ARTICLE IN PRESS

Guidelines for autotransplantation of

developing premolars to the anterior
maxilla
Ewa Monika Czochrowska, and Pawe» Plakwicz

Loss of a permanent maxillary central incisor in a young patient is a thera-

peutic challenge for dental professionals. Autotransplanted developing pre-
molars 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. (Semin Orthod 2020; &:1–12) © 2020 Elsevier Inc. All rights
reserved.

Introduction The advantages of this method include immedi-

ate replacement of a missing tooth, good adapta-
ne of the most important indications for
O tooth autotransplantation is traumatic loss
of maxillary incisors in young patients. Upon the
tion of the transplanted tooth to growth changes,
and normal response to orthodontic forces.
These features are very important in children
loss of an upper anterior tooth, patients and
and young adolescents for whom dental implants
parents are usually very alarmed and seek expert
are generally contraindicated.6-8 Transplanted
help with the main request to explain all possible
developing premolars have a good potential for
treatment options, and to select the best solution
long-term preservation of hard and soft peri-
for the individual situation. Gaining informed
odontal tissues.3,9 Orthodontic mesialization of
consent after a thorough discussion with patients
lateral incisors, which is another viable alterna-
and parents/guardians about potential complica-
tive to replace a missing central incisor in a
tions and alternative solutions must precede the
young patient, is a long and complex treatment
initiation of any treatment.
after the eruption of all permanent teeth.10
Autotransplanation of developing premolars
Moreover, tooth width at the gingival level is usu-
has been reported to be a successful long-term
ally more favorable for premolars than for lateral
treatment alternative in growing patients with
incisors, which is an important factor for satisfac-
congenitally missing or traumatically lost teeth.1-5
tory esthetics of the restoration to resemble the
missing central incisor.10,11
Associate Professor, Department of Orthodontics, Medical Univer-
Developing premolars have good surgical
sity of Warsaw, Poland; Associate Professor, Department of Periodon-
tology, Medical University of Warsaw, Poland. access, which facilitates their gentle removal - a
Corresponding author: Ewa Czochrowska, Department of Ortho- crucial predictor for successful outcome.12-14 In
dontics, Medical University of Warsaw, ul. Binieckiego 6, 02-097 addition, premolars are frequently extracted for
Warsaw, Poland. E-mail: info@czochrowska.com orthodontic purposes, which is another reason
© 2020 Elsevier Inc. All rights reserved. why they can serve as tooth replacements in case
1073-8746/12/1801-$30.00/0
of need.15 When tooth transplantation is
https://doi.org/10.1053/j.sodo.2020.01.007

Seminars in Orthodontics, Vol &, No &, 2020: pp 1 12 1

 ARTICLE IN PRESS

2 Czochrowska and Plakwicz

considered as an alternative to replace traumati- Donor selection

cally lost maxillary incisors, developing premo-
Selection of a premolar as a donor tooth to
lars with 1/2 to 3/4 of the final root length are
replace a missing maxillary incisor, depends on:
the best donors for a successful outcome.16,17
Dental injuries often occur in children at the
- orthodontic indications for its removal,
time of incomplete premolar root development,
- surgical assessment of the optimal match
which may correspond well with the possibility of
between the donor tooth and the recipient site,
using these teeth as donors to replace trauma-
- long-term prognosis, and
tized incisors (Figs. 1 3).

