The nature of malpractice claims related to nerve damage after dental implants insertion in Israel during 2005-2020: A descriptive study.

INTRODUCTION: Dental implant placement is a routine practice in dentistry, with a possible uncommon risk of neurosensory injury. The present study analyzed all dental implant claims involving sensory nerve disturbances between 2005 and 2020 in Israel. The study was conducted to understand implant risk management better and improve the patient's safety. MATERIALS AND METHODS: All legal claims registered by Medical Consultant International (MCI) involving nerve damage claims between 2005 and 2020 were included in the study. The data included demographic details such as age, sex, event date, claim delivery date, and treatment settings. Information on the nerve damage included the damaged nerve, side of injury, and the number of implants performed in the same surgery. RESULTS: There were 218 claims regarding nerve damage out of 1154 claims for dental implant therapy. The mean age for nerve damage claims was 54.1 ± 11 years. There were more female than male claims (p = 0.02), with 87% of cases concerning damage to the inferior alveolar nerve (p < 0.0001), out of those molar areas being more frequently involved in nerve damage (64.3%, p < 0.0001). The left side was 1.4 times more frequent than the right side (p = 0.043). The risk for nerve injury was 7.4 times higher when placing multiple implants compared to single dental implant (p < 0.0001). CONCLUSIONS: Clinicians should be aware that placement of multiple implants, left-side implant placement, and patient gender may increase risk for a malpractice claim for neurosensory disturbances.

Incidence and nature of claims against dental practitioners for dental implant treatment in Israel between 2005 and 2015.

PURPOSE: In recent years, dental malpractice claims have increased dramatically worldwide. The present study aimed to categorise and analyse claims related to implant dentistry that resulted in legal decisions in Israel, seeking to contribute to dental risk management and improve patient safety. MATERIALS AND METHODS: This study analysed legal claims registered by Medical Consultants International between 2005 and 2015. Only closed cases in which a decision was made were included. The parameters studied included patient age and sex, date of the complaint, treatment setting (private/public clinic), description of the adverse event and type of negligence claimed. RESULTS: The cohort included 709 settled claims out of a total of 1066 that were litigated against dental practitioners in Israel during the study period. Of the patients included, 60.0% were women and 63.9% were aged 40 to 59 years. The most common treatment-related damage was neural injury in 133 patients (18.7% of the cohort). Unplanned changes in the treatment plan and violation of autonomy were the most frequent documentation-/information-related claims (66.3% and 32.7%, respectively). The legal responsibility of the dental practitioner was acknowledged in 89.0% of cases. Dental practitioners working in the private sector were more likely to be sued due to violation of autonomy than those working in public clinics. CONCLUSIONS: Although the main cause for lawsuits was actual bodily injury, the high percentage of documentation-/information-related malpractice claims calls for increased awareness of patients' autonomy and rights. Practitioners should dedicate a significant part of the entire treatment time to preoperative diagnosis and planning.

The Incidence and Nature of Claims against Dentists Related to Periodontal Treatment in Israel during the Years 2005-2019.

BACKGROUND: In recent years, worldwide dental malpractice claims have dramatically increased. The purpose of the present study is to analyze periodontal therapy related claims in Israel that led to legal decisions. METHODS: This retrospective cohort study includes malpractice claims against dental practitioners related to periodontology between 2005 and 2019. Only closed cases where a final decision was made were included. The chi-square test or Fisher exact test for categorical variables were performed and a p value of <0.05 was considered statistically significant. RESULTS: During the study period there were 508 legal claims related to periodontal disease. Most plaintiffs were women (63.4%), and 71.3% of the patients were >35 years old. Most claims (82.8%) were settled out of court and ended in compromise. Claims concerning the treatment of periodontal disease by periodontists accounted only for 4.5% (23/508) of the cases while 95.5% (485/508) of the claims were for complications secondary to another treatment. Prosthodontic treatment was involved with the highest number 54.5%, followed by dental implants 17.7%, and endodontics 11.6%. The allegations were related to pain and distress (84.8%), aggravation of existent periodontal disease (83.3%), tooth loss (78.1%), and violation of autonomy (47%). CONCLUSIONS: The main cause for lawsuits was related to aggravation of periodontal disease during prosthetic or implant therapy and related to suspected faulty or inexistent preoperative diagnosis and planning. PRACTICAL IMPLICATIONS: Periodontal consultation before dental treatment may reduce malpractice risks, adverse events, and un-necessary changes of treatment plans.

