DRJ Dent Res J Dental Research Journal Dental Research Journal 1735-3327 2008-0255 Medknow Publications Pvt Ltd India DRJ-10-1 10.4103/1735-3327.111756 Review Article Tooth auto-transplantation as an alternative treatment option: A literature review Nimcenko Tatjana Omerca Gražvydas Varinauskas Vaidas Bramanti Ennio Signorino Fabrizio Cicciù Marco Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, LithuaniaDepartment of Maxillofacial Surgery, Lithuanian University of Health Sciences, LithuaniaDepartment of Maxillofacial Surgery, Lithuanian University of Health Sciences, LithuaniaDepartment of Odontostomatology, School of Dentistry, University of Messina School of Dentistry, Messina, ItalyDepartment of Odontostomatology, School of Dentistry, University of Messina School of Dentistry, Messina, ItalyDepartment of Human Pathology, School of Dentistry, University of Messina School of Dentistry, Messina, Italy Address for correspondence:Marco Cicciù, Department of Human Pathology, Dental School, Messina University, Via Consolare Valeria 98100, Messina, Italy acromarco@yahoo.it Jan–Feb 2013 10 1 1 6 Copyright: © Dental Research Journal 2013

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Rapidly evolving implantation and alveolar ridge reconstruction techniques created a new area in modern dentistry where tooth loss is no longer a problem. Endless variations of implant′s length, diameter, surface, and design along with autogenous, alogenous, aloplastic, or xenogenous bone substitutes made it possible to recreate physiological occlusion, esthetic and masticatory function.

However, none of nowadays technologies in implant dentistry have the potential to adapt to a growth and development changes of a child′s jaw. Therefore, patient′s young age is a restriction for implantation and a particular challenge for a dentist willing to restore missing tooth. Thus, tooth auto-transplantation can be a good choice for treatment. The objective of this review is to underline the biologic principles required for successful auto-transplantation of teeth. Limits, indications, technique, and prognosis will be analyzed.

Autologous auto-transplantation tooth transplantation
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Introduction

Dental auto-transplantation or autogenous transplantation is defined as the movement of one tooth from one position to another, within the same person. 1,2 This could involve the transfer of impacted, embedded, or erupted teeth into extraction sites or into surgically prepared sockets. 2 The procedure itself is not a new invention, and the earliest reports of tooth transplantation involve slaves in ancient Egypt who were forced to give their teeth to their pharaohs. 3,4 Eventually, allotransplantation, transplantation of a tooth from one individual to another, was abandoned because of histocompatibility and replaced with auto-transplantation. 3

Although today dental implant is mostly desirable treatment method in case of lost teeth (because of its predictable and long-term results), it cannot be applied to all patients due to young age or socio-economic reasons; therefore, tooth auto-transplantation could be considered as an alternative.

Indications

There are many reasons for tooth auto-transplantation, but most common indication is teeth to be extracted due to advanced caries destruction: In adolescents, the first permanent molars erupt early and are often heavily restored. When first molar is lost in young patient, it can result in abnormal occlusion because of tooth migration and due to uneven jaw growth. Thus, treatment of such patient should be aimed on maintenance of lost tooth space without alterations to growing jaw. When dental implants are placed in adolescent patients, they do not erupt along with adjacent teeth and result in infraocclusion with functional and esthetic problems. 5 In this case, auto-transplantation is indicated: A tooth with incomplete rhizogeneses and maintained PDL remains ability of further growth and promotes alveolar bone development in the receptor area. 6 Most frequently, a wisdom tooth is transferred to the site of a hopeless molar because of its late development compared to the other teeth.

