Tooth Autotransplantation: A Proven Therapeutic Option
By Francesc Abella, D.D.S., Ph.D., and Miguel Roig, M.D., D.D.S., Ph.D.
Dental autotransplantation entails extracting a tooth from its original site to place it in an edentulous zone, whether it is a post-extraction socket or a surgically prepared socket. (1). This technique was developed as a therapeutic option for teeth loss due to trauma, decay or congenital tooth agenesis, yet fixed dental prostheses and, above all, dental implants, saw its use decline among clinicians.
Decades of problems and complications with implantology have led to reevaluation of tooth preservation and traditional clinical techniques (2). Adverse outcomes associated with implants are largely related to prosthetic (technical) failure and to persistent infections surrounding implants (2, 9, 10). Furthermore, alveolar growth in the anterior maxilla does not stop after pubertal growth peak, but continues throughout the patient’s life. Although this growth is more pronounced in the second and third decade of life, it continues in the fourth and fifth decades. As a result, implant placement in the anterior zone can produce an esthetic compromise due to an implant infraposition caused by progressive growth of the alveolar process in the neighboring teeth and a lack of periodontal ligament (PDL) in the dental implant. This situation is more likely to take place in growing patients, particularly those with a long facial type (3-6). It is recommended therefore to avoid or at least limit dental-implant placement in growing patients, as implants would end up in infraposition (7, 8). Hence, the steady rise in autotransplantations in recent years.
Unlike dental implants, successfully autotransplanted teeth behave identically to natural teeth (11, 12). The presence of PDL allows both the continued formation of bone and soft tissue in the recipient site (13) as well as orthodontic tooth movement (14, 15). Indeed, early orthodontic forces improve prognosis of autotransplanted teeth (16). The main benefits of this technique include enhanced esthetics, dentofacial development, proprioception, and dental arch integrity (17).
Autotransplantation candidates must be carefully selected using clinical and radiographic information. Three-dimensional (3D) cone beam computed tomography (CBCT) radiographic assessment of teeth and their surrounding structures is desirable to plan an autotransplantation procedure (18). Key patient information required consists of anatomic shape, root development of the donor tooth, bone dimension of the recipient socket, as well as compatibility of both the size of the donor tooth and the recipient site. A small field of view CBCT scan not only provides the clinician with a 3D assessment of the area of interest, but also the possibility of segmenting the donor tooth and of manufacturing a 3D-printed tooth replica (19, 20). This step substantially reduces extraoral time, particularly in multirooted teeth where replantation into the socket is challenging.
While successful autotransplantation can yield long-term results, patients should be informed about a possible interruption in the procedure in the event of complications involving the donor tooth extraction and the recipient site (such as insufficient alveolar bone) (21). Frequent complications include inflammatory or replacement resorption, pulp necrosis, lack of healing or compromised healing of the PDL, and a reduction in the final root length (22).
In spite of the large body of research in this area, there is scant scientifically based evidence on autotransplantation due to a lack of randomized controlled clinical trials (RCTs). Careful case selection based on indications can lead to a sufficiently predictable autotransplantation, with survival rates around 90% (22, 23). Besides the extra-alveolar time, other factors that seem to favor a good prognosis include the donor tooth with open apex, good initial primary stability and use of semirigid splinting (21, 24, 25). Regardless of whether donor teeth have an open or closed apex, favorable PDL healing is the key to success (26). Ideal PDL healing occurs when the extracted tooth is replanted in a new site in minimal extraoral time, when most of its cells are still alive (12). PDL cells can be mechanically damaged during extraction or can be affected by changes in pH values, osmotic pressure or dehydration. Atraumatic removal of the donor tooth therefore is critical to successful PDL healing (27).
Most published studies on autotransplantation focus on teeth with immature apices, which might limit the use of this technique to young patients (28-30). Autotransplantation of teeth with open apex, preferably with 2/3 to 3/4 of the root formed, allows root pulp healing and continued root formation. Pulp canal obliteration, a defense response of revascularized pulp, is frequently observed after tooth transplantation procedures (31). Some studies have also reported a high success rate for autotransplantation of mature teeth (11, 32, 33). Since revascularization and pulpal healing are unlikely to occur in closed apex, endodontic treatment is highly recommended to avoid inflammatory root resorption (12, 15). Endodontic treatment can be applied either preoperatively, extraorally during autotransplantation surgery, or within 2 weeks post-surgery (25). In cases with early tooth loss or congenitally teeth agenesis, the recipient site needs to be surgically prepared (34). Satisfactory healing generally appears to take place in autotransplantation in surgically prepared alveolar sockets, since no root resorptions are observed, the PDL space is maintained, and physiological tooth mobility is achieved (33).
To conclude, when the technique is properly and carefully executed in selected cases, autotransplantation is a highly effective procedure. Clinicians must understand the fundamental healing mechanisms of the PDL, the alveolar bone, the gingival tissue, and the pulp. However, there is a need for adequately designed prospective studies with a consensus definition of successful autotransplantation.
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