European Jomd of Orthodmtks 12 (1990) 3S-5O © 1990 European Orthodontic Society

A long-term study of 370 autotransplanted premolars.

Part IV. Root development subsequent to
transplantation
J. 0. Andreasen,1 H. U. Paulsen,2 Z. Yu3 and T. Bayer4
'Department of Oral Surgery and Oral Medicine, University Hospital (Rigshospitalet), Copenhagen,
Denmark department of Orthodontics, Municipal Dental Health Service, Copenhagen, Denmark 3Faculty
of Stomatology, Beijing, China 'Statistical Research Unit, University of Copenhagen, Denmark

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SUMMARY The purpose of the present study was to analyse the extent of root development
subsequent to transplantation in a material of 370 transplanted premolars. Before transplantation,
the grafts were classified according to stage of root development (i.e. quarters of root length and
constriction of the apical foramen) and length of tooth development (measured in mm from the
cusp tip to the apical foramen). At radiographic controls the extent of root formation was
registered. These figures were compared to the final tooth length of 288 non-transplanted
premolars from the present material as well as to tooth length determinations of 534 premolars
extracted for orthodontic purposes. Furthermore, intra-individual and inter-individual differences
in tooth length were examined in a skull material with 40 pairs of premolars. These method studies
indicated that root growth was probably determined genetically with great right-left accuracy and
variation related to location of premolar (maxilla or mandible) and sex. A statistical analysis of the
transplant material revealed that stage as well as length of tooth development assessed prior to
transplantation were significantly related to final tooth length after transplantation. In most cases
of transplantation performed at early stages of root development, a reduction in the final root
length was seen. When a qualitative analysis of root development was performed in teeth with
incomplete root formation at the time of transplantation, and where a homologous non-
transplanted premolar was present, it was found that 14 per cent showed total arrest of root
formation, 65 per cent partial arrest whereas 21 per cent showed no arrest (i.e. normal root
formation). Premolars in ectopic position in the mandible before transplantation showed a
significantly reduced root growth compared to matched pairs with normal position of the tooth
graft. The present study indicated that no, partial or total damage to the Hertwig's epithelial root
sheath was probably the explanatory factor for variations in root growth.

