Talk to the Society

Medico-Legal Journal
0(0) 1–15
When dental implants go wrong ! The Author(s) 2020
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DOI: 10.1177/0025817220902985
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Dr Michael R Norton1,2
1
Adjunct Clinical Professor, University of Pennsylvania and
2
Past-President, Academy of Osseointegration (2017–18)

(The meeting commenced at 7.02 p.m.) because for nearly 30 years that is all I do and that is
The President: Good evening, ladies and gentlemen. all I have done. I did my residency in oral surgery;
Welcome to tonight’s session. We are here to listen to having trained at Cardiff, I came to London, the
Michael Norton who is a distinguished dental implant Royal London Hospital and St Thomas’, and around
surgeon and was the 31st President of the Academy of 1989 my then senior registrar introduced me to some-
Osseointegration and not only was he the 31st President thing that he had seen in America that blew his mind
but he was the first non-American President of that and that was dental implants. In this country in 1989/
organisation. So, he is a man who has deservedly inter- 90, virtually no one was doing dental implants except
national recognition within his field. He is going to talk for the former variety of dental implant which we only
to us about dental implants going wrong, so when I ever whisper about in my profession because it was an
look around and see who is fingering their mouths in embarrassing period. The period of modern dental
a rather suspicious way I will know who is going to be implantology really took off in 1988, which gives us a
his next patient! little bit of perspective.
Dr Norton: Thank you very much, indeed. Thank
you for the invitation; it is very much appreciated.
This is certainly an unusual lecture for me to give.
I actually found it quite interesting to think about
how I would structure it and immediately I realised,
sadly in a way, that I could probably stand up here
and speak for three hours. I know you do not want
me to do that and I do not think I really want to do that.
So what I thought I would do is touch on all of the
fundamental areas where dental implants can go wrong
but I really wanted to focus on one particular area that
I think deserves attention. It is seen by lawyers repre-
senting patients as a principal cause for litigation but
actually I think it is seen by both the legal profession
and, importantly, my own profession in not quite the
right way. I think potentially patients are being poorly
advised, dentists are being possibly poorly treated,
though by no means always, and I just thought I
would try and clear some of that up.
(Speaking to a PowerPoint presentation) I work just
up the road literally the other end of Harley Street at
number 104 and this is my facilities and this was all
developed specifically for an implant-based practice

A meeting of the Society was held at the Medical Society of London,

Of course, dental implants have gone through a nigh
Lettsom House, 11 Chandos Street, Cavendish Square, London, W1G 30-year development since they were first introduced
9EB on Thursday 14 November 2019. The President, Sir Robert Francis into the commercial marketplace. Some of the things
QC, was in the Chair.
2 Medico-Legal Journal 0(0)

that go wrong today never used to go wrong 30 years
ago and a lot of the things that went wrong 30 years
ago do not go wrong today because obviously we learn
and we evolve, but there are areas where it does not
really matter at what stage of that 30-year history you
were doing dental implants. I have just really focused
on the following categories.
Assessment, diagnosis and planning is a big one but it
is actually a relatively easy one to handle, so I will only
touch that in some areas this evening.
Surgical error is also a relatively easy one to handle.
God forbid that I should simplify what I do and make
it sound like you could all go out tomorrow and do it
but, at the end of the day, you have a block of bone,
you have a position that requires a tooth and really the
job of the surgeon is to assist the dentist by making
sure that the implant is in the right position within that
block of bone and that is it. Of course, it does not come
together that easily but we will look at that.
Loading errors is another area and we will just touch
on that. The area that I am really going to focus on this
evening is the last. This is a condition called peri-
implantitis and if you have done any dento-legal
work with implants you have probably come
across this term. I will not pre-empt what I am going
to say now but we are going to talk in some
detail about that.
Let us start at the beginning. The patient comes in.
It makes sense if they are having what is undoubtedly
still considered by my profession as a complex
piece of dentistry, even a single tooth implant
would be considered by the General Dental
Council as complex dentistry, then you need to under-
take an appropriate degree of assessment,
diagnosis and planning. The areas where I have seen
things go wrong are, quite simply, at the most funda-
mental level: poor clinical examination. I will give you
an example.
One of the things that I really do not like, but it seems
that we cannot prevent because the General Dental
Council does not see a problem with it, is the
“roving surgeon – have bag, will travel”. He might
have as many as 15, maybe even 20, satellite surgeries
around the United Kingdom; he takes his bag of tricks,
goes into their surgery, he does the surgery and he
moves on. The problem is that he never really integrates
with that practice, he never becomes a true team
member, and when problems occur it all starts being
the old finger pointing, “It was his fault”, “No, it was
their fault”.
I am doing a case right now where there is no record
of the surgical notes at all in the computer records.
Nothing. Not a thing. The surgeon, who was a “have
bag, will travel” surgeon, said that he always wrote his
notes up by hand and gave the written notes to the
nurse to then transcribe into the computer at the prac-
tice on the patient software. They are not on the patient
software, so he is blaming the practice but the practice
nurse is saying, “He never gave me any handwritten
notes of that surgery”. Of course, the surgery has
gone horribly wrong as well. So, not only do we have
a patient who has been effectively assaulted, but we do
not know how, why, what, when and where because
there is no written record.
Lack of appropriate radiography
We are very lucky in dentistry today. When I qualified,
the idea of having three-dimensional radiography at
our fingertips in a dental practice was total pie in the
sky. If you wanted a CT scan, you sent the patient to a
hospital, they lay down and went in a great big dough-
nut and got irradiated to the point of being like Guy
Fawkes! That is the world we grew up in. Today we
have cone beam CT scans that we can have in our
practice with very low dose radiation but give us phe-
nomenal three-dimensional information and you will
see a bit of that.
