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TRANSPLANTATION
Huong T Le DDS
LSU Health Sciences Center University of Texas Dental Branch 2009
General Considerations
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
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
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
Very large roots, widely spread roots, or curved roots have a tendency towards mechanical trauma to periodontal ligament during extraction or transplantation
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
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
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
Problems in cervical area of tooth deep decay is indication for surgical extrusion Prognosis depends on shape of root
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
Intra-Alveolar Transplantation
Indications
Proper Root Form Conical single-root comparable to orthodontic extrusion Concave roots, short root trunks, curved roots or thickened apices surgical extrusion avoided
2.
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
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.
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.
Teeth with trauma-induced fractures require extrusion Unnoticed fracture lines in the root can sometimes be detected with surgical extrusion
Intentional transplantation
Indications
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
Intentional Transplantation
Failure of Intentional Replantation
Intentional Transplantation
Lesions of Endodontic Origins
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
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
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
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
Fibrin and Erythrocytes scattered between roots attached periodontal ligament and left in extraction socket Hemorrhage is observed in some areas
Fibroblasts and collagen fiber are visible in torn area Indicates beginning of repair 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
Occurs when donor tooth with partial or total lack of vital periodontal ligament is transplanted or replanted Categories:
Extent of missing periodontal ligament and existence of pulp infection determines type of resorption