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Autogenous Premolar Transplantation into Artificial Socket
in Maxillary Lateral Incisor Site
Jo~
ao Batista Gagno Intra, DDS, MSc, PhD,*Armelindo Roldi, DDS, MSc, PhD,
†
Roberto Carlos Bodart Brand~
ao, DDS, MSc, PhD,
‡§
Cyntia Rodrigues de Ara
ujo Estrela, DDS, MSc, PhD,
jj
and Carlos Estrela, DDS, MSc, PhD
¶
Abstract
Introduction: Autogenous transplantation of a natural
tooth to another site has significant advantages over
dental implants, particularly in cases of agenesis, acci-
dental tooth loss, or poor prognosis for the maintenance
of tooth function. Methods: This report describes a case
of autogenous premolar transplantation into an artificial
socket in the site of a missing maxillary lateral incisor in
a 13-year-old girl. Clinical examination and radiography
revealed tooth agenesis (#4, #10, #13, and #20) and mi-
crodontia (#7). The occlusion and skeletal maxilloman-
dibular relations were normal. Results: Tooth #29 was
chosen for transplantation into the site of tooth #10
because of its size, stage of root formation, and possible
closure of the spaces created by agenesis. Conclusions:
Autogenous transplantation is a feasible alternative to
dental implants in cases of tooth agenesis or tooth
loss because of trauma. Autotransplantation was indi-
cated in this case because it ensures the natural (facial)
growth of the alveolar process and preserves the func-
tion of periodontal tissues. A multidisciplinary approach
(ie, combining techniques from different dental spe-
cialties) was important for treatment success. Clinical
and radiographic follow-up confirmed that the trans-
planted premolar was esthetically comparable with the
lateral incisor and that root development and pulp canal
obliteration were complete.
(J Endod 2014;40:1885–
1890)
Key Words
Agenesis, autogenous tooth transplantation, pulp
regeneration, root canal treatment, tooth transplantation
Current rehabilitation strategies include autogenous transplantation to replace
missing teeth or teeth with a poor prognosis (1, 2). Tooth transplantation has
been a well-established procedure in dental practice for many years, and immature
third molars have recently been used to replace carious first molars (1–6).
Teeth may be absent because of several reasons (eg, agenesis [the absence of teeth
because of abnormal tooth germ development]) and dental trauma. Also, in some
cases, teeth may require replacement because of a poor long-term prognosis for the
maintenance of tooth function (5). Tooth autotransplantation is especially indicated
to replace missing teeth in children and adolescents because autotransplanted teeth
continue to participate in the normal development of the alveolar bone (6). On the con-
trary, osseointegrated dental implants are contraindicated in this group of patients
because of their potential interference with the growth of the alveolar process. Other
clinical situations that may benefit from autogenous transplants include partial agenesis,
especially of lateral incisors and premolars, and impacted teeth (3, 6).
Some of the criteria used to classify a transplant as successful are the absence of
progressive root resorption, the presence of normal hard and soft periodontal tissues
adjacent to the transplanted tooth, and a crown-to-root ratio <1 (7). Positive outcomes
depend on the integration of treatment protocols used in different specialties, such as
endodontics, orthodontics, surgery, implants, and operative dentistry, as well as on
careful planning and accurate techniques (5–8).
Autogenous tooth transplantations tend to be more successful when the roots are
incompletely formed (9). The correct selection of cases, assessment of root develop-
ment stage and recipient socket, and adoption of safety protocols are all essential to
ensure success (9–12).
This report describes the autogenous transplantation of a mandibular premolar
into an artificial socket in the site of a missing maxillary lateral incisor (tooth #7) in
an adolescent patient.
Case Report
Clinical and radiographic examination of a 13-year-old girl who sought orthodon-
tic care revealed multiple agenesis (teeth #4, #10, #13, and #20) and microdontia
(tooth #7) (Fig. 1A–E). The occlusion and skeletal maxillomandibular relations
were normal. The treatment plan was to perform autotransplantation of tooth #29
into the site corresponding to tooth #10 because of its size, stage of root formation,
and the possibility of closing spaces left by other missing teeth.
The plan was carefully discussed and accepted, and all steps, benefits, and risks
were explained to the patient and her parents, who provided written informed consent.
Fixed appliances were placed in both arches and spaces distributed in the maxillary
arch. Teeth #5 and #12 were moved distally using a strategy similar to the segmented
arch technique, and titanium-molybdenum alloy T-loop springs were connected to a
palatal bar (Fig. 2A–D)(13). Tooth #6, originally impacted, erupted spontaneously,
and space was opened between teeth #9 and #11.