We have always said with implant dentistry that it
should be restoratively led. What does that mean? It
means that you do not ask, “Where can I put the
implant?” You do not ask, “Where is there enough
bone for me to stick a screw in?” What you ask is,
“Where should the tooth be? Can I place that implant
in that position?” If the answer is “no” because you do
not have enough bone, then you have to regenerate
that; you have to do some bone grafting. You cannot
just stick implants in willy-nilly. So, we need a restor-
ative and an occlusal analysis. The occlusal refers to the
bite. There are many different bites in this world and,
Norton
frankly, some bites are just not suitable for implants, or
you make them suitable before you do the implants and
we will look at some examples of that, I am sure.
Clinical examination
What should it involve? Clearly, a full dental examina-
tion; a full examination of the gum health. That is the
periodontal examination. If you are going to treat
patients with implants there is zero excuse for not
doing a proper periodontal examination. In general
dental practice, the General Dental Council say that
you can do what is called a BPE, a basic periodontal
examination, which is a sort of a skirting round the
gums to get an idea. The scoring goes from zero to
four and if you score three or four you are really sup-
posed to then do a full periodontal charting. One of the
things that I have certainly seen is often they are very
good at doing BPEs and they score three or four but
they then do not go on to do a full periodontal charting
or they do not go on to refer the patient to a periodon-
tist or either or both. It is important that we have that
information.
A full soft tissue examination, that is looking to
ensure that there are no other pathologies that perhaps
are of a more important nature than giving the patient
a new tooth. Every specialist, and I particularly know
this is true of my endodontic colleagues, that is the
“root canal boys”, is that the patient is sent for a
root canal treatment to an endodontist and they are
only looking at the one tooth the patient has been
referred for. I had a very strong relationship with an
endodontist who has now retired and I said to him, “If
you ever had a patient who came in with a squamous
cell carcinoma that was tiny but nonetheless obvious
and you didn’t notice because you were so busy just
looking at the tooth that was referred for the root
canal, you potentially make yourself liable” and he
was so unconvinced that that was the case because he
believed that his duty was simply to focus on what was
referred that he had that discussion with the General
Dental Council and of course they said, “If you miss
something like a squamous cell carcinoma, however
far or remote from the site that you have been referred
to treat, then potentially that is malpractice”. It is
important to do a thorough examination and that
includes the occlusal examination, the jaw joints, what
we call the TMJs (temporomandibular joints) and of
course a full medical history including medications.
Let us talk about radiography very briefly. This you
will have all seen if you have any dento-legal work;
these are panoramic radiographs.
3
They come in all kinds of qualities. Today of course we
live in the digital era, so most panoramics today are
digital. Some practices still do a plain film which is
really prone to the quality of the development process
rather than the X-ray itself, so if the liquids have not
been changed, if they are not kept at the right temper-
ature, and so on and so forth. Panoramics all suffer
from a variety of issues.
For example, you will often see white fuzz that runs
through the centre of the film, this is just superimposi-
tion of the spinal cord but it makes evaluating what is
going on in that region very difficult. On the opposite
side, one can also see very dark areas and it can almost
looks like half the jaw has been eaten away. This is just
a contrast error from the superimposed airway. Also,
there are very important nerves that run through the
lower jaw but it is hard to see or trace them if you have
these difficult contrast errors.
The other problem with these kinds of images is
that they are distorted and the problem is, by how
much are they distorted? In the old days before
CT scans and digital radiography, all we would do
is stick a ball bearing of known diameter on to the
denture or on to the teeth or somewhere in the
mouth and that is what you see here in the centre
of this film. I think you will agree with me that it
does not look very spherical; it is squashed and
sausage-shaped. That is telling us the degree of distor-
tion. So, if you knew the diameter of the ball bearing
and you measured, say, the horizontal length of that
image on that film, you could work out the distortion
factor.
4 Medico-Legal Journal 0(0)
You can start to understand that there is a lot of poten-
tial for human error. The world of digital and in par-
ticular CT scanning eradicates all this error. The
General Dental Council generally I think today feel
that when you are placing implants above vital struc-
tures like very important nerves that could leave a
patient permanently numb and drooling, you probably
should do a CT scan.
The other thing about these panoramic X-rays is
that they are only two-dimensional. This X-ray comes
from a real case that I am dealing with at the moment
where the dentist claims that he was perfectly within his
rights to use this panoramic X-ray to place implants in
the lower jaw because he can see very clearly defined
lines and, with a trained eye, he could pick out the
nerves which are running through the jaw and he
could actually make digital vertical measurements.
So, he knows that there is approximately 9.5 mm of
bone above the nerve, but here is the problem. What
about the thickness of the jaw? What about the shape
of the jaw? Is it completely parallel inside and out? Is
the jaw curved and undercut? We get some wonderful
shapes of lower jaw. One of my favourites is the “figure
of eight” where literally the jaw goes really thin in the
middle and then fat at both ends but when you look at
a “figure of eight jaw” on a two-dimensional panoram-
ic, it looks uniform. It also looks like there is a lot of
jaw height because the whole thickness of the jaw is
superimposed on a flat film. So, CT not only
provides better accuracy but it also provides something
really very important: three-dimensional evaluation of
the site.
