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AUTOTRANSPLANTATION OF TEETH IN ORTHODONTICS:
A BIOLOGICAL METHOD TO SUBSTITUTE MISSING OR
LOST TEETH AND ALVEOLAR BONE
H. U. Paulsen
Autotransplantation of teeth is an old method of tooth replacement, but it
is receiving renewed interest, as treatment today is founded on evidencebased, long-term research. Autotransplantation of premolars has become a
reliable treatment option for the treatment of certain orthodontic problems
(Slagsvold and Bjercke, 1967, 1970. 1974, 1978a,b; Ravn and Nielsen, 1973;
Northway and Konigsberg, 1980; Andreasen, 1981; Kristerson, 1985; Paulsen and Andreasen, 1985, 1990, 1998; Lagerstrom and Kristerson, 1986;
Andreasen et al., 1988, 1989, 1999a,b,c,d; Paulsen, 1989, 1999, 2001; Kristerson and Kristerson, 1991; Paulsen and Zachrisson, 1992, Kugelbrg et al.,
1994; Paulsen et al., 1995, 2001; Josefsson et al., 1999; Czochrowska et al.,
2000a,b). Autotransplantation of incisors, canines and molars are not always
as successful due to the more complex severity of the surgical problems
during transplantation (Nordenram, 1963; Moss 1968, 1975; Oksala and
Kallioniemi, 1977; Berglund et al., 1996; Akiyama et al., 1998; Guthua et al.,
1994; Bauss et al., 2002; Gleiser and Jaramillo, 2002; Ioannidou and Makris,
2003).
In conventional orthodontics, tooth movements usually are limited
to minor distances. However, tooth movement is no longer limited to short
distances in a quadrant of the dental arch if tooth transplantation is included as an orthodontic treatment choice. There is greater freedom to place a
tooth exactly where it is needed, may it be the contralateral side in the dental arch or the opposing jaw. The periodontium is the key to bone induction
and bone modelling in the recipient area. A transplanted tooth can erupt
typically and in a similar manner to a contralateral, non-transplanted tooth
in its normal area (Paulsen and Andreasen, 1998; Paulsen 1999). However,
transplantation of teeth is far more traumatic to the pulp and periodontium
than conventional orthodontics. Donor teeth with wide-open apices and
with a single root canal are recommended as grafts of choice for long-term
survival (Kristerson, 1985; Andreasen et al., 1990b; Paulsen, 1999). The
surgical procedure is thus an essential key to the successful outcome of this
treatment (Andreasen et al., 1990a). As imaginative as this technique appears
to be, very careful case selection and graft choice is necessary to safeguard
the health of the soft tissues; i.e. the pulp, the periodontal ligament with 2-3
mm marginal gingiva, and Hertwig´s epithelial root sheath.
The technique of premolar transplantation has been described in a
series of articles in which the predictors for optimal pulp and periodontal
healing, as well as root growth have been described (Andreasen 1981, 1988;
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Autotransplantation of Teeth
Andreasen et al., 1999a,b,c,d). The survival of transplanted premolars has
been studied postoperatively for more than 25 years. Orthodontists, however, generally would be the most competent professionals to identify available donor teeth (Northway and Konigsberg, 1980; Paulsen, 1999). Because
overall occlusal status must be assessed, the orthodontist should be considered a key person in planning, referring, and coordinating treatment that
includes transplantation (Stenvik, 2003). With autotransplantation, it has
become possible to move problems in the dental arches to regions where
they are easier to solve orthodontically.
TREATMENT PLANNING
A comprehensive treatment plan needs to be developed prior to
autotransplantation. This requires the expertise of the orthodontist,
surgeon, periodontist and the restorative dentist. The orthodontist
particularly needs to be aware of the patient’s craniofacial morphology and
growth tendencies in order to better predict success.
A radiographic screening process has been a very useful method of
diagnosing premolar agenesis around 9 to 11 years-of-age when there are no
erupted premolars (Ravn and Nielsen, 1973; Rolling, 1980). Unfortunately,
new restrictions on the use of radiographic screening exposures of a population have stopped this procedure in Scandinavia. However, agenesis also
may be diagnosed from radiographs taken during diagnostic procedures for
carries of deciduous molars or a late exfoliation of deciduous molars. Furthermore, a new long-term study of agenesis of permanent teeth has indicated a different aetiology and treatment of the deciduous molars. Autotransplantation should be included in the treatment planning for patients
who have deciduous molars with agenesis of permanent successors showing
surface root resorption or replacement root resorption (ankylosis) over a
period of time (Paulsen, 1999).
Non-extraction Cases: Agenesis in the Lower Jaw
In samples of Danish school children, Rølling found the rate of
agencies of lower premolars to be 7.8% (Ravn and Nielsen, 1973; Rolling,
1980). The most frequently missing teeth were the lower second premolars,
representing 67% of congenitally missing teeth. Combined with the most
frequently occurring mandibular growth pattern (the anterior rotational
type; Bjork and Skieller, 1972), this deviation may pose two distinct problems to the clinician.
First, where incisal support remains favourable, the mandibular incisors gradually become more proclined in relation to the mandibular base.
This generally requires space closure through protraction of the posterior
dentition, which is very challenging. Should incisal support fail due to distal
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tipping of the mandibular incisors, a deep bite and increased overjet will
result. Second, conventional orthodontic treatment usually consists of a
combination of mesial movement of the molars into the site of the agenesis
and realignment of anterior teeth. Such treatment often is difficult to perform satisfactorily in patients with a weak and concave profile (Paulsen and
Zachrisson 1992). Autotransplantation of second premolars from the maxilla to the affected or converted regions in the mandible shifts the burden of
closing space to the maxillary arch. Generally speaking, space closure in the
maxilla is much easier to control and carry out.
Extraction Cases: Primary Crowding
Orthodontic treatment of these types of malocclusions can include
a wider donor selection of premolars. Generally, all single-rooted premolars
with a wide-open apex may be candidates for transplantation. Premolars
from the mandible fit very well in the recipient anterior region of the maxilla (i.e. first mandibular premolars as maxillary laterals, and second mandibular premolars as maxillary centrals). The dove-tailing of transplantation
and orthodontic treatment, together with cryopreservation of extracted
teeth for later purposes and restoring avulsed areas in the dental arches,
provides a novel approach to the management of tooth loss in the anterior
region of the maxilla. Autotransplantation of a premolar to the affected
region diminishes the severity of the problem, allowing conventional
orthodontic treatment approaches to manage the extraction site created
(Paulsen et al., 1990).
Alternative Treatment
Other treatment modalities, including the use of implants, are
available to this group of patients. The optimal treatment approach mandates a realistic evaluation of the long-term prognosis of the various treatment methods and cost (Paulsen et al., 1995). In the following section, a
summary of the results of our long-term studies on autotransplantation is
presented.
