doi:10.1111/iej.

12347

CASE REPORT

Successful autotransplantation of a
mature mesiodens to replace a
traumatized maxillary central incisor

U. Dharmani1, A. Rajput1, C. Kamal2, S. Talwar1 & M. Verma3

1
Department of Conservative Dentistry and Endodontics, Maulana Azad Institute of Dental
Sciences, New Delhi; 2Department of Pedodontics, College of Dental Education and
Research, New Delhi; and 3Department of Prosthodontics, Maulana Azad Institute of Dental
Sciences, New Delhi, India

Abstract

Dharmani U, Rajput A, Kamal C, Talwar S, Verma M. Successful autotransplantation

of a mature mesiodens to replace a traumatized maxillary central incisor. International Endodontic
Journal, 48, 619–626, 2015.

Aim This case describes the successful transplantation of a mature mesiodens tooth
to replace a traumatized maxillary central incisor.
Summary A 17-year-old male attended 1 week after a traumatic injury to his left
maxillary central incisor (tooth 21). Radiographs revealed a horizontal root fracture and a
poor prognosis. The tooth was atraumatically removed and replaced with a mesiodens
lying in the same region. After stabilization, root canal treatment was performed and
aesthetics were restored with a tooth coloured restoration. A 2-year follow-up revealed
the tooth had good aesthetics and function.
Key learning points
• A supernumerary nonfunctional tooth such as a mesiodens can be successfully used
to replace a missing permanent tooth by autotransplantation.
• Autotransplantation has a high success rate if case selection is good, appropriate
surgery is carried out and excellent hygiene is maintained.
• Autotransplantation should be considered as one of the most biologic techniques for
replacing a missing tooth with minimal cost.
• Autotransplantation can be carried out even after complete root formation in the
donor tooth.

Keywords: autotransplantation, implants, mesiodens, supernumerary tooth.

Received 19 June 2014; accepted 25 July 2014

Correspondence: Akhil Rajput, Senior Research Associate Department of Conservative

Dentistry and Endodontics, Maulana Azad Institute of Dental Sciences, New Delhi, India
(Tel.: +919650408677; e-mail: akhilraj_24@yahoo.com).

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 619–626, 2015 619
 Introduction
CASE REPORT

Dental autotransplantation is the surgical transposition of a tooth from its original site to
another, replacing a lost or compromised tooth, in the same individual (Tanaka et al.
2008). Autotransplantation is an evidence-based treatment option, provided that proper
case selection has been carried out with in-depth treatment planning (Tsukiboshi 2002,
Kvint et al. 2010). The treatment is cost effective, does not interfere with the orofacial
growth and allows for rapid recovery of function and aesthetics (Park et al. 2011).
Autotransplantation has long-term survival rates varying from 74% to 100% (Tsukibo-
shi 2002, Kvint et al. 2010). Long-term studies of autotransplanted teeth to anterior
sites have reported a success rate of 98–99% within 5 years and 87–95% within
10 years, and 79% within 26.4 years (Czochrowska et al. 2002, Lon et al. 2009). Suc-
cess rates vary because it is influenced by a number of factors such as case selection,
age of the patient, developmental stage of the donor tooth, type of tooth transplanted,
surgical trauma during extraction of donor tooth, storage after removing the donor
tooth, recipient site, surgical technique and skill of the surgeon (Andreasen et al. 1990,
Kallu et al. 2005, Lon et al. 2009). The highest success rate involves teeth with devel-
oping roots with open apices and revascularization (Andersson et al. 2010). Transplant-
ing teeth with fully developed roots has a lower success rate due to the risk of
damaging the PDL with resultant root resorption (Andersson et al. 2010). Studies have
attempted to improve the prognosis in autotransplanted teeth with fully developed
roots using a two-stage technique wherein the recipient beds are left to heal for a few
days before transplantation. (Nethander 1994, Andersson et al. 2010). Nethander (1994)
reported 5-year success rates of over 90% for 68 mature teeth transplanted with a
2-stage technique.
The current case describes the successful autotransplantation of a mature mesiodens
to replace a traumatized maxillary left central incisor.