Figure 1. A 9-year old boy sought orthodontic treatment for his unerupted maxillary left central incisor and
reverse overjet (A, B). The panoramic radiograph evidenced an impacted, dilacerated maxillary incisor on the left
side (C), which was scheduled for extraction due to its unfavorable crown-to-root angulation. Due to the patient’s
Class III tendency, autotransplantation of the unerupted mandibular left first premolar (circle) was planned to
substitute the dilacerated incisor The transplanted premolar did not erupt 8 months after the transplantation and
therefore orthodontic extrusion was performed to confirm the presence of ankylosis (D), which was not clearly vis-
ible on the intraoral radiograph (E). The panoramic radiograph taken after confirmation of ankylosis of the trans-
plant, showed that the mandibular right first premolar was still unerupted (circle) and that its root development
was favorable for a second premolar transplantation (2/3 root growth completed) (F). The ankylosed transplant
was extracted and the second transplantation was performed. The transplanted mandibular premolar erupted
spontaneously into occlusion after 4 months (G). Radiographic signs of pulp obliteration and root growth were
detected (H, I). Space opening was performed before reshaping of the transplant in order to secure an optimal
match between its width and the width of the adjacent natural central incisor (J). A direct composite build-up was
placed following the long axis of the transplant and matching the length of the reference incisor (K). After ortho-
dontic treatment normal overjet and overbite were achieved (L). Pulp obliteration of the transplanted premolar is
present 2 years after the surgery (M).
 ARTICLE IN PRESS
Guidelines for autotransplantation of developing premolars to the anterior maxil
Figure 1. Continued
- careful weighing of all pros and cons com-
pared with other treatment modalities.
Comprehensive interdisciplinary evaluation
of a prospective candidate is mandatory to
select the donor tooth, which will have the
most favorable prognosis for successful heal-
ing, satisfactory esthetics, and good function in
the long term.
Orthodontic indications
Comprehensive evaluation of the individual char-
acteristics of each patient include: occlusion and
profile, space conditions, the number of teeth miss-
ing, the availability of suitable donors, post-treat-
ment stability and patient’s expectations.
Preferably, extraction of a donor tooth should also
be indicated from the orthodontic perspective,
and not only because of incisor loss.18 In this case,
the general indications for the selection of a donor
premolar to replace a missing maxillary central
incisor are the same as orthodontic indications for
premolar extraction. Upper first premolars are less
appropriate as donors because of their morphology
and the arising difficulty to accommodate a dou-
ble-rooted premolar in the anterior maxilla.
Reportedly, these teeth have a lower potential for
successful healing after autotransplanation.19,20
3
While maxillary second premolars are a good
choice in patients with Class II malocclusion, man-
dibular premolars are the better choice in patients
with Class III malocclusions (Fig. 1). In patients
with dental Class I relationships and missing maxil-
lary central incisors, it is advantageous to choose
the upper second premolars, because space closure
in the lower arch is more difficult, even if skeletal
temporary anchorage devices (TADs) are utilized.
Sometimes, after removal of the maxillary second
premolars, the remaining spaces close spontane-
ously by mesialization and rotation of the first
molars around their palatal root. For each patient
radiological examination using cone-beam com-
puted tomography (CBCT) is mandatory to evalu-
ate individual morphological variations of the
premolars in order to assess the best match
between the donor and the recipient site.
Unilateral replacement of a central incisor
requires management of the asymmetry created
in the dental arch after removal of a donor pre-
molar from one quadrant. Compensatory extrac-
tions or the use of TADs are effective treatment
strategies to assist orthodontic tooth movements,
and to obtain normal dental relationships after
premolar transplantation for substitution of a sin-
gle incisor loss. If spontaneous space closure at
the donor site is intended, upper second premo-
lars are usually the best choice.
 ARTICLE IN PRESS

4 Czochrowska and Plakwicz

It is inadvisable to select the donor premolar
from the same quadrant as the lost maxillary
incisor, because this would worsen the initial
problem in case of failure. If the transplant fails,
mesializiation of maxillary lateral incisors still
remains an alternative solution. When two max-
illary central incisors are missing, the mandibu-
lar premolars should be selected as donors
(Fig. 2). Selection of a mandibular premolar in
patients with dental Class I and II relationships
to replace missing central incisors will increase
the orthodontic problem, and necessitates
either optimum patient collaboration with full-
time wear of Class II elastics, or the use of TADs
or Herbst-type anchorage reinforcement appli-
ances for space closure in the lower arch.
(Fig. 2). However, the overwhelming advantages
of replacing a missing maxillary incisor in young
patients with a natural substitute may support
the choice of premolar transplantation, even if
premolar extraction is not indicated from the
orthodontic perspective. When autotransplanta-
tion of developing premolars is considered in
older children, selection of an optimal donor
(an unerupted premolar), might be limited
because of advanced root formation (Fig. 2).
Therefore, treatment planning including auto-
transplanation of developing premolars should
be initiated as early as possible following
trauma. Timely planning of premolar transplan-
tation, when all premolars are still unerupted,
helps to select the optimal donor tooth from an
orthodontic perspective, to secure a good match
between the stage of root development and the
recipient site, and to promote successful healing
and a good esthetic outcome.

