Amrita Journal of Medicine

Vol. 8, No: 2 July-Dec 2012. Page 1 - 44

Case repOrt

Autotransplantation of teeth An overview

K.N.Unni, V.P.P. Singh
ABSTRACT Autotransplantation of immature teeth has good survival rates, and has benefits over ossointegrated implants in the growing child, but is very technique sensitive. For auto transplantationlonge term studies have shown, that with appropriate case selection and careful surgical technique, the survival rates to be 90% over an average of 26.4 years. In addition, the recent popularity of implants has resulted in transplantation being overlooked as a treatment option. However, if the clinical and experimental studies on transplantation over the last 30 years are considered, hope should replace pessimism with regard to this procedure. The aim of this article is to summarize the biologic principles required for successful autotransplantation of teeth.

Autotransplantation as a technique for replacement of teeth was first reported in the 1950s when immature third Pre molars were used to replace decayed first molars1.Survival rates for auto transplantation of immaturepremolar teeth have been shown to be 95% over 5 years2. The auto transplanted tooth also has the capacity for functional adaptation and preservation of the alveolar ridge, which is advantageous when compared to ossointegrated implants that are stationary and do not erupt tocompensate for further growth. This is an important consideration when dealing with missing teeth, whether congenital or acquired, in the young patient. It is well documented that avulsed teeth recover optimal function and esthetics after replantation under ideal conditions. Favorable periodontal ligament [PDL] healing is the critical factor for success whether teeth are mature or immature. Pulp regeneration can be expected in immature (developing) teeth but not in mature teeth. Similar healing patterns can be expected in autotransplantation of teeth. In addition, bone induction is an interesting additional benefit of transplantation. Wound healing in autotransplantation of teeth is discussed below according to PDL healing, bone induction,
* Amrita School of Dentistry, AIMS, Kochi.

pulp healing and root development, respectively. Periodontal tissue healing Favorable healing of the PDL depends on how many viable cells are preserved on the root3. PDL cells can be damaged mechanically during extraction or bio-chemically due to various extra-oral conditions. PDL cells are easily injured under stressful conditions such as variable pH, osmotic pressure, dehydration, etc.4-7 If donor teeth are extracted with minimal mechanical damage to the PDL and are preserved in optimal condition extra-orally until the end of the surgical procedure, successful PDL healing should be expected. Optimal PDL healing is seen when a (avulsed) tooth is immediately replaced into its own socket. In this situation, reattachment occurs in 2 weeks between the connective tissues (PDL tissues) of the root surface and the recipient socket wall8-11. While not quite as predictable, extremely good PDL healing is expected in the case when a donor is immediately placed into the freshly extracted recipient socket12-15 However, PDL healing in the transplantation where the donor is placed into the newly (artificially) formed socket would need more time and the prognosis is a little poorer in comparison with the former two situations16. The slight difference in prognosis described above suggests that although viable cells on the root

surface are critical for successful healing, the importance of progenitor cells on the socket wall should not be overlooked. Another important factor to consider in regard to PDL healing is the repair of mechanically damaged root surface with new cementum and periodontal ligament17. The initial reaction to the trauma of the injury is always acute inflammation. If there is no additional stimulus to maintain this inflammatory response, healing will occur. The type of healing of a damaged root surface when a tooth is replanted or transplanted is dependent on the surface area of damaged root to be repopulated. If the area is small, cells with the potential to form new cementum and periodontal ligament are most likely to cover the damaged root. This type of healing is termed surface resorption or cementalhealing. However if a large area is to be healed, cells programmed to form bone will attach to some areas of the root. A physiologic process of bone turnover takes place as it does throughout the body. The root is resorbed (like the adjacent bone) but in the apposition stage bone (and not dentin) fills the (previously) resorbed area. In this way, the root is replaced by bone. This process has been termed ankylosis, replacement resorption or osseous replacement. Replacement resorption is irrevers-