Another indication is maxillary incisors that are most frequently involved in trauma. In such case, avulsed tooth brought to dental office in a proper condition (during first 24 hours after trauma, in a suitable solution) could be replanted and splinted for a healing period. Even partially damaged tooth (cracked, chipped, or broken crown) could be saved applying endodontic and restaurative treatment. Although when a tooth is lost completely (advanced cariotic destruction, trauma), it could be replaced with patients own tooth. 7 Therefore, considering the stage of root development and the size of the crown of a donor tooth is chosen. Usually, mandibular first or second premolars are appropriate in mesiodistal dimension to replace lost central incisor, although later an adequate reconstruction of the crown with composite resin or artificial crown according to anatomy is needed. The posterior space that results from harvesting of the premolar could be closed by unilateral protraction of the posterior teeth with traditional or mini-implant anchorage mechanics. 8

One more indication for tooth auto-transplantation is congenital tooth absence. Tooth agenesis is mostly of unknown etiology. It was determined that about 90% children with agenesis misses 1 or 2 teeth, and only 3% of people with agenesis lack 2 or more teeth in the same quadrant. 9 Most frequently, absent teeth are mandibular third molars, followed by mandibular second premolars, maxillary lateral incisors. 10 The alternative treatment options to transplantation when missing mandibular second premolars usually include space closure in connection with routine orthodontic treatment involving extractions of 2 maxillary premolars (extraction can be planned for the correction of crowding or reduction of overjet 11,12,13,14 or leaving the deciduous second molars for as long as possible.) 15 Missing lateral incisor alternatively to transplantation can be treated by orthodontic space closure, 16 conventional or resin-bonded bridges, or single-tooth implants. 9

Atypical tooth eruption can also be an indication for auto-transplantation. Ectopically positioned teeth are usually exposed surgically and then orthodontic treatment is applied. In cases of severe ectopic position of maxillary canines (ectopic canines present about 2% of population), 15 correction of its position may present a challenge for traditional orthodontic mechanics. Therefore, auto-transplantation of canine into a more natural orientation could provide a simplified and faster treatment option. 13

Candidate criteria

Patient selection is very significant for the auto-transplantation success. Candidates must be in a good health, demonstrate excellent level of oral hygiene, and be amenable to regular dental care; otherwise successful outcome of auto-transplantation could be jeopardized. Patients must be able to follow post-operative instructions and be available for follow-up visits; co-operation and comprehension are important to ensure predictable results. Above all, the patients must have a suitable recipient site and donor tooth. 17,18,19,20,21,22,23

Recipient site criteria

The recipient site should be free from acute infection and chronic inflammation. 23 Adequacy of bone support is crucial criteria for success. To ensure stabilization of the transplanted tooth and to avoid infection penetration from the mouth, there must be sufficient alveolar bone support in all dimensions with adequate attached keratinized tissue.

Before the auto-transplantation, thorough treatment planning should follow careful clinical and radiographic examination. If the mesiodistal recipient space is insufficient for the donor tooth, an orthodontic space generation prior to transplantation will be necessary. In cases of insufficient buccolingual bone width an autogenous bonegraft or green-stick, fracture may be performed at the recipient site. 19,20,24 The apico-coronal parameters of recipient site bone should be carefully examined from radiographs at the same time evaluating length of the tooth′s root to be transplanted. If needed, additional preparation of recipient alveolus depth may be performed during auto-transplantation.

Donor tooth criteria

Teeth with open or closed apices may be considered as donors. However, the stage of root development of the transplant tooth is very important. Studies have evaluated the success of auto-transplantation looking at both development of the periodontal attachment and pulpal survival. 8,19 Success rates are highest when the root development is one-half to two-thirds. Transplantation of a bud with roots formed less than one-half may be too traumatic and could compromise further root development. Surgical manipulation with full length roots and an open apex (such tooth would remain vital and should continue root development after transplantation) are still possible, but the increased length may cause encroachment on vital structures such as maxillary sinus or the inferior alveolar nerve. If a tooth with a complete root formation is transplanted, it will generally require root canal therapy performed 2 weeks after transplantation. 13 A tooth should be considered appropriate when its roots are sufficiently long to be preserved if no root development occurs after transplantation. Ideally, transplantation should be performed when a tooth is at its maximal length but still has the potential for pulp regeneration (apex opening >1 mm radiographically). 5

