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5 . Sequence and Treatment Procedures

panoramic view. Mandibular left third molar will be transplanted to the area of the non restorable mandibular left second molar in a 39-yearold male.

Fig 5-4a Pretreatment

Figs 5-4b and 5-4c Preoperative view.

Figs 5-4d and 5-4e Preoperative

view

recipient site and the donor tooth.

of

the

Extraction of the donor tooth If an impacted donor tooth is extracted surgically (see Fig 5-3), alveolar bone over the donor tooth must be removed with a surgical round bur with saline irrigation to avoid damage to the crown or the root. Before elevation of the donor tooth, an incision is made with a blade around the cervical area into the periodontal ligament (see Fig 581) to preserve as much periodontal ligament on the root as possible. The extracted donor tooth is immersed in physiologic saline or preservative (see Chapter 3) to prevent drying of the periodontal ligament. The flap of the extraction socket should be closed and sutured to prevent excessive bleeding (see Fig 5-1m). 86
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Mesial migration of the donor tooth and regeneration of alveolar bone can be observed. The radiograph was taken after removing the splint. The amount of periodontalligament is adequate. f Fig 5-4i After the gingival flap has been sutured and the donor tooth has been splinted. Fig 5-4q Two years after transplantation. Fig 5-4p One year after transplantation. The distal aspect of the donor tooth is closed as tightly as possible. f Fig 5-40 Seven months after transplantation.u Sequence and Procedures of Conventional Transplantation Fig 5-4f Extracted second molar. which will be discarded. Fig 5-4j After transplantation. Fig 5-4n Seven months after transplantation. Fig 5-4m Three months after transplantation. Fig 5-41 Six weeks after transplantation. The root canals have been cleaned. Fig 5-4h View of the donor site and preparation of the recipient site. Fig 5-4k Two weeks after trans plantation . shaped. Transplantation was performed 6 weeks after extraction of the tooth from the recipient site. 87 ill . Fig 5-49 Extracted donor tooth. and filled with calcium hydroxide.

and the amount of preserved periodontal ligament should be evaluated and recorded. This information is difficult to accurately obtain with preoperative radiographs (see Figs 5-1h and 580). no more than 2 mm of enamel should be removed when making these adjustments. A caliper or a probe is useful for measuring the mesiodistal or buccolingual width of the crown and the_length 9f the root. The donor tooth is restored with composite resin. Evaluation of crown width and try-in The distance between the teeth adjacent to the recipient site (if both are present) must be measured and compared to the mesiodistal width of the donor tooth before the final preparation of the recipient site (see Fig 5-1i). a small amount of enamel can be removed from the proximal surfaces of the adjacent teeth and the donor tooth. The evaluated shape of the root.2. an extraoral picture of the donor tooth should be taken mesiodistally and buccolingually. Sequence and Treatment Procedures Figs 5-4r to 5-4t One year 6 months after transplantation. the length of the root trunk. 88 . In total.3 Orthodontic treatment is sometimes indicated to control the space. Measurement of the donor tooth The size and shape of the donor tooth is determined extraorally to gather information for the preparation of the recipient site. If the donor tooth is too wide. For these reasons.5 . development of the root (presence of Hertwig's epithelial sheath). Fig 5-4u Three years after transplantation.

Fig 5-5k Fixation of the donor tooth by the sutures.5e The donor tooth.n t. . Fig 5-5c After extraction molarfrom the recipient site. of the second Fig 5-5d Extraction of Fig 5. One end of each suture is left at 30 mm while the other end of the suture is left uncut. lingual gingival tissue of the extraction socket of the third molar to achieve better fit of the gingival flap. The donor tooth is sealed tightly by the gingival flap because of the flap's elasticity. Fig 5-59 Try-in of the donor tooth. The incision is made in the gingival sulcus around the tooth at the recipient site and the donor tooth. Before transplantation of the donor tooth. The extra suture is used for fixation of the donor tooth. the flap of the horizontal incision and the area of the mesial proximal wall are sutured. The releasing incision is made in the Fig 5-5h Releasing incision of the flap. Fig 5. Vertical incision is made in the distobuccal corner of the first molar. 89 .. Fig 5-5b Incision and reflection of the gingival flap. Fig 5-51 After application of the surgical dressing to protect the surgical area. the donor tooth.5f After modification of the recipient site. Fig 5-5j Plantation of the donor tooth. Horizontal incision is made in the buccal corners of the donor tooth and the gingival flap is reflected. Fig 5-5i Suture of gingival flap. Sequence and Procedures of Conventional Transplantation Fig 5-5a Preoperative view. Extra periosteal suturing of the distolingual area is used for fixation.

