Long tooth

BACKGROUND

Mr T is 58 years old and attends his dental surgery complaining that a front tooth (UR2) feels loose and painful. A few months previous he had a bicycle accident and sustained a facial injury but did not attend for dental treatment.

A clinical and radiographic examination reveals UR2 is grade III mobile and has a fractured root, with some associated infection and bone loss.

The patient is referred to an oral surgeon, Dr M, who discusses the treatment options, which include extraction with the provision of a temporary denture to allow healing followed by definitive restoration of the space with a permanent denture, bridge or implant-retained crown. Mr T opts for extraction with an implant and crown.

Impressions are taken for preparation of a temporary denture for placement when the tooth is removed. Dr M notes that the patient has a slightly high lip line and shows some gum when he smiles.

Three days later Mr T attends the practice for confirmation of the treatment plan. UR2 will be removed with curettage to allow bone augmentation. Dr M explains again the alternatives to implant treatment and also possible risks and complications, including implant failure. Mr T signs a written consent form including his preferred treatment option plus risk and benefits of this treatment modality.

Two weeks later Mr T attends for the procedure and UR2 is extracted and a temporary denture placed. He is reviewed a number of times and the socket is found to be healing well. Six weeks after the extraction the patient reattends the surgery for placement of the implant at UR2. A flap is raised and Bio oss is applied to augment the bone and the implant placed.

Five months later the UR2 implant is exposed and a healing abutement placed, and three months after that a cement-retained crown is fitted.

A follow-up appointment is arranged and Mr T complains that the crown at UR2 is longer than the rest of his front teeth and looks odd, especially given his high lip line when smiling. Dr M reassures him that it is not noticeable but Mr T leaves the practice unhappy.

Two weeks later Dr M receives a letter of claim from solicitors acting from Mr T claiming clinical negligence.

It is alleged that Dr M failed to use reasonable skill and care in the assessment, diagnosis and treatment planning of the provision of implant at UR2. In particular, it is claimed that he failed to adopt a prosthetic-led, top-down approach with consideration of desired outcomes by means of pre-operative photographs, articulated study models, occlusal analysis and diagnostic wax ups.

In addition, it is claimed there was no adequate assessment of bone volume, height, width, depth, density and quality with diagnostic imaging and that the bone loss present contraindicated fixture placement without extensive bone grafting. The letter further claims that a phased placement process of bone augmentation with block/particulate grafting with an adequate a period of healing, reassessment and implant placement would have provided a more clinically acceptable outcome both functionally and aesthetically.

It is alleged by Mr T that adequate skill and planning would have resulted in an acceptable aesthetic outcome and avoided the need for future bone grafting and reimplantation at UR2.

ANALYSIS/OUTCOME

An MDDUS dental adviser reviews the case along with a lawyer. An expert opinion is obtained from a specialist in restorative dentistry who comments on each of the allegations.

She concludes that a full clinical examination was undertaken in relation to the surgical placement of the implant in the UR2 region. She advises that she does not consider that it was mandatory to carry out pre-operative photographs, articulated study models, occlusal analysis and diagnostic wax ups for a single tooth implant bounded on both sides by sound unrestored teeth. Accordingly, she concludes that Dr M complied with his duties in terms of treatment planning.

The records show that bone height, volume, width and depth were adequately assessed by preoperative X-rays and CBCT (cone-beam computed tomography) and the expert concludes that there was sufficient bone to place an implant.

In his personal statement Dr M says it is his usual practice to go through all of the possible complications and risks with each patient. The records clearly indicate that Dr M discussed the high smile-line and thin gingival biotype in relation to the risk of a longer tooth as an outcome. Mr T agreed to the treatment plan that was undertaken and the expert concludes there was no breach of duty by Dr M in this regard.

An MDDUS lawyer drafts a letter of response in which liability is denied and the case subsequently discontinued.