The recipient site was defined after the maxillary arch was leveled using a rectan-
gular stainless steel arch wire that bypassed the site of tooth #10. The size of the recip-
ient site was defined according to computed tomographic images showing the exact
dimensions of tooth #29, which was selected for transplantation. At the time of treat-
ment, the root of the transplanted tooth showed three quarters of its final root length.
From the *Brazilian Dental Association, Esp
ırito Santo,
Brazil;
†
Department of Endodontics, Federal University of
Esp
ırito Santo, Esp
ırito Santo, Brazil;
‡
Department of Orthodon-
tics, Federal University of Esp
ırito Santo, ES, Brazil;
§
Brazilian
Board of Orthodontics;
jj
Department of Cellular and Molecular
Biology, University of Cuiab
a, MT, Brazil; and
¶
Department of
Endodontics, Federal University of Goi
as, Goi^
ania, GO, Brazil.
Address requests for reprints to Dr Carlos Estrela, Depart-
ment of Oral Sciences, Federal University of Goi
as, Prac¸a Uni-
versit
aria s/n, Sector Universit
ario CEP 74605-220, Goi^
ania,
GO, Brazil. E-mail address: estrela3@terra.com.br
0099-2399/$ - see front matter
Copyright ª2014 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2014.07.008
Case Report/Clinical Techniques
JOE —Volume 40, Number 11, November 2014 Autogenous Tooth Transplantation 1885
Surgery was carefully performed using an atraumatic aseptic tech-
nique. The artificial alveolus was prepared according to previously
defined dimensions using the following sequence of drills: lance drill
#2.0 and helical cylindrical drills #2.0, #3.15, and #4.3 (Neodent
Comp, Curitiba, PR, Brazil). The procedure was performed under con-
stant internal irrigation with saline solution (Fig. 2Eand F). The donor
tooth was extracted atraumatically using gentle luxation movements
after gingival incision. Subsequently, it was introduced into the artificial
socket and gently held in place until stabilization. The flap was sutured
and the tooth splinted. After the autotransplantation procedure, monthly
follow-up visits were scheduled to evaluate root development until the
root was fully formed (Fig. 3A–F). At these visits, radiographs were ob-
tained to monitor inflammatory root resorption or apical periodontitis
arising from possible infection (10).
After surgery, the autotransplanted tooth was fixed in place by
means of a wirebonded to the tooth and to adjacent teeth using compos-
ite resin and splinted for 2 months. Four monthslater, as recommended
in the literature (14), movement of the autotransplanted tooth was initi-
ated. First, composite resin was used to obtain the appearance of alateral
incisor. Subsequently, a bracket was bonded to the autotransplanted
tooth, which was then moved using 0.14-in heat-activated nickel-titanium
wire placed over a rectangular arch wire (Fig. 3Gand H).
After full eruption of tooth #29, both arches were leveled again,
and the remaining space was closed. Finally, 0.019 0.026-in rectan-
gular arch wires were used to achieve optimal intercuspation of poste-
rior teeth, correct positioning of roots in the bone, and esthetic
positioning of anterior teeth. Orthodontic treatment lasted for
32 months throughout; 12 months were spent preparing the recipient
site for transplantation. There was no tooth movement in the maxilla in
the 6 months immediately after autotransplantation.
Upon appliance removal, the tooth that had been transplanted into
the site of tooth #10 showed better periodontal quality than that of tooth
#7, and root formation and pulp canal obliteration (PCO) were found to
be complete (Fig. 4A–E).
Discussion
Transplantation of a natural tooth into the site of another tooth has
significant advantages over dental implants, particularly for periodontal
ligament (PDL) and alveolar bone development (1, 2, 15–19). Multiple
Figure 1. (A–E) Clinical examination and radiograph showing tooth agenesis (teeth #4, #10, #13, and #20) and microdontia (#7).
Case Report/Clinical Techniques
1886 Intra et al. JOE —Volume 40, Number 11, November 2014
missing teeth, agenesis of mandibular second premolars in low-angle
facial types with standard or weak facial profiles, and accidentally
lost or congenitally missing maxillary central and lateral incisors are
the main indications for autotransplantation of developing premolars
when teeth are unevenly distributed (16, 17).
In the case described here, clinical examination revealed several
missing teeth as well as microdontia (tooth #7). Conversely, occlusion
and skeletal maxillomandibular relation were normal. Therefore, auto-
transplantation of tooth #29 into an artificial socket in the site of tooth
#10 was indicated. The patient’s age (13 years) and incomplete root
development, with two thirds to three quarters of the final root length
(1, 2), were indicative of a positive outcome.
