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,UCY "URBRIDGE
"EN /) #OLE 2OSS 3 (OBSON AND 2ICHARD 2 7ELBURY
!UTO
TRANSPLANTATION IN THE
2ESTORATIVE -ANAGEMENT OF
4RAUMATIZED !NTERIOR 4EETH ! #ASE
2EPORT
!BSTRACT !UTO
TRANSPLANTATION CAN BE USED TO REPLACE MISSING ANTERIOR TEETH FOLLOWING TRAUMATIC INJURIES 4HIS TECHNIQUE HAS THE ADVANTAGE
OVER OTHER FORMS OF TREATMENT OF MAINTAINING ALVEOLAR BONE HEIGHT WHICH ALLOWS ORTHODONTIC AND FURTHER RESTORATIVE INTERVENTION BY WAY
OF IMPLANTS LATER IN LIFE #AREFUL RESTORATIVE MANAGEMENT OF TRANSPLANTED TEETH IS VITAL TO THEIR LONG
TERM SURVIVAL AS INADEQUATE MAINTENANCE
POST TRANSPLANT MAY RESULT IN ROOT RESORPTION AND EVENTUAL TOOTH LOSS 4HIS PAPER DESCRIBES THE RESTORATIVE MANAGEMENT OF TWO CASES
FOLLOWING TRANSPLANTATION
#LINICAL 2ELEVANCE $ENTAL PRACTITIONERS SHOULD BE AWARE OF THE OPTION TO AUTO
TRANSPLANT TEETH AS PART OF AN OVERALL TREATMENT PLAN AND
THE SUBSEQUENT INTERVENTIONS OFTEN REQUIRED
$ENT 5PDATE
$ENTAL TRAUMA IN CHILDREN AND ADOLESCENTS
IS COMMON WITH UP TO OF BOYS AND
OF GIRLS TRAUMATIZING THEIR PERMANENT
INCISORS BY THE AGE OF YEARS AND
APPROXIMATELY HALF OF ALL ADOLESCENTS
SUFFERING ONE EPISODE OF DENTO
ALVEOLAR
TRAUMA BEFORE LEAVING SCHOOL )T HAS
BEEN SUGGESTED THAT TRAUMATIC INJURIES TO
THE TEETH MAY SURPASS DENTAL CARIES AND
PERIODONTAL DISEASE IN THE FUTURE 7HILE
THE MAJORITY OF TRAUMATIZED TEETH REMAIN
FUNCTIONAL A SIGNIFICANT NUMBER ARE LOST
AT THE TIME OF THE INJURY OR AS A RESULT OF
SUBSEQUENT COMPLICATIONS 2ESTORATION
OF THE MISSING UNIT TRADITIONALLY INVOLVES
SPACE MAINTENANCE WITH PROVISION
OF A PARTIAL DENTURE OR BRIDGEWORK
!LTERNATIVELY SPACE CLOSURE CAN BE
ACHIEVED ORTHODONTICALLY WITH OR WITHOUT
CROWN RECONTOURING TO IMPROVE ANTERIOR
AESTHETICS !UTO
TRANSPLANTATION IS A
CLINICAL TECHNIQUE THAT MAY BE A USEFUL
ALTERNATIVE TO THE MORE COMMONLY USED
CLINICAL SOLUTIONS 4HIS TECHNIQUE INVOLVES
THE MOVEMENT OF TEETH FROM ONE SITE
TO ANOTHER WITHIN THE SAME INDIVIDUAL
#OMMONLY ERUPTED OR IMPACTED TEETH
OF GOOD PROGNOSIS ARE TRANSPLANTED INTO
THE EXTRACTION SOCKETS OF TEETH WITH POOR
PROGNOSIS OR SURGICALLY PREPARED SITES !
