Case Report
Orthodontic treatment after autotransplantation Mehrangiz Ghassemia; Abdolreza Jamilianb; Ulrike Fritzc; Dieter Riedigerd; Alireza Ghassemie ABSTRACT Autotransplantation is an alternative method to replace a missing tooth. This study reports a 17year-old man who had autotransplantation of the left upper third molar with the congenitally missing left lower second premolar. No signs of inflammation, root resorption, ankylosis, mobility, sensitivity, pocket problems, or pulp destructions were found after 2-year follow up. Autotransplantation can lead to shorter treatment time and an improved treatment result in certain cases. It also eliminates the need for implants or prosthetic therapy. (Angle Orthod. 2011;81:721–725.) KEY WORDS: Congenitally missing teeth; Autotransplantation; Orthodontic treatment
INTRODUCTION
approach can lead to a shorter treatment time and an improved treatment result in certain cases of tooth loss. In addition, it has also become an alternative treatment similar to dental implants. Autotransplantation has historically been popular in northern European countries.4–6,10–13 Experimental and clinical studies on tooth transplantation still continue. Only a few papers with combined orthodontic treatment and autotransplantation of the first mandibular molar have been reported. This case report demonstrates successful autotransplantation of a left upper third molar of a patient with a missing left lower second premolar after completion of active orthodontic treatment.
Missing teeth can be treated in different ways such as orthodontic space closure, fixed or removable partial dentures, dental implants, and autotransplantation. Agenesis of teeth, either congenital or due to caries or trauma, presents a controversial issue to the concept of a conservative treatment plan. The first case reports of autogenous molar transplantation appeared in the literature in the 1950s.1,2 Successful autotransplantation of immature mandibular third molars was reported by Fong as early as 1953.3 Autotransplantation of a third molar is an alternative treatment for the replacement of the missing tooth due to the high cost of dental implants. Prognosis for autotransplantation is favorable and no immunologic problems are involved;4 moreover, high long-term results are reported.5–9 This treatment
CASE REPORT The patient was a 17-year-old man. He was referred with chief complaints of deep bite for orthodontic assessment due to a missing left lower second premolar. He had no serious medical history and previous orthodontic treatment. Pretreatment panoramic radiograph revealed missing left lower second premolar (Figure 1). Cephalometric analysis showed SNA of 84u, SNB of 81u, and ANB of 3u. The gonial angle was 124u. Clinical examination revealed an Angle Class II division 2 malocclusion with a horizontal growth pattern and a straight profile (Figure 2).
a Dr. Med. Dent, Department of Orthodontics, School of Medicine, University of Aachen, Aachen, Germany. b Associate Professor, Department of Orthodontics, School of Dentistry, Islamic Azad University, Tehran, Iran. c Professor, Department of Orthodontics, School of Medicine, University of Aachen, Aachen, Germany. d Professor, Department of Oral Maxillofacial Plastic and Reconstructive Surgery, School of Medicine, University of Aachen, Aachen, Germany. e Assistant Professor, Department of Oral Maxillofacial Plastic and Reconstructive Surgery, School of Medicine, University of Aachen, Aachen, Germany. Corresponding author: Dr Mehrangiz Ghassemi, Department of Orthodontics, School of Medicine, University of Aachen, Pauwelsstr 30, Aachen, NRW 52074 Germany (e-mail:
[email protected])
Diagnosis and Treatment Objective Due to the above mentioned findings, the diagnosis of a Class II division 1 malocclusion was given to the patient along with a missing left lower second premolar. The main treatment objectives were to correct the deep bite and the missing left lower permanent second premolar and to establish a stable occlusion.
Accepted: January 2011. Submitted: October 2010. Published Online: March 1, 2011 G 2011 by The EH Angle Education and Research Foundation, Inc. DOI: 10.2319/102210-617.1
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Figure 1. Pretreatment panoramic radiograph.
