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CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 104-110

Successful immediate autotransplantation of immature maxillary third molar to rehabilitate grossly mutilated second molar: A 4-year follow-up case report


1 Professor and HOD, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
2 Department of Conservative Dentistry and Endodontics, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India

Date of Submission10-Mar-2020
Date of Decision01-Apr-2020
Date of Acceptance23-Apr-2020
Date of Web Publication09-Jan-2021

Correspondence Address:
Dr. Devika R Krishnan
Bethsaida, Santhigiri, Nad P.O, Kalamassery, Cochin - 683 563, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_37_20

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  Abstract 


Autotransplantation is a viable option for immediate rehabilitation of missing teeth in young patients. It aims to preserve pulp vitality and proprioception, aiding complete root formation and osseous development, resulting in esthetic outcomes. A 20-year-old healthy female patient presented with pain in relation to a grossly mutilated nonrestorable right upper second molar tooth. Due to the young age of the patient, the proposed treatment was autotransplantation of upper third molar with incompletely formed roots to rehabilitate the second molar. Following precise diagnosis and application of strictly standardized treatment protocols, the strategically chosen donor tooth was atraumatically extracted and transplanted into the recipient site causing minimal damage to the periodontal ligament cells (PDLs). Clinical and radiographic findings over the 4-year follow-up period demonstrated normal gingival healing along with gradual bone regeneration. There was continued root formation and pulp revascularization with subsequent partial pulp canal obliteration. Higher survival rates of transplanted teeth are significantly associated with strict case selection criteria and protection of PDL. An analysis of pertinent prognostic factors with a long-term follow-up is required to predict and improve the outcome of tooth transplantation.

Keywords: Immediate autotransplantation, prognostic factors, selection criteria, stage of root development, surgical technique


How to cite this article:
Krishnan DR, Singh P, Mathew N. Successful immediate autotransplantation of immature maxillary third molar to rehabilitate grossly mutilated second molar: A 4-year follow-up case report. Saudi Endod J 2021;11:104-10

How to cite this URL:
Krishnan DR, Singh P, Mathew N. Successful immediate autotransplantation of immature maxillary third molar to rehabilitate grossly mutilated second molar: A 4-year follow-up case report. Saudi Endod J [serial online] 2021 [cited 2021 Jan 23];11:104-10. Available from: https://www.saudiendodj.com/text.asp?2021/11/1/104/306611




  Introduction Top


The rehabilitation of grossly mutilated teeth, especially in young patients, is a challenge to the clinician. Autotransplantation is a good alternative to other rehabilitation modalities when appropriate case selection is done. It is a controlled avulsion of donor tooth and surgical repositioning to a new extraction socket in the receptor site within the same oral cavity.[1] It provides a vital periodontium and continuous skeletal growth, thereby achieving functional adaptation and improved esthetics.

Evidence-based data on autotransplantation has reported highly disparate success and survival rates ranging from 61% to 100%, a difference ascribed to various preoperative and postoperative factors.[2],[3] The stage of development of root apex of the donor tooth, anatomy of the donor tooth root, quality and density of the alveolar bone in the receptor site, type and sterility of surgical technique, extra-alveolar time of donor tooth, method and duration of stabilization and type of follow-up care are among the determining factors for the disparate success of autotransplantation.[4],[5],[6] The long-term prognosis is dependent on atraumatic extractions, causing minimal trauma to the periodontal ligament cells (PDL) and cementum, during extraction and socket preparation of the donor site.

Indication

Recipient

Grossly mutilated, nonsalvageable (chronically infected, severely fractured or resorbing), nonrestorable or missing tooth, which requires replacement for rehabilitation.

Donor

Nonfunctioning (impacted/supernumerary/extraction indicated for orthodontic purpose) but periodontally healthy tooth.

The present case exhibits a tangible outcome as the transplant has met functional and esthetical goals and stands as an evidence for autotransplantation to be considered as a mode of long-term rehabilitation, especially in young patients.


  Case Report Top


A 20-year-old female patient reported with pain in relation to the right upper second molar tooth (#17). A general health history and assessment, including the patient's age, overall dental hygiene, and history of compliance with treatment and follow-up were obtained. Clinical examination revealed grossly mutilated tooth (#17) with caries extending below the alveolar crest. There was only one remaining cavity wall after infected dentin removal and lack of adequate circumferential dentin for bonded restorations.

