Nine-Year Follow-Up of Autotransplantation in the Maxillary Anterior Region: Replacing a Fused Incisor with a Supernumerary Tooth

Abstract

The goal of tooth autotransplantation is to restore a missing tooth by using a functional tooth from the same patient. Although this procedure is gaining more recognition as a viable treatment option in dentistry, it is important to monitor and report long-term results. This case report presents the long-term follow-up of a fused maxillary central incisor that was extracted and replaced with a supernumerary tooth. Although the donor tooth displayed favorable characteristics, including an intact periodontal ligament and minimal extraoral time, which contributed to the success of the transplantation, it also presented certain disadvantages, such as having a fully developed root apex. Over a nine-year follow-up period, no clinical symptoms indicative of functional failure were observed. However, external cervical root resorption, first detected at the six-year follow-up, progressed by the ninth year. Despite the lack of clinical symptoms, radiographic findings suggested that the root resorption was a significant concern. This case underscores the potential for long-term success of autotransplanted teeth, even in complex scenarios involving fused teeth. However, it also highlights the importance of thorough, long-term monitoring to detect complications such as root resorption. The findings suggest that, while autotransplantation can offer favorable outcomes, careful management and periodic evaluations are essential to ensure the longevity of the transplanted tooth.

Full text

CASE REPORT/CLINICAL TECHNIQUES
Nine-year Follow-up of
Autotransplantation in the
Maxillary Anterior Region:
Replacing a Fused Incisor with
a Supernumerary Tooth
ABSTRACT
The goal of tooth autotransplantation is to restore a missing tooth by using a functional tooth
from the same patient. Although this procedure is gaining more recognition as a viable
treatment option in dentistry, it is important to monitor and report long-term results. This case
report presents the long-term follow-up of a fused maxillary central incisor that was extracted
and replaced with a supernumerary tooth. Although the donor tooth displayed favorable
characteristics, including an intact periodontal ligament and minimal extraoral time, which
contributed to the success of the transplantation, it also presented certain disadvantages,
such as having a fully developed root apex. Over a 9-year follow-up period, no clinical
symptoms indicative of functional failure were observed. However, external cervical root
resorption, first detected at the 6-year follow-up, progressed by the ninth year. Despite the
lack of clinical symptoms, radiographic findings suggested that the root resorption was a
significant concern. This case underscores the potential for long-term success of
autotransplanted teeth, even in complex scenarios involving fused teeth. However, it also
highlights the importance of thorough, long-term monitoring to detect complications such as
root resorption. The findings suggest that, while autotransplantation can offer favorable
outcomes, careful management and periodic evaluations are essential to ensure the longevity
of the transplanted tooth. (J Endod 2025;-:1–7.)
KEY WORDS
Autotransplantation; case reports; endodontics; fused tooth; supernumerary tooth
Dental fusion is a rare developmental anomaly characterized by the union of 2 or more independently
developing tooth germs at the dentin level, resulting in the formation of a single, enlarged tooth during
odontogenesis, prior to the completion of crown mineralization
1
. Although its etiology remains
incompletely understood, factors such as physical pressure exerted by adjacent tooth follicles, as well as
genetic and racial predispositions, are believed to play a pivotal role
2
. The clinical presentation of fused
teeth varies depending on the developmental stage at which the anomaly occurs. Typically, a fused tooth
exhibits a large, bifid crown with a groove or incisal notch demarcating the coronal structures of the 2
fused teeth. In most cases, the dental arch displays a reduced tooth count, typically by one, unless fusion
involves more than 2 teeth or includes supernumerary teeth
1-3
. The extent of the anomaly may be
confined to the crown or encompass both the crown and the roots, depending on the stage of
development during fusion. While fused teeth are often asymptomatic, intervention may be warranted in
cases of compromised aesthetics, dental caries, periodontal pathology, and/or pulp necrosis
1,4,5
.
Effective management necessitates a multidisciplinary approach, incorporating surgical, orthodontic,
periodontal, endodontic, and restorative strategies tailored to the specific clinical context.
