Accepted Manuscript

Autotransplantation of premolars with a 3D printed titanium replica of the donor tooth

functioning as a surgical guide: proof of concept in five transplants

J.P. Verweij, MD, Resident Maxillofacial Surgery, D Anssari Moin, DMD, Dentist, G.
Mensink, MD, DMD, PhD, Maxillofacial Surgeon, P. Nijkamp, DMD, Orthodontist, D.
Wismeijer, DMD, PhD, Dentist, Professor, Department Head, J.P.R. van Merkesteyn,
MD, DMD, PhD, Maxillofacial Surgeon, Professor, Department Head

PII: S0278-2391(16)00122-1
DOI: 10.1016/j.joms.2016.01.030
Reference: YJOMS 57114

To appear in: Journal of Oral and Maxillofacial Surgery

Received Date: 24 December 2015

Revised Date: 15 January 2016
Accepted Date: 15 January 2016

Please cite this article as: Verweij J, Moin DA, Mensink G, Nijkamp P, Wismeijer D, van Merkesteyn J,
Autotransplantation of premolars with a 3D printed titanium replica of the donor tooth functioning as a
surgical guide: proof of concept in five transplants, Journal of Oral and Maxillofacial Surgery (2016), doi:
10.1016/j.joms.2016.01.030.

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 ACCEPTED MANUSCRIPT
Autotransplantation of premolars with a 3D printed titanium replica of the
donor tooth functioning as a surgical guide: proof of concept in five
transplants
JP Verweij1 (MD, Resident Maxillofacial Surgery);
D Anssari Moin2 (DMD, Dentist);
G Mensink1,3 (MD, DMD, PhD, Maxillofacial Surgeon);

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P Nijkamp1 (DMD, Orthodontist)
D Wismeijer2 (DMD, PhD, Dentist, Professor, Department Head);

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JPR van Merkesteyn1 (MD, DMD, PhD, Maxillofacial Surgeon, Professor,
Department Head)

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1
Department of Oral and Maxillofacial Surgery, Leiden University Medical Center,
Leiden, The Netherlands

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2
Department of Oral Function and Restorative Dentistry, Academic Centre for
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Dentistry Amsterdam (ACTA), research Institute Move, Amsterdam, The Netherlands
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Department of Oral and Maxillofacial Surgery, Amphia Hospital, Breda, The
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Netherlands
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Running title: Autotransplantation of premolars with 3D surgical guide

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Keywords: Autotransplantation; transplantation; CBCT; three-dimensional; surgical

template; prototyping
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Conflict of Interest and source of funding statement:

The authors declare that there are no conflicts of interest in this study
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Correspondence address:
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Richard (J.P.R.) van Merkesteyn

Department of Oral and Maxillofacial Surgery
Leiden University Medical Center
Albinusdreef 2,
Postbus 9600, 2333 ZA, Leiden
The Netherlands
E-mail: J.P.R.van_Merkesteyn@lumc.nl
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Autotransplantation of premolars with a 3D printed titanium replica of the
donor tooth functioning as a surgical guide: proof of concept in five
transplants

Abstract
Purpose: Autotransplantation of premolars is a good treatment option for young

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patients with missing teeth. This study evaluates the use of a pre-operatively 3D-
printed replica of the donor tooth that functions as a surgical guide during

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autotransplantation.

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Methods: Five consecutive procedures were prospectively observed.
Transplantations of maxillary premolars with optimal root development were included
in this study. A 3D-printed replica of the donor tooth was used to prepare a precisely

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fitting neo-alveolus at the recipient site before extracting the donor tooth. Procedure
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time, extra-alveolar time, and the number of attempts needed to achieve a good fit of
the donor tooth in the neo-alveolus were recorded.
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Results: For each transplantation procedure, the surgical time was less than 30
minutes. An immediate good fit of the donor tooth in the neo-alveolus was achieved
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with an extra-alveolar time of less than one minute for all transplants.
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Conclusion: These results show that the extra-alveolar time is very short when the
surgical guide is used; therefore, the chance of iatrogenic damage to the donor tooth
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is minimized. The use of a replica of the donor tooth makes the autotransplantation
procedure easier for the surgeon and facilitates optimal placement of the transplant.
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Introduction
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Autotransplantation is has long been performed in oral surgery, and it is still a

valuable treatment for young patients with missing teeth.1 Autotransplantation of

maxillary premolars to replace missing mandibular premolars is the most common

procedure.2 This option is particularly useful when orthodontic extraction therapy of

the maxillary premolars is indicated. Other less frequent indications are

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transplantation of premolars to replace missing incisors or transplantation of third

molars to replace heavily damaged molars.3, 4 Nevertheless, autotransplantation is

