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Autotransplantation: The Vital Option forReplacement of Missing Anterior Teethin the Developing DentitionR. David Roden, Jr., DMD, MD, and Mark R. Yanosky, DMD, MS

Missing multiple anterior teeth presents a tremendous challenge for the dental

team. There are several options for successful replacement or masking of the

missing teeth, including orthodontic space closure, fixed or removable pros-

thetics, osseointegrated dental implants, and tooth autotransplantation. Often

these modalities must be combined to obtain the best esthetic and functional

results. An 11.5-year-old girl sustained loss of her permanent central incisors

and right lateral incisor teeth, and in addition sustained a comminuted maxilla

fracture with loss of the buccal plate during a horseback riding accident.

Using autotransplantation and orthodontic space closure, an esthetic and

functional outcome with vital teeth was achieved. The collaboration of a

multispecialty dental team is essential for challenging cases such as the

one presented. The use of autotransplantation provided our patient with

early definitive tooth replacement, and is the only replacement option to

provide vital teeth. Autotransplantation should be considered in the

treatment options for missing anterior teeth in the developing dentition.

(Semin Orthod 2013;19:13-23.) © 2013 Elsevier Inc. All rights reserved.

M issing anterior teeth in the developingdentition poses a very challenging prob-

em for the dental team. Whether the teeth areissing congenitally or owing to trauma, indi-

iduals prefer rapid and definitive replacement.ndreasen et al1 found that most traumatic den-

al injuries occur during the time of the devel-ping dentition.2,3 There are many options for

the replacement of missing teeth, regardless of theetiology. The challenge of planning for their re-placement comes with not only the number andlocation of the missing teeth but also the age anddevelopmental stage of the patient. The replace-ment or masking options include orthodonticspace closure, removable or fixed prosthetic re-

Private Practice, Oral and Maxillofacial Surgery, Birmingham,AL; Private Practice, Orthodontics, Birmingham, AL; University ofAlabama School of Dentistry, Birmingham, AL.

Address correspondence to R. David Roden, Jr., DMD, MD, Oraland Maxillofacial Surgery, 1771 Independence Court, Suite 2,Birmingham, AL 35216. E-mail: [email protected]

© 2013 Elsevier Inc. All rights reserved.1073-8746/13/1901-0$30.00/0

Seminars in Orthodontics, Vol 19, N

placement, osseointegrated dental implant re-placement, and tooth autotransplantation.

Orthodontic space closure is an option, but inmany cases, will leave an unacceptable estheticresult and functional compromise. Instead oftruly replacing the missing teeth, this proceduremasks the defect of the missing tooth. For exam-ple, a mesially positioned cuspid to replace amissing lateral incisor, even with concomitantextrusive forces and prosthodontic recontour-ing, is an esthetic and functional compromise.The gingival contours of the tooth will notmatch the opposite side of the arch, and thepatient will be left in a modified group functionon the affected side. In the patient with multiplemissing teeth, orthodontic space closure can becombined with other replacement options andbe successful. As the sole option for replacingmultiple missing teeth, orthodontic space clo-sure is insufficient.

Asking a teenager to go through many of thesocially developmental years with a removableprosthesis or even a bonded restoration requir-

13o 1 (March), 2013: pp 13-23

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14 Roden and Yanosky

tiple repairs and replacements seems unwise.Even with the advent of new restorative materialsand bonding agents, resin-bonded prostheses havea high rate of short-term and long-term failure.4 Inhe absence of a functioning tooth at the site,lveolar function and development is not stimu-ated, and alveolar bone loss will progress.

The science behind osseointegration and den-al implants is well developed. However, place-

ent of a dental implant before completed facialrowth and alveolar development can result inoor esthetic and functional outcomes. Implantsre a very effective treatment for replacement ofissing teeth; however, this definitive treatment

annot be completed until the patient is at least8 years old. Although the success and survivalf dental implants is �90%, placement of an

mplant at a young age with less than ideal alve-lar bone can lead to esthetic challenges. Asontinued bone loss and gingival thinning oc-ur, gray discoloration at the gingival margin willppear owing to show through of the implantomponents.

