Australian Health Practitioner Regulation Agency - Panel hearing summary 2012.0052
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Panel hearing summary 2012.0052

Decision of the Dental Board of Australia

Performance and Professional Standards Panel

Jurisdiction: Victoria

Date of hearing and decision: 30 January 2012

Classification of Notification:

Clinical Care - Inadequate or inappropriate procedure

A mother complained about the dental implants received by her daughter from the dentist. The patient was missing two teeth next to the front incisors and required implants. The patient ended up attending 12 consultations for the implant process when she had expected to make two or three visits. On occasions the patient experienced intense pain. The implanted crowns were crooked and required five visits for corrections.


The dentist faced allegations that the implant crowns for

  1. tooth 22 had not been fully seated, resulting in a poor occlusion (bite) and allowing a large volume of soft tissue to grow between the abutment (connecting element) and the implant complex and 
  2. tooth 12 had been placed in rotation and was not fully seated which resulted in aggressive soft tissue infection.


The Panel found the practitioner made an incorrect assumption before undertaking the procedure that the type of platform used in the implant therapy was similar to alternative platforms previously used. The practitioner omitted certain steps which may have led to technical difficulties not uncommon in implant therapy. The impact of this was crooked crowns, one of which became loose and infected.

The Panel found that before undertaking the procedure, the practitioner should have transitioned the notifier to a pre-definitive provision restoration, to allow a subgingival emergence profile to be established. Had this been done, the definitive crown would have been more positively located and therefore seated.

The practitioner engaged in unsatisfactory professional performance in that the knowledge, skill or judgement possessed, or the care exercised by the practitioner, was below the standard reasonably expected by their peers. The practitioner’s knowledge of the Astra Tech Implant System was deficient and she did not follow the recommended treatment guidelines.


The Panel determined to caution the practitioner and recommended that she seek advice from an experienced prosthodontist about implant restoration therapy.

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Page reviewed 17/04/2014