JOURNAL OF ORTHODONTICS, 2017

VOL. 44, NO. 4, 287–293

https://doi.org/10.1080/14653125.2017.1371960

CLINICAL SECTION

A 3D printed surgical analogue to reduce donor tooth trauma during

autotransplantation
Richard R. J. Cousleya, Andrew Gibbonsb and Jeremy Naylerc
a
Orthodontic Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK; bOral and Maxillofacial Surgery
Department, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK; cMedia Studio, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK

ABSTRACT ARTICLE HISTORY

Surgical trauma and prolonged extra-alveolar exposure of the donor tooth’s root sheath are both Received 3 July 2017
complicating factors during tooth autotransplantation surgery. This case report describes a 12- Accepted 20 August 2017
year-old female patient who underwent surgical transplantation of a maxillary second premolar
KEYWORDS
to a central incisor site. A three-dimensional printed analogue of the donor tooth was fabricated Tooth transplantation; CBCT;
from a cone beam (CBCT) scan of the tooth in order to minimise the extra-oral (exposure) time 3D printing; root trauma
and frequency of trial insertions of the donor tooth into the recipient socket. The laboratory and
clinical aspects of this novel technique are described.

Introduction
The autotransplantation of teeth is a recognised treat-
ment option where teeth are absent due to either hypo-
dontia, trauma or pathological loss. It involves elective
removal of a donor tooth and its insertion into a surgi-
cally prepared recipient socket. It is a cost-effective bio-
logical alternative to either restorative rehabilitation
involving bridge or implant (and bone graft) solutions,
or orthodontic space closure. The advantages of auto-
transplantation are early tooth replacement in a
growing individual and functional restoration of the
edentulous site. The subsequent bone induction effects
lead to a reduction in the potential growth limitations
of the edentulous alveolar bone’s future (vertical and
transverse) width (Paulsen and Andreasen 1998). Trans-
planted teeth may also be moved orthodontically, pro-
vided that they are not ankylosed.
Tooth transplantation has variable success rates, as
reported in a recently published meta-analysis of trans-
planted teeth with a minimum follow-up period of 6
years (Machado et al. 2016). This demonstrated long-
term survival rates of 75–91% with an effect size of
81%, despite the inclusion of studies with mature tooth
transplantations. This is consistent with the findings of
previous individual studies which indicate that clinical
success rates (notably ‘success’ includes clinical criteria
in addition to tooth survival) are affected by: patient
age and the stage of root development of the donor
tooth; the surgical time involved in the transplant
process, and iatrogenic trauma to Hertwig’s root sheath
(Paulsen et al. 1995; Czochrowska et al. 2002a; Kvint
et al. 2010; Aoyama et al. 2012; Jang et al. 2016). In
effect, the process is technique sensitive.
The potential complications of this surgical technique
include ankylosis, pulp necrosis and inflammatory or
replacement root resorption. Machado et al. (2016)
reported that the long-term rate of ankylosis was 4–
18% (with an effect size of 4.8%) and root resorption
was 3–10%. As with survival rates, the worst compli-
cations were seen in studies with mature root transplan-
tations. In the case of immature teeth transplanted in
adolescent patients, it may be argued that a delayed
failure of the transplanted tooth may still be partially suc-
cessful in terms of space maintenance and the pro-
motion of alveolar growth in the interim period of
dentofacial growth.
The most appropriate donor teeth in children are
upper and lower second premolars because of their rela-
tively favourable root number, morphology and the
timing of their root development. These factors mean
that premolar transplants tend to have higher success
rates than other donor teeth. For example, in a study
of 215 consecutive patients the long-term success rate
for premolars transplanted to upper incisor sites was
100%, compared to the total sample mean of 81%
(Kvint et al. 2010). A 98–100% long-term survival rate
was also observed in three studies of 28, 40 and 40 pre-
molars transplants in children (Czochrowska et al. 2000;