MATERIALS AND METHODS
We evaluated 370 autotransplanted premolars (Andreasen et al.,
1999a,b,c,d) from 16 to 26 years post transplantation. All transplantation’s
were performed at the Department of Oral Surgery and Oral Medicine,
University Hospital, Copenhagen. All treatment planning, controlling, and
follow-up for healing and stability was performed at the Department of
Orthodontics, Copenhagen Municipal Dental Health Service, Copenhagen,
Denmark. Transplantation was used for patients with agenesis of permanent teeth or tooth and alveolar bone loss due to trauma of maxillary incisors.
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Autotransplantation of Teeth
All transplants were followed longitudinally using a standardized
technique for both clinical and radiographic evaluation of pulpal and periodontal healing, root development and root resorption for a time period
ranging between 16-26 years post transplantation. Twenty-four transplants
were followed longitudinally with a standardized clinical and radiographic
technique to examine tooth eruption at 1, 3, 4, 6, 8, 12, 16, 20 and 24 weeks
after surgery (Paulsen and Andreasen, 1998; Paulsen et al., 2001), and yearly
thereafter for 6 to 18 years.
The study showed that the stage of root development at the time of
transplantation was the most important single factor in determining a successful outcome. Transplantation of premolars with three-quarter root formation or full root formation with wide-open apical foramina proved to
have the best prognosis for long-term survival (Paulsen et al., 1995). One
hundred eighteen premolars in stages 3 and 4 (i.e., 3/4 to 4/4 root length
with a wide open apical foramen according to Moorrees and colleagues,
1963) were selected to study the initial healing events following autotransplantation. This stage of root development provided the greatest success for
continued root growth as well as periodontal ligament and pulpal healing
(Paulsen et al., 1995).
Pulp Necrosis
CRITERIA FOR EVALUATING HEALING
AND COMPLICATIONS
Pulp necrosis was considered to be present when there were radiographic signs of periapical radiolucency and/or inflammatory root resorption, plus a negative response to the electrometric sensitivity test. Where an
absence of pulp sensitivity was the only sign of pulp necrosis, it was required that the pulp canal show no sign of obliteration six months post
transplantation.
Periodontal Healing
Periodontal healing was classified as being complete when the root
periphery was surrounded entirely by a newly formed periodontal ligament
space of normal size.
Repair-Related Root Resorption
Repair-related root resorption was defined as the presence of small
resorption cavities on the root surface adjacent to a normal or slightly extended periodontal ligament space and lamina dura, indicating that the root
periphery was undergoing repair.
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Inflammatory Root Resorption
Inflammatory root resorption was defined by the presence of bowlshaped resorption cavities on the root surface associated with similar resorption cavities on the adjacent alveolar bone.
Replacement Root Resorption
Replacement root resorption (ankylosis) presented as a disappearance of the periodontal ligament space with or without resorption of the
root. Clinically, the percussion test on a tooth demonstrated a high pitched
metallic percussion sound.
Root Growth
Root growth (in mm) was evaluated from successive radiographs,
and tooth length was measured to the nearest tenth of a millimetre with a
sliding calliper from the cusp tip to the apex .
HEALING
Pulp Healing
This was evaluated clinically using an electrometric test (Siemens
Sirotest II, Siemens, Munich, Germany), and employing a standardized
radiographic technique using XCP film holders (Rinn Corp., Elgin, Ill.,
USA) and a fixed film focus distance of 33 cm to evaluate signs of pulp
canal obliteration.
Periodontal Healing and Root Growth
Subsequent to transplantation, this was monitored by radiographic
examination. A digital sliding calliper reading to the nearest 0.1 mm was
used to measure pulp canal obliteration and root length. Non-transplanted
homologous premolars served as controls where possible.
Effect on Tooth Eruption
From a group of 90 maxillary second premolars transplanted to the
region of the mandibular second premolar, 24 premolars transplanted with
the cusp at gingival level were selected for a specific study of eruption. Periodontal ligament healing and root growth subsequent to transplantation
were monitored from radiographic examination and tooth eruption. Trabecular structures are relatively stable in the jaw. Using these distinct structures in the spongious part of the basal part of the alveolar process as a
reference, the prefunctional eruption of transplants was analysed from
radiographs. Tooth eruption was measured as the distance from the cusp
tip to the reference structure in the bone. Root growth, evaluated from
successive radiographs, was measured as the difference in tooth length from
the cusp tip to the apex. A Jocal digital sliding calliper (C. E. Johansson,
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Autotransplantation of Teeth
AB, Eskilstuna, Sweden) measuring to the nearest 0.1 mm was used to
measure the distance between distinct structures in the anatomy of the
medullar bone, tooth eruption, and tooth length. All measurements were
repeated, and a mean calculated. In no instance was there a difference of
more than 0.2 mm between the individual measurements.
The direction and speed of eruption were examined by drawing
superimposed sketches from radiographs using the distinct trabecular structures as location references. The radiographs were mounted in 3-mm slide
projectors with a standardized focus distance and set-up. The speed of
eruption of the transplant relative to the neighbouring reference teeth was
analysed by either using the distance to a plane between the buccal cusp of
the first premolar and the disto-buccal cusp on the first molar or, alternatively, using the cusp tip of the first premolar as a reference (Paulsen and
Andreasen, 1998).
Effect of Orthodontic Treatment Upon Healing
Eleven patients who received bilateral transplanted premolars
(maxillary second premolars transplanted to the regions of second premolars) were studied. Transplants were placed in a 45° distal rotation
position at surgery, as the alveolar faciolingual dimension is narrower in the
mandible than in the maxilla. In these patients, one of the premolars was
orthodontically rotated to a normal position after periodontal healing and
before pulp canal obliteration (i.e., 3-9 months after surgery). The contralateral transplanted premolar was not treated orthodontically and, therefore,
served as a control.
Rotation was accomplished using a fixed appliance with elastic
chains (Unitek no 639-0011, Glendora, California, USA) inserted on the
lingual side from the first molar to the transplant and on the facial side
from the first premolar to the transplant. The initial rotational couple
applied to the tooth was 200 gram-mm. The duration of rotation was 4-6
weeks. Postoperative clinical and radiographic examinations were performed as described earlier (Paulsen et al., 1995)
Pulp Healing
RESULTS
Pulp healing was seen in 101 of the transplants. The time for initial
pulp healing (cumulative data) is shown in Figures 1 and 2. Pulp healing
based on the first appearance of pulp canal obliteration appeared to provide
an earlier sign for pulp healing than electrometric pulp testing and demonstrated less variation. A representative example of pulp healing in a second
maxillary premolar transplanted in the maxillary anterior region.
