A dental practice in the Manchester area

3. Mr A complains about the treatment he received from the Practice on 30 May 2025 and 2 June 2025. He states: • a loose crown was recemented in the incorrect orientation • the incorrect procedure was followed to replace the loose crown; dental cement was added and cured before a bite test was conducted and it could not be repositioned • a follow up repair left sharp metal edges and the dental cement exposed

4. Mr A says he has been left with dental cement exposed, sharp edges to the gold crown and in pain when he eats.

5. Mr A is seeking an apology from the Practice acknowledging that the care is below what is reasonably expected. Service improvement from the Practice taking learning from the recognition the procedure has been incorrectly carried out and a financial settlement for the cost of a new gold crown.

6. Mr A attended the Practice as an emergency appointment on 30 May 2025, after his gold crown became unattached.

7. Mr A was given advice from the Practice that the crown had small perforations and should be replaced. Mr A asked for the crown to be recemented, and the Practice refitted the crown.

8. Mr A returned to the Practice as an emergency appointment on 02 June 2025. He was seen by another clinician and Mr A asked for remedial work on the crown due to the pain and discomfort he was in. Mr A remained unhappy with the outcome.

Incorrect Orientation of the crown

11. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong.

12. Mr A tells us he attended an emergency appointment after a gold crown on the left side of his mouth became detached a few days earlier. Mr A says he asked for the original crown to be refitted but it was re-cemented in the incorrect orientation, it had been rotated 180 degrees, and this caused him severe discomfort. He tells us he was unable to eat or to bite down on the left side of his mouth.

13. Mr A says he was in so much pain he asked for another emergency appointment on 2 June and was seen by another clinician. Mr A tells us the second clinician agreed the gold crown had been recemented incorrectly and this was the source of the pain he was experiencing.

14. The Practice in the response to Mr A’s complaint, state the gold crown showed signs of wear and there were three perforations in the biting surface. The Practice recommended replacing the crown with a new one, but Mr A asked for the original crown to be refitted. The Practice state the crown was refitted and was correctly orientated.

15. We can see from the Practice’s response letter it apologises for the continued discomfort Mr A was experiencing and as a gesture of goodwill it offered to pay half of the cost to replace the crown with a new one.

16. We can see from Mr A’s medical notes on 30 May 2025, the Practice discussed the perforations in the crown and warned Mr A there was a risk of bacteria entering beneath the crown. The records indicate Mr A was aware of the risks and asked for the crown to be refitted. This was carried out and the occlusion (how the upper and lower teeth meet when the mouth is closed) was checked.

17. We can see from the medical records Mr A returned on 2 June and was seen by a second clinician. The Practice found the crown had been refitted in the correct orientation and there was no evidence of cementation error.

18. We accept the second clinician could not be considered to be totally independent as they work at the Practice. In this case we could look to take independent advice and would supply all available evidence to reach an independent decision. Unfortunately, we are not able to source any evidence of the crown before it became loose, nor any evidence of the crown in a complete state after being recemented.

19. We would not be able to reach a satisfactory conclusion about the orientation of the crown and there would be no value in providing a response through an investigation.

20. We regret we cannot come to a decision and so we must decline to proceed with this part of the complaint.

The incorrect procedure was used to replace the crown

21. Mr A tells us the procedure the Practice used to replace the crown was not correct. He explains he has had crown fittings before and knows the cement should not be cured before a bite test as there is no way to adjust the fitting once the cement is cured.

22. Mr A explains the height of the crown was incorrect and this led him to experience severe discomfort and unable to bite on the left side of his mouth.

23. The Practice response says the advice given to Mr A after refitting the crown was the crown “may feel a little strange for the next few days and would need time to settle”, because the crown had been out of his mouth for approximately one week.

24. On returning to the Practice on 2 June, Mr A was seen by a second clinician. We can see from his medical records the clinician noted Mr A experienced pain on biting. The crown was checked, and the records note the crown was seated correctly.

25. The records do not show all the steps taken in the procedure to refit the crown. We could ask for independent advice, but we are unable to provide any evidence on how the procedure was carried out. Even if we asked for an independent adviser to provide advice on the sequence of steps which should be used to carry out this procedure, we would not be able to show whether the Practice followed the sequence or not.

26. We would not be able to reach a satisfactory conclusion about the procedure to refit the crown and there would be no value in providing a response through an investigation.

27. We regret we cannot come to a decision and so we must decline to proceed with this part of the complaint.

The follow up repair left sharp edges and exposed dental cement

28. Mr A tells us due to the pain he was in he required the Practice to carry out remedial work in the appointment on 2 June. He explains the only thing which was possible was to file down the biting surface of the crown. This resulted in sharp edges being left on the crown and the dental cement beneath the crown being exposed.

29. Mr A explains at the appointment he was only given one option to resolve the pain he was in and that was to file down the crown. He is still in discomfort and is unable to eat on the left side of his mouth due to the sharp metal edges.

30. We can see from Mr A’s medical records the advice on 2 June was to leave the crown to settle as the crown had been missing from the tooth for a week prior to recementing. The records state this advice was discussed with Mr A, but he was insistent that remedial work needed to be carried out at the appointment and asked for the crown to be removed. The records state removal of the crown was not possible due to the risk of fracturing the tooth and so a high-speed bur was used to remove a high spot.

31. The records show a follow up appointment for two weeks was recommended.

32. Since the appointment on 2 June 2025 Mr A has not had any further work on the crown. The tooth remains with the biting surface filed down. He tells us he is in discomfort and unable to eat on the left of his mouth.

33. We note Mr A has not taken any action to resolve the issue. We have heard and considered Mr A’s account of the discomfort he is experiencing.

34. We can see the Practice has offered to cover half of the cost of a new standard crown at their Practice. We consider this to be a reasonable resolution for Mr A as we have not seen any evidence of failings in the Practice’s actions, Mr A did not keep his follow up appointment, and we saw Mr A’s gold crown was damaged prior to him visiting the Practice.

35. We regret we are not able to take further action of Mr A’s complaint. We thank him for bringing the complaint to us and we are sorry to hear about the difficulties he has experienced.

1. We have carefully considered Mr A’s complaint about treatment he received from the Practice between 30 May 2025 and 2 June 2025.

2. We would like to reassure Mr A we have not seen indications the Practice treated him incorrectly. The Practice acted in line with General Dental Council guidance and standards in patient expectations (GDC). The Practice has responded to Mr A’s complaint and offered a pathway to reach an outcome with him. We hope the explanation below reassures Mr A the Practice handled his care appropriately.