CASE REPORT

Mandibular premolar transplantation to

replace missing maxillary anterior teeth:
A multidisciplinary approach
Pawinee Tankittiwat,a Rungkarn Thittiwong,b Saowaluck Limmonthol,c Waraporn Suwannarong,d
Peerapong Kupradit,e Saengsome Prajaneh,d and Poonsak Piseka
Khon Kaen and Kanchanaburi, Thailand

One of the most challenging problems for orthodontists is that of multiple missing maxillary teeth in a growing
patient. In many patients, a good treatment option is autotransplantation. This case report describes the multi-
disciplinary treatment of an 11-year-old girl with regional odontodysplasia affecting the maxillary right and left
central incisors, and congenitally missing maxillary left lateral incisor and canine. Autotransplantation of the
mandibular second premolars to the affected area was combined with orthodontic space closure, and the trans-
planted premolars were reshaped and restored with a resin composite to be in line with the left central and lateral
incisors. After completion of the orthodontic treatment, gingivectomy was performed to obtain an even gingival
contour and symmetrical gingival tissue. Space closure of the maxillary anterior teeth was achieved. Autotrans-
plantation enabled the patient to retain her natural teeth rather than having a prosthesis or dental implant. The
autotransplanted tooth allows for alveolar bone growth in synchrony with neighboring teeth and the formation of
normal interdental papilla while adapting to functional stimuli and confers a high survival rate in the long term.
(Am J Orthod Dentofacial Orthop 2021;160:459-72)

R
egional odontodysplasia (RO), probably first
described by Hitchin in 1934, is a rare dental
anomaly affecting primary and/or permanent
teeth, most often in one quadrant.1 Clinical appearance
shows brown or yellowish soft teeth with clinical symp-
toms after eruption, such as gingival swelling, gingivitis,
or abscess; in some patients, a failure of tooth eruption
may occur.1,2 Radiographically, the affected teeth
appear as ghost teeth because the enamel and dentin
are hypomineralized and hypoplastic, reducing radio-
density with wide pulp chambers and apical foramen.1
a
Division of Orthodontics, Department of Preventive Dentistry, Faculty of
Dentistry, Khon Kaen University, Khon Kaen, Thailand.
b
Dental Department, Phaholpolpayuhasena Hospital, Kanchanaburi, Thailand.
c
Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Khon Kaen
University, Khon Kaen, Thailand.
d
Division of Periodontology, Department of Oral Biomedical Sciences, Faculty of
Dentistry, Khon Kaen University, Khon Kaen, Thailand.
e
Division of Operative Dentistry, Department of Restorative Dentistry, Faculty of
Dentistry, Khon Kaen University, Khon Kaen, Thailand.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Poonsak Pisek, Division of Orthodontics, Depart-
ment of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Khon
Kaen 40002, Thailand; e-mail, poonsak@kku.ac.th.
Submitted, December 2019; revised, May 2020; accepted, June 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.06.035
Treatment goals of a RO combined with multiple
anterior missing teeth for patients during childhood
include function and esthetic improvement, facilitation
of normal jaw growth, and reduction of the psycholog-
ical impact.2,3 Possible treatment options are implants,
prosthesis, orthodontic space closure, autotransplanta-
tion, or a combination in any complicated cases.2,4
Dental autotransplantation is defined as the reposi-
tioning of a tooth from one site to a tooth extraction
site or a surgically formed recipient site within the
same person,5 which provides the possibility of a nat-
ural tooth rather than a prosthesis or implant to replace
missing teeth. It is an alternative approach suitable for
certain clinical situations, especially in young patients,
for which a high success rate of .95% has been
demonstrated.6-8 A successful autotransplantation
can induce bone formation, reestablish a normal
alveolar process and periodontal ligament, and
permit tooth movement.5,9 Meanwhile, an implant
will not follow the adjacent incisors vertically during
tooth eruption at any age.6
Our case report describes a multidisciplinary treat-
ment carried out by an orthodontist, an oral maxillofa-
cial surgeon, a restorative dentist, and a periodontist
to help a girl with RO at the maxillary right and left cen-
tral incisors and congenitally missing maxillary left