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often not considered in patients with missing teeth or it is dismissed because of the

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chance of transplant-related complications. This is unfortunate because

autotransplantation could be a highly relevant treatment option for single-tooth

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replacement, particularly because transplanted teeth can function as normal teeth
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after successful autotransplantation.5
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An update of the surgical technique may help to further improve the already high

success and tooth survival rates after autotransplantation, and could help to
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establish autotransplantation as one of the preferred options for single-tooth

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replacement in young patients.6

This study investigates the use of a computer-aided designed (CAD) 3D-printed

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titanium replica of the donor tooth which can be used as a surgical guide during the
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autotransplantation procedure. The surgical guide is used instead of the donor tooth
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when preparing an individualised artificial socket (neo-alveolus). This means that the

donor tooth is extracted after preparation of the neo-alveolus, and both the extra-

alveolar time and the chance of iatrogenic damage are minimized.

The aim of this study was to evaluate the use of this individual pre-operatively 3D-

printed donor tooth replica during autotransplantation procedures and assess the

advantages of this new technique.

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Material and Methods

Study design and participants

This prospective observational study analysed the use of a 3D-printed titanium

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replica of the donor tooth to facilitate the autotransplantation procedure. The surgical

guide was manufactured as previously described by Moin et al.7, 8

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All patients were referred by their orthodontist and treated at the department of Oral

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and Maxillofacial Surgery of the Leiden University Medical Center.

Autotransplantation with a surgical guide has been the treatment protocol used in our

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centre since July 2015. One patient functioned as a test case to determine and
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resolve any procedural difficulties. Subsequently, we prospectively analysed the first
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five consecutive transplant procedures that were performed with this technique.

In all cases, the indication for autotransplantation was agenesis of the mandibular
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premolars in patients in whom orthodontic extraction therapy of the maxillary

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premolars was indicated. Only maxillary second premolars with an optimal

developmental stage of the donor tooth (50–75% of expected total root development)
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were included in this study.

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3D surface reconstruction

After intake, a selective cone beam computed tomography (CBCT) scan (Planmeca

Promax®3D Max, 96 kV, 11 mA, 130x55 mm field of view) of the donor tooth was

performed one month prior to autotransplantation. The scan position was with the

occlusal plane parallel to the floor following the manufacturer’s recommendations.

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The scan volumes were exported in DICOM 3 format and imported into the image

analysis software Amira (v5.3, VisageImaging, California, USA). Subsequently, a 3D

surface model of the donor tooth was created (Figure 1).

The exact procedure for segmenting the tooth was performed in a standardised

manner.7, 8 A region of interest was first selected and limited to the donor tooth and

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surrounding periodontium. Subsequently, a threshold value based on the histogram

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analysis, local grey level value, and image gradient was selected to separate the root

and crown from the surrounding bone (Figure 2). A manual selection, on the basis of

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the sagittal slides, was applied for the most apical part of the root if the threshold-

based technique did not confine the entire apex area.

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The images were processed using interactive processing tools to remove resulting
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artefacts. A 3D surface mesh of the donor tooth was created and stored as a
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Standard Triangulation Language (STL) file. The STL files were then reprocessed

and retopologised with SolidWorks software 2015 SP3 software (Dassault Systèmes,
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Vélizy, France) to create a printable mesh. 7, 8

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Printing process
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A high-end Selective Laser Melting (SLM) technology was used to fabricate the

donor tooth copy from the STL files.7 This additive manufacturing technique is
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capable of building complex shaped three-dimensional objects by successively

depositing and melting thin layers of metal powder.8 By scanning the successive

two-dimensional layers (30 µm thickness), each individual layer is molten using a

focused Ytterbium-fibre laser beam. The donor tooth copy (Figure 3) was produced

in a biocompatible grade 23 titanium alloy on a proprietary technology SLM machine

by LayerWise (LayerWise NV, 3DSYSTEMS division, Belgium).

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Surgical procedure

All patients were treated according to the same treatment protocol, and the teeth

were autotransplanted by a single experienced surgeon who used the same surgical

technique. One procedure was planned under general anaesthesia because two

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premolars were transplanted in a young patient that was too anxious to undergo the

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procedure under local anaesthesia. The other procedures were planned under local

anaesthesia (Ultracain D-S, Sanofi-Aventis, Gouda, The Netherlands).

