AAI Limited t/as AAMI v Hamann

DETERMINATION OF REVIEW PANEL
CITATION:	AAI Limited t/as AAMI v Hamann [2025] NSWPICMP 286
CLAIMANT:	Westly Hamann
INSURER:	AAI Limited trading as AAMI
REVIEW PANEL
MEMBER:	Susan McTegg
MEDICAL ASSESSOR:	Geoffrey (Paul) Curtin
MEDICAL ASSESSOR:	John Giles
DATE OF DECISION:	28 April 2025
CATCHWORDS:	MOTOR ACCIDENTS – Motor Accident Injuries Act 2017; review of Medical Assessment Certificate (MAC); dispute related to the assessment of whole person impairment (WPI) of facial scarring; mouth; misshaped bottom lip; injury to upper palate and bone structure; scarring to leg and ankle; Medical Assessor assessed 2% WPI for facial scarring and 5% WPI for impact on mastication; Held – 2% WPI for facial scarring; 2% WPI for leg and ankle scarring; alveolar fracture completely healed; as per clause 6.196 of the Motor Accident Guidelines no loss of structural integrity as a result of a dental injury and no assessable impairment; MAC revoked.
DETERMINATIONS MADE:	MOTOR ACCIDENT INJURIES ACT 2017 WHETHER THE DEGREE OF PERMANENT IMPAIRMENT OF THE INJURED PERSON AS A RESULT OF THE INJURY CAUSED BY THE MOTOR ACCIDENT IS GREATER THAN 10% Certificate issued under s 7.23(1) of the Motor Accident Injuries Act 2017 1. The Panel revokes the certificate of Medical Assessor McGlynn dated 14 June 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a whole person impairment (WPI) of 4%: · alveolar fracture; · facial scarring, and · scarring of the right leg and ankle. 2. The Panel revokes the combined certificate of Medical Assessor Bodel dated 16 September 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a WPI of 9%: · leg – fracture of the right fibula; · ankle – fracture of the right ankle resulting in three surgical operations; · alveolar fracture; · facial scarring, and · scarring of the right leg and ankle. REASONS Certificate of the Review Panel dated 28 April 2025 3. The permanent impairment in relation to the following injuries caused by the accident is 4% WPI: · alveolar fracture; · facial scarring; and · scarring of the right leg and ankle. Certificate of Medical Assessor Bodel dated 15 April 2024 4. The permanent impairment in relation to the following injuries caused by the accident is 5% WPI: · leg – fracture of the right fibula, and · ankle – fracture of the right ankle resulting in three surgical operations. Using the Combined Values Chart at page 322 of American Medical Association Guides to the Evaluation of Permanent Impairment, 4^th edition, the combined permanent impairment is 9%.

REVIEW PANEL REASONS FOR DECISION

INTRODUCTION

On 29 August 2020 Mr Westly Hamann (the claimant) was struck by a reversing vehicle which was attempting to angle park on a roadside verge (the accident). Mr Hamann sustained injury.
Mr Hamann was 33 years of age at the date of accident and is now 38 years of age.
Mr Hamann has brought a claim for common law damages under the Motor Accident Injuries Act 2017 (the MAI Act).
AAI Limited trading as AAMI (the insurer) is the relevant insurer with liability to pay any damages to Mr Hamann under the MAI Act.
Section 4.11 of the MAI Act provides that there is no entitlement to damages for non-economic loss unless the degree of permanent impairment of the injured person as a result of the injury caused by the accident is greater than 10%.
The claimant commenced proceedings in the Personal Injury Commission (Commission) in respect of the dispute as to whether the degree of permanent impairment sustained as a result of the injury caused by the accident is greater than 10%. This constitutes a medical assessment matter pursuant to Schedule 2, cl 2 of the MAI Act.
A medical assessment matter is determined in accordance with Division 7.5 of the MAI Act by a Medical Assessor.[1]
[1] Section 7.20 of the MAI Act.
The referral for medical assessment allocated the permanent impairment disputes as follows:
(a)    Medical Assessor Bodel
·leg – fracture of the right fibula, and
·ankle – fracture of the right ankle resulting in three surgical operations.
(b)    Medical Assessor Vertoudakis
·teeth – severe injury to several teeth which will require to be removed and replaced by crowns both in upper and lower jaw, mastication and deglutition.

(c)    Medical Assessor McGlynn
·face – severe lacerations to chin resulting in permanent scarring;
·mouth – misshaped bottom lip;
·mouth – injury to the upper palate and bone structure, and
·post-surgical scarring over his right leg and ankle region.[2]
[2] Claimant’s documents p 13
Medical Assessor McGlynn issued a certificate dated 14 June 2024. It is that certificate which is the subject of this review.

DOCUMENTS BEFORE THE REVIEW PANEL

On 14 January 2025 the insurer uploaded to the portal an indexed bundle of documents paginated from pages 1 to 776 (insurer’s documents).
On 22 January 2025 the claimant uploaded to the portal an indexed bundle of documents paginated from pages 1 to 110 (claimant’s documents).
Whilst the Panel has reviewed the entirety of the records furnished by the parties the Panel only proposes to reference documents relevant to the dispute it is required to determine.

