Autogenous Transplantation of Maxillary and Mandibular Molars Thesis Submitted to the Faculty of Oral and Dental Medicine Cairo University in partial fulfillment of the requirements for the Master Degree in Oral and Maxillofacial Surgery Presented by Maha Mortaga Mohamed Negm (B.D.S) Cairo University Oral and Maxillofacial Surgery Department Faculty of Oral and Dental Medicine Cairo University (2012)
Supervisors Dr. Mohamed Galal Beheiry Professor of Oral and Maxillofacial Surgery Faculty of Oral and Dental medicine Cairo University Dr. khaled Atef Elhayes Professor of Oral and Maxillofacial Surgery Faculty of Oral and Dental medicine Cairo University Dr. Sameh Seif Lecturer of Oral and Maxillofacial Surgery Faculty of Oral and Dental medicine Cairo University
Dedication To my beloved husband whose dedication, love and persistent confidence in me, has taken the load off my shoulder and for being the most understanding, loving, caring, patient, supportive husband ever. To my cute little girls, you have made me stronger, better and more fulfilled than I could have ever imagined.. I love you to the moon and back To my father, for giving me all the advice, encouragement and guidance You are the best dad anyone could ever have To my mother and my family for their loving care and support
Acknowledgment I would like to express my profound gratitude and appreciation to Doctor Mohamed Galal Beheiry, professor of Oral and Maxillofacial surgery, Faculty of Oral and Dental Medicine, Cairo University, for his remarkable supervision, generous help and support. I would like to mention my heartfelt thank you for, Doctor Khaled Atef El Hayes, professor of Oral and Maxillofacial surgery, Faculty of Oral and Dental Medicine, Cairo University, for all the assistance he has provided me during this research. He gave me all the leads, advice and encouragement anyone could want. I really appreciate his tremendous efforts to accomplish this study. I hope I can return the favor. I would like to thank, Doctor Amr Maher, consultant anesthesiologist, Student Hospital and New Dental Educational Hospital, Cairo University, for his generous cooperation, great efforts and patience in the statistical part of this study.
I would like also to express my appreciation for, Doctor Sameh Seif, lecturer of Oral and Maxillofacial surgery, Faculty of Oral and Dental Medicine, Cairo University, for his generous help. I would like to take this opportunity to express my deep and sincere gratitude to Doctor Omniya Abdel Aziz, assistant Lecturer Oral and Maxillofacial surgery, Faculty of Oral and Dental Medicine, Cairo University, for her marvelous effort, attention and continuous support throughout the research. She is a cooperative colleague, helpful sister and a dear friend. I would like to thank, Doctor Sherif Khattab, for his generous cooperation in collecting the patients. He has been a great help in writing this study. I appreciate all the help and assistance given by my dear colleagues, Doctor Hisham Said and Sherif Ali. Last and never the least, I would like to thank, my dear friends and colleagues.
Contents Introduction 1 Review of literature... 3 Aim of the study. 36 Patients and methods 37 Results 55 Discussion.. 79 Summary and conclusions 86 References.. 88 Arabic summary 103 i
List of figures Number of figure Number of page 1 39 2 Preoperative photographs showing badly decayed nonrestorable lower left 1st molar. 39 3 Preoperative panoramic radiograph showing periapical & periodontal radiolucencies related to lower left 1 st molar. 40 4 42 5 Photographs showing non-surgical atraumatic extraction of lower left 1 st molar. 42 6 43 7 Creation of a 4-wall bony surgically prepared socket with additional apical preparation at the recipient site. 43 8 Elevation of pyramidal flap to extract the unerupted lower left 3 rd molar. 44 9 Bone removal followed by removal of the follicle from around the crown to uncover the unerupted lower left 3 rd molar. 45 10 Haemostasis at the donor site by suturing the flap with 3/0 black silk. 46 11 Examination of the transplant s root buds 47 12 Transplant stabilized & positioned in infraocclusion. 48 13 49 14 Stabilization of the transplanted lower left third molar with 3/0 black silk Basket suture. 49 ii
Number of figure 15 Bar chart showing pocket depths throughout the follow up period. 16 Bar chart showing mobility grades throughout the follow up period. Number of page 59 61 17 62 18 Two weeks follow up photographs of lower left 3 rd molar transplant showing its position in the dental arch. 62 19 20 21 Two weeks follow up photograph of lower left 3 rd molar transplant showing its relation to the upper teeth regarding the occlusion. Four months follow up photograph of lower left 3 rd molar transplant showing its relation to the upper teeth regarding the occlusion. Six months follow up photograph of lower left 3 rd molar transplant showing its relation to the upper teeth regarding the occlusion. 63 63 64 22 Six months follow up photograph of lower left 3 rd molar transplant showing its position in the dental arch. 64 23 Nine months follow up photograph of lower left 3 rd molar transplant showing its relation to the upper teeth regarding the occlusion. 65 24 Nine months follow up photograph of lower left 3 rd molar transplant showing its position in the dental arch. 25 Six months follow up photograph of upper right 3 rd molar transplant showing its position in the dental arch. 65 66 26 Six months follow up photograph of upper 3 rd molar transplant showing its relation to the upper regarding the occlusion. 66 27 Pie chart showing root development of the transplants at the end of the follow up period. 68 iii