One of the factors contributing to successful auto-transplantation is vital intact periodontal ligament (PDL) fibers that play an important role in healing. Usually, the PDL fibers on the walls of the surrounding prepared sockets are absent. Therefore, it is desirable to extract a tooth with as much PDL attached to it as possible as it seems to be effective in preventing root resorption. 24,25,26,27

Timing

Immediate replantation of exarticulated teeth is known to have a good prognosis, while transplanted teeth to recipient beds prepared at the same time show a high prevalence of root resorption. 23 Ideally, extraction of the tooth from recipient site should be performed on the same day when donor tooth is removed for transplantation. In cases when tooth from recipient site must be extracted earlier due to toothache or other reasons, transplantation should be scheduled within a month. 20 The later donor tooth will be transplanted, the less support it will have as resorption of the bone would occur at the recipient site.

Timing is critical when assessing root formation stage suitable for auto-transplantation; therefore, age of the patient must be considered when planning this type of operation. Pulp regeneration can be expected in immature (developing) teeth but not in mature teeth. 28,29,30,31 It is established that formation of the root continues after tooth emerges in the mouth for about 2-3 years Table 1. Mostly, the right stage of root development occurs between the ages 9 and 12 years. Most traumatic injuries to anterior teeth seem to occur at the same period, making auto-transplantation a good option for these patients. 5,17,18,19 Yet, wisdom tooth that is best for replacement of failed molars is better to be transplanted in elder patients. Finally, indicated age groups shouldn′t be followed strictly in case of possible deviations in teeth maturation, and every possible candidate for transplantation should be examined by radiographic evaluation.{Table 1}

Success

Abulcassis documented the first dental surgical interventions of such kind in 1050, but the first surgery with details of tooth bud transplantation was recorded only in 1564, performed by a French dentist Ambroise Pare. In 1965, M.L. Hale described a transplantation technique for molars, and the major principles of his technique are still followed today. 1,2,4 The literature reports excellent success rates following the appropriate transplantation protocol: Cohen 24 found 98-99% survival rates over 5 years and 80-87% over 10 years with transplanted anterior teeth with closed apices. Lundberg and Isaksson 18 had success in 94% and 84% of cases for open and closed apices, respectively, in 278 auto-transplanted teeth over 5 years. Josefsson 33 had 4-year success rates of 92% and 82%, respectively, for premolars with incomplete and complete root formation. Andreasen 11,12 found 95% and 98% long-term survival rates for incomplete and complete root formation of 370 transplanted premolars observed over 13 years. Kugelberg 17 achieved success rates of 96% and 82% for 45 teeth with incomplete and complete root formation transplanted into the upper incisor region over 4 years. Nethander 25,27 found 5-year success rates of over 90% for 68 mature teeth transplanted with a 2-stage technique. Most extensively tooth auto-transplantation has been studied in a long-term review of cases had a follow-up range of 17 to 41 years. 9,19 The success rate was over 90%, which is similar to that of dental implant-supported restorations.

Discussion

The factors that lead to success have been extensively investigated, and it is well documented how extracted teeth gain complete function and good esthetics when replantation happens on ideal conditions Table 2.{Table 2}

It was determined that the most significant contributor is the continued vitality of the periodontal membrane. When the periodontal ligament is traumatized during transplantation, external root resorption and ankylosis is often noted; 35,36,37 root resorption is the most common cause of failure of the transplant. More specifically, the causes of tooth loss following auto-transplantation from most common to least common are: Inflammatory resorption, replacement resorption (ankylosis), marginal periodontitis, apical periodontitis, caries, and trauma. Atraumatic extraction of the donor tooth and immediate transfer to the recipient site to minimize the risk of injury to the PDL can decrease the incidence of most prevalent inflammatory (that becomes evident in 3 to 4 weeks) and replacement (becomes evident after 3 to 4 months) resorption. 36,37,38 Therefore, the biological principles for auto-transplantation success that are understood and described in the literature along with the correct indications may lead to a successful alternative treatment with a very good prognosis.

