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This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
Autotransplantation, defined as the surgical removal of a tooth from one site and implanting it at another site in the same individual has gained much more attention in recent years. This procedure serves to substitute for congenitally or pathologic missing teeth due to trauma, ectopic eruption, severe caries, or periodontal disease and provides to replace the missing teeth with a natural one rather than a prosthesis or dental implant.
Orthodontic treatment plans involving extraction may be chosen for a patient to relieve crowding or compensate for a skeletal or dental discrepancy. The impact of extraction orthodontic treatment becomes more problematic in the adult population with an already missing tooth. They are more reluctant to having another tooth extracted.
Backing to well-documented reports and reviews, after comprehensive case evaluation and selection, autotransplantation can be offered to patients with preextractions and congenitally missing teeth. Despite the high success rate of 80% survival rate of autotransplanted teeth,
Platelet-rich fibrin (PRF) or Choukroun's PRF is a second-generation platelet concentrate and is constituted from three major components: activated platelets and their growth factors, leukocytes and cytokines, and a fibrin matrix which is responsible for the slow release of growth factors during the critical period of healing proliferation stage. PRF is a great reservoir for the sustained release of transforming growth factor β, platelet-derived growth factors, and vascular endothelial growth factors which promote angiogenesis, cell proliferation, and migration.
Here, we report an orthodontic patient with skeletal class I, severe crowding, a fractured premolar tooth, and multiple poor prognosis teeth. We decided to autotransplant a premolar from the left mandibular quadrant to the fractured site using PRF. We represent the results of 4 years of follow-up.
The patient was a 16-year-old female who attended the orthodontic department of X University of Medical Sciences with the primary chief concern of crowding. Initial clinical examination revealed a straight profile and normal competent lips. The tooth and gingival display were normal at rest and on a smile.
Intra-arch assessment showed severe crowding in the maxillary arch, in which both canines were blocked out and lateral incisors had linguversion. There was severe crowding in the lower arch as well, which the left second premolar was lingually blocked out. The patient had previously extracted the lower right first premolar, and the lower right second premolar was already fractured at the level of the cementoenamel junction (CEJ). The mandibular right first molar had a large amalgam restoration. The left and right canine were in a class II relationship, the left molar had a class I, and the right molar had a class III relationship. Maxillary and mandibular dental midlines were deviated 2 and 3 mm to right, respectively. The overjet and overbite were normal. Cephalometric analysis confirmed the normal sagittal and vertical skeletal relationships examined clinically. Maxillary and mandibular incisors had normal inclinations.
After comprehensive periodontal examination, the lower second premolar was confirmed unrestorable due to the fractured crown below CEJ, recurrent caries under the amalgam restoration of the lower right first molar and severe caries of both maxillary second premolars were apparent on the panoramic radiograph. The third molars were normally developing Initial panoramic radiograph of patient.
The summary diagnosis was a skeletal class I patient with severe crowding in the maxilla and mandible, a preextraction of the lower right first premolar, and a fractured second premolar in the same quadrant Composite photographs of patient at the start of treatment. Photography of initial dental models. Initial lateral cephalogram radiograph and tracing.
Orthodontic treatment alternatives
Under normal conditions, extraction of both the upper and lower left first premolar and restoring the lower right second premolar with an implant restoration would be considered the ideal standard treatment. Extracting the upper first premolars and the lower left second premolar and space closure at that site may also be considered an option. A third alternative would be the extraction of the upper first premolars and one lower incisor to correct the canine relationship. Another possible option was destabilizing upper buccal segments to retract canines to a class I relationship. However, the specific condition of this patient, crowding in the mandibular left quadrant and the fractured tooth at the right quadrant lead to another treatment option which was suggested to the patient: Extracting the lower right second premolar and transplanting the left first premolar to this site. The mandibular left first premolar was selected for transplantation, as this tooth was blocked out of the arch, it already had a thin cortical plate covering and did not have adequate keratinized tissue. The upper second premolars were also to be extracted. Despite the anchorage requirements of the upper arch, this extraction plan was chosen to save the first premolars which had much better prognosis than the second premolars. After thorough explanation The patient signed an informed consent to the treatment option of extracting the already poor prognosis teeth and to save the healthy teeth.
Treatment objectives
The objectives for this patient were to: (1) align the teeth and eliminate crowding, (2) Achieve a functional orthopedically stable occlusion, and (3) Manage the fractured tooth with autotransplanting the left premolar, while maintaining the already proportionate facial relationships.
