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									CASE REPORT

S Claimant -VDR RAYMOND KAPLAN Defendant

Background On 28 May 2004 the Claimant first attended upon the Defendant seeking long term treatment to improve his cosmetic appearance and fix the space between his teeth in the lower left corner of his mouth. Discussions took place about how to fill the space in the Claimant s mouth at LL6 and the Defendant advised the Claimant that an implant or a bridge were the options available to him. The Claimant opted for an implant and told the Defendant that he wanted the implant to sit on the gum to look like the other teeth. On 21 July 2005, the Claimant was sedated and the Defendant fitted the implant. Unfortunately the implant came out at an angle sticking out at the side of the gum near to the Claimant s tongue. There was an extra piece of artificial material on the side of the gum attaching the implant to the artificial tooth which was rough and uncomfortable. The cosmetic appearance of the false tooth however was satisfactory. The Claimant informed the Defendant that he could not live with the uncomfortable feeling provided by the new tooth. The Defendant advised him that he had to insert the post at that angle due to previous bone loss. By October 2005 the Claimant could no longer eat or chew on the left side of the mouth. He explained to the Defendant that he was not happy but the Defendant told him that it was simply an occlusal problem. The Claimant re-attended in December but saw the Defendant s colleague, who advised him to see the Defendant again. The Claimant therefore saw the Defendant again on 9 January 2006 and indicated that he was still not happy and wanted the Defendant to do something about it. The Defendant indicated that all he could do was take off the artificial tooth and install a bridge from LL5 to LL7 on top of the implant. As the Claimant insisted that he could not live with the extra piece hanging over his tongue, the Defendant said that he would provide a bridge free of charge. The bridge was subsequently fitted on 30 January 2006.

Immediately following the fitting, the Claimant did not feel comfortable and could not bite down on the bridge without feeling extreme pain. On 7 March 2006 the Claimant attended the Defendant s Practice and was seen by the Defendant s colleague, complaining of pain in the lower left side of his mouth. A radiograph was performed which appeared to demonstrate radiolucency at LL7. On 17 March 2006, the Claimant went back to see the Defendant, who concluded that the Claimant s problems emanated from his bite. He examined the radiograph performed on 7 March and concluded that there was no need for root canal treatment of LL7 and that the radiograph did not show any evidence of radiolucency. The Claimant was subsequently away in Dorset working on a contract but returned to London in early October 2006. By this stage the LL7 had become unpleasantly symptomatic with a smelly discharge and the whole of the left side of his face was swollen. He attended a local dentist in Paddington, who removed the bridge and informed him that it was infected. The Claimant was given strong antibiotics which took 3 weeks to clear the sepsis and approximately 3 weeks later root canal treatment was commenced. The Claimant was unable to work during this 3 week period due to the extent of the infection, pain and swelling. The Claimant was referred for implant treatment and was then referred again for the root canal treatment of LL7 to be completed. The symptoms abated thereafter and the temporary bridge was replaced. Further treatment was then required for the removal of the implant to build up the bone and then to place another implant. Repairs to LL5 and LL7 will also be required and the process will take about 4 months to complete with an additional week of severe pain and suffering following removal of the metal pin.

Claimant s Case A letter of claim was sent to the Defendant on 13 November 2007.

Breach of Duty

It was the Claimant s case on breach of duty that he had received negligent treatment from the Defendant. The principle allegations of negligence were: 1. The Defendant failed to obtain proper consent to the implant treatment. written consent form was provided to the Claimant nor was one signed. No


The Defendant failed to inform the Claimant properly of the nature of the treatment proposed and the risks involved with it. In particular he failed to inform the Claimant that because of his bone loss it would be necessary to place the implant at an angle in order to ensure the maximum degree of osseo-integration. In addition he failed to inform the Claimant that he intended to use an implant of a smaller diameter than usual, and failed to warn the Claimant that the use of a narrower implant would make the care more complex and the long term success rate of the implant would be thereby reduced.


