treatment.

ANALYSIS/OUTCOME

MDDUS acts on behalf of Dr W in the case and instructs an expert oral surgeon to provide an opinion on the case. In his assessment of the clinical records the expert finds no written record of alternative treatment options discussed, such as re-root canal and new crown. Examining the preoperative radiographs the expert also finds no convincing evidence that extraction was even necessary.

In regard to the treatment itself, the expert opines that the loss of gingival tissue and buccal bone was on the balance of probabilities a result of Dr W’s failure to raise a muco-gingival flap and carry out the procedure with direct surgical access. Injudicious use of a dental elevator was also a likely cause of the bony fracture.

Given the unsupportive expert opinion MDDUS seeks to settle the claim with the agreement of the member.

KEY POINTS

• Ensure that patients give fully informed consent, with awareness of viable treatment alternatives including no treatment.
• Consider referral to a specialist for treatment that may be beyond your skill.