459
460
Fig 1. Pretreatment facial and intraoral photographs.
lateral incisor and canine achieve better dentition. The
mandibular second premolars were autotransplanted
to the affected area.
DIAGNOSIS AND ETIOLOGY
A girl aged 11 years and 1 month, with the chief
complaint of esthetic concerns, underwent evaluation
of her maxillary anterior teeth. She was physically
healthy with no contributing medical history. The pre-
treatment facial photographs (Fig 1) showed a convex
facial profile with a slightly protruded lower lip, low
smile line, and absence of multiple maxillary anterior
teeth.
The pretreatment intraoral photographs (Fig 1)
showed the clinical absence of the maxillary right and
left central incisors, left lateral incisor, and canine. She
had no active dental caries, although her maxillary left
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Tankittiwat et al
first molar was restored with a stainless steel crown
because of previously treated dental caries. She had
normal gingiva and alveolar bone at the maxillary central
and lateral incisor area. The pretreatment dental casts
(Fig 2) presented the Angle’s Class II malocclusion: a
spacing of 25.5 mm in the maxillary arch, crowding of
2 mm in the mandibular arch, and 3 mm deep curve of
Spee.
In the panoramic radiograph (Fig 3), all permanent
teeth aside from the left lateral incisor and canine were
visible. However, the maxillary right and left central in-
cisors had been impacted by abnormal formation, with
the appearance of ghost teeth and the formation of short
roots. In addition, cone-beam computed tomography
images (Fig 3) revealed the maxillary right central incisor
to be approximately 9 mm below the alveolar bone with
a 5.6-mm diameter and 11-mm height, whereas the
maxillary left central incisor was 12.6 mm below the
Tankittiwat et al
Fig 2. Pretreatment dental casts.
alveolar bone with a 6.3-mm diameter and 6.6-mm
height. These findings contributed to the diagnosis of
RO.
The pretreatment lateral cephalometric radiograph
(Fig 3) and analysis (Table) revealed a Class I skeletal
pattern with orthognathic maxilla and mandible when
compared with the cranial base (SNA, 81.6 ; SNB,
80.3 ; ANB, 1.3 ). She had an acceptable vertical skeletal
relationship (MP-PP, 25.5 ) but slightly decreased lower
anterior facial height (ANS-Me, 58.1 mm).
TREATMENT OBJECTIVES
The treatment objectives consisted of substitution for
the missing maxillary incisors and canine after removal
of the ghost teeth, using mandibular premolar trans-
plantation.
To achieve the treatment objectives, a 3-dimensional
model setup was created with 3Shape Ortho Analyzer
software (3ShapeE2 lab scanner, Copenhagen, Denmark)
for communication and visualization among the clini-
cians, the patient, and her parents (Fig 4).
TREATMENT ALTERNATIVES
The selected treatment plan for this patient was
autotransplantation combined with orthodontic space
closure. This plan involved surgical removal of the
maxillary right and left central incisors that had
been diagnosed with RO and substitution of the right
central and lateral incisors with the right lateral incisor
American Journal of Orthodontics and Dentofacial Orthopedics
461
and canine, respectively. The maxillary premolars were
substituted for the canines on both sides. Then, the
mandibular second premolars with three fourths of
root length were transplanted to the maxillary left
central and lateral incisors. The teeth in the mandib-
ular arch were leveled and aligned with a slight
mandibular central incisor retraction to improve the
lower lip position, relieve crowding, and correct the
deep curve of Spee. Moderate anchorage preparation
was carried out in both arches. This plan was advan-
tageous in that the patient’s natural teeth were used
instead of prostheses or implants, but the disadvan-
tages included the requirement for the patient to un-
dergo surgery and a longer orthodontic treatment
period.
One treatment alternative was a dental implant or
prosthesis combined with orthodontic treatment to re-
move the maxillary right and left central incisors sur-
gically and to substitute the right central and lateral
incisors with the right lateral incisor and canine,
respectively. The maxillary premolars would be
substituted for the canines on both sides, maintaining
space at the left central and lateral incisors for pros-
thetic treatment or dental implant placement after
completion of the maxillary alveolar vertical growth
process. The second premolars in the mandibular
arch would be extracted to achieve slight retraction
of the mandibular central incisors, improving the
lower lip position, relieving crowding, and correcting
the deep curve of Spee. The advantages of this option
September 2021  Vol 160  Issue 3
462 Tankittiwat et al