RELEVANT LEGAL AUTHORITY

Section 7.21 of the MAI Act provides that the degree of permanent impairment of an injured person is to be assessed in accordance with the Motor Accident Guidelines (the Guidelines).
The Guidelines were issued pursuant to Division 10.2 of the MAI Act and adopt the American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fourth Edition (AMA 4 Guides). Version 9.3 of the Guidelines which commenced on 6 December 2024 are definitive with regard to the matters they address but where they are silent on an issue, the AMA 4 Guides should be followed.[3]
[3] Clause 1.2 of the Guidelines.
Causation of injury is addressed under Part 6 of the Guidelines dealing with permanent impairment:
“6.6 Causation is defined in the Glossary at page 316 of the AMA4 Guides as follows:
'Causation means that a physical, chemical or biologic factor contributed to the occurrence of a medical condition. To decide that a factor alleged to have caused or contributed to the occurrence or worsening of a medical condition has, in fact, done so, it is necessary to verify both of the following:
1. The alleged factor could have caused or contributed to worsening of the impairment, which is a medical determination.
2. The alleged factor did cause or contribute to worsening of the impairment, which is a non-medical determination.'
This, therefore, involves a medical decision and a non-medical informed judgement.
6.7 There is no simple common test of causation that is applicable to all cases, but the accepted approach involves determining whether the injury (and the associated impairment) was caused or materially contributed to by the motor accident. The motor accident does not have to be a sole cause as long as it is a contributing cause, which is more than negligible. Considering the question 'Would this injury (or impairment) have occurred if not for the accident?' may be useful in some cases, although this is not a definitive test and may be inapplicable in circumstances where there are multiple contributing causes.”

OTHER MEDICAL ASSESSMENT CERTIFICATES

Certificate of Medical Assessor Bodel

In a Certificate dated 15 April 2024 Medical Assessor Bodel certified the following injuries were caused by the accident and gave rise to a permanent impairment of 5%:
· leg – fracture of the right fibula, and
· ankle – fracture of the right ankle resulting in three surgical operations.[4]
[4] Insurer’s documents p 462
Medical Assessor Bodel referred to the report of Dr Dias and noted scarring to the right leg, right ankle and foot. Noting the scarring was referred to Medical Assessor McGlynn he did not undertake an assessment. He noted suture marks were clearly visible and there was a 1cm circular scar over the medial malleolus.

Certificate of Medical Assessor Vertoudakis

In a certificate dated 31 May 2024 Medical Assessor Vertoudakis certified as follows:
“I decline to make an assessment under s7.21(4) of the Act. The following injuries are not yet permanent:
Dispute to be assessed – severe injury to several teeth which will require to be removed and replaced by crowns both in upper and lower jaw.
Mastication and Deglutition
I have redefined this as a dispute to be assessed – serve injury to several upper anterior teeth which required extraction and replacement by implant supported bridge work in the upper jaw with a focus on Mastication and Deglutition.”[5]
[5] Insurer’s documents p 440
Medical Assessor Vertoudakis stated:
‘I have declined to make an assessment of Permanent Impairment under s7.21(4) of the act as the redefined injuries are not yet stable and have not reached maximum medical improvement in my opinion, “Severe injury to several teeth which required extraction and replacement by implant supported bridge work in the upper jaw with a focus on mastication and deglutition”.
The injuries have not reached stability or maximum medical improvement as the upper anterior bridge has functionally and aesthetically failed from the day of insertion. The claimant cannot chew on the upper anterior bridge without eliciting pain (note pressure on incisal of 11 and 21 eliciting pain radiating upwards into the upper jaw above 11 implant with less pain elicited when placing pressure on the 21 incisal edge). It has aesthetically failed from time of insertion with the claimant having to cover his mouth when smiling because he is embarrassed by the aesthetics of the labial of the bridge tissue interface.
As Dr Nichols has stated an assessment by an independent non-treating prosthodontic specialist … in conjunction with an oral surgeon … would be needed “for assessment, for an opinion as to diagnosis and causation of the current condition and appropriate treatment”.
This equally applies to the assessment and diagnosis of a) the failed upper anterior bridgework and b) the future appropriate treatment pathway to restore function and aesthetics.’
The claimant made an application under s 7.26 of the MAI Act for referral of this medical assessment to a Review Panel. In a decision dated 3 December 2024 the Delegate of the President declined to refer the review application to a Review Panel. Whilst the Panel finds this decision surprising it means this Panel does not have the power to review the certificate of Medical Assessor Vertoudakis.

Combined Certificate of Medical Assessor Bodel

On 16 September 2024 Dr Bodel issued a Combined Certificate in which he certified a combined permanent impairment of 12% taking into account his own assessment and the assessment of Medical Assessor McGlynn.[6]
[6] Insurer’s documents p 476