MULTI
DISCIPLINARY MANAGEMENT APPROACH
IS RECOMMENDED IN AUTO
TRANSPLANTATION
AND USUALLY INVOLVES A PAEDIATRIC
DENTIST ORAL SURGEON ORTHODONTIST AND A
RESTORATIVE SPECIALIST !UTO
TRANSPLANTATION
HAS GAINED INCREASING POPULARITY IN
THE LAST YEARS AND MORE SPECIALIST
CENTRES ARE NOW USING THE TECHNIQUEn
3UCCESSFUL TRANSPLANTATION DEPENDS UPON
THE SPECIFIC REQUIREMENTS OF THE PATIENT
RECIPIENT TOOTH AND DONOR SITES AND
SURGICAL EXPERTISE OF THE OPERATOR
! DENTAL IMPLANT PLACED
FOLLOWING THE COMPLETION OF BONE GROWTH
WILL PROVIDE THE BEST FORM OF RESTORATION
IN THE MANAGEMENT OF ANTERIOR TEETH LOST
AS A RESULT OF TRAUMA $ENTAL IMPLANTS
ARE NOT ROUTINELY PLACED IN CHILDREN AS
THEY MAY INTERFERE WITH BONE GROWTH
AND BECOME INFRA
OCCLUDED !DDITIONALLY
THEY MAY CAUSE TECHNICAL PROBLEMS UPON
PLACEMENT OWING TO BONE ELASTICITY 4HE
MANDIBULAR MIDLINE SUTURE CLOSES IN THE
FIRST YEAR OF LIFE AND BONE GROWTH IN THE
AREA BETWEEN THE MENTAL FORAMINA IN THE
MANDIBLE DOES NOT APPEAR TO BE AFFECTED
$ENTAL5PDATE
0AEDIATRIC$ENTISTRY
&IGURE ,ABIAL VIEW OF TRANSPLANTED PREMOLAR IN
#ASE
INCLUDING THE RESTORATIVE AND ORTHODONTIC
TREATMENT POST SURGERY
#ASE
&IGURE 0ERIAPICAL RADIOGRAPH OF #ASE
&IGURE 0HOTOGRAPH OF INFRA
OCCLUDED \ IN #ASE
BY THE PRESENCE OF IMPLANTS
)MPLANTS HAVE BEEN USED
SUCCESSFULLY IN THE TREATMENT OF CHILDREN
WITH ECTODERMAL DYSPLASIA WITH ASSOCIATED
SEVERE HYPODONTIA HOWEVER INFRA
OCCLUSION OF IMPLANTS IS REPORTED TO BE
A PROBLEM )T HAS BEEN REPORTED THAT
IMPLANT PLACEMENT IN EDENTULOUS YOUNG
PATIENTS DOES NOT INTERFERE WITH TRANSVERSE
OR SAGITTAL GROWTH OF THE JAWS IN THE
ABSENCE OF TEETH AND INFRA
OCCLUSION
DOES NOT APPEAR TO BE A PROBLEM IN
THIS PARTICULAR GROUP 3TIMULATION OF
ALVEOLAR BONE GROWTH HAS BEEN REPORTED
IN TWO EDENTULOUS CHILDREN FOLLOWING THE
PLACEMENT OF DENTAL IMPLANTS 0LACEMENT
OF IMPLANTS IN YOUNG PATIENTS IS PERCEIVED
TO HAVE ADVANTAGES AND DISADVANTAGES
AND FURTHER RESEARCH IN THIS AREA IS
NECESSARY
4HIS PAPER DESCRIBES THE USE
OF AUTO
TRANSPLANTATION IN TWO PATIENTS
$ENTAL5PDATE
&IGURE #OMPOSITE VENEER MODIFICATION OF #ASE
&IGURE .ON
SETTING CALCIUM HYDROXIDE DRESSING
OF #ASE
CAREFULLY REDUCED IN SIZE WITH HIGH
SPEED
ROTARY INSTRUMENTS TO ELIMINATE OCCLUSAL
INTERFERENCE 4HE TRANSPLANTED TOOTH WAS
SPLINTED FOR DAYS USING A FUNCTIONAL
SPLINT AND THE PULP EXTIRPATED PRIOR TO
THE SPLINT REMOVAL ! DRESSING OF NON
SETTING CALCIUM HYDROXIDE WAS PLACED AND
CHANGED AT
MONTHLY INTERVALS UNTIL THE
COMPLETION OF ORTHODONTIC TREATMENT TO