However, as implant technology has taken great achievements in recent years of predictability in success rates and esthetic results, comparison between auto-transplantation and implantation as treatment options is inevitable. From the patient′s perspective, auto-transplantation preserves the dentition using a natural tooth rather than a mechanical prosthesis, 5 from the doctor′s perspective, it is beneficial in many points. Transplantation is a biological procedure in which teeth, especially in a germ phase, have the potential capacity to induce alveolar bone growth; 26,39,40,41 therefore, it can be applied in patients before puberty growth is finished. Several clinical studies performed rigid protocol in order to have clinically success results. Usually, the patient should then be seen at weekly intervals for one month if there are no complications. After one month, the patient should be seen every 6-8 months for 2-3 years. During this period, the tooth should be clinical and radiographically evaluated for the onset of pulpal breakdown seen as intrapulpal calcification, periapical radiolucency, or root resorption. 42,43

Osteointegrated implants will not grow with the changing patients jaw and result in infraocclusion. The open apex of the transplanted tooth with intact Hertwig epithelial root sheath allows healing and regeneration of the pulpal tissue and thus saving subsequent root canal treatment. 41,43,44,45 Immediate transplantation with extraction at the recipient site is a procedure that provides significant time saving compared to implants. Healing is rapid, and function is regained almost immediately. 46,47,48 Transplanted tooth with its PDL has osteoinducing properties that results in bone regeneration of the bony defects around transplants without graft materials, thus significantly reducing time and cost compared to implants. 5 Transplanted tooth have potential for good esthetical results, since it allows the formation of a normal interdental papilla, the natural emergence profile, and natural crown form is maintained. Moreover, a subsequent orthodontic treatment and the position adjustment after surgery may be possible. 23,43,45,47

Anyway, today osteointegrated implants are the therapeutic alternative of choice when replacing a lost tooth, but transplantation and implantation techniques are similar in difficulty and so is the high prognosis supported by scientific evidence (more than 95% implants survival at 10 years 42,43,49 and a transplant success rate over 90% at 17 to 41 years long-term studies. 9,19,44,50

Conclusion

Tooth auto-transplantation can be considered as an alternative approach in oral rehabilitation for some clinical situations (especially in young patients). It inducts bone formation, and re-establishment of a normal alveolar process permits tooth movement to distant or opposite sides of dental arch or even to opposite jaw. In case of a failure, an intact area still remains possibility of implantation. However, beside its relatively low cost compared to the traditional methods of rehabilitation (such as osteointegrated implants) and high success rates, it requires careful case selection, professional skill, and patient and parent collaboration. Although auto-transplantation has not been confirmed as a traditional means of replacing a missing tooth, the procedure needs more consideration and future clinical studies in order to obtain predictable long-term results. Several research highlight how auto-transplantation of teeth can be considered as successful as endosseous dental implant positioning. 24,43,50,51 This treatment option may also be valuated as a temporary measure in young patient because of replacing missing teeth in order to keep ridge volume of bone for at least 5 next years. 50,51,52,53,54,55

