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AUTOTRANSPLANTATION OF AN UNERUPTED WISDOM TOOTH IMMEDIATELY AFTER REMOVAL OF GROSSLY DESTROYED PERMANENT MANDIBULAR FIRST MOLAR. A CASE REPORT

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Abstract The rapidly evolving implantation and alveolar ridge reconstruction techniques opened a new era in modern dentistry, where tooth loss is no longer a problem. However, none of the modern technologies in implant dentistry have the potential to adapt to the growth and development changes of a child’s jaw. Therefore, patients at young ages appear as a restriction for implantation and as a particular challenge for a dentist willing to restore the missing teeth. Thus, dental autotransplantation is an alternative treatment for replacing the lost teeth when suitable donor teeth are available. A case report is presented, in which the non-restorable tooth was replaced by autotransplantation of the impacted tooth. This article illustrates the option of using impacted teeth as a viable reservoir for autotransplantation in young patients with non-restorable permanent tooth. Keywords: autotransplantation, impacted tooth, oral rehabilitation, biodentin, platelet rich fibrin.
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210 Volume 7 • Issue 3 July / September 2017 •
Pediatric dentistry
AUTOTRANSPLANTATION OF AN UNERUPTED WISDOM TOOTH
IMMEDIATELY AFTER REMOVAL OF GROSSLY DESTROYED
PERMANENT MANDIBULAR FIRST MOLAR. A CASE REPORT
Afzal ALI1, Prahlad SARAF2, Satyrajit DANDAGI3, M.N. VISHWANATH4
1Senior Lecturer, Pacic Dental College & Hospital, Udaipur, Rajasthan, India
2Reader, P.M.N.M Dental College & Hospital, Bagalkot, Karnataka, India
3Professor, P.M.N.M Dental College & Hospital, Bagalkot, Karnataka, India
4Fellowship in head and neck oncology, Malabar cancer centre, Thalassery, Kerala, India
Corresponding author: Afzal Ali; e-mail:abu.ali.4k@gmail.com
Abstract
The rapidly evolving implantation and alveolar ridge
reconstruction techniques opened a new era in modern
dentistry, where tooth loss is no longer a problem.
However, none of the modern technologies in implant
dentistry have the potential to adapt to the growth and
development changes of a child’s jaw. Therefore, patients
at young ages appear as a restriction for implantation and
as a particular challenge for a dentist willing to restore the
missing teeth. Thus, dental autotransplantation is an
alternative treatment for replacing the lost teeth when
suitable donor teeth are available. A case report is
presented, in which the non-restorable tooth was replaced
by autotransplantation of the impacted tooth. This article
illustrates the option of using impacted teeth as a viable
reservoir for autotransplantation in young patients with
non-restorable permanent tooth.
Keywords: autotransplantation, impacted tooth, oral
rehabilitation, biodentin, platelet rich brin.
1. INTRODUCTION
Tooth transplantation is dened as surgical
transposition of a vital endodontically treated tooth
from its site of origin, transplanted to another
natural or surgically prepared socket [1,2].
Abulcassis described this sort of surgical
intervention in endodontics at its inception in
1050 B.C., however, Ambroise Pare was the
first dentist to perform such an endodontic
surgery (tooth bud transplantation) in 1564
and record it in literature with detailed
description. The molar transplantation
technique was first described in 1956 and, since
then, guidelines for this surgical technique
remained almost the same. Newer techniques
have been advocated for improving the
prognosis and success of transplantation
techniques, such as two-stage transplantation
and prototyping [3,4]. Tooth transplantation
can be of autogenous, homogenous or
heterogeneous type [5-7].
The tooth transplantation technique is of
utmost importance, being indicated when the
tooth is congenitally missing, in cases of tooth
loss due to trauma, grossly decayed tooth,
atypical tooth resorption, fracture of tooth root,
endodontically failed cases indicated for tooth
extractions, periodontal compromised tooth, etc.
This technique is an excellent and conservative
alternative approach for oral rehabilitation in
young patients, as well as in patients with
economic constraints [8-10].
Third molar transplantation is useful and
indicated in the following conditions [11-15]:
Extensively carious rst permanent molar
with compromised tooth structure in
adolescent patients
Adolescent patients having excellent chances
of developing third molars with incomplete
root formation.
Missing rst molar tooth in cases of severe
juvenile periodontitis.
The success rate of third molar auto-
transplantation recorded in literature was over
50% [16]. A higher success rate can be achieved
with careful and proper treatment planning,
alongwith a meticulous surgical technique [17].
