Autotransplantation: The Vital Option for Replacement of Missing Anterior Teeth in the Developing Dentition

R. David Roden, Jr., DMD, MD, and Mark R. Yanosky, DMD, MS

Missing multiple anterior teeth presents a tremendous challenge for the dental team. There are several options for successful replacement or masking of the missing teeth, including orthodontic space closure, xed or removable prosthetics, osseointegrated dental implants, and tooth autotransplantation. Often these modalities must be combined to obtain the best esthetic and functional results. An 11.5-year-old girl sustained loss of her permanent central incisors and right lateral incisor teeth, and in addition sustained a comminuted maxilla fracture with loss of the buccal plate during a horseback riding accident. Using autotransplantation and orthodontic space closure, an esthetic and functional outcome with vital teeth was achieved. The collaboration of a multispecialty dental team is essential for challenging cases such as the one presented. The use of autotransplantation provided our patient with early denitive tooth replacement, and is the only replacement option to provide vital teeth. Autotransplantation should be considered in the treatment options for missing anterior teeth in the developing dentition. (Semin Orthod 2013;19:13-23.) 2013 Elsevier Inc. All rights reserved.

issing anterior teeth in the developing dentition poses a very challenging problem for the dental team. Whether the teeth are missing congenitally or owing to trauma, individuals prefer rapid and denitive replacement. Andreasen et al1 found that most traumatic dental injuries occur during the time of the developing dentition.2,3 There are many options for the replacement of missing teeth, regardless of the etiology. The challenge of planning for their replacement comes with not only the number and location of the missing teeth but also the age and developmental stage of the patient. The replacement or masking options include orthodontic space closure, removable or xed prosthetic re-

Private Practice, Oral and Maxillofacial Surgery, Birmingham, AL; Private Practice, Orthodontics, Birmingham, AL; University of Alabama School of Dentistry, Birmingham, AL. Address correspondence to R. David Roden, Jr., DMD, MD, Oral and Maxillofacial Surgery, 1771 Independence Court, Suite 2, Birmingham, AL 35216. E-mail: audavid1@hotmail.com 2013 Elsevier Inc. All rights reserved. 1073-8746/13/1901-0$30.00/0 http://dx.doi.org/10.1053/j.sodo.2012.10.004

placement, osseointegrated dental implant replacement, and tooth autotransplantation. Orthodontic space closure is an option, but in many cases, will leave an unacceptable esthetic result and functional compromise. Instead of truly replacing the missing teeth, this procedure masks the defect of the missing tooth. For example, a mesially positioned cuspid to replace a missing lateral incisor, even with concomitant extrusive forces and prosthodontic recontouring, is an esthetic and functional compromise. The gingival contours of the tooth will not match the opposite side of the arch, and the patient will be left in a modied group function on the affected side. In the patient with multiple missing teeth, orthodontic space closure can be combined with other replacement options and be successful. As the sole option for replacing multiple missing teeth, orthodontic space closure is insufcient. Asking a teenager to go through many of the socially developmental years with a removable prosthesis or even a bonded restoration requiring alteration of otherwise sound teeth and mul13

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tiple repairs and replacements seems unwise. Even with the advent of new restorative materials and bonding agents, resin-bonded prostheses have a high rate of short-term and long-term failure.4 In the absence of a functioning tooth at the site, alveolar function and development is not stimulated, and alveolar bone loss will progress. The science behind osseointegration and dental implants is well developed. However, placement of a dental implant before completed facial growth and alveolar development can result in poor esthetic and functional outcomes. Implants are a very effective treatment for replacement of missing teeth; however, this denitive treatment cannot be completed until the patient is at least 18 years old. Although the success and survival of dental implants is 90%, placement of an implant at a young age with less than ideal alveolar bone can lead to esthetic challenges. As continued bone loss and gingival thinning occur, gray discoloration at the gingival margin will appear owing to show through of the implant components. Tooth autotransplantation is dened as the movement of a tooth or dental germ from one position to another, within the same person.5 It is the only option that will allow for a vital replacement, early denitive replacement, and, many times, fewer surgical interventions. Autotransplantation should be considered for replacement of missing teeth when there are clear indications for extraction of otherwise healthy teeth. Aided by prosthetic recontouring, transplanted teeth can provide an excellent esthetic and functional result. In addition, the concern of implant components showing through the gingiva is no longer an issue. Unless multiple teeth are missing and orthodontic repositioning must be used as well, there is the opportunity for less functional compromise. Several authors have shown tooth autotransplantation to be successful, with survival rates of 74%-100%.6 According to Czochrowska et al,7 the survival rate of 30 transplanted premolars in 25 patients was 90%. This same retrospective review reported success, based on accepted clinical parameters, at 79%. Autotransplantation allows for the replacement of missing teeth with a vital tooth. Vitality is most promising when autotransplantation is performed using donor teeth with open apices in the developing dentition. Because alveolar development at a site is

