DENTOALVEOLAR SURGERY

Retrospective Evaluation of Immediate

Impacted Third Molars
Autotransplantation After Extractions
of Mandibular First and/or Second
Molars With Chronic Periapical
Lesions
Necip Fazıl Erdem, DDS, PhD,* and Zeynep G€ u şer, DDSy
um€
Purpose: To evaluate the success rate of simultaneous autotransplantation of the immature impacted
third molars with the guidance of computer-aided rapid prototyping (CARP) to the place of mandib-
ular first or second molars with extraction indication due to the untreatable radiographic periapical
lesions.
Patients and Methods: Twelve radiographically and clinically hopeless mandibular first or
second molars with periapical lesions of 10 patients between the ages of 15 to 21 were included in this
retrospective clinical study. Cone-beam computed tomography (CBCT) images were used to produce
the CARP models of the donor impacted third molars. Following the extractions of the mandibular first
or second molars with periapical lesions, sockets were curetted and prepared with proper burs until a suit-
able infraocclusal fit of the CARP models. The donor teeth were transplanted synchronously with their sur-
gical extractions. Postoperatively patients were followed clinically and radiographically in the 3rd and 6th
months and every 6th month thereafter for at least 18 months. Clinically, the mobility, periodontal plaque,
bleeding on probing, percussion sensitivity, periodontal pocket, vitality, and occlusion, and radiographi-
cally, the root resorption, ankylosis, presence of lamina dura, and healing of periapical lesion were as-
sessed.
Result: By the end of 12th month, and thereafter, all transplanted teeth were in occlusion and func-
tioning properly with no clinical or radiological signs of pathology. All of the autotransplantation cases
involved in this clinical study were successful within a mean follow-up period of 20.4 months with the
least one of 18 months.
Conclusion: Immediate autotransplantation of the immature third molars to the place of mandibular first
or second molars with extraction indication due to the periapical lesion can be a proper treatment option
for adolescent patients.
Ó 2020 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg -:1-12, 2020

Received from Department of Oral and Maxillofacial Surgery, 34854, Başıb€ uk - Maltepe/ I_stanbul, Turkey; e-mail: nferdem@
uy€
Marmara University, School of Dentistry, Istanbul, Turkey. yahoo.com
*Asistant Professor. Received March 12 2020
yResident. Accepted August 14 2020
Conflict of Interest Disclosures: None of the authors have any Ó 2020 American Association of Oral and Maxillofacial Surgeons
relevant financial relationship(s) with a commercial interest. 0278-2391/20/31059-4
Address correspondence and reprint requests to Dr Erdem, Mar- https://doi.org/10.1016/j.joms.2020.08.014
€ niversitesi Diş Hekimligi Fak€
mara U ultesi, Başıb€
uy€
uk Yolu No: 9/3,

