Orthodontics

Michael J Amos

Peter Day and Simon J Littlewood

Autotransplantation of Teeth: An
Overview
Abstract: Autotransplantation is the surgical repositioning of a tooth within the same patient. It can be thought of as a controlled avulsion
and re-implantation of a tooth in a new, surgically prepared socket. The indications for its use are discussed, as too are factors affecting the
success and the clinical procedures. The preservation and regeneration of the periodontal ligament is the key to success of this treatment. A
case involving the transplantation of a premolar tooth into the central incisor location in a child is presented to show the different stages of
the process.
Clinical Relevance: Autotransplantation is an underutilized technique which, when used within a multidisciplinary team, can offer an ideal
treatment option for child or adolescent patients with missing or failing anterior teeth.
Dent Update 2009; 36: 102–113

Autotransplantation is the surgical
repositioning of a tooth within the same
patient. It can be thought of as a controlled
avulsion and re-implantation of a tooth
in a new, surgically prepared socket. It is
done as a sterile procedure with a minimal
amount of time from the donor tooth being
extracted until it is sited in its recipient socket.
The utmost care is taken not to damage
the periodontal ligament and cementum
physically during extraction and socket
preparation of the donor site.
The concept of moving teeth from
their original location is not a new one. The
transplantation of teeth between individuals
(allo-transplantation) was common in the
18th Century but, owing to a complete lack of
Michael J Amos, BChD, MFDS RCS(Eng),
Specialist Registrar in Orthodontics,
Leeds Dental Institute, Peter Day, BDS,
MFDS RCS(Eng), MDSc, MPaeds RCS(Eng),
FRCD(C), Lecturer and Specialist Registrar
in Paediatric Dentistry, Leeds Dental
Institute, Leeds and Simon J Littlewood,
BDS, FDS(Orth) RCPS, MDSc, MOrth RCS,
FDS RCS, Consultant Orthodontist, St
Luke’s Hospital, Bradford, UK.
102 DentalUpdate
knowledge of histo-compatibility, yielded very
poor results. It was also thought to be a route
for the transmission of syphilis.
In the 1950s, descriptions of the
transplantation of teeth within the same
patient appeared in the literature for the first
time. Initial results suggested only a 50%
success rate and there was little widespread
acceptance of the technique.1 This early work
concentrated on the surgical repositioning of
third molar teeth into a first molar position.2
This undoubtedly meant that traumatic
(surgical) extraction of the teeth was
necessary, which caused excessive damage
to the periodontal ligament and cementum,
which consequently led to poor results.
Recent developments in the understanding
of the nature of the periodontal ligament
and cementum, and the need for careful
atraumatic extractions, have led to a
considerable improvement in the success rate
and an increase in popularity.
Indications for
autotransplantation
The movement of a tooth from one area of the
mouth to another
The basic premise of
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autotransplantation requires a situation of a
failing (chronically infected, severely fractured
or ankylosing), unrestorable or missing tooth
which requires replacement, and a non-
functioning (usually crowded) but healthy
tooth to act as the donor. The movement of
a third molar into a first molar position in an
adult patient has been described.3 In cases
of tooth agenesis, teeth can be redistributed
from other areas of crowding in the mouth.
However, the more common situation of
a missing anterior maxillary tooth is often
seen as a result of dento-alveolar trauma in
children. The teeth most commonly used as a
donor are premolars that need to be extracted
as part of an orthodontic treatment plan for
crowding.
This article will concentrate on
the transplantation of premolar teeth into the
central incisor space.
Intentional reimplantation
This is different from
autotransplantation as the same tooth is
reimplanted into its own socket and a distant
donor tooth is not involved. It is mentioned
here for completeness. It has been described
in the extra-oral apical surgery of a tooth,4 eg
a lower second premolar where the mental
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Advantages
The teeth continue to erupt with the
surrounding dentition maintaining alveolar
bone and gingival margin.
Tooth can be moved as part of an
orthodontic treatment plan.
Avoids removable prostheses.
There is no need to prepare adjacent teeth
(as in conventional bridgework).
Cost-effective (when compared to implants).