CERTIFICATE UNDER REVIEW - CERTIFICATE OF MEDICAL ASSESSOR McGLYNN

Medical Assessor McGlynn issued a certificate dated 14 June 2024.[7]
[7] Insurer’s documents p 452
The following injuries were referred to Medical Assessor Michael McGlynn for assessment:
·        face – severe lacerations to chin resulting in permanent scarring;
·        mouth – misshaped bottom lip;
·        mouth – injury to the upper palate and bone structure; and
·        post-surgical scarring over his right leg and ankle region
Medical Assessor McGlynn noted the Ambulance report relevantly recorded a split lip, upper and lower lip abrasion/graze, and cracked teeth. Facial lacerations were closed with stitches at Sutherland Hospital. He was noted to have damage to the upper incisor teeth and fracture of the adjacent alveolar maxilla. Subsequently Mr Hamann had all four upper incisor teeth removed. A bone graft was inserted to augment the anterior alveolus. Two implants were inserted into the upper anterior alveolus and temporary crowns replaced upper incisor teeth. Mr Hamann then had orthodontic treatment to align his teeth. A four-tooth dental prosthesis was fixed to the implants to replace the four missing upper incisors.
On examination Medical Assessor McGlynn reported the following scars:
·        a vertical scar on the left upper lip crossing the vermilion border 18mm x 2mm, hypopigmented with noticeable colour contrast, minor indentation, barely visible suture marks, minimal trophic features and no adherence;
·        on the lower lip a reverse L-shaped scar with limbs 10mm x 1mm and 10mm x 1mm hypopigmented with noticeable colour contrast, flat with no visible suture marks, minimal trophic features and no adherence;
·        to the right of the centre of the lower lip a transverse curved scar, 5mm x 1mm, hypopigmented with noticeable colour contrast, slightly raised, with no visible suture marks, minimal trophic features and no adherence;
·        on the buccal mucosa of the lower lip, an irregular transverse mucosal scar where the teeth had penetrated the lip. This was only visible with the lip everted. With lips open there was a soft tissue bulge to the right of the centre on the lower lip, and
·        on the underside of the chin, a curved transverse scar 45mm x 1mm, hypopigmented with some colour contrast, flat, with no visible suture marks, no trophic features and no adherence.
Medical Assessor McGlynn reported there was no visible facial skeletal deformity or asymmetry. The four upper incisor teeth were restored with a four-tooth ceramic prosthesis fixed to implants with an excellent aesthetic appearance. He reported the upper anterior maxilla (alveolus and anterior palate) were intact with no visible deformity of asymmetry.
He found normal facial sensation and normal spontaneity of facial muscles.
Medical Assessor McGlynn noted cls 6.189 to 6.191 of the Guidelines (Version 9.1) provides facial scarring and disfigurement are assessed separately to scarring elsewhere on the body. Assessment of permanent impairment involving scarring of the face may be undertaken using chapter three, “The Skin” pages 279-280 of the AMA 4 Guides and/or s 9.2, “The Face” pages 229-230 of the AMA 4 Guides.
Medical Assessor McGlynn assessed the scaring according to the Table for Evaluation of Minor Skin Impairment (TEMSKI) as per page 59 of the Guidelines. He reported Mr Hamann was conscious of the facial scarring, there was noticeable colour contrast with the surrounding skin, he was able to easily locate the scarring, there are minimal trophic changes, some suture marks are barely visible, the anatomic location is visible with normal clothing/hairstyle, there is visible contour defect of the lower lip, the is minor limitation of ADL (activities of daily living) due to facial scarring, no treatment is required, there is no scar adherence. He concluded seven of the ten criteria fit 2% under the TEMSKI scale and in his opinion the best fit is 2% WPI.
In respect of the mastication – palate/alveolar injury he relied upon the following clauses of the Guidelines:
·        6.195 - Damage to the teeth can only be assessed when there is a permanent impact on mastication and deglutition (page 231 AMA 4 Guides) and/or loss of structural integrity of the face (pages 229-230 AMA 4 Guides);
·        6.196 – Where loss of structural integrity occurs as a result of a dental injury, the injury must be assessed for a loss of functional capacity (mastication) and a loss of structural integrity (cosmetic deformity) and an impairment combined, and
·        6.197 – When using Table 6 Relationship of dietary restrictions to permanent impairment (page 231 AMA 4 Guides) the first category is to be 0-19%, not 5-19%.
Medical Assessor McGlynn reported Mr Hamann had a restriction of diet to soft food because eating hard and firm food causes pain in the anterior maxilla and alveolus. He concluded the mastication was mild and assessed a 5% WPI.
Using the Combined Values Chart Medical Assessor McGlynn assessed a total 7% WPI in respect of the following injuries caused by the accident:
·        face – severe lacerations to chin resulting in permanent scarring;
·        mouth – misshaped bottom lip; and
·        mouth – injury to the upper palate and bone structure.

REVIEW PROCEDURE

On 4 November 2024 the insurer sought a review of the medical assessment of Medical Assessor McGlynn.
On 27 November 2024 the delegate of the President being satisfied there was reasonable cause to suspect that the medical assessment was incorrect in a material respect referred the medical assessment to the Review Panel (the Panel).[8]
[8] Section 7.26 of the MAI Act, Insurer’s documents p 7
Rules 127 to 130 of the Personal Injury Commission Rules 2021 (PIC Rules) are made pursuant to Part 5 of the Personal Injury Commission, Act, 2020 (PIC Act). A Review Panel determines how it conducts and determines the proceedings and may determine the proceedings solely based on the written application.[9] The review is by way of a new assessment of all matters with which the medical assessment is concerned.
[9] Rule 128 of the PIC Rules.
On 12 February 2025 the Panel agreed an examination was necessary.

EVIDENCE BEFORE THE REVIEW PANEL

Application for personal injury benefits

In the Application for personal injury benefits dated 11 September 2020 the claimant outlined the following injuries sustained in the accident:
·        broken right leg tibia bone;
·        broken right ankle;
·        cartlidge (sic) damage;
·        broken teeth;
·        broken palate; and
·        stitches chin and lip.[10]

Treating medical evidence

[10] Insurer’s documents p 14

Photographs of scarring

The claimant provided the following photographs:
·        photographs of the scar on the outer side of the claimant’s right leg;
·        photographs of the scarring in the region of the claimant’s right ankle, and
·        photographs of the scarring to and in the vicinity of the claimant’s top and bottom lip.

Ambulance Report

NSW Ambulance attended the accident on 29 August 2020.[11] The report relevantly notes the claimant had a split lip with a cracked front tooth.
[11] Insurer’s documents p 95

Sutherland Hospital

The discharge summary of 29 August 2020 reported an injury to teeth and anterior alveolus and a lip and chin laceration. Analgesia and antibiotics were administered and imaging studies done. A fracture of the right fibular was immobilised with splint. The lip and chin wounds were sutured, and tooth 11 (right upper central incisor) was glued in place. Mr Hamann was transferred to St George Hospital.