CORRECT HER BILATERAL CROSS
BITES AND ALIGN
BOTH ARCHES WHICH TOOK MONTHS IN TOTAL
.OVEMBER
0AEDIATRIC$ENTISTRY
&IGURE $04 OF #ASE
&IGURE 0ERIAPICAL RADIOGRAPH SHOWING ROOT
FILLED
PREMOLAR IN #ASE
TOOTH INITIALLY 4HE TOOTH WAS INCLUDED IN
THE ORTHODONTIC TREATMENT AT MONTHS
POST TRANSPLANTATION WHEN THERE WAS NO
RADIOGRAPHIC EVIDENCE OF ROOT RESORPTION
&IGURE &IXED APPLIANCE TREATMENT WAS
COMPLETE MONTHS AFTER IT STARTED AND
THE TRANSPLANTED TOOTH WAS RESTORED WITH
GUTTA PERCHA &IGURE AND PORCELAIN
VENEER AFTER ORTHODONTIC RETENTION &IGURE
&IGURE #OMPOSITE ADDITIONS MODIFYING #ASE
#ASE
&IGURE 0ORCELAIN VENEER OF #ASE
&IGURE /CCLUSAL RADIOGRAPH OF #ASE
4HE TOOTH WAS RESTORED WITH A COMPOSITE
VENEER TO IMPROVE AESTHETIC APPEARANCE
AFTER SPLINT REMOVAL &IGURE 5PPER AND
LOWER ARCH FIXED ORTHODONTIC APPLIANCE
TREATMENT COMMENCED MONTHS POST
SURGERY WITHOUT LOADING THE TRANSPLANTED
$ENTAL5PDATE
&IGURE 0ORCELAIN VENEER OF #ASE
THAT THE UPPER CANINES WERE IN THE LINE OF
THE DENTAL ARCH 4HE AIM OF ORTHODONTIC
MANAGEMENT WAS TO RELIEVE CROWDING
BY EXTRACTIONS FOLLOWED BY ALIGNMENT
OF BOTH ARCHES 4HIS WOULD INCLUDE THE
EXTRACTION OF BOTH LOWER SECOND PREMOLARS
AND BOTH PALATALLY PLACED PEG
SHAPED
UPPER LATERAL INCISORS 4HE UPPER CANINE
TEETH WERE MODIFIED WITH THE ADDITION OF
COMPOSITE RESIN IN ORDER TO MIMIC UPPER
LATERAL INCISORS ! DECISION WAS ALSO TAKEN
AT THIS STAGE TO EXTRACT THE \ OWING TO
ADVANCED ROOT RESORPTION AND POOR LONG
TERM PROGNOSIS /NE OF THE EXTRACTED LOWER
.OVEMBER
0AEDIATRIC$ENTISTRY
PREMOLARS WAS TRANSPLANTED INTO THE SOCKET
OF THE EXTRACTED \ &URTHER RESTORATIVE
MANAGEMENT WAS AS DESCRIBED FOR THE
FIRST CASE AND THE PATIENT HAD COMPOSITE
ADDITIONS TO MODIFY THE APPEARANCE
OF THE TRANSPLANTED PREMOLAR &IGURE
5PPER AND LOWER FIXED ORTHODONTIC
APPLIANCE TREATMENT COMMENCED SIX
MONTHS AFTER SURGERY AND LASTED FOR
MONTHS ! PORCELAIN VENEER WAS PLACED
ON COMPLETION OF ORTHODONTIC RETENTION
&IGURE
$ISCUSSION
4HE AIM OF RESTORING MISSING
ANTERIOR TEETH IS TO MAXIMIZE FUNCTION
AND AESTHETICS 4REATMENT OPTIONS
INCLUDE ORTHODONTIC SPACE CLOSURE
OSSEO
INTEGRATED IMPLANTS ADHESIVE OR
CONVENTIONAL BRIDGEWORK PARTIAL DENTURE
AND AUTO
TRANSPLANTATION /SSEO
INTEGRATED
IMPLANTS ARE RARELY USED IN CHILDREN UNDER
YEARS OF AGE $OWNWARD AND FORWARD
GROWTH OF THE FACE CONTINUES THROUGHOUT
CHILDHOOD AND EARLY ADOLESCENCE CAUSING
THE ANKYLOSED IMPLANT FIXTURE TO INFRA
OCCLUDE COMPROMISING THE AESTHETIC
RESULT !UTO
TRANSPLANTATION IS A VIABLE