The Association of the One-Abutment at One-Time Concept with Marginal Bone Loss around the SLA and Platform Switch and Conical Abutment Implants.

OBJECTIVES: Repeated abutment disconnection/reconnection may compromise the mucosal barrier and result in crestal bone level changes. The clinical significance of this phenomenon is not yet clear, as most studies on this topic are short-term. Therefore, the aim of the present study was to evaluate the influence of abutment disconnections and reconnections on peri-implant marginal bone loss over a medium-term follow-up period. MATERIAL AND METHODS: Twenty-one patients (6 men and 15 women) with a mean age 66.23 ± 9.35 year at the time of implant placement were included. All patients who received two adjacent nonsubmerged implants were randomly assigned into one of the two groups: definitive multiunit abutments (DEFs) connected to the implant that were not removed (test group) or healing abutments (HEAs) placed at surgery, which were disconnected and reconnected 3-5 times during the prosthetic phase (control group). Peri-implant marginal bone levels (MBL) were measured through periapical X-rays images acquired immediately after the surgery (baseline), at 4-7 months immediately after prosthetic delivery, and at 1-year and 3-year follow-up visits. RESULTS: No implant was lost or presented bone loss of more than 1.9 mm during the 3-year follow-up; thus, the survival and success rate was 100%. Peri-implant mucositis was noticed in 38.1% DEFs and 41.9% of HEAs at the 3-year follow-up assessment. At the end of 3 years, the MBL was -0.35 ± 0.69 mm for participants in the DEFs group and -0.57 ± 0.80 mm for the HEAs group, with significant statistical difference between groups. CONCLUSIONS: Immediate connection of the multiunit abutments reduced bone loss in comparison with 3-5 disconnections noted in the healing abutments 3 years after prosthetic delivery. However, the difference between the groups was minimal; thus, the clinical relevance of those results is doubtful.

The Incidence and Nature of Malpractice Claims against Dentists for Orthodontic Treatment with Periodontal Damage in Israel during the Years 2005-2018-A Descriptive Study.

In recent years, dental malpractice claims have increased dramatically worldwide. The purpose of the present study is to analyze claims related to orthodontic treatment involving periodontal problems that resulted in legal decisions in Israel. This study analyzed legal claims registered by Medical Consultants International (MCI) between 2005 and 2018. Only closed cases of orthodontic claims involving periodontal problems in which a decision was made were included. The parameters studied included patients' demographic data, the main reasons of the claim, and complications. Statistical significance was found for aesthetic damage, which was more common in claims of females (p = 0.035) and in older claims (p = 0.004); tooth damage was more common in claims of older patients (p = 0.032); violation of autonomy was higher in private practice (p = 0.047) and in more recent claims (p = 0.001). As orthodontic treatment is becoming more popular in older patients, and as lawsuit claims become more common in recent years, the orthodontists should always analyze and document the periodontal status of their patients before and during treatment in order to maintain professional practice and avoid future claims.

Allograft and Collagen Membrane Augmentation Procedures Preserve the Bone Level around Implants after Immediate Placement and Restoration.

Background: Immediate implant placement and restoration (IPR), is a reliable treatment modality. Purpose: This historical prospective study evaluated the medium-term outcomes of hard tissue after IPR in the anterior maxilla with simultaneous hard tissue augmentation. Methods: Seventy-three patients treated with single-implant IPR in the anterior maxilla were followed for 1-8 years. Treatment involved, atraumatic extraction, immediate implant placement and abutment adaptation, followed by simultaneous augmentation with mineralized freeze-dried bone allograft (FDBA) particles to fill the gaps and restore the ridge. The surgical site was stabilized with a resorbable collagen membrane, followed by the connection of an acrylic provisional restoration. Results: All implants osseointegrated during the follow-up period (mean, 34 ± 22 months). Radiographic evaluation of the distance between the implant shoulder (IS) and crestal bone level (CBL) was of 0.86 ± 0.86 mm and 0.8 ± 0.84 mm mesially and distally, respectively. Splitting the results into up to 3 years and 3-8 years of follow-up data, the corresponding values were 0.90 ± 0.83 and 0.68 ± 0.88 for the mesial aspect and 0.99 ± 0.87and 0.74 ± 0.83 for the distal aspect, respectively. Mean peri-implant probing depth was 3.63 mm (SD ± 1.06) and 16 implants (22%) presented at least one bleeding pocket of ≥5 mm (peri implant mucositis). Conclusions: The immediate replacement of a single maxillary tooth by implants combined with guided bone regeneration is a predictable treatment modality with favorable peri-implant bony response.