Fig 3. Pretreatment radiographs: A, lateral cephalometric; B, cephalometric tracing; C, panoramic ra-

diographs were taken 2 months before stainless steel crown treatment of the maxillary left first molar
and cone-beam computed tomography images of RO; D, sagittal view of the maxillary right central in-
cisors; E, sagittal view of the maxillary left central incisors; F, axial view

included a shorter orthodontic treatment period; the
disadvantage was the need to insert prostheses or
implants.
Another alternative treatment was the nonextraction
of the mandibular premolars, with slight proclination of
the mandibular incisors to correct crowding and the
deep curve of Spee. Space would be created in the maxil-
lary arch for dental implants or prosthetic replacements
of the right and left central incisors, the left lateral
incisor, and the canine. The advantages of this option
were nonextraction, the elimination of excessive ortho-
dontic movement, and a shorter treatment period, but
the disadvantage was more proclined maxillary and
mandibular incisors, resulting in protruded lips. More-
over, this option would create a long edentulous area,
requiring long-span dental prosthesis or implants,
higher costs, and unpredictability in terms of long-
term efficacy.

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Tankittiwat et al 463

orthodontic archwire and a resin composite (Fig 5, E).

Table. Cephalometric measurements
The transplanted premolar tooth was placed in infraoc-
Variables Thai norm Pretreatment Posttreatment clusion, and the cusp was ground to avoid any pressure
Skeletal or occlusal interference and prevent injury of the perio-
Maxilla to cranial dontium; moreover, the tooth was rotated 90 to achieve
base
the ideal cervical width when compared with the contra-
SNA ( ) 84.0 6 3.6 81.6 80.9
Mandible to lateral tooth and for higher favorability in restoration10
cranial base with sufficient bone support in the transverse direction
SNB ( ) 81.0 6 3.6 80.3 79.3 of the alveolar process.11 Histologic examination of the
Maxillomandibular impacted maxillary central incisors showed tiny tooth-
ANB ( ) 3.0 6 2.5 1.3 1.6
like structures consisting of tubular dentin, interglobular
Wits appraisal (mm) 2.0 6 3.5 N/A 0.6
Vertical dentin, disorganized amorphous material, and pools of
MP-SN ( ) 30.0 6 5.6 30.3 32.9 enamel matrix, thus confirming the RO diagnosis. The
FMA (MP-FH) ( ) 22.7 6 5.4 28.2 30.4 2-month follow-up periapical radiograph showed a
MP-PP ( ) 20.9 6 5.3 25.5 26.0 thick periodontal ligament (PDL) space, normal alveolar
ANS-Me (mm) 68.1 6 5.0 58.1 60.0
bone level, large pulpal size, and nearly completed root.
N-ANS: ANS-Me (%) 45:55 44:56 45:55
S-Go:N-Me (%) 67.0 6 5.0 65.8 64.6 The transplanted tooth was subsequently further ground
Dental to relieve interference during orthodontic tooth move-
Maxillary dentition ment (Fig 6) and was bonded with a lateral incisor
U1-NA ( ) 22.0 6 5.9 N/A 21.4 bracket in the same position as the contralateral tooth.
U1-NA (mm) 5.0 6 2.1 N/A 2.9
Leveling was started with a 0.014-in nickel-titanium
SN-U1 ( ) 108.0 6 6.1 N/A 101.3
Mandibular dentition wire 3 months after surgery.
L1-NB ( ) 30.0 6 5.0 26.1 28.2 After the transplanted tooth had moved to the left
L1-NB (mm) 6.0 6 2.0 5.1 3.2 lateral incisor position by using the 0.016-in stainless
L1-FH ( ) 60.0 6 6.0 60.0 56.0 steel wire and elastic chain to create space at the left cen-
L1-MP ( ) 97.0 6 6.0 91.8 93.7
tral incisor, the 0.016-in Australian wire and V-bend me-
Soft tissue
LL to E-line (mm) 2.0 6 2.0 3.4 0.6 chanics were used in the mandibular arch to carry out
UL to E-line (mm) 1.0 6 2.0 0.7 0.7 mandibular anterior teeth intrusion and posterior teeth
N/A, Not applicable. extrusion.
Five months after the first autotransplantation, the
same technique was used to transplant the mandibular
TREATMENT PROGRESS
left second premolar with three fourths of root length
As a first treatment step, a 0.022 3 0.028-in slot, to the site of the maxillary left central incisor (Fig 7). Af-
straight-wire appliance (MBT prescription; 3M Unitek, ter 1 month, the periapical radiograph showed a thick
3M Dental Products, Monrovia, Calif) was placed in PDL space, normal alveolar bone level, large pulpal
both arches. All first molar teeth were banded, and the size, but the remaining three fourths of root length
bite was opened for prevention of occlusal interference (Fig 8). The tooth had started to move 3 months after
during autotransplantation with a composite raised bite. the operation (Fig 9).
In the aligning and leveling phase, the orthodontist In the movement and contraction phase, we used
started with a 0.016-in nickel-titanium wire in the a 0.016 3 0.022-in stainless wire and corrected the
maxillary and mandibular arches and then used a maxillary dental midline with a light open-coil
0.016-in Australian wire in the maxillary arch and a tis- spring. Meanwhile, the mandibular teeth were cor-
sue guard to maintain the maxillary anterior space. Two rected with an elastic chain placed from the left first
months after the transplantation site had been prepared, molar to the right first molar. In the finishing phase,
the first operation involved surgical removal of the bracket repositioning and a 0.017 3 0.025-in beta-
maxillary central incisors (Fig 5, A and B), and the titanium wire with minor wire bending were chosen
mandibular right second premolar with three fourths for detailing the occlusion. The patient was then
of root length was transplanted to the site of the maxil- referred to a restorative dentist for temporary resto-
lary left lateral incisor. To address root exposure through ration with a resin composite at the maxillary ante-
a bone defect, particulate bone grafting from the chin rior teeth, using Bolton analysis. This aimed to
was placed over the exposed root (Fig 5, C and D), fol- improve orthodontic closure and normalize overjet
lowed by gingival flap suturing and fixation, using an and overbite (Fig 10).

