+

TRANSPLANTATION
Huong T Le DDS
LSU Health Sciences Center University of Texas Dental Branch 2009

+ Basic Definition of Auto Transplantation

Transplantation of teeth from one site to another in the same individual, involving transfer of embedded or impacted or erupted teeth into extraction sites or into surgically prepared sockets

General Considerations


Transplantation superior to other treatments options

   

Implants Removable prosthesis Fixed partial dentures Orthodontics

   

Better in function, time, cost, prognosis, and biocompatibility Patient factors: health and age Donor tooth factors: stage of development, shape, and size Recipient site factors: width and height and presence of periodontal ligament

Classification
three groups: conventional transplantation, intra-alveolar transplantation, and intentional replantation

Conventional Transplantation
Indications


Unrestorable tooth and non-functioning third molar or malpositioned tooth Often indication is third molars to extraction site to unrestorable first or second molars If size of donor tooth is appropriate, possible to premolar area or anterior area Donor tooth not limited to third molars


Malpositioned or impacted premolars or canines can serve as donor tooth

Conventional Transplantation
Transplantation of third molars to area of second molars

Conventional Transplantations
Donor Tooth Factors
 

Nonfunctional with appropriate root form Developing teeth prefer over fully developed teeth
 

Easier to extract Good healing potential

Developing tooth root should be at stage 4 or 5



If development stage is lower than 4, underdevelopment of root may result If development stage is more than 5, pulpal healing may not be expected

Conventional Transplantation
Donor Tooth Factors


Ideal Root Shape relatively smooth, conical single root



Very large roots, widely spread roots, or curved roots have a tendency towards mechanical trauma to periodontal ligament during extraction or transplantation

Makes procedure more challenging



Short Root Trunks tend to develop periodontal pockets at furcation area after transplantation Multi-rooted with enamel projection or periodontally involved teeth with attachment loss of more than one third of roots are contradicted

+ Conventional Transplantation
Indications and Contradictions for donor teeth based on shaped of roots

Conventional Transplantation
Donor Tooth Factors


If more than 2 teeth are available, the choice of donor tooth depends on shape of crowns of the teeth Mandibular third molars are more similar to other mandibular molars than maxillary third molars in shape and more suitable for replacement

Conventional Transplantation
Recipient Site Factors


Ideal recipient socket should have enough width and height to receive donor tooth completely Better healing expected if bony supports of recipient socket have periodontal ligament tissue still attached after extraction of condemned tooth Recipient site improved, if needed, by enlarging the socket surgically


In case of maxillary sockets, sinus lifts may be needed

Conventional Transplantation
Other Considerations


Transplantation should occur within 1 day to 1 month after extraction Horizontally impacted third molars can be transplanted to adjacent second molar are


Prognosis depends on position of third molars

More apically it is located with respects to second molar, the more difficult it is to gain attachment in distal area of autotransplanted tooth Leads to development of distal periodontal pocket


It is desirable for lowest part of crowns of horizontally impacted teeth to be located coronal to middle of root of second molar

Conventional Transplantation
Relationship of position of horizontally impacted third molar to prognosis for transplantation

Intra-Alveolar Transplantation
Considerations


Surgical uprighting and surgical extrusion also follow the same healing process as autotransplantation
 

Considered same category Could be defined as intra-alveolar transplantation

Problems in cervical area of tooth deep decay is indication for surgical extrusion Prognosis depends on shape of root


Conical single-rooted have a less change of attachment loss or resorption

Intra-Alveolar Transplantation
Illustration of Surgical Uprighting

Intra-Alveolar Transplantation
Surgical Extrusion

Intra-Alveolar Transplantation
Illustration of Surgical Extrusion

Intra-Alveolar Transplantation
Surgical Extrusion

Intra-Alveolar Transplantation
Indications


If Restoration or preservation of tooth is difficult due to deep caries or crown fracture, exchanging position of tooth or extrusion by replantation, surgical up righting, or extrusion without complete extraction may be an option. Should be investigated and compared to minor tooth movement, MTM


MTM has better predictability

Intra-Alveolar Transplantation
Indications


Surgical extrusion or uprighting indicated when:

1.

Proper Root Form  Conical single-root comparable to orthodontic extrusion  Concave roots, short root trunks, curved roots or thickened apices surgical extrusion avoided

2.

