Autotransplantation combined with orthodontic treatment to ... › wp-content › uploads › 23-4.pdf · the premolar. A multidisciplinary approach including autotransplantation

CASE REPORT

Autotransplantation combined with orthodontictreatment to restore an adult's posttraumaticdentition

Yoon-Jeong Choi,a Semin Han,b Jeong-Won Park,c Dong-Won Lee,d Kyung-Ho Kim,e and Chooryung J. Chungf

Seoul, Korea

Fromof DeaAssisbResidcProfedAssiseProfefAssocAll auPotenReprinnam SYonsecrchuSubm0889-Copyrhttp:/

268

This case report describes the successful treatment of an adult with a skeletal Class II Division 2 posttraumaticdentition with consequential restorations. The extracted maxillary premolar was autotransplanted to replace thehopeless mandibular first molar. The endodontically treated maxillary right canine was extracted instead ofthe premolar. A multidisciplinary approach including autotransplantation and orthodontic treatment provided asatisfactory outcome. (Am J Orthod Dentofacial Orthop 2013;144:268-77)

Trauma can result in fractures of the facial bones,alveolar bones, and the teeth, along with the lossof multiple teeth. During multidisciplinary recon-

struction procedures, we sometimes confront unwantediatrogenic complications, poor prognoses, or unsatisfy-ing treatment outcomes.1,2

Here, we report the orthodontic treatment of an adultpatient with a Class II malocclusion and severe crowding.Because of trauma and previous reconstruction therapy,there were multiple dental implants, tooth fractures, andendodontically treated teeth. In addition, a molar washopeless as a result of periodontal problems. An unusualextraction regimen was applied by extracting theendodontically treated maxillary canine instead of thedental implant, and the other extracted premolar wasautotransplanted to replace the extracted mandibularmolar.

Gangnam Severance Hospital, Institute of Craniofacial Deformity, Collegentistry, Yonsei University, Seoul, Korea.tant professor, Department of Orthodontics.ent, Department of Orthodontics.ssor, Department of Conservative Dentistry.tant professor, Department of Periodontology.ssor, Department of Orthodontics.iate professor, Department of Orthodontics.thors have completed and submitted the ICMJE Form for Disclosure oftial Conflicts of Interest, and none were reported.t requests to: Chooryung J. Chung, Department of Orthodontics, Gang-everance Hospital, Institute of Craniofacial Deformity, College of Dentistry,i University, 712 Eonjuro, Gangnam-gu, Seoul, 135-720, Korea; e-mail,[email protected], July 2012; revised and accepted, August 2012.5406/$36.00ight � 2013 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.08.031

DIAGNOSIS AND ETIOLOGY

A 37-year-old woman was referred by her periodon-tist for evaluation and treatment of her malocclusion.After trauma 4 years previously, her maxillary right pre-molars were avulsed and replaced with dental implants.Her mandibular left first molar had a periodontalabscess, Class III furcation involvement, probing depthsover 6 mm, a crack in the mesial root, and distal rootcaries with a periapical lesion. After diagnostic surgery,the first molar was diagnosed as hopeless by the peri-odontist. When the periodontist first met the patient,he was concerned that although implants and restora-tions were placed to restore the avulsed teeth, theywere not functionally in contact with the mandibulardentition. Furthermore, the patient had an unestheticsmile caused by severe crowding, which was her chiefcomplaint (Figs 1 and 2).

The patient had moderate to severe crowding. Boththe skeletal and dental relationships were Class II, andthe profile was straight (Figs 1 and 2). According tothe panoramic radiograph, the mandibular left firstmolar had furcation involvement with a periapicallesion, and the maxillary right premolars were restoredwith dental implants. Although a malunion of the rightcondyle was noted, there was no restriction in mandib-ular motion. The cephalometric radiographs showed aretrusive mandible (SNB angle, 70.8�) compared with arelatively well-positioned maxilla (SNA angle, 76.2�),indicating a skeletal Class II malocclusion (ANB angle,5.4�). The maxillary incisors were retroclined (U1-SN,92.5�). Vertically, the patient was normodivergent(SN-MP, 35.3�). The mandible was slightly deviated tothe right side (Figs 3 and 4; Table).

Fig 1. Pretreatment photographs.