American Journal of Orthodontics and Dentofacial Orthopedics September 2021  Vol 160  Issue 3
464 Tankittiwat et al

Fig 4. Diagnostic model setup with 3D Ortho Analyzer software for space preparation of autotrans-
planted teeth and guiding of orthodontic tooth movement: the maxillary right lateral incisor and canine
moved slightly mesially to replace the maxillary right central and lateral incisors, whereas the maxillary
left premolar moved mesially to replace the maxillary left canine, creating space for 2 transplanted pre-
molars. In the mandibular arch, the second premolars were removed for transplantation, the mandib-
ular incisors moved lingually, and the mandibular molars moved slightly mesially, obtaining a molar
Class I relationship.

Fig 5. Autotransplantation: A, surgical removal of the maxillary central incisors; B, malformation of the
maxillary central incisors; C, particulate alveolar bone grafting from chin to recipient site; D, transplan-
tation of the mandibular right second premolar in the recipient site by rotating the tooth and placing the
bone grafting; E, gingival flap suturing and stabilization with the orthodontic archwire. Courtesy of Khon
Kaen University Dental Journal (KDJ). Vol. 18, No. 2 July–December, 2015.29

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Tankittiwat et al 465

Fig 6. Intraoral photographs and a periapical radiograph 2 months after the first operation, showing a
thick PDL space, normal alveolar bone level, large pulpal size, and nearly completed root.

