Autotransplantation: Replacement to Restore Integrity

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1 Mithra N Hegde et al Case Report /jp-journals Mithra N Hegde, 2 Nidarsh Hegde, 3 Raksha Bhat, 4 Nishita Philip ABSTRACT Autogenous tooth transplantation, or autotransplantation, is the surgical movement of a tooth from one location in the mouth to another in the same individual. Once thought to be experimental, autotransplantation has achieved high success rates and is an excellent option for tooth replacement. Although the indications for autotransplantation are narrow, careful patient selection coupled with an appropriate technique can lead to exceptional esthetic and functional results. This paper presents successful autotransplantation of a mature mandibular left third molar used to replace a mandibular left second molar. The mandibular second molar was nonrestorable due to vertical root fracture of distal root with furcation involvement and bony radiolucency. After extraction of mandibular second and third molars, the tooth was reimplanted into the extracted socket of second molar site. Six months of follow-up clinical and radiographic examination revealed satisfactory outcome with no signs or symptoms suggestive of pathology. In selected cases, autogenous tooth transplantation, even after complete root formation of the donor tooth, may be considered as a practical treatment alternative to conventional prosthetic rehabilitation or implant treatment. Keywords: Autotransplantation, Donor tooth, Reimplantation. How to cite this article: Hegde MN, Hegde N, Bhat R, Philip N.. Int J Oral Implantol Clin Res 2015;6(2): Source of support: Nil Conflict of interest: None Introduction The transplantation of embedded, impacted or erupted teeth from one site to another in the same individual into extraction sites or surgically prepared sockets is called autotransplantation. 1 Autotransplantation involves the transfer of a tooth from its alveolus to another site in the same person. 2,3 This site may be either an extraction 1 Senior Professor and Head, 2 Senior Professor 3 Assistant Professor, 4 Resident 1,3,4 Department of Conservative Dentistry and Endodontics AB Shetty Memorial Institute of Dental Sciences, Mangaluru Karnataka, India 2 Department of Oral and Maxillofacial Surgery, AB Shetty Memorial Institute of Dental Sciences, Mangaluru, Karnataka India Corresponding Author: Raksha Bhat, Assistant Professor Department of Conservative Dentistry and Endodontics, AB Shetty Memorial Institute of Dental Sciences, Derlakatte Mangaluru , Karnataka, India, Phone: rkshabhat@gmail.com 48 site or a newly surgically prepared alveolus. 4,5 Successful tooth transplantation offers improved esthetics, arch form and dentofacial development, mastication, speech and arch integrity. A transplanted third molar also maintains natural space, with little or no root resorption; alveolar bone volume; and the morphology of the alveolar ridge through proprioceptive stimulation. 6,7 This type of dental surgical intervention was firstly documented by Abulcassis, in 1050; however, only in 1564, the French dentist Ambroise Paré performed the first recorded surgery with details about tooth bud transplantation. In 1956, a transplantation technique for molars was described, and until today, the general guidelines of this surgical technique are practically the same. Notwithstanding, some techniques have been developed aiming to improve the prognosis, such as two-stage transplantation and prototyping. 8,9 The technique has been advocated in situations where the patient would require a fixed prosthesis, or where osseointegrated implants are contraindicated in a growing patient owing to the risk of infraocclusion. It has been reported that the average lifespan of a conventional bridge in general dental practice was 6.2 years, indicating many replacements over the lifespan of a young patient. 2 While there are many reasons for autotransplanting teeth, tooth loss as a result of dental caries is the most common indication, especially when mandibular first molars are involved. First molars erupt early and are often heavily restored. The main indications of tooth transplantation are related to cases of congenital tooth absence, traumas, iatrogenic, atypical tooth eruption, root resorption, extensive carious lesions, root fractures, periodontal disease, endodontic treatment failures (intentional reimplantation), indication for tooth extractions, and, if the prosthetic treatment is unviable, due to socioeconomic reasons. 2,8,10 The following case report describes an immediate autogenous transplantation from the mandibular left third molar (38) to the mandibular left first molar area (36) which had to be extracted due to extensive carious lesion affecting the periradicular tissues. Case report A 23-year-old female patient reported to the dental speciality clinic with the complaint of pain and discomfort in the area of the tooth 36 since the last 1 year. Clinical examination revealed the presence of a grossly decayed tooth with a temporary restoration.