Hale ML Autogenous transplantsBr J Oral Surg 1965 3 109 13 Northway WM Konigsberg S Autogenic tooth transplantation.The "state of the art"Am J Orthod 1980 77 146 62 Schwartz O Bergmann P Klausen B Autotransplantation of human teeth.A life-table analysis of prognostic factorsInt J Oral Surg 1985 14 245 58 Heithersay GS Replantation of avulsed teeth.A reviewAust Dent J 1975 20 63 72 Tsukiboshi M Autotransplantation of teeth: Requirements for predictable successDent Traumatol 2002 18 157 80 Pacini NM Nery DT De Carvalho DR Lima NJ r Miranda AF Macedo SB Dental autotransplant: Case reportRSBO 2012 9 108 13 Jankiewski J Terry M Autotransplantatio inside view of a delicate procedurePCSO Bull 2010 Fall IV 19 23 Zachrisson BU Planning esthetic treatment after avulsion of maxillary incisorsJ Am Dent Assoc 2008 139 1484 90 Czochrowska EM Stenvik A Bjercke B Zachrisson BU Outcome of tooth transplantation: Survival and success rates 17-41 years posttreatmentAm J Orthod Dentofacial Orthop 2002 121 110 9 Kavadia S Papadiochou S Papadiochos I Zafiriadis L Agenesis of maxillary lateral incisors: A global overview of the clinical problemOrthodontics 2011 12 296 317 Andreasen JO Paulsen HU Yu Z Bayer T Schwartz O A long-term study of 370 autotransplanted premolars.Part IITooth survival and pulp healing subsequent to transplantation 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 IIIPeriodontal healing subsequent to transplantation 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 IVRoot development subsequent to transplantation A long-term study of 370 autotransplanted premolars Part IV Root development subsequent to transplantation Eur J Orthod 1990;12:38-50 Andreasen JO Paulsen HU Yu Z Ahlquist R Bayer T Schwartz O A long-term study of 370 autotransplanted premolars.Part ISurgical procedures and standardized techniques for monitoring healing 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 Bjerklin K Bennett J The long-term survival of lower second primary molars in subjects with agenesis of the premolarsEur J Orthod 2000 22 245 55 Rosa M Zachrisson BU Integrating esthetic dentistry and space closure in patients with missing maxillary lateral incisors.J Clin Orthod 2001 35 221 34 Kugelberg R Tegsjö U Malmgren O Autotransplantation of 45 teeth to the upper incisor region in adolescentsSwed Dent J 1994 18 165 72 Lundberg T Isaksson S A clinical follow-up study of 278 autotransplanted teethBr J Oral Maxillofac Surg 1996 34 181 5 Temmerman L De Pauw GA Beele H Dermaut LR Tooth transplantation and cryopreservation: State of the artAm J Orthod Dentofacial Orthop 2006 129 691 5 Sartaj R Sharpe P Biological tooth replacementJ Anat 2006 209 503 9 Snead ML Whole-tooth regeneration: It takes a village of scientists, clinicians, and patientsJ Dent Educ 2008 72 903 11 Kim K Lee CH Kim BK Mao JJ Anatomically shaped tooth and periodontal regeneration by cell homingJ Dent Res 2010 89 842 7 Marques-Ferreira M Rabaça-Botelho MF Carvalho L Oliveiros B Palmeirão-Carrilho EV Autogenous tooth transplantation: Evaluation of pulp tissue regenerationMed Oral Patol Oral Cir Bucal 2011 16 e984 9 Cohen AS Shen TC Pogrel MA Transplanting teeth successfully: Autografts and allografts that workJ Am Dent Assoc 1995 126 481 5 Nethander G Autogenous free tooth transplantation with a two-stage operation techniqueSwed Dent J Suppl 2003 161 1 51 Vastardis H The genetics of human tooth agenesis: New discoveries for understanding dental anomaliesAm J Orthod Dentofacial Orthop 2000 117 650 6 Nethander G Periodontal conditions of teeth autogenously transplanted by a two-stage techniqueJ Periodontal Res 1994 29 250 8 Liu Y Zheng Y Ding G Fang D Zhang C Bartold PM Periodontal ligament stem cell-mediated treatment for periodontitis in miniature swineStem Cells 2008 26 1065 73 Dannan A Dental-derived stem cells and whole tooth regeneration: An overviewJ Clin Med Res 2009 1 63 71 Zheng Y Liu Y Zhang CM Zhang HY Li WH Shi S Stem cells from deciduous tooth repair mandibular