Cosmetic dentistry is one of the fastest-growing areas of general practice. With patient demand comes pressure, especially when deadlines such as weddings or major life events are involved.

The case 

A young dentist, two years out of university, saw a new patient who was getting married in three weeks and told the dentist she wanted “new teeth”. The dentist, keen to help the patient in time for her big day, wanted to deliver a rapid aesthetic result and so discussed the options of whitening, veneers, and crowns or referral to a specialist. The patient chose to go ahead with crowns and veneers with the dentist, for who this would be his first ‘big case‘.

Rather than taking a more conservative approach, the dentist opted to provide the patient with crowns and veneers on all her teeth – 28 crowns and veneers in total, on teeth that were otherwise healthy, vital, and pathology-free. 

In the rush to meet the deadline, essential steps were skipped. The planning phase was minimal; x-rays were not diagnostic, and no wax-ups, smile design, or occlusal analysis was completed. Critically, the dentist didn’t make note of any conversations he had had with the patient about the risks involved with the treatment. Nor did he clarify what the patient actually meant by “new teeth,” missing an opportunity to align the patient’s expectations with realistic outcomes. 

The conversation of consent was also limited with risks such as loss of tooth vitality, long-term maintenance requirements, potential sensitivity, and occlusal instability not discussed in detail. 

The dentist did meet the patient’s deadline of having “new teeth” in time for the wedding. However, as the definitive restorations were delivered under time pressure, several issues were raised by the patient, including an inability to floss, generalised sensitivity, crowns of the wrong shade and shape, and posterior teeth with little to no morphology. The dentist was poorly equipped to resolve her concerns. 

The patient subsequently sought review by a prosthodontist and the specialist’s report documented widespread deficiencies, including deficiencies with the bonding of the veneers, a lack of appropriate occlusion, open contacts, open margins, and excess cement and subsequently advised the patient required full replacement of all crowns and veneers, with estimated costs exceeding $50,000. 

Dentolegal considerations 

This case underscores several areas of exposure for practitioners, particularly when working in the cosmetic space: 

Inadequate consent process – Failure to provide a comprehensive discussion of risks, benefits, and alternatives left the dentist exposed. Consent should include written documentation of alternatives given to the patient (whitening, limited veneers, orthodontics) and potential risks/complications. It should also include documentation of the discussions about what will happen if the risks eventuate, any costs associated with this, and who is responsible for those costs.

Overtreatment – One of the patient’s main complaints was that had she known she had essentially signed up to a lifetime of dental treatment, and that most of her teeth were otherwise sound, she would not have gone ahead with treatment. Preparing sound teeth for full-coverage restorations in the absence of pathology raises significant ethical concerns and can be viewed as unnecessary harm. 

Poor planning and record keeping – A lack of diagnostic quality radiographs, absence of study models, photographs, and treatment planning documentation weakens any medicolegal defence. While the dentist may have had discussions with the patient, the records did not reflect this, nor was any justification for the treatment provided recorded.

Failure to refer – A commonsense approach for an inexperienced general practitioner is to refer or encourage the patient to seek a second opinion prior to proceeding with complex full-mouth rehabilitation. 

While it’s easy to see how this happened: a motivated patient, a looming deadline, a practitioner who wants to help (and perhaps also to showcase their skills), this case serves as a reminder that the promise of a ‘perfect smile‘ or ’new teeth‘ should never come at the expense of sound planning, clinical standards, and ethical judgement.

For practitioners, the fallout of poorly planned cosmetic treatment can far outweigh the perceived short-term satisfaction of meeting a patient’s self-imposed deadline. 

Learning points 

• Cosmetic timelines (such as weddings) should never override appropriate planning and execution. While we want to help patients, we have to ensure that we can demonstrate that any treatment provided was carefully planned and appropriately performed.

• High-quality radiographs, photography, models, and written documentation when providing complex, extensive, elective or expensive treatments, form a major part of your defence should anything go wrong.

• It is important to work within your scope of practice, training, and experience. Complex occlusal or aesthetic rehabilitations warrant referral to, or collaboration with, a prosthodontist. 

• Clear communication about the patient’s expectations, the risks and costs associated with treatment, and a discussion about realistic outcomes help manage expectations and reduces the risk of litigation and complaints.