Supernumerary teeth, also known as hyperdontia, represent an anomaly characterized by the
formation of additional teeth beyond the normal complement, arising from disruptions during the initiation
and proliferation phases of odontogenesis
6,7
. While the exact etiology remains unclear, a combination of
genetic and environmental factors is believed to contribute
8-10
. Supernumerary teeth may occur as part
of a syndromic presentation or as an isolated phenomenon, sometimes linked to familial inheritance
SIGNIFICANCE
This case highlights
autotransplantation as a viable
long-term solution for replacing
missing teeth, even in complex
cases involving fused teeth,
while emphasizing the
importance of regular follow-
up to identify complications like
external root resorption that
may affect tooth longevity.
From the *Department of Pediatric
Dentistry, School of Dentistry, Çanakkale
Onsekiz Mart University, Çanakkale,
T€
urkiye;
†
Department of Pediatric
Dentistry, School of Dentistry, Marmara
University, _
Istanbul, T€
urkiye; and
‡
Department of Restorative Dentistry,
School of Dentistry, Marmara University,
_
Istanbul, T€
urkiye
Address requests for reprints to Dr
Berkant Sezer, Department of Pediatric
Dentistry, School of Dentistry, Çanakkale
Onsekiz Mart University, Cumhuriyet
Mah., Sahilyolu Cd., No: 5, 17100 Kepez,
Merkez, Çanakkale 17100, T€
urkiye.
E-mail address: dt.berkantsezer@gmail.
com or berkant.sezer@comu.edu.tr
0099-2399/$ - see front matter
Copyright © 2025 American Association
of Endodontists.
https://doi.org/10.1016/
j.joen.2025.02.003
Berkant Sezer, DDS, MSc,*
Bet€
ul S
xen Yavuz, DDS, MSc,
†
Bora Korkut, DDS, PhD,
‡
and
Ali Mentes
x, DDS, PhD
†
JOE Volume -, Number -,-2025 Autotransplantation of Fused and Supernumerary Teeth 1

patterns. Most cases, however, arise
sporadically
10
. Their prevalence is
approximately 10 times higher in the maxilla
compared to the mandible, with the maxillary
anterior region accounting for nearly 90% of
single supernumerary teeth
7,10
. The presence
of supernumerary teeth can lead to various
complications, including delayed or failed
eruption of permanent teeth, displacement of
adjacent teeth, crowding, root resorption of
adjacent teeth, dentigerous cyst formation,
dilaceration, ossification of the pericoronal
space, and crown resorption
6,10,11
.
Management typically involves extraction of
the supernumerary tooth, with the surgical
approach tailored to its size, shape, number,
and the patient’s dental developmental
stage
10,11
.
Autotransplantation is a surgical
procedure involving the repositioning of a tooth
from its original site to another location within
the same individual, providing a biological
replacement for a lost, damaged, or
traumatized tooth
12,13
. This treatment modality
offers a versatile solution, accommodating the
needs of patients across various age groups.
Autotransplantation is indicated in diverse
clinical scenarios, including impacted or
ectopically positioned teeth, premature or
trauma-induced tooth loss, tooth loss
secondary to tumors or iatrogenic factors,
congenital tooth absence, orthodontic
malocclusions, teeth with poor endodontic or
restorative prognosis, developmental dental
anomalies, and/or cleft lip and palate
13-15
.In
pediatric and adolescent populations,
autotransplantation is particularly valuable for
addressing maxillary anterior teeth that are
frequently affected by trauma, caries,
periodontal disease, or developmental
anomalies. Unlike dental implants, which may
impede alveolar development in growing
patients, autotransplanted teeth provide a
functional and vital periodontal attachment and
harmonize with the eruption process of
adjacent teeth
14,16,17
. The success and
survival of an autotransplanted tooth depend
on numerous factors, including the stage of
root development, apical opening dimensions,
management of bone and periodontal tissues,
adherence to surgical, endodontic, and
orthodontic protocols, splinting techniques,
pharmacologic support, and timing of
treatment. Key determinants of success
include employing meticulous surgical
techniques during tooth extraction, minimizing
extra-alveolar time, and preventing exposure
of the root to irritants. These factors collectively
enhance the prognosis and longevity of the
transplanted tooth
13,18,19
.