OPTION IF A SOUND TOOTH IS SCHEDULED FOR
ORTHODONTIC EXTRACTION ! TRANSPLANTED
TOOTH ACTS AS A NATURAL SPACE MAINTAINER
PRESERVES THE ALVEOLAR BONE AND HAS AN
INTACT PERIODONTAL LIGAMENT MAKING IT
AMENABLE TO ORTHODONTIC TREATMENT )F THE
TRAUMATIZED TOOTH TO BE LOST IS EXTRACTED AT
THE SAME TIME AS AUTO
TRANSPLANTATION OF
THE DONOR TOOTH THE SPACE AVAILABLE OFTEN
REQUIRES LITTLE IF ANY SURGICAL ALTERATION
%VIDENCE FOR THE SUCCESS OF
AUTO
TRANSPLANTATION HAS BEEN PRESENTED
BY A NUMBER OF WORKERS INCLUDING
SUCCESS RATES OF FOR IMMATURE TEETH
AND FOR MATURE TEETH TRANSPLANTED
INTO THE UPPER INCISOR REGION 4HE DEGREE OF
ROOT DEVELOPMENT OF THE TOOTH AT THE TIME
OF TRANSPLANTATION IS IMPORTANT )DEALLY
ROOT DEVELOPMENT SHOULD BE A HALF TO TWO
THIRDS COMPLETE AS THE TRANSPLANTED TOOTH
MAY BE CAPABLE OF REVASCULARIZATION
4HESE TEETH MUST BE MONITORED CLOSELY FOR
FURTHER ROOT GROWTH AFTER TRANSPLANTATION
AND THE PULPAL TISSUE SHOULD BE
EXTIRPATED IF THERE IS ANY DOUBT ABOUT
REVASCULARIZATION 4EETH TRANSPLANTED WITH
COMPLETE ROOT DEVELOPMENT SHOULD BE
TREATED AS AVULSION INJURIES AND HAVE THE
PULP EXTIRPATED PRIOR TO SPLINT REMOVAL
! SURVIVAL RATE OF AND OVER
YEARS FOR COMPLETE AND INCOMPLETE ROOT
FORMATION HAS BEEN REPORTED FOLLOWING
.OVEMBER
TRANSPLANTATION OF PREMOLARS WHETHER
THE ROOT OF THE TRANSPLANTED TOOTH IS
IMMATURE OR FULLY FORMED
4RAUMATIZED AND REPLANTED
TEETH IN YOUNG PATIENTS SHOULD BE SEEN
AS LONG
TERM TEMPORARIES THAT WOULD
SERVE TO MAINTAIN THE DEVELOPMENT OF THE
PERMANENT DENTITION AND PRESERVE BONE
)MPLANTS SHOULD NOT BE PLACED
UNTIL BONE GROWTH IS COMPLETE AND IN THE
YOUNG PATIENT AN INTERMEDIATE TREATMENT
IS OFTEN REQUIRED IN THE CASE OF TRAUMA
FOLLOWING THE LOSS OF A TRAUMATIZED TOOTH
PRIOR TO DEFINITIVE RESTORATION OF THE SPACE
WITH A SINGLE TOOTH IMPLANT
)F SUCH TEETH ARE SEEN TO BE AN
INTERMEDIATE TREATMENT THE AESTHETICS
SHOULD REMAIN SATISFACTORY UNTIL SUCH
TIME AS THE TOOTH IS PLANNED FOR DEFINITIVE
REPLACEMENT 4HE WIDTH OF A PREMOLAR
TOOTH AT THE CEMENTO
ENAMEL JUNCTION IS
LESS THAN THAT OF A MAXILLARY INCISOR TOOTH
AND THEREFORE AS PHYSIOLOGICAL GINGIVAL
RECESSION OCCURS THE APPEARANCE FOLLOWING
AESTHETIC CORRECTION OF THE TRANSPLANTED
TOOTH IS LIKELY TO DETERIORATE )T IS IMPORTANT
THAT POTENTIAL PATIENTS ARE MADE AWARE OF
THIS POSSIBILITY
4HE INTERMEDIATE RESTORATION
OF #ASE INVOLVED COMPOSITE ADDITIONS TO
THE TRANSPLANTED TOOTH &IGURE WHEREAS
#ASE HAD A COMPOSITE VENEER USING THE
LABIAL PORTION OF A CELLULLOID CROWN FORMER