Number of figure Number of page 28 Pie chart showing periapical or periodontal radiolucencies of the trasnplants at the end of the follow up period. 68 29 Pie chart showing root resorption of the transplants at the end of the follow up period. 69 30 Pie chart showing ankylosis of the transplants at the end of the follow up period. 69 31 Two weeks postoperative radiograph of lower left 3 rd molar transplant 32 Four months postoperative radiograph of lower left 3 rd molar transplant. 33 Six months postoperative radiograph of lower left 3 rd molar transplant. 34 Nine months postoperative radiograph of lower left 3 rd molar transplant. 70 70 71 71 35 36 Six months postoperative radiograph of upper right 3 rd molar transplant showing resorption of the surrounding bone. Nine months postoperative radiograph of upper right 3 rd molar transplant showing no improvement of bone resorption. 72 72 37 1 st question scale 73 38 2 nd question scale 74 39 3 rd question scale 75 40 4 th question scale 76 41 5 th question scale 77 42 6 th question scale. 78 iv
List of tables Number of table Number of page 1 10-mm Visual analogue scale questionnaire 53 2 Patients demographic characters. 55 3 Statistical analysis and ANOVA test result of pocket depth readings. 4 Post Hoc test showing the significance of comparing follow up intervals regarding pocket depth readings. 5 Statistical analysis and Friedman test result of mobility grades. 6 Frequencies and percentages of mobility grades in patients throughout the follow up period. 7 Post Hoc test showing the significance of comparing follow up intervals regarding mobility. 58 58 60 60 61 8 Presence or absence of the radiographic findings. 68 9 Frequencies, percentages of the1 st question. 73 10 Frequencies and percentages of 2 nd question. 74 11 Frequencies and percentages of 3 rd question. 75 12 Frequencies and percentages of 4th question. 76 13 Frequencies and percentages of 5 th question. 77 14 Frequencies and percentages of 6 th question. 78 v
Introduction
Introduction Introduction A significant number of patients have premature loss of their first and second molars because of dental caries and/or dental crowding. As a result; ridge resorption, malfunction, over eruption of opposing tooth, loss of space, temporomandibular disorder, etc... may occur (Reich 2008). Removable partial denture and fixed partial denture are the options to solve these problems but they have their own disadvantages and limitations (Reich 2008). In planning the treatment for such cases, clinicians should make patients aware of other alternatives, including dental implants and transplantation of teeth (Cohen et al. 1995). Often, these patients are not candidates for replacement of these edentulous areas with titanium dental implants because of their age or simply for financial reasons (Reich 2008). Osseointegrated implants are generally contraindicated for young patients with developing alveolar bone because infraocclusion results when the implant fails to form alveolar bone (Mendes & Rocha 2004). Autotransplantation is a viable option for replacing a missing tooth when a donor tooth is available (Thomas et al. 1998, Lee et al. 2001, Kim et al. 2005, Teixeira et al. 2006). Tooth autotransplantation offers one of the fastest and most economically feasible means of replacing missing teeth (Cohen et al. 1995). Cost and effectiveness of autotransplantation is the obvious advantage of this procedure, which enables the utilization of a tooth that is uptill now nonfunctional (usually third molar tooth) to be transferred to a functional position to replace a lost tooth in the same person (Clokie et al. 2001). 1
Introduction 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 molar erupt early and are often heavily restored. Autotransplantation in this situation involves the removal of a third molar, which may then be transferred to the site of an unrestorable first molar (Clokie et al. 2001, Mejare 2004). Autotransplantation is a technique-sensitive procedure. An atraumatic surgical technique preserves bone and periodontal support. Minimal handling of the transplant is required to protect the Hertwig s root sheath and pulpal tissue. Atraumatic surgical removal of the third molar is essential, preserving the root sheath and apical portion of the developing tooth bud. Adequate exposure and preparation of the recipient site are performed. Stabilization of the transplanted third molar is performed with suture material in a crossover fashion to prevent up-and-down movement of the transplant. Splinting with composite or wire banding isn t advised. Excessive time or rigid splinting of the transplanted tooth will adversely affect its healing outcome (Tsurumachi & Kakehashi 2007, Reich 2008). The goal of this study is to highlight the evidence-based principles for successful autotransplantation; evaluating viability, reliability, lack of discomfort and complications, and stable occlusion of autogenous transplantation. 2
Review of Literature
