Collection Two 2025 | South Africa
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As dentists we understand that we need to meet or exceed the aesthetic expectations of our patents when performing cosmetic dentistry. But what about those occasions when a tooth is not fundamental to a person’s appearance? What if the crown you place is aesthetically sound, but a patient refuses to accept it due to an overall dissatisfaction with their dental appearance? Or what if the patient complains about your care even before you’ve had the chance to deliver definitive treatment? In this case study we’re reminded that high quality work does not guarantee patient satisfaction, especially in patients who are predisposed to disliking the outcome of care.
Ms X, a lady in her mid-40s, was referred to Dr A for an opinion and treatment to her upper anterior teeth due to her concerns around their colour and shape. Her teeth from the 15 to the 25 had a history of cosmetic restorations over the past 20 years, initially in the form of direct composite resin veneers and then, within the past year, placement of indirect zirconia restorations. Ms X remained dissatisfied with those zirconia restorations and sought to have Dr A replace all or some of them using his expertise as a well-regarded prosthodontist. She already had in mind having porcelain veneers placed on the anterior teeth and new crowns on her premolars.
Dr A determined that Ms X’s anterior restorations were slightly too long, had an unfavourable cant to the right, and lacked aesthetic harmony with her remaining dentition, especially due to their opacious and unnatural shade characteristics and lack of characterisation. She also had moderate attrition consistent with self-reported parafunction. Dr A outlined these issues to Ms X and discussed options of leaving the teeth as they were and accepting that result, remodelling two teeth (21 and 23) only, or replacing all ten restorations, depending on Ms X’s budget and preferences. After further discussion, Ms X elected to proceed with replacement of all ten restorations so that her aesthetic issues could be addressed once and for all. A further appointment was booked for a second consultation, quotation and records.
Soon afterwards, Ms X developed pain in her right posterior segment and her new general dentist noted that tooth 16 was now abscessed; it was extracted the following week uneventfully.
Three months later, a further tooth began to cause Ms X discomfort. She was referred to an endodontist who diagnosed a likely necrotic pulp in tooth 14 and a necrotic 13 with symptomatic apical periodontitis. The endodontist also recommended replacing the zirconia crown on the 13 on completion of endodontic treatment to ensure a sound coronal seal.
Due to these new developments, nothing further occurred with Ms X’s cosmetic rehabilitation.
Dr A had not had any opportunity to assess Ms A’s teeth radiographically due to those records being scheduled for her second consultation with him, which had so far been postponed. Further, no restorative treatment had been commenced to address Ms X’s cosmetic issues.
Ms X presented to Dr A following completion of the root canal treatment on tooth 13 with a fractured zirconia crown in situ, requesting that this be replaced. Dr A advised he could proceed, subject to assessing the underlying tooth’s integrity and restorability. After refining the margins, he placed a temporary crown, with the view that the restorative treatment plan would then commence soon afterwards. He photographed the sections of the pre-existing crown and stored them at the patient’s request.
Ms X did not return for another three months, at which time she requested a full copy of her records and the stored crown fragments. At that visit she accused Dr A of losing her original crown fragments and substituting it with someone else’s crown, as to her mind the fragments felt heavier than before. She alleged that Dr A had digitally altered the crown images on file. She made no further appointments for her ongoing care.
Prior to the visit to collect her previous crown, Ms X had engaged a solicitor, who sent a request to Dr A for a report regarding the quality of Ms X’s previous dental treatment. Specific answers were sought, including Dr A’s opinion about whether the previous general dentist had removed too much tooth structure when preparing Ms X’s teeth. Dr A advised he would be unable to provide such answers until the existing restorations were removed and radiography conducted. He also advised that in the interests of ensuring an impartial opinion about her ongoing treatment, an independent report from another prosthodontist would be wise; this would mitigate any later allegations of a conflict of interest, while also preserving the integrity of the referring dentist’s relationship with him.
Soon afterwards, Dr A received a regulatory notification. In that notification, Ms X complained that Dr A had not cooperated with the release of her records, had substituted the crown fragments with another patient’s and hindered the progress of her seeking legal representation to resolve concerns about her previous dental care.
At this point, Dr A contacted Dental Protection for assistance. We assisted him with his submission to the regulator. Due to the high quality records he had made of his limited contact with Ms X, including his photographic records of her previous crown, no further action was deemed necessary and the allegations against him were successfully defended. No further contact has ensued from Ms X.
