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AMERICAN JOURNAL OF MEDICAL AND DENTAL SCIENCES

ISSN Print: 2326-8638, ISSN Online: 2326-8648, doi:10.5251/ajmds.2013.1.1.25.30


2013, ScienceHu, http://www.scihub.org/AJMDS

Autotransplantation of teeth: A Review


1
Farheen Ustad, 2Fareedi Mukram Ali. 1Zaheer Kota, 1Abdelbagi Mustafa and 3Mohd
Inayatullah Khan
1
Department of Oral and Maxillofacial Surgery. King Khalid University Abha.
Reader, Dept of Oral & Maxillofacial Surgery.
SMBT Dental College, Sangamner Taluka
Ahmednagar Dist, Maharashtra State, India
2
Professor & HOD, Dept of Oral & Maxillofacial Surgery.
RKDF Dental College, Bhopal, M. P, India
3
Tutor, Dept of Physiology
Rajiv Gandhi institute of Health Sciences
Adilabad, A.P, India
ABSTRACT
Autotransplantation provides the possibility of a natural tooth rather than a prothesis or an
osseointegratedimplant to replace a missing tooth. The indications for autotransplantation are
wide, but careful patient selection coupled with an appropriate technique is a prerequisite for a
good functional and esthetic outcome. This article discusses about the indications for autogenous
tooth transplantation, the biological principles required for success, the recommended surgical
technique, factors affecting thesuccess, as well as the success rate.
Keywords :Autotransplantation, missing teeth, ankylosis.

INTRODUCTION resorbed followed by apposition of bone rather than


dentine, thus root resorption will ensure. Genetically,
Autotransplantation refers to the repositioning of
PDL cells can differentiate into fibroblasts,
autogenous erupted, semierupted or unerupted tooth;
1 cementoblasts and osteoblasts. In an ideal situation,
from one site into another in the same individual. The
one would hope PDL cells on the root surface to
earliest reports of tooth transplantation involve slaves
differentiate into cementoblasts and induce dentine
in ancient Egypt who were forced to give their teeth
formation, whereas PDL cells on the side of bony
to their pharaohs. Autogenic transplantation of teeth
socket wall surface to differentiate into osteoblasts
was described for the first time in the dental literature
thus inducing bone formation. In addition, the
by the Swedish dental surgeon Vidman in
2 contributions of the progenitors PDL cells on the
1915. Transplantationoffers potential benefits such
recipient fresh extraction sockets also accounts for
as bone induction and the reestablishment of a
the higher success rate for freshly extracted recipient
normal alveolar process in addition to tooth
sockets compared to artificially drilled ones. It is
replacement. Even if the transplant fails later, there is
important to minimize inflammation so that
an intact recipient area that could be used for an
reattachment can progress to the healing stage with
implant. A prerequisite for this method, however, is a
the proper differentiation of the PDL cells.
thorough knowledge of the factors that influence the
Inflammation will be minimized when the transplanted
long-term success rate. If done properly, this method
tooth is sealed with tight suturing of the gingival cuff
may supplement and/or can be used as a viable
around the tooth to prevent ingress of infective
treatment option in present day clinical practice.
agents. This can be achieved by trimming and
Biological Principles and their Clinical suturing of the recipient site flap before the
Applications: The type of healing of transplanted implantation of the donor tooth. It is also important to
tooth is dependent on the surface area of the minimize inflammatory pulpal response from the
damaged root to be repopulated. When the damaged transplanted tooth. For fully developed donor teeth,
PDL surface is small, the healing can be achieved by root canal treatment should be initiated 2 weeks after
cemental healing. However when the damaged PDL transplantation. The interim period of 2 weeks is
surface is large, some of the root surface will be chosen to minimize trauma to the PDL in the initial
Am. J. Med. Dent. Sci., 2013, 1(1): 25-30