Auto-transplantation performed in very young
patients prevents alveolar bone resorption, thus
International Journal of Medical Dentistry 211
AUTOTRANSPLANTATION OF AN UNERUPTED WISDOM TOOTH IMMEDIATELY AFTER REMOVAL OF GROSSLY
DESTROYED PERMANENT MANDIBULAR FIRST MOLAR. A CASE REPORT
allowing continued osseous development
around the transplanted tooth. It also permits
transmission of proprioceptive stimulus in the
transplanted tooth [18]. Most frequently,
transplanted teeth have one-third to three-
quarter root formation, although transplantation
of teeth with complete root formation is also
well documented [19]. Transplantation of teeth
with complete root formation also documents a
high success rate and, hence, may be a viable
alternative option in the absence of ideal donor
teeth [20].
Patients with a suitable donor tooth and
recipient site are perquisites. Patient cooperation,
understanding and comprehension are also of
utmost signicance to achieve remarkable
results. Sufcient alveolar bone support with
healthy surrounding soft tissues must be present
at recipient site to achieve adequate stability of
the transplanted tooth. There should be no
infection or inammation at recipient site.
Position of donor tooth should allow atraumatic
extraction, as much as this is possible. Teeth
with abnormal root morphology or procedure
requiring tooth sectioning are not indicated.
Donor teeth may have open or closed root
apices. Furthermore, teeth with open apex may
remain vital and allow complete root
development following transplantation, without
further need for endodontic therapy, however,
a tooth with complete root formation will
require root canal treatment following
transplantation [21].
The purpose of this article is to present a case
with successful autotransplantation of impacted
mandibular third molar teeth with incomplete
root formation following extraction of mandibular
rst molar with compromised coronal tooth
structure.
2. CASE REPORT
A young 19 year-old male patient reported to
our department with chief complaint of broken
tooth structure in lower right back tooth region
and difculty in chewing food since one week.
Upon clinical examination, extensively destroyed
coronal portion of lower right rst molar (46)
and clinically missing lower right third molar
(48) were noted (Fig. 1).
Fig. 1.
The patient also gave history of intermittent
pus discharge from the soft tissue w.r.t 46 tooth.
Radiographic examination was suggestive of
periapical bone loss at mesial and distal root of
46 and mesio-angularly impacted 48 tooth. No
signicant difference was noted in mesio-distal
dimension of both teeth (46 & 48) at point of
maximum convexity. However, roots of third
molar (48) were comparatively shorter than those
of rst molar (46) (Fig. 2).
Fig. 2.
Based on clinical and radiographic ndings,
diagnosis of pulp necrosis, chronic apical abscess
was made, in relation to 46. The digital
Orthopantamogram (Veraviewpocs, J. Morita;
Kyoto, Japan) was done to evaluate complete
dentition (Fig. 3).
212 Volume 7 • Issue 3 July / September 2017 •
Afzal ALI, Prahlad SARAF, Satyrajit DANDAGI, M.N. VISHWANATH
Fig. 3.
Treatment options included extraction of the
indicated tooth (46), followed by prosthetic
rehabilitation (xed partial denture / implant
supported prosthesis) or post placement in
one / both roots of 46, followed by core build-up.
However, due to nancial constraints, the patient
did not accept the proposed treatment options.
On careful re-evaluation, the third molar auto-
transplantation was proposed to rehabilitate his
oral health. Autogenous tooth transplantation
was feasible in our case because of the young age
(19 years), no contributory systemic condition
and presence of suitable third molars with
incomplete root formation being observed. Bone
grafting was also included in the treatment plan,
due to signicant periapical bone loss and
difference in root length. The patient was
informed on the treatment plan and informed
consent was taken from him and his next of kins.
Prophylactic antibiotics (amoxicillin 500 mg)
were administered.
Modied Ward’s incision was done and the
muco-periosteal ap was raised. The third molar
(48) was exposed, the surrounding bone was
guttered on buccal, and the distal aspect and
tooth was luxate. The third molar was left in toto
in its original socket (Fig. 4).
Fig. 4.
The rst molar (46) was extracted (Fig. 5) and
the granulation tissue was curetted from its
socket (Fig. 6). The third molar (48) was then
carefully extracted in toto with periotomes and
placed into the recipient site (46), to check for its
adaptation - which was found satisfactory.
Fig. 5.
Fig. 6.
International Journal of Medical Dentistry 213
AUTOTRANSPLANTATION OF AN UNERUPTED WISDOM TOOTH IMMEDIATELY AFTER REMOVAL OF GROSSLY
DESTROYED PERMANENT MANDIBULAR FIRST MOLAR. A CASE REPORT
Tooth 48 was then kept in Hank’s Balanced
Salt Solution (HBSS) (Fig. 7), retro-preparation
and root end lling being performed with
Biodentin (Septodont, Saint-Maur-des-Fossés,
France) (Fig. 8).