Difficulty in extrusion and less predictability in obtaining attachments

Pulp Vitality  Surgical extrusion or up righting of teeth with vital pulps require root canal therapy either before or immediately after replantation  Pulpal healing expected when repositioning developing teeth  Pulpal obliteration is common outcome  Orthodontic movement is preferable if tooth is vital

Intra-Alveolar Transplantation
Indications
3.

Orthodontic Appliances


Surgical extrusion is indicated if patient cannot wear orthodontic appliance

Insufficient interocclusal arch space Isolated tooth needs to repositioned

4.

Rotational Movement
 

More beneficial if deep caries or fracture line caused by trauma is located mesiodistally or palatally Maximum amount of root surface can be placed in bone by locating most broken part buccally while keeping healthy tooth structure about the bone crest Maximize contact between root and bone

Intra-Alveolar Transplantation
Indications
5.

Time and Cost

 

Takes less time than orthodontic treatment Restoration treatment is possible 3-5 months after surgical extrusion Relapse tends to happen after orthodontic movement if duration or retention is inadequate Less costly because it does not require any special appliances

6.

Requires definitive diagnosis of traumatized teeth

 

Teeth with trauma-induced fractures require extrusion Unnoticed fracture lines in the root can sometimes be detected with surgical extrusion

Intentional transplantation
Indications


Should be last treatment option for Lesions of Endodontic Origins (LEO)



When conventional root canal treatment or surgical endodontics is not feasible Teeth with LEO with irremovable post and core, calcified apex, accessory canals, etc Apicoectomy is first choice but intentional replantation would be the choice of treatment

Accessibility or definitive diagnosis of suspected root fractures

Intentional Transplantation
Failure of Intentional Replantation

Intentional Transplantation
Lesions of Endodontic Origins

Transplantation relative to Various + Dental Disciplines

Prosthodontics


First and foremost indication for transplantation is in the treatment of edentulous areas


Still remains unclear if one missing first molar would be ideal indication for dental implant

Presence of nonfunctional teeth



Transplantation and removable, fixed, or implant prostheses considered treatment of choice In some cases, autotransplantation makes placement of fixed partial denture (instead of removable) possible

Transplantation relative to Various + Dental Disciplines

Orthodontics


Orthodontic treatment not indicated due to technical reasons or time limitations, surgical repositioning or transplantation is an option Congenitally missing teeth Trauma-induced tooth loss

 

Wound Healing
Five Categories: Healing of Periodontal Ligament, Mechanism of Root Resorption, Healing of Gingival Tissue, Healing of Alveolar Bone, and Healing of Pulp and Continuation of Root Development

Healing of the Periodontal Ligament

Reattachment in Replantation


Defined as reunion of connective tissue and root surface that have been separated by incision or injury


Connective tissue (fibrous) reunion with root surface vital periodontal ligament is attached and surrounds root after replantation

Ideal healing occurs when extracted tooth is replanted in original extraction socket within a short period Takes more than 1 month for periodontal ligament healing to reach initial stage gingival area and cervical areas of root, reattachment occurs in 1-3 weeks

Ideal Healing of Periodontal Ligament

Replantation in Original Extraction Socket

Healing of Periodontal Ligament

Healing Process


3 days post replantation



Fibrin and Erythrocytes scattered between roots attached periodontal ligament and left in extraction socket Hemorrhage is observed in some areas

1-2 weeks post replantation

 

Fibroblasts and collagen fiber are visible in torn area Indicates beginning of repair of periodontal ligament

3-4 weeks post replantation



Proliferation of fibroblasts and regularly aligned bundles of collagen fibers

Vitality of Periodontal Ligament



Success of autotransplantation of teeth depends mainly on vitality of periodontal ligament attached to donor tooth Prevention of root resorption


Desirable to extract tooth with as much periodontal ligament as possible attached to it, even though the cementoblast layer by itself seems to effective in prevention of root resorption

Survival rate of periodontal ligament is susceptible to changes in QH and osmotic pressure

  

Vital > 18mins NonVital : 30-60mins Necrotic <120mins

Vital for hours (<24hrs) in milk or recently developed preservation liquids

Mechanism of Root Resorption



Occurs when donor tooth with partial or total lack of vital periodontal ligament is transplanted or replanted Categories:
  

Replacement Resorption Inflammatory resorption Surface Resorption

Extent of missing periodontal ligament and existence of pulp infection determines type of resorption

Classification of Root Resorption

Replacement Resorption