Choi et al 269

Fromhermedical records,we learned that as a result oftrauma 4 years previously, her right condyle andmandib-ular body were fractured, the maxillary right premolarswere avulsed, the mandibular right canine was fractured,and the mandibular left canine was nonvital. The maxil-lary right canine had most likely been punctured withbone screws during the intermaxillary fixation procedure.Afterward, the premolars were restored with dentalimplants, and the maxillary right and mandibular leftcanines were endodontically treated. The mandibularright canine was left untreated because its vitality andmobilitywerewithin normal limits, withno specific symp-toms. Unrelated to the trauma, the endodontic treatmentof the mandibular left first molar was incomplete with aperiapical lesion and furcation involvement (Fig 5).

According to our evaluation of the orthodonticrecords and her history, the patient was diagnosedwith a skeletal Class II Division 2 malocclusion andsevere crowding.

American Journal of Orthodontics and Dentofacial Orthoped

TREATMENT OBJECTIVES

The treatment objectives were to relieve the crowd-ing, establish a functional occlusion, and maintain thesoft-tissue profile.

TREATMENT ALTERNATIVES

Under normal circumstances, extraction of the 2maxillary first premolars would have been consideredto relieve the crowding. Afterward, the maxillary molarswould be protracted, and the mandibular dentitionwould be distalized to finish with complete Class II molarand Class I canine relationships with no evident changesin the profile. However, because of the preexisting dentalimplants on the maxillary right side, premolar extractionand movement of the maxillary right molar segment wasnot an option. Therefore, we decided to extract theendodontically treated maxillary right canine insteadof the maxillary right premolar in addition to the left first

ics August 2013 � Vol 144 � Issue 2

Fig 3. Pretreatment radiographs.

Fig 2. Pretreatment study models.

270 Choi et al

August 2013 � Vol 144 � Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics

Fig 4. Pretreatment cephalometric tracing.

Fig 5. Recollected record (4 years before this treatment).

Table. Cephalometric summary

Variable Norm Pretreatment PosttreatmentSkeletalSNA (�) 81.6 76.2 76.3SNB (�) 79.1 70.8 70.9ANB (�) 2.4 5.4 5.5FMA (�) 24.0 21.7 22.0Gonial angle (�) 118.6 115.1 115.3SN-MP (�) 34.0 35.3 35.5Ramus height (mm) 51.6 46.5 46.5Body length (mm) 76.0 75.5 75.5Facial height ratio 66.0 64.3 64.2

DentalU1-SN (�) 106.0 92.5 94.5IMPA (�) 94.0 95.5 98.5Interincisal angle (�) 126.0 129.3 127.0Occlusal plane 15.0 12.9 13.0

Soft tissuesUpper lip to E-plane �1.0 �0.5 �2.5Lower lip to E-plane 1.0 �2.5 �3.0

Choi et al 271

premolar. After relieving the crowding, the remainingspace on the right side would be restored with pros-thetics for esthetic reasons. Meanwhile, the mandibularright molar region could be uprighted and distalized torelieve the premolar crowding.

The prognosis for movement of the mandibular rightcanine was questionable because of a fracture line, eventhough the tooth showed no signs or symptoms, andmobility was within normal limits. Fortunately, accord-ing to the treatment plan, major tooth movement inthe mesiodistal or vertical direction was not necessaryfor the mandibular right canine, so we decided to levelthe canine under close monitoring. After orthodontictreatment, the hopeless left molar could be replacedwith a dental implant.

American Journal of Orthodontics and Dentofacial Orthoped

An alternative treatment option would be to replacethe hopeless mandibular molar with an extracted maxil-lary first premolar via autotransplantation, and themaxillary arch would be treated in the same fashion asthe first option. In this case, an additional dental implantwould not be necessary to restore the mandibular molar.Since the recipient site had enough space, extraction andautotransplantation could be done on the same day,thereby reducing treatment time rather than finishingwith a dental implant after orthodontic treatment. Using3-dimensional imaging and a diagnostic setup, weplanned to rotate the autotransplant 90� during trans-plantation to gain a mesiodistal dimension similar tothe extracted first molar (Fig 6).

Both options were discussed with the patient. Shestrongly preferred autotransplantation over dentalimplants, and the orthodontist was also aware of thepositive benefits of autotransplantation. Therefore, thesecond treatment option was selected.