reattachment healing phase, yet further delay will possible within 2 months so that the resorption of
increase the chance of complication of inflammatory bone that occurs in the interim does not compromise
2
resorption secondary to pulpal infection. In the case the wound bed for the donor tooth.
of donor tooth with incomplete root formation, the
Technique: The sequence of autotransplantation of
preservation of the apical Hertwig's epithelial sheath
teeth includes: clinical and radiographic examination,
is important to ensure pulpal regeneration and root
diagnosis, treatment planning, surgical procedure,
maturation and eruption. Ideally, one would prefer the
endodontic treatment, orthodontic treatment,
donor tooth to be at its maximum length but still has
restorative treatment, and follows up.
its potential for pulp regeneration with apex opening
>1mm radiographically. Examination and diagnosis: Anatomicshapes of the
donor teeth and recipient sites, stage of root
Indications for autotransplantationof teeth:
development, ease of preparation of the recipient
Impacted or ectopic teeth: Autotransplantation may
socket and potential for damage of the donor tooth at
provide a simplified and fastertreatment option for
removal are evaluated clinically and radiographically.
patients with ectopically positionedteeth.in cases of
severe ectopic position of maxillary canines, Treatment planning: Timing of tooth extraction at
transplantation can be a consideredas a treatment the recipient site is carefully determined. If the tooth
3
alternative. is extracted prior to the date of transplantation,
transplantation should be performed within 26
Traumatic tooth loss: Maxillary incisors are the teeth
weeks after the extraction because extensive bone
most frequently involved in trauma. Zachrisson
resorption will occur after 6 weeks. Immediate
reported autotransplantation of the developing
transplantation with an extraction at the recipient site
mandibular second premolar to the avulsed maxillary
4 will be preferable if enough gingival tissue to close
incisors.
around the donor tooth is expected. If root-canal
Tumours: autotransplantation shows benefit in treatment is deemed inevitable based onthe stage of
selected cases of jaw reconstruction, with distal bone root development of the donor tooth, it may be
autotransplants as alternative to dental titanium completed before transplantation or initiated 2 weeks
5
implants and supra structures. after transplantation. Restorative treatment of
transplants should be discussed to avoid
Congenitally missing tooth in one arch with clinical
unnecessary tooth reduction. More esthetic results
signs of tooth crowding in the opposing arch:If
will be achieved by restoring transplants with
extraction has been planned in the maxilla for the
composite rather than by fabricating artificial full-
correction of crowding or reduction of anoverjet, a
coverage prosthetics.
maxillary premolar may be transplanted to the
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second premolar site in the mandible. Surgical procedure: It is recommended to
administrate antibiotics a few hours before surgery. In
Teeth with bad prognosis: In most cases, the tooth or
immediate transplantation, the tooth to be extracted
teeth to be extracted due to caries or periodontal
in the recipient site should be extracted before the
disease are the first molars. In this case,
donor tooth. The donor tooth should be examined for
transplantation of third molars to the first molar site
7 anatomical form, size and PDL condition. Care must
may be considered.
be taken not to damage the PDL. An intra-crevicular
Developmental anomalies of teeth and related incision is made before luxation to preserve as much
syndromes: Developmental anomalies of the teeth PDL on the root as possible and the donor is
and relatedsyndromes, such as regional extracted slowly and as atraumatically as possible.
odontodysplasia, tooth aplasia, cleidocranial The donor tooth should be placed back in its original
8 9
dysplasia and tooth agenesis are indications for socket after it is removed. If any extra-oral time is
transplantation. anticipated, the tooth should be stored in a storage
medium like Hanks balanced salt solution that will
Contraindications: include cardiac anomalies, poor
maintain the viabilityof the periodontal ligament cells.
oral hygiene poor self-motivation and insufficient
The mesio-distalwidth of the root and crown and the
width of the alveolar bone. If the recipient site has
length of the root of the donor are measured. The
insufficient buccopalatalor buccolingual width to
recipient socketis prepared a little larger than the
accommodate the donor tooth, resorption of the donor using surgicalround bars at low speed and
8
alveolar ridge may occur. If transplantation cooling with saline. The match between the recipient
isdeferred, it should be scheduled as soon as