Esthetic Assessment of Implants Placed into Fresh Extraction Sockets for Single-Tooth Replacements Using a Flapless Approach.

BACKGROUND: To validate the concept of immediate implant placement and nonfunctional loading for use in the esthetically sensitive anterior maxilla, clinical trials should ideally include objective esthetic criteria. PURPOSE: This study analyzed procedural results as graded by the pink esthetic score and white esthetic score (PES/WES). METHODS: Thirty-nine suitable patients (mean follow-up 44.82 ± 28 months) were evaluated. RESULTS: Thirty-eight implants fulfilled stringent criteria for successful osseointegration: absence of peri-implant radiolucency, implant mobility, suppuration, and pain. The mean total PES/WES was 15.50 ± 2.67 (range: 10-20). The mean total PES of 7.92 ± 1.60 (range: 5-10) indicated favorable overall peri-implant soft-tissue conditions. Root convexity and texture (1.63 ± 0.54) and curvature of the facial mucosa (1.68 ± 0.47) and distal papilla (1.66 ± 0.48) had the highest mean values, whereas acceptable levels of facial tissue (1.53 ± 0.73) and mesial papilla (1.42 ± 0.64) were the most difficult to fully achieve. The mean mesial and distal bone loss at data collection was, was 1.19 ± 0.54 and 1.15 ± 0.51, respectively. Periodontal disease severity (advanced chronic and aggressive periodontitis) was significantly associated with a low total PES (p = .048). CONCLUSIONS: Objective PES/WES assessment validated immediate anterior maxillary single-tooth replacement and restoration as being a successful and esthetically predictable treatment modality in sites where the buccal bone had been preserved during the extraction at 1 year of follow-up.

The Use of Tilted Implant for Posterior Atrophic Maxilla.

PURPOSE: To retrospectively analyze the influence of implant inclination on marginal bone loss at freestanding implant-supported fixed partial prostheses (FPPs) over a medium-term period of functional loading. MATERIALS AND METHODS: Twenty-nine partially edentulous patients with freestanding FPDs supported by two implants placed in a two-stage procedure comprised the study group. The anterior implant was placed axially, and the posterior tilted distally. Mesial or distal inclination of each implant was measured in relation to the vertical axis perpendicular to the occlusal plane. Average bone loss was compared between straight and tilted implants, smokers, and nonsmokers. RESULTS: Mean angulation of the anterior axial-positioned implant was 3.45 degrees distally (range 0-8) and of the distal implants was 32.83 degrees distally (range 20-50 degrees). Average bone loss after 1, 3, and 5 years was 0.89 (SD = 0.73), 1.18 (SD = 0.74), and 1.50 (SD = 0.81), respectively, for axial implants, and 0.98 (SD = 0.69), 1.10 (SD = 0.60) and 1.50 (SD = 0.67) for tilted implants, with no significant correlation between implant angulation and bone loss. A significant correlation between implant angulation and annual bone loss was obtained for tilted implants only (r = 0.52, p = .004).Using Albrektsson criteria, the success rate was 89.6% (26 out of 29 implants) for straight and 93.1% (27 out of 29) for tilted implants. CONCLUSION: The study demonstrates no effect of implant angulation on peri-implant bone loss in the posterior maxilla.

Histomorphometric analysis of newly formed bone after bilateral maxillary sinus augmentation using two different osteoconductive materials and internal collagen membrane.

Deproteinized bovine bone mineral (DBBM) and human freeze-dried bone allograft (FDBA) were compared in five patients undergoing bilateral maxillary sinus floor augmentation using DBBM on one side and FDBA on the contralateral side. After 9 months, core biopsy specimens were harvested. Mean newly formed bone values were 31.8% and 27.2% at FDBA and DBBM sites, respectively (P = .451); mean residual graft particle values were 21.5% and 24.2%, respectively (P = .619); and mean connective tissue values were 46.7% and 48.6%, respectively (P = .566). Within the limits of the present study, it is suggested that both graft materials are equally suitable for sinus augmentation.

Accuracy of a laboratory-based computer implant guiding system.

