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Research, Society and Development, v. 11, n. 17, e220111739196, 2022
(CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v11i17.39196
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Pulp survival and periodontal healing of autotransplanted teeth: a retrospective
study
Sobrevivência pulpar e cicatrização periodontal de dentes autotransplantados: um estudo
retrospectivo
Supervivencia pulpar y curación periodontal de dientes autotrasplantados: un estudio retrospectivo
Received: 12/11/2022 | Revised: 12/21/2022 | Accepted: 12/22/2022 | Published: 12/26/2022
Tereza Jacy da Silva Almeida
ORCID: https://orcid.org/0000-0003-1059-1978
Federal University of Espírito Santo, Brazil
E-mail: terezaja@gmail.com
Armelindo Roldi
ORCID: https://orcid.org/0000-0002-7800-9529
Escola Superior São Francisco de Assis, Brazil
E-mail: roldidco@hotmail.com
Nathalia Silveira Finck
ORCID: https://orcid.org/0000-0002-8435-2390
Federal University of Pelotas, Brazil
E-mail: nathaliafinck@gmail.com
Ludimila Saiter Assis Beltrame
ORCID: https://orcid.org/0000-0002-3510-3195
Rede de Ensino Doctum, Brazil
E-mail: ludimilasaiter@gmail.com
João Batista Gagno Intra
ORCID: https://orcid.org/0000-0003-2446-3432
Brazilian Dental Association of Espírito Santo, Brazil
E-mail: joaobatistababa@hotmail.com
Thiago Farias Rocha Lima
ORCID: https://orcid.org/0000-0002-0852-4672
Federal University of Espírito Santo, Brazil
E-mail: thiagofrl@hotmail.com
Abstract
Aim: The aim of this retrospective study was to evaluate the post-surgical results of autotransplanted teeth, considering
the pulp survival rate and periodontal healing. Methodology: Records of 43 patients with 50 autotransplanted teeth were
analysed. Demographic, clinical and radiographic data were verified. The time between autotransplantation surgery and
the date of endodontic access was considered to assess the pulp survival rate. Periodontal healing was observed through
gingival morphology and the presence of root resorption. Pulp survival was verified and the influence of Nolla stage on
the survival rate was analysed. Results: The pulp survival rate was 72%, and the stage of root development influenced
the survival rate in autotransplanted teeth (p = 0.001). The pulp survival rate in autotransplanted teeth in Nolla stages 6
and 7 was 100%; the pulp survival rate for teeth in stages 8 and 9 was 90% and 75%, respectively. Regarding periodontal
analysis, no tooth was observed in the presence of periodontal pockets and mobility above grade I. Replacement
resorption was diagnosed in 20% and external inflammatory resorption in 4%. Conclusions: Dental autotransplantation
was a safe treatment, showing satisfactory results. The pulp survival rate was considered high , especially in teeth with
incomplete rhizogenesis.
Keywords: Dental pulp; Transplant; Regeneration.
Resumo
Objetivo: O objetivo deste estudo retrospectivo foi avaliar os resultados pós-cirúrgicos de dentes autotransplantados,
considerando a taxa de sobrevivência pulpar e a cicatrização periodontal. Metodologia: Foram analisados prontuários
de 43 pacientes com 50 dentes autotransplantados. Dados demográficos, clínicos e radiográficos foram verificados. O
tempo entre a cirurgia de autotransplante e a data do acesso endodôntico foi considerado para avaliar a taxa de
sobrevivência pulpar. A cicatrização periodontal foi observada pela morfologia gengival e pela presença de reabsorção
radicular. A sobrevivência da polpa foi verificada e a influência do estágio de Nolla na taxa de sobrevivência foi
analisada. Resultados: A taxa de sobrevivência pulpar foi de 72%, e o estágio de desenvolvimento radicular influenciou
a taxa de sobrevivência em dentes autotransplantados (p = 0,001). A taxa de sobrevivência da polpa em dentes
autotransplantados nos estágios 6 e 7 de Nolla foi de 100%; a taxa de sobrevivência da polpa para os dentes nos estágios
Research, Society and Development, v. 11, n. 17, e220111739196, 2022
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8 e 9 foi de 90% e 75%, respectivamente. Com relação à análise periodontal, nenhum dente foi observado com presença
de bolsas periodontais e mobilidade acima do grau I. Reabsorção por substituição foi diagnosticada em 20% e
reabsorção inflamatória externa em 4%. Conclusões: O autotransplante dentário mostrou-se um tratamento seguro,
apresentando resultados satisfatórios. A taxa de sobrevivência pulpar foi considerada alta, principalmente em dentes
com rizogênese incompleta.