1
2 IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS
Introduction
In the modern world, due to the changing diet habits
with a high concentration of carbohydrates, losing
molar teeth at the very early stage of life is commonly
seen. Autotransplantation can be the solution to the
problem. Basically, autotransplantation is known as
the repositioning of organs or tissues from 1 part of
the body to another in the same individual. If there is
a suitable impacted donor tooth, the aim is to treat
the local edentulousness due to severe caries, peri-
odontal disease, trauma, or endodontically hopeless
teeth.1,2 In oral and maxillofacial surgery, especially
impacted third molars are preferred for transplanta-
tion to treat the local edentulousness where the chew-
ing function is mostly taking place. Unless the early
loss of a molar tooth is treated, the distortion of the oc-
clusion, and thus, further dental caries and peri-
odontal diseases will occur. Dental implants and
fixed partial prostheses can be the treatment options
for the edentulous part of the jaws; however, this is
not the case for adolescents due to the continuing
growth process of their jaws. For this group of pa-
tients, the treatment can be challenging as the replace-
ment should adapt to the growth process. Thus,
autotransplantation of an impacted tooth is a predict-
able and the best treatment procedure with its accept-
able esthetic and function outcome, occlusal
rehabilitation, and maintenance of the alveolar bone
volume.2-10 Nevertheless, the treatment cost is less
than any other treatment method, such as
orthodontic space closure or maintainer.
The clinical result of autotransplantation of a tooth
was first reported by Miller in 1950.11,12 Since then,
the success rate of tooth autotransplantation has grad-
ually increased, especially after the advances in diag-
nostic and surgical techniques such as computer-
aided rapid prototyping (CARP) of the donor tooth.
A surgical template prepared by using CARP is
extremely helpful during the preparation of the donor
socket as it minimizes the trauma to the periodontal
ligament or Hertwig epithelial root sheath of the trans-
planted tooth.13,14 It also significantly reduces the ex-
traoral time of the transplanted tooth.9 Thus, it has a
positive effect on the success rate of autotransplanta-
tion.9,15 Besides, there are some other criteria that
are directly related to the success rate of autotrans-
plantation such as patient’s age,16-18 the developing
stage of the donor tooth,18-20 the bone support at
the recipient site,21-23 proper adaptation of the
donor tooth to the reshaped recipient alveolar
socket at the infraocclusion position,24,25 the absence
of acute infection or chronic inflammation at the recip-
ient site26,27 and postoperative care.28,29 Postopera-
tive inflammation, root resorption or ankylosis, pulp
necrosis, and reduced root length are the most
commonly seen complications of tooth autotransplan-
tation.30 The incidence of these complications is
directly related to the revascularization of the trans-
planted tooth, namely the stage of its root develop-
ment and pulpal dimension. The ideal time for
autotransplantation of a tooth is when its root forma-
tion is 75% completed with an open apex as it has a
high chance of revascularization and
apexification.7,10,31
The success rate of autotransplantation has been re-
ported as 59.6 to 100% in the literature, with an
increasing percentage in recent years.32,33 Based on
these studies, autotransplanted teeth, radiographi-
cally, with no evidence of root resorption or ankylosis
and presence of lamina dura, and clinically with no
infection, discomfort, and/or excessive mobility
were defined as successful autotransplantation. How-
ever, to the best of our knowledge, none of these
studies has focused on the success rate of simulta-
neous transplantation of impacted third molars to
the place of mandibular first or second molars with
periapical lesions. Thus, the aim of this retrospective
clinical study is to evaluate the success rate of simulta-
neous autotransplantation of the 12 impacted third
molars of 10 patients within the age range of 15 to
21 with the guidance of CARP to the place of mandib-
ular first or second molars with extraction indication
due to the untreatable radiographic periapical lesions.
Methods
This retrospective study was approved by the Mar-
mara University School of Dentistry Clinical Research
Institutional Review Board, and all participants signed
an informed consent agreement. Twelve radiographi-
cally and clinically hopeless mandibular first or
second molars with periapical lesions of 10 patients be-
tween the ages of 15 to 21 were included in this retro-
spective study. Prior to the autotransplantation
procedures, endodontic consultations of all cases
were performed. The following set of indications were
considered for the autotransplantation procedure:
- Endodontically hopeless molars due to compli-
cated, nonnegotiable root canals
- Molars with a history of severe infection with peri-
apical lesion
- Molars that require crown lengthening together
with an apicoectomy.
- Molars with failed endodontic treatments
- Molars with extensively damaged crowns that
have lost their substantial structures due to caries,
previously failed restorations, or fractures.
All of the patients, 8 females and 2 males, were sys-
temically healthy. Before the surgery, all of the
 € MU
ERDEM AND GU € ŞER 3