Treatment progress
The patient was referred to the endodontic and restorative departments to eliminate active caries and restore teeth. She was also referred to the periodontics department for phase I periodontal therapy. After 2 months, fixed orthodontic therapy was initiated in the lower arch by leveling and aligning teeth with an MBT slot 0.022-inch system (Pinnacle, ortho technology, USA). The tooth to be transplanted was not bonded. Since space had been lost in the recipient site, space was regained by implementing a NiTi open coil. The upper arch was also leveled and aligned by extraction of the second premolars simultaneously. A transpalatal bar connected the two maxillary molars. This in addition to banding the upper second molars was planned to reinforce posterior anchorage. A cone-beam computed tomography evaluation was done, and the recipient socket length and the root length of the donor's tooth were measured. Endodontic treatment of that tooth was performed before surgery. (a) PRF clot, (b) PRF membrane, (c) PRF applied in tooth socket. PRF: Platelet-rich fibrin.
To prepare a PRF membrane, briefly, 9cc of the patient's venous blood was withdrawn and collected in a plastic tube with a glass coating. The sample was immediately centrifuged at 2000 RPM, 400 g for 10 min. Residual cells were scraped and removed, and the fibrin clot (a) Entire arch before surgery, (b) extraction of fractured teeth, (c) preparation of recipient site.
The surgical procedure was performed as follows: first, the fractured premolar root at the recipient site was atraumatically extracted (a) Autotransplantation of teeth, (b) Sutured tooth, out of occlusion.
Two weeks after the surgery, the patient returned to the orthodontic department and orthodontic treatment was resumed. After leveling and aligning, the canines and anterior teeth in the lower arch were retracted, and final adjustments for better occlusion were done.
Treatment results
After 25 months of treatment, a class II canine relationship was apparent on both sides. As the patient did not cooperate with using class II elastics and due to the missed appointments (during the very 1st months of the COVID-19 pandemic) and the resultant anchorage loss, this occlusion was considered acceptable. However, we might be able to prevent this anchorage loss by application of skeletal anchorage as bilateral miniscrews are inserted in the palatal or alveolar region. This result was compatible with a functionally stable occlusion planned initially and there were not any occlusal interferences on the nonworking side, nor there were posterior contacts on the protrusive position. Composite photographs of patient at debonding of orthodontic appliances. Photography of final dental models. Superimposition of initial and final lateral cephalograms. Final lateral cephalogram radiograph and tracing. Posttreatment panoramic radiograph.
The results were stable 4 years after the surgery (2.5 years after debond). The transplanted tooth had no symptoms during and after orthodontic treatment. The serial periapical radiographs confirmed the absence of any pathological status: ankylosis, replacement resorption, and inflammation were ruled out and the lamina dura was intact around the root Four-year follow-up periapical radiograph of the transplanted tooth.
Despite orthodontic mechanics implemented to correct the rotation of the transplanted teeth, it was not totally eliminated as were concerned to put heavier forces for longer durations.
The challenging topic of whether or not to extract teeth for orthodontic reasons has been a debating one for long years. Various factors including facial esthetics, age, periodontal condition of the patient, restorations, missing, and extracted teeth, all influence the orthodontic treatment plan to be conducted by an extraction or nonextraction plan.
The most common complications associated with tooth autotransplantation are root resorption and ankylosis.
From a clinical perspective, alongside a comprehensive and well-coordinated teamwork of a periodontist/oral surgeon, an endodontist, and an orthodontist, a successful autotransplantation is dependent on a series of factors: prescription of systemic antibiotics, endodontic treatment performed preoperatively, postoperatively or extraorally, splinting with proper technique, and the donor tooth morphology. The assumption that this procedure will fail in teeth with completely formed roots is no longer acceptable. Meta-analysis has confirmed that autotransplantation of the tooth with complete roots is stable and 5-year survival rates are excellent: 90.4% (95 confidence interval of: 84.9%–94.1%).
Other factors such as preapplication of orthodontic force, atraumatic extraction, and minimal extraoral manipulation time (<15 min)
In this case, we applied very light orthodontic force (0.012 NiTi) 2 weeks after the surgery was performed, which may also have contributed to periodontal healing.
In the 4-year follow-up periapical radiograph, the alveolar crest and lamina dura of the transplanted premolar were intact and healthy.
The autotransplanted tooth showed an acceptable result after 4 years of follow-up. Autotransplantation of teeth with complete roots should be considered a treatment alternative to prosthetic restorations. Surgical adjuncts may greatly enhance the success rates of autotransplantation. PRF can eliminate the risk of ankylosis or resorption.
Financial support and sponsorship
The authors didn't receive any grants upon preparing this manuscript.
Conflicts of interest
The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.