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ible and will progress until the tooth is lost. The speed of the root replacement depends on the age of the patient; the younger, the more rapid. In adult patients, the teeth are lost very slowly and can maintain function and esthetics for many years. In contrast, in the young pre-puberty children, the teeth are lost quickly and intervention is necessary to prevent serious functional and esthetic problems. If the pulp space becomes infected, the bacteria in the canal act as a constant stimulus for inflammation, thus preventing it from advancing to the healing stage. This process has been termed inflammatory root resorption. This type of resorption can usually be seen radiographically within 2 months after replantation. Inflammatory resorption can be arrested if found in its early stage and treated with endodontic treatment, i.e. disinfection of the root-canal system. The resorbed lacunae will be repaired by new attachment. Bone healing Periodontal ligament of a transplanted tooth appears to be able to induce bone production. Genetically, PDL cells can differentiate into three types of cells: fibroblast, cementoblast, and osteoblast. The differentiated osteoblast may generate bone around the transplant. Bone induction is observed as rapid bone regeneration and the emergence of lamina dura around the transplant. Bone graft materials are unnecessary between bone walls and transplant roots even if the space is wide18. However, when donor teeth are placed into recipient site with poor spacing bucco-lingually, resulting in roots that protrude through a bone dehiscence, graft materials should be placed over the exposed root in order to create space for bone regeneration. Bone induction around a transplanted tooth is a significant advantage for this procedure compared to the use of implants Pulp regeneration Pulp regeneration can be expected in replantation (under optimal conditions) and transplantation of teeth with incomplete root formation19. Such a pulp healing response can be expected when the diameter of the apical foramen is radiographically at least 1 mm 20. Provided that the necrotic pulp stays uninfected, blood capillaries can invade the pulp canal through the wide apical foramen supplying nutrition to invading replacement cells that will eventually fill the pulp space21. In most cases, these cells will differentiate into the cells of a functioning pulp. The teeth will usually react positively to sensitivity tests in 6 months. Pulp canal obliteration (hard tissue deposition inside of canals) is inevitable. Root development Continued root development after transplantation can also be expected if a donor tooth is immature and Hertwigs epithelial sheath is preserved around the apices22. However, the amount of root development to be expected cannot be predicted by the stage of root development of the donor tooth or controlled by surgical technique23. It has been suggested in one study on the transplantation of premolars that root development occurred to completion post transplantation in 22%, no development in 18% and partial development in 60% of cases24. Since no additional root development is possible, it has been suggested that donor teeth should be at a development level higher than stage 4. This will ensure that a sufficiently long root can still be preserved if no root development occurs after transplantation. Ideally, we would want to transplant a tooth that is at its maximal length but still has the potential for pulp regeneration (apex opening >1 mm radiographically) Transplantation of a fully formed root negates the potential for pulp regeneration but adequate endodontic therapy of the pulp space will still ensure success. Technique The sequence of autotransplantation of teeth includes clinical and radiographic examination, diagnosis, treatment planning, surgical procedure, endodontic treatment, orthodontic treatment, restorative treatment, and follow up25. Examination and diagnosis Cases are examined and diagnosed mainly with clinical and radiographic information about whether or not transplantation is indicated. Important information includes anatomic shape of the donor teeth and how they match with recipient sites, stage of root development, ease of preparation of the recipient socket and potential for damage of the donor tooth at removal. Treatment planning Timing of tooth extraction at the recipient site is carefully determined. If the tooth is extracted prior to the date of transplantation, transplantation should be performed within 26 weeks after the extraction because extensive bone resorption will occur after 6 weeks. Immediate transplantation with an extraction at the recipient site will be preferable if enough gingival tissue to close around the donor tooth is expected. If root-canal treatment is deemed inevitable based on the stage of root development of the donor tooth, it may be completed before transplantation or initiated 2 weeks after transplantation. Restorative treatment of transplants should be discussed to avoid unnecessary tooth reduction. More esthetic results will be achieved by restoring transplants with composite rather than by fabricating artificial full-coverage prosthetics.Using standardized two-dimensional radiography, it is difficult to diagnose a partial ankylosis and there are many cases where root resorption starts undetected. Recently, the digital volume tomography (DVT) has been introduced in Dentistry. The main advantage of this technique is
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3-D imaging and remarkable reduction of radiation exposure in comparison with conventional computer tomography (CT) Surgical procedure The sequence of the surgical procedures is as follows 1 Pre-operative administration of antibiotics: It is recommended to administrate antibiotics a few hours before surgery. 2 Disinfection and anesthesia of the surgical sites. 3 Extraction of tooth at the recipient site : In immediate transplantation, the tooth to be extracted in the recipient site should be extracted before the donor tooth. 4 Extraction of the donor tooth: Before preparing the recipient socket, the donor tooth should be extracted and examined for anatomical form, size and PDL condition. Care must be taken not to damage the PDL. An intra-crevicular incision is made before luxation to preserve as much PDL on the root as possible and the donor is extracted slowly and as atraumatically as possible. The donor tooth should be placed back in its original socket after it is removed and waiting to be placed in the donor socket. If any extra-oral time is anticipated, the tooth should be stored in a storage medium like Hanks balanced salt solution that will maintain the viability of the periodontal ligament cells. Water should not be used for this purpose, since it is hypotonic and will damage the periodontal cells. 5 Measurement of the donor tooth: The mesio-distal width of the root and crown and the length of the root of the donor are measured. 6 Preparation of the recipient site: The recipient socket is prepared a little larger than the donor using surgical round bars at low speed and cooling with saline. 7 Try-in and adjustment: The match between the recipient and the donor is periodically checked by attempting to place the tooth into the socket with light pressure. Obstacles in the socket wall are removed as encountered. The optimal placement of the donor to the recipient is to establish the biologic width similar to that of a naturally erupted tooth. Deep placement to a position below the occlusal level of adjacent teeth should be avoided, if possible, so that orthodontic treatment will not be needed at a later stage. 8 Trimming and suturing of the flap: The most critical procedure in surgery is tight closure of the gingival flap around the donor tooth. This optimizes reattachment and, importantly, may block bacterial invasion into the blood clot between the tooth and socket. In order to achieve this close adaptation around the
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donor tooth, trimming of flap is needed in some cases, and suturing of flap before the donor is positioned into the socket is recommended in every case. Tighter and closer adaptation between the flap and the donor tooth will be achieved by suturing before the donor positioning than after it. This technique is especially important distal to the transplant in the case when the impacted donor is transplanted into the adjacent second molar recipient site. If the donor is to be splinted using a suture, one string of each suture should be left long enough for this purpose. 9 Positioning and splinting of the donor tooth: The donor tooth is placed lightly into the recipient socket through the opening of the sutured gingival flap. Ideally, the gingival opening should be a little narrower than the donor diameter because a tight adaptation between the tooth and gingiva is desirable. Splinting by means of sutures is then performed. If the transplant is not stable after suture splinting or if much more occlusal adjustment is necessary, splinting is changed to one with wire and adhesive resin. If the transplant is not stable but no occlusal adjustment is needed, splinting with wire and resin can be delayed for 2 or 3 days after suture splinting because the former is time consuming and bleeding during the surgical procedure makes optimal results difficult. 10 Occlusal adjustment: The occlusion must be checked to ensure that no occlusal interference is present. If a suture is used for stabilization, ideally the occlusal contact should be reduced extra-orally prior to positioning of the donor, taking care not to damage the PDL. It could also be performed intraorally before the extraction of the donor. If a wire splint is used, occlusal adjustment can be done after placing the splint. Occlusal adjustment should be conservative, since a composite restoration will be needed after healing to adjust the occlusion and/or esthetic appearance of the crown of the tooth. 11 Radiographic evaluation: A radiograph is taken preoperatively, before and after splinting to evaluate the position of the donor tooth in the new socket. 12 Surgical dressing : Surgical dressing (periodontal packing) is applied to protect the transplant against infection during the first 23 days in the wound healing. This dressing is removed at about 34 days post surgery. The sutures are removed 45 days after the surgery Root-canal treatment of transplanted teeth Pulp healing can be expected in the transplantation of developing teeth. In such a case, a radiograph is taken every month for 3 months after the surgery to monitor inflammatory resorption or apical periodontitis