Intraoral periapical radiograph (IOPAR) examination of tooth showed extensive carious involvement of coronal region with sub cervical extension and widening of the PDL space [Figure 1]a.
Figure 1: (a) Preoperative radiograph showing extensive caries extending subgingivally. (b) Presurgical orthopantomograph showing impacted donor tooth (#18) and recipient #17. (c) Presurgical cone beam computed tomography image (coronal view) of tooth #17. (d) Presurgical cone beam computed tomography image (coronal view) of #18

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Impacted right upper third molar tooth (#18) with incompletely formed roots was also revealed in IOPAR and orthopantomography [Figure 1]b.

Cone-beam computed tomography (CBCT) was also taken to assess the radicular morphology of #17 and #18, the quality of alveolar bone, and the proximity to adjacent structures. On CBCT, tooth #17 showed long, slender, fused conical root, and adequate alveolar bone surrounding the root [Figure 1]c. Tooth #18 showed incomplete root formation [Figure 1]d. The dimensions of the donor and recipient root were also assessed to determine the need for any socket modification. The root of donor and recipient teeth at the cervical level was precisely measured in all three orthogonal planes using the linear measuring tool and was compared with each other. Since the recipient tooth (#17) had fused roots and donor (#18) had partially formed roots, and the recorded measurements were matching, no socket modification was planned from the CBCT assessment.

Based on clinical and radiographic examination, tooth #17 was deemed nonrestorable. Given the impossibility of implant placement due to family's refusal, with due consideration to the age of the patient and intended tangible outcome, the proposed treatment plan was the extraction of #17 and immediate autotransplantation of #18 to #17 recipient socket. The treatment plan and prognosis were explained to the patient, and written consent was obtained.

Since the patient reported with pain, caries was excavated; access and chemomechanical preparation followed by calcium hydroxide dressing was given to reduce any infection in tooth #17.

On preoperative CBCT analysis of radicular anatomy and dimensions of recipient and donor root from CBCT, recipient socket modification required was minimal to nil and would be further confirmed after the try-in of the donor in recipient socket [Figure 2]a,[Figure 2]b,[Figure 2]c.
Figure 2: Presurgical intra.oral picture of tooth #17. (a) Occlusal view. (b) Lateral view of occlusion at #17 region. (c) Presurgical radiograph after caries excavation and temporary restoration

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Following disinfection and local anesthesia (2% lidocaine with 1:100,000 epinephrine) of the surgical sites, tooth #17 was non traumatically avulsed using rotating or tensile dislocation movements. Since no modification of alveolus was planned, the recipient site was gently curetted and thoroughly irrigated with normal saline.

At the donor site, a crestal incision with an anterior-releasing incision was placed. Mucoperiosteal tissue was raised, and the buccal bone guttering was performed carefully. Donor tooth (#18) was luxated passively, taking precautions to preserve PDL on the root surface.

The extracted tooth (#18) was immediately placed into the recipient site of #17 with minimal trauma to the root surface. The tooth snugly fitted into the socket, thus negating the need for any further modification of the socket, as was assessed in the preoperative CBCT. The tooth was placed at the same level of the eruption as in its donor location, to permit continual normal eruption and root development. However, functional contacts of the transplanted tooth with opposing teeth were avoided.

The tooth was stabilized in position using 3–0 silk sling sutures, allowing minor movement [Figure 3]a. A tight marginal gingival adaptation to the tooth surface was achieved to optimize reattachment and ensure oral hygiene management.
Figure 3: (a) Transplanted tooth #18 into recipient site #17 stabilized using 3-0 silk sutures. (b) Postsurgical radiograph showing fit of transplanted tooth #18 in #17 recipient site

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A radiograph was taken, before and after splinting to evaluate the position of the donor tooth in the new socket [Figure 3]b.

Surgical dressing (COE-PAK™ AUTOMIX, GC America INC, Alsip, Illinois) was applied. For the postsurgical period, the patient was prescribed an antibiotic (Amoxicillin 500 mg every 8 h for 7 days), an analgesic (Paracetamol 650 mg every 6 h for 3 days), soft diet for 1 week and 0.12% chlorhexidine mouth rinse for the same period.