CONTACT Richard R. J. Cousley rcousley@yahoo.com

© 2017 British Orthodontic Society
288 R. R. J. COUSLEY ET AL.
Jonsson and Sigurdsson. 2004; Tanaka et al. 2008). All 40
premolars were successfully implanted in the maxillary
central incisor site in the study by Czochrowska et al.
(2000) and only one tooth (2%) was infra-occlusal due
to ankylosis. Surprisingly, the survival rate was unaf-
fected by a 39% incidence of the endodontic treatment
in the sample of 28 transplant cases (Tanaka et al.
2008). Therefore, second premolar teeth are the
optimum candidates for the replacement of absent
maxillary central incisors in terms of both their high
success rate and favourable secondary outcomes. For
example, a favourable gingival response was observed
in the study undertaken by Czochrowska et al. (2000)
where none of the 40 cases had gingival recession and
the adjacent gingival papillae filled the interdental area
in most cases. Furthermore, a follow-on study of aes-
thetic outcomes compared 22 of these premolars with
their contralateral natural incisor. There was a high
overall degree of patient satisfaction and any patient
concerns focussed on the quality of the post-transplan-
tation restoration (Czochrowska et al. 2002b).
Various attempts have been made to reduce autotrans-
plantation surgical morbidity, including fabrication of
metal templates apparently representing typical premolar
sizes and morphologies (Day et al. 2012; Ashkenazi and
Levin 2013). These could be used to pre-prepare the reci-
pient site and hence potentially reduce the extra-oral time
from donor tooth extraction to recipient site insertion, and
trauma to the periodontal tissues incurred when the tooth
is repeatedly tried into the recipient socket. However, the
template would not be an exact replica of any individual
patient’s donor tooth. Lee et al. (2001) addressed this
Figure 1. Frontal and upper occlusal photographic views of the
pre-treatment occlusion (a, b) and the pre-treatment panoramic
radiographs (c).
issue by individually customising the template principle.
They used 3D (CT scan) radiography data to then print a
rapid prototype version of a molar donor tooth in either
‘resin’ or starch, i.e. a donor analogue. A follow-on study
by the same South Korean team analysed the results of
182 transplanted teeth, where 90% were mature third
molar teeth (Kim et al. 2005). The mean extra-oral time
for the donor tooth was only 7.2 minutes where the
donor teeth did not undergo extra-oral endodontic treat-
ment. However, 54% of the transplanted teeth lacked suf-
ficient primary stability without rigid splinting. This may
have been due to inadequate root–bone proximity due
to the effects of previous periodontal disease at the reci-
pient site, but the authors also attributed this to inaccurate
surgical preparation in some cases. Significantly, the rate
of complete early healing was higher (88%) in cases
with good primary stability compared to cases where
poor primary stability was observed (73%). This suggests
that the use of a customised analogue may assist the
surgeon to achieve favourable primary stability of the
transplanted tooth.
More recently, Honda et al. (2010) utilised CBCT-
derived data to produce a 3D printed analogue of a
molar tooth transplant. They described this in an adult
patient where the surgeon used the analogue in an
attempt to make the recipient site the optimal size
prior to insertion of the real tooth. However, none of
these reports of 3D printed analogues have described
the more typical scenario in children of transplantation
of an immature premolar tooth into an edentulous alveo-
lar site. Therefore, this current paper reports a case where
a CBCT-derived 3D printed analogue was made of an
immature premolar tooth destined for a maxillary
incisor site. The relevant preparatory and surgical
stages will be described with a view to other clinicians
replicating this technique.
Case report
An 11-year-old girl was referred to the Orthodontic
department following traumatic loss of the upper right
central incisor 3 months previously. The patient pre-
sented with a mild class II division 1 malocclusion on a
mild class II skeletal relationship and a reduced Frank-
fort-mandibular planes angle. She was in the mixed den-
tition phase with absence of the upper right central
incisor tooth (Figure 1). There was a 2 mm shortage of
space in the upper right central incisor site (relative to
the 9 mm width of the upper left central incisor), and
the labial alveolar surface was concave, indicating a
loss of alveolar width.
Radiographic examinations (Figure 1(c)) confirmed
the presence of all permanent teeth except the upper