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due to pulp space infection. If any sign of pulp infection is observed (for example, if inflammatory resorption is observed), root-canal treatment should be initiated as soon as possible26. If no sign of pulp infection is seen, a radiograph is taken 6 months after the surgery to evaluate continued root development and pulp canal closure. When regeneration is successful, pulp canal obliteration is inevitable and should be considered a positive sign of pulpal health27. Sensitivity tests should become positive at this 6-month recall. On the other hand, the pulp in fully developed transplants cannot regenerate. This does not disqualify these teeth from transplantation. Root-canal treatment should be planned at the appropriate time. If the donor tooth is accessible, the endodontic treatment can be completed before surgery. If the donor is impacted or erupted in a position that makes endodontic access difficult, the root-canal treatment should be started 2 weeks after transplantation. The 2-week timing for endodontic treatment is extremely important, since endodontic treatment performed too soon after surgery may cause additional PDL damage and if it is delayed past 2 weeks, inflammatory resorption may develop due to infection in the root-canal system. On the first day of the endodontic treatment, the canal is opened, cleaned and filled with a creamy mix of Ca(OH)2 spun into the canal with a lentulo spiral instrument. Two weeks later the final canal instrumentation and shaping is completed and the canals filled with gutta-percha and sealer. At this time (4 weeks post surgery), the splint is left in place. In younger patients, where regeneration of the pulp has failed, or whose transplanted teeth are too closed for pulp regeneration but are still open enough to make endodontic treatment difficult, an apexification procedure with long-term Ca(OH)2 treatment should be carried out. Natural closure of the apices with cementum can be expected with this technique. The splint with wire and resin is removed about 6 weeks after transplantation. The transplant is allowed to move naturally for 26 months with adjustment of occlusal interference until it is settled to new position. In immature teeth, the final root-canal filling with sealer and gutta-percha is done around the end of the natural tooth movement. Orthodontic treatment, if necessary, can be initiated 1 month after transplantation with mature teeth. Restorative treatment In an ideal situation, when a developing third molar is transplanted to another site in the arch, restorative treatment is not necessary, provided pulp healing occurs. In less ideal situations, restoration of crown is needed, such as filling an access cavity for root-canal treatment, creating improved interproximal contact, or recontouring the crown for occlusion and esthetic purposes. Composite resin is the first choice of material