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First, the neo-alveolus was prepared at the recipient site with surgical burrs. The 3D-

printed replica (surgical guide) was fitted to make sure the donor tooth would fit

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exactly in the artificial socket (Figure 4). Subsequently, the donor tooth was
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extracted with forceps, and care was taken not to damage the cementum,
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periodontal ligament, or apex of the tooth. The surgical guide and donor tooth were

optically compared to evaluate the possible differences between the 3D-printed

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replica and the original tooth (Figure 5). The donor tooth was placed into the neo-
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alveolus in a slight infra-occlusion to prevent occlusal forces postoperatively. A Vicryl

Rapide 3-0 suture (Johnson & Johnson International, New Brunswick, NJ, USA) was
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placed across the occlusal plane to fix the transplanted premolar into place.
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Data collection

The following preoperative data were collected; the patient’s age, gender, donor- and

acceptor-sites, and root development stage of the donor tooth. Intra-operative data

were recorded, including the fitting attempts with the surgical guide, the extra-

alveolar time of the donor tooth, and the number of fitting attempts needed to place

the donor tooth in the newly prepared alveolus (neo-alveolus) at the recipient site.
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This study was performed in accordance with the guidelines of our institution and

followed the Declaration of Helsinki on medical protocol and ethics. The study

protocol was reviewed and approved by the Leiden University Medical Centre

institutional ethical review board (P15.002).

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Results

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The characteristics of the transplant procedures that were performed with the 3D-

printed replica of the donor tooth are represented in Table 1.

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The first patient was a 12-year-old girl. First, the right maxillary premolar was

transplanted to the right mandibular premolar position under local anaesthesia.

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Transplantation of the left maxillary premolar to the left mandibular recipient site was
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performed two weeks later. In both procedures, the socket was prepared with the
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titanium replica of the donor tooth until a good fit of the surgical guide was achieved.

The donor tooth was subsequently extracted with forceps, and care was taken to
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protect the periodontal ligament of the tooth. The donor tooth was directly placed in
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the prepared tooth socket at the recipient site, and no additional fitting of the donor

tooth was necessary. An immediate good fit of the donor tooth in the neo-alveolus
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was thus achieved in both procedures, and the extra-alveolar time was less than one
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minute for both transplants.

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The second patient was a 13-year-old boy in whom extraction therapy of the right

and left maxillary premolar was planned. After examination of the preoperative

CBCT-scan, the left maxillary premolar was found to be the most suitable option for

transplantation to the right mandibular recipient site. Autotransplantation was

performed under local anaesthesia, and the neo-alveolus was prepared by fitting the

titanium replica of the left maxillary premolar. The donor tooth was extracted, and an
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immediate good fit in the neo-alveolus was achieved. The extra-alveolar time of the

donor tooth was 45 seconds.

The third patient was an 11-year-old girl who was treated under general anaesthesia.

Transplantation of the right premolar was performed to the right mandibular recipient

site. The left premolar was transplanted to the left mandibular recipient site. Each

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neo-alveolus was again prepared with the replica of the corresponding donor tooth.

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On both sides, an immediate good fit of the donor tooth was achieved with an extra-

alveolar time of less than one minute.

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Discussion
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This study shows that a 3D-printed replica of the donor tooth allows for hands-on
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preoperative and intra-operative planning during the autotransplantation procedure.

The surgical guide protects the donor tooth from iatrogenic damage by reducing the
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extra-alveolar time and minimizing the number of fitting attempts during the
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preparation of a neo-alveolus. This enables a quick and easy autotransplantation

procedure.
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Successfully transplanted premolars can function as normal teeth with a high long-

term survival rate.5 The procedure is nevertheless still accompanied by the risk of
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complications, such as root canal obliteration, root resorption, ankylosis, endodontic

pathology, and periodontitis. Tooth survival and success after autotransplantation

mainly depend on the prevention of damage to the periodontal ligament and

nerve/apex of the donor tooth.9 Therefore, several aspects are important in order to

maximise the chance of success after autotransplantation. Extraction of the donor

tooth should be performed atraumatically without damaging the periodontal ligament

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and developing apex. The extra-alveolar time should be minimized as much as

possible. Iatrogenic damage during implantation at the recipient site should be

prevented by minimizing the attempts of fitting the donor tooth in the neo-alveolus.