Fig 7. Second operation: the mandibular left second premolar was transplanted in the recipient site by
rotating the tooth and gingival flap suturing. Courtesy of Khon Kaen University Dental Journal (KDJ).
Vol. 18, No. 2 July–December, 2015.29

After orthodontic treatment was completed, a wrap-
around retainer was placed, and the patient was referred
to a periodontist for frenectomy and gingivectomy of the
maxillary anterior teeth because of high frenulum
attachment, asymmetry of tooth length, and inconsis-
tent gingival margin.
TREATMENT RESULTS
Three years and 9 months after starting the ortho-
dontic treatment, Class I canine and molar relationships
were achieved; the maxillary midline shifted slightly to
the right relative to the mandibular midline, and the
extraction spaces were closed without prosthesis need
(Figs 11 and 12). The profile was acceptable, and the pa-
tient’s satisfaction had improved. Moreover, the cortical
bone had formed with a normal PDL space and alveolar
bone level. Both transplanted premolar roots had
continually developed, and the apical end of both roots
were completely closed but total pulp obliteration. How-
ever, there was neither sign of inflammatory root resorp-
tion nor pulp necrosis. Root canal treatment was not
necessary.12 (Figs 13 and 14).
From the posttreatment cephalometric radiograph
(Fig 13) and analysis (Table), the patient still maintains
a Class I skeletal pattern with orthognathic maxilla and
mandible (SNA, 80.9 ; SNB, 79.3 ; ANB 1.6 ). In addi-
tion, she has a normal vertical skeletal relationship

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466 Tankittiwat et al

(MP-PP, 26.0 ), slightly decreased lower anterior facial

Fig 8. A periapical radiograph, 1 month after the second
operation, showing a thick PDL space, normal alveolar
bone level, and large pulpal size for the remaining three
fourths of root length.
height (ANS-Me, 60.0 mm), and a good proportion of
upper and lower anterior facial height (N-ANS: ANS-
Me, 45:55). The maxillary incisors have a normal inclina-
tion and position (U1-NA, 21.4 ; U1-NA, 2.9 mm), and
the mandibular incisors are normally inclined but slightly
retruded (L1-NB, 28.2 ; L1-NB, 3.2 mm). In terms of soft
tissue, her upper and lower lips are positioned normally
compared with the E-line (UL to E-line, 0.7 mm; LL to
E-line, 0.6 mm).
The cephalometric superimposition shows pretreat-
ment conditions represented by the black line without
central incisors and posttreatment conditions repre-
sented by the red line, with right and left central incisors
substituted with the right lateral incisor and left trans-
planted premolar. The image reveals favorable growth,
slight anterior teeth retraction in centric occlusion, and

Fig 9. Intraoral photographs taken 3 months after the second operation.

Fig 10. Direct resin composite restoration of the maxillary anterior teeth.

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Tankittiwat et al
Fig 11. Posttreatment facial and intraoral photographs.
good anchorage control as planned (Fig 15). The func-
tional analysis showed that incisor-protected protrusion
and group function lateral excursions were established,
and the substituted teeth were reshaped to the central
and lateral incisors through adjustment of palatal cusps
and incisal edge so that they made contact at the same
time when the jaw was moved forward. The substituted
canines were also adjusted so that the palatal cusps
made simultaneous contact with the posterior teeth dur-
ing lateral jaw movement on the working side, thus facil-
itating the distribution of occlusal loading.
A frenectomy was performed to correct the frenulum
attachment, and a gingivectomy procedure at the maxil-
lary anterior teeth decreased excessive gingival tissue
display, useful in improving smile esthetics. Finally, if
the patient is diagnosed with altered passive tooth erup-
tion of maxillary anterior teeth when she is aged
American Journal of Orthodontics and Dentofacial Orthopedics
467
18-20 years, surgical crown lengthening and bone re-
constructing should be performed to achieve biological
width (Figs 16 and 17).
DISCUSSION
Treatment of patients with RO and multiple congen-
itally missing teeth is controversial and requires a multi-
disciplinary approach.2,3 Surgical removal should be
considered a treatment option if the affected teeth
inhibit tooth eruption or orthodontic tooth movement
or if it can help retain uninfected teeth to preserve the
alveolar bone.2,3
Several treatment options are available for growing
patients with congenitally missing teeth, including ortho-
dontic closure of the space, replacing the teeth with im-
plantation after growth is complete, fixed prostheses,
removable partial dentures, or autotransplantation.6,7,9
September 2021  Vol 160  Issue 3
468 Tankittiwat et al

Fig 12. Posttreatment dental casts.