Figure 2. A 10-year old boy with an increased overjet and severe traumatic injury of his maxillary central incisors
was scheduled for extraction of the compromised teeth. Autotransplantation of both mandibular second premo-
lars was performed to replace the missing incisors, as these were the only unerupted premolars present (A). Nor-
mal healing after transplantation with pulp obliteration, eruption of the transplants, and continuous root
development could be radiographically evidenced (B-D). Orthodontic treatment with fixed appliances and a Class
II corrector (Forsus, 3M Unitek) was started two years after transplantation with the aim to correct the overjet and
to close the lower extraction spaces (E-J). After closing the spaces in the lower arch, the premolar brackets were
removed and the transplants were reshaped using direct composite build-ups without any enamel grinding. The
incisor brackets were subsequently bonded (K, L). Satisfactory occlusal relations and closure of the extraction
spaces were achieved after the orthodontic treatment (M-Q). Intraoral radiographs confirmed normal root devel-
opment after transplantation including pulp obliteration (R, S).
 ARTICLE IN PRESS

Guidelines for autotransplantation of developing premolars to the anterior maxil 5

Figure 2. Continued

Surgical planning of autotransplantation  the morphology of all potential donor premo-

lars indicated by the orthodontist,
Two major issues need to be addressed at the
 the space between teeth adjacent to the recipi-
time when surgical autotransplantation of a
ent site and bone conditions.
developing premolar to the anterior maxilla is
planned. They include:
 ARTICLE IN PRESS
6 Czochrowska and Plakwicz
The morphology of developing premolars and
selection of the best donor tooth
Based on occlusal conditions and patient needs,
the orthodontist indicates the potential donor
tooth/teeth for autotransplantation. Premolars
differ not only in shape and size, but also in
inclination in the alveolar process during erup-
tion, which is an important feature from the sur-
gical perspective. Impacted premolars are
generally more difficult, if not impossible, to
remove gently, which is a prerequisite for suc-
cessful healing. Upper first premolars have usu-
ally two clearly separate roots and their
cumulative bucco-palatal dimension may
exclude their accommodation within the vol-
ume of the alveolus along the entire root length.
Upper second premolars are often smaller since
their roots are often close to each other, making
them the preferable donors for maxillary auto-
transplantation compared to first maxillary pre-
molars. Mandibular premolars, both first and
second, are usually the smallest and the easiest
ones to remove from their alveolar crypt and to
accommodate in the recipient site in the ante-
rior maxilla, and for this reason surgically pre-
ferred as replacement of maxillary incisors. The
downside is that orthodontic indications for
their removal are not easy to find. In cross-sec-
tion, mandibular premolars are less oval and
more rounded when compared to the maxillary
premolars, and the lingual cusp is less pro-
nounced, requiring less grinding when the final
shaping of the incisor is performed.
Space and bone conditions at the recipient site
The amount of space at the recipient site
should ensure safe preparation of the new arti-
ficial socket, which is created parallel between
the roots of the adjacent teeth. The size of the
new socket should be wider then the cross-sec-
tion of the root, providing approximately 1 mm
of space around the entire surface of the root.
The oval cross-section of the artificial socket
corresponding to the morphology of most roots
of premolars differs from the triangular or
round cross-section of the existing incisor alveo-
lus, especially in the vestibulo-palatal dimension
at the coronal part of the root. When the char-
acteristics of the donor tooth and the recipient
site do not match, other options in terms of
selection of an alternative donor tooth or
changing the feature that prevents transplanta-
tion to the recipient site need to be considered.
Key aspects of the surgical procedure
According to a recent study of Jakobsen,21 the
success of transplantation does not depend on
the experience of the surgeon. This is contrary
to the findings of a previous study by Schwartz
et al.,13 who reported that the surgeon’s experi-
ence improves treatment outcomes.
Surgery may be performed under local or gen-
eral anesthesia depending on the patient’s coop-
eration and psychological status, and on the
operator’s experience. However, general anesthe-
sia with nasal intubation is reasonable for more
complex cases (e.g. transplantation of two or
more premolars). If the deciduous molar is still
present over its premolar successor, it is simply
extracted with a forceps; if ankylosis is detected,
the tooth must be separated into fragments and
gently removed. The buccal and coronal part of
the bone over the donor’s crypt is removed until
the premolar can be easily reached.
Special effort should be made to avoid direct
contact of any instrument with the surface of the
donor root, which requires that the inner thin
layer of bone that stays in direct contact with the
periodontal ligament of the root, is not drilled
with a bur, but only gently deflected from the
root surface with a small elevator. Most studies
describe preparation of the recipient site with
rotary instruments (straight or contra-angled
handpieces with either round or conical burs of
large diameter), chisels, or more recently, piezo-
surgery has been proposed.
If the traumatized incisor is still present, prep-
aration of the new socket can be mostly per-
formed without elevation of a flap, which allows
easy adaptation of the soft tissues around the
transplant. However, preparation of the flapless
socket without increasing the risk of trauma to
the adjacent teeth is more difficult due to the
extremely limited visual control of the adjacent
structures. In most cases, the initial size of the
socket must be enlarged for ensuring a loose
accommodation of the donor within the walls of
the new artificial bed. Since the premolar root is
usually bigger than the root of an incisor, osteot-
omy involves the removal of labial alveolar bone
of about 1/3 to 1/2 of the coronal socket height,
 ARTICLE IN PRESS