2 The tooth was mobile with grade III mobility. Gingival inflammation was present. On periodontal probing, pocket was found on the distal aspect measuring more than 8 mm and on the mesial aspect measuring 5 mm. grade III furcation involvement was also present. Radiographic examination revealed vertical bone loss distally. There was presence of isolated bone loss indicative of root fracture. Furcation involvement as revealed in the clinical examination was confirmed on the orthopantomogram (OPG). Periapical radiolucency was present on both the roots. The tooth was found to have undergone endodontic treatment with voids and porosities (Fig. 1). After taking the complete medical history and explaining the risks and benefits of the procedure to the patient, an informed consent was read and signed by the patient. Patient was prescribed 100 mg doxycycline 2 hours before surgery to prevent infection and a diclofenac; serratiopeptidase combination was prescribed to prevent post-treatment pain and swelling and facilitate the healing process. Preoperative procedures were performed, i.e. thorough oral prophylaxis followed by intraoral antisepsis with 2% chlorhexidine digluconate, for 1 minute; perioral antisepsis with iodine. Patient underwent local anesthesia of inferior alveolar, lingual and buccal nerves with 2.5 ml of 2% lignocaine with 1: epinephrine. Extraction of 36 was done using Emdent first molar forceps, followed by irrigation with 2% chlorhexidine solution (Figs 2 and 3). Extraction of 38 was carried out by Emdent Bayonet forceps. The extracted tooth was placed on a wet gauge soaked in chlorhexidine in a kidney tray (Fig. 4). The first molar Emdent forceps was used to hold the extracted 38 and placed into the socket of 36 in the same orientation as it was on the distal area; held in place under pressure with a wet gauge under occlusion for 10 minutes. The patient was instructed to perform daily mouthrinsing with 2% chlorhexidine mouthwash twice a day, except 8 hours postoperatively. The decision of employing tooth 38 as donator tooth was performed by the clinical assessment of the tooth and of the space at the receptor area, i.e. the mesial-distal Fig. 2: Extraction socket of 36, radiographically Fig. 3: Extraction sockets of 36 and 38 respectively Fig. 1: Orthopantomogram revealing vertical bone loss of 36 distally, isolated bone loss indicative of root fracture, furcation involvement and periapical radiolucency on both the roots. Also, voids and porosities can be seen in the endodontic treatment Fig. 4: The extracted third molar to be autotransplanted placed in a chlorhexidine soaked wet gauge International Journal of Oral Implantology and Clinical Research, May-August 2015;6(2):

3 Mithra N Hegde et al diameter of the donator tooth (38) was compatible with the diameter of the receptor socket, contributing for the transplant s favorable prognosis. Also, the root length of 38 was short and could be easily placed in the 36 socket (Fig. 5). No splinting was done since the tooth appeared stable (Fig. 6). The patient was recalled every week to check the position and mobility. The patient was clinically and radiographically followed up for sixth months, comprising weekly appoint ments in the first month. Patient was asymptomatic during recall visits. Clinical examination demonstrated grade II mobility in 1 month. The occlusion was found to be normal. There were no signs of rejection around the autotransplanted tooth like implantation and infection (Fig. 7). At the third month follow-up, radiographic examination revealed healing of the site (Fig. 8). At the sixth month follow-up, clinical evaluation revealed normal gingival, attachment apparatus did not show any pocket around the autotransplanted tooth, absence of mobility, percussion test did not produce the characteristic metallic sound of ankylosis and no pain was reported. There were no signs suggestive of root resorption or other pathological processes and revealed normal periodontal attachment. New bone formation was seen around the autotransplanted tooth which was considered satisfactory (Fig. 9). Fig. 7: One month follow-up Fig. 5: Radiograph revealing placement and adaptation of the autotransplanted tooth Fig. 8: Three months follow-up Fig. 6: Autotransplanted tooth placed in the socket of 36 Fig. 9: Six months follow-up 50