Introduction material of 100 transplanted teeth published by

Autotransplantation of premolars usually
implies surgical removal at a time of incomplete
root formation. Subsequent.to.transplantation it
is expected that continued root growth of the
premolar takes place. So far; limited information
exists upon this aspect of premolar transplan-
tation. In premolar transplantation with incom-
plete root formation, it has been shown that a
certain reduction in root growth takes place,
amounting to an average of 1.3 mm in a study of
34 transplanted ^premolars published by Slags-
void and Bjercke (1974) and 0.5 to 3.9 mm in a
Kristerson (1985). Only a few clinical factors
have so far been found to influence root develop-
ment after transplantation. These include the
stage of root development and whether the tooth
germ is ectopically placed before transplantation
(Kristerson 1985). Furthermore, a superficial
position of the transplant in its socket has been
found both clinically and experimentally to
result in reduced root growth (Apfel, 1950; Clark
et al 1955; Singh and Dudani, 1970; Kristerson
and Andreasen, 1984).
It is known that root growth is dependent
upon the coordinated activity of the Hertwig's
AUTOTRANSPLANTED PREMOLARS. PART IV
epithelial root sheath and pulpal and periodontal
ligament cells (Andreasen et al., 1988). In this
combination of tissues, the Hertwig's epithelial
root sheath has the dominating role. Based on
present knowledge about the function of the
Hertwig's epithelial root sheath the following
possibilities appear to exist for the activity of this
structure after transplantation and thereby root
growth: it continues unaffected by the transplan-
tation procedure or a partial or total arrest of
root development occurs (Andreasen et al.,
1988).
The purpose of the present study was to
examine the following items:
1. The effect of autotransplantation of premolar
tooth germs on further root growth (i.e. whether
unimpeded or partially or totally arrested).
2. To identify developmental or surgical factors
related to possible root growth disturbances.
Material and methods
The material consisted of 370 premolars auto-
transplanted at varying stages of root develop-
ment. The details of this material including the
surgical and follow-up procedure has been de-
scribed previously (Andreasen et al., 1990).
The stage of root development was divided
into 6 groups according to a qualitative classifi-
cation by Morrees et al (1963).
Stage 1: initial to one-quarter root formation
Stage 2: one-half root formation
Stage 3: three-quarter's root formation
Stage 4: full root formation with open apical
foramen
Stage 5: full root formation with half-open
apical foramen
Stage 6: full root formation with closed apical
foramen
Root development was also evaluated quanti-
tatively (in mm tooth length) on radiographs
taken immediately before transplantation (preo-
perative radiographs) or immediately after trans-
plantation (postoperatively or one week after
transplantation). Furthermore quantitative root
development was analysed using the same cri-
teria at follow-up examinations 2 and 6 months
and 1, 2, 5 and 10 years after transplantation.
All radiographs were taken with a standar-
dized right angle, long cone technique using a
Rinn film-holder for premolars and molars
39
(Rinn Corp., Illinois, USA), with a film-focus
distance of 36.5 mm and an object-film distance
of 1.5 cm. The geometry of this combination
resulted in a 3.7 per cent enlargement of tooth
dimensions on the radiographs.
All radiographs were exposed at 65 kVp and
radiographic quality and consistency in film
processing in a Pantomat® film processor (Sie-
mens, Reiniger Werke, AG, Erlangen, West
Germany) were controlled daily with test films.
A magnifying viewer providing a 2.5 x magni-
fication was used in all radiographic evaluation.
A digital sliding caliper (PAV electronic work-
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shop caliper, PAVA, Liechtenstein) was used for
all measurements to 0.01 mm and rounded to 0.1
mm. The precision and accuracy of this method
have been described previously (Andreasen et al.,
1990). The tooth length was defined as the
distance from the cusp tip to the apex. The
position of the graft in relation to the marginal
socket wall after transplantation was defined as
the length of the perpendicular line from the cusp
tip to a line .connecting the mesial and the distal
interdental bone septum (Fig. 1).
Ectopic position of the potential tooth graft
was in this study classified into two categories:
Grade 1 comprised cases with an approximate 45
degrees tilting of the axis of the graft away from a
normal position, grade 2 comprising cases with
approximate tilting of 90 degrees or more.
As a general reference for the extent of com-
pleted tooth formation, radiographs taken of 288
non-transplanted premolars from the present
material extracted were used, supplemented by
Figure 1 Measures used to characterize tooth length and
graft position in relation to the cervical bone margin. L
indicates tooth length and P the graft position.

