Fixed versus removable appliances

A woman in her late 50s with a large number of missing teeth sought advice from a dentist, a DDU member, about the possibility of dental implants and requested fixed upper and lower bridgework to improve her appearance, confidence and comfort. She was a heavy smoker with poor oral hygiene.

In view of concerns regarding the occlusal vertical dimension, bone loss (which was considerable) and that further soft tissue support would be required, the member counselled her against having fixed appliances in her upper and lower jaw. He also warned her that, given the particular clinical circumstances, a fixed upper bridge would affect her ability to speak naturally as air would pass below the bridgework. It was noted that speech was particularly important in her work.

Instead, the dentist recommended an upper implant-retained removable prosthesis with minimal palatal coverage to facilitate normal tongue-to-palate contact. This would require extraction of seven teeth, with the retention of the two canines in the lower jaw. These would be crowned and joined with a Dolder bar to which a removable cobalt-chrome partial denture would attach. Two pairs of implants would be needed in the patient's upper jaw, each pair connected by a Dolder bar which would hold a metal complete upper denture. The dentist advised that using implant and/or precision attachment retained conventional dentures would allow the considerable tissue loss to be restored with appropriate 'padding' of the gum work of the dentures.

The patient was still insistent that she wanted fixed, non-removable appliances in both jaws, even though the dentist explained that excessive bone loss, particularly in the upper jaw, would make implant retained fixed bridgework unfeasible.

Following discussion, the dentist referred her to a consultant oral and maxillofacial surgeon for a surgical opinion on the viability of placing implants. The surgeon acceded to the patient's request and outlined an alternative treatment plan which involved the insertion of eight implants in the maxilla and six in the mandible with a view to providing fixed bridgework in both jaws – considerably more implants than the dentist had originally envisaged. The patient opted for this plan; surgery took place and the implants were placed and temporary upper and lower dentures fitted.

After the healing phase, our member undertook the superstructure and the fitting of an upper removable implant retained full denture with minimal palatal coverage and considerable bulking of the flanges to replace lost tissue. Three fixed bridges were fitted in the lower jaw, supported on six implants.

A few months after the treatment had been completed, the patient returned to the dentist to complain that the retention clips on the Dolder bars clicked while she was eating. This was resolved by simple adjustment to the clips and to the occlusion. On examination, the dentist noted that some of the implants were now slightly loose and that the patient's oral hygiene was still very poor. He advised her again about this, but the patient wanted a second opinion as she still wanted fixed upper bridgework.

In fact, the patient consulted the maxillo-facial surgeon again to discuss replacing her upper removable prosthesis with an implant retained bridge. The patient was insistent and he agreed to carry out the procedure, which required a further three implants, leaving the dentist to arrange fixed bridgework. This was never done and the three extra implants were left as sleepers.

Nothing further was heard from the patient until nearly a decade later, several years after the dentist had retired.

The patient was then seen regularly by the member over a period of several years for maintenance, during which time nothing untoward was noted and the patient seemed happy with the result.

Nothing further was heard from the patient until nearly a decade later, several years after the dentist had retired, when the member received a letter from the patient's solicitors alleging he had failed to use reasonable care and skill in fitting the bridges and upper denture. The patient sought damages of up to £150,000 and also made a claim against the maxillofacial surgeon and two other dentists who had treated her after our member retired.

The MDU obtained expert opinions from a general dental practitioner and a consultant in restorative dentistry. The GDP expert was of the view that the dentist had used reasonable care and technical skill in fitting the superstructures on the implants inserted by the consultant oral and maxillofacial surgeon.  In his opinion, the slight mobility of the implants had caused the bridges to become loose but that the dentist had produced the best bridgework on the available implants, achieving a compromise design that the patient could keep clean with good oral hygiene.

The restorative dentistry expert was critical of the consultant oral and maxillofacial surgeon for deviating from the dentist's original treatment plan. He also criticised the decision to insert further implants when there were problems with those already placed. He had no criticism of the member's clinical management.

The DDU instructed its solicitors to send a detailed and comprehensive letter of response on behalf of the member, denying liability. The letter robustly defended each of the allegations, arguing that the failure of the implants was because of the patient's poor compliance with oral hygiene instructions and her poor motivation to maintain oral hygiene and stop smoking. In addition, these factors had increased her susceptibility to periodontal disease which had also contributed to the failure of the implants.

Six months later, the patient's solicitors discontinued the claim against the DDU member.

The member was delighted to retain his record of 45 years of DDU membership without a successful claim or a GDC investigation.

Taiye Omo-Ikerodah
Senior claims handler

This page was correct at publication on 04/12/2013. 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.