Tooth autotransplantation is defined as theovement of a tooth or dental germ from one

osition to another, within the same person.5 Itis the only option that will allow for a vital re-placement, early definitive replacement, and,many times, fewer surgical interventions. Auto-transplantation should be considered for re-placement of missing teeth when there are clearindications for extraction of otherwise healthyteeth. Aided by prosthetic recontouring, trans-planted teeth can provide an excellent estheticand functional result. In addition, the concernof implant components showing through thegingiva is no longer an issue. Unless multipleteeth are missing and orthodontic repositioningmust be used as well, there is the opportunity forless functional compromise.

Several authors have shown tooth autotrans-plantation to be successful, with survival rates of74%-100%.6 According to Czochrowska et al,7

the survival rate of 30 transplanted premolars in25 patients was 90%. This same retrospectivereview reported success, based on accepted clin-ical parameters, at 79%. Autotransplantation al-lows for the replacement of missing teeth with avital tooth. Vitality is most promising when au-totransplantation is performed using donorteeth with open apices in the developing denti-

reliant on tooth presence and eruption, loss of afunctioning tooth at a site will lead to alveolarbone loss and insufficient bone quality and quan-tity for implant placement in the future. Having atransplanted tooth present will allow for continuedalveolar stimulation. Furthermore, it provides anesthetic replacement during development withoutaltering adjacent teeth. Should the transplant beunsuccessful, and future bone grafting and im-plant placement be indicated, there will be a morefavorable biological situation for implant success.

Multiple authors have outlined keys for suc-cess with autotransplantation with regard to thedeveloping dentition. One can expect high au-totransplant success and survivability if theseprinciples are followed (Table 1). Czochrowskaet al7 defined success using modified parametersfrom several authors. Their criteria were ab-sence of progressive root resorption, normalhard and soft periodontal tissues adjacent to thetransplanted tooth, and crown-to-root ratio �1.Other measures of success include a vital trans-planted tooth and continued root developmentafter transplantation. These objectives can be metwith careful planning and surgical technique.

Root development after transplantation can beunpredictable but likely to continue with preserva-tion of the root sheath of an immature tooth.8-12 Thenitial response to healing is inflammation, whichan lead to root resorption if not controlled.lthough excellent surgical technique cannotredict how much development will occur,aintaining Hertwig root sheath with good sur-

ical technique is essential for having continuedoot formation. A tooth with ½ to 2⁄3 root devel-

opment has the greatest predictability for sur-vival.13 This stage of development allows fornough root structure should no further rootevelopment occur and, if Hertwig root sheathemains intact, the potential for further rootevelopment is favorable. Andreasen et al9

Table 1. Keys for Autotransplant Success

1 Donor tooth ½ to 2⁄3 root development, with�1-mm open apex.

2 Atraumatic extraction, maintaining periodontalligament cells.

3 Brief extraoral time of donor tooth.4 Best result if recipient site is fresh extraction site.5 Overprepared recipient site.6 Functional fixation.7 Follicle cells and Hertwig root sheath intact.

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15The Vital Option for Replacement of Missing Anterior Teeth

found that 82% of transplanted premolars un-derwent partial or complete root development,and only 18% had no further development.

Normal hard and soft periodontal structuresare obtained after transplantation by maintain-ing as many viable periodontal ligament (PDL)cells on the transplanted root as possible. Thepresence of PDL cells at the recipient site is alsobeneficial, but many times, they are unintention-ally obliterated during preparation of thesite.8,14 PDL cells are maintained on the donortooth by careful surgical technique and minimiz-ing their exposure to harmful environmentssuch as desiccation and chemicals. The presenceof these cells on the majority of the donor rootsurface can prevent replacement resorption orankylosis by minimizing the surface of the rootexposed, which maintains an active inflamma-tory response.8 If a small area of the root is

issing PDL cells, it can be repopulated by ad-acent PDL cells and harmful inflammatory heal-ng can be avoided. Large areas devoid of PDLells will maintain the inflammatory responsend have an unfavorable outcome.