534 premolars. These teeth were extracted in
young individuals for orthodontic reasons and
had all completed root development with no
occlusal attrition. The lengths of these teeth were
measured with a sliding ca'liper to the nearest
0.01 mm.
To examine the intra-individual and inter-
individual differences in tooth length, skull
material was examined where the tooth length of
40 pairs of premolars could be measured. Details
of this material has been reported previously
(Andreasen et al., 1990). In 21 pairs of premolars
no wear of the cusp tips had occurred whereby an
intra-individual analysis of both the real tooth
length and the radiographic tooth length could
be made. The same teeth were then used in an
inter-individual analysis by pairing premolars of
similar types but originating from different
skulls.
Statistical approach
The statistical strategy of the root growth analy-
sis was to undertake both a qualitative and
quantitative analysis of root growth after trans-
plantation, and relate this to various clinical
variables at time of transplantation such as stage,
extent and position of the transplant before
transplantation as well as other parameters such
as sex, age, surgical difficulty and status of the
graft before transplantation. In the quantitative
analysis of the average final root length after
completion of root growth was compared among
the various clinical parameters registered.
In order to examine the influence of graft
O.d. 1 week
Figure 2 No arrest of root formation after transplantation of a second maxillary premolar compared to a homologous control.
J. O. ANDREASEN ET AL.
position in the socket to later root development
and reduce the background 'noise' from other
associations to clinical factors a subgroup of 82
teeth was examined where bilateral symmetric
premolar transplantations were carried out. In
these cases the position of the graft in relation to
cervical bone margin and the final tooth length
was recorded. Differences in the position of the
two transplants were then related to differences
in subsequent root development.
In order to examine the effect of ectopic
position upon subsequent root growth at the
same time as the factor tooth length is controlled
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a paired approach was made. 39 ectopically
positioned premolars with completed root for-
mation at last examination were paired with
normally positioned premolars of the same type
with similar preoperative tooth lengths. In this
way a paired analysis could be made of 16 ectopic
second mandibular premolars and 23 ectopic
second and first maxillary premolars. In the
paired analysis a one tailed t test was used on the
assumption that ectopic position led to equal
root growth compared to normally positioned
grafts, and the alternative hypothesis being
reduced root growth.
In order to make a qualitative analysis of root
growth subsequent to transplantation a sub-
group of 186 transplants was examined where
due to the presence of non-transplanted homolo-
gous controls three root growth events could be
examined (i.e. uninterrupted, partial or total
arrest). These transplants all fulfilled the follow-
ing criteria: a non-transplanted homologous
2 years 2 years
AUTOTRANSPLANTED PREMOLARS. PART IV
2 months 2 years
Figure 3 Total arrest of root formation of a transplanted second maxillary premolar.
O.d. 2 months
Figure 4 Partial arrest of root formation subsequent to transplantation of an ectopic positioned premolar compared to a
homologous control.
premolar present, root development incomplete
at time of transplantation and completion of
root formation at the last control.
The definitions for disturbances in root
growth were the following. No arrest was regis-
tered when the transplant reached approxima-
tely the same length or more as the non-
transplanted antimere (Fig. 2). Included in this
definition was a deviation of +1 mm. for the
transplanted tooth to compensate for the com-
bined error of exposure and measuring technique
(Andreasen et ai, 1990), as well as intra-indi-
vidual right and left differences in tooth length
development (see later). Total arrest was
recorded when the transplant showed no further
root formation (Fig. 3). Included in this defini-
tion was also a deviation of ± 1 mm which also
amounted to the above-mentioned errors. Partial
arrest was registered when root formation could
41
5 years 10 years
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3 years 3 years
not be classified as either no arrest or arrested
(Fig. 4).
Results
The normal premolar tooth length of non-
transplanted premolars was estimated from two
sources namely 288 radiographically examined
non-transplanted premolars and 534 extracted
premolars from the Department of Dental Ana-
tomy, Dental College, Copenhagen. The result of
this analysis is shown in Table 1. In order to
make radiographic and clinical figures compar-
able, the radiographic enlargement factor of 3.7
per cent was added to the latter figures. A
comparison of these figures using /-tests showed
that the root lengths among the two groups of
teeth showed no significant differences. How-
ever, a significant difference could be found
42 J. O. ANDREASEN ET AL.

Table 1 Mean tooth length of extracted premolars from a Danish

population sample (extracted teeth) and non-transplanted premolars
(control teeth) in the present material.

Tooth location Source of material n x s .d.

Maxillary first premolar Extracted teeth 154 21.4 .9

Extracted teeth corrected 154 22.7 .9
Control teeth 39 22.4 .4
Maxillary second premolar Extracted teeth 161 21.5 .9
Extracted teeth corrected 161 22.2 .9
Control teeth 174 22.8 :2.0
Mandibular first premolar Extracted teeth 107 22.5 .6
Extracted teeth corrected 107 23.3 .6

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Control teeth 44 23.5 .3
Mandibular second premolar Extracted teeth 112 22.5 .6
Extracted teeth corrected 112 23.3 .9
Control teeth 31 23.0 .9

•Tooth length increased with the radiographic enlargement of 3.7% and 6.4% used
in the present study for mandibular and maxillary teeth respectively, in order to make
the two materials comparable.