&IGURE 4HESE SIMPLE RESTORATIONS COULD
BE CARRIED OUT WITHIN PRIMARY CARE 4HIS
COULD REDUCE THE NUMBER OF HOSPITAL
APPOINTMENTS AND PROMOTE JOINT PATIENT
CARE
3UCCESS OF AUTO
TRANSPLANTED
TEETH CAN BE COMPLICATED BY INFLAMMATORY
RESORPTION AND REPLACEMENT RESORPTION
ANKYLOSIS %NDODONTIC FAILURE WHICH IS
REPORTED TO OCCUR IN n OF CASES MAY
COMPROMISE THE AMOUNT OF BONE AVAILABLE
FOR FUTURE IMPLANTS
4HE CASES PRESENTED
HERE DEMONSTRATE SUCCESSFUL AUTO
TRANSPLANTATION IN THE SHORT TERM HOWEVER
THIS IS A PROCEDURE WHICH MUST ONLY BE
UNDERTAKEN ONCE THE PATIENT IS FULLY
INFORMED AND HAS A FULL UNDERSTANDING OF
THE IMPLICATIONS OF SUCH TREATMENT AND THE
POSSIBLE NEGATIVE SEQUELAE THAT MAY OCCUR
4HE USE OF THIS TECHNIQUE IN
THE CASES DOCUMENTED HERE INVOLVED
TREATMENT UNDER GENERAL ANAESTHESIA
WHICH IS A RISK FACTOR 4HIS DECISION WOULD
HAVE BEEN TAKEN FOLLOWING DISCUSSION OF
THE ANAESTHETIC OPTIONS WITH BOTH PATIENTS
AND PARENTS )T IS POSSIBLE TO CARRY OUT
THIS PROCEDURE UNDER LOCAL ANAESTHETIC
WITH OR WITHOUT THE CONCOMITANT USE OF
CONSCIOUS SEDATION )T IS A PROCEDURE WHICH
IS HIGHLY TECHNIQUE
SENSITIVE AND THEREFORE
A HIGH LEVEL OF PATIENT CO
OPERATION WOULD
BE REQUIRED IF UNDERTAKEN UNDER LOCAL
ANAESTHETIC WITH OR WITHOUT CONSCIOUS
SEDATION
&INAL RESTORATION OF THE
TRANSPLANTED TOOTH IN #ASE COULD HAVE
BEEN ACHIEVED WITH COMPOSITE RESIN
ADDITIONS HOWEVER THIS MAY HAVE LED TO A
LESS SATISFACTORY RESULT AS BUCCAL REDUCTION
OF THE TRANSPLANTED TOOTH WAS REQUIRED FOR
THE TOOTH TO HARMONIZE WITH THE ADJACENT
TEETH 4HE ADVANTAGE OF USING COMPOSITE
RESIN FOR AESTHETIC TREATMENT IS THAT AS
THE POSITION OF THE GINGIVAL MARGIN ALTERS
THE APPEARANCE OF THE RESTORATION CAN BE
IMPROVED RELATIVELY QUICKLY AND EASILY
UNLIKE A PORCELAIN VENEER
)T IS POSSIBLE THAT THE FINAL
AESTHETIC RESULT IN #ASE COULD HAVE
BEEN IMPROVED BY MAINTAINING THE UPPER
LATERAL INCISORS AND BUILDING THEM UP WITH
COMPOSITE RESIN IN ADDITION TO BUILD
UP OF
THE TRANSPLANTED TOOTH
#ONCLUSION
!UTO
TRANSPLANTATION OF TEETH
CAN RESULT IN SATISFACTORY TREATMENT
OUTCOMES IN TERMS OF FUNCTION AND
AESTHETICS 4HE DECISION TO TRANSPLANT
SHOULD ALWAYS INVOLVE A JOINT SPECIALTY
APPROACH 0RIMARY CARE DENTISTS SHOULD BE
INVOLVED IN THE LONG
TERM MANAGEMENT OF
PATIENTS BY PROVIDING ROUTINE CARE WHILST
CHANGE OF NON
SETTING CALCIUM HYDROXIDE
DRESSINGS IS UNDERTAKEN IN THE HOSPITAL
4HIS WOULD ALLOW PATIENTS TO MAINTAIN
CONTINUITY OF CARE AND RECEIVE ROUTINE
TREATMENT NEARER HOME
2EFERENCES