This is one of my patients who had some implants pre-
viously. Now the bridge at the top is failing with decay,
but again I ask, what is the jaw thickness? I will tell you
what normally happens. The untrained surgeon goes,
“Ah, that’s a nice thick jaw”; they look at the pano-
ramic and they say, “Oh, yes, lots of bone height; it’s a
slam dunk; I could do that with my eyes shut”, but the
more trained surgeon knows that it is not always like
that and, as you can see from the CT scan, the jaw is
extremely thin. I can tell you that it only measures
about 2–3mm thick. You just could not get an implant
in there. In fact, if you tried to put a drill through that
bone it would completely disintegrate. So, what looked
good on a two-dimensional X-ray and what felt good
in the mouth was actually thin. Why was it feeling good
in the mouth? Because much of the thickness is gum,
palatal gum. So, when I am feeling the jaw with my
fingers I am feeling the total thickness but what I really
want to know is the thickness of the bone. So, it is easy
to make mistakes if you really do not know what you
are doing. Once you know that, as you can see on this
CT scan, I have drawn some lines just to show how
much bone I need to add to get a bare minimum in
order to place an implant. It is almost twice the thick-
ness of what is there, so I need to create double the
thickness of what currently exists. We will come back
to this but also note the white line that you see in front
of the jaw, this is part of what we call a radiographic
stent that is based on a tooth setup that is based on a
full restorative analysis, and confirms the tooth posi-
tion on the scan.
Norton 5

The CT scan and the occlusal and restorative analysis

Just to give you some idea, ultimately we can take
are all kind of intertwined, so forgive me if I go back
these CT scans and use them to do virtual surgery. We
one to the other. Here is a case that was sent to me. We
can place the implants in the scan. You can see that I
have failing teeth on the far left – the patient’s right –
have outlined the nerves in this scan, that is the yellow
and I do not think you need to be a dentist to see that
“strings”, and we can also look in cross-section. This
something bad is going on there. There is decay under
shows a relatively parallel mandible. There is a very
the bridge and she has an implant, a very successful
mild undercut but sometimes that undercut can come
single tooth implant on her left. The post crown next
all the way in and if you do not know that you are in
to it is failing; and this post keeps coming out all the
big trouble. The nerve, clearly outlined from my anal-
time and so on and so forth. How are we going to plan
ysis, allows me to now measure how big an implant I
a complex case like this?
can use and how close I want to get to the nerve and
you start to understand how much safer that can be
than just relying on the two-dimensional panoramic
X-ray. So, when you get cases where all they have is
a panoramic X-ray, alarm bells should start ringing.

The first thing that we do is take impressions of her

mouth and we get them mounted on what is known as
an articulator and then we get a complete restorative
setup. Basically, what the lab has done here is to cut
each of her teeth off the model and set up a false tooth
in its position roughly the same shape and size, maybe
better looking in colour and so on, and then the green
material is recording the bite registration. We can
duplicate that into a surgical or radiographic template.
So, it gets duplicated into a clear acrylic plastic tem-
plate, which can have little holes or little notches in and
I can use that in the surgery to place my implants. This
is what we call an analogue template; this is not very
sophisticated.
6 Medico-Legal Journal 0(0)
I show you this because this is really the bare min-
imum. Today we can do all the planning on the CT
scan as I have shown you and actually get a printed
surgical guide made from the computer. They are more
sophisticated. Interestingly, if you compare the accura-
cy of a computer-driven guide to an analogue guide in
the hands of an experienced surgeon, there is not a vast
amount of difference but in the hands of a relative
novice there is a huge amount of difference. So,
CT-derived guides are more accurate than this.
What can we do with the CT scan? A lot. We can
import it into third-party software; we can extract the
teeth on the computer; we can take our restorative
setup and superimpose it on the scan so that we now
have a set of perfect virtual teeth related to the jaw-
bone, in an ideal position. Having done that, we can
now go in and place the implants virtually.
The different colours of the implants are specific to
the size of implants we want to use and the numbers
you see correspond to the tooth position. So, every-
thing is pre-planned and I am going to use that surgical
template that I showed you during surgery to help me
drill and place the implants so that you can now start
to understand that the work done in the laboratory, the
work done on the CT scan, the work done on the
restorative analysis and ultimately the work done in
surgery all ties together. It should be seamless.
I hope none of you are too squeamish! I tried not to
put too many squeamish slides in but you have to have
some! Five of those implants are mine, they are the
ones with the serrated pins, the other one is the one
that was already in the patient’s mouth.
We can take the restorative work that was done
before an implant was ever placed – they were only
ever placed in the computer – and we can take that
piece of dentistry that was made before the implants
were physically placed. We can seat it over the implants
that have now been inserted, pick up the registrations,
make sure that it is in the right bite registration, and it
can be immediately retrofitted to the implants and then
eventually it can be sent to the dentist for the definitive
restoration. In this case, the referring colleague of
mine, he has made an all Zirconia full arch bridge
and it is, give or take, exactly what we planned on
the very first outing before we had done any surgery
or taken a single tooth out. If you look at the position
of the implants you will see that apart from the one
implant she came in with all the other implants which
we have placed, according to the CT scan and
Norton
according to our template, are in the right position in
the centre of each tooth. Then you can get a nicely
fitting restoration with really nice bone and aesthetic
result and that is how this should be done.
There is one natural tooth left and that is because if
a tooth has value or merit and is not diseased we do not
necessarily extract it. Unfortunately, too many teeth
are being pulled out “just because”, and we need to
be very careful that patients are not having teeth
pulled out unnecessarily. There is a company in
America called ClearChoice. ClearChoice is now a cor-
porate entity that has bought dental practices all over
the United States and they quite simply have a “one
treatment fits all” policy. If you go into one of their
practices, it really does not matter what state your teeth
are in – I am assuming there is some disease there –
good, bad or indifferent, because they will pull all of
your teeth out and give you a full upper and lower
implant-supported bridge. In my opinion, there is a
class action suit just waiting to happen! There are com-
panies that have tried to replicate that in the UK and I
am pleased to say that so far they have failed.