Fig 13. Posttreatment radiographs and cephalometric tracing.

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Tankittiwat et al 469

Fig 14. Periapical radiographs from pretreatment to posttreatment: A and B, pretreatment radiograph;
C and D, postorthodontic treatment.

Fig 15. Superimposition of pretreatment and posttreatment cephalometric tracing.

Fig 16. Intraoral photographs: A, frenectomy; B, design of gingival margin for gingivectomy; C, gingi-
vectomy.

American Journal of Orthodontics and Dentofacial Orthopedics September 2021  Vol 160  Issue 3
470
Fig 17. Final intraoral photographs at follow-up 1 month after gingivectomy.
The combination of multiple treatment options in
complicated cases is often most appropriate.
In growing patients, implant placement is a contrain-
dication because the implant does not erupt along with
adjacent teeth, and there is a risk of infraocclusion post-
adolescence.6,9,13 Long-term follow-up has also found
this treatment option to be unfavorable in terms of
esthetic appearance because of minor marginal bone
loss, especially at the unilateral maxillary incisor
implant.14,15 Use of a conventional fixed bridge in
adolescent patients should be delayed because of large
pulpal size, a lengthy site maintenance process, and
the need for irreversible tooth preparation. In addition,
removable dentures may be disadvantageous; for
example, their temporary nature requires them to be
replaced periodically during growth.9 In contrast,
autotransplantation is a beneficial treatment option,
especially for young patients who can retain their natural
teeth rather than needing a prosthesis or dental implant.
Potential benefits include bone induction, promotion of
a normal alveolar process and PDL development, and the
fact that an autotransplanted tooth can be moved ortho-
dontically in the same way as any other tooth. Even if the
treatment fails in the future, the bone and implant
placement will have been preserved after facial develop-
ment is complete.6,9 For these reasons, autotransplanta-
tion was the most appropriate option for this patient.
The stage of the donor tooth’s root development is
one of the most important factors determining the suc-
cess of autotransplantation. Some authors recommend
an ideal root of the premolar tooth from three fourths
September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Tankittiwat et al
to fourth fifths16 or one half to three fourths of the final
root length.8,13,17 If the root has developed by less than
half, the treatment may be too traumatic and interfere
with further root development. In contrast, if a tooth
with complete root formation is transplanted, it will
require root canal therapy.5 In open apex teeth, the
pulp can revascularize through capillary vessel growth
at the apex.18 In this case report, autotransplantation
was carried out with proper timing because three fourths
of the root had formed in the patient’s mandibular sec-
ond premolars.
Long-term studies have shown the positive effects of
autotransplantation,10-12 with survival rates at over 90%
and success rates of .79%.16,17,19 According to a sys-
tematic review,8 survival and success rates for tooth au-
totransplantation with incomplete root formation were
also high (.95%), with a low rate of complication
(\5%). Complications that did occur resulted from con-
ditions such as ankylosis, severe infection, or root
resorption.17,19 Although these problems have not
been presented in this patient, follow-up evaluations
will be necessary. Moreover, the most successful proced-
ures have involved transplantation of premolars to the
maxillary anterior region, with reported success rates
of 82%-100%.4,13,20,21 The optimal premolars to trans-
plant to the maxillary anterior region are the second
mandibular premolars because of their root anatomy,
and longitudinal studies have demonstrated their favor-
able long-term results.9
Normally, bone grafting is unnecessary between
bone walls and transplant roots. However, if the donor’s
Tankittiwat et al
teeth are placed in the recipient site with insufficient
buccopalatal width, roots can protrude through a bone
defect, resulting in an increase in replacement root
resorption and ankylosis. A previous study reported
that bone coverage of less than two thirds of the buccal
surface was significantly more frequent in lost trans-
plants and was correlated with pathologic mobility.22
Therefore, bone grafting should be placed over the
exposed root for bone regeneration, especially in pa-
