High smile

BACKGROUND: Mr B has long been dissatisfied with his "gummy smile" and attends the dental surgery to discuss possible cosmetic improvement. Dr P examines the patient and notes a high smile line with the upper lip 4mm above the gingival margins of the upper anterior teeth. A treatment plan is devised involving surgical crown lengthening around the patient’s upper ten teeth and then the provision of porcelain veneers.

The crown lengthening surgery is undertaken and the veneers are fitted a few months later. Mr B is pleased with the outcome but two weeks later he re-attends the practice complaining of bleeding gums and sensitivity in the upper right quadrant, with pain on biting. Dr P treats the cervical areas with a desensitising paste and reassures the patient that the pain will settle.

A few weeks later Mr B is back at the dental surgery with persistent pain and difficulty eating. Dr P discusses possible treatment options and it is decided to replace the veneers at UR45. However, over the next year, Mr B continues to suffer pain, bleeding and food packing.

Conservative treatment proving ineffective, Dr P carries out a gingivectomy on the patient in order to alleviate gingival inflammation. Mr B registers with a different dental practice and is later referred to a periodontal specialist.

Six months later a letter from solicitors is received by Dr P claiming negligence in his treatment of Mr B. The letter alleges that not only was the crown lengthening treatment inappropriate but the dentist also failed to inform Mr B of the benefit-versus-risk involved in the procedure. The same allegation is made in regard to the subsequent gingivectomy.

It is also alleged that the Dr P failed to refer Mr B for an opinion from a specialist periodontist.

ANALYSIS/OUTCOME: MDDUS commissions an expert report from a GDP and he observes that the reason for providing the crown lengthening surgery was to improve the length-to-width ratio of the teeth being treated by the placement of veneers, thereby improving the appearance of Mr B’s smile – thus it was an appropriate treatment to have offered for the outcome desired.

The expert also points out that there are very few risks associated with crown lengthening surgery, apart from a poor aesthetic result immediately post-procedure, transient tooth mobility if considerable periodontal bone is removed, and a risk of tooth sensitivity if the cementum is left exposed on root surfaces. The records show that Dr P removed very little periodontal tissue and that the purpose of the procedure was again to achieve an optimal aesthetic result. None of the other risks were applicable in this case and Dr P was therefore not negligent in failing to discuss them prior to treatment.

However, in regard to the gingivectomy, the expert points out that the records show that Dr P’s stated intention was to reduce the interdental papillae width and periodontal pocket depths. Nothing in the records show that Mr B had increased pocket depths or needed papillae width reduction, and it is probable that the gingival bleeding was associated with irritation at the veneer margins. The expert opines that Dr P should have advised the patient on adequate oral hygiene and/or the removal of the veneers adjacent to inflamed gingival tissue. He concludes that in these circumstances there was a breach of duty in providing a gingivectomy and that Dr P should have considered referral to a periodontal specialist. This lead to unnecessary bleeding and discomfort to Mr B subsequent to the procedure.

A decision is made by MDDUS to settle the case in agreement with the member.

KEY POINTS

• Ensure patients understand the risk-vs-benefit of procedures.
• Discuss relevant risks.
• Ensure treatment decisions can be adequately justified.
• Refer onwards when a case goes beyond your level of expertise.