If you do not do any planning, if you do not really
understand what drives good implant dentistry, this is
what you get and this is one of the cases that I acted for.
7
What really amused me is that this photograph is not
one I took; this was sent to me from the dental practice.
Usually when people photograph their dentistry it is
because they take pride in it! (Laughter)
What was really interesting is that by the time this
patient came to me, such was the planning – you will
see there is a tooth here and that tooth was part of that
lower implant-supported bridge – that tooth had gone.
Why? Because it was rotten. So, not only did they put
in all these implants and they have put five implants in,
(1) why did they keep that tooth if it was rotten espe-
cially if they were only going to cut it and remove it
from under the bridge afterwards and (2) you will see
this is a very typical picture and one I find very upset-
ting; this is very simply a case of opening the top
drawer and saying, “What screws have I got in here?”
and rummage around.
These are all different brands of implant. All he has
done is try and see what he has on the shelf that he
can use up. You can clearly see that they have not been
put in with any planning forethought at all. Similarly in
the top jaw, the angles of the implants: he actually has
a cantilever on the upper right bridge. If he put one
implant mesially and put it vertically parallel to the
distal implant, he could have done a four-tooth
bridge on two implants or he could have put three
implants in but kept them all parallel, but for reasons
that we cannot decipher from the records he put them
where he put them and he has done a cantilever. Let
alone the fact – this is really when the GDC get very
upset and I would say rightly so – that he has done all
8 Medico-Legal Journal 0(0)
of this very expensive work and there are huge carious
lesions in some of the remaining teeth. I mean, do your
basic dentistry first! The back tooth on the patient’s top
left needs to be extracted; it is a non-functional tooth
for a start. The lower tooth needs to be extracted and
the implants needed to be placed further back to bring
the left quadrant into function.
Why did he not do that? I will tell you exactly why.
This is a dentist who wants to avoid any risk. So, he
does not want to place implants above the nerve. This
is someone who is not a surgeon who has no surgical
expertise at all. In the anterior part of the lower jaw it is
easy; there are no nerves; there are no major blood
vessels; it is quite thick; it is quite deep. You know
what, my 15-year-old son could put an implant in
there! That is the attitude that he has taken to it. The
problem is that unfortunately a lot of these patients are
not even being given a good deal. They think that if
they come to Harley Street and see someone like me it
is going to cost a fortune. Actually, they are already
spending a fortune. Even if it as not as much as some-
one like me would charge, if you are telling me that that
is £10,000 or £14,000 worth of quality work, you are
better off wearing full dentures.
Then there is just the inexcusable, the surgical
errors. This is another case that I am in the middle of
at the moment. Here you can actually see the nerve
quite clearly. Why is that implant half in and half out
the bone? I will tell you why it is only half in: he clearly
knew that the nerve was right there and he has put it as
close as he possibly could without damaging the
patient. So, why use an implant that is twice the
length? Implants cost a lot of money. Dentists do not
keep drawers full of armamentarium and if they take
the attitude of, “Well, whatever I’ve got on the day is
what I’ll use”, that is what you get. (Laughter).
Interestingly, this implant – by the way, again, different
brands – looks to be placed at the correct depth just
about in front of the nerve but why is this implant not
being used? It is because from day one the patient com-
plained that when he exposed that implant and tried to
remove the little healing screw it hurt, so he buried it and
said, “We’ll leave it as a sleeper, you don’t really need
it”. So, the patient has paid for three implants and now
because one hurts a little bit she does not need it? Are
you going to refund her that money? No, probably not.
Why does the implant hurt? Actually, it looks quite well
integrated and it is set at the right depth. Seen two-
dimensionally it is actually in a better position than
the one he has used! So why does it hurt?
Unknown speaker from the floor: It is very close to
the nerve.
Dr Norton: It is actually far enough forward to the
nerve that that is not the problem. I will tell you what
the problem is and this really drives home the difference
between a two-dimensional X-ray and a three-
dimensional X-ray. You see, in three dimensions you
can see that the implant was not even in the jawbone!
He did the surgery flapless. We call flapless surgery
where you basically either punch a hole or you make
an incision but you do not actually peel the gum all the
way back off the bone for good intention, to try and
reduce the trauma and the morbidity for the patient. He
has done it flapless and he has missed the bone entirely.
He has basically screwed the implant into soft tissue.
Here is where I start to get a bit upset because I am
acting for the patient against the dentist. We have said
this; we have provided evidence and the indemnity
company are digging their heels in and saying, “It
clearly states in the notes that he drilled an osteotomy
into bone and that the implant achieved good primary
stability. We do not accept it’s outside the envelope of
bone”. I am like – hello! Open your eyes! (Laughter) Of
course we will win! This is what is going on out there.
If you look here there is another implant. It looks very
close to the top of the nerve and this is where you have to
actually understand about CT scans because with that
image you might say, “It’s not really in the nerve canal;
surely that can’t be responsible”, but if we skip through
Norton
the slices of the scan and we go a little farther back
we start to see the implant protruding into the nerve
canal and this patient had paresthesia from this implant.
Unfortunately, even in today’s world with CT scans and
everybody knowing this is a high-risk game, we still have
dentists doing things like this – straight into the mental
foramen which is the hole in the bone where the nerve
comes out and spreads into the lip and chin.