Vitality of transplanted teeth is expectedhen immature teeth with open apices are trans-lanted. With an open apex of �1 mm, angio-enesis can occur, providing nutrients to thenvading pulp cells. Tsukiboshi showed evidencehat pulp canal obliteration is a positive sign ofulpal health and should be expected.8 The

donor teeth should respond to vitality testingapproximately 6 months after transplant. If anysigns of persistent inflammatory healing appearclinically or radiographically, endodontic ther-apy should be initiated immediately.

Case Presentation

Much like the case presented by Zachrisson in2008,2 our case involves a child with developing

entition and a horseback riding accident. An1.5-year-old girl fell from horseback on aooded trail. After falling, the rear hoof of theorse impacted the face and maxilla of the pa-

ient, avulsing multiple maxillary anterior teeth.t the time, the patient was wearing orthodonticppliances and was in the mixed dentition. Sheustained avulsion and severe intrusion of herermanent upper right maxillary lateral andentral incisors as well as her permanent left

f the anterior maxilla, with avulsion of the buccallate. She had a degloving injury of her maxillaryingiva and mucosa up to the nasal floor. Theeeth were displaced high into the maxillary softissues and the nasal floor along with her orth-dontic appliances (Fig 1A). She also sustained 2eep facial lacerations on the right face. She pre-ented to the emergency department and under-ent complete trauma workup.

Surgical Sequence and Technique

Owing to the patient’s age and the severity ofher injury, she was taken to the operating roomon the evening of her injury, and using intu-bated general anesthesia, her wounds were ex-plored and cleaned. Owing to the lack of buccalbone and the uncleanliness of her injury, it wasdetermined that she was not a candidate forreimplantation of the avulsed teeth. The avulsedteeth were extracted, and the orthodontic hard-ware was removed (Fig 1B). Her wounds werethoroughly cleansed, and the nasal floor andfacial lacerations were closed. To better prepareher for future replacement of the missing teeth,the maxillary alveolus was grafted with DBX Mix(Synthes, Inc, West Chester, PA), a mixture ofdemineralized bone matrix and cortical chips ina sodium hyaluronate carrier (Fig 1C). Her in-traoral soft tissues were advanced and closedprimarily (Fig 1D).

During the 6 months of required healing forthe bone graft, a team of dental practitioners wasassembled to plan treatment for her missingteeth. Her orthodontic evaluation revealed ananterior open bite and ectopically erupting rightmaxillary cuspid. The patient and her familywere opposed to her wearing a removable pros-thesis for the next 8 to 10 years of her life, andno other fixed prosthetic option seemed reason-able. After many discussions, we determined thatshe likely was going to need mandibular premo-lar extractions to better manage her skeletaldiscrepancy, and that her mandibular premolarswere at a stage of development appropriate fortransplant. Because she already had an openbite, there would be no problem with occlusalinterference after transplantation. Transplanta-tion, if successful, would provide her esthetic,long-term, and vital replacements for her miss-ing central incisors. Her right maxillary cuspid

16 Roden and Yanosky

Figure 1. 1 (A) Initial surgery after accident. Teeth in the floor of the nose, severely displaced orthodonticappliances, missing buccal plate, and degloving injury of the anterior maxilla are shown. (B) After hardwareremoval, extraction of teeth, and cleansing of the wound, the right piriform rim of the nose and the extent ofthe bone loss can be clearly seen. The erupting right maxillary cuspid can also be identified. Deep periorallacerations are present on the right face. (C) DBX Mix (Synthes, Inc, West Chester, PA) bone grafting materialin place. (D) Primary closure of the intraoral wounds and facial lacerations. (E) Panoramic radiograph takenimmediately before initial transplant surgery. Excellent bone height in the anterior maxilla noted. The right andleft mandibular premolars have open apices, indicating a good opportunity for revascularization of the pulpchamber. (F) Three-month postoperative image after the grafting surgery, showing good ridge form for future

