Autotransplantation of Odontoma-Associated Impacted Teeth-A ...

Autotransplantation of Odontoma-Associated Impacted Teeth—A Treatment Strategy for Satisfying Immediate Esthetic Demands: A Case Report Lisa Alice Hwang, DDS,* Chih-Yin Kuo, DDS,y Jung-Wu Yang, DDS,z and Wei-Fan Chiang, DDS, MSx Compound odontomas are common odontogenic tumors associated with permanent tooth impaction in the premaxilla. This report describes the case of a 14-year-old girl with an odontoma-associated impaction over the premaxilla that was treated using autotransplantation to satisfy an immediate esthetic demand. At postoperative follow-up conducted in the 14th month, a satisfactory cosmetic appearance with a healthy periodontal status was observed. In addition, the authors discuss the possible complications of autotransplantation and different treatment strategies for odontoma-associated impaction and for correcting bone defects in this case report. Autotransplantation for treating odontoma-associated impaction can be an alternative solution for satisfying an immediate cosmetic demand and providing a favorable outcome. Ó 2017 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 75:1827-1832, 2017 Odontomas are the most common odontogenic tumors and are mostly diagnosed in the second decade of life.1 These tumors are often associated with delayed primary tooth exfoliation and permanent tooth impaction, the incidence of which has been reported to be 41 to 87%.1-4 The etiology of odontomas is proposed to be associated with local trauma, infections, and hereditary anomalies.5 The World Health Organization classifies odontomas into complex odontomas, which consist of dental tissue but form an irregular mass in a disordered pattern, and compound odontomas, malformations in which all dental tissue is arranged in an order similar to that of a natural tooth but with an altered size and

conformation, giving rise to multiple small tooth-like structures called denticles. Large retrospective studies have reported that most compound odontomas are observed in the anterior maxilla, whereas complex odontomas are observed predominantly in the posterior mandible.6,7 The histopathologic features can overlap with those of ameloblastic fibro-odontomas, which are considered an immature form of odontomas, and odontomas and fibro-odontomas are treated with conservative curettage, with tumor recurrence being rare after complete removal.8,9 The surgical removal of odontomas can eliminate pathosis; however, the deeply impacted teeth are often removed because their prognosis with orthodontic

*Resident, Department of Oral and Maxillofacial Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.

Address correspondence and reprint requests to Dr Chiang: Chi-Mei Medical Center, No 201, Taikang Village, Liouying Distinct,

yVisiting Staff, Department of Dentistry, Chi-Mei Medical Center,

Tainan, Taiwan; e-mail: [email protected]

Liouying, Taiwan.

Received October 11 2016

zChief, Department of Oral and Maxillofacial Surgery, Sin-Lau Hospital, Tainan, Taiwan.

Ó 2017 American Association of Oral and Maxillofacial Surgeons

xChief, Department of Oral and Maxillofacial Surgery, Chi-Mei Medical Center, Liouying; Associate Professor, School of Dentistry,

Accepted March 29 2017 0278-2391/17/30370-1 http://dx.doi.org/10.1016/j.joms.2017.03.052

National Yang-Ming University, Taipei, Taiwan. Conflict of Interest Disclosures: None of the authors have a relevant financial relationship(s) with a commercial interest.

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1828 treatment is poor or a patient becomes discouraged because of the high cost and long duration of orthodontic treatment. Autotransplantation provides an option of maintaining the natural tooth and restoring the dentition when a donor tooth is available. The reported survival rates are mostly higher than 90%.10,11 Immediate autotransplantation of the impacted tooth has been performed after cyst enucleation12; however, it has gained little attention thus far in the management of odontoma-associated impaction. Therefore, the authors present a case of autotransplantation of an impacted central incisor and canine after removal of a large odontoma in the premaxilla to meet an immediate esthetic demand.

Report of Case A 14-year-old girl was referred to the Department of Oral and Maxillofacial Surgery, Chi-Mei Medical Center (Liouying, Taiwan) for a slow-growing painless mass in the left upper gingiva for 2 years and the failure of the eruption of her left anterior permanent teeth. Her medical history was noncontributory. On examination, the authors found a mild protuberance of the left upper lip and a solitary swelling of the left maxillary alveolar bone with intact mucosa, and the left incisors and canine were deciduous. Panoramic radiography visualized a well-circumscribed, multiple radiopaque, and tooth-like structure at the left anterior maxilla, and the permanent incisors and canine were upwardly displaced to the nasal floor (Figs 1, 2).