Even when healing of the transplant is
unfavourable (ankylosis), bone is
maintained so giving treatment options
once growth has finished. The ankylosed
tooth will provide years of satisfactory
appearance (this duration is related to age
of the patient) while slowly being replaced
by replacement resorption.
Table 1. Advantages and disadvantages of autotransplantation.
nerve may be at risk with conventional
apicectomy.
Surgical repositioning
In cases of complex crown/
root fractures, coronal root fractures or
intrusion of teeth due to trauma, teeth can
be surgically repositioned within the same
socket.
Contra-indications of
autotransplantation
„ Autotransplantation is contra-indicated
in patients with medical conditions that
preclude surgery.
„ Patients with poor oral hygiene or
motivation should not be considered.
Multiple visits are required for both the
post-surgical follow up and for the possible
orthodontic treatment to correct their
malocclusion. This can often take place over a
2−4 year period.
„ Where no teeth need to be extracted for
orthodontic alignment and no other suitable
non-functioning tooth exists.
The advantages and
March 2009
pg102-113 Autotransplantation.indd 2
Orthodontics
Disadvantages generally the case that a premolar will be
transplanted into its final position as part
Resorption and tooth loss is a possibility. of an ongoing orthodontic treatment plan
to correct crowding, therefore involving an
orthodontist at the treatment planning stage
is imperative. It is vital to have a surgeon with
Requires a multidisciplinary team to the necessary understanding and sympathy
provide the treatment. for the procedure to respect the periodontal
ligament during transplantation. Sometimes
Requires the patient to commit the surgery is undertaken by a paediatric
standardized follow-up. dentist. Paediatric dentists have the
experience and training to manage the post-
operative care of these teeth and, in addition,
restore them and institute root canal therapy,
where required, as a result of seeing many
children who have suffered dento-alveolar
trauma.
„ Recipient site
The recipient site should have
enough space for the donor tooth, with
adequate height and width of bone.
Success of an
autotransplantation
The success of treatment can be
defined by a number of parameters. The first
three parameters are based on the healing of
the tooth in its new location.
disadvantages of autotransplantation are
summarized in Table 1.
Periodontal ligament
Factors affecting success of The aim is to re-establish a
autotransplantation vital periodontal ligament between the
transplanted tooth and the surgically
The following points increase
prepared socket. This will be shown
the chances of a successful result and
radiographically as a normal continuous
should be present when considering
lamina-dura and clinically as the absence
autotransplantation:5,6
of ankylosis, eg reduced mobility or high
„ Root morphology
percussion sound.
The donor tooth should have a
conical, smooth root which will enable an
atraumatic extraction preventing damage to
Pulp
the periodontal ligament.
In an immature transplant tooth
„ Stage of root development of the donor
there is an excellent chance that pulpal
Immature teeth with an open
regeneration will occur in the original root
apex have a greater chance of success, with
canal space. It can be expected that 87%
the ideal root being 3/4 to 4/5 complete.7,8,9
of teeth will show pulpal healing if the
„ Surgeon skill
apical diameter is greater that 1 mm.8 A
Prevention of damage to the
vital transplanted tooth will show pulpal
periodontal ligament is only possible if
obliteration on serial radiographs but
meticulous surgical technique is applied to
maintain a positive result to electric pulp
the operation.
testing.5,6
„ Multidisciplinary team
The planning of an
autotransplantation should involve an Tooth survival
orthodontist and a paediatric dentist. It is Where there has been damage
DentalUpdate 103
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20/2/09 11:16:12
 Orthodontics
to the periodontal ligament, healing will take
place by ankylosis/replacement resorption,
with the tooth eventually being lost.10 While
the tooth is still in situ it will maintain the
anterior aesthetic appearance and the height
of alveolar bone in the site for several years
and will also act as a space maintainer during
the often difficult adolescent period.
Aesthetic appearance
The appearance of transplanted
premolars in incisor sites is generally good
once they have been camouflaged with
composite. A study of 22 patients, that had
premolars reshaped to look like incisors,
showed that only four were dissatisfied with
the final appearance.11
Patient opinion
In a study of 28 patients who had
33 teeth transplanted, the overall perception
of the treatment was good, with the only
concern being some pain and discomfort
associated with the surgery itself.12
We will consider the response
of the periodontal ligament and pulp to
transplantation in more detail.