As dentists we understand that we need to meet or exceed the aesthetic expectations of our patents when performing cosmetic dentistry. But what about those occasions when a tooth is not fundamental to a person’s appearance? What if the crown you place is aesthetically sound, but a patient refuses to accept it due to an overall dissatisfaction with their dental appearance? Or what if the patient complains about your care even before you’ve had the chance to deliver definitive treatment? In this case study we’re reminded that high quality work does not guarantee patient satisfaction, especially in patients who are predisposed to disliking the outcome of care.
Ms X, a lady in her mid-40s, was referred to Dr A for an opinion and treatment to her upper anterior teeth due to her concerns around their colour and shape. Her teeth from the 15 to the 25 had a history of cosmetic restorations over the past 20 years, initially in the form of direct composite resin veneers and then, within the past year, placement of indirect zirconia restorations. Ms X remained dissatisfied with those zirconia restorations and sought to have Dr A replace all or some of them using his expertise as a well-regarded prosthodontist. She already had in mind having porcelain veneers placed on the anterior teeth and new crowns on her premolars.
Dr A determined that Ms X’s anterior restorations were slightly too long, had an unfavourable cant to the right, and lacked aesthetic harmony with her remaining dentition, especially due to their opacious and unnatural shade characteristics and lack of characterisation. She also had moderate attrition consistent with self-reported parafunction. Dr A outlined these issues to Ms X and discussed options of leaving the teeth as they were and accepting that result, remodelling two teeth (21 and 23) only, or replacing all ten restorations, depending on Ms X’s budget and preferences. After further discussion, Ms X elected to proceed with replacement of all ten restorations so that her aesthetic issues could be addressed once and for all. A further appointment was booked for a second consultation, quotation and records.
Soon afterwards, Ms X developed pain in her right posterior segment and her new general dentist noted that tooth 16 was now abscessed; it was extracted the following week uneventfully.
Three months later, a further tooth began to cause Ms X discomfort. She was referred to an endodontist who diagnosed a likely necrotic pulp in tooth 14 and a necrotic 13 with symptomatic apical periodontitis. The endodontist also recommended replacing the zirconia crown on the 13 on completion of endodontic treatment to ensure a sound coronal seal.
Due to these new developments, nothing further occurred with Ms X’s cosmetic rehabilitation.
Dr A had not had any opportunity to assess Ms A’s teeth radiographically due to those records being scheduled for her second consultation with him, which had so far been postponed. Further, no restorative treatment had been commenced to address Ms X’s cosmetic issues.
Ms X presented to Dr A following completion of the root canal treatment on tooth 13 with a fractured zirconia crown in situ, requesting that this be replaced. Dr A advised he could proceed, subject to assessing the underlying tooth’s integrity and restorability. After refining the margins, he placed a temporary crown, with the view that the restorative treatment plan would then commence soon afterwards. He photographed the sections of the pre-existing crown and stored them at the patient’s request.
Ms X did not return for another three months, at which time she requested a full copy of her records and the stored crown fragments. At that visit she accused Dr A of losing her original crown fragments and substituting it with someone else’s crown, as to her mind the fragments felt heavier than before. She alleged that Dr A had digitally altered the crown images on file. She made no further appointments for her ongoing care.
Prior to the visit to collect her previous crown, Ms X had engaged a solicitor, who sent a request to Dr A for a report regarding the quality of Ms X’s previous dental treatment. Specific answers were sought, including Dr A’s opinion about whether the previous general dentist had removed too much tooth structure when preparing Ms X’s teeth. Dr A advised he would be unable to provide such answers until the existing restorations were removed and radiography conducted. He also advised that in the interests of ensuring an impartial opinion about her ongoing treatment, an independent report from another prosthodontist would be wise; this would mitigate any later allegations of a conflict of interest, while also preserving the integrity of the referring dentist’s relationship with him.
Soon afterwards, Dr A received a regulatory notification. In that notification, Ms X complained that Dr A had not cooperated with the release of her records, had substituted the crown fragments with another patient’s and hindered the progress of her seeking legal representation to resolve concerns about her previous dental care.
At this point, Dr A contacted Dental Protection for assistance. We assisted him with his submission to the regulator. Due to the high quality records he had made of his limited contact with Ms X, including his photographic records of her previous crown, no further action was deemed necessary and the allegations against him were successfully defended. No further contact has ensued from Ms X.
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