patients’ medical histories were reviewed, and clinical fissure burs under saline irrigation. The donor tooth
and radiographic examinations of the donor and recip- was passively luxated with minimal usage of elevators
ient sites were performed. Inclusion criteria were be- and proper forceps placement above the cement-
ing systemically healthy, having a donor third molar enamel junction to prevent any damage to the peri-
with a root development of three-quarters of the ex- odontal ligament. Then the donor tooth was placed
pected final root length, and being aged 15 or older. immediately to the prepared socket at the infraocclu-
In contrast, the exclusion criteria were being an unco- sion position, and the flap was sutured (Figs 4A, B).
operative patient, having insufficient oral hygiene, The transplanted tooth was splinted to the adjacent
malocclusion, horizontal impacted donor third molar, teeth by fixation wires and resin for 2 weeks; in case
acute infection at the recipient site, and donor tooth proper stability could not be provided by suturing. Su-
with divergent root morphology. Cone-beam tures were removed after 1 week. Thus, the autotrans-
computed tomography (CBCT), and panoramic im- plantation of the impacted third molar to the local
ages were taken from all of the patients preoperatively
(Figs 1 and 2). The largest diameters of the periapical
lesions were measured on CBCT and re-
corded (Table 1).
According to the classification of Moorrees et al., the
root development of the donor third molars were at
the fourth stage (three-quarters of the expected final
root length) (Table 2).34 The donor teeth were me-
sioangularly or vertically positioned and partially or
fully impacted preoperatively (Table 1). The broadest
mesiodistal and buccolingual dimensions, the length
of the crown and root, and cervical dimensions of
the donor tooth were measured and compared with
the residual bone height and width of the recipient
sites on the tomography images. If the donor tooth
can safely be adapted to the donor site, a 3D chrome
cobalt CARP model of the donor tooth was fabricated
from chromo cobalt (remaniumÒ Star CL Laser
Melting Powder [CrCoW Alloy]) using the CBCT im-
ages of the patients and a rapid prototyping machine
(metal 3D printer: LaserCUSING [Concept Laser
GmbH]), running by Remainium Star CL software pro-
gram (Fig 3).
A written informed consent was obtained from all of
the 10 patients or their parents in case they were un-
der 18 years old. All 12 transplantation surgeries
were performed at the University of Marmara, School
of Dentistry, Department of Oral and Maxillofacial Sur-
gery by the same surgical team. One day before the sur-
gery, 500 mg penicillin, 275 mg naproxen sodium, and
0.1% chlorhexidine rinse 2 times a day were pre-
scribed and continued for a week. After local anes-
thesia was performed, a mucoperiosteal flap was
elevated at the site. The tooth was extracted atraumati-
cally in order to protect the alveolar bone. If needed,
the tooth was sectioned with a tapered fissure bur.
The periapical lesion was curetted by using proper
bone curettes and irrigated with saline thereafter.
Then, the bone at the recipient site was prepared
with round and fissure burs under saline irrigation un-
til a suitable infraocclusal fit of the sterilized CARP FIGURE 1. The CBCT image of an autotransplantation case with a
model of the donor tooth (Fig 4A). Next, a mucoperios- periapical lesion of tooth # 47.
teal flap was elevated, and an ostectomy was per- Erdem and G€ um€u şer. Immediate Autotransplantation of
formed at the donor tooth site with round and Impacted Third Molars. J Oral Maxillofac Surg 2020.
4 IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS

FIGURE 2. Preoperative panoramic radiograph of a patient.

Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.

edentulous areas, synchronized with its surgical
extraction, was performed.
Patients were postoperatively put on a soft diet for
10 days and followed at the end of the 1st week, 3rd
and 6th months, and every 6th month thereafter.
Clinically mobility, periodontal plaque, bleeding on
probing, percussion sensitivity, periodontal pocket
measurement at 6 sites, vitality, and occlusion
were evaluated at follow-up visits. Vitality was
measured by using a vitalometer (Digitest IIÔ Pulp
Vitality Tester). Articulating paper was utilized to
verify whether the transplanted tooth was in occlu-
sion. In order to evaluate the root resorption, anky-
losis, presence of lamina dura, and healing of

Table 1. THE TABLE SUMMARIZES THE BASIC INFORMATION OF THE PATIENTS RELATED TO THEIR AUTOTRANS-
PLANTATION PROCEDURES

Diameter of the
Periapical Follow up Period Preoperative
Transplantation Lesion Age/ Extracted Transplanted of Transplanted Position of
# (in Centimeter) Gender tooth # tooth # tooth Donor tooth

1 1,5 17/F 18 (37) 17 (38) 27 mo V/PI

2 1,2 16/F 31 (47) 32 (48) 24 mo MA/FI
3 1 15/F 31 (47) 32 (48) 22 mo V/FI
4 1,7 21/F 18 (37) 17 (38) 21 mo V/PI
5 2,1 15/F 30 (46) 32 (48) 21 mo V/FI
6 2 19/M 30 (46) 1 (18) 21 mo V/PI
7 1,5 16/F 18 (37) 17 (38) 19 mo MA/FI
8 1,8 16/F 31 (47) 32 (48) 18 mo MA/FI
9 1,5 17/F 30 (46) 17 (38) 18 mo V/FI
10 1 17/F 31 (47) 32 (48) 18 mo V/FI
11 1,9 16/M 18 (37) 17 (38) 18 mo V/FI
12 1,3 19/F 30 (46) 32 (48) 18 mo V/PI
Teeth Numbers in Parentheses are According to International Tooth Nomenclature.
Abbreviations: FI, Fully Impacted; MA, Mesioangular; PI, Partially Impacted; V, Vertical.
Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.
 € MU
ERDEM AND GU € ŞER 5

Table 2. STAGES OF ROOT DEVELOPMENT OF A MOLAR TOOTH ACCORDING TO MOORREES ET AL. IMMATURE TEETH
FROM LATE STAGE-2 TO STAGE-4 WERE RECOMMENDED FOR AUTOTRANSPLANTATION. STAGE-4 DONOR TEETH
WERE UTILIZED IN THIS STUDY

Stage-1 Initial root formation with

diverge edges

Stage-2 ¼ of the root length formed.