The success of dental transplants is associated with several factors
(eg, correct selection of cases, early stage of root development, and use
of aseptic and atraumatic techniques) (1–3, 15–19). In 1985,
Kristerson (20) evaluated 100 transplanted human premolars in a
group of 87 patients. The author found a relationship between the stage
of root development and periodontal healing without root resorption,
with 93% of success in teeth with three quarters of root development
compared with 37% in teeth with fully developed roots. Pulp revascu-
larization was also inversely proportional to root development, with
100% in teeth at initial/middle stages of root development versus 0%
in teeth with fully developed roots. Pulp obliteration was observed in
all cases with revascularized pulp tissue. The author concluded that
transplantation of premolars with one half to three quarters of root
development provides a good chance of pulp survival, a limited risk
of root resorption, and sufficient final root length.
In our case, root development followed by PCO continued after
transplantation. Revascularization occurs because of the growth of vas-
cularized connective tissue into the pulp space or anastomosis of blood
vessels already present in the pulp of the transplanted tooth and peri-
odontal blood vessels (21–24). In turn, PCO results from the
formation of mineralized tissue on the root canal walls, a physiological
process characteristic of aging and defense mechanisms of the vital
pulp. PCO is frequently confirmed after tooth transplantation
procedures (25–27) and seems to accelerate after dental trauma,
autotransplantation, and orthodontic treatment (27).
PCO is believed to be a consequence of the pulp repair process
after injury to the apical neurovascular bundle (25–31). However, it
is more clearly associated with teeth with incomplete root
development; therefore, prophylactic endodontic treatment is not
recommended in these cases (27). In fact, endodontic treatment is rec-
ommended only when pulp infection is suspected; when no signs of
infection are present, continued root development and pulp canal
closure should be followed up radiographically (10).
Viability of periodontal cells and preparation of the recipient site
may also pose risks to the healing process after autogenous transplants
(3–5, 10, 27, 32). In the case reported here, an artificial socket was
Figure 2. (A–D) Teeth #5 and #12 moved distally using a strategy similar to the segmented arch technique and titanium-molybdenum alloy T-loop springs con-
nected to a palatal bar. (Eand F) Preparation of artificial alveolus according to predetermined dimensions using drills of compatible size under constant internal
irrigation with saline solution.
Case Report/Clinical Techniques
JOE —Volume 40, Number 11, November 2014 Autogenous Tooth Transplantation 1887
prepared to receive the transplanted tooth. Preparation should be
carefully performed to avoid bone trauma. Wang et al (32) examined
the effect of delayed autotransplantation combined with periodontal tis-
sue engineering using autologous PDL cells on periodontal healing. Pre-
molar teeth were extracted from dogs and maintained in a dry
environment for 1 month after isolation and proliferation of PDL cells.
Tooth roots coated with 1 10
6
cultured autologous PDL cells were
autotransplanted into artificial sockets created in the mandible. The
dogs were killed 60 days after transplantation. Histologic analysis
showed a root-PDL-bone complex in all samples loaded with PDL cells
versus no PDL-like tissue and frequent ankylosis in control specimens.
The new PDL-like connective tissue was located between the alveolar
bone and the transplanted roots, with fibers inserted into the newly
formed cementum in 1 end and the alveolar bone in the other. The
results suggest that PDL cells can potentially regenerate periodontal
tissues in artificial alveolar sockets. In our case report, bone structures
and gingival esthetics confirmed that autotransplantation had a clini-
cally positive outcome. Also, radiographs showed that root growth
and PCO were complete, as expected.
Endodontics has shared extraordinary advances with tissue engi-
neering, creating new prognostic expectations in cases of dental trauma
and developmental abnormalities. Treatment strategies based on cur-
rent scientific knowledge can be used for the regeneration of a func-
tional pulp-dentin complex and periodontal tissues, and conservative
treatments can ensure continued root development, an increase in
dentinal wall thickness, and apical closure (33–35).
In sum, autotransplantation stands out as a feasible alternative to
dental implants in cases of tooth agenesis or tooth loss because of
trauma, with the advantage of not affecting the natural (facial) growth
of the alveolar process and the function of periodontal tissues. Rather,
Figure 3. (A–F) A donor tooth placed into an artificial socket and held gently until stabilization. Flap suturing and tooth splinting. (Gand H) An autotrans-
planted tooth fixed in place with a wire bonded to the tooth and to adjacent teeth using composite resin and splinted for 2 months. Tooth movement initiated
4monthslater.
Case Report/Clinical Techniques
1888 Intra et al. JOE —Volume 40, Number 11, November 2014
it allows the preservation of alveolar bone volume and the height of the
attached gingival, 2 structures closely associated with continued facial
growth. The multidisciplinary approach adopted in our case
(ie, combining techniques from different dental specialties) and the
regular clinical and radiographic follow-up were important for treat-
ment success and corroborate the positive outcomes that can be ob-
tained with this technique.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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