Palavras-chave: Polpa dentária; Transplantes; Regeneração.
Resumen
Objetivo: El objetivo de este estudio retrospectivo fue evaluar los resultados posquirúrgicos de dientes
autotrasplantados, considerando la tasa de supervivencia pulpar y la cicatrización periodontal. Metodología: Se
analizaron los expedientes de 43 pacientes con 50 dientes autotrasplantados. Se verificaron datos demográficos, clínicos
y radiográficos. Se consideró el tiempo entre la cirugía de autotrasplante y la fecha del acceso endodóntico para evaluar
la tasa de supervivencia pulpar. Se observó cicatrización periodontal a través de la morfología gingival y la presencia
de reabsorción radicular. Se verificó la supervivencia pulpar y se analizó la influencia del estadio de Nolla en la tasa de
supervivencia. Resultados: La tasa de supervivencia pulpar fue del 72%, y la etapa de desarrollo radicular influyó en la
tasa de supervivencia en los dientes autotrasplantados (p = 0,001). La tasa de supervivencia pulpar en dientes
autotrasplantados en estadios 6 y 7 de Nolla fue del 100%; la tasa de supervivencia de la pulpa para los dientes en las
etapas 8 y 9 fue del 90% y 75%, respectivamente. En cuanto al análisis periodontal, no se observó ningún diente con
presencia de bolsas periodontales y movilidad superior al grado I. Se diagnosticó reabsorción por reemplazo en el 20%
y reabsorción inflamatoria externa en el 4%. Conclusiones: El autotrasplante dental fue un tratamiento seguro,
mostrando resultados satisfactorios. La tasa de supervivencia pulpar se consideró alta, especialmente en dientes con
rizogénesis incompleta.
Palabras clave: Pulpa dental; Trasplantes; Regeneración.
1. Introduction
Use Dental autotransplantation or autogenous dental transplantation is an efficient alternative method of oral
rehabilitation in cases of agenesis, ectopias and premature loss of permanent teeth as a consequence of accidental dental trauma
or caries. The procedure is defined as the extraction of a tooth or more teeth from one site to be implanted into another site of
the dental arch in the same individual (Akhlef, et al., 2018; Andreasen, et al., 1990; Kafourou, et al 2017; Kristerson, L. &
Lagerstrom L (1991). The donor tooth can potentially induce bone formation and re-establishment of a normal alveolar process
without the need for special care. Prostheses and implants are contraindicated for young patients due to ongoing bone growth
and maturation (Czochrowska, et al., 2002; Thomas, et al., 1998). Low costs, the possibility of aesthetic restoration and
orthodontic movement without damage to adjacent teeth are important considerations when autotransplantation is indicated
(Paulsen, et al., 1995; Schatz, & Joho, 1994).
Survival rate has often been the primary outcome parameter in studies on dental autotransplantation. High survival rates
have been reported, especially with premolar autotransplantation (Candeiro, et al., 2015; Kristerson, 1985; Ninomiya, et al.,
2002). However, the greatest challenge with autotransplanted teeth is pulp and periodontal healing due to several factors such as
age, general health status, the stage of root development of the tooth to be transplanted, the health of periodontal and alveolar
tissue of the recipient bed, strict control of infections and the health of the patient. Among the potentially unfavourable results
are pulp necrosis, substitution resorption and lack of root development (Kristerson, 1985; Schwartz, et al., 1985)
Studies on autotransplantation have great clinical relevance, because the identification of factors that can interfere with
pulp and periodontal healing help in achieving more predictable results that further validate this treatment modality. This
retrospective study aimed to evaluate the post-surgical results of autotransplanted teeth, considering the pulp survival rate and
periodontal healing.
2. Methodology
This study was approved by the Research Ethics Committee of Federal University of Espírito Santo.
This retrospective study followed the Strengthening Reporting Observational Studies in Epidemiology (STROBE)
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guidelines (Vandenbroucke, et al., 2007; Von Elm, et al., 2007). The study sample was selected from the clinical records of
patients treated at the Endodontics Clinic of Endodontics Clinic of UFES between 1993 and 2003 who underwent dental
autotransplantation. The inclusion criteria were as follows:
- Patients with completed clinical and radiographic records;
- Patients who were followed up for at least 6 months after autotransplantation;
- Patients who signed the informed consent form.