St George Hospital

The discharge summary dated 31 August 2020 documented the following injuries:
·        a three part fibula shaft fracture likely with an unstable ankle mortise;
·        dental injury with an intrusion, Ellis 2 fracture and overlying maxillary/alveolar fracture of the right 1^st upper incisor and subluxation of left 1^st upper incisor;
·        laceration to chin and lower lip, and
·        loose 12 tooth post LMA insertion which was glued in the Sutherland Hospital with alveolar fracture.
It was noted Mr Hamann underwent syndesmotic fixation of the right ankle under
Dr Gunkelman on 31 August 2020.

Australian Health Care Centre clinical notes

Mr Hamann consulted Dr Malik, general practitioner (GP) on 13 September 2020. Dr Malik reported:
“he was a pedestrian
car revered (sic) and ran over his fibular spiral fracture
fell forward sustained mouth dental trauma lip laceration
attended Sutherland hospital where his lip was sutured and was transferred to St George where he had internal fixation of ankle
saw dentist who did dental alignment…”.[12]
[12] Insurer’s documents p 590

Dr Glen Baker, Jacaranda Dental

Dr Baker provided a report dated 20 October 2020.[13] He provided the following pre-accident dental history:
“Westley was a patient that I had last seen in 2010 after some dental restoration on his broken front teeth. The upper right central incisor (tooth 11), upper left central incisor (tooth 21) and upper left lateral incisor (tooth 22) were first injured in 2008 with a traumatic injury that saw a moderate break of all these teeth and resulted in endodontic treatment (root canal treatment – RCT) on tooth 21 and 22. These large restorations were re-treated in 2009 after some restorative failures and a further breakage of the 22 saw it being treatment with a crown in late 2009. All was dentally stable until the accident in August 2020.”
[13] Insurer’s documents p 379

He stated Mr Hamann presented on 7 September 2020. He provided the following diagnosis:
·        soft tissue injury of the lower lip and chin;
·        dental fracture of tooth 11 and 21;
·        complex dento-alveolar fracture of tooth 11 and 21, and
·        intrusion injury of the 11 with pulp necrosis requiring root canal treatment.
Dr Baker reported the teeth were manipulated under anaesthetic and rigidly splinted for six weeks. At removal of the splint the teeth were firmer. The roots of the 11 and 21 teeth were still buccal to the bony housing and displaced labially. He stated the positioning was not ideal and Mr Hamann was unhappy with their appearance. He recommended orthodontic repositioning and restoration to improve appearance and the longevity of the teeth.

Dr Matthew Lee, Worldciti medical dental

In a reported dated 30 October 2020 Dr Lee reported Mr Hamann splinting and stabilisation of the loose upper teeth.[14] He had undergone root canal of tooth 11 as it was necrosed. His upper front teeth 22, 21, 11 and 12 had bitten through his lower lip requiring stitches in his mouth, lower lip fold and mobility. Teeth 21, 11 and 12 were broken and protruded and he had an anterior open bite. His broken teeth were biting into his lower lip and ulcerating. Temporary restorations were placed on 21 and 11. Mr Hamann was referred to Assoc Prof Max Guazzato.
[14] Insurer’s documents p 363

Report of Dr Susie Kim, Dentist

On 17 January 2025 Dr Kim reported Mr Hamann presented with discomfort on chewing on the RHS anterior region felt in the upper maxilla and palate[15]. She reported the clinical implants were stable, gingiva healthy and maintained. She noted excellent aesthetics and occlusion and no movement or pocketing. She reported the OPG showed full integration of the implants.
[15] Claimant’s documents p 100

Assoc Prof Max Guazzato, specialist prosthodontist

Assoc Prof Guazzato assessed the claimant on 5 November 2020 and provided a report dated 16 March 2021.[16] He reported a radiograph showed fracture of the buccal wall of the alveolar ridge in the region of teeth 12 and 11. There was some bone loss in the interproximal region between teeth 11 and 21 and a concavity in maxilla apically to tooth 21. Tooth 21 had a deep root fracture. He reported tooth 11 was ankylosed (fused to the bone), tooth 21 had a root fracture, tooth 12 had root resorption and tooth 22 had undergone root canal treatment and been restored with a ceramic crown. He recommended treatment including extraction of teeth 11 and 21, bone grafting, stage 1 surgery to insert dental implants and stage 2 surgery to uncover the implants three to four months after stage one followed by placement of crowns or a bridge on the implants.
[16] Insurer’s documents p 391
On or about 17 November 2022 Assoc Prof Guazzato reported Mr Hamann appeared distressed, having been told by another dentist (a referee of the insurance company) that the maxilla was loose, and the implants were loose. Ass Prof Guazzato reported he did not find the implants to be mobile or the anterior maxilla. He found no gingival inflammation or suppuration and noted Mr Hamann was asymptomatic. Professor Louise Brown, dentomaxillofacial radiologist reviewed a Cone Beam CT dated 17 November 2022 (see below) which confirmed the stability of the implants.[17]
[17] Claimant’s documents p 17
In a report dated 18 November 2022 Assoc Prof Guazzato referred to the Cone Beam CT (CBCT) scan which was assessed by Prof Brown. He stated on examination, the gums, bone and implants were stable.[18]
[18] Claimant’s documents p 27
In a report dated 8 November 2024 Assoc Prof Guazzato reported the definitive bridge was inserted on 23 October 2023.[19] The bridge and the peri-implant tissues had been reviewed regularly and most recently on 7 July 2024 when they were noted to be healthy and unchanged with no signs of inflammation or infection. He stated the implant-supported bridge was stable and well-integrated with the surrounding tissues.
[19] Claimant’s documents p 15

