Comprehensive forensic medical examination of defects in the provision of orthopedic dental care (clinical case)

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relevance

The problems of professional errors and defects in dental care are relevant and are becoming increasingly important. In recent years, there has been an annual increase in examinations in cases of improper performance of professional duties by medical workers.

Consideration and investigation of civil cases involving the prosecution of medical workers for improper provision of medical care (services) in the field of orthopedic dentistry presents great difficulties. Therefore, forensic medical examination of medical cases is carried out only on a commission basis (with the participation of leading orthopedic dentists with extensive experience and practical experience) and refers to examinations based on case materials, and its production has its own characteristics. On the one hand, the criteria for any modern treatment method are acceptable for expert assessment of the quality and volume of dental care, on the other hand, it is impossible not to take into account the specificity of dental treatment methods, which include not only medical, but also technical aspects arising in the practice of orthopedic dentistry [1-10].

CASE DESCRIPTION

In the expert practice of the expert legal center of the Federal State Budgetary Educational Institution of Higher Education "KrasSMU named after Prof. V.F. Voino-Yasenetsky" of the Ministry of Health of the Russian Federation, there was a case of conducting a comprehensive forensic medical examination based on the materials of a civil case and medical documents of a patient who received medical care in the field of orthopedic dentistry.

During the examination of medical documents and an objective examination of the sub-expert A., who gave written consent to the expert examination and written permission to process personal data, photograph and publish information about the expert case, a comprehensive forensic medical assessment was carried out on issues related to the quality and volume of dental care (services):

1) assessment of the general condition of the patient, the condition of his dental system and oral cavity before dental treatment;

2) the correctness of the examination and diagnosis;

3) evaluation of the treatment plan, adequacy and effectiveness of treatment measures;

4) assessment of the completeness and correctness of medical records;

5) evaluation of the denture design and the correctness of the clinical pre-orthopedic management of the patient;

6) assessment of the correctness of the clinical management of the patient during the manufacture of the denture and the patient's supervision during the period of adaptation to the denture;

7) assessment of the correctness of the technical performance of the denture and the quality of the materials used for the manufacture of prostheses.

The subexpert complained about the absence of teeth in the upper jaw and lower jaw, the inability to use removable dentures, the presence of fallen (cemented) support crowns and pin structures.

Objective examination: with closed lips, there is a decrease in a third of the lower part of the face, nasolabial folds and folds in the corners of the mouth are clearly pronounced (the presence of pronounced signs of the progenic nature of the senile type of face). The opening of the mouth is free, without the presence of crepitation and displacement of the TMJ heads. The skin is without visible pathological changes, palpation of the skin in the upper and lower jaw is painless. The bite is not fixed, progenic.

 

Table 1. Dental formula

П	R	О	О	О	О	О	R	O	R	O	O	O	O	O	O
18	17	16	15	14	13	12	12	21	22	23	24	25	26	27	28
48	47	46	45	44	43	42	41	31	32	33	34	35	36	37	38
O	O	O	K								П	R	O	R	O

There is a 100% loss of chewing efficiency according to Agapov (without prostheses).

Description of the existing teeth in the upper jaw (according to the corresponding numbers of the dental formula) (Table 1):

The 18th channel is sealed with a contrast agent, prepared for a crown.

17 - the X-ray image shows the filling of only one root (palatine), there is no clinical crown.

11 - a part of the natural stump of the root rises above the gum within 1 mm., the tooth canal is sealed by 2/3, the remaining part of the root is filled with food deposits.

22 - the root canal is sealed by 2/3, there is a metal pin in the root canal (according to the orthopantomogram), which ends on the outer part of the root with a ball attachment with a metal substrate. Between the edge of the substrate and the edge of the gum of this tooth, the vestibular part of the root is exposed by 2 mm, and is affected by the carious process.

27 - there is a solid metal crown.

Description of the existing teeth in the lower jaw:

37- the channels are sealed by 1/3, there is a hole in the distal canal area, empty for a pin, the root is dark in color, motionless. The mesial canal is not prepared for the pin. On the distal side of the 37th tooth, there is bone atrophy by 2/3 of the root length.