TREATMENT PROGRESS

Roth prescription 0.022-in slot self-ligating brackets(Clippy C; Tomy, Tokyo, Japan) were bonded on themandibular arch for alignment. Meanwhile, the maxil-lary left first premolar (donor tooth) was endodonticallytreated for autotransplantation. The alveolar socket ofthe first molar region (recipient site) (Fig 7, A) was eval-uated with 3-dimensional imaging, and a rapid proto-typing model was used to fabricate a replica of thedonor tooth (Fig 7, B). Reducing the donor tooth’sextraoral time and adjusting the recipient site'smorphology for the best adaptation of the donor toothare considered critical factors for successful autotrans-plantation.3,4 The tooth replica was used duringrecipient site preparation and adjustment. After therecipient site was ready, the donor tooth was extractedand rotated 90� during placement in the recipient site(Fig 7, C). The donor tooth was held in position withwire fixation during the healing period for 6 weeks. After7 weeks, a bracket was also bonded to the transplant,

ics August 2013 � Vol 144 � Issue 2

Fig 6. Occlusogram and diagnostic setup (*, transplant).

Fig 7. Three-dimensional imaging and intraoral photographs before and after autotransplantation:A, recipient site; B, rapid prototyping model and the replica of the donor tooth (arrow; dotted line, alve-olar bonemargin);C, intraoral adaptation of the transplant;D-F, 1 week after autotransplantation;G-I, 8weeks after autotransplantation.

272 Choi et al

August 2013 � Vol 144 � Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics

Fig 8. Posttreatment photographs.

Choi et al 273

and the arch was aligned with 0.016-in copper-nickel-titanium and 0.016 3 0.022-in low-hysteresis nickel-titanium wires (Tomy) (Fig 7, D-F). In the maxillaryarch, the left segment was aligned, and partial canineretraction was carried out until space was created torelieve the crowding. After extraction of the maxillaryright canine, high-torque brackets were bonded on themaxillary anterior segment, and leveling of the entirearch was continued. Maxillary space closure followed,and the mandibular arch was distalized with orthodonticminiscrews (Fig 7, G-I).

After 21months of active treatment, the brackets wereremoved. The space distal to the maxillary right lateral in-cisors was closed with a newly fabricated pontic attachedto the implant crown. In the final restoration, the trans-planted premolar was shaped as a first molar. Lingualfixed retainers were bonded from lateral incisor to premo-lar in the maxillary arch and from canine to canine in themandibular arch. Themandibular right caninewas still vi-tal, and no specific symptoms were noted during

American Journal of Orthodontics and Dentofacial Orthoped

treatment. Although there were limitations to finishingthe right side to an ideal occlusion because of the im-plants, the occlusion was functionally acceptable. Addi-tional circumferential retainers were delivered and usedfull time for 6 months. The patient was fully satisfiedwith the functional and esthetic outcome (Figs 8-11).

According to the cephalometric superimposition, themaxillary anterior torquewas improved, themaxillary leftmolars were protracted, and the mandibular molars weredistalized, while the soft-tissue profile was maintained(Fig 12). From the serial periapical radiographs, the alve-olar bone of the recipient site appeared to remodel afterautotransplantation and orthodontic treatment. Therewere no signs or symptoms of ankylosis or replacementresorption throughout the evaluation period (Fig 13).

DISCUSSION

The success and prognosis after autotransplantationof a tooth with complete root formation is affected by

ics August 2013 � Vol 144 � Issue 2

Fig 9. Posttreatment study models.

Fig 10. Posttreatment radiographs.

274 Choi et al

August 2013 � Vol 144 � Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics

Fig 11. Posttreatment cephalometric tracing.

Fig 12. Superimposed cephalometric tracings. Black,pretreatment; red, posttreatment.

Choi et al 275

the amount of intact and viable periodontal ligamentcells, the quality of root filling, the pocket depth, thedonor tooth’s extraoral time, the distance between therecipient site tissue and the transplant root surface,and the patient's age.4-8 In our patient, the maxillaryleft premolar was functional with sufficient occlusalcontact that provided intact and viable periodontalligament cells, did not have a history of root canalfilling, and had periodontal pocket depths under 3mm, and the patient’s age was less than 40 years.9 Allof these factors fit the selection criteria of a successfuldonor tooth as described above.