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Am. J. Med. Dent. Sci., 2013, 1(1): 25-30

and the donor is periodically checked by attempting Root-canal treatment: Pulp healing can be expected
to place the tooth into the socket with light pressure. in the transplantation of developing teeth. In such a
Obstacles in the socket wall are removedas case, a radiographis taken every month for 3 months
encountered. The optimal placement of the donor to after the surgery tomonitor inflammatory resorption or
the recipient is to establish the biologic width similar apical periodontitis due to pulp space infection. If any
to that of a naturally erupted tooth. Deep placement sign of pulp infectionis observed, root-canal treatment
10
to a position below the occlusallevel of adjacent teeth should be initiated assoon as possible. If no sign of
should be avoided, if possible, so that orthodontic pulp infection is seen, aradiograph is taken 6 months
treatment will not be needed at a later stage.Tight after the surgery to evaluatecontinued root
closure of the gingival flap around the donor tooth is development and pulp canal closure.When
most important. This optimizes reattachment and regeneration is successful, pulp canal obliterationis
may block bacterial invasion into the blood clot inevitable and should be considered a positive sign
11
between the tooth and socket. In order to achieve this ofpulpal health. Sensitivity tests should become
close adaptation around the donor tooth, trimming of positiveat this 6-month recall. On the other hand, the
flap is needed in some cases, and suturing of flap pulp in fully developedtransplants cannot regenerate.
before the donor is positioned into the socket is This does not disqualifythese teeth from
recommended in every case. Tighter and closer transplantation. Root-canal treatmentshould be
adaptation between the flap and the donor tooth will planned at the appropriate time. If the donortooth is
be achieved by suturing before the donor positioning accessible, the endodontic treatment can
than after it. The donor tooth is placed lightly into the becompleted before surgery. If the donor is impacted
recipient socket through the opening of the sutured orerupted in a position that makes endodontic
gingival flap. Ideally, the gingival opening should be a accessdifficult, the root-canal treatment should be
little narrower than the donor diameter because a started2 weeks after transplantation. The 2-week
tight adaptation between the tooth and gingiva is timing forendodontic treatment is extremely
desirable. Splinting by means of sutures is then important, sinceendodontic treatment performed too
performed. If the transplant is not stable after suture soon after surgerymay cause additional PDL damage
splinting or if much more occlusal adjustment is and if it is delayedpast 2 weeks, inflammatory
necessary, splinting is changed to one with wire and resorption may develop dueto infection in the root-
adhesive resin. If the transplant is not stable but no canal system.
occlusaladjustment is needed, splinting with wire and
Orthodontic treatment: if necessary, can be initiated1
resin can be delayed for 2 or 3 days after suture
month after transplantation with mature teeth.
splintingbecause the former is time consuming and
bleeding during the surgical procedure makes optimal Restorative treatment: In an ideal situation, when a
results difficult. developing third molaris transplanted to another site
in the arch, restorativetreatment is not necessary,
Occlusal adjustment: The occlusion must be checked
provided pulp healing occurs.In less ideal situations,
to ensure that no occlusal interference is present. If a
restoration of crown isneeded, such as filling an
suture is used for stabilization, ideally the occlusal
access cavity for root-canaltreatment, creating
contact should be reduced extra-orally prior to
improved interproximal contact,or recontouring the
positioning of the donor, taking care not to damage
crown for occlusion and esthetic.
the PDL. It could also be performed intraorallybefore
the extraction of the donor. If a wire splint is used, The patient should also be advised to eat a soft diet
occlusal adjustment can be done after placing the for the first few days after the
splint. Occlusal adjustment should be conservative, transplant.Chlorhexidine rinse and antibiotics should
since a composite restoration will be needed after be prescribed for a week after the surgery.
healing to adjust the occlusion and/or esthetic
Factors affecting success:
appearance of the crown of the tooth. A radiograph is
taken preoperatively, before and after splinting to Atraumatic Procedure: An atraumatic surgical
evaluate the position of the donor tooth in the new technique preserves bone and periodontal support.
socket. Surgical dressing (periodontalpacking) is Minimal handling of the transplant is required to
applied to protect the transplant againstinfection protect the Hertwigsroot sheath and pulpal tissue;
during the first 23 days in the woundhealing. This otherwise root growth may be compromised,leading
dressing is removed at about 34 dayspost-surgery. to ankylosis or root resorption and attachment
8
The sutures are removed 45 days after the surgery. loss. The tooth to be transplanted should be out of its