This case report presents the
comprehensive treatment approach and 9-
year follow-up outcomes of a pediatric patient
presenting with a fused permanent central
incisor and a supernumerary tooth in the
maxillary anterior region. The treatment plan
involved the extraction of the fused permanent
central incisor, followed by the
autotransplantation of the supernumerary
incisor into the appropriate site. Subsequently,
the patient underwent a multidisciplinary
treatment protocol, encompassing
endodontic, orthodontic, and restorative
interventions, to ensure functional and
aesthetic rehabilitation.
CASE DESCRIPTION
A 9-year-old male patient was referred to the
pediatric dentistry clinic with the chief complaint
of an unaesthetic appearance of his front teeth
when smiling. The patient had no history of
systemic diseases, congenital anomalies,
syndromes, or previous dental treatments.
Furthermore, according to the anamnesis
obtained from the patient’s parents, there was
no record of craniofacial or dental trauma.
Intraoral examination revealed a
supernumerary and incisor-form tooth located
between the maxillary right permanent central
and lateral incisors. In the maxillary left central
incisor region, a fused incisor was identified,
characterized by a mesiodistally widened
crown and a notch at the incisal third of the
crown. The maxillary right permanent canine
had not yet erupted, whereas approximately
two-thirds of the crown of the maxillary left
permanent canine was visible. The maxillary
right permanent lateral incisor was rotated,
while the left counterpart was displaced
palatally. Additionally, the supernumerary tooth
in the maxillary right anterior region was rotated
along its long axis and exhibited a crossbite
relationship (Fig. 1A–C). Further examination
revealed crowding in both the maxillary and
mandibular anterior regions. The overbite rate
was 70%, with an overjet of 2 mm. The patient
exhibited a bilateral Angle Class I molar
relationship and was in the early permanent
dentition phase. Oral hygiene assessment
indicated poor hygiene, with significant dental
plaque accumulation on all teeth. Gingival
evaluation confirmed a diagnosis of gingivitis.
The intraoral findings were corroborated
through radiographic examination. A
panoramic radiograph revealed 2 distinct pulp
horns within the crown of the fused incisor,
located on either side of the incisal notch
(Fig. 2A). A single, large root canal was
observed within a common root structure,
ruling out the feasibility of hemisection in the
treatment plan. Given the anatomical form of
the supernumerary incisor and its mesiodistal
width compatibility with the dental arch,
autotransplantation of the supernumerary
incisor was planned to follow the extraction of
the fused incisor.
The proposed treatment plan was
thoroughly explained to the patient and his
parents, and their informed consent was
obtained. During the initial session, a Nance
holding arch was planned to maintain the
recipient site for the transplanted tooth and to
facilitate orthodontic management during the
treatment process. Impressions of both the
maxillary and mandibular arches were taken
using irreversible hydrocolloid impression
material (Hydrogum 5; Zhermack, Badia
Polesine, Italy). Impressions of the mandibular
arch were taken for 2 key purposes: first, to
evaluate the interarch relationship on the plaster
model, and second, to design a removable
appliance for the lower jaw to prevent occlusal
contact between the transplanted tooth and
the opposing arch postautotransplantation.
The surgical procedure was scheduled for 1
week later, and the patient was prescribed a
prophylactic antibiotic regimen (amoxicillin/
clavulanic acid; Augmentin ES 600/42.9 mg,
GlaxoSmithKline, UK; 2 !1) to be followed
during the interim period.
In the second session, a Nance holding
arch with molar bands (Narrow Contoured
Molar Bands; 3M Unitek, California, USA) was
cemented onto the maxillary right and left first
permanent molars using luting glass ionomer
cement (Meron Plus; VOCO, Germany)
(Fig. 1D). Additionally, a Hawley appliance with
an occlusal bite plane extending over the right
and left premolars was fabricated and placed.
Given the patient’s cooperation, the surgical
procedure was performed under local
anesthesia. Buccal and palatal infiltration
anesthesia was administered to the fused
permanent central incisor and the
supernumerary incisor using 4% articaine with
1:200,000 epinephrine (Ultracain D-S; Sanofi-
Aventis GmbH, Frankfurt, Germany). The fused
central incisor was gently extracted first,
followed by the careful extraction of the
supernumerary incisor, with special attention
to preserving the integrity of its radicular
structure. The entire surgical procedure lasted
30 minutes, with the interval between the
extraction of the supernumerary incisor and its
transplantation into the extraction socket of the
fused tooth being less than 2 minutes.
