Loss of a permanent maxillary central incisor in a young patient is a therapeutic challenge for dental professionals. Autotransplanted developing premolars replacing missing maxillary incisors provide predictable long-term results and assure bone preservation during growth. Moreover, they can be successfully transformed to the morphology of the missing incisors, which is very important since these teeth are placed centrally in the esthetic zone. Comprehensive interdisciplinary treatment planning is necessary, combining a thorough evaluation of the occlusion and the profile, existing indications for premolar removal, space conditions, and the optimal match between the donor tooth and the recipient site. Orthodontic space management before and after surgery is often needed to create favorable conditions for donor accommodation, and to establish both normal occlusion and a good esthetic result. Monitoring of pulpal and periodontal healing and root development after transplantation of developing premolars is mandatory during follow-up appointments. https://www.digistore24.com/redir/283755/Doctorkhan93/ https://www.digistore24.com/redir/283755/Doctorkhan93/

1. Guidelines for autotransplantation of
developing premolars in anterior
maxilla:As an alternative treatment option
Dr Mamoon
Resident MDS Orthodontics PGY-III
Sardar Begum Dental College & Hospital
Gandhara University
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https://www.digistore24.com/redir/299134/Doctorkhan93/

2. Contents
◦ Dental autotransplantation
◦ Orthodontic indications
◦ Surgical Assesment of donar tooth and recipient site
◦ Clinical guidelines after autotransplantation of tooth
◦ Post Surgical orthodontics

3. 20XX
Dental
autotransplantation

4. Autotransplantation
◦ Dental autotransplantation is defined as:
~ The movement (surgical transplantation) of one tooth from one position
to another within the same individual.
◦ Autotransplanation of developing premolars;
~A successful long-term treatment alternative in growing patients.
~Congentially missing or truamtically lost teeth.
Northway WM, Konigsberg S. Autogenic tooth transplantation. The “state of the art”. Am J Orthod
1980;77:146-62.
Stange KM, Lindsten R, Bjerklin K. Autotransplantation of premolars to the
maxillary incisor region: a long-term follow-up of 12-22 years. Eur J Orthod.
2016;38:508–515.

5. Autotransplantation:
◦ Advantages of autotransplantation developing premolars :
i. Immediate replacement of missing teeth
ii. Good adaptation of transplanted tooth to growth changes
iii. Normal response to orthodontic forces
iv. long term preservation of hard and soft periodontal tissues
v. Good option in young individuals

6. • When tooth transplantation is indicated developing premolars with
• ½ or ¾ of the final root length, best donars for successful outcome.
• Dental injuries often occurs in childrens at the time of developing
premolars, possibility of using these teeth as donars.
Andreasen JO, Paulsen HU, Yu Z, et al. A long-term study of
370 autotransplanted premolars, root development
subsequent to transplantation. Eur J Orthod. 1990;12(1):38–50.

7. Clinical case report
A 9-year old boy sought orthodontic treatment for his unerupted maxillary
left central incisor and reverse overjet.
 Panaromic radiograph evidenced an impacted dilacerated 21
 35(Yellow circle) was planned to substitute the 21 after extraction

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12. 20XX
Donor selection

13. Donor selection:
◦ Selection of premolars as a donar tooth to replace missing maxillary
incisor, depends on:
~orthodontic indication
~Surgical assessment of optimal match between donar/recipient
~Long term prognosis
~ Care ful weighing of pros and cons with other treatment options

14. Donor selection:
◦ Comprehensive interdisciplinary evaluation of a prospective candidate
is mandatory to select the donor tooth which will have
~Favorable prognosis for successful healing
~Satisfactory esthetics
~Good function in the long term.

15. 20XX
Orthodontic
indications
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16. Orthodontic indications
Comprehensive evaluation of individual characteristics of each patient
~Occlusion
~Space condition
~The number of teeth missing
~Availablity of sutiable donars
~Post treatment stability
~Patient expectations

17. Orthodontic indications
◦ Extraction of a donor tooth should also be indicated from the
orthodontic perspective, and not only because of incisor loss.
◦ Upper premolars are less appropriate as donars
~Morphology
~lower potential for successful healing after autotransplantation
Jakobsen C, Stokbro K, Kier-Swiatecka E, et al.
Autotransplantation of premolars: does surgeon
experience matter? nt J Oral Maxillofac Surg.
2018;47(12):1604–1608.

18. Orthodontic indications
◦ Maxillary second premolars are a good choice in patients with Class II
malocclusion and Class 1.
◦ Mandibular premolars are the better choice in patients with Class III
malocclusions.
◦ Unilateral replacement of a central incisor requires management of the
asymmetry created in the dental arch after removal of a donor premolar
from one quadrant

19. Orthodontic indications
◦ It is inadvisable to select the donor premolar from the same quadrant
as the lost maxillary incisor.
◦ When two maxillary central incisors are missing, the mandibular
premolars should be selected as donors.
◦ Selection of a mandibular premolar in patients with dental Class I and
II relationships to replace a missing central incisor will increase the
orthodontic problem.