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Paulsen
Figure 1. Cumulative pulp healing in 101 immature autotransplanted premolars.
Occurrences of the first sign of pulp canal obliteration and the first sign of
sensitivity (in months and in percent), and the range (in months).
Figure 2. Cumulative clinical and radiographic signs of pulp healing in orthodontic
treatment.
One tooth with reinnervation showed partial pulp canal obliteration
and one tooth without reinnervation showed pulp canal obliteration.
Sixteen teeth showed pulp necrosis. This condition was usually detected
about 6 months after transplantation. One tooth had partial pulp necrosis.
Teeth with pulp necrosis and associated inflammatory root resorption were
detected two months after transplantation (Paulsen et al., 1995).
Periodontal Healing
Partial periodontal ligament healing was seen radiographically after
4 weeks. The majority of transplants showed complete periodontal healing
8 weeks post-transplantation (Fig. 3). Repair-related root resorption and
inflammatory root resorption usually were found in the cervical area of the
root. Inflammatory root resorption was seen in four cases and was detected
1 to 2 months after transplantation, whereas repair-related root resorption
usually was diagnosed within the first year after transplantation.
Replacement root resorption occurred in 5 cases. This complication usually
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Autotransplantation of Teeth
Figure 3. Transplantation of a maxillary second premolar to the region of the mandibular second premolar. A clinical photograph and a radiograph taken a few days
after transplantation. Note that the transplant is placed in infraocclusion to avoid
traumatic occlusion.
Eruption of the transplant can be seen in radiographs exposed one, two, three and
four months after transplantation.
A clinical photograph and radiograph taken 6 months after transplantation when
orthodontic treatment was begun to correct rotation.
A clinical photograph and radiograph taken 18 months after transplantation. Note
that root growth has continued in spite of the orthodontic rotation.
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could be diagnosed within 6 months after transplantation (Andreasen 1981;
Andreasen et al., 1990c).
Root Development Disturbance
Root development either proceeded unimpeded or at a decreased
rate, and in some cases was arrested. Arrested root forma- tion was found
in 14% of patients studied. Unimpeded root formation was found in 21%
of patients studied and a decreased rate of root formation was found in
the majority of patients, i.e., 65%. Interrupted root formation was followed
by the development of the missing root structure at the donor site. The
newly formed root tip growth had attained almost the length of the
missing part of the interrupted root form, compared to the contralateral
premolar (Kristerson and Andreasen, 1984; Lagerstrom and Kristerson,
1986; Paulsen et al., 1995; Andreasen 1999d).
Tooth Eruption
Tooth eruption took place from 3 to 24 weeks after transplantation
(Figs 3-11). The speed of eruption accelerated from 3 to 8 weeks post transplantation, was fastest during the period of 6-12 post transplantation weeks,
and declined after the period of 12-24 weeks post transplantation when the
transplant approached the occlusal plane and before any significant root
growth had occurred. The maximum rate was 0.24 mm/week (range 0.190.29 mm) 8 weeks post transplantation. Eruption distance from gingival
emergence to occlusal plan was 2.4 mm (range 1.2-5.0 mm) over 24 weeks
post transplantation. When the occlusal plane had been reached, a very slow
but continuous eruption was recorded that was similar to the rate of eruption of the adjacent teeth (Figs 4-7). One tooth with a broken Hertwig´s
epithelial root sheath showed similar eruption, but the rate of eruption was
slower. The newly formed apex, after extraction, could be seen growing in
the donor region during the healing and closing period (Fig 8-10). One
tooth with replacement root resorption (ankylosis) showed no sign of
eruption and therefore was excluded from the calculation of the eruption
rate of transplants (Fig 11). Additionally, the periodontal membrane of the
autotransplanted premolars created new alveolar bone growth along with
tooth eruption (Paulsen and Andreasen, 1998; Paulsen et al., 2001).
Orthodontic Rotation
Orthodontic rotation of 11 premolars induced slight repair-related
root resorption and a significant shortening of root length (a mean of 1.2
mm) compared with transplanted, nontreated control teeth. After orthodontic treatment, a new periodontal ligament space was established, leaving
an indentation in the root surface. In addition, the periodontal ligament of
autotransplanted premolars created new alveolar bone growth along with
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Autotransplantation of Teeth
Figure 4. A transplant with normal root development. Radiographs show healing a
few days, 4 weeks, 6 weeks, 8 weeks, 12 weeks and 16 weeks post surgery. Refer to
schematics in Figures 5, 6, and 7.
Figure 5. Drawing of radiographs from the transplant. The speed of eruption, relative to neighbouring reference teeth, measured using the distance to a plane between the buccal cusp of the first premolar and the distobuccal cusp on the first
molar as a reference.
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Figure 6. Drawing of radiographs from the transplant. The speed of eruption, relative to neighbouring reference teeth, measured using the buccal cusp of the first
pre-molar as a reference.
Figure 7. Drawing of transplant radiographs. The speed of eruption is based on
distinct structures in the trabecular structures of the medulla bone. The selected
measuring point is marked with an arrow.
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Autotransplantation of Teeth
Figure 8. A transplant with arrested root development (i.e. a broken Hertwig´s epithelial root sheath). The specimen during surgery: Note the broken apex region.
the healing- and the orthodontic rotation process. Late pulp necrosis occurred in 2 of the 11 treated cases six years after surgery and five years after
orthodontic rotation (Paulsen et al., 1995; Paulsen, 1999).
Pulp Healing
DISCUSSION
Pulp healing can be monitored using pulpal sensitivity and/or radiographic
signs of pulp canal obliteration (Andreasen et al., 1990b). In most of the
teeth transplanted in stages 3-4, both events were observed. Only a few
teeth showed signs of only one or the other event. As transplantation of
teeth implies, severance of the vascular and nervous supply to the pulp can
cause serious damage to the architecture and function of the pulp. Subsequent healing processes usually restore the content of the pulp canal including the nervous supply. Pulpal sensitivity without pulp canal obliteration
may take place in rare cases; similarly, pulp canal obliteration without pulp
sensitivity may occur where nerve regeneration fails. Early reinnervation
and partial pulp canal obliteration or no pulp canal obliteration appear to be
signs of fast pulp canal revascularization (i.e., end-to-end anatomises of
ruptured vessels) (Paulsen et al., 1995).
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Figure 9. Radiographs show healing and eruption a few days, three weeks, four
weeks, six weeks, three months, four months and nine months after surgery and
one month of orthodontic rotation of the transplant (first seven radiographs).
Donor region nine months after surgery; note the newly formed apex (second last
radiograph). Donor region 16 months after surgery; note that the apex has grown
(last radiograph).