35 - the tooth is presented in the form of a root, with a spherical attachment fixed in it, there is a depulpated canal with filling for half the length of the root (in accordance with X-ray. A snapshot)

34 - seal with complete canal depulpation

41 - there is a chip of the incisor part within 2 mm

45 - there is a metal-ceramic crown, the X-ray image shows the depulpation of the root canal, half of which is replaced by a stump pin structure

The defect of the dentition of the upper jaw according to Kennedy is rated as class 3

The defect of the dentition of the lower jaw according to Kennedy is rated as class 1

Analysis of existing prostheses outside the oral cavity:

Upper jaw:

In the area of the 17th tooth there is a stump pin structure fixed to cement in a milled metal crown (internal telescopic crown) with a groove in the frontal area. This non-removable structure was cemented and fell out in August 2021 when chewing, after that this structure was not fixed in the oral cavity.

Fig. 1. Removable and non-removable dentures of the upper jaw. View of the removable prosthesis from the side of the prosthetic bed.

Fig. 2. Removable and non-removable dentures of the upper jaw. View of the removable prosthesis from the side of the prosthetic bed (indicating the size of the distal side of the prosthesis).

Fig. 3. View of the removable upper jaw prosthesis from the oral side (indicating the size of the medial side of the prosthesis).

There is also an all-cast removable plate prosthesis with an exposure of the hard palate in the frontal part in the form of a triangle, the rear metal part does not reach the A line by 2-3 mm. In this non-removable prosthesis, in the area of the 17th tooth, there is an integral external telescopic metal crown with an internal protrusion for fixation (Fig. 1,2,3).

In the area of the roots of the 11 and 22 teeth on the inner surface of the removable prosthesis there are plastic matrices with a metal substrate for fixing this prosthesis in the oral cavity. On metal balls fixed on metal pins in the area of the root canals of these roots.

On the removable prosthesis in the area of the 27th tooth there is an inner shoulder of the Acker support-retaining clamp and an occlusive patch, the vestibular shoulder is broken off.

The subexpert asserts that the cementation of the supporting structure in the area of the 17th tooth and the breakage of the outer shoulder of the 27th tooth occurred simultaneously during the act of chewing in August 2021. The subexpert notes that klammer's inner shoulder constantly caused pain when the soft tissues of the tongue and cheek moved, which the attending physician did not pay attention to and did not take any action to eliminate this shortcoming.

On the outside of the removable upper jaw prosthesis, the base plastic at the point of transition to metal in the frontal area between the canines is loosely adjacent to the metal base, which makes it possible for food to constantly linger there. The plastic surfaces are insufficiently polished along the entire perimeter from the vestibular side. In the area of 24,25,26 teeth on the chewing surfaces, there is a visible bite correction using self-hardening plastic.

The lower jaw:

The non-removable prosthesis in the lower jaw area has an internal telescopic crown with a stump pin structure, which is fixed in the crown with cement due to a pin in the distal canal of the 37 tooth, for the medial canal there is no pin in the stump pin structure (Fig. 4,5,6).

Fig. 4. Removable (clasp) and non-removable dentures (cast crowns) on the lower jaw (view of the removable prosthesis from the lingual side).

Fig. 5. Removable (clasp) and non-removable dentures for the lower jaw (view of the removable prosthesis from the lingual side).

Fig. 6. Removable (clasp) and non-removable dentures (cast crowns) for the lower jaw (view of the removable prosthesis from the prosthetic bed).

There is a clasp prosthesis on the lower jaw with an Acker support-retaining clamp in the area of the 45th tooth.

In the area of the tooth 35 there is a plastic matrix with a metal substrate, which should fix this prosthesis in the oral cavity. On the ball of the attachment fixed in the root canal when fixing this prosthesis in the oral cavity, satisfactory fixation is observed only in the area of the support-retaining clamp, the matrix in the area of the 35 tooth does not hold the prosthesis. The existing external telescopic crown of tooth 37 is broken off from the base of the mandibular denture. When examining the fracture line of this crown from the base, insufficient metal thickness (within 2 mm) was revealed, which is unacceptable and underestimated by half.

All cementations and fractures on the upper and lower jaw occurred at the same time in August 2021 during the act of chewing.

Polishing of the plastic parts of the lower prosthesis is satisfactory, but in the area of the plastic 47 tooth there is a defect on the chewing surface of a round shape with a diameter of 2 mm and a depth of 2 mm.

discussion

Analyzing the studied clinical, radiological, orthopedic, dental indicators of this orthopedic dental treatment, the following was revealed:

Three different fixation options for removable dentures are used on both the upper and lower jaw; they have different working mobility tolerances:

A) Telescopic milled solid–cast crowns (complete lack of mobility in lateral horizontal projections) - rigid fixation system.

