Long-Term Outcomes of Autotransplantation of Teeth: A Case Series

2018 MEETING OF THE WORLD CONGRESS ON DENTAL
Mitsuhiro Tsukiboshi, DDS,

TRAUMATOLOGY
PhD,* Nozomu Yamauchi, DDS,
MS,† and Yosuke Tsukiboshi,
Long-term Outcomes of
DDS*
Autotransplantation of Teeth:
A Case Series
ABSTRACT
SIGNIFICANCE
The aim of autotransplantation of teeth (ATT) is to replace a lost tooth with a functional tooth
Autotransplantation of teeth within the same patient. Although it has recently become more of a recognized and viable
can be a beneficial, long-term treatment approach in dentistry, the long-term outcomes are still not well-documented. The
treatment alternative for principal author (M.T.) has performed more than 1000 ATTs for reasons such as treating
patients who have teeth with a missing teeth, deep caries, poor endodontic results, and periodontitis over the past 30 years
poor prognosis or missing in private practice. During the course of private practice, 2 separate analyses were performed
teeth. on a total of 319 cases with follow-up ranging from 2–26 years. The results showed a
tendency toward higher success rates in younger patients; the success rate was highest in
ATTs performed on immature teeth (about 95%), about 90% in patients younger than 30 years
of age and approximately 80% in patients older than 30. The failures were most often caused
by replacement resorption (ie, ankylosis-related resorption). The purpose of this case series
was to show successful long-term outcomes of ATT as well as to provide clinical insights and
describe tendencies noted over the course of 30 years of performing ATTs. (J Endod
2019;45:S72–S83.)
KEY WORDS
Autotransplantation of teeth; pulp revascularization; reattachment; root resorption
Autotransplantation of teeth (ATT) has been performed for centuries, but its popularity has varied over the
years because of unpredictable results1–9. However, with recent advancements in technology and better
biological understanding, ATT has become more predictable. Yet, many clinicians are still not confident
about this technique, in part because of the lack of studies on the long-term outcomes of these cases.
The principal author (M.T.) has performed more than 1000 ATTs since 1987 in general private
practice. Almost all of the cases were carefully recorded with photographs and radiographs in a
standardized manner, and many were followed long-term. Here, the authors provide a case series
showing long-term successful outcomes of ATT and general observations and tendencies noted
throughout 30 years of performing ATTs in private practice.
Case 1
From *Private Practice, Aichi, Japan, and The patient was a 16-year-old female at the initial examination. Her chief complaint was with the
†
Private Practice, Honolulu, Hawaii mandibular right second premolar, which erupted ectopically on the lingual aspect (Fig. 1A). Extraction of
Address requests for reprints to Dr the tooth was indicated, but a congenitally missing tooth (the mandibular left second premolar) was
Mitsuhiro Tsukiboshi, Tsukiboshi Dental observed on the contralateral side, which had been restored with a fixed bridge (Fig. 1B). The root
Clinic, 6-8, Gakuto, Kaniechou, Amagun, development of the mandibular right second premolar was around stage 4, which is considered an ideal
Aichi 497-0050, Japan.
stage as a donor tooth for ATT. After discussion of the risks, benefits, and options, transplantation of the
E-mail address: moonstar@guitar.ocn.ne.
jp premolar into the aplasia site was performed.
0099-2399/$ - see front matter After anesthesia of the donor and recipient sites, the bridge was sectioned, and the approximate
© 2019 John Wiley & Sons A/S and recipient socket was formed. The donor tooth was extracted (Fig. 1C) and tried in the socket. This case
American Association of Endodontists. was performed 25 years ago, and the techniques used then have changed over the years. A more
This article is being published concurrently contemporary way of ATT therapy includes cone-beam computed tomographic (CBCT) analysis and
in Dental Traumatology. The articles are preparing 3-dimensional replicas to reduce the extraoral time and the potential damage to the periodontal
identical. Either citation can be used when
citing this article.