Along with a proper diagnosis, the multidisciplinaryteam also followed several clinical principles during

American Journal of Orthodontics and Dentofacial Orthoped

treatment. In general, endodontic treatment of thetransplant is recommended after autotransplantationbut before tooth movement. However, in our patient,primary endodontic treatment of the transplant wasdone before autotransplantation surgery. This allowedthe endodontist to fully understand the rootmorphology before the transplant surgery and gave thepatient sufficient healing time between the transplantsurgery and the initiation of orthodontic treatment,which was around 6 weeks. During surgery, secondaryapical sealing by the retro-filling method was also per-formed extraorally to reduce the possibility of apicalinflammation after transplantation. In addition, using3-dimensional imaging, a replica of the donor toothwas fabricated with rapid prototyping. Because thisreplica was used to prepare the recipient site, an idealcontact of the recipient site and the transplant wascreated while minimizing trauma to the periodontal lig-ament cells of the donor tooth.3 This procedure alsoreduced the extraoral time to less than 5 minutes andminimized the damage to the periodontal ligament ofthe donor tooth during surgery.4

Although the success rate of autotransplantation is re-ported to be fairly high, between 63.1% and 100%,6,10,11

the most common complications mentioned in theliterature are ankylosis of the transplant and replacementresorption after ankylosis.4,10 For orthodontic treatment,tooth movement after transplantation is mandatory inmost cases. Therefore, several postoperative procedureswere considered to reduce the chances of ankylosis.Since long-term rigid splinting has been shown to increasethe risk of ankylosis, splinting was only applied during theinitial healing period of 6 weeks.1,12-14 Furthermore, thelack of occlusal stimuli is considered to be a factor inankylosis.12 Therefore, the transplant was splinted out ofocclusion during the initial healing period to preventexcessive occlusal contacts; thereafter, the segment wasleveled by orthodontic tooth movement.

Conventionally, orthodontic treatment begins 3 to 6months after transplantation, but recently the applica-tion of stable biological loading just after the initialhealing period has been reported to have positive effectsin preventing ankylosis.14,15 Thus, the transplant wasleveled using a light continuous improved nickel-titanium archwire starting at 7 weeks. This wire hashigh superelasticity, low hysteresis, high dumpingcapacity, and a shock-absorbing property.16 Those prop-erties enabled us to deliver light constant forces and topreserve the transplant from excessive occlusal stimuli.

A posttraumatic dentition is challenging to treatorthodontically because of fractured teeth or bone,missing teeth replaced with prosthodontics or dental im-plants, and unstable mandibular positioning when a

ics August 2013 � Vol 144 � Issue 2

Fig 13. Serial periapical radiographs of the recipient site (*, transplant; dotted line, alveolar bonemargin).

276 Choi et al

condylar fracture or scar tissue is involved. From thepatient’s recollected panoramic radiograph, anteriordisplacement of the proximal segment of the fracturedright condyle was noted, but it united with the distalsegment spontaneously during the 4 years after the ac-cident with no restrictions in motion. The patientrecalled that physical therapy was advised after thetrauma, and there was no change in her occlusion otherthan the missing teeth, indicating that the mandibularposition was not affected by the trauma.

The fractured mandibular right canine was quitechallenging. Even though tooth vitality was normaland there were no specific symptoms, the fracture linewas evident. According to the model setup and the oc-clusogram, approximately 1.0 mm of distal movementof the fractured canine was needed to relieve the mildanterior crowding without flaring. Since major toothmovement could jeopardize the vitality and separatethe coronal and apical parts of the tooth, we restrictedmovement and allowed minor flaring of the anteriorteeth during leveling, rather than distalizing the canine.Fortunately, the tooth was still vital after orthodontictreatment without specific symptoms, but it is still beingmonitored carefully.

Loss of several premolars after trauma is traditionallytreated with prosthetics or dental implants. However,when severe crowding is noted, orthodontic treatmentmight help to reduce the number of prosthetic replace-ments and result in more favorable outcomes. If thispatient had visited the orthodontist at the proper timebefore the dental implants were placed, the treatmentof choice would have been to extract the left second

August 2013 � Vol 144 � Issue 2 American

premolar and to recycle this tooth as a right premolar.This way, conventional orthodontic treatment for a ClassII malocclusion with severe crowding could have beencontinued without additional implants or restorations.However, according to the patient, after a tragically trau-matic incident, orthodontic treatment, which is usuallyconsidered time-consuming and done for esthetic rea-sons, was not an affordable option. Proper patient coun-seling by an orthodontist might have changed herthoughts, but it was unfortunate that proper orthodonticdiagnosis was not combined with the initial stages oftreatment before the reconstruction therapy was started.