Less than crown length with
visible bifurcation area

Stage-3 ½ of the root length developed.

Root length equals to crown
length

3
Stage-4 /4 of the root length developed

Stage-5 Root length completed with

parallel ends

Stage-6 ½ of the apex closed with wide

periodontal ligament

Stage-7 Apex closed with normal

periodontal width

Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.

periapical lesion, all patients were radiographically
followed by panoramic and periapical radiographs
that were taken at 6-month intervals postoperatively.
The periapical radiographs were taken by using the
paralleling technique. All transplanted teeth were
clinically and radiologically assessed by the
same clinician.
A tooth with no radiographic evidence of root
resorption or ankylosis, and clinical evidence of
inflammation, abnormal mobility or pathological peri-
odontal packet (>3 mm), and functioning at the occlu-
sion at the recipient site without pain during the
follow-up period was defined as successful autotrans-
plantation. On the contrary, the tooth that was still
6 IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS
FIGURE 3. Produced chrome cobalt CARP model of a donor tooth.
Erdem and G€ um€u şer. Immediate Autotransplantation of
Impacted Third Molars. J Oral Maxillofac Surg 2020.
present at the recipient site and functioning well with
no pain or inflammation but with root resorption or
ankylosis was evaluated as survived autotransplanta-
tion. The transplanted tooth with more than 3 mm
of periodontal pocket by the end of the first year of
transplantation, pain in function, abnormal mobility,
infection at the recipient site during the follow-up
period was recorded as pathological and failure.
Results
All of the patients tolerated the surgical procedure
well with minor complications such as edema and
postoperative pain. Regular diet without restrictions
occurred after 10 days postoperatively for all of the
cases in this study. Eight of the autotransplanted teeth
(67%) showed satisfactory stability by the end of the
3rd month, others (33%) by the end of the 6th month
with only physiological movement. Only 1 of the trans-
planted teeth (transplantation #2) (8%) showed
bleeding on probing by the end of the 3rd-month visit
due to the periodontal plaque, which had disappeared
at the following visits. None of the other transplanted
teeth (92%) showed any sign of bleeding on probing or
plaque during their follow-up visits. The same case had
an average periodontal pocket of 3 mm until the end of
the 6th-month follow-up visit, and by the end of the
12th month the average periodontal pocket was at
the physiological limit (less than 3 mm), and at the
18th-month follow-up visit the transplanted tooth
was in occlusion. Three of the other 11 transplanted
teeth (25%) were in occlusion in the 3rd month, 5 of
them (42%) at the 6th month, and 3 of them (25%)
in the 12th month follow-up visits. The vitality of the
transplantation #2 was negative until the 18th-month
follow-up visit; however, pain in the percussion test
was also negative by the end of the 6th month postop-
eratively. Thus, we decided not to initiate a root canal
treatment for this case as it was asymptomatic. All
other 11 transplanted teeth (92%) were vital at the
3rd or 6th month follow-up visits and did not show
any pain in percussion or inflammation signs at their
3rd- or 6th-month follow-up visits and there-
after (Table 3).
Radiographically, the lamina dura of all the trans-
planted teeth (100%) could be observed at the periap-
ical radiographs at their 6th, 12th, and 18th month
follow-up visits. None of the transplanted teeth
showed any radiographic signs of root resorption or
ankylosis during the total follow-up periods
(Table 4). Panoramic radiography of 4 of the 12 cases
(33%) demonstrated complete healing of the periapi-
cal lesions by the end of the 6th month and the other
8 cases (67%) by the end of the 12th month (Fig 5)
(Table 4). (Due to the long waiting patient list, the con-
servative treatments of this case could not be
completed during the follow-up period of this study.)
In this clinical study, the mean periapical lesion diam-
eter was calculated as 1.54 cm.
The follow-up periods of the transplanted teeth in
this study were ranging from 18 to 27 months, with
a mean of 20.4 months. Three years of retrospective
data, between the years of 2016-2019, was analyzed
to collect the information on the 12 cases in this study.
Based on these results, all of the 12 autotransplanta-
tions of impacted third molars (100%) after the extrac-
tion of mandibular first or second molars with chronic
periapical lesions were successful. None of the cases
showed any radiological or clinical signs of failure dur-
ing their follow up periods.
Discussion
The success rate of tooth autotransplantation varies
mainly with case selection, surgical technique, and
postoperative care.34-36 Although it is high, this
surgical procedure has not been as popular as
expected due to the prejudice that it is a complex
 € MU
ERDEM AND GU € ŞER 7