Review of Literature Review of Literature Autotransplantation may be defined as the transplantation of embedded, impacted or erupted teeth, from one site to another in the same individual into extraction socket or surgically prepared site (Natiella et al. 1970). It s simply defined as the surgical movement of a tooth from one location in the mouth to another in the same individual (Cohen et al. 1995, Clokie et al. 2001). Also it refers to the extraction of a tooth from one location and its replantation in a different location in the same individual. The new location may be a fresh extraction socket after extraction of a non-restorable tooth, or an artificially drilled socket on an edentulous alveolar ridge (Mendes & Rocha 2004, Eddie 2009). The early history of tooth transplantation involves slaves in ancient Egypt who were forced to give their teeth to their pharaohs. Allotransplantation of teeth, moving teeth from one person to another, continued for centuries. However, allotransplantation was eventually abandoned because of problems of histocompatibility and the danger of disease transmission, and then replaced with autotransplantation (Cohen 1995, Clokie 2001). Apfel, Hale and Miller were the first to report successful autotransplantation in the early 1950 s. Also they were the early beginners to thoroughly describe the technique for autotransplantation. The major principles of their technique are still followed nowadays (Smith et al. 1987, Thomas et al. 1998, Clokie et al. 2001, Teixeira et al. 2006). Many authors have followed their technique with different approaches, different locations, and varying degrees of Success (Reich 2008). 3
Review of Literature Advantages of autotransplantation as an alternative to dental implants for young adult patients: Autotransplantation is now a common procedure in dental practice especially in children and adolescents. It s considered as a viable alternative to conventional prosthetic and implants rehabilitation from both therapeutic and economic standpoints (Kallu et al. 2005). Although its long-term prognosis is not predictable, autogenous transplantation of teeth with both complete and incomplete root formation appears to be a sound treatment option for replacement of a lost or hopeless tooth, usually providing satisfactory clinical, aesthetic and functional outcomes. In addition, autotransplanted teeth can preserve the amount and quality of alveolar bone, thus permitting later insertion of a metallic implant, if this should be necessary (Teixeira et al. 2006). Jonsson & Sigurdsson (2004) demonstrated the long-term outcome of 40 consecutive patients having transplanted premolars. The transplants were removed from maxillary second premolar positions in 35 of 40 patients. This is not unexpected because orthodontic treatment planning commonly includes extractions in the maxillaty arch to reduce arch length or relieve crowding. After initial healing periods, 35 of 40 (87.5%) of the transplanted teeth were orthodontically moved. The possibility of orthodontically reposition the transplant makes this procedure of specific interest when compared with dental I mplants. Another advantage of autotransplants, compared with dental implants, is the possible avoidance of space maintainers when orthodontic treatment is finished in young patients and implant placement scheduled later. Transplantation has a key role in the replacement of young patient's missing teeth (Mendes & Rocha 2004). At this age, the alveolar bone is not yet complete thus becoming a difficult problem to solve in the future treatment (Lon et al. 2009). Despite the increasing use of osseointegrated implants in patients with missing teeth, their use is contraindicated in growing patients. If implants 4
Review of Literature are placed in patients with residual facial growth, infra-occlusion of the implant occurs as the implant becomes ankylosed to the bone (Thilander et al. 1994, Thilander et al. 2001, Rossi & Andreasen 2003). Subsequent alveolar bone growth produces a poor esthetic result. The potential for using autogenous transplanted teeth in children thus requires further consideration (Thomas et al. 1998). Advantages of immature third molars autotransplantion: Transplantation of teeth is usually performed into fresh extraction sites, immediately after removal of the non-retainable tooth. The transplant is placed into a favorable buccolingual position and is fixed in infraocclusion; afterwards the transplant tooth is expected to erupt into the occlusal plane and to obtain an adequate position (Bauss O & Kiliaridis 2009). The work of Andreasen and colleagues has been fundamental to understanding the delicate nature of the root sheath and developmental age of the transplanted root. The correlation between root length at the time of transplantation and vitality was: the more open the root apex the better the reinnervation (Andreasen et al. 1990a). They found that teeth with incomplete and complete root formation showed 96 and 15 percent pulpal healing respectively. This discrepancy reflects the potential for revascularzation in teeth with open and closed apices (Andreasen et al. 1990b). The advantage of transplanting immature teeth is that immature teeth are usually covered by a thick follicle or periodontal ligament and little force is necessary to remove the tooth. Thus the periodontal ligament may sustain minimal damage. Extraction of a fully erupted tooth with a strong attachment may leave some areas of the root surface devoid of vital periodontal ligament cells (Andreasen et al. 1990c). Most surgeons performing tooth transplantation would advise to decide for transplantation at the moment of which the donor tooth would have reached a 5