reliant on tooth presence and eruption, loss of a functioning tooth at a site will lead to alveolar bone loss and insufcient bone quality and quantity for implant placement in the future. Having a transplanted tooth present will allow for continued alveolar stimulation. Furthermore, it provides an esthetic replacement during development without altering adjacent teeth. Should the transplant be unsuccessful, and future bone grafting and implant placement be indicated, there will be a more favorable biological situation for implant success. Multiple authors have outlined keys for success with autotransplantation with regard to the developing dentition. One can expect high autotransplant success and survivability if these principles are followed (Table 1). Czochrowska et al7 dened success using modied parameters from several authors. Their criteria were absence of progressive root resorption, normal hard and soft periodontal tissues adjacent to the transplanted tooth, and crown-to-root ratio 1. Other measures of success include a vital transplanted tooth and continued root development after transplantation. These objectives can be met with careful planning and surgical technique. Root development after transplantation can be unpredictable but likely to continue with preservation of the root sheath of an immature tooth.8-12 The initial response to healing is inammation, which can lead to root resorption if not controlled. Although excellent surgical technique cannot predict how much development will occur, maintaining Hertwig root sheath with good surgical technique is essential for having continued root formation. A tooth with to 23 root development has the greatest predictability for survival.13 This stage of development allows for enough root structure should no further root development occur and, if Hertwig root sheath remains intact, the potential for further root development is favorable. Andreasen et al9
Table 1. Keys for Autotransplant Success
1 2 3 4 5 6 7 8 Donor tooth to 23 root development, with 1-mm open apex. Atraumatic extraction, maintaining periodontal ligament cells. Brief extraoral time of donor tooth. Best result if recipient site is fresh extraction site. Overprepared recipient site. Functional xation. Follicle cells and Hertwig root sheath intact. Keep donor tooth out of occlusion.

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found that 82% of transplanted premolars underwent partial or complete root development, and only 18% had no further development. Normal hard and soft periodontal structures are obtained after transplantation by maintaining as many viable periodontal ligament (PDL) cells on the transplanted root as possible. The presence of PDL cells at the recipient site is also benecial, but many times, they are unintentionally obliterated during preparation of the site.8,14 PDL cells are maintained on the donor tooth by careful surgical technique and minimizing their exposure to harmful environments such as desiccation and chemicals. The presence of these cells on the majority of the donor root surface can prevent replacement resorption or ankylosis by minimizing the surface of the root exposed, which maintains an active inammatory response.8 If a small area of the root is missing PDL cells, it can be repopulated by adjacent PDL cells and harmful inammatory healing can be avoided. Large areas devoid of PDL cells will maintain the inammatory response and have an unfavorable outcome. Vitality of transplanted teeth is expected when immature teeth with open apices are transplanted. With an open apex of 1 mm, angiogenesis can occur, providing nutrients to the invading pulp cells. Tsukiboshi showed evidence that pulp canal obliteration is a positive sign of pulpal health and should be expected.8 The donor teeth should respond to vitality testing approximately 6 months after transplant. If any signs of persistent inammatory healing appear clinically or radiographically, endodontic therapy should be initiated immediately.

of the anterior maxilla, with avulsion of the buccal plate. She had a degloving injury of her maxillary gingiva and mucosa up to the nasal oor. The teeth were displaced high into the maxillary soft tissues and the nasal oor along with her orthodontic appliances (Fig 1A). She also sustained 2 deep facial lacerations on the right face. She presented to the emergency department and underwent complete trauma workup.