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Autotransplantation of Teeth
Figure 10. Drawing of radiographs from the transplant. The speed of eruption is
based on distinct structures in the medullary bone. The selected measuring point is
marked with an arrow.
Periodontal Healing
Root resorption occurred in some patients even though transplantation was performed during the initial stages of root development. Inflammatory root resorption diagnosed within two months after transplantation
was mostly related to later stages of root development. Replacement root
resorption (ankylosis) also was noted in situations where more than 25% of
the periodontal ligament was damaged (Paulsen et al., 1995; Andreasen
1999c).
Root Development Disturbances
Transplantation of premolars requires surgical removal while root
growth is still not complete. Continued root growth is anticipated, therefore, after transplantation. Findings that some of the transplants attained
nearly normal root lengths demonstrate that the Hertwig´s epithelial root
sheath can function adequately subsequent to transplantation. Arrest of
root development in other transplants was related to a severance of the
Hertwig´s root sheath during transplant removal (Andreasen et al., 1988,
1999d; Paulsen et al., 1995; Paulsen and Andreasen, 1998;). The initial arrest
of root formation due to transplant usually is followed by development of
the missing root structure (a newly formed apex) at the donor site. The root
tip can grow almost to the anticipated tooth length including the length of
the transplant (Paulsen and Andreasen, 1998).
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Figure 11. A transplant with normal root development but replacement root resorption. Radiographs show healing at a few days, 12 weeks, 24 weeks, one year
and two years after transplantation (left). Note that orthodontic force was applied to
the ankylosed tooth immediately after surgical luxation to accelerate eruption.
Radiographs taken three years, four years, and five years after transplantation (right:
first three radiographs). Treatment was unsuccessful with pronounced infraposition of
the transplant during puberty. A radiograph taken seven years after transplantation
shows a marked internal resorption of the crown (right: last radiograph). The relative
eruption of neighbouring teeth resulted in further infraposition of the transplant (as
it became part of the bone) like an implant inserted in the jaw of a growing person.
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Autotransplantation of Teeth
Tooth Eruption After Transplantation
Tooth eruption after transplantation appears to depend on wound
healing and nerve induction. The fibroblasts will produce and replicate
collagen with a high rate of turnover. Newly synthesized collagen fibrils will
reorganize the periodontal ligament with an increase in tensile strength
during wound healing and probably will cause the tooth to erupt. By the
third week post-transplantation, a new socket has formed, and newlydeveloped periodontal fibers extending from the cementum to the alveolar
surface might cause the tooth to erupt together with an ingrowth of nerve
fibers. Furthermore, the autotransplanted premolars create new alveolar
bone growth along with the eruption process; the periodontal membrane
induces the bone formation. Transplantation of teeth thus can be used as a
viable method for restoring missing or lost alveolar bone in edentulous
areas. In contrast, the autotransplanted premolar with ankylosis showed the
same reaction as implants with osseous-integration. Disturbance in jaw
growth is found when implants are placed before termination of alveolar
growth (Paulsen and Andreasen, 1998). Furthermore, teeth will not erupt
without nerve supply (Bank et al., 1995). Reestablishment of the nerve
connection will probably stimulate tooth eruption.
Orthodontic Treatment of Transplanted Premolars
The extent of apical root resorption found in this study is equivalent to that found in previous investigations of orthodontic treatment of
non-traumatized teeth. The occurrence of pulp necrosis subsequent to
orthodontic rotation could be related to a strangulation of the blood vessels
entering the apical foramen. It is known that the apical foramen may deviate slightly from the anatomic apex. If the foramen is located eccentrically,
orthodontic rotation might damage the apical blood vessels, especially in
late stages of pulp canal obliteration (Paulsen et al., 1995).
Restoration of Transplanted Teeth
Subsequent to transplantation, an intense production of secondary
dentin occurs that contributes to the rapid maturation of the root (i.e. pulp
canal obliteration). The newly formed dentin contains vascular canals, and if
a deep preparation of a transplant is performed, these canals may be exposed and lead to pulp necrosis. For similar reasons, carious lesions may
invade post-traumatic formed dentin rapidly. Tooth preparation for restorative purposes should involve only enamel preferably. If dentin has to be
removed, it should be removed only to the level of post-traumatic formed
dentin (Paulsen et al., 1990; Paulsen and Zachrisson, 1992). The use of composite materials for young patients and porcelain veneers for adult patients
is advocated due to the difference in pulp maturity.
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Paulsen
Osseousintegrated Implants Versus Autotransplantation of Teeth.
Single standing implants have been found to be a reliable substitute
for missing teeth. However, because osseointegration occurs with such implants, they behave like ankylosed teeth; i.e., they limit the growth of the
alveolar process in their vicinity because they lack the potential to erupt.
However, no soft tissue is transferred with this procedure (i.e., no marginal
gingiva and papillae). Autotransplanted teeth continue erupting allowing for
normal development of the alveolar processes (Paulsen and Andreasen,
1998). Furthermore, soft tissue is transferred with this procedure, including
marginal gingiva with papillae. The optimal treatment approach mandates a
realistic evaluation of the long-term prognosis of the various treatment
methods and cost. However, no commercial interests measures to make
tooth transplantation more available, such as companies arranging training
courses in the surgical procedure for implants. Treatment must be initiated
by professionals, because there is no demand for treatment option with
which the public is unfamiliar (Stenvik, 2003).
Autotransplantation of teeth in orthodontics is a biological method
of replacing missing or lost teeth. However, a prerequisite for using this
method is a thorough knowledge of the prognosis. Thus the stage of root
development of the transplant is very important. Performing transplantation when there is 3/4 to full root development of the transplant with wide
open apices, employing a surgical technique that preserves the periodontal
ligament, and using a light-force orthodontic tooth movement or tooth
rotation three to nine months after surgery are the most crucial factors for
the survival of transplants and their continued development. The periodontal ligament, with bone induction potential, will induce new alveolar bone.
Furthermore, the transplanted tooth will erupt in a similar manner to that
of the contralateral, non-transplanted tooth if the transplanted tooth is not
ankylosed to the alveolar bone (Paulsen and Andreasen, 1998; Paulsen et al.,
2001). Autotransplantation provides the potential to replace a missing tooth
with a natural tooth with bone formation, rather than with a prosthesis or
an endosseous implant without bone formation. It provides a unique
orthodontic treatment approach for young patients as a complex orthodontic problem (i.e., premolar agencies and avulsed or malformed anterior
teeth) can be transferred to anther region in the dental arch where it can be
treated more easily. A prerequisite for the use of this treatment approach
mandates a thorough knowledge of the risk factors associated with poor
prognosis. If used with care, transplantation may greatly enhance orthodontic treatment results in selected cases (Paulsen and Zachrisson, 1992;
Paulsen et al., 1995).