Stabilization of the transplanted
supernumerary incisor was achieved using
semi-rigid fixation with stainless steel wire and
composite resin during the same session
(Fig. 1E2K). Postoperative care included
prescribing antiseptic and disinfectant spray
(chlorhexidine; Corsodyl 0.2%,
GlaxoSmithKline, UK; 2 !1), anti-
inflammatory (ibuprofen; Dolven 100 mg/5 ml,
2Sezer et al. JOE Volume -, Number -,-2025

Sanofi, France; 3 !1) for pain management,
and amoxicillin/clavulanate (Augmentin ES
600/42.9 mg, 2 !1) as an antibiotic regimen
for 1 week. The patient and his parents were
provided with detailed oral hygiene instructions
and dietary recommendations to ensure
optimal healing.
As the transplanted supernumerary
incisor exhibited mature root development,
root canal treatment was initiated 2 weeks
after transplantation, following the removal of
the semi-rigid splint (Figs. 1Land 2B–C).
Access cavity preparation was performed
under water cooling using a high-speed
handpiece (NSK, Nakanishi Inc, Japan). The
root canal was prepared using Wave One Gold
(Dentsply Maillefer, Ballaigues, Switzerland)
primary file (size 25, .07 taper) activated in a
VDW Gold Reciproc motor (VDW, Munich,
Germany), at the RESIPROC ALL setting,
adjusted for reciprocating motion at 350 rpm
speed. The file was used with a short up-and-
down motion with minor apical pressure in 3
cycles, one to prepare each third of the canal
(coronal, middle, and apical) using an
ethylenediaminetetraacetic acid-containing gel
(EDTA; Cerkamed, Stalowa Wola, Poland) as a
FIGURE 1 –Treatment progress of the 9-year-old boy with a maxillary fused left central incisor and right supernumerary tooth. (A–C) Pretreatment intraoral photographs. (D) Intraoral
photograph with Nance appliance. (E–I) Extractions of the fused and supernumerary teeth. (J–L) Transplantation of the tooth, the semi-rigid fixation, and removable appliance for
occlusal adjustment. (M) Orthodontic alignment. (Nand O) Intraoral photographs of restoration renewal 9 years after the transplantation.
FIGURE 2 –(A) The initial panoramic radiograph. (B–D) The root canal treatment procedure of transplanted tooth. (E–H) Follow-up periapical radiographs of 1, 9, 12, and 18 months
after transplantation, respectively. (Iand J) 21-month follow-up cone-beam computed tomography images. (K–M) Follow-up periapical radiographs of 2, 3, and 6 years after
transplantation, respectively. (N) The axial cone-beam computed tomography image of 9-year follow-up.
JOE Volume -, Number -,-2025 Autotransplantation of Fused and Supernumerary Teeth 3

lubricant. The canal was irrigated with 1.5 ml of
5.25% sodium hypochlorite (NaOCl)
(Chloraxid, Cerkamed, Stalowa Wola, Poland)
after each cycle, using a 27-gauge needle.
Final irrigation was performed with 0.9% sterile
saline solution (Geno Technology, St. Louis,
USA). The canal was then dried using
absorbent paper points (Dentsply
International, York, PA, USA). Calcium
hydroxide dressing (Kalsin; Aktu, Izmir,
T€
urkiye) was applied as an intracanal
medicament, and the patient was scheduled
for a follow-up 14 days later. During this
period, the patient continued to use the
mandibular removable appliance to prevent
occlusal contact with the transplanted tooth.