FIGURE 4. A, The chrome cobalt CARP model of the donor tooth at the prepared alveolar socket. B, The donor tooth placed passively to the
prepared alveolar socket at the infraocclusion position. C, Surgical area sutured after the autotransplantation surgery.
Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.

treatment method. However, today with the help of
CARP it has become a straight-forward procedure
with minimal complication, risk, and failure. There
are also other factors that affect the success rate of
autotransplantation, whereas CARP is more critical
than others. Without CARP of the donor tooth,
preparing the socket at the recipient site can only be
done by the guidance of the donor tooth itself. This
will prolong the extra-alveolar time of the donor tooth
and destroy the periodontal ligaments and Hertwig
epithelial root sheath as it is going to be tried into
the new socket for several times.14,36 Thus, postoper-
ative complications such as inflammation, root resorp-
tion, and ankylosis would have been seen more
commonly. It has been shown that the reliability of
CARP is extremely high since the average discrepancy
between the CARP model and the donor tooth was
reported to be as low as 0.291 mm.37 Therefore, it
was preferred to be used in this clinical study. CARP
did not only help us preparing the recipient sites
properly, but also shorten the extra-alveolar time of
the donor teeth less than a minute for each of the 12
autotransplanted teeth involved in this study. Kim
et al reported that root resorption is mostly related to
the root surface injuries during the surgical process
rather than any other factors.36 In this retrospective,
clinical study, preoperative positions of the donor teeth
were vertical or mesioangular, and partially or fully
impacted. The position of the third molar, regarding
the removal of the tooth without injury of the periodon-
tium, will not be crucially important for an experienced
surgeon; and thus, it does not have a direct effect on the
success of autotransplantation. However, a horizontal
impacted donor third molar may be another case.
Another important factor that affects the success
rate of tooth autotransplantation is the root develop-
mental stage as it is directly related to the revasculari-
zation of the pulp and the periodontal ligaments,38-40
and thus, root resorption and ankylosis.
Revascularization of the pulp tissue by new capillary
vessels through the immature apical foramen keeps
the tooth vital after the transplantation procedure.41
Jang et al reported that immature teeth from late
stage-2 to stage-4 were recommended for
 8
Table 3. THE TABLE SUMMARIZES THE CLINICAL FOLLOW UP RESULTS OF THE PATIENTS

Periodontal Pocket
Mobility Bleeding on Probing Plaque Occlusion (Average of 6 Sites) Vitality Pain in Percussion

Transplantation # 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M 3. M 6. M 12. M 18. M

1 - - - - - - - - - - - - + + + + - - - - + + + + - - - -
2 + - - - + - - - + - - - - - - + + + - - - - - + + - - -

IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS

3 - - - - - - - - - - - - + + + + - - - - + + + + - - - -
4 - - - - - - - - - - - - + + + + - - - - + + + + - - - -
5 + - - - - - - - - - - - - - + + - - - - - + + + + - - -
6 - - - - - - - - - - - - - - + + - - - - + + + + - - - -
7 - - - - - - - - - - - - - + + + - - - - + + + + - - - -
8 + - - - - - - - - - - - - - + + - - - - + + + + - - - -
9 - - - - - - - - - - - - - + + + - - - - - + + + + - - -
10 - - - - - - - - - - - - - + + + - - - - - + + + + - - -
11 - - - - - - - - - - - - - + + + - - - - + + + + - - - -
12 + - - - - - - - - - - - - + + + - - - - + + + + - - - -

For Mobility: (-) Means Physiological Mobility, (+) Means Approximately 1 mm Mobility in Horizontal Direction. For Bleeding on Probing: (-) Means No Bleeding, (+) Means
Bleeding When Probing. For Plaque: (-) Means No Plaque, (+) Means There is Plaque. For Occlusion: (-) Means Transplanted Tooth is in Infraocclusion, (+) Means at the Occlusion.
For Periodontal Pocket: (-) Means the Average Periodontal Pocket Depth of Transplanted Tooth is Less Than 3 mm, (+) Means 3 mm or More. For Vitality: (-) Means the Vitality Test
is Negative, (+) Means Positive. For Pain in Percussion: (-) Means no Pain, (+) Means There is Pain in Percussion. M: Month.
Erdem and G€
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u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.
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Table 4. THE TABLE SUMMARIZED THE RADIOLOGICAL FOLLOW UP RESULTS OF THE PATIENTS