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Autotransplantation of Teeth
CONCLUSIONS
The first evidence of pulp canal obliteration as seen radiographically
appeared to provide an earlier sign of pulp healing than electrometric
pulp testing.
Root growth of transplanted premolars usually continued.
Arrest of root development usually was followed by development of the
missing root structure at the donor site.
Marginal gingiva with papillae normally was transferred with the soft tissue.
Periodontal ligament of autotransplanted teeth created new alveolar bone
surrounding the transplant. During orthodontic tooth movement and/
or rotation, alveolar bone reformed alveolar bone to fit the contour of
the root.
Eruption of transplanted premolars occurred from 3 to 24 weeks after
transplantation and apparently before root growth continued, with a
maximal eruption rate occurring from 6 to 12 weeks after transplantation.
During the eruption process, new alveolar bone appeared and followed the
eruption path of the transplant.
Orthodontic rotation induced a slight surface resorption and a significant
shorter tooth length (the mean was 1.2 mm), and few cases showed late
pulp necrosis.
To prevent late pulp necrosis, orthodontic rotation is recommended after
periodontal healing and before total pulp canal obliteration (i.e., three to
nine months after transplantation).
There should be clinical and radiographic follow-up for many years to ensure long-term results.
Osseousintegrated Implants Versus Autotransplantation of Teeth
Implants.
Implants can be a substitute for normal tooth material
without soft tissue.
No transmission of marginal gingiva with gingival papillae
is possible.
No periodontal ligament induction of alveolar bone
modelling and growth occurs.
Eruption of implants not possible along growth.
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Paulsen
Orthodontic tooth movement and/or rotation is not possible.
Autotransplanted Teeth
Patient’s normal tooth material with soft tissue is used.
Transmission of marginal gingiva with gingival papillae is
possible.
Periodontal ligament induction of alveolar bone modelling
and growth occurs.
Normal tooth eruption is possible along with growth.
Orthodontic movement and/or rotation are possible.
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Andreasen JO, Kristerson L, Andreasen FM. Damage to the Hertwig's
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teeth in monkeys. Endo Dent Traumatol 1988;4:145-151.
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Bang E, Kjaer I, Christensen LR. Etiologic aspects and orthodontic treatment of unilateral localized arrested tooth-development combined with
hearing loss. Am J Orthod Dentofacial Orthop 1995;108:154-161.
Berglund L, Kurol J, Kvint S. Orthodontic pre-treatment prior to autotransplantation of palatally impacted maxillary canines: Case reports on
a new approach. Eur J Orthod 1996;18:449-456.
Bauss O, Schilke R, Fenske C, Engelke W, Kiliaridis S. Autotransplantation
of immature third molars: Influence of different splint methods and
fixation periods. Dent Traumatol 2002;18:322-328.
Björk A, Skieller V. Facial development and tooth eruption, an implant
study at age of puberty. Am J Orthod 1972;62:339-383.
Czochrowska EM, Stenvik A, Album B, Zachrisson BU. Autotransplantation of premolars to replace maxillary incisors: A comparison with
natural incisors. Am J Orthod Dentofacial Orthop 2000a;118:592-600.
Czochrowska EM, Stenvik A, Zachrisson BU. The aesthetic outcome of
autotransplanted premolars replacing maxillary incisors. Dent Traumatol 2002b;18:237-245.
Gleiser D, Jaramillo C. Autotransplantation of a permanent maxillary incisor. J Clin Orthod 2002;36:671-675.
Guthua SW, Mwaniki DL, Maina DM. Replacement therapy utilising autotransplanted wisdom teeth, East Afr Med J 1994;71:35-38.
Ioannidou E, Makris GP. Twelve-year follow-up of an autogenous mandibular canine transplant. Oral Surg Oral Med Oral Pathol Oral Radiol
Endo 2003;96:582-590.
Josefsson E, Brattstrom V, Tegsjo U, Valerius-Olsson H. Treatment of
lower second premolar agenesis by autotransplantation: Four year evaluation of eighty patients. Acta Odontol Scand 1999;57:111-115.
Kristerson L. Autotransplantation of human premolars. A clinical and
radiographic study of 100 teeth. Int J Oral Surg 1985;14:200-213.
Kristerson L, Andreasen JO. Influence of root development on periodontal and pulpal healing after replantation of incisors in monkeys. Int
J Oral Surg 1984;13:313-323.
Kristerson L, Kristerson L. Autotransplantation of teeth in cases with
agenesis or traumatic loss of maxillary incisors. Eur J Orthod 1991;13:
486-492.
Kugelberg R, Tegsjo U, Malmgren O. Autotransplantation of 45 teeth to
the upper incisor region in adolescence. Swed Dent 1994;18:165-172.
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Lagerström L, Kristerson L. Influence of orthodontic treatment on root
development of autotransplanted premolars. Am J Orthod 1986;89:
146-149.
Moorrees CFA, Fanning FA, Hunt EE Jr. Age variation of formation
stages for ten permanent teeth. J Dent Res 1963;42:1490-1502.
Moss J. Autogeneous transplantation of maxillary canines. Int J Oral Surg
1968;26:775-783.
Moss JP. The indication for the transplantation of maxillary canines in the
light of 100 cases. Br J Oral Surg 1975;12:268-274.
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investigation. Acta Odont Scand 1963;21:sup 33.
Northway W, Konigsberg S. Autogenic tooth transplantation. The "State
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Oksala E, Kallioniemi H. A longitudinal clinical and radiographic study of
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117-125.
Paulsen HU, Andreasen JO. Autotransplantation in orthodontic treatment.
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Teeth. Andreasen JO (ed), Medi Globe, Fibourg 1992:258-274.
Paulsen HU, Andreasen JO. Tooth eruption subsequent to transplantation.
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20:45-55.
Paulsen HU, Andreasen JO, Schwartz O. Pulp survival, periodontal healing
and root development of autotransplanted premolars in orthodontic
treatments. Am J Orthod Dentofacial Orthop 1995;108:630-640.
21
Autotransplantation of Teeth
Paulsen HU. Autotransplantation of teeth in orthodontic treatment. Am J
Orthod Dentofacial Orthop 2001;119:336-337.
Paulsen HU, Shi XQ, Welander U, Huggare J, Scheutz F. Eruption pattern
of autotransplanted premolars visualized by radiographic color-coding.
Am J Orthod Dentofacial Orthop 2001;119:338-345.
Paulsen HU. Premolar autotransplantation in orthodontic treatment. A
clinical and radiographic long-term study. Thesis, Kgl Carol Med Chir
Inst, Stockholm, Sweden 1999.