So, this patient has a permanently numb chin and lip
and because nothing was done for a very long time it is
too late now. You could take that implant out to try
and decompress the nerve and you could send the
patient to Professor Tara Renton who has become an
expert on nerve damaged by dental implants but if an
implant has been sat there like that for two years, forget
it. The patient is permanently numb.
What about that! That is the sinus cavity. What is so
impressive about this is that the hole that was drilled
through the bone has healed up sealing the implant
inside the sinus. So, the patient has healed well.
Someone has to go in and retrieve that implant that is
just rattling around. What is worse is, what is that
retained root doing there? Where is the treatment plan
here? Why are you leaving this piece of rotten root that is
9
a potential nidus for infection? It is interesting how when
you see an X-ray like that, it is not just the bad implant
surgery that tells you this is a bad dentist, it is the other
little things that go with it that paint a picture.
Now I am going to be really brave and honest because I
am going to show you a case of my own. This is a lovely old
Polish lady who when she came to me about 12/13 years
ago, maybe more, had smashed her upper bridge to pieces,
broken teeth on the top right, smashed the porcelain on the
top left because she has a really deep bite
She came into my surgery, a lovely lady, survivor of the
Holocaust, bit of an alcoholic, bit of a smoker, the most
incredible personality I have ever met and I will not try to do
her accent. When I told her she could not be treated with
immediate same day bridgework, she just kept saying, “Dr
Norton, I’ve heard you are the magic man. I know you can
do it, Dr Norton. You can do it”. Of course, she massaged
my ego to the point that I thought, okay, maybe with careful
planning I can do this! I will tell you, the first thing you have
to do in a case like this is open the bite. Number one, you
have to create space. I cannot put implants in there; I will
never get teeth on them because there is no space. So, we did
a full workup: a full occlusal analysis and a full restorative
analysis. This is what will be her temporary bridgework
tried in before I placed any implants having extracted the
top teeth and you can immediately see, if you look at what
we have done is we have opened the bite by giving her back
teeth and support. We then went ahead and put the
implants in and we finished this bridge off which looked
pretty much like you see there except I did not really appre-
ciate that when someone has had a bite for 80 years their
system is not going to accept anything new, not easily, and
that system, the stomatognathic system as we call it, is going
to try and bite that bite right back down to where it used to
be, which she did to great effect. So, surgical stent, place the
implants and here we are just one-month post-op – in a
mess. Implants failing, broken bridgework; she has
smashed it to pieces.
10
What is the difference between her suing me and all
the other patients suing all the other dentists? The
answer is that when things go badly wrong, the true
definition of a specialist is someone who knows how to
get him or herself out of trouble rather than saying,
“Urgh, what do I do?” Worse than that, “Urgh, what
do I do?” and “No, I’m not giving you a penny back
because it’s your fault, it’s not my fault” which is the
standard mantra of most dentists who end up being
sued. Today, if I see a bite like that now they can mas-
sage my ego all they like, I’m not doing it! (Laughter)
In a case where things go wrong like this, I will take
it right back to square one and I will do the whole thing
again and I will not charge the patient a penny and I
will deal with the problem. The indemnity companies
tell us all the time that if you say to a patient, “I’m
sorry don’t worry, I will deal with the problem, you
won’t have to pay anything”, that is all it takes. You
may or may not be capable of doing it but that is what
it takes to stop a patient being litigious. That is all it
takes: promising to redo it and promising to redo it at
no charge to the patient.
Anyway, she eventually got treated and cleaned up.
With one of the original implants you can see that we
had some bone and gum retraction but we were keeping
it immaculately clean and she ended up with a reason-
able smile – the teeth are far too white but that is what
she wanted – and she continued to drink a bottle of gin
or vodka a day, smoke 30 cigarettes a day until sadly
about three or four years ago she passed away with all
her teeth! (Laughter).
Now is really the bit that I want to focus on. I do not
need to tell you about the definitions of negligence and
Bolam, but actually the reason why I put up Bolam here
is because I think the difference between Bolam and
Montgomery is actually of critical importance when it
comes to the condition of peri-implantitis. Why is it
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critically important? Bolam, as you know, says that the
standard of care is what is comparable or deemed accept-
able by a responsible body of medical practitioners. I ask
you, why do you think we place implants in patients?
Because they have lost their teeth. Why do most patients
lose their teeth? It is actually not because of tooth decay.
It is not because they all get their teeth smashed whilst
skiing on the slopes at Courchevel. It is mostly because
of gum disease. That means that the responsible body of
the profession globally is placing millions of implants
into periodontally compromised patients. So, you have
a problem legally I would argue because at least until
Montgomery comes along Bolam is not the answer.
Most adult patients will lose one or more teeth and
will present with one or more periodontal sites that score
a BPE of greater than or equal to 3. It is really not that
uncommon. Of course, the problem is that you only
need one site to score 3 in the whole mouth, according
to the latest workshop from the American Academy of
Perio and the European Federation of Perio, for that
patient to be deemed a periodontal patient. So, we
have a problem. You could look at that and I can tell
you that is a periodontal patient. Her teeth are all
moving and splaying and drifting and whatever. Why?
Because she has rabid gum disease.
What about this patient? This is a case I am dealing
with at the moment. Healthy gums and a good stan-
dard of oral hygiene. Surely this patient is not a perio
patient. Well, if you look at the patient’s panoramic X-
ray and actually if you look in the mandible the bone
levels are excellent and if you look in the maxilla for the
most part excellent, but there are some sites, specifically
in the posterior upper jaw, that score a 3. Here is where
I really start to have a problem with what is going on in
the litigation world because this patient is now being
deemed a periodontal patient. According to the BPE
when you have a score equal to 3 you should perform a
6-point pocket chart [at least] in that sextant only.