ligament (PDL) of the donor tooth. In this case, the adjustment of a recipient socket was made until the
https://doi.org/10.1016/ donor tooth could be placed into the appropriate position (Fig. 1E). The gingival flap was closed tightly
j.joen.2019.05.016 around the transplant. The donor tooth was splinted with the suture strings, and the wound was covered
S72 Tsukiboshi et al. JOE Volume 45, Number 12S, December 2019
Descargado para Anonymous User (n/a) en Pontifical Xavierian University de ClinicalKey.es por Elsevier en marzo 10, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.
with a surgical dressing for 4 days (Fig. 1D). female (Fig. 3A). The left second molar was 2 weeks after the surgery, and the obturation
However, in cases in which the mobility of a replaced through ATT of the adjacent, was completed with sealer and gutta-percha 4
transplant is high, more rigid splinting with wire impacted, mandibular left third immature molar weeks after the ATT. The transplanted tooth
and resin is applied for another 3 weeks after (Fig. 3B). Successful PDL and pulp healing was was followed for 30 years and showed no
removing the suture splinting. noted at the 12-year follow-up, but the root complications throughout (Fig. 6C and D).
In ATT of immature teeth, a radiograph development was likely arrested (Fig. 3C
is taken every month for the first 3 months to and D). Case 7
monitor for possible inflammatory resorption or A 17-year-old female presented with an
pulp necrosis (Fig. 1F [also see Fig. 7]). If no Case 4 ectopically impacted, maxillary second
pulp pathosis is observed, the next radiograph A 45-year-old woman suffered a crown-root premolar. The retained primary tooth was
will be taken about 6 months after ATT fracture of the maxillary left first molar (Fig. 4A). extracted, and ATT of the second premolar
(Fig. 1G) and every 2–3 years thereafter The tooth was extracted, and the impacted was performed and repositioned (Fig. 7A and
(Fig. 1G–I). Electric pulp testing (EPT) of the maxillary left third molar was transplanted 3 B). Two months later, the transplant showed
donor teeth will usually become positive 6–12 weeks later (Fig. 4B and C). Because of the signs of inflammatory resorption (Fig. 7C), and
months after the surgery, and pulp canal pneumatization of the sinus floor, sinus endodontic treatment was initiated (Fig. 7D).
obliteration and root development will likely elevation via a crestal approach was The necrotic pulp space was cleaned and filled
occur over time (Fig. 1G–J). performed simultaneously with ATT (Fig. 4D). with calcium hydroxide (Vitapex; Neo Co,
Because the donor tooth had complete root Tokyo, Japan). The root filling with sealer and
formation, root canal treatment (RCT) was gutta-percha was completed 17 years after the
Case 2
necessary. The RCT was initiated 2 weeks ATT because the patient visited irregularly.
A typical indication for ATT is found in
after the surgery, and after instrumentation and Healing was followed for 24 years and showed
compromised cases of poor endodontic and
cleaning of the canal space, calcium hydroxide no evidence of further resorption or
restorative treatments. An 18-year-old man
was placed. Two weeks later, the obturation complications (Fig. 7E–G).
presented for evaluation of the mandibular
was completed with sealer and gutta-percha
right first molar, which suffered tooth fracture
(Fig. 4E). The restoration of the crown was Case 8
and infection of the root canal system with
performed with composite resin 4 months after In this case, the mandibular left first molar had
chronic apical periodontitis (Fig. 2A and B).
surgery (Fig. 4F). The patient was reviewed an unfavorable prognosis and was replaced
Fortunately, he had preserved the mandibular
every 4 months thereafter. Other than with the maxillary left third molar in a 46-year-
right third molar, which seemed to have
replacing the composite resin, there were no old man (Fig. 8A and B). Unfortunately, the
favorable root form and root development
other issues over the 15 years of follow-up transplanted tooth developed ankylosis-
(Fig. 2A) as a donor tooth for ATT. After
visits (Fig. 4G and H). related resorption, but the resorption
discussion of the risks, benefits, and options,
ATT was accepted and performed (Fig. 2C). progressed very slowly (Fig. 8C–F) over the 13
The case was followed for 14 years, and no Case 5 years of follow-up.