. Co

17The Vital Option for Replacement of Missing Anterior Teeth

a chain to direct its eruption into the position ofher right lateral incisor. The cuspid and trans-planted teeth would then later undergo pros-thetic recontouring to satisfy esthetic needs.

Transplant Surgery Technique

Preoperative radiographic evaluation was per-formed to determine the appropriate donortooth and adequate bone height at the recipientsite (Fig 1E). Clinical evaluation of the donorand recipient sites was also performed to ensurelack of pathologic processes and adequate bonywidth for receiving the transplant (Fig 1F). The

Figure 1

patient was brought to the Oral and Maxillofa-

cial Surgery Clinic operating suite, and sherinsed her mouth with 0.12% chlorhexidine glu-conate for 1 minute and expectorated. An intra-venous catheter was inserted, and general anes-thesia was accomplished to ensure her comfort.A preoperative dose of intravenous antibiotic,cefazolin (1 g), was administered (Hospira, Inc,Lake Forest, IL). Local anesthesia at the donorand recipient sites was administered in the formof 2% lidocaine with 1:100,000 epinephrine(Hospira, Inc, Lake Forest, IL) and 0.5% Mar-caine with 1:200,000 epinephrine (Hospira, Inc,Lake Forest, IL). Once an adequate level of localanesthesia was obtained, a crestal incision was

ntinued

made at the recipient site, and a full-thickness

18 Roden and Yanosky

Figure 2. (A) Nobel Biocare Replace Select (Nobel Biocare, Yorba Linda, CA) osteotomy drills used to make theinitial recipient site osteotomy. (B) Initial osteotomy for transplant site, created using implant drills. (C) Afterextraction of the left mandibular primary second molar, the left mandibular second premolar was exposed. Carehad been taken to preserve as much of the follicle as possible, and bone had been removed, exposing a smallportion of the cervical root. (D) The extracted donor tooth, left mandibular premolar. Large amount of follicleremains at the cervix, which will aid in tight closure and encourage rapid healing. The fuzzy appearance ofthe root is due to the presence of periodontal ligament cells on the root surface. Rapid assessment of the rootform and existing tissues must be accomplished to minimize the out-of-socket time for the transplant tooth.(E) Further preparation of the recipient site by widening the osteotomy buccolingually. Also note that themaxillary right cuspid has been exposed and ligated with a button and gold chain. (F) Initial placement of 4-0silk sutures mesially and distally to aid in rapid and tight closure immediately after the transplanted tooth is placedin the recipient site. (G) Transplanted tooth in place without pressure or impingement on any structures. (H) Closureof the operative site with silk suture mesially and distally. The tails are crossed over the occlusal surface of thetransplant and tied. With proper socket preparation and no impingement from the opposing occlusion, this is the

. Continued

19The Vital Option for Replacement of Missing Anterior Teeth

flap was elevated. The ectopically erupting rightcuspid was easily identified. Bone was removedfrom the facial surface, and a button and goldchain were bonded to the facial surface using astandard technique. The bone at the recipientsite was deemed as having adequate width forthe transplant. Many techniques in the literaturedescribe using a round bur for site preparation.To better control the osteotomy and to provideinternal irrigation reducing the amount of heatgenerated, we used tapered implant osteotomydrills from the Nobel Biocare Tapered GroovyImplant system (Nobel Biocare, Yorba Linda,CA) to initiate the osteotomy (Fig 2A). The os-

Figure 2

teotomy was created at proper position and

Figure 3. One week after transplant surgery and aftersilk suture removal. (Color version of figure is avail-

emr e.)