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Slagsvold O, Bjercke B. Autotransplantation of premolars with partly
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1974;66:355-366.
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Slagsvold O, Bjercke B. Indications for autotransplantation in missing
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J Orthod Dentofacial Orthop 2003;123:18A.
22
Hans Ulrik Paulsen, Odont
Dr1
Jens Ove Andreasen, DDS,
PhD2
Ole Schwartz, DDS, PhD3
TOOTH LOSS TREATMENT IN THE
ANTERIOR REGION:
AUTOTRANSPLANTATION OF
PREMOLARS AND CRYOPRESERVATION
Avulsed and lost anterior teeth are common in young people. Using
autotransplantation, it is possible to move problems in dental arches
to regions where they are more easy to solve orthodontically. Transplantation of premolars with three-quarter root formation or full root
formation with wide-open apical foramina provides the best prognosis for long-term survival. This article describes the use of autotransplantation and orthodontic treatment, together with cryopreservation,
in connection with complicated trauma in the anterior region of an 8year-old girl. World J Orthod 2006;7:27–34.
A
1Department
of Orthodontics,
Karolinska Institute, Stockholm,
Sweden and Municipal Dental
Health Service, Copenhagen, Denmark.
2Department of Maxillo-Facial
Surgery, Copenhagen University
Hospital, Copenhagen, Denmark.
3Department of Maxillo-Facial
Surgery, Copenhagen University
Hospital, Copenhagen, Denmark.
CORRESPONDENCE
Hans Ulrik Paulsen
Moelleaaparken 46
2800 Lyngby
Denmark
E-mail: [email protected]
ut ot r ansplantation of t eet h has
become a predictable treatment
approach for certain orthodontic conditions, namely aplasia of premolars and
malformation or tooth loss of permanent incisors. In conventional orthodontics, tooth movements are usally limited
to relatively small distances in sagittal,
ver tical, and transverse dimensions.
Including tooth transplantation in the
or thodontic equipment, tooth movement is no longer limited to short distances in a quadrant of the dental arch,
but wider freedom is achieved to place
the tooth exactly where needed, may it
be the contralateral side in the dental
arch or the opposing jaw. The periodontium is the key for bone induction and
bone modeling in the recipient area,
and the tooth will normally erupt in a
similar manner as a contralateral, nontransplanted tooth in its normal area.
However, transplantation of teeth is
more traumatic to the pulp and periodontium than conventional orthodontics. Donor teeth with wide-open apices
and a sing le root canal are recom mended as graf ts of choice for longterm survival. The surgical procedure is
thus an essential key for the successful
outcome of this treatment selection and
outcome.
However, orthodontists are generally
the most competent professionals to
identify available donor teeth; because
o v er all occlusa l s tatus m u s t be
assessed, the orthodontist should be
considered a key person in planning,
referring, and coordinating treatment
that includes transplantation of teeth.
With autotransplantation, it has become
possible to move problems in the dental
arches to regions where they are easier
to
solve
orthodontically.
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The survival of transplanted premolars
has been studied postoperatively for more
than 25 years. A prerequisite for the use
of this method is, however, a thorough
knowledge of the prognosis. Thus, the
stage of root development of transplants
has been found to be of great importance.
Transplantation at 3/4 to 4/4 root development of transplants with wide-open
apices, a careful surgical technique preserving the periodontal ligament, and a
light-force orthodontic tooth movement or
tooth rotation carried out from 3 to 9
months after surgery are the most crucial
factors for the survival of transplants and
their continued development. Autotransplantation, if applied with knowledge of
the predictive outcomes, is a method that
supplements and enhances conventional
orthodontic treatment.1–16
This article describes the use of autotransplantation and or thodontic treatment, together with cryopreservation, in
connection with a complicated trauma in
the anterior region in an 8-year-old girl.
Despite improved possibilities for treating
trauma injuries in the anterior region,
there are unfortunately still some types
of trauma (eg, exarticulation with replantation, intrusion and crown/root fractures), in which the permanent tooth is
lost after treatment. This is due to root
resorption.
The definitive treatment of such tooth
loss includes an evaluation of the following treatment options:
tion of the anterior region of the maxillary
jaw is therefore sometimes indicated. In
that connection, the question of autotransplantation of premolars to the damaged area can arise. However, because of
their root anatomy, these premolars are
not suitable as donor teeth. The most suitable teeth for transplantation are second
premolars from the maxillary jaw and premolars from the mandibular jaw because
of suitably shaped roots and a possibility
of altering the shape of the crown. Furthermore, for transplantation of premolars
to the anterior region, a complete analysis
of the development of the patient’s teeth
and jaws is required. Therefore, it is necessary to draw up an orthodontic treatment plan. The plan will depend on
whether the patient has a malocclusion
that requires treatment, as well as the
dental injury. If the orthodontic treatment
plan means that several premolars have
to be extracted, there is a further treatment option—namely, freezing and storage of premolars in a tooth bank (cryopreservation) for possible later use.
In addition, an evaluation must be carried out to determine: (1) the type of premolar that best replaces a given incisor;
(2) the timing of the treatment; (3) coordination of transplantation and orthodontic
treatment; (4) restoration of the transplanted tooth; and (5) the possibility of
storing premolars in a tooth bank for possible later use.
• Prosthetic replacement in the form of
a fixed partial denture
• Orthodontic closure of the diastema
that has occurred
• Autotransplantation of a premolar to
the anterior region followed by orthodontic closure of the donor area and
morphologic reconstruction of the
crown on the transplanted premolar
TREATMENT OF A PATIENT
WITH REPLANTATION OF 3
INCISORS
COORDINATION OF
SURGICAL AND
ORTHODONTIC TREATMENT
Many serious dental injuries are related to
extreme maxillary overjet. Extraction of
first premolars in connection with retrac-
Description of the trauma
While playing in the schoolyard, a girl, 8
years of age (Fig 1), fell and hit her face
on a bench. This resulted in serious laceration of about 1 cm of the mandibular
jaw at the transition to the prolabia.
Both maxillary central incisors and the
right mandibular central incisor were
exarticulated with gingival lacerations in
the traumatized regions, and the facial
bone lamella was pushed in at the right
maxillary central incisor region. Immediately after the fall, the teeth were gath-
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Fig 1
(left) Facial morphology of trauma patient (8 years 1 month of age).
Fig 2 (center) Serious laceration in the anterior region shown immediately after
arrival to the hospital, about 90 minutes after the trauma. The right maxillary central
incisor has been placed in physiologic saline solution for resetting.
Fig 3 (right) Three years after the trauma, the right maxillary central incisor is in
infraocclusion as a result of ankylosis. Management is by the interdisciplinary orthodontic and surgical treatment plan.
ered up from the asphalt and kept in a
serviette for a few minutes, after which
they were immediately reset by the dentist at the school. On arrival at the hospital it was found that the right maxillary
c e n t r al i nc iso r w as o nl y p a r t ia ll y
re- implanted.