Associate Professor Sam Adie, orthopaedic surgeon

Assoc Prof Adie diagnosed right ankle Maissoneuve (a three-part midshaft fibular fracture) injury with malreduced syndesmosis. On 19 September 2020 Mr Hamann underwent surgery at St George Hospital. The operation was described as “revision fixation right ankle Maissoneuve injury, incorporating removal of hardware, fixation of fibula shaft fracture, open reduction syndesmosis, tightrope syndesmosis reconstructions, and revision syndesmosis screw open reduction internal fixation”.[20]
[20] Insurer’s documents p 357
On 20 January 2021 Assoc Prof Adie removed the syndesmosis screw and inserted an Arthrex ankle tightrope.[21]
[21] Insurer’s documents p 353
Assoc Prof Adie reviewed Mr Hamann on 14 February 2022 when he reported Mr Hamann stood with normal alignment of his lower limbs. He described well-healed scars.[22] He recommended an MRI scan where Mr Hamann was complaining of lateral ankle pain and swelling with weight bearing activity. On 7 March 2022 Assoc Prof Adie reported the syndesmosis appeared well aligned and intact. He thought the main source of pain was probably early posttraumatic arthritis, although he noted a large degree of synovitis may be contributing to the pain.
[22] Insurer’s documents p 351

Statement of claimant dated 11 November 2024

Mr Hamann’s statement, in the main, addresses the certificates of Medical Assessor Vertoudaki.
In relation to the assertion by Dr Nichols that the “implant was loose” the claimant referenced the report of Assoc Prof Guazzatto dated 18 November 2022 where he stated a cone beam CT reviewed by a maxillofacial radiologist confirmed the implants were stable. Mr Hamann disputes he received a non-functional unesthetic implant bridge.

Imaging

CT facial bones/sinuses/brain, 29 August 2020 – the report states:
“The maxillary antra showed no air fluid levels. There is no fracture of the maxillary sinus or zygomatic arch. No fracture of the orbits. CT of the facial bones is also degraded because of motion artefact. Conclusion: Images degraded by motion artefact.”
X-ray OPG 31 August 2020 – the report states:
“There are no missing teeth. Tooth 18 is partially erupted. Previous root canal implantation at teeth 21 and 22. There is mild alveolar resorption. No neurologically occult carious disease. No periodontal lucency. The TMJs are normally located. The maxillary antra are well aerated.”
Cone Beam CT radiology report, 17 November 2022 - the report states:
“Anterior maxilla: The maxillary incisors are missing. Implants have been placed in the 11 and 21 sites fitted with healing abutments.
The implants have been well-positioned within the alveolar ridge, placed midway between the labial and palatal plates of bone. There is no evidence of effacement of the labial and palatal plates of bone. The implants do not encroach upon the cortical borders of the incisive canal. Within the limitations of CBCT imaging, there is no evidence of loss of crestal bone height. Correlation with the soft tissue parameters is required to assess the peri-implant status.
There is no evidence of bony pathology surrounding the implants. The heterogeneous radiodensity of the bone in the 12 and 22 sites is consistent with the use of bone graft material for ridge augmentation. The graft material appears to be well integrated with the underlying alveolar ridge. The cortical floor of the nasal fossa is intact.
Other Findings:
·tooth 18 is impacted with the crown tilted disto palatally.
·there is no obvious decay, periapical bony lesions or loss of crestal bone height affecting the maxillary dentition. …
·the visualised floors of the maxillary sinuses are radiographically clear.”

Medico-legal evidence

Dr Paul Nichols, dental surgeon

Dr Paul Nichols assessed the claimant at the request of the insurer and provided a report dated 11 November 2022.[23]
[23] Insurer’s documents po 410
On examination he noted the claimant had no upper incisors. His upper anterior (pre-maxilla) region was tender, and he could not bite on his front teeth. He noted residual scarring under the chin and residual cheloid scarring of the lower lip. He reported the mandibular opening and movements appeared normal. He reported teeth 11, 12, 21 and 22 were missing although 11 and 21 had been replaced by implants which were tender and loose. He noted the pre-maxilla was mobile and tender to palpation. Teeth 13 and 23 were tender to palpation and percussion. Oral hygiene was good.
Dr Nichols concluded as the accident caused the alveolar bone fracture it was likely the most significant factor causing the loss of teeth 11 and 21. He found the implants had failed. He found the claimant’s condition was not stable and he could not provide an opinion on causation in the absence of X-rays and clinical notes.
Dr Nichols recommended that Mr Hamann be referred to an independent specialist prosthodontist (in consultation with an oral surgeon) to be recommended by the ADA NSW branch for assessment and opinion as to diagnosis and causation of the current condition and appropriate treatment.

Dr Robin Mitchell, occupational physician

Dr Mitchell assessed the claimant for the insurer and provided a report dated 14 November 2022.[24]
[24] Insurer’s documents p 431
In respect of the scarring Dr Mitchell reported right leg scarring on both sides of the lower right leg and ankle measuring 10cm in length over the lateral aspect of the lower leg and
6cm at the ankle.
Dr Mitchell reviewed the claimant and provided a report dated 19 November 2024.[25]
[25] Insurer’s documents p 739
He reported Mr Hamann sustained a Maisonneuve fracture with disruption of the distal tibio-fibular syndesmosis and a possible undisplaced posterior malleolus fracture which required syndesmotic fixation of his right ankle on 31 August 2020. Mr Hamann underwent a revision fixation of his right ankle Maisonneuve injury with removal of hardware, fixation of the displaced fibular shaft fracture and open reduction of the syndesmosis, with a tight rope syndesmosis reconstruction and revision of the syndesmosis screw on 19 September 2020. He underwent a further procedure to remove a broken syndesmosis screw, with insertion of an ankle right rope around the syndesmosis on 20 January 2021.
Dr Mitchell did not comment on the surgical scarring.