Table 2 Tooth length of 21 pairs of premolars (skull material) analysed for intra- and inter-individual variation.

Radiographic values True values

Mean Mean Mean Mean

tooth length difference tooth length difference
(mm) (mm) (mm) (mm)

X| s.d. X2 s.d. % variation X| s.d. X2 s.d. %variation

Intra-individual 21 .7 2.2 0.46 0.34 2.1 20.3 2.0 0.51 0.39 2.5
Inter-individual 21 .7 2.2 2.5 1.51 11.6 20.3 2.0 2.44 1.27 11.9
Defined a s — x 100
Xl

between the tooth lengths of maxillary versus
mandibular teeth with the latter being approxi-
mately 1 mm longer (p = 0.003, /-test).
The intra-individual analysis of tooth length
based on the skull material showed a mean
radiographical difference in tooth length of only
0.46 mm amounting to 2.1 percent of the average
tooth length. The figures for true tooth length
were 0.51 mm and 2.5 per cent. (Table 2 and Figs.
5 and 6). In the inter-individual analysis the
mean radiographic difference in tooth length was
2.52 mm amounting to 11.6 per cent of the
average tooth length, and 2.44 mm for true tooth
length representing 11.9 per cent of the average
tooth length.
In Table 3, 288 non-transplanted premolars
from the patient material are divided according
to sex. It appears that male's premolars were
always significantly longer than corresponding
female's premolars being on the average 1.2 mm
longer.
In Table 4 the results are listed for the
univariate analysis of the extent of tooth de-
velopment related to various clinical factors.
This analysis comprised 264 cases transplanted
with incomplete root formation and where root
AUTOTRANSPLANTED PREMOLARS. PART IV 43

Comparison of actual and radiographic formation was complete at the last control. It
tooth length of 21 paired (homologous) premolars appears that all groups showed a rather large
variation in final tooth length. In this analysis
deviation
only stage of tooth formation at time of trans-
m.m.
plantation seems to be related to final tooth
length. A multivariate analysis (multiple regres-
sion analysis) was then attempted but for metho-
dological reasons was not considered reliable.
Instead an intraindividual analysis of root
growth variation was performed on cases where
homologous controls existed. In 186 teeth with
incomplete and complete root formation at time
of transplantation a non-transplanted control

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existed. To further characterize root growth, the
length of the graft at thefinalcontrol was then
compared to the non-transplanted control teeth.
The difference in final tooth length (negative
1.0. when graft was shorter than control and vice
versa) was then plotted against the graft length at
time of operation. In Figs. 7 and 8 such an
analysis is shown for both maxillary and man-
dibular grafts. It appears that three events could
happen. The root development could become
arrested or could go on unimpeded or root
05. development could become impaired. In Table 4
it can be seen that root growth was related to the
stage of root development at time of transplan-
tation. It thus appears that transplantation in
stages with incomplete root formation resulted in
m a reduction of final root length which was
increasingly prominent the less mature root
m
development was at time of transplantation. As
expected another parameter of tooth develop-
actual radiographic ment, namely length of the tooth at transplan-
tation, was likewise found related to further root
Figure 5 Intra-pair difference in tooth length (mm) among development. In stages with completed root
paired homologous premolars.

Figure 6 A. Identical tooth length of two maxillary homologous second premolars. B. 1.7 mm difference in tooth length among
two homologous mandibular first premolars.
44 J. O. ANDREASEN ET AL.

Table 3 Mean tooth length of non-transplanted premolars related to

location and sex.

Males Females

Tooth location n X s.d. n X s.d.

Maxillary first premolar 19 23.0 1.2 20 21.7 1.6

Maxillary second premolar 82 22.7 2.0 92 21.5 2.1
Mandibular first premolar 21 23.9 1.4 23 23.1 1.2
Mandibular second premolar 11 24.2 2.1 20 21.8 1.9

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Table 4 Relation between various clinical variables and root growth in 264 autotransplanted premolars.