At the follow-up appointment, the temporary
restoration (Cavit G; 3M ESPE, Germany) was
removed, revealing purulent discharge from
the canal. The canal was re-irrigated with
NaOCl, dried with paper points, and re-
dressed with calcium hydroxide. The patient
was scheduled for an additional follow-up after
14 days. At the subsequent appointment, no
adverse symptoms were reported, indicating
clinical improvement. The root canal was
irrigated with 5.25% NaOCl and sterile saline,
then dried using paper points. No exudate flow
was observed during the procedure. The root
canal was subsequently filled with mineral
trioxide aggregate (MTA-Angelus; Angelus,
Brazil) using endodontic pluggers (GDC, India)
with an incremental technique. To allow the
MTA to set, it was covered with a moist cotton
pellet and a temporary filling (Cavit G) for
24 hours. At the subsequent appointment, the
upper portion of the root canal, filled with MTA
up to 3 mm below the cemento-enamel
junction, was restored with conventional glass
ionomer cement (Ionofil; VOCO GmbH,
Cuxhaven, Germany) (Fig. 2D–E). The coronal
restoration involved etching with 37%
orthophosphoric acid (Scotch Bond Etchant;
3M ESPE, Seefeld, Germany), followed by the
application of a universal adhesive
(Scotchbond Universal; 3M ESPE, Seefeld,
Germany), cured with a light-emitting diode
curing light in soft-start polymerization mode
(Celalux 2 High-Power light-emitting diode
Curing Light; VOCO GmbH, Cuxhaven,
Germany). A composite resin (A1, Gradia; GC,
Tokyo, Japan) was used for restoration, with
incisal adjustments confirmed using
articulating paper. Polishing was completed
with composite polishers (Shofu, Tokyo,
Japan).
Orthodontic treatment initiated 9
months later, and fixed appliances were
installed to improve leveling and alignment.
Progressive nickel titanium arch wires (Sia
Orthodontic Manufacturer S.r.l.; Rocca
D’Evandro, Caserta, Italy) and elastic chains
(Ortho Technology; Lutz, Florida, USA) were
used in the upper dental arch to close
remaining interdental spaces (Figs. 1Mand
2F–G). Normal occlusal relationships were
obtained at the end of treatment, besides good
facial and acceptable smile harmony and
normal speech and swallowing. The patient
was scheduled for periodic follow-ups at
predetermined intervals of 3, 6, 9, 12, 15, 18,
21, and 24 months, transitioning to annual
check-ups until the third year (Fig. 2H–J).
During the first 3 years, the transplanted tooth
remained stable and free of complications
(Fig. 2Kand L). At the sixth-year follow-up,
initiation of the external root resorption was
noticed at the cervical third of the root
(Fig. 2M). Although cervical root resorption
was observed radiographically at the mesial
cemento-enamel junction border of the
affected tooth, no clinical symptoms were
present including no tenderness to the
palpation or percussion. The patient and their
parents were informed about the relevant
complications and treatment options. They
stated that they had no complaints and
expressed their preference to continue with
routine follow-up visits. However, the patient
did not attend any follow-up appointments for
3 years. The patient was finally reached at the
9th year follow-up. Even though the patient
and his parents reported no complaints,
clinical and radiographic evaluations revealed
several findings. Tooth discoloration was
present in the transplanted tooth due to the
MTA, alongside a noticeable size discrepancy
among the maxillary anterior teeth (Fig. 1N).
Cone-beam computed tomography revealed
ongoing root resorption on the mesial side of
the transplanted tooth, although there was no
evidence of clinical symptoms (Fig. 2N).
Additionally, the white spot lesion on the
buccal surface of the maxillary left lateral
incisor, which had developed following
orthodontic treatment, had turned to a
yellowish spot without cavitation. During the
appointment session, the patient confirmed
the absence of any discomfort or functional
issues related to the affected teeth. Due to the
progression of external root resorption in the
affected tooth, creating a connection between
the root surface and the root canal, an option
of implant insertion was offered for the
concerned region. However, as the patient and
his parents reported no complaints, and
contented with his teeth, they expressed no
desire for surgery and postponed the implant
procedure. It was decided to temporarily
restore the maxillary central teeth to address
the size discrepancy issue for a better
esthetics. A monochromatic composite
restoration was performed without tooth
preparation. The button technique was
employed for shade selection. After isolating
the teeth with a rubber dam, the surfaces were
cleaned using air polishing (Aquacare;
Velopex, London, England). The enamel
surfaces were etched with 37%
orthophosphoric acid for 30 seconds, followed
by the application of a universal adhesive (G-
Premio Bond; GC, Japan). A monochromatic
layering technique was utilized with the
selected “body”shade composite resin (A1B,
Estelite Asteria; Tokuyama, Japan). Composite
was carefully applied to the mesial surface of
the lateral incisor and the distal and incisal
surfaces of the central incisor using the free-
hand technique. The restorations were refined
with finishing and polishing using spiral
polishers (DiaComp Plus; EVE, Germany)
(Fig. 1O). Final outcome was satisfactory for
the patient and his parents, and they were
encouraged for yearly visits.