right central incisor. All of the second premolar roots
were immature with less than half root lengths evident
radiographically and divergent apical areas. After dis-
cussions with the patient and her parents regarding
long-term options for the edentulous site, the following
treatment plan was agreed: (1) provision of an ortho-
paedic (functional) appliance; (2) placement of a sec-
tional fixed appliance on the upper anterior teeth to
increase the right central incisor space; (3) CBCT of the
upper second premolar teeth; (4) premolar transplan-
tation to the anterior maxillary edentulous site and
subsequent restorative augmentation of its crown; (5)
full fixed appliances, with closure of the premolar
donor site.
Pre-surgical orthodontics
The patient commenced orthopaedic treatment with a
Twin Block appliance, at the age of 11 years and 8
months since it was judged that correction of the class
II features was the clinical priority given the patient’s
chronological age and somatic appearance. Conversely,
the immature status of the maxillary second premolar
roots meant that the surgical phase could be delayed.
A sectional fixed appliance was bonded onto the upper
Figure 2. Initial periapical radiographs of the right and left
second premolars, showing immature root development.
JOURNAL OF ORTHODONTICS 289
anterior teeth 2 months later, in order to align these
teeth and increase the right central incisor space to a
minimum of 9 mm.
Periapical radiographs of the maxillary premolar areas
(Figure 2) were taken 6 months after the initial panora-
mic radiograph. These showed that these premolar
roots had developed by approximately half of their
likely root length, and had divergent root apices. Accord-
ing to the findings of Paulsen et al. (1995) this meant that
the premolars’ developmental stage was at the start of
the optimum period for transplantation. Therefore, the
patient was referred for a CBCT scan to ascertain the
dimensions and morphology of the maxillary second
premolar roots and whether there was sufficient labio-
palatal alveolar bone depth to accommodate a trans-
planted premolar root in the edentulous maxillary
incisor site. On the basis of these scan findings,
coupled with the displacement of the mandibular
dental centreline to the left side (Figure 3) it was
decided that the right maxillary second premolar tooth
was the best candidate for autotransplantation. This
upper right tooth loss would allow for the post-trans-
plantation use of right class III inter-maxillary traction
for simultaneous orthodontic space closure and centre-
line corrections.
Figure 3. Photographs showing the immediate pre-operative
incisor positions, teeth present and alveolar morphology.
290 R. R. J. COUSLEY ET AL.

Analogue fabrication 28 mm per hour, depositing fine droplets of a water-

based binder onto 100 µm successive layers of powder
The patient’s CBCT scan, with a layer thickness of 0.3 mm,
(Visijet PXL, 3D Systems). This produced a gypsum-
was forwarded to a software technician (JN) for image
based plaster model, which was then hardened for
manipulation and subsequent 3D printing of the ana-
additional strength and water-resistance with cyanoacry-
logue tooth. The right maxillary second premolar tooth
late infiltrate (Figure 4(c,d)). The total cost of this ana-
was first isolated within the CBCT scan (Figure 4(a))
logue tooth process was approximately £35.
then OsiriX MD1 software (Pixmeo, Geneva, Switzerland;
www.osirix-viewer.com) was used to process the 3D
DICOM data. This process is typically used for visualisa- Surgical procedure
tion of virtual 3D anatomy and Osirix software is a com-
The transplantation surgery was performed, under
monly used software in radiology departments. The
general anaesthesia, at 12 years of age and 4 months fol-
image was then segmented to extract the tooth image,
lowing the CBCT scan. The recipient site was prepared
following determination of the maximum and
using a palatal flap for access and a fine osteotome to
minimum density limits (in Hounsfield Units). The fine
out-fracture the edentulous buccal alveolar plate. A
detail of its outline was also cross-checked with two-
large round bur was then used to drill a hole for the
dimensional sectional views of each CBCT slice.
tooth transplant with a bone trap attached to the
A 3D model of the tooth was then exported from the
suction apparatus in order to collect the bone debris.
OsiriX MD software in STL (stereolithography) file format,
The analogue tooth, which had been soaked in chlorhex-
suitable for 3D printing. Any mesh errors which might
idine mouthwash pre-operatively, was repeatedly placed
prevent the tooth from printing were fixed in Meshlab2
in and out of the socket. It was orientated at a ninety
(ISTI-CNR Research Center, Rome, Italy; www.meshlab.
degrees rotation so that the analogue’s bucco-palatal
net). Mesh errors can cause artefacts in the 3D print, or
dimension filled the available mesio-distal space
prevent it from translating into a printable model. They
between the adjacent teeth (Figure 5(a)). The socket
do not exist in real objects, but may occur in a virtual
was developed until the analogue fitted into it in the
model, e.g. an infinitely thin edge or surface, or non-
planned infra-occlusal position (to allow post-operative
manifold geometry (where two different shapes share
eruption and subsequent root development). Notably,
the same surfaces or edges). The STL file (Figure 4(b))
an allowance was made for the presence of the real
was loaded into the 3D printer software and printed in
donor tooth’s apical soft tissues since these were not
a binder-jetting printer (3D Systems Projet 660 Pro; 3D
evident on the CBCT images and hence did not feature
Systems Inc. Rock Hill, USA; www.3dsystems.com). This
in the analogue tooth. This allowance also allowed for
machine builds the model layer by layer at a rate of
any root development which had occurred since the
CBCT scan date.
The upper right second premolar tooth was exposed,
extracted (with forceps) and placed immediately into the