Guidelines for autotransplantation of developing premolars to the anterior maxil 7

deliberately creating a labial bone dehiscence.
The artificial socket should also provide 2-3 mm
of extra- space apically to accommodate the soft
tissues of the donor root apex.
In cases with a time lag between incisor loss
and transplantation surgery, a significant vertical
and horizontal bone defect might be detected at
the recipient site. In these situations, flap prepa-
ration becomes necessary. The mucosal tissue
covering the resorbed buccal and marginal bone
is deficient, the keratinized gingiva is narrow,
and scars are present, which makes flap handling
difficult. For this reason, the flap is usually
extended to at least one adjacent tooth on each
side, and vertical releasing incisions are per-
formed to ensure better visual inspection of
bone and adjacent roots (Fig. 3A-B). In patients
with pre-existing horizontal bone atrophy, the
socket is usually a three-wall defect with a labial
dehiscence created during surgery (Fig. 3C).
Once the socket is ready, the donor tooth is
removed from the crypt with forceps or elevators,
which should only contact the coronal portion of
the tooth, clearly distant from the periodontal
ligament covering the root in presence of the
dental follicle. Should the dental follicle still sur-
round the donor crown, it can be gripped with
surgical forceps and extracted together with the
tooth inside. The donor should be directly trans-
ferred to the recipient socket without any delay.
Because of the labial dehiscence, the buccal root
surface of the premolar may partially lack bony