Treatment Plan All of the maxillary and mandible teeth were bonded with a 0.022-inch straight wire, and deep bite was corrected by fixed orthodontics (Figure 3). On the basis of diagnostic records, various treatment options for the missing left lower second premolar were considered. These options included fixed orthodontic or mini screw anchorage for space closure, fixed or removable partial dentures, dental implant, and autotransplantation. The parents agreed with transplanta-
Figure 2. Pretreatment cephalometric radiograph. Angle Orthodontist, Vol 81, No 4, 2011
tion of the left upper third molar in the left lower premolar space. Treatment Progress The autotransplantation was performed in the Department of Maxillofacial Plastic and Reconstructive Surgery of the University Hospital RWTH-Aachen, using a standardized surgical technique. The operation was performed in an ambulatory setting under general anesthesia. Prior to surgery, a clinical and radiographic examination of the recipient site was performed to clarify the available space and determine the stage of root development. Presurgical examination consisted of intraoral radiographs of the donor and recipient sites, using orthopantogram (OPG). Space conditions were measured according to the space required in the same OPG. There was no vertically atrophied alveolar process (Figure 1). The left upper third molar was transplanted in the left lower premolar space as soon as one to two thirds of the root was visible (Figure 1), and the transplant was fixed about gingival level (Figure 4). Fixation of the transplant was performed with a suture splint crossing the occlusal surface.
Figure 3. Intraoral photo after fixed appliances.
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ORTHODONTIC TREATMENT AFTER AUTOTRANSPLANTATION
Figure 7. Intraoral photo after 6 months of autotransplanted tooth.
Figure 4. Intraoral photo after insertion of autotransplanted tooth.
Space for eruption of autotransplantation was maintained with an open coil spring (Figures 5 and 6). Orthodontic movement of the transplanted tooth was done after 4 months. The position of autotransplanted tooth after 6 months is shown in Figure 7. Periapical radiographs showed no inflammatory root resorption or other pathologic lesions after 6 months (Figure 8). Posttreatment intraoral photos show the normal position of the autotransplanted tooth after 1 year (Figure 9). Two years later, all fixed appliances were removed and a good occlusion was achieved (Figures 10 through 13). Treatment Results Posttreatment results showed an acceptable overjet and overbite with a normal corrected deep bite. No signs of ankylosis, mobility, sensitivity and pocket problems, pulp destruction, inflammatory root resorption, and inflammation in the periodical area of the recipient site were detected radiographically after 2year follow up (Figures 11 through 13). A good occlusion was achieved, and the patient was satisfied with the results of the treatment (Table 1).
Figure 5. Periapical radiograph after insertion of autotransplanted tooth.
Figure 6. Intraoral photo after 2 months of autotransplanted tooth.
Figure 8. Periapical radiograph after 6 months of autotransplanted tooth. Angle Orthodontist, Vol 81, No 4, 2011
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Figure 9. Intraoral photo after 1 year of autotransplanted tooth.
Figure 10. Intraoral photo after 2 years of autotransplanted tooth (left view).
Figure 13. Posttreatment cephalometric radiograph after 2 years of autotransplanted tooth.
DISCUSSION
Figure 11. Intraoral photo after 2 years of autotransplanted tooth (occlusal view).
Autotransplantation is a traditional method in the field of dentistry to recreate a functional tooth substitution. Success rates of autotransplantation have been reported in various long-term studies. Kitahara et al.5 reported autotransplantation treatment is an effective modality for the replacement of tooth when a donor tooth is available. Czochrowska et al. 6 reported a high success rate in a study of 33 transplanted premolars. Andreasen et al.14–17 reported survival rates of more than 90% in a comprehensive study, but only a few of their transplants had an observation period of more than 10 years. The most complications associated with Table 1. Cephalometric Measurements at Pretreatment and Posttreatment Cephalometric Measure
Figure 12. Posttreatment panoramic radiograph after 2 years of autotransplanted tooth. Angle Orthodontist, Vol 81, No 4, 2011
SNA SNB ANB Gonial angle Interincisal angle Upper incisor to SN Lower incisor to ML
Pretreatment Posttreatment 84 81 3 124 140 95 90
81 80 1 128 127 103 94
Treatment Change 23 21 22 +4 213 +8 +4
ORTHODONTIC TREATMENT AFTER AUTOTRANSPLANTATION
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autotransplantation are ankylosis and root resorption. Pohl et al.18 mentioned that adequate mobility reduced the probability of ankylosis since bone repair is stimulated when functional movements of the transplanted tooth are preserved. Other factors such as the developmental stage of the tooth, damage to the root cementum, the type of donor’s tooth, the duration of extraoral exposure of the donor tooth during surgery, the periodontal conditions, and the experience of the oral surgeon can influence the results.18,19 However, autotransplantation requires consideration of the state of the periodontal ligament, pulp, and the length and diameter of the donor’s tooth and alveolar bone.6 Preserving the periodontal membrane and minimizing the time that the tooth is out of the mouth during transplantation have tremendous effects on the quality of the transplantation.20 The preservation and regeneration of the periodontal ligament is the key to success of this treatment.21 Transplanted tooth recovers its proprioceptive function and normal periodontal healing. Thus, the patient has a natural chewing feeling and natural biologic response.22 Similarly Patel et al.23 reported the use of autotransplantation as part of an orthodontic treatment plan. The necessity of an atraumatic technique and handling of the transplant to preserve an intact periodontal ligament and Hertwig’s root sheath are important considerations. This means that sufficient surgical procedures and orthodontic preoperative space preparation are important factors for a successful outcome. It shows the importance of the surgeon’s experience and adequate orthodontic treatment.