Primary trauma treatment and
observation
The right maxillary central incisor was
removed from the alveolus about 90 minutes after the accident and was stored for
30 minutes in physiologic saline solution,
while the alveolar bone fracture was reset
(Fig 2). The tooth was then replanted. All
the damaged teeth were fixed with a scutaneous rail. (A scutaneous rail is made
of an elastic material. It is placed on the
facial side of the traumatized and neighboring teeth. It allows the teeth to move
during a fixation period, to prevent ankylosis.) Two months after the trauma, ankylosis of the replanted teeth was suspected, particularly of the right maxillary
central incisor, which was in slight infraposition. One year after the trauma, a
combined r adiog r aphic and mobility
examination showed that there was no
ankylosis of the lef t maxillar y central
incisor and the right mandibular central
incisor. Pulp sensitivity was positive in all
the replanted teeth. After 2 years, the
right maxillary central incisor was clearly
in infraposition. The right mandibular central incisor showed reparative-related root
resorption in the middle of the distal root
face and pulp obliteration.
Three years after the trauma, a coordinated orthodontic and surgical treatment
plan was established because the infraposition of the right maxillar y central
incisor had increased (Fig 3). Due to the
untreatable ankylosis, the patient was
offered autotransplantation of a premolar to the right maxillary central incisor
region.
Orthodontic examination
All the teeth were forming (except all third
molars); the right maxillary central incisor
was in pronounced infraposition and
ankylosis, t he lef t maxillar y canine
showed mesial ectopic eruption. The first
molars were poorly mineralized, with large
restorations, particularly in the maxillary
jaw. The maxillary overjet was caused by
an enlarged inclination of the maxillary
incisors, together with an enlarged sagittal jaw relation due to bimaxilliary retrognathy. Both jaws were inclined posteriorly,
particularly the mandible, resulting in an
increased vertical jaw relationship. The
maxillary jaw zone had increased to compensate a basal-based open bite. Furthermore, there was crowding of the anterior
regions of the maxillary and mandibular
jaws (Fig 4).
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Fig 4 (a) The right maxillary central incisor was in
p r o nounce d infrapositio n
and ankylosis. There was
additional crowding of the
anterior regions of the maxillary and (b) mandibular jaws.
a
Fig 5 Three and one-half years after
the trauma. The right mandibular second premolar—as a donor tooth—is
estimated to have reached 3/4 root
length.
b
Fig 6 The ankylosed right maxillary
central incisor is extracted just before
transplantation.
Treatment plan
Transplantation of the right mandibular
second premolar (Fig 5) (alternatively, the
left mandibular second premolar) was
advised since extraction of the maxillary
first molars would be part of the orthodontic treatment plan. The left mandibul a r s e c o n d p r e mola r w ould ac t as
“reserve donor tooth,” either directly from
the oral cavity or after an observation
period during which the tooth was cryopreserved in Copenhagen University Hospital’s tooth bank. Extensive preliminary
and subsequent orthodontic treatment
had to be anticipated.
Treatment
When the patient was 11 years 3 months
of age, both mandibular second premolars were estimated to have reached 3/4
root length. To create room for transplantation of the right mandibular second
premolar to the right maxillary central
30
Fig 7 The apical part of the
root shows the fracture to
the ankylosed part of the
apex.
incisor region, an expansion plate was
used for 2 months. At the time of transplantation, the right maxillar y central
incisor was extracted (Figs 6 and 7), after
which the right mandibular second premolar was surgically removed and placed
in the right maxillar y central incisor
region after expansion of the alveole with
a drill with internal cooling (Figs 8 and 9).
Three months after the transplantation,
electrometric sensitivity reaction of the
pulp was positive for the new right maxillary central incisor (Fig 10). Ten months
after autotransplantation, the maxillary
first molars and the remaining temporary
teeth were extracted to speed up eruption of the permanent teeth (Fig 11). At
that time, incipient obliteration of the
right maxillary central incisor and incipient eruption of both maxillar y second
molars were found. Six months later, a
fixed appliance was inser ted on both
jaws (Figs 12 and 13). Two years after the
transplantation, a radiograph of the new
right maxillar y central incisor showed
total obliteration of the pulp formed
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Fig 8 (left) The donor tooth is estimated to have reached 3/4 root length. The periodontal membrane and the tooth sac are intact.
Fig 9 (center) The transplant is fixated with a single suture in infraposition (patient
is 11 years 3 months of age).
Fig 10 (right) Three months after the transplantation. The transplant shows normal periodontal healing and incipient pulp obliteration.
Fig 11
Transplant 10 months after
transplantation. Both maxillary first
molars were extracted a few days earlier.
Fig 12 Fixed appliance inserted the
mandibular jaw for orthodontic closure
of the donor region (patient is 12 years
of age).
before the transplantation, together with
continued root growth of the transplant.
In addition, the right mandibular central
incisor had healed, with the distal root
face almost remodeled, pulp obliterated, and the length of the root shorter
t han t he h o mo lo gou s i nci so r. Six
months later, the transplant’s crown
morphology was altered by selective
grinding in the enamel and subsequent
buildup with composite plastic (Fig 14).
Three years after the transplantation,
the prognosis for the transplant was
considered so satisfactory that the alternative tooth, the left mandibular second
Fig 13 Fixed appliance inserted the
maxillary jaw. The second molars have
been guided to erupt to the first molar
region.
premolar, could be extracted and cryopreserved for later use in case the new
right maxillary central incisor or another
tooth was later lost. A reverse headgear
was placed for mesial shifting of the left
firs t and second molars. Four years
af te r t h e t r ansplantation, when t h e
patient was 16 years of age, the root of
the new maxillary right central incisor
w as finall y full y for med and a little
longer than that of the maxillar y lef t
central incisor (Fig 15). All appliances
were then removed and retainers were
inser ted and glued to the canines in
both jaws (Figs 16 and 17).
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Fig 14 Result 4 years 7 months after
transplantation . Morphology of the
transplant has changed from a premolar
to a central incisor, by selective grinding
in the enamel and composite plastic.
Fig 15
Radiograph 4 years 7 months
after transplantation. The transplant’s
root length has now finally formed.
Fig 16
Result in occlusal view. The
left mandibular second premolar was
extracted and cryopreserved 3 years
after the transplantation. Orthodontic
treatment was completed with mesial
shifting of the m a nd ibu lar molars
(patient is 16 years of age).
Fig 17 Result in occlusal view. The
transplant and second molars are in correct positions.