Healing of the periodontal
ligament
The fate of a transplanted
or re-implanted tooth is dependent on
the viability of the periodontal ligament
attached to the root.5,6,10,13 Where there
is only minor damage to the cementum
during transplantation, healing will occur by
regeneration of periodontal ligament into the
area of damage. Where extensive damage of
the cementum has occurred, the tooth will
heal by osseous replacement or ankylosis.5,6,13
Regeneration
The ideal situation is to have
vital periodontal ligament on the root
surface. In this case, there may be complete
healing and maintenance of a vital and
functioning periodontal ligament. This is
called regeneration and is more likely to
occur when a donor tooth is implanted into
a socket immediately following extraction
of another tooth or is placed directly into a
surgically prepared socket. The atraumatic
extraction of the tooth is paramount to
preserve the periodontal ligament. The
104 DentalUpdate
pg102-113 Autotransplantation.indd 3
cementum can be thought of as a protective
layer covering the root, into which new
PDL can attach. Without it, the root is at risk
of attack from resorbing osteoclast cells
derived from the bone.5,6,10 The cementum
can tolerate damage up to an area of 2 mm2
by in-growth of adjacent cementum into this
area of damage.13
Replacement resorption/ankylosis
If the area of necrosis of
cementum is too large, healing will occur
by bony replacement, with direct contact
between the root surface and the adjacent
bony socket. The root is progressively
replaced by bone until the crown eventually
fractures off as a result of having no support.
This is replacement resorption or ankylosis
(Table 2).5,6,9,10 The time taken before the
crown is lost is related to the speed of bone
turnover and, consequently, the age of the
patient. A young patient has more rapid
bone turnover and therefore more rapid root
resorption.14
The fate of the pulp
Whether the pulp of a
transplanted tooth heals and remains vital or
whether it becomes necrotic is dependent
on the stage of development of the root. The
ideal situation is to transplant a tooth with
an incomplete root that will continue root
development and regenerate a vital pulp. This
will be demonstrated on serial radiographs
by progressive pulp canal obliteration.5,6,8
Pulp canal obliteration
The pulp of any tooth that is
transplanted will suffer ischaemic damage
and become necrotic. In open apex teeth,
the pulp canal space can revascularize by
the ingrowth of capillary vessels through
the apex.5,6,15 This revascularization proceeds
at 0.5 to 1 mm per day.8 A tooth with an
open apex will have remnants of Hertwig’s
epithelial root sheath (HERS) present when it
is transplanted, which is important for both
continued root development and pulpal
healing. Following revascularization, there
is calcification of the pulp canal space with
the radiographic appearance of progressive
obliteration. It should be noted that the tooth
still contains vital pulpal tissue and usually
gives a positive result to vitality testing.6
All efforts should be made to maintain
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vitality by not insulting the pulp, eg by too
aggressive or early orthodontic treatment or
preparation of the tooth for initial aesthetic
build-up, as subsequent root canal therapy
can be difficult to provide successfully. Any
preparation of the tooth should remain in
enamel to prevent exposure of the dentinal
tubules, which would provide a route of
ingress of bacteria into the vulnerable pulp.
Pulp necrosis
Healing of the pulp cannot be
expected if the apical foramen of the donor
tooth is less than 1 mm in diameter, and a
tooth with a closed apex will always require
root canal therapy.8 This does not, however,
preclude closed apex teeth from being
transplanted.
Necrosis of the pulp in an
immature tooth and infection of the root
canal will lead to necrosis of HERS and no
further root development. At this point,
apexification of the root canal is undertaken
with repeated application of non-setting
calcium hydroxide to institute a hard tissue
barrier against which the tooth can be
obturated. This is not an ideal situation as,
although it is possible to generate an apical
barrier, the root canal walls are immature and
weak and subsequently liable to coronal root
fracture.16,17,18 Consequently, the ideal time
for transplantation is when the donor tooth
has completed root development but still
retains an open apex. If necrosis and infection
of the pulp does occur at this stage, there
is a less severe effect on root strength and
subsequent long term prognosis.