clinical abnormalities were observed. A CBCT A mandibular left first molar was deemed to
study at a 10-year follow-up visit (Fig. 2G) have an unfavorable prognosis because of
DISCUSSION
showed the development of the mesial root severe periodontitis with a large bony defect
was likely arrested and healed via inner PDL (Fig. 5A and B). The tooth was replaced with ATT was first documented by a French
formation. The distal root appeared to develop the impacted maxillary left third molar (Fig. 5C physician, Pierre Fauchard, in his book Le
normally, and there was a positive response to and D). The donor tooth was placed deeply Chirurgien Dentiste published in 1728 in which
EPT throughout the 14 years. into the recipient socket because the bony he surgically moved a tooth from 1 site to
defect was very large. The transplant was left another in the same individual10. In the early
In ATT, the size of a donor and the
to erupt naturally for 2.5 months. However, it 1950s, ATT was popular to replace decayed
recipient are usually different, and it appears
did not erupt sufficiently (Fig. 5E–G), and first molars with impacted, very immature third
to be beneficial if the donor is placed in an
orthodontic extrusion was performed. The molars1–6 but fell out of favor because of the
infraocclusal position to avoid occlusal
transplanted tooth was extruded in 1 month low success rates at the time (about 50%)11.
adjustment. That is why some spaces are
(Fig. 5H). A radiograph 8 years later showed However, the clinical and experimental studies
observed interproximally and occlusally after
resolution of the previous large bony defect on ATT over the last 40 years have shown that
the surgery (Fig. 2D and E). However, those
(Fig. 5I and J). A CBCT study showed ATT can be a more predictable treatment
spaces will naturally close in many cases
resolution of the radiolucency consistent with option in dental therapy9,12,13. As shown in
(Fig. 2F). This is a great advantage and
successful healing and bone regeneration Figures 1 and 2, optimal healing can be
benefit of ATT; the transplanted teeth move
around the transplant (compare Fig. 5E–G and achieved in the transplantation of immature
naturally to adapt to the surrounding
K–M). teeth where PDL healing, pulp healing, and
dentition and can also be moved
root development are expected.
orthodontically because of maintenance of a
Case 6
viable and functional PDL.
A mandibular left first molar of a 39-year-old PDL Healing and Root Resorption
patient had a very poor prognosis and was The most critical factor for the success of ATT
Case 3 replaced with the mandibular third molar is the presence of a viable PDL on the root
Extensive resorption of a mandibular left (Fig. 6A and B). Because the donor tooth had surface of transplanted teeth (donor teeth),
second molar was seen in a 17-year-old complete root formation, the RCT was initiated regardless of whether or not the transplanted
JOE Volume 45, Number 12S, December 2019 Autotransplantation of Teeth S73
FIGURE 1 – An aplasia. (A ) A radiograph of a donor tooth of a 16-year-old female. She wanted the extraction of the mandibular right second premolar, which was a good candidate for
autotransplantation. (B ) A radiograph of the recipient site. The mandibular left second premolar was congenitally missing. ATT was suggested and accepted after discussion about the
options available. (C ) The extracted donor tooth. The PDL and dental papilla were nicely preserved around the root. (D ) The clinical view immediately after the transplantation. The
transplant was rotated 90 because the recipient ridge was narrow. The tooth was fixed with suture strings. (E ) A radiograph immediately after the surgery. Note the apex was wide
open, and the root development was incomplete. (F ) A radiograph 3.5 months later. No root resorption was observed. (G ) Eight months postoperative. Slight calcification (pulp canal
obliteration [PCO]) seemed to be taking place. The transplant showed positive EPT. (H ) A radiograph at the 2-year follow-up. PCO and root development were obvious. (I ) Thirteen years
later. No resorption was observed. (J ) A radiograph taken 25 years after the transplantation. No complication was observed.