Surgical Sequence and Technique

Owing to the patients age and the severity of her injury, she was taken to the operating room on the evening of her injury, and using intubated general anesthesia, her wounds were explored and cleaned. Owing to the lack of buccal bone and the uncleanliness of her injury, it was determined that she was not a candidate for reimplantation of the avulsed teeth. The avulsed teeth were extracted, and the orthodontic hardware was removed (Fig 1B). Her wounds were thoroughly cleansed, and the nasal oor and facial lacerations were closed. To better prepare her for future replacement of the missing teeth, the maxillary alveolus was grafted with DBX Mix (Synthes, Inc, West Chester, PA), a mixture of demineralized bone matrix and cortical chips in a sodium hyaluronate carrier (Fig 1C). Her intraoral soft tissues were advanced and closed primarily (Fig 1D). During the 6 months of required healing for the bone graft, a team of dental practitioners was assembled to plan treatment for her missing teeth. Her orthodontic evaluation revealed an anterior open bite and ectopically erupting right maxillary cuspid. The patient and her family were opposed to her wearing a removable prosthesis for the next 8 to 10 years of her life, and no other xed prosthetic option seemed reasonable. After many discussions, we determined that she likely was going to need mandibular premolar extractions to better manage her skeletal discrepancy, and that her mandibular premolars were at a stage of development appropriate for transplant. Because she already had an open bite, there would be no problem with occlusal interference after transplantation. Transplantation, if successful, would provide her esthetic, long-term, and vital replacements for her missing central incisors. Her right maxillary cuspid would be surgically exposed and bracketed with

Case Presentation
Much like the case presented by Zachrisson in 2008,2 our case involves a child with developing dentition and a horseback riding accident. An 11.5-year-old girl fell from horseback on a wooded trail. After falling, the rear hoof of the horse impacted the face and maxilla of the patient, avulsing multiple maxillary anterior teeth. At the time, the patient was wearing orthodontic appliances and was in the mixed dentition. She sustained avulsion and severe intrusion of her permanent upper right maxillary lateral and central incisors as well as her permanent left central incisor. There was a comminuted fracture

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Figure 1. 1 (A) Initial surgery after accident. Teeth in the oor of the nose, severely displaced orthodontic appliances, missing buccal plate, and degloving injury of the anterior maxilla are shown. (B) After hardware removal, extraction of teeth, and cleansing of the wound, the right piriform rim of the nose and the extent of the bone loss can be clearly seen. The erupting right maxillary cuspid can also be identied. Deep perioral lacerations are present on the right face. (C) DBX Mix (Synthes, Inc, West Chester, PA) bone grafting material in place. (D) Primary closure of the intraoral wounds and facial lacerations. (E) Panoramic radiograph taken immediately before initial transplant surgery. Excellent bone height in the anterior maxilla noted. The right and left mandibular premolars have open apices, indicating a good opportunity for revascularization of the pulp chamber. (F) Three-month postoperative image after the grafting surgery, showing good ridge form for future transplantation. (Color version of gure is available online.)

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Figure 1. Continued

a chain to direct its eruption into the position of her right lateral incisor. The cuspid and transplanted teeth would then later undergo prosthetic recontouring to satisfy esthetic needs.