With increases in multidisciplinary treatment, or-thodontists now face many adults who already havedental implants in place before seeking orthodontictreatment, as seen in this patient. Because of the re-striction of tooth movement in the region of theimplant, there can be limitations in treatment plan-ning. However, in some patients, an implant can beadvantageous because absolute anchorage can beachieved. In this patient, the periodontist was the firstto notice the nonfunctional occlusion and referred herfor an orthodontic evaluation. Bone augmentation ofthe implant site after orthodontic treatment was per-formed by the periodontist, the remaining space onthe maxillary right side was closed with prosthodontictreatment, and endodontic treatment and autotrans-plantation were completed by the endodontist. All ofthis treatment occurred under the orchestration ofthe orthodontist with a complete treatment plan,which resulted in successful improvement of the oc-clusion.

Journal of Orthodontics and Dentofacial Orthopedics

Choi et al 277

CONCLUSIONS

This case report illustrates the diagnosis and treat-ment process of a patient with a skeletal Class IIposttraumatic dentition. Multidisciplinary treatment,including the recycling of an extracted premolar by au-totransplantation, successfully improved esthetics andestablished a functional occlusion for the patient.

REFERENCES

1. Day PF, Kindelan SA, Spencer JR, Kindelan JD, Duggal MS. Dentaltrauma: part 2. Managing poor prognosis anterior teeth—treat-ment options for the subsequent space in a growing patient.J Orthod 2008;35:143-55.

2. Kindelan SA, Day PF, Kindelan JD, Spencer JR, Duggal MS. Dentaltrauma: an overview of its influence on the management of ortho-dontic treatment. Part 1. J Orthod 2008;35:68-78.

3. Lee SJ, Jung IY, Lee CY, Choi SY, Kum KY. Clinical application ofcomputer-aided rapid prototyping for tooth transplantation.Dent Traumatol 2001;17:114-9.

4. Kim E, Jung JY, Cha IH, Kum KY, Lee SJ. Evaluation of the prog-nosis and causes of failure in 182 cases of autogenous tooth trans-plantation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod2005;100:112-9.

5. Andreasen JO. Interrelation between alveolar bone and peri-odontal ligament repair after replantation of mature permanentincisors in monkeys. J Periodontal Res 1981;16:228-35.

6. Watanabe Y, Mohri T, Takeyama M, Yamaki M, Okiji T, Saito C,et al. Long-term observation of autotransplanted teeth with com-plete root formation in orthodontic patients. Am J Orthod Dento-facial Orthop 2010;138:720-6.

American Journal of Orthodontics and Dentofacial Orthoped

7. Sugai T, Yoshizawa M, Kobayashi T, Ono K, Takagi R, Kitamura N,et al. Clinical study on prognostic factors for autotransplantationof teeth with complete root formation. Int J Oral MaxillofacSurg 2010;39:1193-203.

8. Hupp JG, Mesaros SV, Aukhil I, Trope M. Periodontal ligamentvitality and histologic healing of teeth stored for extended pe-riods before transplantation. Endod Dent Traumatol 1998;14:79-83.

9. Mine K, Kanno Z, Muramoto T, Soma K. Occlusal forces promoteperiodontal healing of transplanted teeth and prevent dentoalveo-lar ankylosis: an experimental study in rats. Angle Orthod 2005;75:637-44.

10. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome oftooth transplantation: survival and success rates 17-41 years post-treatment. Am J Orthod Dentofacial Orthop 2002;121:110-9.

11. Tanaka T, Deguchi T, Kageyama T, Kanomi R, InoueM, Foong KW.Autotransplantation of 28 premolar donor teeth in 24 orthodonticpatients. Angle Orthod 2008;78:12-9.

12. Andreasen JO, Paulsen HU, Yu Z, Schwartz O. A long-term study of370 autotransplanted premolars. Part III. Periodontal healing sub-sequent to transplantation. Eur J Orthod 1990;12:25-37.

13. Zachrisson BU, Stenvik A, Haanaes HR. Management of missingmaxillary anterior teeth with emphasis on autotransplantation.Am J Orthod Dentofacial Orthop 2004;126:284-8.

14. Tsukiboshi M. Autotransplantation of teeth: requirements for pre-dictable success. Dent Traumatol 2002;18:157-80.

15. Fujita K, Kanno Z, Otsubo K, Soma K. Autotransplantation com-bined with orthodontic treatment in adult patients. Orthod Waves2008;67:128-34.

16. Yoneyama T, Doi H, Kobayashi E, Hamanaka H, Tanabe Y,Bonfield W. Stress transmission through Ti-Ni alloy, titaniumand stainless steel in impact compression test. J Mater Sci MaterMed 2000;11:333-6.

ics August 2013 � Vol 144 � Issue 2