Norton
These are the very latest recommendations. I am kind
of glad that they specify “in that sextant only” because
here is the thing. She needs implants in her lower jaw,
not in her upper jaw. Yes, she has a site that needs
managing by the hygienist or the periodontist but, as
you know, Montgomery says that the test of materiality
is whether in the circumstances of a case a reasonable
person in the patient’s position would likely attach sig-
nificance to the risk. Here is where we have a problem
because I can tell you that if you asked a patient after
the event when something has gone wrong, “Would
you have had it done had you known that” blah-
blah-blah, of course they are going to say, “I would
never have had it done”.
This patient, no doubt with the advice of her lawyer,
is quoting Montgomery and saying that had she known
she was a periodontal patient, she would never have
had implants. Why is she saying that? Because it
turns out that the implants that she did have in her
lower jaw have peri-implantitis and they are claiming
that she is a periodontal patient and therefore she
should never have had implants. This is not the case.
I have no doubt there other factors which have caused
those implants to go that way, but I am afraid peri-
odontal disease is just not one of them and the fact that
she has a Code 3 in the upper left sextant does not give
her the right to quote Montgomery, but how you
manage that from a legal perspective I do not really
know.
Now, even though I am acting on behalf of the
patient, I am having this debate with her lawyer
because he is saying, “But there’s bone loss around
these implants, that is peri-implantitis”. I have just
given this lecture at the Royal College in Glasgow
just last week where the whole idea of what is peri-
implantitis is being driven by the periodontal specialists
in my profession and periodontal specialists live for
plaque, they live for calculus, and they believe that all
disease comes from plaque and calculus including peri-
implantitis. I am not saying it does not but I do not like
the way they are controlling the profession with their
classification. This is the very latest advice that has
come out from their working body consensus
11
from 2017. It defines peri-implantitis as “a plaque asso-
ciated pathological condition occurring in tissues
around implants characterised by inflammation”
blah-blah-blah:
Peri-implant mucositis that is just inflammation of the
gum is assumed to precede peri-implantitis. Peri-
implantitis is associated with poor plaque control and
patients with a history of severe periodontal disease.
This patient neither had poor plaque control – and you
could see from the photographs that she had a very
clean mouth – nor does she have a history of severe
periodontal disease. So, what is the cause of the prob-
lem? I am not saying that the dentist is not guilty of
something but let us find the real cause of the problem.
In my view, peri-implantitis could either be as the gum
specialists want us to believe, that is a primary disease
of infectious origin from plaque, or it could be a sec-
ondary opportunistic infection, that is that the bone is
lost first and that causes an inflammation of the tissue
which becomes sore and the patient cannot clean it so
well, so plaque starts to build up on it. It is cause and
effect. The periodontists want us to believe that it is
always plaque, inflammation, suppuration or infection,
and then bone loss. I say that it can be bone loss first,
then inflammation, suppuration, peri-implantitis. They
are the opposite way around.
This is a huge debate and with my colleagues at
UPenn in Philadelphia we recently published an article
arguing this very fact. We know/dentists know that
there are other things that can cause peri-implantitis,
for example foreign body reaction. What is that? I will
come to that at the end.
Take some dental cement around an implant that
was left underneath the gum. We call that cement-
induced peri-implantitis. It has nothing to do with
plaque. The interesting thing is that if you look at
this picture, you can actually see that the cement is
on the surface of the implant. How the hell did
cement get between the bone and the implant? If the
bone and the implant are tightly integrated, when the
dentist cemented the crown, how did the cement get
down on to the surface of the implant? The answer is:
because there was obviously never bone there in the
first place. So then we have to turn back and ask our-
selves, why was there no bone there in the first place? If
you remove the cement, clean the implant, maybe do
some bone grafting around it, whatever, this is a highly
predictable case to treat. This implant will heal up, be
healthy and it has nothing to do with periodontal dis-
ease or plaque.
12
What about Implants placed too close together or
implants placed too far forwards. Not as bad as the one
I showed you on the earlier X-ray but still if it has been
placed too far forwards, so there is no bone covering
the front of that implant. These are not plaque induced,
so, please, be very careful with these cases because
pretty much 70 per cent of all the cases that are landing
on my desk are saying that the patient should never
have had implants because they had periodontal dis-
ease and they are susceptible. There may be cases like
that.
The FDA hid a reality that was discovered very
recently in June by a tabloid newspaper in America,
that did an undercover investigation and discovered
that the FDA were hiding the fact that there were mil-
lions of records for incidents involving medical devices
like breast implants, hip implants, and, as I have
highlighted, dental implants. In fact, what they found
was that the FDA had 2.1 million reports of bad dental
implants and as many as 114,000 just last year. What is
going on with all these implants? Of course, a lot of
them are just badly placed implants/badly restored
implants.
I am on the Board of a new not-for-profit organisa-
tion called the Clean Implant Foundation. There are at
least 300 to 500 different brands of implant out there in
the marketplace. Out of those 300 to 500 implants, only
five would be considered premium brand and by
“premium brand” I mean an implant with any signifi-
cant documentation at all. In the FDA and in fact
under the old Medical Devices Directive, which you
may or may not know is about to change and
become much, much more stringent, in America they
call it a 510(k) approval. Basically, if it looks like an
implant, smells like an implant, tastes like an implant
and is made of titanium, you do not need any docu-
mentation at all. All you need to demonstrate is good
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manufacturing practice. In other words, they come and
they inspect the facility and that is it. Of those 300 to
500 implants on the market, 295 of them or maybe 495
of them have no documentation whatsoever and what
we have found at the Clean Implant Foundation – we
have only just, if you will pardon the pun, scratched the
surface – is that many of these implants are covered in
impurities.