Figure 5. (a) Intra-oral photographs showing intra-operative trial

Figure 4. (a) A CBCT view with coloured identification of the insertion of the analogue, (b) the post-operative position of the
right maxillary second premolar. (b) A virtual image of the transplanted premolar and (c) after bonding of the full upper
donor tooth, and (c, d) photographs of the printed tooth. fixed appliance and composite resin crown.

newly created recipient socket to the correct depth and
rotated orientation. This resulted in the tooth’s root
being exposed for less than 1 minute, with minimal
apparent disturbance of Hertwig’s root sheath. Retrieved
autologous bone debris was packed around the tooth in
areas of the socket that had gaps between the socket
walls and the tooth, as is customary practice for filling
bone voids in dental implant surgery. Multiple 4/0
vicyrl interrupted and purse string sutures were used to
close the mucosa tightly around the neck of the trans-
planted tooth. The upper right second molar area was
also closed with sutures. Post-operative Augmentin anti-
biotics and paracetamol analgesics were prescribed for 5
days.
Post-surgical phase
The Twin Block appliance was relieved to avoid pressure
on the transplanted tooth and adjacent soft tissues. The
transplanted premolar remained infra-occlusal and free
from occlusal contact during these 2 months (Figure 5
(b)). Full arch fixed appliances were then bonded, except
on the transplant tooth for two reasons. Firstly, the
crown of this tooth was temporarily restored with the
free-hand placement of composite resin to mimic a
central incisor crown (Figure 5(c)), and this could have
been damaged by bracket placement. Secondly, spon-
taneous eruption (corresponding to root development)
of this tooth was favoured, and the palatal and occlusal
surfaces of the composite crown were incrementally
trimmed to keep the transplant tooth out of direct occlu-
sal loading and hence facilitate further eruption. The fixed
appliance treatment continued to bypass the transplant
tooth, during the alignment phase and subsequent
closure of the upper right donor tooth space (Figure 5(d)).
Periapical radiographs, taken 3 and 6 months after the
transplant procedure, showed continued root develop-
ment of the transplanted premolar root (Figure 6(a,b)).
There was no apical pathology and progressive loss of
definition of the pulp chamber was indicative of pulpal
obliteration. A subsequent periapical view, taken 10
Figure 6. Periapical radiographs taken (a) 3, (b) 6 and (c) 10
months post-operatively.
JOURNAL OF ORTHODONTICS 291
months post-operatively and prior to bonding of the
transplant tooth, showed a healthy root appearance
except for a cervical concavity on the mesial aspect of
the root (Figure 6(c)). This is suggestive of localised exter-
nal (replacement) root resorption and it was arranged for
the tooth to be reviewed in the longer term in order to
check for signs of progressive ankylosis (and surgically
subluxate the tooth if required).
Discussion
Tooth transplantation entails complete rupture of the
neurovascular bundle and periodontal fibres during the
extraction step. Hence, the technique’s success relies
on the integrity of Hertwig’s root sheath and the post-
operative healing process. Continued root development
and pulpal obliteration are the typical radiographic signs
of normal healing and subsequent root growth in those
teeth transplanted with an open apex (Paulsen et al.
1995; Czochrowska et al. 2002a, 2002b; Jonsson and
Sigurdsson 2004). These were observed during the first
post-operative follow-up year in the premolar transplant
reported here (Figure 6). Normal eruption of this premo-
lar was also evident. This is consistent with the obser-
vations of Paulsen and Andreasen (1998) in their
classical longitudinal radiographic study, where signifi-
cant eruption of immature premolar teeth occurred
within the first 3 post-operative months, followed by
normal alveolar growth.
Unfortunately, cervical external root resorption was
evident in this case (Figure 6(c)), by 10 months after
surgery. This secondary complication may have been
due to root injury during the forceps extraction
process, since ankylosis has not found to be related to
the extra-oral time of the donor tooth (Kim et al. 2005).
Notably, the analogue innovation described here
cannot mitigate such initial surgical trauma. Surgical
preparation of the recipient socket may also delay revas-
cularisation of the transplanted tooth’s periodontal liga-
ment, resulting in an increased risk of ankylosis
(Skoglund and Hasselgren 1992). If the localised external
root resorption is not self-limiting (as shown by longer
term radiographs) then additional treatment will be indi-
cated, e.g. the tooth may either be extruded orthodonti-
cally (with surgical subluxation if required) or have the