defect in swineJ Dent Res 2009 88 249 54 Scheller EL Krebsbach PH Kohn DH Tissue engineering: State of the art in oral rehabilitationJ Oral Rehabil 2009 36 368 89 Ash Major M Nelson Stanley J Wheeler′s dental anatomy, physiology, and occlusion.Philadelphia: WB Wheeler's dental anatomy, physiology, and occlusion Philadelphia: WB Saunders; 2003 p 32,45,53 Josefsson E Brattström V Tegsjö U Valerius-Olsson H Treatment of lower second premolar agenesis by autotransplantation: Four-year evaluation of eighty patientsActa Odontol Scand 1999 57 111 5 Park JH , Tai K, Hayashi D.Tooth autotransplantation as a treatment option: A reviewJ Clin Pediatr Dent 2010 35 129 35 Hermann NV Lauridsen E Ahrensburg SS Gerds TA Andreasen JO Periodontal healing complications following concussion and subluxation injuries in the permanent dentition: A longitudinal cohort studyDent Traumatol 2012 28 386 93 Hermann NV Lauridsen E Ahrensburg SS Gerds TA Andreasen JO Periodontal healing complications following extrusive and lateral luxation in the permanent dentition: A longitudinal cohort studyDent Traumatol 2012 28 394 402 Waldon K Barber SK Spencer RJ Duggal MS Indications for the use of auto-transplantation of teeth in the child and adolescentEur Arch Paediatr Dent 2012 13 210 6 Ding G Liu Y Wang W Wei F Liu D Fan Z Allogeneic periodontal ligament stem cell therapy for periodontitis in swineStem Cells 2010 28 1829 38 Tsukiboshi M Autogenous tooth transplantation: A reevaluationInt J Periodont Restor Dent 1993 13 120 49 Volponi AA Pang Y Sharpe PT Stem cell-based biological tooth repair and regenerationTrends Cell Biol 2010 20 715 22 Yau CK Tooth autotransplantation as a treatment optionHong Kong Med Diary 2009 14 21 4 Gimbernat H Recio CL Torres LD Ruiz R Gutiérrez P Current state of dental autotransplantationMed Oral Patol Oral Cir Bucal 2011 16 948 52 Waldon K Barber SK Spencer RJ Duggal MS Indications for the use of auto-transplantation of teeth in the child and adolescentEur Arch Paediatr Dent 2012 13 210 6 Yoshino K Kariya N Namura D Noji I Mitsuhashi K Kimura H Comparison of prognosis of separated and non-separated tooth autotransplantationJ Oral Rehabil 2013 40 33 42 Waikakul A Punwutikorn J Kasetsuwan J Korsuwannawong S Alveolar bone changes in autogenous tooth transplantationOral Surg Oral Med Oral Pathol Oral Radiol Endod 2011 111 e1 7 Kumar R Khambete N Priya E Successful immediate autotransplantation of tooth with incomplete root formation: Case reportOral Surg Oral Med Oral Pathol Oral Radiol [Epub ahead of print] 2 [E Successful immediate autotransplantation of tooth with incomplete root formation: Case report Oral Surg Oral Med Oral Pathol Oral Radiol 2012 [Epub ahead of print] Yoshino K Kariya N Namura D Noji I Mitsuhashi K Kimura H A retrospective survey of autotransplantation of teeth in dental clinicsJ Oral Rehabil 2012 39 37 43 Herrera-Gimbernat D Recio-Lora C Torres-Lagares D Romero-Ruiz MM Gutiérrez-Pérez JL Current state of dental autotransplantationMed Oral Patol Oral Cir Bucal 2011 16 e948 52 Tsurumachi T Kuno T Autotransplantation of a maxillary first premolar to replace an ankylosed maxillary incisor: 7-year follow-upInt Endod J 2011 44 863 75 Abu Tair JA Rahhal A Tooth autotransplantation in orthodontic patients.J Contemp Dent Pract 2010 11 63 70 Tatli U Kürkçü M Cam OY Büyükyilmaz T Autotransplantation of impacted teeth: A report of 3 cases and review of the literatureQuintessence Int 2009 40 589 95 Vilhjálmsson VH Knudsen GC Grung B Bårdsen A -Dental auto-transplantation to anterior maxillary sitesDent Traumatol 2011 27 23 9 Cho JH Hwang HS Chang HS Hwang YC Application of orthodontic forces prior to autotransplantation-case reportsInt Endod J 2013 46 187 94 Mimura H Fukuyo S Orthodontic reconstruction with autotransplantation and bone grafting after a traffic accidentAm J Orthod Dentofacial Orthop 2012 141 (4 Suppl) S119 29 Schmidt SK Cleverly DG Tooth autotransplantation: an overview and case studyNorthwest Dent 2012 91 29 33