Root length in mm

Variable No. X s.d.

Sex Male 105 19.8 2.8

Female 159 18.7 2.2
Graft type P, sup 14 19.9 2.8
P2 sup 198 19.0 2.5
P, inf I 22.9 —
P2 inf 51 19.3 2.6
Position of graft Occlusion 30 20.2 2.1
Infraocclusion 44 19.5 2.1
Not erupted, abnormal position 29 18.1 2.8
Not erupted, normal position 161 19.0 2.6
Age of patient (years) 9-11 55 19.0 2.0
12-13 162 19.2 2.5
14-31 47 19.0 3.1
Stage of root development 0 2 13.2 2.0
1 4 14.6 2.4
2 65 17.8 2.4
3 193 19.3 2.2
Apical pulp widths preoperatively (mm) 0-0.9 1 18.7
1.0-1.9 19 19.5 2.7
2.0-2.9 81 19.5 2.4
3.0-3.9 74 19.5 2.2
4.0-4.9 22 17.8 1.7
5.0-7.0 II 17.4 1.7
Apical pulp width, postoperatively (mm) 1.0-1.9 2 19.1 1.2
2.0-2.9 43 19.0 2.3
3.0-3.9 66 19.6 2.6
4.0-4.9 76 19.4 2.6
5.0-7.0 53 18.3 2.6
Pulp length, preoperatively (mm) 6-8 20 15.9 1.6
9-11 83 18.1 1.2
12-14 115 20.0 2.0
15-20 22 22.3 2.3
AUTOTRANSPLANTED PREMOLARS. PART IV 45

Table 4 Relation between various clinical variables and root growth in 264 autotransplanted premolars.

Root length in mm

Variable No. X s.d.

Pulp length, postoperatively (mm) 6-8 12 15.9 2.3

9-11 76 18.0 1.8
12-14 94 20.1 1.9
15-20 20 21.7 1.8
Inflammation in recipient region no 263 19.1 2.5
yes 1 15.1
Alveolar process atrophy no 134 19.2 2.6
yes 127 19.0 2.4

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Osteotomy at graft removal no 88 19.6 2.2
yes 173 18.9 2.4
Type of bur cooling internal 115 18.9 2.3
external 149 19.3 2.7
Damage to PDL 0-25% 222 19.0 2.3
26-50% 15 15.3 2.4
51-75% 9 21.0 2.4
76-100% 6 18.5 2.1
Storage of graft (min.) 0 73 18.5 2.3
1-5 115 19.3 2.4
6-10 45 19.6 3.2
11-30 24 19.0 2.6
Bone graft used no 208 19.1 2.5
yes 56 18.9 2.3
Recipient region max. anterior 18 20.5 2.3
max. premolar 37 19.2 2.2
mand. premolar 197 19.0 2.6
other 12 17.9 2.0
Antibiotics postoperatively 151 19.1 2.7
pre and postoperatively 110 18.8 2.1
Fixation type no splinting 6 16.3 3.6
suture 212 19.0 2.4
flexible 10 20.4 2.2
rigid 35 19.7 2.7
Orthodontic movement of graft no 139 19.1 2.7
yes 124 19.1 2.0

The numbers of teeth in the various groups do not always add up to 264 due to missing values.

formation at the time of transplantation, a slight
reduction in final root length occurred which
could in most cases be attributed to surface
resorption of the root apex in connection with
the endodontic procedure in these cases.
In order to analyse deviations in root growth
in a subgroup of 164 transplanted premolars
with incomplete root formation at the time of
transplantation they were compared with non-
transplanted homologous controls and analyzed
with regard to consecutive no arrest, arrested or
partially arrested root formation. These events
were then related to extent of tooth development
(measured in mm) at time of transplantation
(Table 5).
Arrested root formation was found in 14 per
 i. O. ANDREASEN ET AL.