Autotransplantation of teeth An overview

considering cost benefit and preservation of esthetic of the enamel. Bleaching can be performed before restoration on a root canal-treated anterior transplanted tooth. In the case of developing teeth, any preparation should be finished within enamel. The exposure of dentine may cause bacterial invasion and result in apical periodontitis. If dentine exposure is inevitable, immediate restoration must be performed. Transplants are natural teeth and any appropriate restorative treatment can be used with the correct indication. Maintenance Transplanted teeth that have healed normally have the same risks as any natural tooth with regards to caries and periodontal disease, etc. Thus, periodic follow up should be carried out with the same frequency as for the other teeth in the mouth. Compliance and maintenance is essential to ensure positive long term results Classification and clinical indications Autotransplantation can be classified into three groups: (1) conventional transplantation, (2) intra-alveolar transplantation, and (3) intentional replantation29. Conventional transplantation Conventional transplantation is moving teeth surgically from one site to another in the same individual. Autotransplantation is the term that is usually used to describe this procedure. This procedure is indicated when missing teeth with a hopeless prognosis are present in a mouth where an appropriate donor tooth can be used without any negative effects from its loss from its position in the arch. Good candidate donor teeth are those with simple root form, at the optimal stage of root development, easy extraction, and of sizes matching for recipient sites. Intra-alveolar transplantation Intra-alveolar transplantation is surgical intervention to move teeth within the original socket. Extrusion, rotation and/or uprighting can be performed surgically. Examples of indications include cases such as when the biologic width has been jeopardized due to deep caries, fractures or root resorption30, and when teeth have erupted in tilted direction and there are more advantages in uprighting them surgically than orthodontically31. Intentional replantation Intentional replantation is performed to solve an endodontic problem that cannot be solved by a conventional non-surgical or surgical approach. The sequence of the procedures is: the tooth is extracted; 3 mm of the apex is cut off; the root canal is prepared and retrofilled extra-orally; and then the tooth is replanted into the original socket without changing its original position32. Teeth with single, convex and conical shape root would give more predictable results than the ones with spread multi
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roots, or single but concave or enlarged root, because of the potential for fracture at extraction or mechanical damage to the PDL because of a difficult extraction. Follow-up results Reported survival rates of autotransplantation vary from 74100% 33. The follow-up periods and the kinds of teeth transplanted are different in each study. Several factors would affect the results of autotransplantation. The author has performed over 250 conventional autotransplantations of teeth in 15 years. Of those, most were done with fully developed teeth; about 20 cases involved developing teeth. A total of 220 consecutive cases, which were observed for more than 2 years, were analyzed. The average follow-up period is about 6 years. The survival rate is in the range of 90% and success rate 82%. The survival rate of the transplants into extracted sockets is 100% and their success rate is 95%. The survival and success rate of intra-alveolar transplantation are high as well. On the contrary, the survival rate of the transplants into artificially formed sockets is about 75% and their success rate is 60%. The decrease in success for transplants into artificial sockets mirrors the histological results of a study in monkeys and appears to highlight the importance of the periodontal ligament cells remaining on the socket wall after extraction34. Another reason may be the increased extra-oral time when forming a large recipient socket into a compact bone which is time consuming and increased PDL damage due to socket adjustment and occlusal adjustment that is more difficult in these cases. However, as with all procedures, the younger the patient the higher the success rate. It is nearly 90% if patients are younger than 40 years of age35. Comparison of dental implant and autotransplantation of teeth It is inevitable to compare transplants with implants because the two techniques have similar purposes. So, the criteria for choosing each must be discussed. Implants are indicated to all patients (who can afford them) while transplants are limited to those who have appropriate donor teeth36. The techniques for transplants and implants are similar in difficulty and so is the high prognosis. However, the post-surgical restorative options are generally much simpler for transplanted teeth. Studies shows, transplants would be chosen prior to implants in the following cases: Patients treated before pubertal growth: If osseointegrated implants are placed in these patients, they do not erupt along with adjacent teeth and result in infraocclusion with functional and esthetic problems. Transplanted teeth erupt in harmony with the adjacent teeth. However, it should be emphasized that transplantation should not be carried out too early, since at
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this stage of root development, the prognosis is not as predictable37-41. When patients have an unrestorable tooth requiring extraction and an ideal donor tooth is present: Transplants have several advantages over implants in terms of function, esthetics, time and cost. Immediate transplantation with extraction at the recipient site is a procedure that provides significant time saving compared to implants. Healing is rapid and function is obtained almost immediately. The transplanted tooth has osteoinducing properties that results in bone regeneration of the bony defects around transplants without graft materials, significantly reducing time and cost compared to implants. Transplants have the potential for superior esthetic results, since the natural emergence profile and the natural beauty of enamel and crown form is maintained. Usually, the total cost of transplantation is much lower than implant treatment. When intra-alveolar transplantation or intentional replantation is indicated: Severely decayed teeth and crown-root fractured teeth can often be saved by surgical extrusion42-45. In addition, intentional replantation is a treatment option for teeth with endodontic disease that cannot be treated by conventional means. In clinical practice, it usually makes sense to maintain the use of natural teeth for as long as possible. With such procedures available, extractions can be avoided or at least delayed