The reason transplanted teeth
need close follow-up post-operatively is the
risk of inflammatory resorption. When there
are both necrotic and infected contents
within the root canal and adjacent damage to
the cementum, there is direct communication
via the dentinal tubules to the periodontal
ligament space. The inflammatory
products from the root canal increase the
inflammatory response, driving further
resorption of the periodontal ligament and
cementum.10 This is called inflammatory
resorption (Table 2). Histologically,
inflammatory resorption is characterized
by the presence of granulation tissue at the
root surface.19 Unlike replacement resorption,
inflammatory resorption can be arrested by
promptly instituting root canal therapy, and
removing the infected pulp, and dressing
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20/2/09 11:16:59

Surface Resorption
Replacement Resorption/ Ankylosis
Inflammatory Resorption
Table 2. Types of resorption affecting the transplanted tooth.
with non-setting calcium hydroxide to
eliminate infection. It progresses much
more rapidly than replacement resorption,
and so close follow-up is required to
identify and treat it early.
Prognosis of treatment
There are limited
published data on the success of
autotransplantation. The largest study by
Andreasen looked at 370 transplanted
premolar teeth with a mean 5-year follow-
up. He reported that 86% showed normal
healing, 13.9% were clinically successful,
but with evidence of root resorption, and
0.1% were extracted.7,8,9 In the longest
follow-up study, Czochrowska looked at
March 2009
pg102-113 Autotransplantation.indd 6
Following traumatic or other insults
(eg orthodontic movement) small areas of
necrosis are caused in the cementum. This
necrotic tissue is removed by osteoclasts.
At this point the area of damage is small
enough for adjacent cementum to grow
into the area and a normal periodontal
ligament is re-established. This is self
limiting and the tooth will survive with no
loss of root.
Occurs if an area of root is in direct contact
with the bone. Caused by a necrotic
area of periodontal ligament that is too
large to allow healing by in-growth of
periodontal ligament. Osteoclasts from
the bone directly resorb the root, and it
is replaced by new bone laid down by
osteoblasts. Its slow progress cannot be
halted once started and the tooth will be
lost eventually.
Caused by a necrotic and infected
pulp communicating with the adjacent
periodontal ligament space via dentinal
tubules. There is a rapid resorption of the
root within months. This resorption will
continue until the inflammatory stimulus
has been removed by instigating root canal
therapy. The size of the area of necrotic
cementum will determine whether
cemental or bony (replacement resorption)
healing occurs.
33 transplanted teeth in 28 patients with a
mean follow-up of 26 years. They reported
three teeth were lost at 9, 10 and 29 years
and, therefore, a 90% clinical success. There
was a 79% overall success rate as four teeth
had evidence of ankylosis or did not fulfil
the criteria for success.12
If we specifically look at
transplants into the area of upper anterior
central and lateral incisors, one study has
shown 96% of immature donor tooth
implants had no complications at four
years post placement.20
These studies show that
autotransplantation can be a successful
treatment, which compares favourably with
other options for treating missing upper
anterior teeth.
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Orthodontics
Comparison with other options
to restore missing teeth
Implants
An autotransplanted tooth is a
superior option in children and adolescents
over an implant for several reasons. It may
establish a new periodontal ligament
attachment to the bone. This will allow it
to continue to erupt with the surrounding
dentition, thereby inducing new bone. As
it acts like a normal tooth, it can be moved
orthodontically into the correct position, if it
was not possible to position the tooth in the
ideal position at the time of initial surgery. An
implant, without a vital periodontal ligament,
will act like an ankylosed tooth and will
become progressively infra-occluded as the
patient grows. The placement of an implant
is therefore contra-indicated until the patient
has finished growing. It can also be difficult
to achieve a good interdental papillae and
gingival aesthetics with implants compared to
autotransplanted teeth.
Partial dentures
An unpopular choice of
restoration in the adolescent or child for social
and comfort reasons.