AUTOTRANSPLANTED ODONTOMA-ASSOCIATED TEETH

Under general anesthesia, an intrasulcular incision from the left first premolar to the right maxillary central incisor with 2 vertical releases was made, and the full-thickness mucoperiosteal flap was reflected. The buccal bone plate was removed using the BoneMed UI-1 piezoelectric instrument (Via-Tech Biomedical Co, Taichung, Taiwan) and preserved for bone grafting. Multiple denticle-like tumors covered with a thin connective tissue capsule were noted. Then, the tumors and deciduous teeth were removed using the piezoelectric instrument and a dental elevator, and the impacted incisors and canine were meticulously luxated from the alveolar socket. Because of limited space, only the central incisor and canine with complete root formation were autotransplanted to their ideal functional and esthetic sites (Fig 3). The bony defect was filled with autologous blood clots and Gelfoam (Pfizer, New York, NY), and the buccal bone plate was repositioned to stabilize the teeth. The 2 autotransplanted teeth were semi-rigidly fixed to an acrylic splint using a stainless steel wire with a diameter of 0.026 mm (Fig 4). The pathologic findings for the 196 denticles showed compound odontoma and 1 lateral incisor (Fig 5). The acrylic splint was removed in the second week after surgery, and functional splinting through wire and resin fixation was subsequently performed for another 2 weeks to gain adequate stability (Fig 6). Root canal treatment was started 2 weeks after surgery. Calcium hydroxide paste was applied as an intracanal medicament to prevent root resorption, and the dressing was changed every month. Although apical resorption of the autotransplanted

FIGURE 1. Preoperative panoramic radiograph showed a multiple radiopaque and tooth-like structure over the left premaxilla and the permanent incisors and the canine were upwardly displaced to the nasal floor. Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017.

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FIGURE 4. The 2 autotransplanted teeth were semi-rigidly fixed to an acrylic stent using a stainless steel wire with a diameter of 0.026 mm. Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017. FIGURE 2. Preoperative computed tomogram showed palatal displacement of the permanent lateral incisor. Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017.

teeth was noted at radiography (Figs 7, 8), the teeth showed normal mobility, occlusal function, and no exacerbated sensitivity to percussion. In the seventh month after surgery (Fig 7), the root canal was dry and radiography showed that the bone level reached three fourths of the root length with adequate lamina dura at the coronal half of the root. Therefore, the root canals were blocked using gutta-percha, and the diastema was restored with composite resin. No complication or vitality change was observed in adjacent

teeth. At the follow-up examination in the 14th month, a satisfactory appearance and a healthy periodontal status with a probing depth of 2 to 4 mm and mobility of grade 0 were observed (Figs 8, 9).

Discussion Many indications for autotransplantation have been established. The most common is the transfer of a third molar to the site of a molar, with a poor prognosis; however, the use of this technique for treating odontoma-associated tooth impaction is very limited. The authors present the case of large odontomaassociated impaction of incisors and a canine that were successfully autotransplanted to the ideal position in the dental arch, resulting in a satisfactory outcome. Empirically, the odontoma-associated tooth impaction has been managed through spontaneous eruption, with the eruption rate ranging from 32 to

FIGURE 3. The central incisor and canine were autotransplanted to their ideal position in the dental arch. Subsequently, the bone defect was filled with autologous blood clots and Gelfoam and then the buccal bone plate was repositioned to stabilize the teeth.

FIGURE 5. Specimens of 196 denticles and 1 lateral incisor.

Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017.


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FIGURE 6. Functional splinting was performed for another 2 weeks after semirigid fixation for 2 weeks. Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017.

48.5%,3,13,14 or orthodontic forced eruption. The factors predicting poor spontaneous eruption of impacted teeth include a large angle of impaction relative to the midline,14,15 impaction located at the apical third of the contralateral tooth,16 and complete root formation.17 If the impaction fails to erupt spontaneously, then orthodontic correction is performed.18 However, orthodontic correction that involves correcting impaction in the anterior maxillary region

FIGURE 8. Periapical film showed adequate bone density and lamina dura around the left central incisor and canine; however, it showed root apex resorption of the transplanted teeth. Hwang et al. Autotransplanted Odontoma-Associated Teeth. J Oral Maxillofac Surg 2017.

takes a longer time (at least 6 to 8 months) than does orthodontic treatment without impaction.19 In the present case, the central incisor was impacted at the nasal floor, and the canine cusp tip was close to the apex of the second premolar. The 2 teeth were

FIGURE 7. Root canal filling was performed in the seventh month after surgery. The bone level reached three fourths of the root length.

FIGURE 9. Clinical photograph showed a satisfactory cosmetic appearance in the 14th month after surgery and adequate keratinized gingiva around the autotransplanted left central incisor and canine.