Figure 3. Surgery in a 10 year-old patient is described in Figure 2. Autotransplantation of the mandibular right
and left second premolars to replace both traumatized central incisors; incision and flap elevation (A) after extrac-
tion of the resorbed central incisors - note the existing labial fenestration over the left incisor (B), surgical labial
bone dehiscences created during preparation of new sockets (C), second mandibular premolars placed in new
sockets with labial exposure of the coronal parts of their roots (D), suturing of the flap over the premolar crowns
(E). The status of the soft tissues at the time of suture removal 3 weeks after surgery, (F).Cone Beam Computed
Tomography scans performed 5 years later prove regeneration of a normal labial cortical plate (G,H, I).
 ARTICLE IN PRESS
8 Czochrowska and Plakwicz
coverage, but the apical portion should be
placed within the alveolus (Fig. 3D). Depending
on the stage of root development, the transplant
may be placed at the level of marginal gingiva or
in a more advanced eruption stage. Different
protocols for stabilization of the transplant have
been described; however, most studies support
the finding that flexible splinting with sutures
alone (Fig. 3E) decreases the risk of complica-
tions of periodontal healing.22,23
In patients with a short anterior maxilla (due
to the individual growth pattern or significant
posttraumatic atrophy of the alveolus), smaller
premolars with shorter roots (1/2 instead of 3/4
root development) should be selected.
In order to prevent bacterial infection during
early stages of healing, systemic antibiotic is rec-
ommended after surgery. Additionally, according
to a systematic review by Chung et al.,23 antibiotic
prophylaxis reduces the risk of inflammatory,
infection-related root resorption, and postopera-
tive failure rate.
The patient is advised to take non-steroidal
anti-inflammatory drugs for 2-3 days, and to
apply a chlorhexidine gel on the operated area
until the sutures/splinting is removed two weeks
after surgery (Fig. 3F). Subsequently, the patient
can resume normal masticatory function regard-
less of the transplanted tooth.
Follow-up after transplanation
Monitoring after tooth transplantation is neces-
sary to evaluate periodontal healing, postsurgical
root development, and to detect any signs of
pathology. After transplantation of developing
teeth, typical parameters to evaluate include
pulp obliteration, tooth eruption (for donors
which were placed at the level of gingiva or sub-
gingivally to continue their eruption after sur-
gery), and ongoing root formation (Figs. 1H, 1I,
2B-C, 2R).17,19,20 Pulp obliteration is a common
finding in transplanted developing teeth. It is a
sign of preserved pulp vitality and does not
require endodontic therapy. In presence of a nat-
ural, contralateral premolar, comparing root
development of the transplanted and non-trans-
planted premolar is very helpful to assess root
formation. Periodic clinical and radiological
examinations are necessary at least during the
first 12 months after surgery. The protocol after
transplantation of developing teeth includes
control examinations upon the removal of the
suture (7-10 days), after 2, 6, 12, 18, 24 months,
and then annually. In cases of uncertain healing,
the follow-up appointments are scheduled every
month until healing is established. The clinical
examination includes assessment of tooth mobil-
ity, eruption and percussion sound. The radio-
logical examination includes periapical
radiographs of the transplanted premolar in
order to monitor the healing of bone at the
recipient site, root development, pulp oblitera-
tion of the transplanted premolar, and signs of
different types of resorption.
Horizontal growth of the new alveolar bone is
expected several months after surgery.24,25
Regeneration of the labial cortical plate was
reported even in sites where significant bone
dehiscence was present at the time of surgery
(Fig. 3G-I).26,27
Most complications of transplanted teeth with
developing roots can be detected within the first
year after surgery, however a longer observation
period is always more reliable (Fig. 1A-F). Anky-
losis is one of the most common complications
after tooth transplantation, and is suspected
when the transplant presents lack of normal
mobility and a high metallic sound on percus-
sion. Ankylosis of the transplant is confirmed
when orthodontic force application does not
move the tooth, while the adjacent teeth are tilt-
ing towards the transplant. Radiological exami-
nation of the root surface of the ankylosed tooth
is usually not conclusive, because spot ankylosis is
often not visible on radiographs (Fig. 1E-F).
Management of complications
Impaired healing of the transplanted tooth is
usually related to the surgical procedure, namely
to the injury to the surface of the developing
root and manifests itself typically as cervical root
resorption or replacement resorption (ankylo-