Presence of
Lamina Dura at
Periapical Healing of
Radiograph Periapical Lesion
Ankylosis Root Resorption
Extracted Transplanted
Transplantation # tooth # tooth # 6. M 12. M 18. M 6. M 12. M 18. M 6. M 12. M 18. M 6. M 12. M 18. M

1 18 (37) 17 (38) + + + - + + - - - - - -
2 31 (47) 32 (48) + + + + + + - - - - - -
3 31 (47) 32 (48) + + + + + + - - - - - -
4 18 (37) 17 (38) + + + - + + - - - - - -
5 30 (46) 32 (48) + + + - + + - - - - - -
6 30 (46) 1 (18) + + + - + + - - - - - -
7 18 (37) 17 (38) + + + - + + - - - - - -
8 31 (47) 32 (48) + + + - + + - - - - - -
9 30 (46) 17 (38) + + + - + + - - - - - -
10 31 (47) 32 (48) + + + + + + - - - - - -
11 18 (37) 17 (38) + + + - + + - - - - - -
12 30 (46) 32 (48) + + + + + + - - - - - -
Teeth Numbers in Parentheses are According to International Tooth Nomenclature.
For the Presence of Lamina Dura; (+) Means Lamina Dura is Present, (-) Means Lamina Dura is Absent. For the Healing of Peri-
apical Lesions; (-) Means Limited Healing of the Bone at Periapical Lesion Site With Less Radiopacity Compare to the Healthy Jaw
Bone, (+) Means Complete Healing of the Bone at the Periapical Lesion Site With the Same Radiopacity Compare to the Healthy
Jaw Bone. For Ankylosis; (+) Means Ankylosis is Present, (-) Means Ankylosis is Absent. For Root Resorption; (+) Means Root
Resorption is Present, (-) Means Root Resorption is Absent. M: Month
Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.

autotransplantation (Table 2).10 This is not only crucial
for the vitality of the transplanted tooth but also
proper alveolar bone growth without any root resorp-
tion or ankylosis.10,34,35,42 The 12 cases included in
this study were all at the stage-4 of root development,
and all of them stayed vital without any root resorption
or ankylosis during the follow-up periods. Therefore,
none of the transplanted teeth needed further end-
odontic treatment. Ankylosis of the transplanted tooth
can be challenging for future implant placement; how-
ever, as ankylosis was not observed in this clinical
study, we suggest that it is not a reason for not consid-
ering the autotransplantation procedure.
The main difference of this study from the other
similarly published ones is that in this retrospective
clinical study, all extracted teeth had untreatable
chronic periapical lesions. It is known that during
the healing process of a periapical lesion, an environ-
mentally rich new blood capillaries formation has
occurred. This might have a positive effect on pulp
and periodontal ligament revascularization of an auto-
transplanted tooth unless there is acute infection at
the recipient site. We believe this might be the
reason why periapical lesions did not cause any fail-
ure of the 12 autotransplanted teeth in this study.
Initial stability and infraocclusal positioning of the
transplanted tooth is another key point of success in
tooth autotransplantation procedure. Kim et al re-
ported a high healing ratio (87.7%) in those cases
with good initial stability.36 It is possible that initial sta-
bility with infraocclusal positioning of the donor tooth
promotes the healing process in the early stage by
contributing blood supply. The initial stability can be
established by precise socket preparation, and if
necessary, splinting the transplanted tooth to the adja-
cent teeth via wires and resin. However, splinting
should not be longer than two weeks as it will
adversely affect the healing and may cause ankylosis
or root resorption.29,42 During the late stage of heal-
ing, as root formation continued, almost all trans-
planted teeth in this study were in occlusion and
functioning properly without any sign of pain by the
end of the 12th month. Only 1 case took 18 months
to be in occlusion.
The main objective of this study was to treat the pa-
tients at related age intervals with extraction indica-
tion of mandibular first or second molars by
immediate autotransplantation of their impacted third
molars. Therefore, they will not lose their chewing
functions and be prevented from related diseases.
10 IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS

FIGURE 5. A, Panoramic radiograph taken at sixth-month follow-up visit of a patient with autotransplantation of tooth#48 to the place of tooth
#47. B, Panoramic radiograph taken at 12th-month follow-up visit. (Fig 5 continued on next page.)
Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.