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impacted by a large odontoma and the 2 roots were completely formed; therefore, the possibility of spontaneous eruption was low. In addition, the patient was discouraged by the lengthy orthodontic treatment for the impacted teeth. Autotransplantation offers a promising alternative option. In a previous meta-analysis, autotransplanted anterior teeth with complete root formation exhibited a 5-year survival rate of 96.9% with an annual failure rate of 0.6% and low rates of complications: for example, the infection-related root resorption rate was 2.4%, and the ankylosis rate was 0.7%.10 Moreover, root canal treatment is suggested to be initiated within 2 weeks after surgery to decrease the infection-related root resorption rate. However, despite all efforts, an autotransplanted anterior tooth still might not have a biological condition identical to that of a contralateral nontransplanted tooth. A retrospective study reported that autotransplanted teeth can exhibit a deeper probing depth, a higher tendency to have bleeding on probing, and a higher likelihood of discoloration, which could be due to endodontic treatment, whereas the mobility status and tenderness to percussion show no relevant difference.20 Although autotransplantation is not usually the first-line treatment option for restoring missing teeth, the promising survival rates and low comorbidity make autotransplantation an alternative for patients who are unwilling to undergo lengthy orthodontic treatment. Various treatment options are available for correcting maxillary defects after the removal of an odontogenic tumor. Autogenous bone grafts are considered the standard treatment option because of their osteogenic ability. Common recommended donor sites are the iliac crest, tibia, scalp, and mandible; however, patients must sustain a donor wound. Guided tissue regeneration with a freeze-dried bone allograft and a bioabsorbable membrane has been proposed for treating smaller defects.21 In the present case, the buccal wall was cautiously kept in an appropriate shape after odontoma removal, forming a hollow alveolar cavity after repositioning of the buccal plate. A barrier membrane was not indicated; however, a large amount of graft material was required to fill the cavity and stabilize the teeth. Gelfoam, which is composed of gelatin, is one of the most widely used natural polymers for the controlled and sustained delivery of biomolecules because of its biodegradability, biocompatibility, biosafety, and cost effectiveness.22 The combination of blood clots and gelatin has been beneficial in periodontal regeneration, in which the blood clots served as the reservoirs of growth factors and the gelatin foam served as the carrier.23 Gelatin enables rapid hemostasis and shows minimal foreign body reaction, and the absorption time is approximately 4 to 6 weeks.24 The slow degradation of gelatin can enable controlled

release of growth factors in blood clotting, facilitating the maximization of bone regeneration capability.25 In the present case, the autotransplanted teeth were not mobile or tender to percussion, and probing depths were within the normal limit in the seventh month after surgery. The absence of ankylosis and the presence of the lamina dura around the root were evident radiographically, indicating that the outcome was favorable. Similar results have been reported in several cases in which autologous blood clots were used in combination with gelatin for the regeneration of periodontal tissue.23 Recent studies have proposed using extracted human teeth or benign pathologic hard tissue as a novel graft material because of their physicochemical characteristics being similar to those of bone, with osteo-inductivity and osteoconductivity.26,27 This might be considered an alternative option for correcting surgical defects. This is the first case report presenting combined odontoma removal and autotransplantation of 2 impacted teeth with a satisfactory result. Compared with conventional treatment, autotransplantation has several benefits, including satisfying immediate esthetic demands, preventing the lengthy technical detours of orthodontic treatment, and being cost effective for patients. Autotransplantation can offer an immediate solution for satisfying cosmetic demands and a favorable functional outcome, and it is a promising treatment for odontoma-associated tooth impaction.

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AUTOTRANSPLANTED ODONTOMA-ASSOCIATED TEETH 20. Patel S, Fanshawe T, Bister D, et al: Survival and success of maxillary canine autotransplantation: A retrospective investigation. Eur J Orthod 33:298, 2011 21. Blumenthal NM, Mostofi R: Repair of an intrabony defect from an adenomatoid odontogenic tumor. J Periodontol 71:1637, 2000 22. Song J, Leeuwenburgh SC: Sustained delivery of biomolecules from gelatin carriers for applications in bone regeneration. Ther Deliv 5:943, 2014 23. Kabashima H, Sakai T, Mizobe K, et al: The usefulness of an autologous blood clot combined with gelatin for regeneration of periodontal tissue. J Oral Sci 55:363, 2013 24. Schonauer C, Tessitore E, Barbagallo G, et al: The use of local agents: Bone wax, gelatin, collagen, oxidized cellulose. Eur Spine J 13(suppl 1):S89, 2004 25. Yamamoto M, Takahashi Y, Tabata Y: Controlled release by biodegradable hydrogels enhances the ectopic bone formation of bone morphogenetic protein. Biomaterials 24:4375, 2003 26. Kim YK, Kim SG, Byeon JH, et al: Development of a novel bone grafting material using autogenous teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109:496, 2010 27. Lee J, Lee EY, Park EJ, et al: An alternative treatment option for a bony defect from large odontoma using recycled demineralization at chairside. J Korean Assoc Oral Maxillofac Surg 41:109, 2015