Review of Literature root length between half and three quarters of its intended root length (Kristeron 1985, Andreasen et al. 1990d). Indications of autotransplantation: The most common indication is tooth loss as a result of dental caries, especially when mandibular first molars are involved. Also it s indicated in tooth agenesis (especially premolars and lateral incisors), traumatic tooth loss, atopic eruption of canines, root resorption, large endodontic lesions, cervical root fractures, localized juvenile periodontitis, other dental anomalies (Clokie et al. 2001). According to Mendes & Rocha (2004), autotransplantation of teeth are performed in cases of impacted or ectopic teeth (maxillary canines), premature tooth loss, traumatic tooth loss, congenitally missing tooth, teeth with bad prognosis, developmental anomalies of teeth and related syndromes. 1.Teeth of poor prognosis (Non restorable): While there are many reasons for autotransplantating 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. Autotransplantation in this situation involves the removal of a third molar, which may then be transferred to the site of an unrestorable first molar (Leffingwell 1980, Clokie et al. 2001, Reich 2008). Kristerson et al. (1991) investigated the outcome of replacing molars with advanced periodontitis by autotransplanted third molars in 18 patients over an 18-72 month period. After extraction of the molar, the granulation tissue and epithelium inside the flap were removed and autotransplantation of a third molar was immediately carried out. In 15 cases, the autotransplantation was successful. 6
Review of Literature 2.Impacted or ectopic teeth: In cases of malpositioned maxillary canines the surgical repositioning is better and more predictable than surgical removal and prosthodontic treatment especially in children and adolescents (Sagne & Thilander 1990). 3.Early tooth loss: Autotransplantation of teeth has become a well-established treatment modality in cases of early loss of teeth (Bauss et al. 2002, Bauss et al. 2004), especially in children and adolescent where implant and other prosthetic replacement are contraindicated for various reasons (Tsukiboshi 1993). 4.Developmental anomalies of teeth and related syndromes: Replacement of developmentally absent teeth by transplanted teeth, as in cases of regional odontodysplasia (von Arx 1998), tooth aplasia (Kristerson & Andreasen 1984), cleidocranial dysplasia (Davies et al. 1987, Jensen & Kreiborg 1992) and tooth agenesis (Kristerson & Langerström 1991, Josefsson et al. 1999). 5,Congenitally missing teeth: Treatment for children with several congenitally missing teeth is challenging because the growth and development of the oral structures have to be taken into account. If implants are used as a treatment option, infraocclusion may occur as the implant becomes ankylosed to the alveolar bone. On the other hand, autotransplantation will promote alveolar growth along with the eruption process especially in case of lateral incisors and premolars, as they are amongst the most commonly reported missing teeth (Kristerson 1985, Neal & Bowden 1988, Schatz & Joho 1994, Paulsen & Andreasen 1998, Paulsen 2001, Aslan et al. 2010). 7
Review of Literature 6.Traumatic tooth loss: In developed and developing countries where a significant decrease in dental caries is found, there is increasing interest in studying other oral health problems like dental trauma. Dental injuries are escalating all over the world, especially in school children and adolescents, because of a rise in recreational and sports activities. These oral injuries cause aesthetic, psychological, social, and therapeutic problems. They also affect a large number of people, causing irreparable dental loss not only at the accident time but also during posttreatment. Missing permanent teeth by trauma in children are a particular challenge, especially in the anterior region of the maxilla. This clinical situation is even more complex, considering that alveolar bone growth is not yet complete in these patients. Furthermore, they raise important phonetics compromise, detrimental mastication function, and aesthetics impairment. The treatment should adapt to both growth and developmental changes in the oral region to have potential for long-term survival of the affected teeth (Diaz et al. 2008). In the past few decades, tooth transplantation has been successfully researched for the treatment of anterior tooth loss in young individuals, especially when orthodontic space closure, fixed prosthetics, and implants are contraindicated (Czochrowska et al. 2002, Zachrisson et al. 2004, Kallu et al. 2005). It is well known that immediate replantation is the best treatment option and the most indicated measure after tooth avulsion, as it is the conservative procedure most suggested in treatment protocol for dental trauma. It allows the viability of the periodontal ligament responsible for proper reattachment to the alveolar bone to be maintained (Andreasen et al. 1995, Jorge et al. 2009, Castilho 2009). Also, pulp regeneration can be expected in immature replanted teeth (Tsukiboshi 2002). A similar healing process can be expected in well planned tooth autotransplantation, with absence of pulpal and periapical 8