|Year : 2012 | Volume
| Issue : 1 | Page : 46-49
Restoring biological width after autotransplantation of an impacted endodontically treated third molar
M Swamy Ranga Reddy1, M Daneswari2, M Jaydev1
1 Department of Endodontics, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, India
2 Department of Pedodontics, Mamatha Dental College, Khammam, Andhra Pradesh, India
|Date of Web Publication||10-Dec-2012|
M Swamy Ranga Reddy
Department of Endodontics, Panineeya Mahavidyalaya Institute Of Dental Sciences, Hyderabad, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Whenever unrestorable teeth need to be extracted or tooth agenesis is evident, other treatment alternatives, such as tooth transplantation, should be considered, instead of immediately replacing teeth with fixed, removable, or implant-supported prostheses. Supernumerary and impacted teeth should be considered as a reservoir for transplants. Transplanted tooth should be managed carefully during transplantation and endodontic treatment. This present case report discusses an autotransplantation of an impacted third molar into an unrestorable second molar.
Keywords: Impacted teeth, third molar, tooth transplantation
|How to cite this article:|
Ranga Reddy M S, Daneswari M, Jaydev M. Restoring biological width after autotransplantation of an impacted endodontically treated third molar. Saudi Endod J 2012;2:46-9
|How to cite this URL:|
Ranga Reddy M S, Daneswari M, Jaydev M. Restoring biological width after autotransplantation of an impacted endodontically treated third molar. Saudi Endod J [serial online] 2012 [cited 2019 Sep 19];2:46-9. Available from: http://www.saudiendodj.com/text.asp?2012/2/1/46/104422
| Introduction|| |
Autogenous transplantation is defined as the transplantation of one's own teeth from one socket to another. The recipient socket may be an extraction socket or surgically prepared site.  Autogenic transplantation of teeth was described for the first time in the dental literature by the Swedish dental surgeon Vidman in 1915. Success rates reported in studies vary considerably, ranging from 74 to 100% for the transplantation of third molars. ,
The dental practice has developed transplantation of natural teeth or implantation methods to substitute for loss of critical teeth. Cost effectiveness is the obvious advantage of this procedure which enables the utilization of a tooth that is hitherto nonfunctional (usually the third molar tooth) to be transferred to a functional position to replace a lost tooth in the same person. The main disadvantages are surgical involvements, technique sensitivity, relatively low versatility in their applications (e.g., tooth and space size discrepancy) and more importantly low predictability in results compared to conventional prosthetic restorations.  Careful manipulation of the root and socket under favorable preoperative, surgical, and postoperative conditions ensures survival of the cells of the periodontal ligament and promotes the reformation of a normal supporting apparatus.  The purpose of this present case report is not to achieve dramatic approval for autogenous tooth transplantation but to determine whether this treatment can survive the option in the future dental armamentaria.
| Case Report|| |
A healthy 24-year-old woman presented to Department of Conservative Dentistry and Endodontics, Panineeya Mahavidyalaya Institute of Dental Sciences, Hyderabad, India with the chief complaint of pain in the lower right back tooth since a year. Her medical history was noncontributory. On clinical examination, tooth 47 was grossly carious involving the furcation area with associated periodontal breakdown. The tooth was non-responsive to hot and cold pulp sensitivity tests. Panoramic radiographic examination confirmed the clinical impression of an unrestorable tooth 47 with chronic apical periodontitis and extraction was indicated, a class 2 position A, horizontally impacted tooth 48 according to Pell and Gregory classification was evident.  We advised autotransplantation of the third molar though impacted but healthy with completely formed roots, amenable for root canal, to the site of second molar [Figure 1]. The steps, benefits and risks of the technique were explained to the patient and an informed consent was taken.
|Figure 1: Preoperative panoramic radiograph showing impacted third molar and unrestorable second molar|
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As the tooth 47 was infected, with apical periodontitis, prophylactic antibiotics (Amoxicillin 500 mg every 6 hrs) were initiated 48 hrs before surgery and maintained for 7 days after intervention. Analgesic and anti-inflammatory drugs (Diclofenac every 8 hrs) were prescribed for the management of postoperative pain.
Under aseptic and sterile conditions, local anesthesia 2% lignocaine containing 1:100,000 epinephrine (Xylocaine; Astrazeneca Pharma Ind Ltd, Bangalore, India) was administered; the following surgical procedures were performed: Tooth 48 remained in the socket, until complete atraumatic removal of tooth 47. The socket of tooth 47 was curetted for removal of granulation tissue. A crestal incision with releasing vertical incision was made from the retromolar region to the first molar region. A mucoperiosteal flap was lifted, and the retentive bone areas were removed with sharp cutting burs. The impacted tooth was extracted but remained in the alveolus until the socket of the second molar was fully prepared. Because of differences in root shape and length, the recipient socket was prepared with a round bur (centrepunch bur, size 3 mm; Degusa, Dusseldorf, Germany). The transplanted third molar was seated in the recipient site with firm finger pressure and stabilized with silk sutures and semi-rigid splinting to the adjacent first molar with a steel wire and composite resin. Occlusal contacts were removed with sharp burs to keep the transplant from postoperative traumatic occlusal forces. The patient was instructed to have semisolid diet, mouth rinses and antibiotics as prescribed before the procedure.