DISCUSSION
Autotransplantation presents a viable
alternative in cases where implants or
prosthodontic solutions are either impractical
or contraindicated, particularly in young
patients or individuals facing financial
limitations
4
. The reported survival rates for
autotransplanted teeth vary widely, ranging
from 60% to 98%. For instance, Cohen et al
20
observed a 10-year survival rate of 60%–95%
for transplanted anterior teeth with fully
developed roots. Andreasen et al
21
, in a 13-
year longitudinal study involving 370
autotransplanted premolars, documented a
remarkable long-term survival rate of 95%–
98%. In the study by Kvint et al
22
, which
evaluated the long-term clinical success of 215
autotransplanted teeth, the success rate was
reported to be 81%, with failures typically
observed around the 2.4-year mark on
average. In the present case, a clinically
acceptable outcome was achieved over the 9-
year period. However, radiographically,
external cervical root resorption, first detected
in the sixth year, progressed by the ninth year,
indicating that the tooth had become a
candidate for extraction.
The success of autotransplantation is
contingent upon multiple factors, including
patient-related variables, the characteristics of
the donor tooth, the condition of the recipient
site, atraumaticity of the extraction procedure,
and the clinician’s expertise
23
. Optimal
outcomes are typically achieved in younger,
healthy, and cooperative patients who
maintain adequate oral hygiene
24
. Ideal donor
teeth possess specific features, such as an
intact periodontal ligament, minimal extraoral
exposure time, root development at
approximately 3-quarters to four-fifths
4Sezer et al. JOE Volume -, Number -,-2025

completion, apical foramina exceeding 1 mm
in diameter, and a single, cone-shaped root
morphology
16
. In the present case, the donor
tooth exhibited several favorable attributes,
including an intact periodontal ligament, a
single cone-shaped root structure, and an
extraoral time of less than 2 minutes
postextraction. These factors significantly
contributed to the overall success of the
procedure. However, certain challenges were
also encountered, such as the patient’s
suboptimal oral hygiene and the fully
developed root of the donor tooth—an age-
related characteristic. These limitations
introduced potential risks to the long-term
prognosis of the transplanted tooth.
Studies have demonstrated that young,
immature permanent teeth with open apices
possess sufficient blood supply and stem cells
to facilitate pulp revascularization following
transplantation
14,17,25
. This regenerative
process occurs through the ingrowth of
vascularized connective tissue into the pulp
cavity or the anastomosis of transplanted
dental blood vessels with periodontal blood
vessels
14
. As a result, autotransplantation of
immature permanent teeth is widely
considered a preferred treatment option for
children and adolescents. This approach not
only promotes pulp vitality through
revascularization but also preserves aesthetics
by maintaining the natural contour of the
attached gingiva
26
. On the other hand,
regardless of whether the transplanted tooth is
mature or immature, the integrity and healing of
the periodontal ligament are pivotal for the
procedure’s success
19
. A healthy periodontal
ligament facilitates bone regeneration, reduces
the risk of severe complications such as root
resorption, and allows for effective orthodontic
movement during subsequent treatment
phases
14,19
. In the present case, the fully
matured apex of the transplanted donor tooth
rendered pulpal revascularization unfeasible.
Consequently, root canal treatment was
initiated 2 weeks post-transplantation, and the
canal was filled with MTA, a biocompatible and
highly effective material for preserving tooth
integrity
27,28
. The preservation of periodontal
ligament health depended on several critical
factors, including adequate pre-transplant
bone support, minimal extraoral time during
the procedure, and atraumatic surgical
extraction performed by an experienced
clinician
29,30
. Despite these precautions,
external root resorption was observed in the
transplanted tooth after 9 years of follow-up,
although the patient remained asymptomatic.