Fig 7.
Fig 8.
The allograft material mixed with Platelet rich
brin (PRF) (Fig. 9) was packed into the extraction
socket. The third molar was then transplanted
into the recipient site and stabilized, after which
a resorbable Guided Tissue Regeneration (GTR)
membrane was placed (Fig. 10).
Fig 9.
Fig 10.
Flaps were sutured in the 46 and 48 regions,
using 3-0 silk. Splinting of tooth (46) was
performed using both gure-of-eight wiring and
composite splinting. The immediate post-
operative radiography (IOPA) revealed an
adequate positioning of 48 in socket of 46 (Fig.
11). To improve the initial stability of the
transplanted tooth, a surgical cement dressing of
Coe-Pak (De Trey/Denstply, Konstanz, Germany)
was placed on the buccal and lingual aspects wrt
45 to 47 region.
Fig 11.
Antibiotic (Amoxicillin 500 mg TID) and
analgesics (diclofenac sodium50 mg TID)
were prescribed for 05 days. Periodontal
dressing and sutures were removed after one
week. Post-surgical course was uneventful,
and root canal treatment was initiated after
2 weeks using magnifying loupes (4.2x
magnification, Amtec, India), under rubber
dam isolation. Following access cavity
preparation, the working length was
determined and confirmed radiographically.
The canals were shaped and cleaned up to a
214 Volume 7 • Issue 3 July / September 2017 •
Afzal ALI, Prahlad SARAF, Satyrajit DANDAGI, M.N. VISHWANATH
size of 30 K files (DentsplyMaillefer,
Ballaigues, Switzerland) for the mesiobuccal
and mesio-lingual area, while distally up to
a size of 40 (DentsplyMaillefer, Ballaigues,
Switzerland), by the standardised technique.
Throughout the shaping and cleaning
procedure, the root canals were irrigated
with 3% sodium hypochlorite (Novo Dental
Product Pvt Ltd, Mumbai, India) and saline.
The tooth was then temporized using Cavit
G (3M, ESPE, Germany).
Calcium hydroxide paste (Kalsin, Aktu,
Turkey) was placed for 2 weeks, followed by
temporization with Cavit G (3M, ESPE, Germany).
Obturation of root canals was done by cold
lateral compaction of gutta-percha (GP)
(DentsplyMaillefer), using sealapex (Kerr Corp.,
Glendora, CA, USA) root canal sealer (Fig. 12).
Digital OPG (Veraviewpocs, J. Morita; Kyoto,
Japan) was taken (Fig. 13).
Fig 12.
Fig 13.
The tooth was in normal occlusion with
normal physiological mobility and masticatory
function, no other pathological signs and
symptoms being noted clinically on the follow-up
visit. Radiographically, a decrease in radiolucency
size was observed, suggesting healing of the
defect. (Fig.13)
3. DISCUSSION
For a successful auto-transplantation, the
donor tooth and the recipient site should be
examined thoroughly, to ensure feasibility of
root canal treatment of the donor tooth, as well
as its adequate stability at recipient site. The
recipient site should have an adequate bony
support and sufcient surrounding soft tissues
to achieve post-operative stability.(1) To minimize
damage to the periodontal ligament and
cementum, and for a good prognosis, the tooth
(#48) was atraumatically extracted. Teeth with
anomalous morphology and marked root
curvatures are not indicated for transplantation,
due to an increased risk of damage of the
periodontal ligament during extraction [22,23].
In literature, it has been documented that the
transplanted teeth with incomplete root formation
shows pulpal healing in 96% cases, however,
transplanted teeth with complete root formation
have shown a success rate of only 15%. The
endodontic treatment is indicated within 1-2 weeks
of auto-transplantation of teeth with complete root
development, otherwise pulpal necrosis may result
in inammatory resorption [24].
Andreason et al. studied the incidences of
pulpal healing in 370 premolar transplantations
at various developmental stages and classied
them into 7 stages. According to their study, a
satisfactory pulpal healing occurred until stage
5 (complete root formation, apical foramen wide
open). Considering the pulpal healing and the
continued root development, the ideal timing for
transplantation of the developing teeth is attained
when the development of the donor tooth roots
is three-fourths to four-fths completed (i.e., at
developmental stage 4 or 5,respectively) [25]. In
our case, tooth development occurred in stage 6
(complete root formation, apical foramen half
closed). As pulp healing was not expected, a root
canal treatment was performed within 2 weeks
after transplantation and calcium hydroxide
dressing was placed for 2 weeks. This medication
was expected to enhance bone healing, inhibit
root resorption, provide an antimicrobial effect
and thus stimulate the healing process [26,27].