In conclusion, an adolescent who is systemically
healthy and has sufficient oral hygiene can be a candi-
date for immediate autotransplantation of the imma-
ture third molar to the place of a molar tooth
requiring extraction. However, the development
stage and position/angulation of the donor tooth
and the precision surgical technique can be the limi-
tations of this treatment protocol. Another limitation
to consider is the cost and availability of the technol-
ogy to carry out the procedure to create the CARP
model of the donor tooth, which is pivotal in the suc-
cess rate of the autotransplantation procedure.
Future studies can focus on the late autotransplanta-
tion and augmentation techniques for the cases
with limited residual bone height and width of the
recipient sites.
 € MU
ERDEM AND GU € ŞER
FIGURE 5 (cont’d). C, Panoramic graph taken at 18th-month follow-up visit. D, Periapical radiograph taken at 18th-month follow-up visit.
Erdem and G€
um€
u şer. Immediate Autotransplantation of Impacted Third Molars. J Oral Maxillofac Surg 2020.
References
1. Abella F, Ribas F, Roig M, et al: Outcome of autotransplanta-
tion of mature third molars using 3-dimensional–printed guid-
ing templates and donor tooth replicas. J Endod 44:1567,
2018
2. Gupta S, Goel M, Sachdeva G, et al. Autotransplantation J Con-
serv Dent 18:500, 2015
3. Pogrel MA: Evaluation of over 400 autogenous tooth transplants.
J Oral Maxillofac Surg 45:205, 1987
4. Kim S, Lee SJ, Shin Y, Kim E: Vertical bone growth after auto-
transplantation of mature third molars: 2 case reports with
long-term follow-up. J Endod 41:1371, 2015
5. Aoyama S, Yoshizawa M, Niimi K, et al: Prognostic factors for au-
totransplantation of teeth with complete root formation. Oral
Surg Oral Med Oral Pathol Oral Radiol 114:216, 2012
6. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU:
Outcome of tooth transplantation: Survival and success rates
17-41 years posttreatment. Am J Orthod Dentofacial Orthop
121:110, 2002
7. Day PF, Lewis BRK, Spencer RJ, et al: The design and develop-
ment of surgical templates for premolar transplants in adoles-
cents. Int Endod J 45:1042, 2012
11
8. Denys D, Shahbazian M, Jacobs R, et al: Importance of root devel-
opment in autotransplantations: A retrospective study of 137
teeth with a follow-up period varying from 1 week to 14 years.
Eur J Orthod 35:680, 2013
9. Jang Y, Choi YJ, Lee SJ, et al: Prognostic factors for clinical out-
comes in autotransplantation of teeth with complete root forma-
tion: Survival analysis for up to 12 years. J Endod 42:198, 2016
10. Jang JH, Lee SJ, Kim E: Autotransplantation of immature third
molars using a computer-aided rapid prototyping model: A
report of 4 cases. J Endod 39:1461, 2013
11. Miller HM: Transplantation: A case report. J Amdent Assoc 40:
237, 1950
12. Chugh A, Aggarwal R, Chugh VK, et al: Autogenous tooth trans-
plantation as a treatment option. Int J Clin Pediatr Dent 5:87, 2012
13. Cousley RRJ, Gibbons A, Nayler J: A 3D printed surgical analogue
to reduce donor tooth trauma during autotransplantation. J Or-
thod 44:287, 2017
14. He W, Tian K, Xie X, et al: Computer-aided autotransplantation
of teeth with 3D printed surgical guides and arch bar: A prelim-
inary experience. PeerJ 6:5939, 2018
15. Ashkenazi M, Levin L: Metal tooth-like surgical templates for
tooth autotransplantation in adolescents. Dent Traumatol 30:
81, 2014
12 IMMEDIATE AUTOTRANSPLANTATION OF IMPACTED THIRD MOLARS
16. Schwartz O, Bergmann P, Klausen B: Autotransplantation of hu-
man teeth. Int J Oral Surg 14:245, 1985
17. Hernandez SL, Cuestas-Carnero R: Autogenic tooth transplanta-
tion: A report of ten cases. J Oral Maxillofac Surg 46:1051, 1988
18. Gonnissen H, Politis C, Schepers S, et al: Long-term success and