The Defendant placed the implant incorrectly. The implant is in fact emerging on the lingual aspect of the gum below the LL6 pontic. It would have been quite clear to the competent practitioner that any crown placed on this implant would also be at the wrong angle. In addition the implant was placed too supragingivally and because of the angle any crown placed on the implant would be too far lingually placed so that it would protrude towards the gum and interfere with freedom of tongue movement.

Causation It was the Claimant s case on causation that as a result of the above negligence the Claimant underwent significant pain and suffering. He had an implant in place at an uncomfortable angle and suffered further unnecessary treatment including placement of a bridge and the unnecessary destruction of two perfectly good teeth. As a consequence of the placement of the bridge the Claimant developed an infection at LL7 and subsequently required root canal therapy on LL7 and treatment to LL5. Had the original implant placement by the Defendant been of a competent standard then the treatment to LL5 and LL7 would have been unnecessary. The Claimant requires further treatment including the removal of the implant, bone grafting and the placement of a further implant and thereafter placement of an abutment and a crown.

Defendant s Case In a letter of response dated 1 February 2008, the Dental Protection, on behalf of the Defendant admitted liability and confirmed that breach of duty would not be an issue and that the breach caused the Claimant harm. However, in a letter dated 7 February 2008, the Defendant denied that the Claimant was entitled to a refund of the fees paid for the original treatment, together with the cost of replacement implant treatment. Furthermore, it was

denied that the Claimant was entitled to the cost of replacement crowns, and argued that these would have been required in any event. Whilst the claim was being investigated, the Claimant received notification that the General Dental Council was investigating the Defendant. In December 2007 the Council found the Defendant s fitness to practice to be impaired and he was reprimanded at the hearing.

Claimant s Expert Opinion Dr Anthony R. Halperin Dental Surgeon

Dr Halperin noted in his report that full consent was not given for the treatment carried out. In addition, Dr Halperin was of the opinion that the position of the implant was incorrect and it was clear from the evidence that this implant was unsatisfactory. Dr Halperin stated that it would appear that the implant was placed too supra gingivally and because of the angle, any crown placed on the implant would be too far lingually placed. Dr Halperin concluded that in the placement of this implant in the LL6 region, the Defendant fell below an acceptable standard of care. In regard to causation, Dr Halperin was of the opinion that because of the poor angle of the implant for LL6, the Defendant has been unable to place a crown on this tooth. Furthermore, the root canal treatment subsequently required on LL7 would have been avoided had the implant on LL6 been placed in an appropriate position and a crown placed thereon. Dr Halperin concluded that treatment to LL5 and LL7 was unnecessary and flowed from the original poor implant placement by the Defendant.

Settlement On 13 November 2007, the Claimant made a Part 36 offer to settle at the sum of £25,079.43 conditional upon payments of costs to be assessed in default of agreement. On 1 February 2008 the Defendant rejected the offer and on 7 February 2008 made a counter offer of £15,000.00. The Claimant subsequently made a further offer of £21,595.90 on 11 February 2008, which was rejected by the Defendant on 11 March 2008 with a counter offer of £16,500. The matter was eventually settled on 18 March 2008 when the Defendant agreed to pay £17,000 together with reasonable costs in satisfaction of the claim.

Outcome/damages The Claim against the Defendant was settled on 18 March 2008 when the Defendant accepted the Claimant s offer of £17,000.00 together with reasonable costs in full and final settlement.

Total Damages:


Solicitor for the Claimant:

Simon Elliman, Partner Withy King Solicitors Bryer Ash Business Park Bradford Road, Trowbridge BA14 8AW Telephone: 01225 777464 Email: David Hards, Senior Claims Advisor Dental Protection 33 Cavendish Square, London, W1G 0PS Telephone: 020 7399 1400 Email:

Acting for the Defendant:

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