CAIN OR L O U OF ROOT LENSTH OF 1J4 A U T O T R A H m j U f l X O MAXILLAflY OA1N OR LOSS O F ROOT LEHQTH OF 11 AUTOTRAMSFLAKTED
FREKOLARS COMPARED TO THEIR CONTRALATERAL CONTROLS MANDIBUtAR PREMOLARS COMPARED TO THEIR CONTROLS

. . . « - .
• ' • ' • » • . " . • . " . " . • - " . ' . ' . " .

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a-0

10

1O0 12.0 MO 16.0 *ao 20.0 22.0 24 0 264

Figure 7 Gain or loss of root length of 154 autotransplanted

maxillary premolars compared to their contralateral con- Figure 8 Gain or loss of root length of 32 autotransplanted
trols. The Y axis represents the gain or loss in mm after mandibular premolars compared to their controls.
completion of root formation. The .faxis the tooth length at
time of transplantation. The light shaded area represent those
cases where similar tooth length occurred between transplant
and control (allowing for a mm difference for methodological
reasons). The dark shaded areas represent cases with arrest of
root formation (again allowing for a 1 mm difference). In
between these two areas are found those cases with partial
arrest of root formation.

Table 5 Root formation related to length of tooth development at time of transplantation among teeth with non-
transplanted homologous controls.

Initial tooth length (mm)

Root formation 10 II 12 13 14 15 16 17 18 19 20 21 10-21

Total arrest 0 0 0 1 2 1 5 9 0 3 2 0 23 (14%)

Partial arrest I 2 1 8 10 13 13 15 25 8 9 2 107 (65%)
No arrest 0 I 1 0 3 3 6 3 6 6 3 2 34(21%)
Total I 3 2 9 15 17 24 27 31 17 14 4 164(100%)

Table 6 Mean achievement of expected tooth length or residual root growth in cases with partial arrest of root
formation in comparison to non-transplanted homologues.