OBJECTIVE: Computer-guided implant placement is a growing treatment modality in partially and totally edentulous patients, though data about the accuracy of some systems for computer-guided surgery is limited. The purpose of this study was to evaluate the accuracy of a laboratory computer-guided system. STUDY DESIGN: A laboratory-based computer guiding system (M Guide; MIS technologies, Shlomi, Israel) was used to place implants in a fresh sheep mandible. A second computerized tomography (CT) scan was taken after placing the implants . The drill plan figures of the planned implants were positioned using assigned software (Med3D, Heidelberg, Germany) on the second CT scan to compare the implant position with the initial planning. Values representing the implant locations of the original drill plan were compared with that of the placed implants using SPSS software. RESULTS: Six measurements (3 vertical, 3 horizontal) were made on each implant to assess the deviation from the initial implant planning. A repeated-measurement analysis of variance was performed comparing the location of measurement (center, abutment, apex) and type of deviation (vertical vs. horizontal). The vertical deviation (mean -0.168) was significantly smaller than the horizontal deviation (mean 1.148). CONCLUSION: The laboratory computer-based guiding system may be a viable treatment concept for placing implants.

Effect of reduced post length on the resistance to fracture of crowned, endodontically treated teeth.

OBJECTIVE: To examine the influence of a reduced post length sealed with a titanium-reinforced composite luting agent on the fracture resistance of crowned endodontically treated teeth with a 2-mm ferrule on healthy tooth structure. METHOD AND MATERIALS: The study consisted of 60 intact single-rooted premolars with similar root diameters and lengths. Teeth were endodontically treated and randomly divided into 6 experimental groups (n = 10) with various post lengths (5, 8, and 10 mm) and types (ParaPost and Dentatus) of equal diameter. Posts were luted with a titanium-reinforced composite resin luting agent. Titanium-reinforced composite resin cores were constructed, and cast crowns with a 2-mm ferrule on healthy tooth structure were cemented. Specimens were mounted in a jig that allowed loading of the buccal cusp in the axio-occlusal line at a 30-degree angle to the long tooth axis. A continuous compressive force at a crosshead speed of 2 mm/min was applied by an Instron testing machine. Forces at fracture (in newtons) and mode of failure were recorded. One-way analysis of variance (ANOVA) and the Scheffe test were used to statistically compare the differences among groups at a significance of 5%. RESULTS: ANOVA showed no statistically significant differences among the mean failure forces for the tested groups in their resistance to fracture under load. The Scheffé contrast test showed no statistically significant differences among all combinations of the 6 tested groups (F [5.59] = 0.032; P > .05). CONCLUSION: Within the limitations of this study, post length did not influence the fracture resistance of crowned endodontically treated teeth with a 2-mm ferrule on healthy tooth structure. For tooth resistance, prosthesis design is more important than post characteristics.

Effect of remaining coronal structure on the resistance to fracture of crowned endodontically treated maxillary first premolars.

OBJECTIVE: Endodontically treated maxillary first premolars present a restorative challenge. The objective of the present study was to assess the resistance to fracture of crowned endodontically treated maxillary first premolars under simulated occlusal load, while preserving various degrees of remaining coronal structure. METHODS AND MATERIALS: The study consisted of 50 intact maxillary first premolars with bifurcated roots and similar root diameter and length, randomly divided into 5 equal experimental groups. All dowels were luted with Flexi-Flow titanium-reinforced composite resin cement. TiCore titanium-reinforced composite resin was used to fabricate the core. Complete cast crowns were fabricated and cemented with zinc phosphate cement. Forces at fracture and mode of failure were recorded. RESULTS: Statistically significant differences (P < .05) were found among mean failure forces for all tested groups in their resistance to fracture under load with the Kruskal-Wallias test and among all combinations of the 5 groups (Z = -1.56/-2.34; P > .05) with the Mann-Whitney test. This indicates that crowned maxillary first premolars with varying degrees of remaining coronal structure differ significantly in their resistance to fracture under occlusal load. There was increased protection against fracture under occlusal loads with more remaining tooth structure. CONCLUSIONS: Within the limitations of this study, remaining coronal structure influenced the fracture resistance of crowned endodontically treated maxillary first premolars. Preservation of tooth structure is important for its protection against fracture under occlusal loads and may influence the tooth prognosis.

Effect of endodontic access type on the resistance to fracture of maxillary incisors.