Enough height of bone is not available for transplantation because of the level of the sinus floor.. Fig 5-6f Extracted maxillary left deciduous second molar from the recipient site. part of the bone and mucosa of sinus floor is lifted. Fig 5-69 Sinus lift. To create space for the donor tooth. .) 91 .n Sequence and Procedures of Conventional Transplantation Fig 5-6a Preoperative panoramic view. Fig 5-6e The recipient site and the donor tooth. Figs 5-6b and 5-6c Preoperative occlusal view. Fig 5-6d Preoperative view of the recipient site and the donor tooth. (Procedure is explained in detail on the next page. Maxillary left third molar will be transplanted to the area of congenitally missing maxillary left second premolar in a 22-year-old female.

Fig 5-6k After the procedure. Fig 5-61 Osteotome and periosteal elevator used for socket lifting. The space between the root. Fig 5-6j Elevation and lifting of the sinus membranewithout damaging it-from the sinus floor with elevators through the space created by lifting the cortical bone. the sinus membrane. and the cortical bone of the sinus floor will be filled with bone. Fig 5-6i Lifting the bone slightly with an osteotome.e and Treatment Procedures k Fig 5-6h Pilot drilling on the bone of sinus floor with round bur. .

Fig 5-65 Seven months after transplantation. Fig 5-6n The donor tooth. Root canal therapy was started immediately. . Inflammatory resorption can be observed. 93 . which is splinted to the adjacent tooth.. Fig 5-6q After transplantation. Fig 5-6x One year after transplantation. Figs 5-6u to 5-6w After restoration of the donor tooth. The donor tooth should be extracted prior to preparation of the recipient site and its size and shape should be measured and evaluated. the donor tooth is planted in the new site and the soft tissue is sutured tightly around the tooth. Fig 5-6r Two months after transplantation. Root resorption has been arrested and the sinus floor elevation has been successful. Fig 5-6t Seven months after transplantation. Fig 5-6p After satisfactory try-in. Fig 5-60 Try-in of the donor tooth.u Sequence and Procedures of Conventional Transplantation Fig 5-6 (continued) Fig 5-6m Prepared recipient site.

If the depth or length of the prepared recipient site is not adequate. Attention must be paid during the plantation not to damage the periodontal ligament of the donor tooth mechanically by pushing it into the recipient site. 94 . Sequence and Treatment Procedures Fig 5-7a Preoperative panoramic view. The tooth was extracted because little root length remained. Changing the direction of the donor tooth by rotating it 90 degrees helps to find a better fit if the initial direction is not possible. 5 .Ii . The patient visited the clinic because of root fracture of the maxillary right lateral incisor in the cervical area. adjustment must be made accordingly by removing bone with round surgical burs. Fig 5-7b Preoperative view. Maxillary left third molar will be transplanted to the area of the nonrestorable maxillary right lateral incisor in a 34-year-old female. Fig 5-7e Two weeks after extraction ofthe lateral incisor and just before transplantation. Try-in and plantation of the donor tooth The donor tooth needs to be tried into the prepared recipient site. _ Fig 5-7d Removal of fractured fragment. '. Fig 5-7c Recipient site prior to treatment.

Sequence and Procedures of Conventional Transplantation view of the donor tooth. the fitting of the tissue must be done by beveled incision to preserve all keratinized gingival tissue (see Figs 5-8aa and 5-8bb). If excess soft tissue is present. and 5-4i). If there is minimal keratinized tissue at the site. de is being replaced with Trimming and suturing of the flap After try-in of the donor tooth in the recipient site. The cleaned and filled with ths after transplantation. d donor tooth. the fit of the gingival tissues around the donor teeth is checked. 5-3i. making sure that adequate keratinized gingival tissue is available (see Figs 5-2j. The success of transplantation depends on the primary closure of the gingiva around the donor tooth (see Chapter 3). the excess is trimmed and the remaining soft tissue is fitted around the donor tooth. fter transplantation of the after transplantation. 95 .