Fixed prosthodontics
Resin-retained bridgework (RRB)
is usually the only fixed prosthesis that can
be considered as full coverage bridgework is
contra-indicated in the adolescent as it usually
involves the preparation of virgin teeth to
act as abutments. RRB has a finite life span
and will need replacing when the adolescent
patient is still relatively young. Two studies
on survival rates reported a 23% failure rate
over 13 years, and 26% over 4 years.21,22 This
is unacceptable as the restoration would fail
in the patient’s twenties, with a lifetime of
replacements needed in the future.
Orthodontically aligning a lateral incisor into the
central space
This is a complex option that can
lead to poor aesthetics and excessive occlusal
load on a relatively diminutive root.23
Accepting the space
A poor option which will lead to
drifting of adjacent teeth, loss of the centre
line and poor aesthetics.
DentalUpdate 107
20/2/09 11:17:43
 Orthodontics
Figure 1. Obvious chronic sinus related to UL1
tooth at the outset of fixed appliance therapy.
a b
Figure 4. (a, b) Extracted UL1 showing perforation of root.
The surgical procedures
A case is presented that illustrates
the autotransplantation of a lower first
premolar into the upper left central incisor
location.
Pre-operative (Figures 1, 2, 3)
Following a crown root fracture
of UL1, a persistent buccal abscess developed
which was resistant to treatment. (This
was due to multiple fractures extending
subgingivally following trauma and
subsequent root filling).
Extraction of tooth in recipient site (Figure 4)
Following multidisciplinary
planning UL1 was extracted. This was carried
out four weeks prior to transplant to allow
elimination of infection from the area.
Healing of the recipient site (Figure 5)
Healing was allowed to occur, and
the space maintained prior to the transplant.
Extraction of the donor tooth. (Figure 6)
Both lower first premolars were
to be extracted to relieve crowding as part
of the orthodontic treatment plan. In order
to ensure that the donor tooth would be in
good condition for transplantation, it was
108 DentalUpdate
pg102-113 Autotransplantation.indd 7
Figure 2. Chronic palatal pathology related to Figure 3. The crowded lower arch which requires
UL1 tooth. extraction of both lower first premolars.
Figure 5. Space maintainer in position following
extraction of UL1.
Figure 6. A lower first premolar is extracted with
minimal trauma. Care is taken to ensure that the b
forceps do not contact the root.
extracted atraumatically with the minimum
damage to the periodontal ligament. This
was achieved by ensuring the forceps
only gripped the crown of the tooth. No
contact was made with the root surface, and
elevators were not used. The tooth was gently Figure 7. (a, b) The transplant is carried out
left in its own socket prior to the preparation under general anaesthetic. Buccal and palatal
of the recipient site. mucoperiosteal flaps are raised.
Preparation of the recipient site (Figures 7, 8, 9)
Careful preparation of the
recipient site is essential. An initial pilot hole
was prepared and the socket was created
with implant burs at slow speed with copious
cool irrigation to minimize the risk of damage
to the bone. In order to prevent the need to
try the donor tooth in the socket repeatedly
and risk unnecessary damage to the Figure 8. A pilot hole is drilled into the bone.
periodontal ligament, an implant bur of the
March 2009
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20/2/09 11:18:10

Figure 9. The recipient site is prepared with an
implant drill at slow speed with copious cool
irrigation.
same size was carefully selected (Figure 10). A
metal template tooth can also be matched to
the size of the donor and be used to prepare
the socket to the correct dimensions.
Transfer of the tooth (Figure 11)
The tooth was quickly transferred
into the surgically prepared socket and with
the minimum of trauma to the root surface.
The tooth was placed at the same level of
eruption as it was in its donor location. This
allowed for continued normal eruption and
root development. The aim is to place the
tooth in light occlusal function but, at the
same time, not excessively loading it. The
donor tooth may be rotated in the socket in
order to give the ideal cervical width when
compared to the contra-lateral tooth and
therefore an ideal aesthetic result.
When placing the transplanted
tooth into its new socket, it is important
to ensure that there is keratinized gingiva
tightly adhered to the root of the tooth. This
will give an aesthetically pleasing gingival
contour following healing.
