Tooth Transplantation. a viable alternative endodontic treatment or extraction ? fixed or removable...

Tooth Transplantation

Tooth Transplantation

• a viable alternative

• endodontic treatment or extraction ?

• fixed or removable prosthetic treatment is not ideal treatment in adolescent

Why tooth transplantation Why tooth transplantation is successful?is successful?

Hertwig’s epithelial root sheath

Tooth transplantationTooth transplantation

1.1. Autogenous transplantationAutogenous transplantation

2.2. Allogeneic transplantationAllogeneic transplantation

3.3. Isogeneic transplantationIsogeneic transplantation

4.4. Xenegeneic transplantationXenegeneic transplantation

Tooth Tooth autotransplantationautotransplantation

1. Sufficient crown space and alveolar bone

2. No periapical or periodontal inflammation

3. Proximity of the transplant to the socket wall to assure rapid organization of the clot between the alveolar bone and the tooth

4. Excellent oral hygiene, low caries index

IndicationIndication

Tooth autotransplantationTooth autotransplantation

1. Transplantation from one region to another

2. Transalveolar transplantation

Sagne S. : Autotransplantation of teeth Int Dent J. 1985 : 35 , 280-283

Transplantation from one Transplantation from one legion to anotherlegion to another

1. Transplant from lower 3rd molar to lower 1st molar

2. Transplant from upper 3rd molar to upper 1st molar

3. Transplant from lower premolar to upper premolar or upper premolar to lower premolar

4. Transplant from premolar to upper central incisor

Transplant from Transplant from lower 3lower 3rdrd molar to molar to

lower 1lower 1stst molar molar

Transplant from lowerTransplant from lower33rdrd molar to lower 1 molar to lower 1stst molar molar

Most reported cases of autotransplantation

1. a result of caries the first molar is frequently missing or removal in adolescents

2. Developing third molars are usually available in adolescents

3. In a majority of case the rate of success is well over 95%* for an extended period of time

*Andreasen et al. 1992

Indication Indication for for 33rdrd molar to 1 molar to 1stst molar molar

1. Appropriate candidates are adolescent patients ( 13 to 20 years )

2. Recent lost or about to lose a permanent first molar

3. A suitable third molar

• The roots on the donor tooth developed to the point of bifurcation ( should be equal to approximately 3 -4 mm in root length )

• A fully formed crown

Indication Indication for for 33rdrd molar to 1 molar to 1stst molar molar

3. A suitable third molar

• Complete enamel calcification coincides closely with development of the bifurcation

• The third molar should be no larger than the first molar it is replacing

• Slight of third molar to make it a suitable size is acceptable

• During instrumentation in the removal of the donor tooth, the vulnerable tooth buds are avoided

Surgical techniqueSurgical technique

1.Mobilization of the transplant

• A mucoperiosteal flap prepared by a sulcular incision from the mesial of second premolar to the distal of second molar then extending distolaterally and no vertical incision, assuring an excellent blood supply

• It is important that the flap design allow both adequate surgical field and blood supply


• The impacted third molar is carefully exposed , avoiding any contact of bone-cutting instruments with the tooth, grasping the crown with forceps avoid trauma to the root sac



• The tooth is then luxated, elevated from its position and gently returned to its position or maintained in its socket

• Leaving the donor tooth in the socket after luxation will allow it to continue to receive nutrients and be hydrate while the host site is being preparation


2. Preparation of the host site

• The first molar and interradicular bone are carefully removed

• Amount of cortical bone removed is critical, if an injudicious amount of bone is removed , there will not be an adequate bone support



2. Preparation of the host site

• The required amount of bone can be estimated by radiograph

• Irrigate and inspected for debris before a trial positioning of the transplant


3. Transplantation and stabilization

• The third molar is carried forward to new socket

• The area of resistance is relieved before seating the third molar

• The transplant may be stripped to seating but the roots of the transplantation should not be scraped or filed



• The occlusion should be carefully examined to be certain that the opposing teeth will not exert pressure on the transplant

• avoid premature contact

• Infraocclusion about 2 – 3 mm

• Mucoperiosteal flap is repositioned and suture

• The transplant is splinted in position using 0.14 gauge stainless steel wire

• The wire ligation technique used can be figure eight or circumferential technique





• Additional stabilization of the transplant can be achieved by gently packing periodontal surgical dressing such as Coe-Pak around the transplant and adjacent teeth

Postoperative care and Postoperative care and follow-upfollow-up

• Postoperative instructions are the same as those given following extraction of impacted teeth

• After surgery

1 day : the tooth has retained its new position

: periodontal pack still in good position

: swelling is within acceptable levels

7 days : stitch off


• The patient should be seen at weekly intervals

• At the end of a month the transplant may still be slightly mobile, but splinting can be removed

• Follow-up every month within 6 months

every 3 month within 2 years

every year


• At each visit should be checked

− The stability of the transplant

− Sulcular depth

− Gingival recession

− Vitality test

− Occlusion

− Root formation, thickness of periodontal ligament, root resorption in radiograph

− Oral hygiene

PrecautionsPrecautions

The precaution that help ensure successful autogenous transplantation are the following :

1. Root development of donor tooth is between 1/3 to 1/2 of the total root

2. Hertwig’s epithelial root sheath is not injured during surgery

3. The host site is prepared to avoid injury to the epithelial root sheath

4. The patient should be healthy with adequate oral hygiene

5. Pulpy foods that might pack into the cervicular space should be avoided

6. The patient should consider the procedure important, keep operative site clean and avoid trauma from occlusion

Transplantation from one Transplantation from one legion to anotherlegion to another

1. Transplant from lower 3rd molar to lower 1st molar

2. Transplant from upper 3rd molar to upper 1st molar

3. Transplant from lower premolar to upper premolar or upper premolar to lower premolar

4. Transplant from premolar to upper central incisor

Transplant from Transplant from premolar to premolar to

upper central incisorupper central incisor

Transplant from premolar Transplant from premolar to to

upper central incisorupper central incisor


The treatment plan is to transplant a maxillary second premolar to the maxillary central incisor which is to be removed due to root resorption


The maxillary central incisor is extracted


The socket is enlarged with surgical bur

The socket is expanded palatally , then rinse with saline


Testing the size of socket by a glass replica of a premolar


Removing maxillary second premolar using gentle luxation movement


Repositioning of the transplant, it is placed 45◦ rotate in order to achieve sufficient cervical width


Splint the transplant with 0.20 mm stainless steel wire


Complete treatment, after grinding and restore with crown

SummarySummary

Although it is not possible to perform tooth autotransplantation in

all patients with nonrestorable molars, it may be a viable alternative in some

instance

ReferenceReferenceBowden David E. J. et al : Autotransplantation of premolar teeth to replace missing maxillary central incisor, British Journal of orthodontics, Vol. 17, 1990

Munksgaard : Text book and color atlas of traumatic injuries to the teeth, 1994

Plainfield S. et al : A viable alternative : Tooth transplantation, Journal of Prosthodontics, Vol. 50, 1983

Robison J. Peter and Grossman I. Louis : Tooth Transplantation, Clinical transplantation in dental specialties

Smith J. J. et al : Successful Autotransplantation, Journal of Endodontics, Vol.13, 2, 1987

Tooth Transplantation. a viable alternative endodontic treatment or extraction ? fixed or removable...

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