All information was collected from the patients’ medical records. Data on gender, age of the patient at the time of
autotransplantation, date of autotransplantation, cause of tooth loss, donor tooth and stage of root development, site of the
recipient alveolus and date of endodontic treatment after autotransplantation, if it occurred, were verified. The results of cold
(Endo-Frost Roeko-Wilcos do Brasil, Rio de Janeiro, RJ, Brazil) and electrical (digital pulp tester, model RD101-NTC, ODOUS
COML Ltda and Gesund Bio Engenharia, Belo Horizonte, MG, Brazil) pulp tests were recorded, as well as the presence of
sensitivity to palpation, percussion, fistulas or oedema.
The periodontal evaluation comprised analysis of the level of periodontal insertion, the presence of gingival bleeding,
mobility and gingival morphology, as registered in the medical records. The insertion level was classified into three categories:
0–3 mm, 3–5 mm and >5 mm; mobility was classified as grade I, II and III; and gingival morphology was classified as normal,
retracted or swollen (Andreasen, et al., 1990; Borring‐Møller, & Frandsen, 1978).
Radiographic analysis
Radiographic analysis was performed by three radiologists. Radiographs were taken using a previously calibrated Dabi
Atlante Spectro 70x radiographic device (Dabi Atlante, São Paulo) and analysed using a magnifying glass and a negatoscope.
The following parameters were analysed.
Pulp chamber
- Normal: morphological aspects of normality without change in size or shape;
- Partially calcified: presence of diffuse calcifications not fully obliterating the inside of the pulp chamber;
- Fully calcified: dentin deposition fully occupying the space.
Root canal
- Normal: Morphological aspects of normality without alteration in size or shape;
- Partially calcified: presence of pulp calcification occupying up to two thirds of the duct space;
- Fully calcified: presence of pulp calcification occupying up to two thirds of the duct space;
- Internal inflammatory resorption: radiographic aspect of alteration in root canal path continuity in any third of the dental
root;
- Endodontic treatment performed: root canal filled with obturator material.
Periapical
- Normal;
- Thickening of the apical periodontal ligament: indicated by an increase in the radiolucent line located between the root
and the hard blade in the apical third;
- Presence of a periapical lesion: area of bone rarefaction, indicated by diffuse or circumscribed radiolucent image at the
root apex;
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- Presence of condensing osteitis: indicated by the presence of a radiopaque, dense and uniform alteration near the apex
of the tooth.
Stage of root development at autotransplantation
The Nolla stages were used to determine the stage of root development. The radiographic image of the tooth was
compared with Nolla schemes, and each tooth was given a representative value correlated to the stage of root development at the
time of the transplantation and at the last follow-up consultation.
Pulp survival analysis
The time elapsed between autotransplantation surgery and the date of endodontic access was considered to assess the
pulp survival rate. In all cases, access was performed on the day pulp necrosis was diagnosed. The diagnosis of necrosis was
characterized by the absence of response to the pulp and electrical tests, associated with the presence of at least one other clinical
or radiographic criterion: presence of sensitivity to palpation, percussion, fistulas or oedema, coronary darkening and periapical
radiolucency. The pulp was considered vital when the radiographic analysis showed partial or total presence of root canal
obliteration, continuation of root development and absence of clinical and radiographic signs of necrosis.
Statistical analysis
The results of the clinical and radiographic analysis are presented by descriptive statistics. Pulp survival was verified
using the Kaplan-Meyer test. The influence of the Nolla stage on the survival rate was analysed using the log rank test. A 5%
significance level was adopted. The SPSS program (IBM, Armonk, NY, USA, version 24) was used for the analyses.
3. Results
A total of 43 patients were examined, 23 men and 20 women, with 50 autotransplanted teeth. The age of the patients at
the time of autotransplantation ranged from 10 to 22 years and the follow-up period ranged from 8 months to 9 years. The 50
autotransplanted teeth included 40 premolars (39 lower premolars and 1 upper premolar), 1 supernumerary upper lateral incisor,
6 molars (4 third upper molars and 2 lower molars) and 3 upper canines. The 40 premolars, 3 canines and the incisor were
transplanted to the region of upper central incisors lost by dental trauma. The 6 molars were transplanted to the region of other
molars lost due to caries disease.