Transplant Surgery Technique

Preoperative radiographic evaluation was performed to determine the appropriate donor tooth and adequate bone height at the recipient site (Fig 1E). Clinical evaluation of the donor and recipient sites was also performed to ensure lack of pathologic processes and adequate bony width for receiving the transplant (Fig 1F). The patient was brought to the Oral and Maxillofa-

cial Surgery Clinic operating suite, and she rinsed her mouth with 0.12% chlorhexidine gluconate for 1 minute and expectorated. An intravenous catheter was inserted, and general anesthesia was accomplished to ensure her comfort. A preoperative dose of intravenous antibiotic, cefazolin (1 g), was administered (Hospira, Inc, Lake Forest, IL). Local anesthesia at the donor and recipient sites was administered in the form of 2% lidocaine with 1:100,000 epinephrine (Hospira, Inc, Lake Forest, IL) and 0.5% Marcaine with 1:200,000 epinephrine (Hospira, Inc, Lake Forest, IL). Once an adequate level of local anesthesia was obtained, a crestal incision was made at the recipient site, and a full-thickness

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Figure 2. (A) Nobel Biocare Replace Select (Nobel Biocare, Yorba Linda, CA) osteotomy drills used to make the initial recipient site osteotomy. (B) Initial osteotomy for transplant site, created using implant drills. (C) After extraction of the left mandibular primary second molar, the left mandibular second premolar was exposed. Care had been taken to preserve as much of the follicle as possible, and bone had been removed, exposing a small portion of the cervical root. (D) The extracted donor tooth, left mandibular premolar. Large amount of follicle remains at the cervix, which will aid in tight closure and encourage rapid healing. The fuzzy appearance of the root is due to the presence of periodontal ligament cells on the root surface. Rapid assessment of the root form and existing tissues must be accomplished to minimize the out-of-socket time for the transplant tooth. (E) Further preparation of the recipient site by widening the osteotomy buccolingually. Also note that the maxillary right cuspid has been exposed and ligated with a button and gold chain. (F) Initial placement of 4-0 silk sutures mesially and distally to aid in rapid and tight closure immediately after the transplanted tooth is placed in the recipient site. (G) Transplanted tooth in place without pressure or impingement on any structures. (H) Closure of the operative site with silk suture mesially and distally. The tails are crossed over the occlusal surface of the transplant and tied. With proper socket preparation and no impingement from the opposing occlusion, this is the only xation necessary for a tooth autotransplantation. (Color version of gure is available online.)

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Figure 2. Continued

ap was elevated. The ectopically erupting right cuspid was easily identied. Bone was removed from the facial surface, and a button and gold chain were bonded to the facial surface using a standard technique. The bone at the recipient site was deemed as having adequate width for the transplant. Many techniques in the literature describe using a round bur for site preparation. To better control the osteotomy and to provide internal irrigation reducing the amount of heat generated, we used tapered implant osteotomy drills from the Nobel Biocare Tapered Groovy Implant system (Nobel Biocare, Yorba Linda, CA) to initiate the osteotomy (Fig 2A). The osteotomy was created at proper position and

Figure 3. One week after transplant surgery and after silk suture removal. (Color version of gure is available online.)

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Figure 4. (A) One month after transplant. Gingival healing has occurred, and there are no occlusal interferences present. Although the tooth is somewhat malpositioned, this will be taken care of with orthodontic movements. (B) Periapical radiograph taken 1 month postoperatively, demonstrating an open apex and no root resorption. (Color version of gure is available online.)

depth to ensure no occlusal contact would be present between the transplanted tooth and the mandibular dentition after surgery (Fig 2B). After the initial preparation of the recipient site, we directed our attention to harvesting the donor tooth. Careful planning with the dental team determined the mandibular second premolars as the most appropriate donor teeth. A ap was developed over the lower left second premolar. Bone was removed to well below the height of contour of the tooth ensuring no contact of the bur with the root surface and preserving as much of the follicle as possible (Fig 2C). As discussed previously, one of the principles of autotransplantation surgery is to maintain as

many PDL cells as possible. To achieve this, the tooth was gently luxated and extracted (Fig 2D). To decrease the amount of out-of-socket time for the tooth, its root form was quickly evaluated, and the tooth was immediately returned to its original socket. Because the root was wider buccolingually than we had prepared, the osteotomy at the recipient site was widened in the necessary dimensions (Fig 2E). Next, the transplanted tooth was tried into the recipient socket and found to t passively. To fully prepare the recipient site, the tooth was again returned to its original socket while preparation of the recipient site was completed. Although there are many media in which the tooth can be stored ex-

Figure 5. (A) One week follow-up appointment after the second transplant. Malposition of the right transplanted tooth and the better position of the left transplanted tooth after orthodontic movements is noted. (B) Periapical radiograph taken at 1 week after second transplant. The open apices of the transplanted teeth are noted. The left transplanted tooth had begun to have some canal obliteration. (Color version of gure is available online.)