Professor David David, clinical professor craniomaxillofacial surgery

Prof David assessed Mr Hamann on 12 May 2023. He provided a report dated
[26] Claimant’s documents p 60
16 May 2023.[26]
Prof David reported Mr Hamann complained of pain in and around his restored teeth. He reported gum recession which caused mild irritation as food gets caught in the junction between his prosthetic teeth and his upper gum. He reported Mr Hamann cannot bite into and chew hard and tough food unless it is cut into very small pieces. Mr Hamann reported he is very self-conscious of his appearance and his smile, reporting asymmetry of his lower lip when he smiles. He also complained of grinding his teeth and bruxism when sleeping. Prof David reported Mr Hamann constantly tried to cover his mouth and repeatedly said it was ugly.
Prof David concluded the prognosis for the claimant’s teeth was good as he had had proper restoration. He described his dental care as very good.
Prof David assessed mastication and deglutition using table 6 of the AMA 4 Guides
page 231. He noted the injury to Mr Hamann’s teeth, even after full restoration caused him to have pain biting into and chewing hard and tough food. He assessed a 5% WPI.
Prof David assessed facial scarring in accordance with page 229 of the AMA 4 Guides. He considered Mr Hamann met Class 1 Facial abnormality limited to disorder of cutaneous structures such as visible scars with a range of 0% to 5%. He noted a 1cm visible scar on the left lower lip, a horizontal distorting scar on his lower lip which produces a slight bulging and a 5cm scar on the underside of his chin. He assessed 2% WPI for the facial scarring.
Prof David assessed a total 7% WPI.

Good Rehab, earning capacity assessment report

Ms Katie Thomson undertook an assessment and provided a report dated 7 March 2024.[27] Whilst she was predominantly concerned with Mr Hamann’s orthopaedic injuries she reported Mr Hamann advised he had mild difficulty with his jaw and teeth when eating something hard or chewy.

SUBMISSIONS

[27] Insurer’s documents p 756

Insurer’s submissions

The insurer provided submissions dated 4 November 2024[28]. The insurer’s submissions also refer to the certificate of Medical Assessor Vertoudakis who declined to assess impairment for injury to teeth, and resultant mastication and deglutition on the basis the claimant’s injury had not stabilised and not reached maximum medical improvement.
[28] Insurer’s documents p 3
The insurer submits Medical Assessor McGlynn erred in attributing the claimant’s pain and difficulty masticating as caused by a palate injury where Medical Assessor Vertoudakis found the failed bridge implant was the cause of the claimant’s pain. The insurer submits Medical Assessor McGlynn erred in his diagnosis of the claimant’s injuries and assessed permanent impairment in circumstances where the impairment is not permanent.
The insurer relies on the conclusion of Medical Assessor Vertoudakis who considered there was no impact on mastication and deglutition as the claimant ate a healthy diet with a wide variety of foods and his molar and pre-molar teeth were intact and functional for chewing and crushing food as were his canines.
The insurer also submits the impact on the claimant’s mastication is a result of the failed bridge implant which can be corrected with treatment meaning that the impairment with respect of mastication is not permanent.

Claimant’s submissions

The claimant provided submissions dated 19 November 2024.
The claimant submits that if there is a review of the assessment of Medical Assessor McGlynn the assessment of Medical Assessor Vertoudakis should also be reviewed by the same Panel.
The claimant notes that Assoc Professor Guazzato in his report dated 18 November 2022 referred to a cone beam CT which determined that the gums, bones and implants were stable. The only treatment recommended by Assoc Prof Guazzato was the placement of temporary crowns on the two implants. The claimant also notes that Dr David also stated there was no further operative treatment required.
The claimant also submits that post-surgical scarring of the right leg and ankle region should also be assessed where the referral for medical assessment of Champa Ravikumar states Medical Assessor McGlynn is “to assess post-surgical scarring over his right leg and ankle region”.
The claimant provided additional submission dated 20 January 2025.[29]
[29] Claimant’s documents p 2
The claimant relies upon the report of Assoc Prof Guazzatto dated 18 November 2022 which, it is submitted, confirm that the gums, bone and implants were stable, and the report of
Dr Nichols was incorrect.
The claimant relies on the recent report of Assoc Prof Guazzatto dated 8 November 2024, and the report of Professor Louise Brown dated 17 November 2022 which confirms that the bridge has been stable since the date of insertion.
The claimant asserts he continues to experience pain whenever eating directly over the bone damage of the upper palate which affects mastication and degustation of most food types.

MEDICAL EXAMINATION

Mr Hamann was assessed by Medical Assessor Curtin in his rooms at Westmead on 11 April 2025.