20 Roden and Yanosky

depth to ensure no occlusal contact would bepresent between the transplanted tooth and themandibular dentition after surgery (Fig 2B).

After the initial preparation of the recipientsite, we directed our attention to harvesting thedonor tooth. Careful planning with the dentalteam determined the mandibular second pre-molars as the most appropriate donor teeth. Aflap was developed over the lower left secondpremolar. Bone was removed to well below theheight of contour of the tooth ensuring no con-tact of the bur with the root surface and preserv-ing as much of the follicle as possible (Fig 2C).As discussed previously, one of the principles ofautotransplantation surgery is to maintain as

Figure 4. (A) One month after transplant. Gingivalnces present. Although the tooth is somewhat maovements. (B) Periapical radiograph taken 1 month

esorption. (Color version of figure is available onlin

Figure 5. (A) One week follow-up appointment afteplanted tooth and the better position of the left transPeriapical radiograph taken at 1 week after second tnoted. The left transplanted tooth had begun to h

many PDL cells as possible. To achieve this, thetooth was gently luxated and extracted (Fig 2D).To decrease the amount of out-of-socket timefor the tooth, its root form was quickly evaluated,and the tooth was immediately returned to itsoriginal socket. Because the root was wider buc-colingually than we had prepared, the osteot-omy at the recipient site was widened in thenecessary dimensions (Fig 2E). Next, the trans-planted tooth was tried into the recipient socketand found to fit passively. To fully prepare therecipient site, the tooth was again returned to itsoriginal socket while preparation of the recipi-ent site was completed. Although there are manymedia in which the tooth can be stored ex-

ng has occurred, and there are no occlusal interfer-tioned, this will be taken care of with orthodonticoperatively, demonstrating an open apex and no root

e second transplant. Malposition of the right trans-ted tooth after orthodontic movements is noted. (B)lant. The open apices of the transplanted teeth areome canal obliteration. (Color version of figure is

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21The Vital Option for Replacement of Missing Anterior Teeth

traorally during this period, there is no substi-tute for the original tooth socket. One mustensure that the tooth fits passively and no pres-sure is placed on it during placement, removal,and replacement in any socket. This will ensureminimal damage to the remaining PDL cells.Some have proposed the use of prefabricatedmodels of the donor tooth made from computedtomography scans before surgery to reduce theout-of-socket time for the donor tooth.15 The ad-

itional expense and fear of radiation exposure,lthough minimized with focused-field cone-beamomputed tomography, is not accepted by manyatients and their families.

Preparation of the recipient site was contin-ed by placing a 4-0 silk suture mesial and distal

o the recipient site (Fig 2F). These sutures wereoosely tied, and long tails remained. A tight softissue fit at the site assists with retention of theonor tooth and provides less opportunity foreepage of fluids into the subgingival transplantite. At this point, the donor tooth was removedrom its socket and transplanted to the recipientite (Fig 2G). The tooth was placed, and minimalressure was applied. The sutures were tight-ned mesially and distally. The long tails werehen crossed over the occlusal surface of theooth and tied tightly, providing a splint and

Figure 6. Transplanted teeth before prosthodonticreshaping. Also note the good healing of the peri-odontal soft tissues around the teeth. (Color versionof figure is available online.)

xation for the transplant (Fig 2H). The donor

ite and the maxillary flap were closed using a-0 chromic gut suture.

The patient was allowed to recover from hernesthesia and was discharged home. She waslaced on a 1-week course of amoxicillin (500g) every 8 hours. She was also instructed to use

ver-the-counter nonsteroidal anti-inflammatoryedications for pain control and was given a

rescription for hydrocodone (5 mg)/acetamin-phen (500 mg) to be used every 4 to 6 hours aseeded for breakthrough pain. After 3 days of

nitial healing, she started twice-daily 0.12%hlorhexidine gluconate mouth rinses (Peridex,M ESPE, St Paul, MN).