COncLUsIOn
Autotransplantation is often not considered as a treatment option when teeth are lost. This is very unfortunate given that the biological principles for success are understood and the correct indications are present; it is an extremely successful treatment form with significant savings in time and cost compared to implants. From the patients perspective, the dentition is preserved using a natural tooth rather than a mechanical prosthesis. The dental practitioner should definitely have the knowledge to recommend and carry out this procedure to the appropriate patient. Autotransplantation of teeth based on science and the state of art will promise happiness and healthy smiles of patients for a long time.

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Autotransplantation of teeth An overview

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bleaching of pulpless teeth with oxygen peroxide. Endod Dent Traumatol 1985;1: 5660. 37 Rygh P. Orthodontic root resorption studied by electron microscopy. Angle Orthod 1977;47: 116. 38. Wesselink P, Beertsen W. Initiating factors in dental root resorption. In: The biological mechanisms of tooth eruption and root resorption. Birmingham, Alabama: EBSCO Media; 1988. 32934. 39. Soder PO, otteskog P, Andreasen JO, Modeer T. The effect of drying on the viability of the periodontal membrane.Scand J Dent Res 1977;85: 1648. 40. Wesselink PR, Beertsen W, Everts V. Resorption of the mouse incisor after the application of cold to the periodontal attachment apparatus. Calcif Tissue Int 1986;39: 1121. 41. Andreasen JO. Effect of extra-alveolar period and storage media upon periodontal and pulpal healing after replantation of mature permanent incisors in monkeys.Int J Oral Surg 1981;1: 4353. 42. Takizawa H. Studies on the teeth preservation for replantation and transplantation: viability of the PDL cells. J JpnSocProsthodont 1991;35: 72337. 43. Andreasen JO, Borum MK, Jacobsen HL, Andreasen FM. Replantation of 400 avulsed permanent incisors. 4. Factors related to periodontal ligament healing. Endod Dent Traumatol 1995;11: 7689 44. Patil S, Dumsha TC, Sykdiskis RJ. Determining periodontal ligament (PDL) cell vitality from exarticulated teeth stored in saline or milk using fluorescein diacetate. IntEndod J 1994;27: 15 45. Lindskog S, Blomlf L. Influence of osmolality and composition of some storage media on human periodontal ligament cells. ActaOdontolScand 1982;40: 43541. 46. Andersson L, Bodin I, Sorensen S. Progression of root resorption following replantation of human teeth after extended extraoral storage. Endod Dent Traumatol 1989;5: 3847. 47. Czochrowska EM, Stenvik A, Album B, Zachrisson BU Autotransplantation of premolars to replace maxillary incisors: a comparison with natural incisors. Am J OrthodDentofacialOrthop 2000;118:592600. 48 Czochrowska EM, Stenvik A, Zachrisson BU. The esthetic outcome of autotransplanted premolars replacing maxillary incisors. Dent Traumatol 2002;18:23745. 49. Zachrisson BU. Planning esthetic treatment after avulsion of maxillary incisors. J Am Dent Assoc 2008;139:1484 50. Jung RE, Pjetursson BE, Glauser R, Zembic A, ZwahlenM,Lang NP. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. ClinOral Implants Res 2008;19:11930.

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