sis). Based on the authors’ clinical experience,
ankylosis is the most serious complication after
autotransplantation of developing premolars to
the anterior maxilla. In case of complications,
alternative solutions may include transplantation
of another developing premolar (second trans-
plantation), or orthodontic mesialization of the
neighboring lateral incisor after extraction of the
failed transplant (Fig. 1G-I).10 If a contralateral
premolar is anyhow scheduled for extraction in
 ARTICLE IN PRESS
Guidelines for autotransplantation of developing premolars to the anterior maxil
order to achieve dental arch symmetry, it can
then serve as a suitable donor for a second trans-
plantation. Consequently, it is very important to
carefully monitor transplanted teeth after sur-
gery, because early detection of complications
usually provides a better chance for a second
transplantation (Fig. 1G-I). Preservation of an
ankylosed transplant in the anterior maxilla in
young children is usually not advisable, because
of the unpredictable long-term prognosis and
impaired smile esthetics.
Post-surgical orthodontics
Most patients who have undergone autotrans-
plantation of developing premolars to replace
missing maxillary incisors need orthodontic
treatment after surgery in order to:
- close the space in the dental arch after
removal of the donor premolar,
- align the transplanted premolar in the dental
arch,
- level the gingival margins,
- position the transplant for optimal reshaping
to mimick the morphology of a natural inci-
sor, or
- correct a concomitant malocclusion.
If the selection of a donor premolar is predom-
inantly based on the optimal stage of root devel-
opment rather than on orthodontic indications,
anchorage control must be supplemented. TADs
or Herbst-type Class II correctors may be helpful
to assist planned tooth movements (Fig. 2). Alter-
native treatment options after removal of a donor
premolar usually include prosthodontic substitu-
tion of the donor tooth with either partial fixed
dentures (PFD) or dental implants after the end
of growth.7,8 Transplantation of developing wis-
dom teeth constitutes another good option which
may be performed before the cessation of growth
depending on their root development.
Orthodontic alignment of the transplanted
premolar should preferably start after comple-
tion of the post-surgical healing phase. If donor
premolars were transplanted at the earlier stages
of root development, it is necessary to wait until
root development reaches at least 3/4 of the final
root length. Orthodontic repositioning of trans-
planted premolars at earlier stages of root
9
development can affect the development of their
hard tissues. If premolars are transplanted dur-
ing later stages of their root formation (about 3/4
of the final root length), it is usually recom-
mended to wait 3-6 months after surgery to ascer-
tain undisturbed healing.28 On the other hand,
orthodontic mobilization shortly after transplan-
tation (at about six weeks) was reported to
decrease the risk for ankylosis after transplanta-
tion of more mature teeth.
Orthodontic repositioning for optimal reshaping
Orthodontic repositioning of the transplanted pre-
molar after surgery significantly improves the
esthetic outcome and should be recommended to
the patient and parents/caregivers before surgery.11
Orthodontic repositioning of the transplanted
premolar usually includes tooth alignment and
levelling of the gingival margin between the trans-
planted premolar and the neighboring teeth, and
should be performed using light forces, consider-
ing the transplant a traumatized tooth.
It is often better to reshape the transplanted
premolar before orthodontic repositioning, if
the position of the transplant and its long axis
need to be adjusted to the neighboring incisors.
Sometimes, extra space is needed to match the
width of the transplant with the natural central
incisor. In this case, it is necessary to bond a pre-
molar bracket on the unrestored transplanted
premolar, and to open an adequate space for its
reshaping (Figs. 1J, 2K). The optimal position of
the zenith should be defined and respected.
After the adequate space for reshaping is
achieved, the premolar bracket is removed, and
the morphology of the transplanted premolar is
adapted to that of the central incisor using indi-
rect or direct techniques. If further orthodontic
repositioning of the reshaped transplant is neces-
sary, a corresponding central incisor bracket is
bonded, and the orthodontic treatment is contin-
ued until satisfactory alignment is obtained
(Figs. 1K, 2L). It is usually easier to perform a
good direct composite restoration of the trans-
planted premolar, if some mesial and distal space
excess has been created (Fig. 1J-K). The palatal
cusp of the transplanted premolar does not
require grinding, because occlusal interferences
can be avoided by palatally directed orthodontic
tooth movement (Fig. 2K).
 ARTICLE IN PRESS