The postsurgical course was uneventful and sutures removed after one week. Root canal treatment was performed 2 weeks after transplantation. Under rubber dam isolation, working length was established and chemomechanical preparation performed with 2.6% sodium hypochlorite solution as an irrigant. After drying the root canal with paper points, a calcium hydroxide paste (ApexCal Ivoclar Vivadent, Liechtenstein, Switzerland) was applied and the access cavity temporarily sealed with Cavit (ESPE, Seefeld, Germany). The patient returned after 2 months, the calcium hydroxide paste was removed and the root canal was filled with gutta-percha (Denstply Maillefer, Ballaigues, Switzerland) with AH Plus resin sealer (Maillefer, Denstply, Konstanz, Germany) using lateral condensation and the tooth was restored with a posterior composite resin core (P60; 3M Dental Products, St. Paul, MN) [Figure 2] later the splint was debonded after one month. Clinical and radiographic controls were taken at the three, six month [Figure 3] and at one year. Periodontal probing revealed no pockets or other pathological signs, and the patient was symptom-free with both physiologic mobility and the mastication function of the tooth.
|Figure 2: Panoramic radiograph showing root canal obturation of transplanted tooth stabilized with a splint|
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|Figure 3: Intraoral periapical radiograph after six months of autotransplantation with crown|
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| Discussion|| |
Transplantation of mature teeth enjoys high levels of success and may be a viable treatment option in the absence of other suitable donor teeth. 
The teeth to be transplanted had an uncomplicated and atraumatic extraction, which minimized damage to the periodontal ligament and cementum which is an important factor for successful prognosis. Teeth with accented root curvatures and other anomalies of form and position are generally contraindicated for transplantation because there is an increased risk of damage to the periodontal ligament during extraction.  Transplantation to the recipient site should be performed immediately after extraction of the tooth. It is desirable to extract a tooth with as much periodontal ligament attached to it as possible, even though the cementoblast layer by itself seems to be effective in preventing root resorption. As the time interval between extraction from the recipient site and transplantation increases, more resorption of bone occurs at the recipient site and there will be less support for the donor tooth. 
The distance between the teeth adjacent to the recipient site must be measured and compared to the mesiodistal width of the donor tooth before the final preparation of the recipient site. Transplantations to the surgically prepared sockets result in less functionally aligned periodontal ligament which is parallel rather than perpendicular, but however, clinically, it appears equally satisfactory.  In our present case, the extra-alveolar time was kept minimal as they remained in their original sockets during extraction of the second molars and preparation of the recipient sites. The transplanted tooth must be carefully placed to achieve ideal biologic within the cervical area, as the tooth's attached periodontal ligament level is present at 1 mm above the bony crest. The fit of the gingival tissues around the donor teeth is checked to make sure that the adequate keratinized gingival tissue is available. The third molar was impacted more apically in our present case, leads to the development of a distal periodontal pocket. The vertical incision which is given in our case is to have a more desirable tight fit to the donor tooth on the distal aspect and also prevent ingress of infective agents. 
The most important factor is the proper adaptation between the root surface of the transplanted tooth and the bony walls of the recipient site. In this case report, the recipient socket was remodeled with surgical burs under saline irrigation to obtain adequate depth and width, which has improved prognosis. Close contact with the autotransplanted tooth with the alveolar bone of the recipient site might provide better blood supply and adequate nutrition to the periodontal ligament cells, thereby increasing the number of viable cells.  A semi-rigid splint was used in our present case, which provided necessary stability and adequate mobility to reduce the probability of ankylosis.  Tsukiboshi et al. reported that tooth should be fixed for between 2 weeks and 2 months depending on whether mobility is reduced; in our case, splint is deboned after one month when vertical mobility had been disappeared.  The entire osteogenic process consists of the beginning of osteoid secretion and culminates in the development of a mineralized trabecular pattern. An active phase of bone formation occurred between 4 and 8 weeks, followed by a quiescent period of 4 weeks in which the individual trabeculae became mature and increased in volume. Twelve to 16 weeks after the tooth extraction, the newly formed bone was stabilized and retained the architecture of a normal bone.  Chlorhexidine rinse and antibiotics were prescribed for a week after the surgery, but in order to have a desirable antibiotic level in the blood during and immediately after surgery, antibiotics should be taken orally a few hours prior to the procedure. ,
According to Trope, the regeneration of the dental pulp tissue of a completely mature tooth is extremely limited.  Thus, the pulp tissue in our case was extirpated after two weeks of transplantation. This two week period is very important because if endodontic treatment is performed too early after autogenous tooth transplantation, additional injury to the periodontal ligament may occur; however, after two weeks, inflammatory resorption may develop. ,
The interim dressing of calcium hydroxide is placed to favor bone repair and inhibit root resorption due to its high pH providing an antimicrobial effect and stimulating the healing process. The alkaline environment stimulates the action of alkaline phosphatase and subsequent hard tissue deposition around tooth. 
An excellent success rate following tooth transplantation of mature teeth was reported to be up to 98% of 10 year follow-up when the appropriate protocol is followed.  In our case, wound healing and absence of clinical signs of ankylosis or sensitivity to percussion were confirmed clinically and radiographically at all follow-up visits.
| Conclusion|| |
Furthermore, transplantation offers other potential benefits such as bone induction and the reestablishment 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 can be used as a viable treatment option in present day clinical practice.
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[Figure 1], [Figure 2], [Figure 3]