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site and the maxillary ap were closed using a 4-0 chromic gut suture. The patient was allowed to recover from her anesthesia and was discharged home. She was placed on a 1-week course of amoxicillin (500 mg) every 8 hours. She was also instructed to use over-the-counter nonsteroidal anti-inammatory medications for pain control and was given a prescription for hydrocodone (5 mg)/acetaminophen (500 mg) to be used every 4 to 6 hours as needed for breakthrough pain. After 3 days of initial healing, she started twice-daily 0.12% chlorhexidine gluconate mouth rinses (Peridex, 3M ESPE, St Paul, MN).

Figure 6. Transplanted teeth before prosthodontic reshaping. Also note the good healing of the periodontal soft tissues around the teeth. (Color version of gure is available online.)

traorally during this period, there is no substitute for the original tooth socket. One must ensure that the tooth ts passively and no pressure is placed on it during placement, removal, and replacement in any socket. This will ensure minimal damage to the remaining PDL cells. Some have proposed the use of prefabricated models of the donor tooth made from computed tomography scans before surgery to reduce the out-of-socket time for the donor tooth.15 The additional expense and fear of radiation exposure, although minimized with focused-eld cone-beam computed tomography, is not accepted by many patients and their families. Preparation of the recipient site was continued by placing a 4-0 silk suture mesial and distal to the recipient site (Fig 2F). These sutures were loosely tied, and long tails remained. A tight soft tissue t at the site assists with retention of the donor tooth and provides less opportunity for seepage of uids into the subgingival transplant site. At this point, the donor tooth was removed from its socket and transplanted to the recipient site (Fig 2G). The tooth was placed, and minimal pressure was applied. The sutures were tightened mesially and distally. The long tails were then crossed over the occlusal surface of the tooth and tied tightly, providing a splint and xation for the transplant (Fig 2H). The donor

Figure 7. (A) Facial view of reshaped teeth. Gingival healing is present. Gingival recontouring to create symmetry will be performed in the future. (B) Occlusal view after prosthodontic reshaping. (Color version of gure is available online.)

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The patient was followed up at 1 week for radiographs and suture removal (Fig 3). Her donor and recipient sites were healing uneventfully. There was no evidence of infection or any resorption at this time. She was seen every 2 weeks during the initial healing period to evaluate for complications (Fig 4A and B). Early detection of root resorption or persistent inammation is essential so that endodontic therapy can be initiated to help prevent failure of the transplant. The literature on initiation of orthodontic therapy after tooth transplant is inconclusive. Some authors advocate starting 3 to 9 months

posttransplant.2,6 Our team decided to proceed with earlier orthodontic intervention to obtain proper positioning and excellent bone stimulation and development. There was a need to move the transplanted tooth to the right central incisor position to have room for a subsequent transplant to the left central incisor position. Our patient was tted with orthodontic appliances, and movements were initiated approximately 2 months after transplant surgery. She was followed clinically and radiographically, with no complications noted. Six months later, the patient underwent transplantation of another mandibular second pre-

Figure 8. (A) Radiograph taken 3 months before debonding. Some canal obliteration noted with the transplanted teeth. The anterior open bite persists. (B) After debonding, the teeth have good position and form. The anterior open bite persists. The discoloration of the repositioned cuspid is evident. Tooth shape and color corrections are planned with future prosthodontic intervention. (Color version of gure is available online.)

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molar to the right central incisor position using the same technique previously described (Fig 5A and B). After adequate orthodontic positioning (Fig 6) of her transplanted teeth, recontouring of the teeth was performed (Fig 7A and B). At 6 months after transplant and subsequent follow-up visits, her transplanted teeth tested vital and did not require endodontic therapy. No external resorption was noted. The teeth had normal hard and soft periodontal structures clinically and radiographically. Two years after her initial injury, orthodontic appliances were removed, and her transplants were stable (Fig 8A and B). The patient and her family are satised with the esthetic and functional results. Bimaxillary orthognathic surgery is planned in the future to correct her skeletal discrepancy. Tooth shape and color corrections were planned with future prosthodontic intervention.

orthodontic care was provided by Dr Mark Yanosky, and restorative care was provided by Dr Thomas Dudney.