FIGURE 2 – Tooth fracture and compromised endodontic result. (A ) A partial panoramic view around the surgery site. A mandibular right first molar of an 18-year-old man who
suffered tooth fracture and compromised endodontic results. He had preserved an appropriate donor tooth, the mandibular right third molar, to replace the first molar. (B ) A clinical view
at the first examination. (C ) A radiograph immediately after the transplantation. The transplantation was performed 3 weeks after the extraction of the first molar. (D ) A clinical view
taken 2 weeks later. There were some spaces left on the occlusal and mesial aspect because the transplant was placed a little deeper into the recipient socket to avoid occlusal
adjustment. The width of the crown of the donor tooth was smaller than the recipient mesiodistal width. (E ) A radiograph at the 4-year follow-up. PCO of the transplant was progressing,
and EPT was positive. (F ) A clinical view after 4 years. (D ) The spaces observed at the 2-week follow-up were completely closed. (G ) A sagittal appearance of CBCT scanning 10 years
after surgery. The distal root of the transplant developed almost completely, but the mesial root development was arrested and a healing termed “inner PDL” was observed. (H ) A
radiograph at the 14-year follow-up. The EPT was positive, and no problems were observed.
FIGURE 3 – External root resorption. (A ) A partial panoramic view around the surgical site of a 17-year-old female. The mandibular left second molar was involved in severe external
root resorption. ATT using the mandibular left third molar as a donor was considered to be the best option for this situation. (B ) A radiograph immediately after the transplantation in
which the extraction of the tooth in the recipient site was performed at the same time. (C ) Three years later. PCO was progressing, and EPT was positive, but there was little root
development. (D ) Twelve years postoperatively. No problem was observed, except the arrested root development of the transplant.
tooth is immature or mature14–16 (Figs. 1, 3–7). root resorption is very slow in adult patients, 6 months. Such a pulp healing response can
If the PDL is compromised or damaged during even such teeth will maintain their function for a be expected when the diameter of the apical
the surgical procedures or healing process, long time (Fig. 8C–F). The main reason for foramen is radiographically 1 mm or larger12.
several types of root resorption may failures observed with ATT is AR, which Sometimes, although rare, there are cases in
develop15–23 including repair-related appears to happen more frequently in older which the PDL and bone cells appear to invade
resorption, infection-related resorption (IR), patients. the pulp space. This type of pulp healing is
ankylosis-related resorption (AR), or invasive The mechanism of invasive cervical called “inner PDL” healing, but no treatment is
cervical resorption. resorption is not well understood19,20, but it necessary (Fig. 3G).
Repair-related resorption is arrested can be treated by flap surgery or orthodontic
resorption, and no treatment is necessary. IR extrusion followed by curettage and
is caused by the damage of a small part of the restoration of the defect if the resorption is Root Development
PDL and pulp infection22,23 (Fig. 2A). Because accessible and in its earlier stages in order to Continued root development after
IR usually takes place within 3 months after benefit long-term tooth retention25,26. transplantation also can be expected if a donor
transplantation (Fig. 2B and C) and tooth is immature and the Hertwig epithelial
progresses fairly rapidly regardless of the age sheath is intact13,30-32 (Fig. 1). However, the
of the patient, a radiograph should be taken Pulp Healing extent of root development cannot be
every month during the first 3 months to Pulp healing is expected after transplantation predicted solely based on the stage of root
monitor for signs of IR. Once signs of IR are of immature teeth12 (Figs. 1, 3, and 4). The development of the donor tooth or controlled
detected, RCT should be performed as soon healing is likely by revascularization27–29. Blood by surgical techniques13 (Fig. 4). Because root
as possible (Fig. 2D). IR will heal naturally after capillaries can invade the pulp canal through development is unpredictable, it is suggested
RCT (Fig. 2E–G) if the resorption area is the large apical foramen, supplying nutrients to that donor teeth should be at a root
small24. invading cells that will eventually fill the pulp development stage between stages 4 and 6
AR does not have any known space. Those cells usually cause rapid pulp where pulp healing is expected as well. Even if
predictable treatment. The roots are resorbed canal obliteration (calcification inside of canal the root development is arrested, the crown-
and replaced with bone eventually15,16,18 spaces), and the teeth will typically respond root ratio does not affect the prognosis of the
(Fig. 8). However, because the speed of the positively to sensibility tests for approximately transplant from the clinical point of view.