This resorption was likely multifactorial in origin,
with contributing factors including suboptimal
oral hygiene and mechanical forces exerted
during orthodontic treatment—both of which
are known to negatively affect periodontal
ligament integrity. An additional determinant of
periodontal ligament health is the adaptation of
the donor tooth’s root surface to the extraction
socket. Although achieving a perfect fitis
challenging, compatibility between the root
morphology of the donor tooth and the
recipient site is advantageous
31
. In this case,
the root of the fused tooth was both
mesiodistally and buccopalatally wider than
that of the donor tooth. This morphological
discrepancy may have compromised the
adaptation of the donor tooth to the
surrounding bone, potentially affecting the
health and long-term integration of the
periodontal ligament.
Various methods and materials have
been proposed for stabilizing transplanted
teeth, including orthodontic brackets,
ligatures, sutures, composite resins, and, in
specific cases, frictional stabilization between
adjacent teeth
1
. Lundberg and Isaksson
32
emphasize the importance of nonrigid fixation
for a period of 7–14 days, as this approach
supports bone healing and promotes the
proliferation of periodontal ligament cells.
Consistent with these recommendations, a
semirigid fixation was applied to the maxillary
arch in the present case for a duration of 2
weeks following the autotransplantation
procedure.
Several studies have investigated the
short- and long-term complications associated
with autotransplanted teeth. Andreasen et al
21
examined tooth survival and pulp healing
following autotransplantation, reporting that
pulp canal obliteration occurred in nearly all
immature teeth that showed positive
responses to pulp testing. Additionally, their
findings indicated that the use of antibiotics
both preoperatively and postoperatively
significantly reduced the incidence of root
resorption in mature teeth. Accordingly, in the
present case involving a mature donor tooth,
antibiotics were prescribed preoperatively and
postoperatively. Andreasen et al
33
also
reported that surface resorption occurred in
4.6% of transplanted teeth, typically localized
in the cervical region of the root and diagnosed
within the first-year post-transplantation.
Inflammatory resorption, observed in 4.6% of
cases, was commonly identified 1–2 months
after the procedure and strongly associated
with the stage of root development, often
coinciding with pulp necrosis. Furthermore,
replacement resorption (ankylosis) was
detected in 4.8% of transplanted teeth, with
diagnosis generally occurring within the first
year following transplantation. Lundberg and
Isaksson
32
monitored 278 autotransplanted
teeth over an average of 6 years, reporting that
only 3% of teeth with open apices exhibited
various forms of root resorption, compared to
20% of teeth with closed apices, which
presented resorption at different sites and in
varying forms. Similarly, a systematic review
and meta-analysis
15
revealed that teeth with
open apices at the time of transplantation have
a significantly lower risk of ankylosis, pulp
necrosis, and root resorption compared to
teeth with closed apices. Consistent with the
literature, external root resorption was
observed in the present case during the sixth-
year follow-up, predominantly in the cervical
region of the transplanted tooth.
CONCLUSION
In this case, a fused maxillary central incisor
was extracted and replaced with a
supernumerary tooth, which demonstrated
better dimensional compatibility with the
recipient site. Over the 9-year follow-up period,
no adverse clinical symptoms indicative of
functional failure was observed. However,
cervical external root resorption, initially
detected in the sixth-year follow-up, showed
progression by the ninth year.
This case underscores the potential for
achieving long-term success and functionality
with autotransplanted teeth, even in complex
clinical scenarios involving fused teeth. It also
highlights the critical need for meticulous long-
term follow-up to monitor complications such
as root resorption, particularly in cases with
morphological and periodontal challenges. The
findings suggest that, with comprehensive
planning, precise execution, and diligent
patient management, autotransplantation
remains a valuable treatment modality, even in
demanding clinical situations.
ETHICS
Written consent for publication regarding the
treatment and follow-up processes and the
use of images was obtained from the patient
and his parent.
DECLARATION OF GENERATIVE
AI AND AI-ASSISTED
TECHNOLOGIES IN THE
WRITING PROCESS
In writing this paper, ChatGPT-4 software was
used only to check grammar and spelling rules.
After using this tool, the authors reviewed and
edited the content and takes full responsibility
for the content of the publication.
ACKNOWLEDGMENTS
The authors deny any conflicts of interest
related to this study.
JOE Volume -, Number -,-2025 Autotransplantation of Fused and Supernumerary Teeth 5

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