Case report

A 17-year-old male suffered traumatic injuries to the face and teeth and reported to the
dental outpatient department after one week. At that time, the patient had minor
bruises to the perioral region and face with no other evident facial fracture/severe inju-
ries. Intraoral examination revealed traumatic fractures to his two maxillary central inci-
sors (tooth 11 and 21) at different levels. The right maxillary central incisor (tooth 11)
had a simple crown fracture with enamel–dentine involvement, not involving the pulp.
Electric pulp tests were within normal limits, and the prognosis of the tooth seemed
favourable. The left maxillary central incisor (tooth 21), however, had grade III mobility.
Further radiographic examination revealed an infrabony horizontal root fracture commi-
nuted coronally. The tooth had a poor long-term prognosis. Incidentally, the patient had
an additional intact mature mesiodens lying close to the maxillary central incisors (tooth
11and 21) (Fig. 1c).
The treatment plan involved restoration of tooth 11 with composite and extraction of
tooth 21. As the supernumerary tooth in question was in the same dental arch with
dimensions proportional to those of the maxillary central incisor, transplantation of the
mesiodens in place of tooth 21 was considered.
The patient and his guardians were informed regarding the treatment planning and
informed consent was obtained.
Chlorhexidine (0.12%) mouthwash was started 2 days prior to the transplantation
procedure. The treatment commenced with the careful extraction of tooth 21, taking
care not to damage the socket walls and gingival tissue, utilizing a periotome which

620 International Endodontic Journal, 48, 619–626, 2015 © 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
 CASE REPORT
(a) (b)

(c) (d)

Figure 1 Preoperative presentation of the case. (a) Preoperative labial view of the fractured right
and left central incisors. (b) Preoperative palatal radiograph of fractured tooth 21 and mesiodens. (c)
Preoperative view of mesiodens present close to fractured tooth 21. (d) Preoperative IOPA radio-
graph of fractured tooth 21 and mesiodens.

gently broke the periodontal attachments circumradicularly, hence maintaining the resid-
ual sockets dimensions and minimizing trauma to the periodontium (Fig. 2a). The
mesiodens was extracted using a similar technique and was tried-in the transplant site.
The donor tooth fitted well on the first attempt, being neither too loose nor snugly fit-
ting, the recipient site was not modified and the transplant was initially stabilized with
gingival flap sutures (2–0 silk) and then with a semirigid splint (Fig. 2). The centric rela-
tion and occlusion were checked, and occlusal interferences were corrected using a
pear-shaped diamond finishing bur. Systemic tetracycline (1 g per day) was prescribed
for 7 days (starting 1 h prior to surgery) along with appropriate analgesics (Ipubrufen
400 mg) if required, and a 0.12% chlorhexidine rinse was used for 2 week. The patient
was advised to continue on a soft diet. The immediate postoperative radiograph
revealed satisfactory adaptation of the transplanted tooth in the new site (Fig. 2). At the
1-week follow-up, the patient was asymptomatic. The splint was removed
after 3 weeks when the transplant was immobile and gingival tissues were healed
(Fig. 3).
Root canal treatment of the transplanted tooth was carried out 2 weeks post-trans-
plantation. Under rubber dam isolation, working length was established and chemome-
chanical canal preparation performed with 2.6% sodium hypochlorite solution as the
irrigant. After drying the root canal with paper points, a calcium hydroxide paste (Endo-
cal, Septodont, Saint Maur des Fosses, France) was applied and the access cavity tem-
porarily sealed with Cavit (3M ESPE, St. Paul, MN, USA). The patient returned after
2 weeks and fresh calcium hydroxide paste was placed. After another 2 weeks, the cal-
cium hydroxide paste was removed and the root canal was filled with gutta-percha and
AH Plus sealer (Dentsply DeTrey, Konstanz, Germany) using lateral compaction. The
entire treatment was carried out using a split dam technique. The transplanted mesio-
dens was then reshaped to match a central incisor morphology using direct composite
resin (Fig. 3).
The 6-month follow-up radiograph revealed successful transplantation with no appar-
ent radiographic pathosis with respect to the root of the transplanted tooth. A full cov-
erage porcelain fused to metal crown was used to finally restore the aesthetics of the
tooth (Fig. 4). A 2-year follow-up revealed no apparent pathosis (Figs 5 and 6).