FIGURE 4 – A transplant with sinus elevation. (A ) A radiograph at the first examination of a 45-year-old woman. The chief complaint was the maxillary left first molar, which suffered
crown-root fracture and caused pain. The tooth had a poor prognosis because the fracture was running so deeply up to the sinus. She fortunately preserved a candidate, the maxillary
left third molar, for ATT. (B ) The extracted third molar for the transplantation, which was performed 3 weeks after the extraction of the first molar. (C ) The clinical appearance just after
surgery. (D ) A radiographic view immediately after the transplantation. Note the transplant was place deeply into the sinus after the sinus membrane was elevated carefully. No graft
material was placed. (E ) A radiograph taken 4 months later. The RCT of the transplant was initiated 2 weeks after the surgery and finished 4 weeks later. (F ) A clinical picture taken 4
months after the transplantation and immediately after the restoration with composite resin. The crown of the transplant and the adjacent teeth were restored with composite resin at
the same time. (G ) Nine years later. No problem was observed, and the root of the transplant was nicely surrounded with bone. (H ) The 15-year follow-up. The patient was satisfied
with the esthetic and functional result.
FIGURE 5 – Advanced periodontitis. (A ) A panoramic view of a 46-year-old woman before treatment. The mandibular left first molar was hopeless because of advanced periodontitis.
Fortunately, she preserved the maxillary right third molar as a candidate for transplantation. (B ) A radiograph before treatment. (C ) The extracted third molar for transplantation. (D ) A
radiograph immediately after ATT. The transplant was placed as deep as possible to ensure the PDL and bone healing. The transplanted tooth was left to erupt naturally thereafter.
(E–G ) CBCT appearance taken 2.5 months after the surgery and just before orthodontic eruption. The (E ) axial view and (F ) coronal view showed the root was located slightly out of the
socket and was not covered with bone. (H ) A radiograph taken 3.5 months after the transplantation and 1 month after orthodontic extrusion. The transplant was extruded almost out of
the socket. (I ) Two years later. Remarkable bone regeneration around the transplant was observed. (J ) Eight years 2 months later. The bone healing was maintained. (K–M ) CBCT
pictures taken 8 years 2 months postoperatively. It is obvious that bone had regenerated and maintained 3-dimensionally around the transplant (compare with E–G ).
FIGURE 6 – Thirty years of follow-up. (A ) A radiograph before treatment of a 39-year-old woman. The mandibular left first molar was deemed to have an unfavorable prognosis and
was replaced with the mandibular left third molar. (B ) Three months after ATT and just after fabricating the crown. (C ) A radiograph at the 15-year follow-up. (D ) Thirty years after ATT.
No problem was observed, and normal function was maintained.
Bone Healing (Bone Induction) principal author (M.T.) has gained knowledge better prognosis (ie, PDL healing) in ATT of
An advantage of ATT is bone healing (bone and considerable experience of ATT. An younger patients, and the main risk or
induction) (Figs. 5 and 6). A viable PDL of the analysis of 190 consecutive cases was complication is that of root resorption. We are
transplanted tooth is capable of inducing and conducted in 199343. The mean age of the still in the process of obtaining long-term data
maintaining alveolar bone. PDL-resident stem patients was 37 years, and the mean follow-up on these and other patients. A more extensive
cells can differentiate into 3 types of cells: period was 5.6 years. The criteria for success study and data collection will be the subject of
fibroblasts, cementoblasts, and osteoblasts. was the absence of progressive root another study.
Differentiated osteoblasts may form bone resorption or pocket formation. The survival
around the transplant33–37. Bone induction or rate was 90%, and the success rate was
regeneration can be observed in the recipient 77.9%. Since the 1990s, more improvements Clinical Implications
socket along with the emergence of the lamina in technology (eg, the use of CBCT image- Many clinicians may compare transplants with
dura around the transplant (Figs. 5 and 6). guided therapy, 3-dimensional printing of teeth implants because the 2 techniques have
The growth of the jaws is related to to help reduce trauma and dry time of the similar purposes. Implants have a wide range
tooth eruption38,39, and the morphology of donor, and so on), and experience of of uses and applications, whereas transplants
alveolar bone is partly maintained by the treatments have helped improve the success are limited to those who have appropriate
teeth40–42. The PDL of teeth plays an of ATT. donor teeth. The surgical treatment aspects of
important role in bone remodeling. PDL also A second analysis of 129 teeth was transplantation are more technique sensitive
plays a critical role in long-term dentition performed in 2013. The mean age of the compared with most implant cases. However,
changes and movements that occur patients was 30 years, and the mean follow- the postsurgical restorations are most often
throughout life. Many important biological up period was 10.2 years. The observed simpler for transplants than those of implants.