History

Mr Hamann sustained injuries in the accident on 29 August 2020. He said the accident occurred while he was standing by the side of a car driven by his girlfriend which was reversing from a nature strip onto the road. As the car went over the gutter, it accelerated and swung around sharply striking him on the right lower leg and throwing him onto the ground. He said that he fell onto his face and most of the impact was taken by his chin, which was forced upwards and damaged the upper front teeth.
An ambulance attended and reported that Mr Hamann was fully conscious and complaining of pain in his right ankle. The report noted that he had a split lip with a cracked front tooth and an abrasion to the bottom lip. He was taken to Sutherland Hospital where he was assessed, and the following day was transferred to St George Hospital for treatment.
Imaging revealed a displaced fracture of the distal shaft of the fibula and a syndesmosis injury was diagnosed. The hospital notes reported few details concerning his facial injuries but noted that a laceration to the chin was sutured in the Emergency Department. A maxillofacial review recorded damage to two upper anterior teeth (11,12) associated with an alveolar fracture. Mr Hamann said that his lower lip sustained lacerations when the lip was forcefully driven onto the upper teeth. A CT scan of the facial bones was carried out, but apparently the images were degraded by motion artefact. Nevertheless, the report stated that there was no facial bone fracture visible. An OPG X-ray reported that no teeth were missing and noted previous root canal therapies on teeth 21 and 22. The alveolar fracture was eventually confirmed by CBCT on 7 September 2020. The upper teeth, which had been partially avulsed, were supported by a splint, and the unstable syndesmosis was stabilised in the operating room. He was discharged home on 31 August 2020.
On 7 September 2020 he attended a dentist, Dr G Baker, who noted that teeth 11 and 12 were mobile and displaced labially, and that there was an associated mobile alveolar fracture which he confirmed with a CBCT. Dr Baker provided splinting of the damaged teeth and further dental treatment over the ensuing two weeks.
On 19 September 2020 he was readmitted to the St George Hospital and underwent open reduction and internal fixation (ORIF) of the fractured fibula and a revision of the syndesmosis.
At some point later in 2020 he consulted Assoc Prof Max Guazzato, specialist prosthodontist, who treated him over the ensuing months, removing four upper incisor teeth (12, 11, 21, 22) and eventually inserted dental implants and a four-unit bridge prosthesis.

Current symptoms

Mr Hamann said he was happy with the appearance of the prosthetic replacement of his upper front teeth. He thought he had obtained a good outcome. He was questioned as to how the injury was now affecting his diet. He replied that the injury to his upper teeth and jaw had caused a “massive interference” with his diet and that he was unable to chew food without experiencing pain. He said that he did not think that the teeth were a problem and that he experienced discomfort in that part of the jaw around the teeth where there had been bone loss.
He said he was concerned about the disfigurement from scarring on his face and right lower leg. He said the scarring of his lower lip had left some irregularity which was apparent when he smiled. He said the scar on his upper lip was quite noticeable, as were the scars on his leg which he usually liked to keep covered with long trousers.

Findings on clinical examination.

Mr Hamann was a strong looking man of 38 years. He had a fair complexion and a BMI of 30.2 (99 kg and 181 cm).
On the left side of the upper lip there was a vertical scar, visible as a crease extending for
12mm. There were a few fine suture marks, no pigmentary changes and no adherence.
On the lower lip there was an irregular, pale, flat scar extending along and just below the vermilion border for about 20mm. There was some associated pigmentation but no suture marks and no adherence. There was no deformity of the lower lip at rest, but when he smiled, there was a very slight fullness of the central lip mucosa due to a small scar on the mucosal surface. On the undersurface of the chin there was a curved, flat, pale scar extending for 4cm, with no suture marks and no adherence. None of these scars were associated with any sensory loss or disturbance of facial movement.

On the lateral aspect of the right lower leg there were two vertical scars. At the level of the ankle joint, a flat, soft pale scar extended for 4cm. There were some fine suture marks, trophic changes but no contour deformity. Immediately above this scar there was another pale, soft, flat scar extending for 8cm. There were no visible suture marks but there was some associated loss of the normal contour of the lower leg. On the medial aspect of the ankle there were two further vertical scars. Overlying the medial malleolus there was a pale, flat, soft scar extending for 4cm with a few visible suture marks. Immediately adjacent to this was a further flat area of scarring extending for 1 square cm. Just above these scars was a further vertical scar extending for 6cm. This scar was also quite soft and flat but there was some associated darker pigmentation. None of these scars on the leg were adherent to deeper structures.
Examination of the mouth revealed a normal range of jaw opening with no evidence of temporomandibular joint dysfunction. He had a full dentition in good condition and in class I dental occlusion. The four upper incisor teeth (12, 11, 21, 22) were replaced by a four-unit bridge supported on two implants. The appearance of this bridge was satisfactory, and the upper dental arch appeared to be in good alignment. There was no mobility of the anterior alveolus although Mr Hamann complained of discomfort when the area was palpated. There were normal contours of the anterior palate and anterior vestibule. Gentle pressure on the incisal surfaces of the four-unit bridge produced inconsistent responses with regard to discomfort.

Results of any additional investigations

A letter dated 8 November 2024 from Assoc Prof Max Guazzato to Mr Hamann is in response to an earlier email from Mr Hamann which referred to various expert opinions critical of the four-unit bridge.
Assoc Prof Guazzato stated following the placement of implants, it was not until 23 October 2023 that the definitive bridge was finally put in place. He said Mr Hamann had been kept under review since then and had last been reviewed on 7 July 2024 when he stated that the bridge was symptom-free and did not cause Mr Hamann pain or reduce his ability to chew or talk. He further stated there were no signs of inflammation or infection and that no bone loss had occurred since the implants were inserted in 2022. Attached to the letter was a CBCT report dated 17 November 2022 of the anterior maxilla from Prof Louise Brown, dentomaxillofacial radiologist. The report stated “there is no evidence of effacement of the labial and palatial plates of bone …. there is no evidence of bony pathology surrounding the implants”.

Consistency of presentation

The clinical examination of the upper anterior alveolus was accompanied by inconsistent responses by Mr Hamann and some resistance to examination.

DIAGNOSIS AND CAUSATION

Mr Hamann sustained a fracture of the upper anterior alveolus and facial scarring caused by the accident.
He also sustained surgical scarring of the right lower limb caused by a Maisonneuve fracture with disruption of the distal tibio-fibular syndesmosis and a possible undisplaced posterior malleolus fracture caused by the accident.

