Complex cleft palate

The scene

 Over the years, she had undergone treatment to improve the appearance of the upper anterior region, including adhesive bridgework to replace upper lateral incisor teeth, and a veneer at UR1. Some time later, she began to experience symptoms with the UR1.
The patient was not happy with the treatment she had received at her dental surgery and instead attended our member's practice. The member noted her dental history, and her complaint that UR2 adhesive bridge pontic felt delicate and mobile. The member obtained scanning and periapical radiographs, and noted the prognosis of UL1/ UR1 to be poor due to reduced bone support and internal resorption at UR1. The patient's lip line was noted as showing gingivae on smiling - possibly due to scar shrinkage on the cleft repair.

The dentist considered extraction of the UR1 and UL1 and implant replacement of UR2 and UL2 to enable provision of an implant retained bridge replacing all upper incisor teeth.

The dentist's colleague examined the patient and confirmed the poor prognosis of UL1, which had reduced alveolar bone support, and suggested a CT scan for bone quality. An orthodontic specialist colleague to whom our member referred before starting the intended treatment agreed that the UL1 had a compromised prognosis.

Our member removed the patient's existing adhesive bridges and extracted the UR1/UL1. One month later, the member noted that the UL1 was healing with considerable deficiency and would require a bone graft. The bone in UR2 and UL2 regions was also noted as insufficient. Following referral for further orthodontic consultation, the orthodontist decided in view of the complexity of the case to refer the patient for a second opinion at her local hospital, where she later underwent bridgework to replace UR12; UL12 and orthodontics for the lower arch.
Almost two years after our member last saw the patient, he received a letter of claim naming him as the sole defendant.

The outcome

The claimant alleged several breaches of duty on the part of our member, including failure to use reasonable skill and care in assessment, diagnosis and treatment planning for the UL1; failure to recognise the impact of the patient's Class III malocclusion, and failure to appreciate the complexity of the restorative treatment proposed. The claimant alleged that the dentist should have considered retaining the UL1 and the existing adhesive bridges in UL32; UR23, while extracting the UR1 and replacing it with an adhesive restoration utilising the UL1 as abutment.
The claimant alleged that had our member adequately advised her regarding appropriate treatment, then on the balance of probability she would have avoided extraction of UL1, would have undergone extraction of the UR1, and had a small adhesive bridge UR1; UL1. She would then have avoided the replacement bridgework and orthodontic treatment to the lower jaw.

The DDU obtained an expert opinion from a general dental practitioner. His report was generally not supportive of the member's treatment. He stated that while the member's treatment plan may have been suitable in the long term, he was critical of the extraction of the UL1 and the removal of the adhesive bridge replacing the UR2; UR1. He added that the UR1 had been properly removed and the resulting space could have been easily managed. Any further treatment to the UL1 or the adhesive bridges could have been delayed until a final treatment plan had been devised.

Finally, the expert stated that he believed placing implants where there had been a cleft, missing teeth and need for orthodontic treatment was not ideal. He concluded that the member should not have extracted the UL1 and removed the bridges at UL23; UR23.
The member was anxious that the DDU should try and settle the matter amicably without admitting liability. An offer was made for general damages including pain and suffering and loss of amenities. For special damages for any further surgery required, the DDU agreed the cost of extraction of the UL1, the consultation and the denture, but did not accept the claim for the cost of future replacement of the four unit bridge. The DDU also argued that even if the member had not removed the claimant's pre-existing bridges, the patient would have needed future replacement in any case and this was not as a result of any alleged claim against the member. The claim was settled for over £2,500 for general and special damages plus costs of over £6,000.

This page was correct at publication on 22/12/2010. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.