Plantation of the donor teeth after the suture has been placed is not difficult because of the elasticity of the gingival flap. tion. toration of the transplanted tooth.. Fig 5-7q Three years after transplantation. Notice the dark appearance of the crown. It is easier to suture the vertical incision area or proximal area without the donor tooth in place (the donor tooth can be preserved in physiologic saline) (see Fig S-Si). Fig 5-7m After bleaching of the transplant. an extra length of the suture should be for fixation (see Figs S-Si and S-Sk). Figs 5-7n and 5-70 Composite resin res. a better fit actually can be obtained this way. . If the suture is to be used for fixation. 96 . By making a releasing incision. Sequence and Treatment Procedures Fig 5-71 Three months after transplanta. the tissue flap can be brought to a more desirable tight fit to the tooth (see Fig S-Sh). Fig 5-7p Five months after transplantation. it may be r difficult to obtain a tight fit of the gingival tissue on the distal aspect of the donor r tooth. When a third molar is transplanted to the area of an adjacent second molar.u 5 . ed tooth.

Figs S-8b to 5-89 Preoperative intraoral view.8a Preoperative panoramic view. The maxillary left first premolar will be extracted for orthodontic reasons and transplanted to the area of mandibular left second premolar in a 15year-old female. Fig S-8h Preoperative 99 . Fig S.__ Sequence and Procedures of Conventional Transplantation Fig 5-8 Transplantation of an extracted tooth (for orthodontic reasons) to the area of a con genitaJIYrnissingrnandibular premolar. view.

'i 5 . After measurement. 100 . Fig 5-8n Extracted donor tooth. Sequence and Treatment Procedures Fig 5-8i Radiographic evaluation of the donor tooth. consider using the second premolar as a donor tooth. Several angulations should be used to determine the likely fit of the donor tooth into the recipient site. Fig 5-8q Preparation of the recipient site prior to transplantation. Fig 5-80 Measurement of the donor tooth. Fig 5-8j Preoperative view of the recipient site. 0 Fig 5-8p Reflection of the gingival flap at the recipient site. Fig 5-8m Extraction of the donor tooth using diamond-coated extraction forceps for better grip of the tooth crown. A part of the periodontal ligament was lost. Fig 5-8k Two weeks after extraction of deciduous second molar. Fig 5-81 Initial incision from the sulcus into periodontal ligament around the donor tooth prior to extraction. A minimal amount of gingival sulcus incision is made on both ofthe adjacent teeth so that attachment loss of these healthy teeth will be minimal. If the first premolar is doublerooted. the donor tooth is preserved in physiologic saline.U I.

101 . Fig 5-8u Try-in of donor tooth. Fig 5-8z Fixation with a suture. The recipient site is prepared slightly larger than the root of the donor tooth.000 rpm. surgical or implant burs can be used for this purpose. it should be carefully removed and the new socket should be further enlarged.Sequence and Procedures of Conventional Transplantation Figs S-8r to 5-8u The sequence of preparation of the recipient site in an area without a prior extraction socket. Fig 5-8t Preparation of the recipient site. Fig 5-8y Suture placed on the distal and the mesial gingival flap. If the donor tooth is too large. running at about 2. Fig 5-8r Use of a bur to mark the size of the socket to be prepared. Fig 5-8x Plantation of the donor tooth. Fig 5-8s After removal of the cortical plate from the crest of the bone. Fig 5-8v Burs for socket preparation. Fig 5-8w The recipient site after the surgical preparation.

served on the distal aspect of the donor tooth. Fig 5-8hh One month after temporary obturation with calcium hydroxide. Fig 5-8dd One week after transplantation. Fig 5-8gg Three months after transplantation. 102 II "' . Root canal therapy was started immediately.5 . Sequence and Treatment Procedures Fig 5-8aa An oblique incision made in the buccal gingival tissue to obtain tight closure of proximal gingival tissue. Inflammatory root resorption is ob. thus preserving the keratinized gingiva. Tight fit between the gingival flap and the donor tooth can be obtained. Fig 5-8ee Six weeks after transplantation. Arrest of root resorption was confirmed and orthodontic treatment was started. Fig 5-8cc After transplantation. Fig 5-8ff Clinical view 6 weeks after trans plantation. Fig 5-8bb Suture of the area.

which is replacing the calcium hydroxide initially placed in the canal.Sequence and Procedures of Conventional Transplantation Fig 5-8ii Two years after transplantation. Normal appearance of periodontal ligament and lamina dura is observed. Figs 5-8kk to Fig 5-8nn Two years 6 months after transplantation. Fig 5-8jj Completion of orthodontic movement. 103 . Fig 5. The root canal is being filled with gutta percha. Fig 5-800 Two years 6 months after transplantation.8pp Five years after transplantation.