survival rates of autogenously transplanted canines. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 110:570, 2010
19. Kristerson L: Autotransplantation of human premolars. A clin-
ical and radiographic study of 100 teeth. Int J Oral Surg 14:
200, 1985
20. Lundberg T, Isaksson S: A clinical follow-up study of 278 auto-
transplanted teeth. Br J Oral Maxillofac Surg 34:181, 1996
21. Tsukiboshi M: Autotransplantation of teeth: Requirements for
predictable success. Dent Traumatol 18:157, 2002
22. Cohen AS, Shen TC, Pogrel MA: Transplanting teeth success-
fully: Autografts and allografts that work. J Am Dent Assoc
126:481, 1995
23. Hillerup S, Dahl E, Schwartz O, Hjorting-Hansen E: Tooth trans-
plantation to bone graft in cleft alveolus. Cleft Palate J 24:137, 1987
24. Czochrowska EM, Stenvik A, Album B, Zachrisson BU: Auto-
transplantation of premolars to replace maxillary incisors: A
comparison with natural incisors. Am J Orthod Dentofacial Or-
thop 118:592, 2000
25. Marques-Ferreira M, Rabaca-Botelho MF, Carvalho L, et al: Autog-
enous tooth transplantation: Evaluation of pulp tissue regenera-
tion. Med Oral Patol Oral Cir Bucal 16:984, 2011
26. Moin DA, Derksen W, Verweij JP, et al: A Novel approach for
computer-assisted template-guided autotransplantation of teeth
with custom 3D designed/printed surgical tooling. An ex vivo
proof of concept. J Oral Maxillofac Surg 74:895, 2016
27. Northway WM, Konigsberg S: Autogenic tooth transplantation.
The ‘state of the art’. Am J Orthod 77:146, 1980
28. Mendes RA, Rocha G: Mandibular third molar autotransplanta-
tion—literature review with clinical cases. J Can Dent Assoc
70:761, 2004
29. Almpani K, Papageorgiou SN, Papadopoulos MA: Autotransplan-
tation of teeth in humans: A systematic review and meta-anal-
ysis. Clin Oral Invest 19:1157, 2015
30. Andreasen JO: Challenges in clinical traumatology. Dent Trauma-
tol 1:45, 1985
31. Andreasen JO, Paulsen HU, Yu Z, et al: A long-term study of 370
autotransplanted premolars. Part II. Tooth survival and pulp
healing subsequent to transplantation. Eur J Orthod 12:14, 1990
32. Bavitz JB: Autotransplantation of teeth: A procedure that gets no
respect. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110:
441, 2010
33. Bae JH, Choi YH, Cho BH, et al: Autotransplantation of teeth
with complete root formation: A case series. J Endod 36:1422,
2010
34. Moorrees CFA, Fanning EA, Hunt EE: Age variation of formation
stages for ten permanent teeth. J Dent Res 42:1490, 1963
35. Kallu R, Vinckier F, Politis C, et al: Tooth transplantations: A
descriptive retrospective study. Int J Oral Maxillofac Surg 34:
745, 2005
36. Kim E, Jung JY, Cha IH, et al: Evaluation of the prognosis and causes
of failure in 182 cases of autogenous tooth transplantation. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 100:112, 2005
37. Lee SJ, Jung IY, Lee CY: Clinical application of computer-aided
rapid prototyping for tooth transplantation. Dent Traumatol
17:114, 2001
38. Kumar R, Khambete N, Priya E: Successful immediate autotrans-
plantation of tooth with incomplete root formation: Case report.
Oral Surg Oral Med Oral Pathol Oral Radiol 115:16, 2013
39. Bauss O, Zonios I, Rahman A: Root development of immature
third molars transplanted to surgically created sockets. J Oral
Maxillofac Surg 66:1200, 2008
40. Chung H, Kim M, Yang W, Ko H: An interesting healing outcome
of a replanted immature permanent tooth: A case report. Dent
Traumatol 27:77, 2011
41. Kaku M, Shimasue H, Ohtani J, et al: A case of tooth autotrans-
plantation after long-term cryopreservation using a pro-
grammed freezer with a magnetic field. Angle Orthod 85:518,
2015
42. Bauss O, Zonios I, Engelke W: Effect of additional surgical pro-
cedures on root development of transplanted immature third
molars. Int J Oral Maxillofac Surg 37:730, 2008