B) Spherical (push-button clamps) with an acceptable mobility of 12-15 degrees in the hemisphere; (labile fixation system).

C) Support-retaining clamps of type 1 according to Her (Akker) on permissible mobility in horizontal projections up to 0.5-1 mm (semi-flexible or semi-rigid fixation system).

According to all literary data, especially in the writings of the corresponding member. RAS V.N. Kopeikin, such combinations of fixators with varying degrees of mobility in one prosthesis are not recommended, because this can lead to: mobility and dislocation of the supporting teeth; to breakage of the fixator elements; cementation of pin structures under telescopic crowns; split roots.

Almost all of the above complications are present during the operation of removable dentures for 1 year on the upper and lower jaw of the patient.

Upper jaw:

Dislocation and cementation of the stump pin structure of tooth 17 with an internal telescopic crown fixed to cement; imbalance and lack of fixation of the matrix on the matrix in the area of the spherical push-button retainer of tooth 22; spherical retainer (patriza) in the area of tooth 11 (root) was cemented and (according to the patient) was swallowed with food; fracture of the vestibular shoulder-the retaining clamp of the Acker in the area of the 27th tooth.

The lower jaw:

Dislocation and cementation of the stump pin structure 37 of the tooth with the internal telescopic crown fixed on it with cement; unbalance and lack of fixation of the matrix on the matrix in the area of the spherical push-button retainer 35 of the tooth; breakage of the external telescopic crown 37 of the tooth from the metal seat of the lower clasp prosthesis.

Consequently, the planning of orthopedic treatment with removable dentures with such sets of fixing elements was erroneous both on the upper and lower jaw.

A medical error was made when choosing 37 teeth for a telescopic crown for the following reasons:

1) Significant inclination of the tooth in relation to the frontal group of teeth (not parallel supports);

2) Significant bone atrophy (2/3 of the root length, which is a contraindication to installing a telescopic crown on it)

3) Fixation of the stump pin structure only in one channel of this tooth, which in advance weakened the fixation of both the stump structure itself and, accordingly, the internal telescopic crown fixed to it.

A technical error was made when modeling the frame of the clasp prosthesis at the junction with the telescopic crown of the 37th tooth – the junction was excessively thinned, therefore, even with a small load, the thin junction (2 mm thick) could not withstand.

Conclusion

The considered case will prevent the occurrence of such professional errors and avoid adverse outcomes, therefore, reduce the number of conflict situations between doctors (or medical institutions) and their patients.

Additional information

Funding. The authors state that there is no external funding for the study.

Conflict of interest. The authors declare the absence of obvious and potential conflicts of interest related to the publication of this article.

Contribution of authors. All authors confirm that their authorship meets the international ICMJE criteria (all authors have made a significant contribution to the development of the concept, research and preparation of the article, read and approved the final version before publication).

The patient's informed consent. The authors received a written request from the patient to publish medical data and photographs in the journal "Forensic Medicine".

作者简介

Yuri Chizhov

Email: gullever@list.ru
ORCID iD: 0000-0001-9324-2380
俄罗斯联邦

Natalya Khludneva

Email: n.hludneva@mail.ru
ORCID iD: 0000-0002-7636-3583
SPIN 代码: 6697-9796
俄罗斯联邦

Tamara Kazantseva

Email: Kazancevatv@mail.ru
ORCID iD: 0000-0002-3303-1394
俄罗斯联邦

Irina Sargsyan

Email: sarxii@mail.ru
ORCID iD: 0009-0009-5851-5078
SPIN 代码: 2129-5896
俄罗斯联邦

Fedor Alyabyev

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

Email: alfedval@mail.ru
ORCID iD: 0000-0003-4438-1717
SPIN 代码: 2995-4963

Dr. Sci. (Med.), Prof.

俄罗斯联邦, Krasnoyarsk

Alexandra Yusupova

Professor V.F. Voino-Yasenetsky Krasnoyarsk State Medical University

编辑信件的主要联系方式.
Email: aleksandra-yusup@mail.ru
ORCID iD: 0009-0000-8687-4312
SPIN 代码: 4651-5075

6th year student of the Pediatric Faculty

俄罗斯联邦, 1 P. Zeleznyak street, 660022 Krasnoyarsk, Russia

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