Tooth length at time

of transplantation (mm) 10 11 12 13 14 15 16 17 18 19 20 21
No. of teeth 1 2 1 8 10 13 13 15 25 8 9 2 107
Mean achievement of
expected tooth length (%) 58 78 91 81 88 83 84 87 88 86 91 91 85
s.d. 7 7 9 5 5 4 6 2 7
Mean achievement of
residual root growth (%) 16 56 81 47 46 47 41 42 47 39 39 35 44
s.d. 22 17 19 16 17 14 15 17 17
AUTOTRANSPLANTED PREMOLARS. PART IV
FINAL TOOTH LENGTH OF 16 PAIRED ECTOPIC PREMOLARS
100.
1tD- _
Figure 9 Final tooth length of 16 paired ectopic premolars.
The black bars represent the ectopic premolars and the empty
bars the paired normal positioned transplant controls.
cent of the cases. Although all stages of root
development showed instances of arrested root
formation, 2/3 of these cases were found among
teeth transplanted at a length of 16 or 17 mm
equivalent to late stage 2 tooth formation. The
O.ri.
Figure 10 Slightly reduced root fonnation after transplantation of an ectopically mandibular premolar compared to a
homologous control.
47
accumulation of arrested root formation at this
particular stage of tooth development was found
to be highly significant in comparison to other
stages (p = 0.001, Fisher's exact test).
No arrest of root formation was found in 21
per cent and appeared to occur independent of
the initial tooth length at time of transplantation.
Partial arrest of root formation was found in
the majority of the transplants (65%) and
appeared to occur independent of the initial
length of the transplant. It appears from Table 6
that in the range of 13 to 20 mm tooth formation
(where reliablefigureswere available) a systema-
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tic reduction in the final tooth length took place
ranging from 81 per cent (13 mm tooth length) to
91 per cent (20 mm tooth length) of the antici-
pated tooth length in the group with partial
arrest of root formation. In order to get more
information about this reduction in root de-
velopment with regard to the expected residual
root growth the following calculation was made.
The initial tooth length of the graft at time of
transplantation was subtracted from the final
tooth length of the homologous control and
48
related to the actual final tooth length of the
transplants. By concentrating on the expected
residual root growth and not the tooth length a
magnification of the influence of transplantation
upon root growth could be obtained. It appears
from Table 6 that the usual achievement of root
growth was about 40 per cent and this figure
appeared to be relatively constant in the range
from 13 to 20 mm tooth formation at time of
transplantation.
The graft position before transplantation had
in the univariate analysis a slight, but not
significant influence upon subsequent root
growth. Thus the non-erupted ectopic tooth
grafts developed afinalroot length of 18.1 mm in
comparison to 19.0 mm for non-erupted tooth
grafts placed in normal position (Table 4). The
relation between position of the graft and sub-
sequent tooth length before transplantation was
further examined in a matched pairs analysis
including 39 cases with ectopic position of the
graft before transplantation matched with cases
with similar length of root development but with
normal position of the graft. An analysis of the
entire group showed no significant difference in
tooth length (p = 0.11, paired /-test); however,
when ectopic position was broken down into
maxillary and mandibular premolars a signifi-
cantly shorter root length was found for man-
dibular ectopic premolars (p = 0.03, Figs. 9 and
10), whereas this was not the case in the maxilla
(p = 0.33). The severity of ectopic position of
mandibular premolars (i.e. grade 1 versus 2) was
related to subsequent tooth length, but such a
relation could not be demonstrated (p = 0.33).
The effect upon final tooth length of position-
ing the graft in the socket, was examined in 82
cases of bilateral transplanted homologous pre-
molars. The result of this analysis is shown in
Fig. 11 where the difference (in mm) infinaltooth
length position of the two grafts is indicated on
the X axis (i.e. the length of the left premolar
subtracted from the length of the right pre-
molar), and the difference in position in relation
to the cervical bone margin is shown on the Y
axis (with values for left premolars always sub-
tracted from values for right premolars). In the
two shaded areas of the plot diagram are all the
cases where the teeth placed more superficial
than their control showed a subsequent shorter
final tooth length. It appears from the scatter-
gram in Fig. 11 that there was no significant
correlation between position of the graft and
J. O. ANDREASEN ET AL.
DIFFERENCE IN GRAFT POSITION RELATED TO FINAL TOOTH LENGTH
Difference m poi
between oght
and lift graft
• • • « ^ •«
— I 1 1- 1
njm • m m
OiHt.nnci in toolh
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Ifrngth tMtwHn rt|M
and left flf«f1
Figure 11 Relation between graft position in relation to
cervical bone margin and subsequent root growth in 82
paired observations. The difference in mm in final tooth
length is shown on the X axis i.e. the length of the left molar is
subtracted by the length of the right premolar, and the
difference in position in relation to the cervical bone margin is
shown on the Y axis. Again values for left premolars are
subtracted by values for right premolars. Shaded areas
represent cases where the teeth are placed more superficial
than their control showed subsequent shorter tooth length.
subsequent tooth length (r = 0.086, p = 0.22,
Spearman rank correlation). In general a super-
ficial position of the graft resulted in 41 cases
with increased tooth length and in 31 cases with
decreased tooth length whereas 10 teeth showed