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Am. J. Med. Dent. Sci., 2013, 1(1): 25-30

socket a minimal amount of time to avoid desiccation. Splints can also compromise oral hygiene
The longer the tooth is left outside the socket, the procedures, thus leading to periodontal inflammation
12
poorer the prognosis. A 5 year follow up study by around the transplanted tooth. The transplanted tooth
vrien showed that despite damage to the follicle of must be placed at the same occlusallevel as the
the upper third molar during surgical transplantation donor site so that it will develop a longer root
13
shows a good result. thanthose placed in a superficial, more occlusal,
position. However,if the graft has a mature root and is
The Development of the Root: Transplanted teeth
fully erupted, the graftshould be placed just slightly
with incomplete root formation have a 96% rate of
below the occlusal level to preventpostoperative
pulpal healing, compared with 15% for transplanted 8
10 trauma.
teeth with complete root formation. Most authors
believe that the roots should be developed beyond Periodontal Healing: Preservation of the periodontium
their bifurcation for successful transplantation of the of the grafted tooth is keyto a successful clinical
tooth. Some authors prefer radiographic evidence outcome. When the periodontal fibresare vital, natural
that the root has developed at least 2 to 3 mm, reorganization of the periodontal fibersoccurs.
whereas others advocate root development of at Periodontal healing is usuallycompleted after 7-8
14
least 3 to 5 mm. Still othersstipulate root weeks and can be diagnosed radiographically as
development between one-third to three-quarters of acontinuous space around the root with absence of
8
its final length. Although higher success rates are rootresorption and presence of a lamina dura. The
achieved with teeth that have immature roots, these final position of the donor tooth within the recipient
teeth have less root growth after transplantation than socket influences periodontal healing. The donor
other autografted teeth that have more mature, tooth should be placed so that 1 to 2 mm of the width
8
although not completely formed, apices. The of the periodontal ligament stays above the bone
diameter of the apical foramen is a reliable predictor crest to achieve an ideal biologic width.Apical
of pulpal healing. Teeth with an apical diameter migration of epithelium may occur and result in
greater than 1 mm have a diminished risk of necrosis vertical bone resorption due to deep placement or
because postoperative revascularization is more long connective tissue attachment due to too shallow
2
likely. Overall, transplantation of teeth with immature placement.
roots offers high success rates because root
Infection at the host site and postoperative control
development of the donor tooth and adjacent alveolar
15 ofsupragingival plaque: adversely influence the
bone growth are unimpeded. The success rate of
success of tooth transplantation.bacterial
autotransplantation of teeth with complete root
contamination of either the pulp tissue or the
formation is questionable. The American Association 17
dentinaltubules can lead to inflammatory resorption.
of Endodontists recommends that the pulp of teeth
Patients should routinely rinse with
with closed apices be extirpated 7 to 14 days after
chlorhexidinegluconate (0.12% in aqueous solution)
transplantation; otherwise the necrotic pulp and
for several daysperioperatively to reduce plaque and
subsequent infection may result in inflammatory 15
promote healing. Although some studies show no
resorption and decrease the survival time of the
2 relation between graft survival and administration of
autografts. Moreover, all postoperative treatment 18
16 antimicrobials, few authors believe that
should be done within 8 weeks. Endodontic
antimicrobials improve the patientschance of having
treatment or apicoectomy during the 10, 19
a good clinical outcome.
surgicalprocedure is not advisable because it
8
increases the risk of rootresorption. Evaluation of success: Success is defined as
normal periapical healing, without any inflammatory
Adequate Fixation: Excessive time or rigid splinting
pulpal changes or progressive root resorption, and
of the transplanted toothwill adversely affect its
continued development of root growth.Complete
healing outcome. Thesplint should not force the tooth
periapical healing and periodontal health are more
against the bony walls of thealveolus because it may
16 reliable parameters of prognosis and success
damage the periodontium. Most reports advise
because slight external root resorption (either
flexiblesplinting for 7 to 10 days,with sutures placed
surface, inflammatory or replacement resorption) is
through themucosa and over the occlusal surface of
often not detected radiographically, perceiving a
the crown becausethis permits some functional
metallic percussive sound is an accurate indication
movement of the transplantand stimulates 19
that the tooth is ankylosed.
periodontal ligament cellular activity and bonerepair.

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Am. J. Med. Dent. Sci., 2013, 1(1): 25-30

Success:Success rates are found to be 90% or reported in studiesover the past decade, these
higher. In a recent study, Sugai followed 114 studies demonstrate that autotransplantation is a
transplants and found a one- year success rate of viable option for tooth replacement for carefully
20 14
96%, with 84% at five years. Other studies have selected patients.
shown between 79 and 95% success rates, with
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