OBJECTIVE: To compare the effect of endodontic access cavity location--labial versus palatal--on the resistance to fracture of maxillary incisors. METHOD AND MATERIALS: Sixty intact human maxillary incisors were selected: 20 pairs of central incisors and 10 pairs of lateral incisors. From each pair, 1 tooth was randomly selected to receive a palatal access cavity; the other tooth of the same pair received a labial access cavity. The teeth were divided into 4 test groups: group 1, central incisors with labial access; group 2, central incisors with palatal access; group 3, lateral incisors with labial access; and group 4, lateral incisors with palatal access. A lateral condensation technique was used to fill the canals with gutta-percha cones and AH-26 (Dentsply DeTrey). The access cavities were restored with hybrid resin composite. Specimens were mounted in a jig that allowed loading at the center of the palatal surface of the tooth, over the cingulum, at an angle of 130 degrees to the long axis of the tooth. Continuous compressive force at a crosshead speed of 2 mm/min was applied by an Instron universal testing machine. Load at fracture and mode of failure were recorded. Multiple analysis of variance (MANOVA) with repeated measures was used to statistically compare differences between groups at a significance of 5%. RESULTS: Mean failure loads for the 4 test groups were as follows: 894 N (group 1), 821 N (group 2), 774 N (group 3), and 705 N (group 4). No significant difference in failure load values was found among all tested groups (F = 0.5; P >.05). The mode of failure in all groups was an oblique radicular fracture, either at the level of the cementoenamel junction in 40% to 45% or at the root level in 55% to 60% of the teeth. CONCLUSION: Different endodontic accesses-labial or palatal-did not affect the failure resistance of maxillary incisors under simulated occlusal load.

Resistance to fracture of crowned endodontically treated premolars restored with ceramic and metal post systems.

OBJECTIVES: The objective of this study was to assess the resistance to fracture of crowned endodontically treated premolars with varying ceramic and metal post systems under simulated occlusal load. METHOD AND MATERIALS: The study consisted of 60 extracted intact premolars with similar root diameter and length. Teeth were divided equally into 4 groups (n = 15) and prepared for posts and cast crowns as follows: group 1 = preformed metal post, composite core, and cast crown; group 2 = cast post and core and cast crown; group 3 = zirconia post, composite core, and cast crown; and group 4 = zirconia post and heat-pressed ceramic core and cast crown. All prepared teeth had 2 mm of sound dentin on which the cast crowns were cemented. A continuous load (kg) was applied by an Instron testing machine to the buccal cusp at a 30-degree angle to the long axis of each tooth at a crosshead speed of 2 mm/min until failure. One-way analysis of variance with Scheffe test was used to statistically compare the differences between groups. RESULTS: Mean failure loads (in newtons) for the 4 test groups were as follows: 1,103.3 (group 1), 1,234.5 (group 2), 826.6 (group 3), and 870.6 (group 4). No significant difference in failure load values was found among all tested groups (F[3,59] = 2.05; P >.05). The primary mode of failure (85%) in all groups was an oblique radicular fracture, either apical to the post or at the post level. Horizontal fracture (15% to 20%) of the root and post was found in groups 3 and 4. CONCLUSION: Within the limitations of this study, varying ceramic and metal post systems did not affect the failure resistance of teeth restored with full-coverage cast metal crowns, under simulated occlusal load.

Heat transfer of impression plasters to an implant-bone interface.

PURPOSE: The purpose of this in vitro study was to measure heat generated at the implant-bone interface caused by exothermic setting reaction of 2 impression plasters. MATERIALS AND METHODS: The study consisted of 20 titanium-alloy abutment impressions connected to a titanium-alloy cylindrical implant embedded in an acrylic-resin mandible in a 37 degrees C water bath. There were 2 types of impression plaster used, Snow-White (Kerr, Romulus, MI) and Xantano (Kulzer, Dormagen, Germany). Temperature changes were recorded via embedded thermocouples at the cervix and implant surface apex. Analysis of variance for repeated measures was used to compare 2 treatment groups. RESULTS: Temperature increased less at the implant apex (1.5 degrees-2.1 degrees C) than at the implant cervix (7.4 degrees-10.5 degrees C). Differences between the 2 impression plasters were statisticallysignificant only at the implant cervical level (P < 0.05). A lower temperature increase was shown with the Snow-White compared with the Xantano. Although both plasters generated an exothermic reaction on setting (mean temperature change 22 degrees C), the increase in the temperature rate of the Snow-White was slower than the Xantano. CONCLUSIONS: Under the conditions of the present study, Snow-White impression plaster appears to be safer to use in implant prosthodontics compared with the Xantano because of its slower and lower exothermic reaction at the implant-bone interface. However, use of the material with the rapid setting time would require more care, such as limiting the volume of material used (e.g., by using a custom tray).

Impression technique for partially edentulous patients.

This article describes an implant impression technique for partially edentulous patients in which impression plaster and irreversible hydrocolloid are used. The technique ensures accuracy, ease of manipulation, and decreased working time.