tients with large bone defects after the removal of uner-
upted teeth.18,23 For the patient in the present case,
alveolar bone grafting was required after removing the
RO in the maxillary right and left central incisors. The
defect caused incomplete bone coverage of the buccal
root surface at the transplanted premolar teeth. Bone
grafting was performed during autotransplantation
with no negative effect.23-25
After autotransplantation, the orthodontic force can
be applied. However, the timing for such treatment re-
mains controversial. Although some studies generally
recommend delaying orthodontic treatment until
6 months after the surgical procedure,7,10,20 Stenvik
and Zachrisson26 recommend that orthodontic move-
ment of transplants be postponed for about 6-9 months.
For the patient in the present case, the orthodontist
started orthodontic movement 3 months after the oper-
ation, as recommended by Andreasen et al16 and Tsuki-
boshi.18 They suggest initiating active orthodontic
treatment 3-9 months after periodontal healing but
before pulp canal obliteration.
Another consideration is that autotransplanted
teeth do not match the natural contralateral incisor;
for example, there tends to be a color mismatch and
asymmetry in crown width. Such features can be
improved with tooth rotation during surgery to
achieve the ideal cervical crown width.11 Zachrisson
et al6 recommends reshaping the premolar crown to
resemble incisor morphology. In their study, they
initially made a direct resin composite buildup and
later replaced it with porcelain laminate veneer. How-
ever, establishing normal incisor width using compos-
ite buildup is difficult and the material tends to
discolor with time. Furthermore, the use of prosthetic
crowns in adolescents is avoided because the large
pulp chambers limit preparation, and the gingival
retraction over time can lead to unaesthetic root
display. Czochrowska et al19 compared transplanted
premolars reshaped to incisor morphology with the
natural contralateral incisor teeth and found no dif-
ference in either clinical characteristics (color, soft-
tissue appearance, tooth morphology, and position)
or radiographic parameters other than pulp oblitera-
tion. They also found that hard and soft tissues
American Journal of Orthodontics and Dentofacial Orthopedics
471
adjacent to the transplanted teeth appeared normal,
and patients were left feeling satisfied. In the present
case, the patient received interim restoration with
direct composite buildup, and final restoration was
conducted after facial development was complete.
After orthodontic treatment and to improve es-
thetics, the patient was referred to further treatment of
frenectomy and gingivectomy because of high frenulum
attachment and asymmetry of gingival tissue. However,
in adolescent patients, gingivectomy of anterior teeth
for esthetic purposes should be postponed and reeval-
uated in early adulthood because the gingival contour
in an adolescent is not stable, and a cervical displace-
ment takes place during growth. Adolescents (aged
14-18 years) and adults (aged 20-51 years) show a
mean apical displacement of gingival margin of
0.51 mm and 0.13 mm, respectively, related to a second-
ary eruption of the incisors and a slowed increase in
facial height.27 In contrast, a study that conducted a
1-year follow-up to a surgical crown lengthening found
that the amount of tooth structure immediately after
surgery had decreased to 0.5 mm at interproximal sites
and 1.2 mm at buccal and lingual sites. This indicates
that the marginal periodontal tissue has a tendency to
grow in a coronal direction and relates to the gingival
phenotype and the patient’s healing response.28
Therefore, gingival surgery in the present study should
be reconsidered when the patient reaches the age of
18-29 years.
CONCLUSIONS
In growing patients with multiple congenitally
missing teeth, autotransplantation combined with or-
thodontic treatment is an alternative treatment option,
and a multidisciplinary team is a key factor in achieving
all objectives.
ACKNOWLEDGMENTS
The authors express gratitude to the postgraduate
students, Dr Siriwannapa Kawsamer from the Depart-
ment of Restorative Dentistry, and Dr Thananya Tara-
sena from the Department of Periodontology, Khon
Kaen University, for making this case report possible.
REFERENCES
1. Tervonen SA, Stratmann U, Mokrys K, Reichart PA. Regional odon-
todysplasia: a review of the literature and report of four cases. Clin
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