This is a true scanning electron image of a dental
implant at low magnification. Believe me, you would
not want to see it at high magnification. It looks noth-
ing like the surface from a premium brand manufac-
turer.
In a recent article that we have just published, actu-
ally, I was not part of the list of authors on this – I was
too busy having a hip implant which I hope was clean –
the hypothesis was that three well-established implant
systems were not only produced with a higher level of
surface cleanliness but also provided significantly more
comprehensive clinical documentation.
Conclusions: In contrast to the original implants of
market leading manufacturers, the analysed look
alike implants showed significant impurities underlin-
ing the need for reviews of sterile packaged medical
devices and their clinical documentation.
So, when we go back to implants like the one I was
showing you in the lower jaw, this is straight out of the
instruction letter that I received:
It is alleged that the patient should never have been
treated with implants in the first place because she
was known to suffer from periodontal disease.
I do not believe that is the case in this particular
patient. In fact, the implant is an implant I have
never heard of and I know most implants. I found
Norton 13

out that it is manufactured in France . . . (Laughter)

Many of the implants that we see go dento-legal are
often implants that we do not even recognise and we
have a far bigger problem than that and that is this.
Forget all the ones that go legal, we have millions of
implants out there from small here today gone tomor-
row manufacturers and when they go wrong five years
down the line or ten years down the line and you go to
another dentist because you had it done in Hungary or
wherever you had it done or even here, and we ask,
“What implant is that?” and they say, “Umm, don’t
know” or maybe they say, “Oh, it’s an “Other”
implant” and you look on the internet for “Other”
implant, you cannot find it and you do some research
and you find out that they went out of business three No bone loss. No gum disease. Again, Bolam or
years ago. There are no spare parts, no components. Montgomery or neither? All I am asking is that you
What options do we have? Only one: cut the implant be very careful about throwing peri-implantitis out
out and start again. If there are no spare parts or you there as “this patient should never have been treated
cannot identify the implant to get the spare parts, there because she had periodontal disease”. It is often not the
is no option: you have to remove the implant otherwise case.
it cannot be treated. That is happening every single
day.
At the moment, litigation is not paying much atten-
tion to whether an implant is a premium brand implant
or not. I believe that is an area that we need to look at
far more closely and we need to understand that the
pathway to peri-implantitis may not in fact be because
the patient has a history of periodontal disease, may
not be because they do not brush their teeth and we
need to look beyond that dogmatic view of what peri-
implantitis is.
That all said, do not be under any illusions. You can
take a genuine periodontal patient and you can treat I would say some myth busting is needed. Is it a
them very successfully. primary bacterial infection that causes bone loss?
Well, it is under some circumstances but not necessar-
ily. Can it be a secondary opportunistic infection?
Absolutely. Is it an epidemic? No. Is it untreatable?
No, in the right hands. Does it mean inevitable implant
failure? As I showed you with the 82-year-old, I kept an
implant going with 70 per cent bone loss around it and
I kept that implant going for over a decade until she
died. So, it is not inevitable implant failure and it does
not have to ruin your patients’ lives. However, it does
entirely depend on the execution of atraumatic surgery,
implants from well documented premium manufac-
turers placed in a sound envelope of bone with at
The problem is that the periodontal world has told least one millimetre of bone thickness around the
me and I would argue the legal world is telling me that I entire circumference of the implant and a restoration
should not be doing that. Yet I have many cases like that is free of mechanical and/or material irritations
the one shown on page 9 who were treated and that are appropriately designed to ensure access for effective
doing extremely well after 11 years in function. oral hygiene.
More than all of that, it requires one other thing: a
compliant patient. I am afraid that the last thing I will
leave you with is this. At what point – I think this goes
in the medico- as well as the dento-legal world – does a
14
patient have to take some responsibility for themselves?
Too many times I have had cases come across my desk
where to all intents and purposes the dentist has done
everything if not by the book pretty close to by the
book but the patient just does not look after them. It
does not even have to be that. I had a case where the
patient was advised straight off the bat that she should
not have immediate same day bridgework like I have
presented, but, she should have extractions and a den-
ture first. She would need bone grafting because she did
not have enough bone or at least the dentist was con-
fident that she did not have enough bone. She should
have a CT scan and full work-up. She did not like that;
she went somewhere else and was told, “You don’t
need a CT scan, you’ve got enough bone, I can do
this in a day, it’s a piece of cake”. Of course, it all
went horribly wrong. Of course, the dentist who did
that is guilty of negligence, I get that, but the patient
had been given good advice and sometimes I think
patients have to accept responsibility for themselves.
With that, I say thank you very much. (Applause)
The President: Thank you very much, Michael. We
will be cleaning our teeth very carefully from now on.
We do have time for just a couple of questions as it is a
little late.
Mr Miller: My name is Douglas Miller. What is the
aetiology of bone loss before inflammation in peri-
odontal failure?
Dr Norton: Principally surgical. For example, if I
were to strip the gum off everybody in this room, you
and I both know that a number of these people would
have dehiscence defects in their anterior segments. The
average bone thickness in the pre-maxilla on the facial
aspect is less than one millimetre and we know that it is
not very sustainable. I think probably if we were to go
back and strip the gum off of all the implants ever
placed in the world, we would find that many of
them had a lack of bone on the facial aspect. So, I
would put that right at the top of my list for a pre-
disposing bone loss or the sort of surgical cases I
showed where they were just simply placed outside of
the bony envelope. I put that pretty much as the
main cause.