22. 20XX
SURGICAL
PLANNING

23. Surgical Planning
◦ Two major issues need to be addressed:
1. The morphology of all potential donar premolars indicated
by the orthodontist
2. The space between teeth adjacent to the recipient site and
bone condition

24. • Premolars differ in shape, size and inclination in alveolar process.
• Impacted premolars are generally more difficult to extract.
• Upper second premolars, preferable donars for maxillary
autotransplantation than first premolars.

25. ◦ Mandibular premolars, both first and second, are usually
~ The smallest
~ Easiest one to remove from the alveolar crypt
~ Accomodation in the anterior maxilla

26. ◦ Mandibular premolar in cross section
~ Less oval
~ More rounded
~ Lingual cusp is less pronounced.

27. 2. Space and bone conditions at the recipient site
◦ Space at the reciepnt site
◦ Size of the new socket > cross section of the root
◦ Providing 1mm space around the entire surface of the root
◦ Round or triangular cross section of the incisor alveolus.

28. Key Aspects of the surgical procedure
1. Surgeon experience improves the treatment outocmes.
2. Surgery may peformed under local anesthia or general.
3. Decidious molar is present extract with forcep
4. Ankylosis is detected, tooth must be separated into fragment
5. Buccal and coronal part of the bone over the crypt.

29. 6. Avoid direct of any instrument with surface of donar tooth
7. Preperation of the recipient socket with rotary instrument is preferd.
8. Flapless socket preparation , increase the risk of trauma to adj teeth.
9. Intial size of the socket must be enlarged, to ensure the loose
accomadition of the donar within the walls of the artificial bed.

30. 10. Premolar root is usually bigger than the roots of an incisor
Osteotomy involves removal of labial alveolar bone
Artifical socket should provide 2-3 mm space apically to accommodate
the soft tissue of the donar root apex.

31. 11.Different protocols of stabilization has been described: most studies
support
Flexible splinting with sutures alone decrease the risk of
complication.

32. 12. In patients with a short anterior maxilla
~ Smaller premolars with shorter roots ( ½ instead of ¾ root
development) should be selected.
13. Systemic antibiotic is recommended after surgery.
14. NSAIDS for 2-3 days and Chlorohexidine gel till splinting removal.

33. 20XX
Follow-up after
transplantation

34. Follow-up after transplantation
◦ Monitoring after tooth transplantation is necessary to evaluate
~ Periodontal healing
~ Post surgical root development
~ To detect any pathology.

35. Follow-up after transplantation
◦ After transplantation typical parameters to evaluate include:
~ Pulp obliteration
~ Tooth eruption
~ Ongoing root formation

36. Follow-up after transplantation
Followup protocols after transplantation of teeth:
1. Pulp obliteration is common finding.
2. Assesment of root development, comparision with non
transplanted premolar
3. Periodic clinical and radiological examination

37. 4. Control examination after the removal of the suture(7-10 days)
~ After 2, 6, 12, 18, 24 months and then annually.
5. In case of uncertain healing followup appointment are scheduled
every month until healing is complete

38. 6. Clinical examination include:
Assessment of tooth mobility and eruption
Percussion
7. Radiological examination include:
Periapical radiograph of the transplanted tooth
Root development
Pulp obliteration
Sign of different types of resoprtion

39. 8. Most complications of transplanted teeth with developing roots can
be detected within the first year after surgery.
9. Ankylosis is one of the most common complications after tooth
transplantation, and is suspected
Lack of normal mobility
A high metallic sound on percussion

40. Management of complications:
◦ Cervical root resorption or replacement resorption
◦ Based on author clinical experience ankylosis is the most serious
complication after autotransplantation of developing premolars.
~ Autotransplantation of developing premolars
~ Mesalization of the other teeth after failed transplant.

41. 20XX
Post Surgical
Orthodontics

42. ◦ Post surgical orthodontics include
~ Close the space in the dental arch after removal of donar premolar
~ Align the transplanted premolar in the dental arch
~ Level the gingival margin
~ Optimal reshaping to mimick the morphology natural incisor
~ Correct cocimitant malocclusion

43. ◦ Orthodontic alignment of the transplanted premolar should
preferably start after completion of post surgical healing phase.
◦ Donar premolar were transplanted at earlier stages, wait till ¾ of root
◦ If transplanted premolar at 3/4 , it is usually recommend to wait 4-6
months to ascertain undisturbed healing

44. ◦ Orthodontic repostioning of the transplanted premolar usually
include
~ Tooth alignment
~ levelling the gingival margin between transplanted premolar and
neighbouring teeth
~ Should be performed using light forces
~ Opening of space is needed to match the central incisor

45. Reshaping transplanted premolars in the anterior maxilla:
◦ Premolars have comparable morphology to the width of maxillary CI
◦ Third molars are considerd as donar teeth are mostly unsutiable
◦ Supernumeray lateral incisor
◦ Contemporary techniques for reshaping autotransplanted premolars
include the use of direct and indirect composite restorations or
porcelain Laminate veneers (PLV)

46. ◦ Bonded restoration should not include any dentine preperation,.
◦ Preferably enamel reduction should be avoided
◦ Extensive grinding of premolar can interfere with pulp healing

47. ◦ If unerupted donor premolars are transplanted, they are usually placed under the
gingiva or at the gingival level, final restoration is placed until fully eruption of
tooth
◦ Most frequently, the transplanted premolars are initially restored with composite
material, and later receive PLVs

50. Thank You