10 Czochrowska and Plakwicz

Reshaping transplanted premolars in the
anterior maxilla
Transplanted teeth replacing traumatically lost
maxillary incisors should not only have a good
potential for successful healing, but also a
favorable tooth form to match incisor morphol-
ogy, as these teeth are placed in the center of
the esthetic zone. Premolars have a compara-
ble morphology to the width of maxillary
central incisors, which have the highest inci-
dence of traumatic loss. A matching cervical
width of the transplant and the lost incisor is
critical, as only limited preparation of the
transplant is possible during restorative treat-
ment. Third molars, which are often consid-
ered as donor teeth, are mostly unsuitable for
reshaping to maxillary incisors.29 Occasionally,
supernumerary lateral incisors can be trans-
planted to the anterior maxilla.9

Figure 4. The maxillary right second premolar was transplanted to replace the traumatically injured maxillary left
central incisor in a 9-years old girl (A). The transplanted premolar was reshaped to the incisor morphology with a
direct composite build-up and orthodontic treatment was performed in order to align the transplanted tooth and
to obtain normal occlusal relations (B). Four years after transplantation, the composite restoration was replaced
by a feldspatic porcelain veneer to improve dental esthetics (C). The patient was satisfied with her smile after
placement of the veneer (D).
 ARTICLE IN PRESS
Guidelines for autotransplantation of developing premolars to the anterior maxil
Contemporary techniques for reshaping auto-
transplanted premolars include the use of direct
and indirect composite restorations or porcelain
laminate veneers (PLV) (Figs. 1, 2, 4). The
bonded restoration should not include any den-
tine preparation, because the presence of tertiary
dentine in transplanted developing teeth may
lead to different types of root pathology. Prefera-
bly, enamel reduction should also be avoided
(Fig. 1J-L). Extensive grinding of premolars can
interfere with pulp healing after surgery.28
If unerupted donor premolars are trans-
planted, they are usually placed under the gingiva
or at the gingival level. It must be acknowledged
that transplanted teeth should continue their root
development and erupt similarly to normal devel-
oping teeth, hence the final restoration should
only be placed after their full eruption.
Post-surgical root development of a trans-
planted premolar depends on the initial stage of
its root development upon surgery and may take
more than two years in less mature premolars.
Careful monitoring of the transplanted tooth by
clinical inspection, and evaluation of a good
quality intraoral radiograph of both the trans-
plant and the control contralateral tooth, if pres-
ent, is mandatory.
Most frequently, the transplanted premolars
are initially restored with composite material,
and later receive PLVs (Fig. 4B-C). The introduc-
tion of 3-D technologies offers new options for
fabrication of printed indirect restorations,
which can be bonded on the transplanted teeth.
PVLs offer the best biologic compatibility and
esthetics and are thus recommended as “gold
standard” procedure. Feldspathic PLVs are par-
ticularly indicated for minimally invasive reduc-
tion of hard tissues and good biomechanical
properties (Fig. 4C-D).
Conclusions
Autotransplanation of developing premolars is a
viable treatment option for replacing missing
maxillary central incisors in children and adoles-
cents. It is necessary to evaluate the orthodontic
indications for premolar removal and to match
the morphology of the donor and the recipient
site using CBCT assessment before treatment. Sur-
gical damage to the root surface of the trans-
planted premolar must be avoided, and pre-
surgical orthodontic space opening is frequently
11
necessary. After surgery, healing and root develop-
ment of the transplanted teeth requires periodic
monitoring in order to detect early signs of fail-
ure. Post-surgical orthodontic repositioning of the
transplanted premolar and reshaping or restoring
them to incisor morphology is often indicated to
ensure the best esthetic treatment result. Close
interdisciplinary cooperation is imperative for
achieving a successful long-term outcome.
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