Professor Zeitlin: Harry Zeitlin. Very briefly, is it
possible to give us a rough estimate of what the differ-
ence in cost is between somebody who knows what they
are doing and can do it properly and plan it but it takes
more time than, say, the average high street dentist?
Dr Norton: I can try. I will say that the only reason
why I hesitate is because it is not that easy because a
number of high street dentists will charge as much if
not more than me. I will give you a classic example. I
had a patient who came to me about four years ago
now from Poole in Dorset and she was told that she
needed her front teeth replaced and the way they
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wanted to do it was very involved, let us just put it
like that, and they basically quoted her over £5000
per tooth. She said, “I didn’t want to come to Harley
Street because I assumed you would be more than that”
and I said, “Well, you’ll be pleasantly surprised to hear
that I can do it for at least £1000 per tooth less than
that”. That is why I slightly hesitate but, as a general-
isation, of course there is a difference. If you looked at
the country as a whole, if you went to the Polish
implant centre you could get an implant from start to
finish for £900; I think that is what they advertise. If
you come to me, if I am doing the whole thing from
start to finish, it is going to cost about £4000. If you
want to look at the average, the average in the country
is about £2500 per tooth. If you are paying less than
that you really are going to get monkeys I should say.
Professor Isaacson: Thank you, Michael, for a very
nicely produced lecture. I am Keith Isaacson from the
charity HealthWatch and we are particularly looking at
devices that are implanted in general, hips, knees, you
name it, and we are looking at recording the data. Are
the implants individually coded? Is the patient given a
record of what implants they have so that when they
change dentists they can be traced?
Dr Norton: I can tell you that as President of the
British Association of Dental Implantology and as
President of the Academy of Osseointegration – during
my presidencies we campaigned for a registry and on
both occasions it got absolutely halted at the first
hurdle. People are not interested. The implants are not
individually marked. They have a reference number and
a lot number but they do not have a unique individual
identifier. Interestingly, now that we’re entering into the
world of CAD/CAM, the posts that we get made to
screw into the implants are actually individually custom-
ised posts and those have individual numbers. However,
implants are basically stock; they are off the shelf; they
come in a variety of sizes; but they are stock off the
shelf. They all come with stickers. I will guarantee you
that in 90 per cent of all the dento-legal cases I see those
stickers are not put into the notes, the batch numbers
are not recorded, nothing is recorded. All they put is the
size of the implant. If you get the size, you can count
yourself very lucky. In my practice, we actually peel the
stickers off, we note in the clinical records the batch
number and the reference number and we have little
cards that we stick the stickers on and give it to the
patient, which they then throw in a bin usually!
The President: Non-compliant patients! We will take
one last question.
Ms Parsno: My name is Shirin and I am a dentist
from Sweden. I actually trained for implant surgery
with Professor Brånemark about 20 years ago and I
started with Brånemark implants, you know the origi-
nal machine surface, implants and eventually we are
Norton
looking at the latest implants. Six or seven months ago
I was in Sweden back at the hospital in Halmstad and
Gothenburg and now we have peri-implantitis as an
actual speciality in the hospital. I agree with what
you said, the many things you mentioned here about
the cement, about alignment mistakes, about many
things, but, to my surprise – you know in Sweden
Nobel is one of the implants we place, and
Straumann – most of the failed implants because of
peri-implantitis were actually Nobel and Straumann
and augmented implants and any augmentations, so
we could see good patients. In fact, we had someone
from the Royal Family there with really clean teeth,
everything, and they were showing us that peri-
implantitis is a concept that we do not get and the
argument was it is not actually so much the impurity
of titanium but actually more the abutments and the
corrosion between the abutment and the implant and
the systemic problems. Most of these patients have
high cholesterol levels, so when we were treating
those implants in the hospital we are immediately con-
tacting the GPs asking them to bring down the choles-
terol level and, if they are diabetics, to control the
diabetes, and the systemic problems and then, like
you mentioned, maintenance and compliance.
Dr Norton: I did not actually mention host factors
but in all medicine and surgery you can never rule out
host factors. I do not think we pay nearly enough
attention in the world of dentistry to host factors. We
talk about uncontrolled diabetes or this and that but
we do not really pay enough attention to that. I think
that is a point well made. I am not saying that peri-
implantitis is not a big problem, I am just saying it is
15
not all about plaque and tooth cleaning. There are
many, many factors involved and I think that from a
dento-legal point of view, since that is what this eve-
ning is about, all I am really saying is that we together,
your experts and yourselves, need to make sure that we
are in fact presenting the right argument, the right aeti-
ology of disease, and not just allowing ourselves to
have this blanket statement of “The patient had peri-
odontal disease; she should never have had implants”.
It is not a truth. Patients with periodontal disease can
have implants and can have implants very successfully
for a long time and patients who frankly do not have
periodontal disease and have beautifully clean mouths
can get peri-implantitis and it could be host factors. I
suspect it was the surgery but that was the case where
we do not have the surgeon’s records, so I cannot know
what happened in surgery.
I think that a lot more detective work needs to be
done. I am not trying to disparage experts but I think
that very often the path of least resistance is easiest and
if someone says “periodontal disease” and the patient
says “Montgomery tells me I have the right to say I
would never have had it done had I been told that I
had gum disease”, to me it is just making it a little bit
one-sided.
The President: Michael, thank you very much for
telling us lawyers that we cannot do things too
simply! We have to be more complicated than we are.
We have learned a great deal from tonight and it was a
fascinating lecture. Thank you very much, indeed.
(Applause)
(The meeting concluded at 8.20 p.m.)