The dressing was removed 3–4 days posttransplantation. One week after the procedure, sutures were removed, and the tooth was evaluated for gingival healing and occlusal interferences [Figure 4]a. The radiograph was recorded to evaluate the position in the socket [Figure 4]b. The patient was asymptomatic, and further review was scheduled at 3 weeks, 1 month, 3 months and 6 months. Subsequently, the patient attended a recall visit once a year up to 4 years.
Figure 4: Follow-up after 1 week. (a) Clinical picture demonstrating satisfactory healing of gingiva. (b) Radiograph reassessing the position of transplanted tooth

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At every visit, the transplanted molar was evaluated clinically and radiographically. Clinical evaluation included gingival assessment for healing and contour, periodontal probing, clinical attachment level, mobility testing, resonance to percussion, occlusal assessment and vitality tests.

At the 3-week postoperative follow-up, favorable soft-tissue healing was demonstrated by the gingiva. At 3 months, mobility was reduced to first-degree [Figure 5]a,[Figure 5]b,[Figure 5]c.
Figure 5: Follow-up at 3 months. (a) Transplant tooth with healthy gingiva. (b) Assessment of pocket depth. (c) Radiograph showing gradual root development

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At 6 months, there was normal mobility with the recovery of the sulcus depth to normal range. Furthermore, the tooth was submitted to thermal and electrical pulp sensitivity tests, presenting a positive response from 6 months and remained positive through 4 years. Radiographic evaluation showed continued root formation evident at 6 months with the gradual regeneration of the alveolar bone and the emergence of lamina dura around the transplant. There were no other pathological changes.

The 4-year follow-up indicated successful postoperative outcomes as there were no radiographic or clinical signs of root resorption or periodontal disease. The patient presented no complaints, and the autotransplanted tooth was found to be stable with good contacts, contours, and occlusion [Figure 6]a and [Figure 6]b. Radiographs showed root development, apex closure and partial obliteration of root canals through the follow-up period [Figure 6]c and [Figure 6]d and [Figure 7]a,[Figure 7]b,[Figure 7]c,[Figure 7]d.
Figure 6: Follow-up at 4 years. (a and b) clinical pictures showing healthy and functional tooth. (c) Intra-oral radiograph showing complete root development (d) Orthopantomograph

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Figure 7: Cone beam computed tomography images of transplanted tooth showing root development, apex closure and partial obliteration of root canals. (a) Three-dimensional reconstructed image. (b) Sagittal view. (c) Coronal view. (d) Axial view at apical third level

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  Discussion Top


When the remaining dentin girth and quality is poor for bonded restoration and lacks a three dimensional ferrule to provide retention and resistance for prosthetic restoration, a tooth is deemed nonrestorable.[7],[8]

With due consideration to the young patient, suffering early loss of the tooth, autotransplantation was planned as it entails a single surgical phase, cost-effective, and predicts a long-term alternative to other restorative modalities.

Periodontal reattachment and alveolar bone regeneration are possible with autotransplanted teeth. It also preserves proprioception in the PDL, resulting in appropriate phonetics and occlusion. It also improves esthetics and maintains normal gingival contour.

Autotransplantation of premolars was reported in the treatment of certain orthodontic problems, such as premolar aplasia and traumatic loss of anterior teeth by Slagsvold and Bjercke.[9],[10] The first surgical protocol of autotransplantation was published by them in 1974 in a study that reported postoperative root formation of 38 transplanted premolars with a mean follow-up period of 6.2 years. The study concluded that the premolars transplanted before completion of root formation regularly maintain their capacity to grow and to complete root development by the formation of an apex. They also highlighted the importance of maintaining the integrity of the epithelial root sheath.[11],[12]

The recognized surgical procedures, in this case, were based on the protocols and techniques described by Andreasen and Tsukiboshi. In 1973, a large prospective study was carried at the University Hospital in Copenhagen on patients aged 7 years to 35 years investigating various healing parameters following autotransplantation of 370 premolars over 13 years by Andreasen. He postulated a standardized surgical procedure for transplantation, which optimizes pulpal and periodontal healing as well as root growth subsequent to transplantation.[13],[14],[15],[16] Tsukiboshi has performed more than1000 autotransplantations since 1987, and his techniques described integrates the biologic principles that are crucial to success.[17] Two separate analyses performed on 319 cases with follow-up ranging from 2 to 26 years showed long-term successful outcomes. The observed survival rate was 94.6%, and the success rate was 85.3%. The main reason for failure being the development of ankylosis-related resorption.[18]

A consensus has been reached that the optimal moment to conduct autotransplantation is when the donor tooth root has reached two-thirds to three-quarters of its final length (stages 3 and 4 by Moorrees et al.[19] or Cvek et al.[20]). It enables revascularization resulting in narrowing of the root canals as a response to pulp vitality.