The pathways of communication between the
root canal system and its surrounding tissues
International Journal of Medical Dentistry 215
AUTOTRANSPLANTATION OF AN UNERUPTED WISDOM TOOTH IMMEDIATELY AFTER REMOVAL OF GROSSLY
DESTROYED PERMANENT MANDIBULAR FIRST MOLAR. A CASE REPORT
should be sealed with an ideal endodontic repair
material. We used Biodentinas as an apical
barrier as, when Biodentin comes in contact with
dentin, it results in formation of a ‘‘Mineral
Inltration Zone,’’ the tag-like structures next to
an interfacial layer, which enhances the adhesive
properties. It has improved the physical
properties, reduced the settling time to 12 min,
and induced odontoblast-like cell differentiation
and mineralization [28].
A resorbable barrier membrane was used to
protect the adjacent soft tissues from cells
impeding bone formation and, additionally, to
provide mechanical stability to the graft materials
[29]. The absence of a barrier membrane may
result in apical migration of the junctional
epithelium along the root surfaces [30].
Autologous platelet-rich brin (PRF) was
used as a matrix. In 2001, Choukroun et al.
introduced PRF, the second-era of platelet
concentrates with no biochemical blood handling
procedure for specialized use in oral and
maxillofacial surgery [31,32]. Growth factors,
such as platelet cytokines (PDGF,TGFb-1, IGF-1),
are slowly released as the brin is reabsorbed,
thus creating a favourable environment for
healing [33]. PRF recruits cells to the site of the
injury, induces cell differentiation, initiates
vascular ingrowths, stimulates collagen
production, controls the local inammatory
process and improves soft and hard tissue
healing [31]. Considering these properties, PRF
was used in the present case report as a biological
internal matrix.
Periodontal healing occurs within 8 weeks after
transplantation. X-rays reveal a continuous space
around the root, the absence of root resorption and
the presence of intact lamina dura [34].
Kim et al. studied the prognosis and causes of
failures of 182 auto-transplanted teeth and found
no statistical correlation for the extra-alveolar
time of up to 25 minutes. The absence of external
inammatory resorption or ankyloses was also
noted. No resorption was observed in our case,
however, we kept the transplanted tooth in its
original socket and also in a HBSS solution.
Auto-transplantation of the cryopreserved
teeth has also been well documented in literature
[35]. Special care, facility and expertise are
required to avoid damage of the periodontal
ligament and dental pulp [23]. It is hoped that
the teeth extracted for orthodontic purposes,
third molars, and impacted and supernumerary
teeth can be used for future auto-transplantation
by preserving them with this method. However,
considering the stage of development of the
method and the cost for the patient in time,
these areas should be further improved before
this method may become a routine clinical
treatment [10].
4.CONCLUSIONS
Whenever non-restorable teeth need to be
extracted or tooth agenesis is evident, other
treatment alternatives, such as tooth
transplantation, should be considered, instead
of immediately replacing the teeth with fixed,
removable, or implant-supported prostheses.
Supernumerary teeth and impacted teeth
should be considered as a reservoir for
transplants.
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... Transplantation of the impacted third molar is a conservative alternative approach for oral rehabilitation of young patients with compromised or absent first molars and may be preferred instead of the insertion of dental prostheses or implants (43,44). ...
... The impacted third molar transplant procedure is indicated when adolescent patients have extensively carious first permanent molar with compromised tooth structure or have excellent chance of developing third molar with incomplete root formation or when missing first molar tooth in cases of severe juvenile periodontitis (44). ...
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Tissue regeneration by using membrane barriers and bone grafting materials in periapical surgery is an example of tissue engineering technology. Membrane barriers and/or bone grafts are often used to enhance periapical new bone formation. However, the periapical tissues also consist of the periodontal ligament (PDL) and cementum. For regeneration of the periapical tissues after periapical surgery, one of the important requirements is recruitment and differentiation of progenitor/stem cells into committed pre-osteoblasts, pre-PDL cells, and pre-cementoblasts. Homing of progenitor/stem cells into the wounded periapical tissues is regulated by factors such as stromal cell-derived factor 1, growth factors/cytokines, and by microenvironmental cues such as adhesion molecules and extracellular matrix and associated noncollagenous molecules. Tissue regeneration after injury appears to recapitulate the pathway of normal embryonic tissue development. Multiple tissue regeneration involves a complex interaction between different cells, extracellular matrix, growth/differentiation factors, and microenvironmental cues. Little is known concerning the biologic mechanisms that regulate temporal and spatial relationship between alveolar bone, PDL, and cementum regeneration during periapical wound healing. Simply applying a membrane barrier and/or bone graft during periapical surgery might not result in complete regeneration of the periapical tissues. It has not been clearly demonstrated that these biomaterials are capable of recruiting progenitor/stem cells and inducing these undifferentiated mesenchymal cells to differentiate into PDL cells and cementoblasts after periapical surgery.