identical tooth length, again this relation was not
significant (p = 0.29, Sign test).
Discussion
The very limited intra-individual variation in
tooth length of similar types of premolars sup-
ports the theory that tooth length is strongly
genetically determined. A paired analysis of
cases where a homologous non-transplanted
premolar was present is therefore of special
importance in revealing the influence of various
factors upon residual root growth. The average
AUTOTRANSPLANTED PREMOLARS. PART IV
O.d. O.d.
Figure 12 Transplantation of a maxillary second premolar leads to arrested root formation. A radiograph of the donor site
reveals formation of a root tip.
tooth lengths for the various types of premolar is
in accordance with previous anatomical studies
(Bjorndal et al., 1974; Okpo and Akpata, 1986).
The sex difference found in tooth length among
premolars has not previously been recorded,
probably because in the previous studies only
extracted teeth have been available without
information on their origin.
The results from the present study indicate
that the main factor determiningfinalroot length
after transplantation was the stage or length of
root formation at time of transplantation. The
results shown in Table 4 indicated that a reduc-
tion in final root length occurred in all groups
examined, which might lead to the assumption
that transplantation results in a percentage
reduction in the expected root growth. However
the analysis shown in Table 5 revealed that the
percentage reduction was composed of cases
with either total, partial or no arrest of root
growth. Relating these events to the function of
the Hertwig's epithelial root sheath, the pathoge-
nesis of thesefindingsmay be the following: The
arrest of root development could be related to
either the severance of the Hertwig's root sheath
when the transplant is removed from its socket,
or disturbance of this structure subsequent to
transplantation. The former possibility is sup-
ported by cases where the arrest of root forma-
tion of the transplant is followed by development
of the missing root structure at the donor site
(Fig. 12).
The predominance of this event at the late
stage 2 root development (see Table 5), could
indicate specific morphologic changes in the
49
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follicle leading to these events. Anatomical
studies of the follicle at different developmental
stages is therefore indicated and are presently
being performed using a monkey model
(Andreasen, 1990). The possibility of arrest of
root formation due to trauma to Hertwig's
epithelial root sheath has recently been shown in
an experimental study in monkeys (Andreasen et
al., 1988).
The finding that 21 per cent of transplants
attained their anticipated tooth lengths demon-
strates that Hertwig's epithelial root sheath can
in some cases function normally subsequent to
transplantation. This is surprising, but is sup-
ported by recent histological evidence of root
sheath survival subsequent to replantation
(Andreasen et al., 1988) as well as histologic
demonstration of normal root development sub-
sequent to autotransplantation of incisors in
monkeys (Kristerson and Andreasen, 1984;
Andreasen et al., 1988).
The usualfindingin this study was, however, a
certain reduction in root length so that the
grafted tooth achieved less than half the expected
root growth. Thisfindingcould be the result of a
partial severance or destruction of the Hertwig's
epithelial root sheath resulting in only a fraction
of this structure completing root growth.
Another possibility could be impaired nutrition
until full revascularization of the graft has been
established, resulting in a restriction in the
potential root growth. Experimental studies are
being carried out to solve this problem. The first
mentioned possibility has recently been demon-
strated in monkeys where both types of injury
50
was performed experimentally in monkeys
(Andreasen et al, 1988).
A significant finding in this and a previous
study (Kristerson, 1985) was that an ectopic
position of the mandibular graft before trans-
plantation resulted in a reduced root growth.
The explanation for this finding is possibly the
difficult surgical approach to these teeth. Thus
the usual lingual approach to these teeth due to
the lingual tilt makes it difficult to obtain a strict
axial removal of the grafts. Instead the tooth
germs during removal has to be forced in lingual
and coronal direction which could lead to
trauma to Hertwig's epithelial root sheath.
The lack of effect of positioning of the graft in
its socket is not in accordance with a previous
experimental study in monkeys where a super-
ficial position of the graft in an existing socket led
to a reduction in root growth (Kristerson and
Andreasen, 1984). The most likely explanation
for this discrepancy is that the grafts in the
present study were usually not placed in a
superficial position but represented actual differ-
ences in position according to the size of the
prepared socket. Unfortunately it was in most
cases not possible to see the outline of the
prepared socket radiographically because the
new socket was usually prepared in cancellous
bone, so this factor could not be further con-
trolled.
Acknowledgements
This study was supported by grants from Dan-
marks Sundhedsfond. Dr O Carlsen, Depart-
ment of Dental Anatomy, Dental College,
Copenhagen is thanked for providing measure-
ments of extracted premolars.
Address for correspondence
Dr J O Andreasen
Rigshospitalet
University Hospital
Department of Oral Medicine and Oral Surgery
(Z7512)
20 Tagensvej-2200
Copenhagen
Denmark
J. O. ANDREASEN ET AL.
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