rates 17–41 years posttreatment. Am J Orthod Dentofacial Orthop. 2002;121:110–119. Tsukiboshi M. Autotransplantation of teeth: requirements for predictable success. Dent Traumatol. 2002;18:157–180. Kristerson L, Lagerstrom L. Autotransplantation of teeth in cases with agenesis or traumatic loss of maxillary incisors. Eur J Orthod. 1991;13:486–492. Nethander G. Autogenous free tooth transplantation with a two-stage operation technique. Swed Dent J Suppl. 2003: 1–51. Slagsvold O, Bjercke B. Indications for autotransplantation in cases of missing premolars. Am J Orthod. 1978;74:241– 257. Tsurumachi T, Kakehashi Y. Autotransplantation of a maxillary third molar to replace a maxillary premolar with vertical root fracture. Int Endod J. 2007;40:970–978. Jonsson T, Sigurdsson TJ. Autotransplantation of premolars to premolar sites. A long-term follow-up study of 40 consecutive patients. Am J Orthod Dentofacial Orthop. 2004;125:668–675. Slagsvold O, Bjercke B. Autotransplantation of premolars with partly formed roots. A radiographic study of root growth. Am J Orthod. 1974;66:355–366. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer T, Schwartz O. A long-term study of 370 autotransplanted premolars. Part I. Surgical procedures and standardized techniques for monitoring healing. Eur J Orthod. 1990;12: 3–13. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-term study of 370 autotransplanted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Eur J Orthod. 1990;12:14–24. Andreasen JO, Paulsen HU, Yu Z, Schwartz O. A long-term study of 370 autotransplanted premolars. Part III. Periodontal healing subsequent to transplantation. Eur J Orthod. 1990;12:25–37. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A long-term study of 370 autotransplanted premolars. Part IV. Root development subsequent to transplantation. Eur J Orthod. 1990;12:38–50. Pohl Y, Filippi A, Tekin U, Kirschner H. Periodontal healing after intentional auto-alloplastic reimplantation of injured immature upper front teeth. J Clin Periodontol. 2000;27: 198–204. Schwartz O, Bergmann P, Klausen B. Resorption of autotransplanted human teeth: a retrospective study of 291 transplantations over a period of 25 years. Int Endod J. 1985;18:119–131. Ahlberg K, Bystedt H, Eliasson S, Odenrick L. Long-term evaluation of autotransplanted maxillary canines with completed root formation. Acta Odontol Scand. 1983;41:23–31. Natiella JR, Armitage JE, Greene GW. The replantation and transplantation of teeth. A review. Oral Surg Oral Med Oral Pathol. 1970;29:397–419. Aslan BI, Ucuncu N, Dogan A. Long-term follow-up of a patient with multiple congenitally missing teeth treated with autotransplantation and orthodontics. Angle Orthod. 2010; 80:396–404. Patel A, Brennan JA, Sandler PJ. Autotransplantation of an impacted third molar: an orthodontic case report. Dent Update. 2004;31:596–598.
CONCLUSION
7. 8.
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N Tooth transplantation is an effective treatment modality when a donor tooth is available. 19.
REFERENCES 1. Miller HM. Transplantation and reimplantation of teeth. Oral Surg Oral Med Oral Pathol. 1956;9:84–95. 2. Apfel H. Transplantation of the unerupted third molar tooth. Oral Surg Oral Med Oral Pathol. 1956;9:96–98. 3. Fong CC. Transplantation of the third molar. Oral Surg Oral Med Oral Pathol. 1953;6:917–926. 4. Slagsvold O, Bjercke B. Applicability of autotransplantation in cases of missing upper anterior teeth. Am J Orthod. 1978; 74:410–421. 5. Kitahara T, Nakasima A, Shiatuschi Y. Orthognathic treatment with autotransplantation of impacted maxillary third molar. Angle Orthod. 2009;79:401–406. 6. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: survival and success
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