Bridging the gap

18 November 2019

Mrs R attended Dr A’s practice to discuss treatment options to restore her upper arch. She had lost a number of teeth in the buccal segments, as well as the 22, and the remaining anterior teeth were discoloured and heavily restored. The existing partial denture was worn and ill-fitting on account of recent tooth loss.

Options were discussed and a plan was agreed, including placing three upper implants and restoring the arch with a course of treatment involving crowns and bridgework. The patient was pleased with the prospect of being able to replace the partial denture with implant supported bridgework. The treatment was to include six crowns (13 12 11 21 23 26) as well as a further implant-supported crown to replace the 22, a cantilever implant-supported bridge at the 25 with a pontic at the 24, and a four-unit bridge supported by implants at the 17 and 14. 

Dr A referred the patient to his colleague Dr B with a request to carry out the necessary assessment and to place implants at 17, 14, 22 and 25. In the meantime, the large restorations in the remaining teeth were investigated and replaced, as required by Dr A, to form a stable basis for the proposed crowns. A temporary denture was constructed, pending the completion of the definitive treatment.

On receiving the referral, Dr B duly saw and assessed the patient. The relevant investigations were carried out to ensure the feasibility of the implants requested and arrangements were made for the patient to attend for treatment. The four implants were placed, under sedation, at the same appointment. The procedure was uneventful. Aside from some transient discomfort in the immediate postoperative period, the patient reported no major concerns or complications after the surgery. 

The patient was discharged back to the care of Dr A to proceed with the restorative phase.

Once the healing was complete, Dr A commenced the crown and bridge treatment. During this, the patient reported problems “with the gum” around the temporary bridge and also occasional, poorly localised pain on the left side. There were plaque accumulations around the implant sites and temporary crowns so Dr A emphasised the need for meticulous oral hygiene. The final bridgework and crowns were eventually fitted by Dr A after some remakes and adjustments were carried out.

The patient experienced ongoing problems with the four-unit bridge and some months later sought a second opinion from Dr C, who advised the patient that the supporting implants were failing and recommended removal. The patient wrote to Dr A to demand a full refund for the treatment she had received from him and Dr B. Dr A then discussed this with Dr B before both dentists sought assistance from Dental Protection.

The patient’s records were carefully reviewed to arrive at an accurate understanding of the situation. It was not immediately obvious that there had been any issue with the original implant placement. The records of Dr A and Dr B were sparse in places. There was insufficient information to indicate that valid consent had been obtained, including the discussion of risks associated with the treatment. The findings of Dr C suggested that the occlusion and bridge design may have contributed to the failure.

The patient was clearly disappointed that the bridge had failed and was keen to have this replaced. After seeking advice, both Dr A and Dr B agreed to accommodate the patient’s straightforward request for a refund of the cost of the failed implant-retained bridge, to prevent any further escalation.

Learning points

  • It is not always possible to establish the primary cause of implant failure, which can be multi-factorial. An implant may fail because of issues with the implant itself, the placement technique or factors connected to the restoration. The possible contributory causes need to be assessed before a decision can be made about how to manage the situation. Each case must be judged on its merits.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits Dental Protection members enjoy as part of their subscription. 
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