Figure 7. (A) Facial view of reshaped teeth. Gingivalhealing is present. Gingival recontouring to createsymmetry will be performed in the future. (B) Occlu-sal view after prosthodontic reshaping. (Color version

22 Roden and Yanosky

The patient was followed up at 1 week forradiographs and suture removal (Fig 3). Herdonor and recipient sites were healing unevent-fully. There was no evidence of infection or anyresorption at this time. She was seen every 2weeks during the initial healing period to evalu-ate for complications (Fig 4A and B). Early de-tection of root resorption or persistent inflam-mation is essential so that endodontic therapycan be initiated to help prevent failure of thetransplant.

The literature on initiation of orthodontictherapy after tooth transplant is inconclusive.Some authors advocate starting 3 to 9 months

Figure 8. (A) Radiograph taken 3 months before dplanted teeth. The anterior open bite persists. (B) Afteanterior open bite persists. The discoloration of the

posttransplant.2,6 Our team decided to proceedwith earlier orthodontic intervention to obtainproper positioning and excellent bone stimula-tion and development. There was a need tomove the transplanted tooth to the right centralincisor position to have room for a subsequenttransplant to the left central incisor position.Our patient was fitted with orthodontic appli-ances, and movements were initiated approxi-mately 2 months after transplant surgery. Shewas followed clinically and radiographically, withno complications noted.

Six months later, the patient underwent trans-plantation of another mandibular second pre-

ding. Some canal obliteration noted with the trans-bonding, the teeth have good position and form. Theositioned cuspid is evident. Tooth shape and color

ebonr derep

ntion. (Color version of figure is available online.)

23The Vital Option for Replacement of Missing Anterior Teeth

molar to the right central incisor position usingthe same technique previously described (Fig 5Aand B). After adequate orthodontic positioning(Fig 6) of her transplanted teeth, recontouringof the teeth was performed (Fig 7A and B). At 6months after transplant and subsequent fol-low-up visits, her transplanted teeth tested vitaland did not require endodontic therapy. Noexternal resorption was noted. The teeth hadnormal hard and soft periodontal structuresclinically and radiographically. Two years afterher initial injury, orthodontic appliances wereremoved, and her transplants were stable (Fig8A and B). The patient and her family are satis-fied with the esthetic and functional results. Bi-maxillary orthognathic surgery is planned in thefuture to correct her skeletal discrepancy. Toothshape and color corrections were planned withfuture prosthodontic intervention.

Conclusions

Loss of teeth in the developing dentition poses agreat challenge for the dental team when plan-ning replacement options. This is especially truewhen multiple anterior teeth are missing. Thereare several options for replacement of theseteeth, each with its associated advantages anddisadvantages. The only treatment option thatallows for reducing the number of interventions,providing a vital replacement, avoiding remov-able prostheses, and not altering adjacent teethis autotransplantation. Tooth autotransplanta-tion has proven successful in the literature andshould be considered because it is the sole vitalreplacement option.

Autotransplantation treatment is indicated inmany situations, but likely overlooked owing tolack of experience. The overall success of auto-transplantation requires a dental team, includ-ing orthodontists, oral surgery, and restorativedentistry, working together toward commonfunctional and esthetic results.

AcknowledgmentsThe patient illustrated in this paper was surgically treated at

orthodontic care was provided by Dr Mark Yanosky, andrestorative care was provided by Dr Thomas Dudney.

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13. Clokie CM, Yau DM, Chano L: Autogenous tooth trans-plantation: An alternative to dental implant placement?J Can Dent Assoc 67:92-96, 2001

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15. Keightley AJ, Cross DL, McKerlie RA, et al: Autotrans-plantation of an immature premolar, with the aid ofcone beam CT and computer-aided prototyping: A case