PERMANENT IMPAIRMENT

Facial scarring

With regard to facial scarring, cl 6.189 of the Guidelines direct that facial scarring and disfigurement are assessed separately to scarring elsewhere on the body. Clause 6.191 of the Guidelines states the assessment may be undertaken using Chapter 13 (pages 279-280 of the AMA 4 Guides) which deals with the skin generally, or by reference to s 9.2 (pages 229-230 AMA 4 Guides) which refers to facial deformity.
The Panel has assessed the facial scarring using chapter 13, Table 2 p 280 of the AMA 4 Guides and the TEMSKI scale which in accordance with paragraph 6.264 of the Guidelines is an extension of Table 2. Because there were no limitations in Activities of Daily Living (ADLs), the facial scarring falls into the Class 1 category of Table 2. The Guidelines require that impairments in this class are assessed in accordance with the TEMSKI criteria.
Under the TEMSKI scale, the scarring falls into the 2% WPI category because the claimant is conscious of the scarring and is able to easily locate it. The location of the scarring is in an area which is usually visible with usual clothing, there is a visible contour defect, visible suture marks, and some parts of the scarring make a colour contrast with the surrounding skin as a result of pigmentary change. There was however no adherence and no treatment is required.
The Panel assesses 2% WPI for facial scarring.

Scarring of the right leg and ankle

In accordance with the Guidelines the scarring on the right leg is also assessed using Table 2 on p 280 of the AMA 4 Guides. As these scars have resulted in few limitations of ADLs, the scarring falls into the Class I category. Under the TEMSKI scale, the scarring also falls into the 2% WPI category on a best fit basis. The claimant is conscious of the scarring and is able to easily locate it. The scarring is located in areas which are usually visible with usual clothing. There are easily visible contour defects, but suture marks are barely visible. Some parts of the scarring make a colour contrast with the surrounding skin as a result of pigmentary change. There is a minor limitation in the performance of few ADLs, but the scars are not adherent.
The Panel assesses 2% WPI for scarring of the right leg and ankle.

Mouth – injury to the upper palate and bone structure

There is no evidence that the injury to the upper palate and bone structure has resulted in any impairment. The alveolar fracture appears to have completely healed. Clinical examination yielded no abnormal findings, and the most recent CT scan of the area did not show any abnormality.
Mr Hamann clearly held Assoc Prof Guazzato in high regard and was asked how his current symptoms could reconcile with the opinions of AssocProf Guazzato noted above.
Mr Hamann said that he agreed there was nothing wrong with his teeth, it was just the jaw that was painful. However, the Panel notes the alveolar fracture, is a minor injury of that small part of the maxilla which supports and invests the anterior teeth. Alveolar fractures normally heal quickly and do not require internal fixation. The fact that Mr Hamann had bone grafts prior to implant placement did not mean he had sustained a major injury causing bone loss. In fact, bone grafting prior to implant placement is a common procedure, and a requirement when teeth have been extracted recently. Very small amounts of bone graft material are required, and very often bone substitutes are used rather than autogenous bone.
The Panel notes that Mr Hamann was reviewed by Assoc Prof Guazzato on 7 July 2024. At that time, nine months after the bridge was put in place on the implants, he found that the bridge was symptom free and did not cause Mr Hamann pain or reduce his ability to chew or talk. The assessment of Assoc Prof Guazzato on 7 July 2024 was undertaken subsequent to the reports of Dr Nichols, Prof David, Medical Assessor Vertoudakis and Medical Assessor McGlynn.
Although Mr Hamann states that his anterior palate is painful when he eats, there is no objective evidence to support his claims. The original fracture of the maxilla was confined to the alveolar process and did not extend into the palate. Clinical examination indicated that the alveolar fracture was firmly united and the CT scan of the anterior maxilla of November 2022 taken by a specialist dental radiologist showed no evidence of any bony abnormality. The examination undertaken by Medical Assessor Curtin was consistent with the examination undertaken by Assoc Prof Guazzato and referred to in his report of 8 November 2024.
The Panel notes cl 6.21 of the Guidelines requires that the evaluation of permanent impairment should only consider the impairment as it is at the time of the assessment.
The Panel does not consider the injury to the upper alveolus of the maxilla has resulted in any permanent impairment. Clause 6.196 of the Guidelines governs assessment of permanent impairment where a loss of structural integrity occurs as a result of a dental injury. In that case the injury must be assessed for a loss of functional capacity (mastication) and a loss of structural integrity (cosmetic deformity) and any impairment combined. However, the Panel finds there has been no loss of structural integrity as a result of a dental injury and, therefore, there is no assessable impairment.

Combined impairment

The Panel refers to the Combined Tables chart to conclude the claimant has sustained a
4% WPI arising out of the following injuries caused by the accident:
·        facial scarring;
·        scarring of the right leg and ankle, and
·        alveolar fracture.

CONCLUSION

The Panel revokes the certificate of Medical Assessor McGlynn dated 14 June 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a WPI of 4%:
·        alveolar fracture;
·        facial scarring, and
·        scarring of the right leg and ankle.
The Panel revokes the combined certificate of Medical Assessor Bodel dated 16 September 2024 and issues a new certificate determining that the following injuries were caused by the motor accident and give rise to a WPI of 9%:
·        leg – fracture of the right fibula;
·        ankle – fracture of the right ankle resulting in three surgical operations;
·        alveolar fracture;
·        facial scarring, and
·        scarring of the right leg and ankle.

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Citations

AAI Limited t/as AAMI v Hamann [2025] NSWPICMP 286

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[2025] NSWPICMP 286

28 April 2025