4 Discussion The success rate of autogenous tooth transplantation in the 1950s was approximately 50% because of the difficulty in predicting root development after transplantation and dental root resorption. 5,6 Since 1990, many studies have evaluated the healing of periodontal tissues and the incidence of dental root resorption after transplantation; and the transplant success rate has increased rapidly, drawing new clinical interest. 7-9 Tsukiboshi reported a 90% survival rate and an 82% success rate in 250 cases observed for 6 years. 6 Lundberg and Isaksson reported a success rate of 94% in cases with incompletely formed roots and 84% in cases with completely formed roots, whereas Mejare et al reported a high success rate for cases with mature teeth. 8,9 First molars are the teeth presenting the highest rate of tooth loss in young patients aging from 15 to 25 years old due to extensive carious and/or endodontic lesions, mainly because they are the first permanent teeth to erupt into oral cavity as well as to exhibit a favorable morphology to plaque accumulation, similarly to the case described here. 10,11 For this reason, autogenous transplantations employ, in most times, the third molar because this tooth shows a late development compared to the other teeth, as highlighted by Giancristófaro et al (2009) 6 and Bosco et al (2000). 3 Like other surgical procedures, careful case selection and treatment planning is essential for successful autotransplantation. The donor tooth and recipient site should be both examined meticulously for suitability and appropriate dimensions. 4,10 The recipient site should have adequate bone support with sufficient attached keratinized tissue to allow tooth stabilization and be free of infection and/or inflammation. 4 Insufficient buccolingual width in the recipient site or excessive preparation of the site may result in resorption of the alveolar ridge, loss of buccal bone coverage, and consequent loss of periodontal integrity. Preservation of the periodontal ligament cells is critical for the success of a tooth transplant Accordingly, teeth which have sharp root curvatures are not good candidates for transplantation because there is an increased risk of perio dontal ligament damage and cemental tear during extraction. 1,10 Extraction procedure was carried out with special care and to preserve periodontal ligament cells of third molar, the roots were wrapped with gauze soaked in saline. Effective and successful transplantation requires approximation between shape and size of the donor tooth and the receptor site. It also has been postulated that maxillary transplants have greater risk of failure due to the wide variation in the size and shape of the teeth and the proximity of the maxillary antrum to the molar sockets. 14 However in this case, the tooth to be transplanted fitted the recipient site; thus, the procedure caused minimal trauma. In addition, the favorable cervical adaptation between the tooth and bone decreased the chance of infection and increased the likelihood of an uneventful healing and periodontal reattachment. The physiologic mobility of the transplanted tooth stimulated the activation of periodontal ligament cells (i.e. fibroblasts, cementoblasts and osteoblasts) and bone repair. 5 The transplanted molar tooth in the present case had complete developed roots, that encouraged transplantation in these teeth. Both clinical, and radiographic outcomes were considered satisfactory after 6 months. Other treatment option for this case was to extract 36 followed by the placement of an implant. But due to the expenses of implant therapy, which required bone grafting or bone replacement material since bone support was minimal, autotransplantation was selected as treatment option. Complications of autogenous tooth transplant include root resorption and attachment loss, and its success rate is lower than implant prosthesis. Nonetheless, autogenous teeth transplantation results in good utilization, the maintenance and regeneration of alveolar bone, and the maintenance of attached gingiva with a natural shape. Conclusion Autotransplantation of teeth offers a new treatment option for some clinical situations. It permits tooth movement to distant or opposite sides of the same dental arch, as well as to the opposite jaw. Furthermore, transplantation offers other potential benefits such as bone induction and the re-establishment of a normal alveolar process in addition to tooth replacement. Even if the transplant fails later, there is an intact recipient area that could be used for an implant. A prerequisite for this method, however, is a thorough knowledge of the factors that influence the long-term success rate. If done properly, this method may supplement and/or be used as a viable treatment option in present day clinical practice. References 1. Natiella JR, Armitage JE, Greene GW. The replantation and transplantation of teeth. Oral Surg 1970;29(3): Frenken JW, Baart JA, Jovanovic A. Autotransplantation of premolars: a retrospective study. Int J Oral Maxillofac Surg 1998;27(3): Sailer HF, Pajarola GF. Retained (non-erupted) teeth. In: Rateitschak KH, Wolf HF, editors. Color atlas of dental International Journal of Oral Implantology and Clinical Research, May-August 2015;6(2):

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