Fig 18 Treatment analysis: 11 to 16
years of age; both maxillary second
molars have been moved to the maxillar y first molar region, and both
m andibular first molars have been
moved to second premolar region.
Fig 19 Facial morphology, patient is
16 years 2 months of age.
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AU: pleae provide label (%)
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100
90
80
70
60
50
40
30
20
10
Root
length
Normal
periodontal
ligament
Pulp
healing
1
Fig 20 Healing of autotransplanted premolars
related to stage of root
development.
2
3
4
5
6
7
Stage of root development
Analysis of treatment
The pattern of growth was mainly vertical
for both jaws. The alveolar prognathy was
not reduced as a result of the extraction
treatment (Figs 18 and 19).
DISCUSSION
This case demonstrates the result of coordinated traumatologic, orthodontic, and
surgical treatment, including the possibility
of later use of a cryopreserved premolar in
the event one of the traumatized teeth is
later lost.1,2 The entire therapy took more
than 7 years due to continued observation
of the trauma, timing of the transplantation, guided eruption of maxillary jaw premolars and molars, orthodontic treatment,
waiting for the premolar to develop to full
root length for the tooth bank, and concluding orthodontic treatment.
Experimental and clinical research of
autotransplantation of teeth in recent
years has shown that it is now advantageous to include this method as an orthodontic treatment option. 3–12 When the
method is used in the anterior region, it
is important to conduct a thorough analysis and evaluation of the dif ferences
(esthetic, functional) and risks (durability,
root resorption) resulting from intervention in the recipient region, and also of
the problems created in the donor region
and how these can be solved in a traum a t o l o g i c , o r t hodontic tr e at m e n t
plan.6,11–16 The risks connected with the
intervention relate mainly to the occurrence of pulp and periodontal complications in connection with the revascularization of these structures. A prospective
study of the long-term prognosis for 370
autotransplanted premolars has shown
that most healing complications can be
predicted and avoided if the transplantation is performed at specific root stages.
For example, Fig 20 shows that root
length, pulp healing (ie, without partial or
total pulp necrosis), healing of periodontal membrane (ie, without root resorption), and achievement of expected root
lengt h, are decisive l y related to th e
choice of donor tooth and its root development stage. In that connection, it
seems obvious to transplant premolars
at the 3/4 to full root-development stage,
assuming a fully open apex (stages 4 to
5, see Fig 20). In these stages, the transplantation is a predictable procedure that
ensures optimum healing in more than
90% of cases.7–10
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OSSEOINTEGRATED
IMPLANTS VERSUS
AUTOTRANSPLANTATION
OF TEETH
Implants
• A substitute to normal tooth material
without soft tissue
• No transmission of marginal gingiva
with gingival papillae possible
• No periodontal ligament induction of
alveolar bone modeling and growth
• Eruption of implants not possible
during growth
• Orthodontic movement and rotation
not possible
Autotransplanted teeth
• Patient’s normal tooth material with
soft tissue
• Transmission of marginal gingiva with
gingival papillae possible
• Periodontal ligament induction of alveolar bone modeling and growth
• Tooth eruption normal during growth
• Orthodontic movement and rotation
possible
CONCLUSION
The value of autotransplantation of premolars to the anterior region has been
demonstrated. The treatment example
shows careful coordination of a traumatologic, orthodontic, and surgical treatment, including cryopreservation of a premolar. With careful case selection and
correct surgical and or thodontic techniques, it can be invaluable to the clinical
orthodontist because long-term results
are encouraging.
REFERENCES
1. Schwartz O. Cryopreservation as long-term storage of teeth for transplantation or replantation.
Int J Oral Maxillofac Surg 1986:15;30–32.
2. Schwartz O, Rank PC. Autotransplantation of
cryopreserved teeth in connection with orthodontic treatment. Am J Orthod Dentofacial
Orthop 1986:90;67–72.
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3. Kristerson L. Autotransplantation of human
premolars. A clinical and radiographic study of
100 teeth. Int J Oral Surg 1985:14;200–213.
4. Schwartz O, Bergmann P, Klausen B. Autotransplantation of human teeth. A life table analysis
of prognostic factors. Int J Oral Surg 1985:14;
25–58.
5. Schwartz O, Bergmann P, Klausen B. Resorption
of autotransplanted human teeth: A retrospective study of 291 transplantations over a period
of 25 years. Int Endod J 1985:18;119–131.
6. Paulsen HU, Andreasen JO. Autotransplantation in orthodontic treatment. Nederlandse
Vereniging Voor Orthodontische Studie Studieweek 1985:248–264.
7. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R,
Bayer T, Schwartz O. A long-term study of 370
autotransplanted premolars—Part I. Surgical
procedure and standardized techniques for
monitoring healing. Eur J Orthod 1990;12:3–13.
8. Andreasen JO, Paulsen HU, Yu Z, Bayer T,
Schwartz O. A long-term study of 370 autotransplanted premolars—Part II. Tooth survival
and pulp healing subsequent to transplantation. Eur J Orthod 1990;12:14–24.
9. Andreasen JO, Paulsen HU, Yu Z, Bayer T,
Schwartz O. A long-germ study of 370 autotransplanted premolars—Part III. Periodontal
healing subsequent to transplantation. Eur J
Orthod 1990;12:25–37.
10. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A
long-germ study of 370 autotransplanted premolars—Part IV. Root development subsequent
to transplantation. Eur J Orthod 1990;12:
38–50.
11. Paulsen HU, Andreasen JO, Schwartz O. Pulp
and periodontal healing, root development and
root resorption subsequent to transplantation
and orthodontic rotation. A long-term study of
autotransplanted premolars. Am J Orthod
Dentofacial Orthop 1995;108:630–640.
12. Paulsen HU, Andreasen JO. Tooth eruption subsequent to transplantation. A longitudinal study
of autotransplanted premolars. Eur J Orthod
1998;20:45–55.
13. Papika S, Paulsen HU, Shi X-Q, Welander U, Linder-Aronson S. Orthodontic application of color
image addition to visualize differences
between sequential radiographs. Am J Orthod
Dentofacial Orthop 1999;115:488–493.
14. Paulsen HU. Commentary. Autotransplantation
of teeth in orthodontic treatment. Am J Orthod
Dentofacial Orthop 2001;119:336–337.
15. Paulsen HU, Shi X-Q, Welander U, Huggare J,
Scheutz F. Eruption patterns of autotransplanted premolars visualized by radiographic
color-coding. Am J Orthod Dentofacial Orthop
2001;119:338–345.
16. Paulsen HU. Premolar autotransplantation in
orthodontic treatment. A clinical and radiographic long-term study [thesis]. Stockholm:
Kongl Carolinska Medico Chirurgiska Instituttet,
1999.