References
1. Andreasen JO, Ravn JJ: Epidemiology of traumatic dental injuries to primary and permanent teeth in a Danish population sample. Int J Oral Surg 1:235-239, 1972 2. Zachrisson BU: Planning esthetic treatment after avulsion of maxillary incisors. J Am Dent Assoc 139:14841490, 2008 3. Glendor U, Marcenes W, Andreasen JO: Classication, epidemiology and etiology, in Andreasen JO, Andreasen FM, Andersson L eds: Textbook and Color Atlas of Traumatic Injuries to the Teeth, 4 ed. Ames, IA, Blackwell, Munksgaard, 2007, pp 217-254 4. Thomas S, Turner SR, Sandy JR: Autotransplantation of teeth: Is there a role? Br J Orthod 25:275-282, 1998 5. Andreasen JO, Paulsen HU, Yu Z, et al: A long-term study of 370 autotransplanted premolars. part I. Surgical procedures and standardized techniques for monitoring healing. Eur J Orthod 12:3-13, 1990 6. Mensink G, van Merkesteyn R: Autotransplantation of premolars. Br Dent J 208:109-111, 2010 7. Czochrowska EM, Stenvik A, Bjercke B, et al: Outcome of tooth transplantation: Survival and success rates 17-41 years posttreatment. Am J Orthod Dentofacial Orthop 121:110-119, 2002 8. Tsukiboshi M: Autotransplantation of teeth: Requirements for predictable success. Dent Traumatol 18:157180, 2002 9. Andreasen JO, Paulsen HU, Yu Z, et al: A long-term study of 370 autotransplanted premolars. Part IV. Root development subsequent to transplantation. Eur J Orthod 12:38-50, 1990 10. Kristerson L, Andreasen JO: Inuence of root development on periodontal and pulpal healing after replantation of incisors in monkeys. Int J Oral Surg 13:313-323, 1984 11. Kristerson L, Andreasen JO: Autotransplantation and replantation of tooth germs in monkeys. Effect of damage to the dental follicle and position of transplant in the alveolus. Int J Oral Surg 13:324-333, 1984 12. Andreasen JO, Kristerson L, Andreasen FM: Damage of the Hertwigs epithelial root sheath: Effect upon root growth after autotransplantation of teeth in monkeys. Endod Dent Traumatol 4:145-151, 1988 13. Clokie CM, Yau DM, Chano L: Autogenous tooth transplantation: An alternative to dental implant placement? J Can Dent Assoc 67:92-96, 2001 14. Andreasen JO: Periodontal healing after replantation and autotransplantation of incisors in monkeys. Int J Oral Surg 10:54-61, 1981 15. Keightley AJ, Cross DL, McKerlie RA, et al: Autotransplantation of an immature premolar, with the aid of cone beam CT and computer-aided prototyping: A case report. Dent Traumatol 26:195-199, 2010

Conclusions
Loss of teeth in the developing dentition poses a great challenge for the dental team when planning replacement options. This is especially true when multiple anterior teeth are missing. There are several options for replacement of these teeth, each with its associated advantages and disadvantages. The only treatment option that allows for reducing the number of interventions, providing a vital replacement, avoiding removable prostheses, and not altering adjacent teeth is autotransplantation. Tooth autotransplantation has proven successful in the literature and should be considered because it is the sole vital replacement option. Autotransplantation treatment is indicated in many situations, but likely overlooked owing to lack of experience. The overall success of autotransplantation requires a dental team, including orthodontists, oral surgery, and restorative dentistry, working together toward common functional and esthetic results.

Acknowledgments
The patient illustrated in this paper was surgically treated at the University of Alabama at Birmingham (Dr David Roden),