After successful implantation, the donor tooth should be fixed in infra-occlusion to

prevent postoperative occlusal forces. A suture splint is advised, as this reduces the

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chance of ankylosis compared to a more rigid splinting system.10

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The availability of 3D imaging and additive manufacturing technologies has given

rise to many improving techniques in dentistry and oral surgery. This includes CAD-

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CAM manufacturing of crowns and bridges, computer-assisted surgical planning of

mandibular reconstruction and orthognathic surgery, and the manufacturing of

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individualised maxillofacial implants. However, rapid prototyping to facilitate
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autotransplantation of teeth is new.11
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The use of an individually designed tooth replica to facilitate autotransplantation has

several important advantages. It minimizes the number of fitting attempts that have
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to be made to achieve a good fit of the donor tooth in the newly prepared socket.
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The chances of iatrogenic damage to the periodontal ligament are therefore

minimized, and the extra-alveolar time is reduced, which can only improve the status
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of the periodontal ligament of the donor tooth.12, 13 The chances of iatrogenic

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damage to the developing apex are also reduced for the same reasons. A replica of
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the donor tooth furthermore makes the procedure safer for the patient and easier for

the surgeon because exact individualised planning of the autotransplantation is

possible with this surgical guide even when intra-operative modifications are

necessary. These enhancements will hopefully further improve the success rate and

survival rate of transplanted teeth.14

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An alternative for an individualised 3D-printed replica of the donor tooth is the use of

predesigned surgical templates of premolars.15, 16 Such a surgical template (that is

not patient-specific) can be sterilised and re-used in subsequent autotransplantation

procedures. However, in this study, we chose to use an individualised patient-

specific 3D-printed replica of the donor tooth. This ensures a good fit of the donor

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tooth in the neo-alveolus, without the risk of complicating the procedure due to

discrepancies between a ‘generic’ surgical template and the actual donor tooth.17

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In summary, we believe that in the future, the autotransplantation of teeth will include

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using a surgical guide as an alternative for the donor tooth when preparing the neo-

alveolus. Nevertheless, possible disadvantages should also be considered. For the

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manufacture of an individualised replica of the donor tooth, a CBCT scan of the
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donor tooth is performed. The use of ionising radiation should be justifiable for each

specific patient and should be limited.18 Therefore, we performed a selective CBCT

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scan focused on the donor tooth with the smallest field of view possible. The
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radiation load was kept as minimal as possible. The selective CBCT scan not only
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enables the manufacture of the surgical guide, but it also allows the surgeon to

carefully plan the extraction of the donor tooth. The CBCT scan facilitates a shorter
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and easier surgical procedure, which in turn could minimize the chance of
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complications and is beneficial for the patient. We therefore believe this limited
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amount of additional ionising radiation is appropriate. Manufacturing of a replica of

the donor tooth is furthermore associated with additional costs. We believe this can

be compensated by the fact that the surgical guide shortens the surgical time and

because higher success and survival rates could prevent expensive treatments in

the future.14 The cost-effectiveness should nevertheless be evaluated.

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This study aimed to evaluate our autotransplantation technique using a 3D-printed

replica of the donor tooth. Therefore, we reported the technical and intra-operative

characteristics of the procedure. In the future, long-term evaluation of the

transplanted teeth will be necessary to evaluate the success and survival of teeth

that were transplanted with the help of this surgical guide.

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Conclusions

The use of a 3D-printed titanium replica of the donor tooth enables a quick and easy

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autotransplantation procedure. Preparation of the neo-alveolus with optimal

placement of the donor tooth is facilitated by this surgical technique, and the chance

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of iatrogenic damage to the donor tooth is minimized. Further research regarding the
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success rate and survival of transplanted teeth should investigate the clinical
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advantages of this technique.

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References
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clinical follow-up. J Clin Periodontol. 2015; doi:10.1111/jcpe.12492

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2. Mensink, G. & van Merkesteyn, R. Autotransplantation of premolars. Brit Dent J

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3. Kvint, S., Lindsten, R., Magnusson, A., Nilsson, P. & Bjerklin, K.

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80: 446-51.
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4. Yan, Q., Li, B. & Long, X. Immediate autotransplantation of mandibular third molar

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subsequent to transplantation. Eur J Orthod 1990; 12: 14-24.

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TABLES

Table 1: Fitting attempts and extra-alveolar time of donor teeth (maxillary premolars)

during autotransplantation procedures with an individualized surgical guide

Donor tooth Recipient site Fitting Extra-alveolar Procedural

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(Maxilla) (Mandible) attempts time (min:sec) time (min)

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Right Right premolar site 1 0:15 20

Left Left premolar site 1 0:19 20

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Left Right premolar site 1 0:45 30

Left Left premolar site 1 0:40 20

Right Right premolar site 1

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FIGURE CAPTIONS
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Figure 1: 3D surface rendering of the donor tooth.

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Figure 2: Volumetric segmentation of the donor premolar from the scan.

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Figure 3: Individualised surgical guide.

Figure 4: Fitting the surgical guide.

Figure 5: Donor tooth and titanium replica (surgical guide).

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