Splinting (Figures 12, 13)
The tooth was immobilized for
7−10 days. A physiological splint was used
that allowed some movement of the tooth,
whilst immobilizing it enough to allow
healing. Allowing some minor movement
reduces the incidence of ankylosis. The tooth
can be splinted with a composite resin and
wire or held in place with a silk suture sling,
which is a quick and effective method of
immobilizing the tooth but, when not placed
correctly, can have the disadvantages of
becoming loose over a 7−10 day period and
preventing sufficient cleaning of the gingival
tissues.
March 2009
pg102-113 Autotransplantation.indd 8
Orthodontics
Figure 10. The correct sized drill is selected by Figure 11. The donor tooth is inserted with care
comparing it to the root of the donor tooth. This into the socket.
means the root of the tooth is not repeatedly tried
in the prepared socket. a
b
Figure 12. The transplanted tooth is held in place
with a sling silk suture.
Follow-up (Figures 14, 15, 16, 17, 18)
The tooth was followed up
closely to look for clinical or radiological signs
of failure. The tooth was vitality tested and
examined for signs of mobility, pain, infection
c
and abnormal resonance to percussion which
would indicate ankylosis. Radiographs were
taken at 7−10 days, 1, 2, 4 and 6 months. In
the case of a tooth with a closed apex, root
canal therapy is instituted at 7−10 days, at
the same visit as splint removal, but before
this occurs, as the splint stabilizes the tooth
during the endodontic treatment. For
immature teeth, it was started at the first sign
of pulpal necrosis.
Figure 13. (a, b, c) Immediately post-operative.
Orthodontic movement of
transplanted teeth
Almost all patients with Orthodontic movement infers a constant
transplanted teeth require orthodontic pressure on the root of the tooth, which is a
treatment to correct their malocclusion. long-lasting stimulus for root resorption.10
Frequently, the transplanted tooth is not in Consequently, using teeth with at least ¾
the ideal location, and requires orthodontic root length is important to prevent this
movement to improve the aesthetics as part resorption becoming significant and leading
of the orthodontic treatment. This should to long term mobility. It is recommended
be undertaken carefully as orthodontic that a transplanted tooth should be moved
movement of a transplanted tooth does following periodontal ligament healing, but
result in some minor root shortening. before pulpal obliteration and complete
DentalUpdate 109
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20/2/09 11:18:33
 Orthodontics
Figure 14. Following healing.
Figure 15. Camouflage of the tooth with composite
restoration.
Figure 16.Fixed appliance therapy is recommenced
to align the arches. The transplanted tooth is
moved with care.
healing of the bone. This is usually 3 to 9
months post implantation.24
Restorative procedures
Obviously, a premolar
transplanted into a central incisor
location will need camouflage. This
is usually achieved with composite
resin restorations. The preparation of
these teeth, eg for crowns or to reduce
a palatal cusp, should be avoided as
this can further damage an already
vulnerable and healing pulp, which could
lead to pulpal necrosis. Simple build ups
are therefore performed in the short
term prior to orthodontic treatment
to give the orthodontist an idea of
the size and shape of the definitive
restoration. The definitive restoration
110 DentalUpdate
pg102-113 Autotransplantation.indd 9
is then left until after the completion of a
orthodontics. With a closed apex tooth, as
the endodontic therapy is started at 7−10
days following transplantation, tooth
preparation can be more significant.
Conclusion
Autotransplantation
is an under used technique in the
dental profession’s armamentarium
for treating missing or unrestorable
teeth. In particular, it can be used for
young patients suffering early loss of b
permanent incisors with co-existing
crowding that require extractions as
part of an orthodontic plan. It offers a
cost-effective and predictable long term
alternative to osseointegrated implants.
We recommend that patients undergoing
autotransplantation should be treated as
part of a multidisciplinary team in order
to maximize the success and outcome. Figure 17. (a, b) Treatment complete.
Acknowledgements
Orthodontics performed by
Gerry Rahilly (Orthodontic SpR, Leeds
Dental Institute) and supervised by
James Spencer (Consultant Orthodontist,
Leeds Dental Institute). Surgery
performed by John Russell (Consultant
Oral and Maxillofacial Surgeon, Leeds
General Infirmary). We would like to
thank Paul Cook for his advice on
autotransplantation.
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Figure 18. Post-operative radiograph showing
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23/2/09 14:45:59
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