Clinical data
Fourteen teeth underwent endodontic treatment (3 canines, 6 premolars, 4 molars and 1 incisor); 10 were transplanted
after complete root development (Nolla stage 10), 2 were transplanted in stage 9 and 2 in stage 8 (Table 3). Of the 36 teeth that
had not yet undergone endodontic treatment, 5 responded positively to the cold test and 31 did not respond. No teeth responded
positively to the electrical test. All five teeth that showed a positive response to the cold test had not completed 1 year since
surgery. Although most teeth did not respond to pulp tests, they were considered vital, because no other clinical and radiographic
signs of necrosis were identified. Regarding the periodontal analysis, no teeth presented periodontal pockets and mobility above
grade I (Figure 1). The gingival aspect was classified as normal in 78%. The clinical parameters are presented in Table 1.
Radiographic data
Table II shows the results of the radiographic analysis. Of the 36 teeth without endodontic treatment, 34 presented
calcifications of both the chamber and the root canal. The periapex was considered normal in 76% of the total sample.
Research, Society and Development, v. 11, n. 17, e220111739196, 2022
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Replacement resorption was diagnosed in 10 teeth and external inflammatory resorption in 2. No cases presented internal
inflammatory resorption.
Pulp survival analysis
The mean pulp survival was 72% and the Nolla stage influenced the survival rate in autotransplanted teeth (p = 0.001).
The survival rate of autotransplanted teeth in Nolla stages 6 and 7 was 100%, and the survival rate for teeth in stages 8 and 9
was 90% and 75%, respectively. No teeth in stage 10 remained vital after autotransplantation.
Table 1 - Descriptive analysis of the clinical results after dental autotransplantation.
Clinical analysis
Autotransplanted teeth, n (%)
Cold test
Negative
45 (90)
Positive
5 (10)
Electrical test
Negative
50 (100)
Positive
0 (0)
Palpation tests
Negative
50 (100)
Positive
0 (0)
Percussion test
Negative
50 (100)
Positive
0 (0)
Fistula
Absent
50 (100)
Present
0 (0)
Oedema
Absent
50 (100)
Present
0 (0)
Gingival bleeding
Absent
45 (90)
Present
5 (10)
Gingival morphology
Normal
39 (78)
Retracted
6 (12)
Swollen
5 (10)
Periodontal insertion
0–3 mm
50 (100)
3–5 mm
0 (0)
>5 mm
0 (0)
Mobility
I
50 (100)
II
0 (0)
III
0 (0)
Source: Authors.
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Table 2 - Descriptive analysis of the radiographic results after dental autotransplantation.
Radiographic analysis
Autotransplanted teeth, n (%)
Pulp chamber
Normal
2 (4)
Partially calcified
9 (18)
Fully calcified
25 (50)
Root canal
Normal
2 (4)
Partially calcified
19 (38)
Fully calcified
15 (30)
Internal inflammatory resorption
0 (0)
Endodontic treatment
14 (14)
Periapical
Normal
38 (76)
Thickening of the ligament
8 (16)
Periapical lesion
4 (8)
Condensing osteitis
2 (4)
Periodontium
External inflammatory resorption
2 (4)
Resorption by substitution
10 (20)
Souce: Authors.
Table 3 - Survival rate of autotransplanted teeth and the relationship with the Nolla stage.
Nolla stage
No.
Pulp vitality
Pulp survival (%)
Yes
No
6
2
2
0
100
7
10
10
0
100
8
20
18
2
90
9
8
7
2
75
10
10
0
10
0
Mean
72
Souce: Authors.
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Figure 1 - Flow chat describing clinical data.
Source: Authors.
4. Discussion
This study aimed to evaluate the post-surgical results of autotransplanted teeth in a sample of 43 patients and 50 teeth.
Different dental groups were included because the main indications for autotransplantation involve transplantation of premolars
to the region of missing central incisors, third molar transplants for the region of missing first or second molars and transplants
of retained canines. Supernumerary tooth transplants are also indicated in cases of agenesis or loss of upper incisors (Andreasen,
et al., 1990; Kafourou, et al., 2017; Schatz, & Joho, 1994; Candeiro, et al., 2015; Xu, et al. 2021).
Caries and dental trauma are the main causes of tooth loss in permanent dentition (Schatz, JP & Joho, JP, 1994). In this
study, 44 teeth were transplanted as a result of dental trauma and 6 due to caries lesions.
Autotransplantation success rates are considered high. Two recent systematic reviews reported a survival rate greater
than 95% (Akhlef, et al., 2018; Rohof, et al., 2018). In this study, all autotransplanted teeth remained in the mouth after the
follow-up period. However, one of the main objectives of this study was not to evaluate the survival of the transplanted tooth
but rather pulp survival, which, in these cases, is associated with canal obliteration and continuation of root development (Rohof,
et al., 2018).
