A nervous 25-year-old male attended a new dentist, requesting that all treatment be carried out under general anaesthetic. He had no relevant medical history to contra-indicate such treatment. Dental examination, including bitewing x-rays, revealed generally sound dentition with good bone support, though all third molars, and several other lower teeth, had been extracted.

Routine conservation was carried out under intravenous sedation and an appointment was arranged for the extraction of the grossly carious upper left second molar under general anaesthesia. Once the anaesthetist was happy for him to proceed, the dentist placed the forceps on the tooth, and, in view of the gross caries, applied gentle lateral pressure. There was an immediate loud crack, and the tooth became completely mobile. It was obvious that the tooth and the adjacent bone were only held in by the attached mucosa, which was dissected away until the tooth and the fractured maxillary tuberosity were removed. (Subsequent examination revealed the bone to be almost eggshell thin, and the extracted segment retained intact.)

After the patient had recovered from the anaesthetic, it was evident that there was still considerable bleeding from the soft tissues, and total haemostasis could not be achieved. Further appointments in the day were cancelled and the dentist, together with a colleague took the patient to a local oral and maxillofacial unit, where, under local anaesthesia, a consultant applied sutures to close the wound and arrest the haemorrhage. The patient was admitted, but discharged the following day. Subsequent out-patient visits showed eventual resolution of the postoperative swelling and the patient made a complete recovery.

Negligence alleged

The patient brought a claim against the dentist and made the following allegations:

He had failed to warn the patient of the possible complication fracture of a fracture of the tuberosity
He had not taken a periapical X-ray to assess any possible complications
The tooth and tuberosity should have been removed more carefully when it was dissected from the mucosa, and sufficient mucosa should have been left to seal the wound
Following the fracture, the tooth and tuberosity should have been left in position to help plug the bleeding area

Expert opinion

Detailed expert opinion on the treatment was sought on behalf of the
dentist. The expert's report included the following statements:

"Fracture of the maxillary tuberosity during extraction of teeth is a well-recognised phenomenon that usually occurs out of the blue...I believe that (the dentist) took the only course open to him when this unexpected complication of dental extraction occurred. I suggest that he should be defended."

The Dental Advisory Committee agreed that the claim should be defended.

To substantiate the expert's report from the perspective of general dental practice, further expert opinion was sought from a dental practitioner. Another lengthy and detailed report included the following observations:

In a routine extraction of a posterior molar, it is not normal to warn a patient of this possible complication
It is not normal practice to take a periapical X-ray before such an extraction unless an isolated upper molar is being extracted, or there is a previous history of difficult extractions or postoperative haemorrhage
With the patient under a general anaesthetic, it would have been extremely difficult during the dissection of the fractured segment to have ensured that sufficient mucosa was retained to seal the wound
As the tooth could not be saved it would have been impractical to leave it in place as suggested, it would have posed a risk of infection from the carious tooth to the surrounding tissues

Case set down for trial

The dentist was particularly keen that his actions should be defended. As the patient's expert continued to support the allegations, the case was set down for trial, and the DDU's solicitors instructed counsel to represent the dentist. The trial started just before lunchtime on the Wednesday, and finished during the Thursday afternoon. The judge appeared to rely heavily on the expert report presented by the general dental practitioner.

Outcome

Immediately the closing speeches had finished, the judge delivered his judgement, finding that there was no evidence of negligence on the dentist's behalf. The dentist had always believed that he had acted in the very best interests of his patient. The knowledge that eminent experts in his own field were available to advise and support him has enabled him to continue his practice unchanged.

Unexpected complication of dental extraction

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