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Extensive bone grafting remains a delicate procedure, because of the slow and difficult integration of the grafted material into the physiological architecture. The recent use of platelet concentrates aims to improve this process of integration by accelerating bone and mucosal healing. Choukroun's platelet-rich fibrin (PRF) is a healing biomaterial that concentrates in a single autologous fibrin membrane, most platelets, leukocytes, and cytokines from a 10 mL blood harvest, without artificial biochemical modification (no anticoagulant, no bovine thrombin). Whether used as a membrane or as fragments, PRF allows a significant postoperative protection of the surgical site and seems to accelerate the integration and remodeling of the grafted biomaterial. These properties are particularly helpful for vestibular bone grafting on the alveolar ridges. Moreover, it provides a very high quality of gingival maturation.A small quantity of a 0.5% metronidazole solution (10 mg) can also be used to provide an efficient protection of the bone graft against unavoidable anaerobic bacterial contamination. This article describes a new technique of total maxillary preimplant bone grafting using allograft, Choukroun's PRF membranes and metronidazole. This first part focused on the preimplant reconstructive treatment using allogeneic bone granules. PRF membranes are particularly helpful to protect the surgical site and foster soft tissue healing. This fibrin biomaterial represents a new opportunity to improve both the maturation of bone grafts and the final esthetic result of the peri-implant soft tissue.
Article
Autogenous tooth transplantation has been used as a predictable surgical approach to correct malocclusion and replace edentulous areas. This article focuses on the surgical approach and technique for molar transplantation. Thirty-two patients aged between 11 and 25 years underwent 44 autogenous molar transplantations. The procedure involved transplantation of impacted or newly erupted third molars into the extraction sockets of nonrestorable molars and surgical removal and replacement of horizontally impacted molars into their proper vertical alignment. Five basic procedural concepts were applied: 1) atraumatic extraction, avoiding disruption of the root sheath and root buds; 2) apical contouring of bone at the transplantation site and maxillary sinus lift via the Summers osteotome technique, when indicated, for maxillary molars; 3) preparation of a 4-wall bony socket; 4) avoidance of premature occlusal interferences; and 5) stabilization of the tooth with placement of a basket suture. All 32 patients successfully underwent the planned procedure. To date, 2 patients have had localized infection that resulted in loss of the transplant. The remaining 42 transplants remain asymptomatic and functioning, with a mean follow-up period of 19 months. No infection, ankylosis, loss of the transplant, or root resorption has been noted. In addition, endodontic therapy has not been necessary on any transplanted teeth. Autogenous tooth transplantation has been discussed and described in the literature previously, with a primary focus on cuspid and bicuspid transplantation. The molar transplant is infrequently discussed in today's literature, possibly because of the preponderance of titanium dental implants. Autogenous molar transplantation is a viable procedure with low morbidity and excellent functional and esthetic outcomes. This report shows the successful transplantation of 42 of 44 molars in 32 patients with a mean follow-up period of 19 months.
Article
The purpose of the present investigation was to determine the long-term prognosis of autotransplanted premolars with respect to tooth survival and pulpal healing. The material consisted of 195 patients aged 7 to 35 years, with a total of 370 autotransplanted premolars with observation period ranged from 1 to 13 years. Teeth transplanted with incomplete and complete root formation showed 95 per cent and 98 per cent long-term survival respectively: Pulp healing as evaluated by sensibility testing and radiographic signs of partial pulp canal obliteration was usually verified 6 months after transplantation. The frequency of pulpal healing (versus pulp necrosis), appeared to be closely related to stage of root development at time of transplantation. Teeth transplanted with incomplete and complete root formation showed 96 per cent and 15 per cent pulp healing respectively. Another and associated factor which could equally well predict pulpal healing was the diameter of the apical foramen of the graft. Finally, in teeth with completed root formation, the use of burs with internal cooling and no extra-alveolar storage prior to transplantation seemed to increase the chance for pulpal healing. The present study indicates, that the size of the apical foramen and possibly the avoidance of bacterial contamination during the surgical procedure are explanatory factors for pulpal healing.