Root canal obliteration is one of the main criteria used to verify if the pulp remains vital after autotransplantation,
because the presence of viable cells in the pulp space is a marker of deposition of mineralized tissue. Radiographic signs of
partial or total obliteration of the root canal were identified in 34 cases (94.4%) among the 36 who did not receive endodontic
treatment. These results corroborate previous investigations that reported radiographic signs of pulp canal obliteration within 6
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months after surgery (Andreasen, et al., 1990; Paulsen, et al., 1995; Jonsson, & Sigurdsson, 2004). Plakwicz et al. (2013)
reviewed 23 cases and reported pulp healing in most of their sample, with continuous root development and pulp canal
obliteration in several cases.
The time elapsed between autotransplantation surgery and the date of endodontic access was considered to determine
the pulp survival rate. In all cases, access was performed on the day pulp necrosis was diagnosed. The pulp survival rate was
72%, and the stage of root development at the time of transplantation influenced the pulp prognosis. No autotransplanted teeth
with closed apex remained vital. The survival rate of teeth in Nolla stages 6 and 7 was 100%; the pulp survival rate of teeth in
stages 8 and 9 was 90% and 75%, respectively.
The length of stay outside the alveolus and root maturation influence pulp necrosis of autotransplanted teeth.
Furthermore, autotransplantation interrupts the vascular and nervous supply to the pulp. Thus, serious damage to pulp tissues
occurs during the surgical procedure (Andreasen, et al., 1990; He, et al., 2017; Skoglund, & Hasselgren, 1992). Healing occurs
by revascularization of the blood and nerve supply, therefore teeth with incomplete root formation have a better chance of
revascularization due to increased vascularization related to wider open apexes2. This corroborates with a systematic review
reporting that the stage of root development correlated with pulp survival (Almpani, et al., 2018). Pulp necrosis in
autotransplanted teeth with complete rhizogenesis is common (Andreasen, et al., 1990), which also agrees with the results of our
study.
The maintenance of viable periodontal ligament cells in transplanted teeth is considered the most critical factor for the
success of periodontal healing (Clokie, et al., 2001; de Freitas Coutinho, et al., 2021; Hupp, et al., 1998; Lee, et al., 2001). Thus,
donor teeth should remain outside the alveolus for a minimum period or be preserved in a storage medium capable of maintaining
periodontal ligament vitality. In this study, we inserted the teeth into a new alveolus shortly after exodontia, without using storage
medium.
Periodontal ligament healing was considered satisfactory; few cases presented root resorption, 2 teeth with external
inflammatory resorption (4%) and 10 teeth with replacement resorption (20%). These findings are similar to those in several
other studies (Kafourou, et al 2017; Kristerson, & Lagerstrom 1991; Czochrowska, et al., 2002; Plakwicz, et al., 2013;
Tsukiboshi, 2002). Even though some teeth developed replacement resorption, they may play an important role in maintaining
bone in this location. Bone atrophy in edentulous sites is inevitable, often requiring bone grafting before implantation. Even if
the autotransplantation fails in the future, a good amount of bone structure can be preserved for planning an implant (Kafourou,
et al., 2017).
In general, the condition of gingival tissues was considered adequate. Bleeding was observed in only 5 teeth, but was
related to accumulation of plaque. Minimal gingival retraction was found in 6 teeth and no periodontal pockets or associated
bone loss were verified. In a recent study that considered gingival aesthetics as one of the criteria for evaluating autotransplanted
teeth, the authors observed good aesthetic success; the results were considered good or excellent in 65% of the evaluations and
poor and in only 7.5% (de Freitas Coutinho, et al., 2021).
One of the methodological limitations lies in the retrospective nature of this study. Clinical and radiographic data were
collected from the patients’ clinical records. In some cases, we noticed that the patients missed follow-up consultations, which
were then rescheduled for another date. This may have delayed the diagnosis of pulp necrosis and, therefore, the onset of
endodontic treatment. Even so, studies on autotransplantation are important to validate and disseminate this treatment modality
among dentists. Autotransplantation has been shown to be a safe and predictable therapeutic option, especially in cases of early
tooth loss.
Research, Society and Development, v. 11, n. 17, e220111739196, 2022
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5. Conclusion
Dental autotransplantation is a safe and viable treatment option, showing satisfactory results for clinical and
radiographic procedures. The pulp survival rate was considered high, especially in teeth with incomplete root formation.
Conflict of Interest
We declare no financial or personal relationships with other people or organizations that could inappropriately influence
our work.
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