aspects of alveolar bone formation are partly survival rate was 94.6%, and the success rate In the case of osseointegrated implants,
regulated by the PDL, and these can be was 85.3%. It was observed that those they do not erupt nor move along with adjacent
expected in teeth that have undergone ATT younger than 30 years of age had higher teeth, especially in younger patients, and this
(Figs. 3, 5, and 6). success rates (around 92%), whereas those can lead to infraocclusion with functional and
older than 30 years had lower success rates esthetic problems. On the other hand,
(around 80%). The main reason for failures transplanted teeth can erupt and move in
Long-term Follow-up and General observed was the development of AR. harmony with the adjacent teeth. Even if some
Observations Transplantation of immature teeth showed spaces to the adjacent teeth and the opposing
Over the past 30 years of clinical practice around a 95% success rate. The data teeth are left after the surgery, they will likely
performing more than 1000 ATT cases, the collected from the cases are suggestive of a close naturally. In the transplantation of
FIGURE 7 – Inflammatory root resorption. (A ) A radiograph before treatment of a 17-year-old female. The maxillary left second premolar was impacted. The patient chose a tooth
alignment by ATT instead of conventional orthodontics because of financial reasons. (B ) Immediately after the surgery. (C ) A radiography taken 2 months later. Inflammatory resorption
was observed on the mesial aspect of the transplant. (D ) A radiograph taken just after RCT and the same day as C. The necrotic pulp was removed, and the canal was filled with calcium
hydroxide. (E ) A radiograph taken 1 year later. The resorption seemed to be arrested. The root developed slightly. (F ) A radiography taken 10 years later. The resorption did not progress
and the root developed. (G ) A radiograph at the 24-year follow-up. Inflammatory root resorption can be stopped if it is found early and the pulp infection is controlled immediately.
immature teeth, restoration of the crowns is using a membrane or bone graft materials is teeth are possible with relatively low risks and
seldom required. not necessary. Transplants have the high benefits, ATT should be taken into
When patients have a tooth with an potential for superior esthetic results consideration before other treatment
unfavorable prognosis or congenitally because the natural emergence profile as alternatives when there is an appropriate donor
missing teeth and an appropriate donor well as the natural color and form of the tooth available.
tooth is preserved, transplants have several enamel and crown are maintained. Usually,
advantages over implants in terms of the total cost of transplantation is
function, esthetics, time, and cost. Healing is significantly lower than that of implant
ACKNOWLEDGMENTS
rapid because of the viable PDL, even if there treatment.
is a large bony defect in the recipient site. Given that predictable and successful The authors deny any conflicts of interest
Ridge augmentation of recipient sockets long-term outcomes of autotransplantation of related to this study.
FIGURE 8 – Ankylosis. (A ) A radiograph before treatment of a 46-year-old man. A mandibular left first molar had a poor prognosis and was replaced with the maxillary left third molar.
(B ) A radiograph immediately after ATT. (C ) A radiography 1 year later. The healing looked normal. (D ) A radiography 2 years later. Ankylosis of the transplant was obvious because no
PDL space or tooth mobility was observed. (E ) A radiography 7 years later. The root was eventually replaced by bone. (F ) A radiograph at the 13-year follow-up visit. The speed of AR is
very slow in adult patients.
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Long-Term Outcomes of Autotransplantation of Teeth: A Case Series

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2018 MEETING OF THE WORLD CONGRESS ON DENTAL

Mitsuhiro Tsukiboshi, DDS,

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