Following multidisciplinary planning, teeth #17 and #18 were carefully extracted to cause minimal trauma to the periodontium and supporting alveolar bone. PDL cells can be damaged mechanically during extraction or biochemically due to various extra-oral conditions.[17]

The functional periodontium exhibits a higher resistance to dislocation forces as it is predominantly made up of fibroblasts positioned perpendicularly to the dentinal walls.[21] The preservation of epithelial cell rests of Malassez prevents root resorption and maintains the PDL space, thereby preventing ankylosis and root resorption.

The morphology and dimensions of roots of the donor and recipient teeth were assessed presurgically from CBCT. The match between the recipient and the donor was pre-assessed, and thus in the present case, no further recipient site preparation was required. In case of a mismatch, when recipient site preparation is required, three-dimensional morphological evaluation and surgical simulation enables a stereoscopic preoperative treatment planning.[22] The creation of computer-aided rapid prototyping models enables the accurate fit of donor tooth and decreases the extra-oral dry time.[23]

Although the prognosis of transplant is questionable in an infected recipient site, there are reports of management of infected recipient site with curettage, debridement and copious irrigation with antimicrobials. Following disinfection, the transplant is placed into a site where fresh bleeding is incited.[24]

Immediate transplantation was done to reduce extra-oral dry time since the viability of PDL cells are highly sensitivity to osmotic changes.[6],[25]

While transplanting donor into recipient socket, it was ensured that there was keratinized gingiva tightly adherent to the root of the tooth. This renders an aesthetically pleasing gingival contour following healing.[1],[26]

Silk suture sling was used to immobilize the tooth for a week, as it is a quick and effective method, while maintaining physiologic movement, reducing the risk of external resorption and ankylosis.[27]

The preparation of the transplanted tooth, for example, for prosthetic restorations or to reduce a palatal cusp, was avoided as this can further damage an already vulnerable and healing pulp.[1]

In a retrospective study on the survival of autologous tooth transplants, Yoshino et al. reported that the main reasons for autotransplantation failure were periodontal attachment loss (54.9%), root resorption (26.5%), dental caries (4.0%), root fracture (2.9%), and other causes (11.8%).[28] Studies have also reported ankylotic-related resorption after 10 years or more.[18],[29] Hence, obtaining long-term data on the patient is mandatory to assess the survival of the transplant.

We used the criteria described by various authors to assess the prognosis of transplantation. An autotransplantation is considered successful when physiologic mobility is present, PDL reattachment has occurred, no progressive root resorption, gingival tissue and alveolar bone has healed, pulp revascularization has occurred, and root development has continued, which translate into improved aesthetics, masticatory function, phonetics and integrity of the dental arch.[2],[15],[17],[30]

At the 4-year follow-up time-point, autotransplanted tooth met the standard success criteria. Since the donor tooth was immature, with open apices, there was pulp revascularization,[31] with subsequent partial pulp canal obliteration, which could be considered as a sign of healing.[32],[33] A 4-year follow-up of the present case has shown achievement of functional, biological and esthetic goals compared to other rehabilitative modalities, with significant advantages from the cost-benefit perspective. The success can be attributed to the strict selection criteria, protection of the PDL, and proper oral hygiene. However, long-term maintenance and follow-up are required to ensure the survival of the transplant.


  Conclusion Top


The present case demonstrates that autotransplantation is a viable option for the rehabilitation of missing tooth in growing patients when a suitable donor tooth is available. Successful autotransplantation offers improved esthetics, arch form, dentofacial development, mastication, speech, and arch integrity through proprioceptive stimulation. In addition, it maintains natural spacing, preventing migration of adjacent and opposing teeth. It is recommended that patients undergoing autotransplantation should be treated as part of a multidisciplinary team to maximize success and outcome. Compliance and maintenance are essential to ensure positive long-term results.

Acknowledgment

We would like to acknowledge Dr. Ravi Varma, Professor Emeritus, Department of Conservative Dentistry and Endodontics, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India, and Dr. Ravi Veeraraghavan, Professor and HOD, Department of Oral and Maxillofacial Surgery, Amrita School of Dentistry, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India, for their expert opinion. We also thank the patient who allowed the publication of this case report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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