cervical resorption site exposed by restorative crown
lengthening.
Another complicating factor in dental autotransplan-
tation may be the limitations of the recipient site
anatomy. In circumstances such as the case reported
here, the tooth was lost at the recipient site some time
before the transplant was undertaken. Hence, as
observed in Figure 1(f), alveolar necking developed at
292 R. R. J. COUSLEY ET AL.
the recipient site. The effect of this, on reducing trans-
plantation success rates, has been observed in a study
of 259 transplanted teeth (Aoyama et al. 2012). This
study found that a 2.5 months or greater delay in trans-
plantation to the edentulous site caused a significant
reduction in the success rate, although the vast majority
of cases studied were adults. It was hypothesised that the
affected recipient sites had undergone alveolar atrophy
to leave a narrow alveolar ridge. In turn this potentially
complicates surgery due to the need for additional prep-
aration of the recipient site. Arguably, any reduction in
the donor tooth’s extra-oral time will help in such circum-
stances, and this was achieved in the case reported here
by the use of the customised analogue tooth.
The conventional tooth transplantation technique
involves extraction of the donor tooth and subsequent
use of this tooth to prepare the size and shape of the reci-
pient site, with the aim of achieving a close fit between
the root and alveolar bone socket. However, there are
two key problems with this technique: the duration of
extra-oral (extraction to final implantation) time for the
donor tooth; and injury to the periodontal tissues of the
donor tooth during the repeated try-ins into the recipient
socket. These iatrogenic injuries to the root may signifi-
cantly affect the viability of the donor tooth’s periodontal
ligament cells (Hupp et al. 1998) and consequently lead to
root resorption and/or ankylosis. On the other hand, an
optimal proximity of the root surface to the recipient
site bone surface may optimise the blood supply and
hence healing of the periodontal ligament cells (Nethan-
der 1994), which in turn may increase the success rate
of autotransplantation (Kim et al. 2005).
There has been a widespread application of 3D
imaging and printing technologies in recent years
throughout dentistry. This has resulted in the ability to
fabricate 3D printed versions of many orthodontic appli-
ances and orthognathic wafers (Christensen 2017;
Cousley et al. in press). It should therefore be unsurpris-
ing that this approach can be utilised for tooth autotrans-
plantation. Shahbazian et al. (2010) undertook an in vitro
study comparing the dimensions of stereolithographi-
cally printed plastic teeth with the corresponding real
teeth. They found that 79% of the surface points ana-
lysed were within 0.25 mm accuracy, indicating that
the printed teeth were sufficiently similar to the real
ones for clinical use. Aside from possible shrinkage or dis-
tortion of the printed plastic, the errors may have also
been due to the relatively low resolution of the CBCT
scans used. This information was not provided by the
authors and it’s possible that more modern scanners
now available may produce better accuracy rates. Fur-
thermore, in terms of the analogue material, new bio-
compatible 3D printing resins are being released on a
regular basis for intra-oral applications, such that the cya-
noacrylate-coated plaster material used in this case is no
longer the first choice. Instead, a biocompatible, rigid,
rapid prototyping photopolymer material such
as MED610 (www.stratasys.com/materials/polyjet/bio-
compatible) would be suitable. This has been used
recently for the fabrication of 3D printed orthognathic
wafers where the material was exposed to the oral
tissues and surgical environment in a similar way to a
transplant analogue tooth (Cousley et al. in press).
Another potential limitation of the CBCT process is that
Hertwig’s root sheath is not visualised in the scan. Hence
the surgeon must make an allowance for the additional
length of the donor tooth due to the apical soft tissues,
compared with the analogue. In this case, the surgeon
drilled the recipient site to an additional 1 mm depth
after successful seating of the donor analogue.
Conclusions
. The use of a CBCT-derived 3D printed analogue is a
cost-effective means of reducing the surgical time
and potential iatrogenic trauma to the donor tooth
during tooth autotransplantation surgery.
. This novel technique should be the subject of a pro-
spective study of multiple cases to both validate it
and optimise clinical outcomes.
Acknowledgments
The authors are grateful to 3D digital technician, Geoffrey
Oliver, for his technical expertise in producing the analogue
tooth.
Disclosure statement
No potential conflict of interest was reported by the authors.
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