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 619–626, 2015 621
CASE REPORT
(a) (b)

(c) (d)

Figure 2 Intraoperative presentation of the case. (a) Extracted mesiodens and fractured root show-
ing proportional dimensions. (b) Mesiodens at the recipient site. (c) Splinted mesiodens at the reci-
pient site. (d) IOPA X-ray immediately after transplantation.

(a)

(c)

(b)

Figure 3 Three-week postoperative stage (a) splint removed and transplanted tooth is firm with
excellent periodontal healing, (b) mesiodens reshaped into a central incisor and (c) 3-week follow-
up radiograph.

Discussion

Autotransplantation has been used for many years with varying degrees of success
(Czochrowska et al. 2002, Tsukiboshi 2002, Kvint et al. 2010). Third molars are the
most commonly used transplants because of their late development (Lundberg & Isaks-
son 1996, Bosco et al. 2000, Tsukiboshi 2002, Demir et al. 2008). Success rates for
autotransplanted mature molars have been reported to be around 84% at 2- to 21-
month follow-up (Bae et al. 2010).
The donor tooth in this case fitted passively at the recipient site, and so the alveolus
was not surgically manipulated. Thus, after extraction, the donor tooth was immediately
transplanted to the recipient site. The extra-oral time of donor teeth significantly affects
the viability of periodontal ligament cells and, therefore, extended extra-oral time of the
donor teeth results in severe damage to the periodontal ligament cells and subsequent
root resorption (Lee et al. 2001). Another important factor in autotransplantation is the
distance between the recipient site tissue and the root surface of the transplanted
tooth (Lee et al. 2001). The graft should fit the recipient site loosely, avoiding contact

622 International Endodontic Journal, 48, 619–626, 2015 © 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
 CASE REPORT
(a)

(c)

(b)

Figure 4 Six-month postoperative stage. (a) Labial view of the definitive restoration performed with
PFM crown showing excellent gingival healing and contour, (b) palatal view and (c) follow-up radio-
graph.

(a)

(c)

(b)

Figure 5 One-year postoperative stage (a) normal probing depth, no gingival recession, (b) palatal
view and (c) follow-up radiograph at 1 year.

with adjacent bone and providing at least 1 mm of space to the adjacent roots (Lee
et al. 2001). In case of poor fit, the recipient site could be prepared using surgical round
burs under copious irrigation (Bae et al. 2010). Computer-aided rapid prototyping (CARP)
can be used to prepare the recipient site and thus minimise the extra socket time and
the possible injury of the transplanted tooth during the process of autotransplantation
(Lee et al. 2001, Bae et al. 2010). The use of a surgical template instead of the trans-
planted tooth itself, during the preparation of the socket, has been shown to reduce
unnecessary additional periodontal ligament trauma caused by the adjustment of the
donor tooth in the recipient socket (Day et al. 2012). The donor tooth can also be
placed back in its original socket after its removal whilst waiting to be placed in the
donor socket (Tsukiboshi 2002).
Pulp regeneration can be expected in immature (developing) teeth but not in mature
teeth, so in fully mature transplant cases, root canal treatment is essential and can be
performed preoperatively or within 2 weeks postoperatively (Tsukiboshi 2001, Amos

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 619–626, 2015 623
CASE REPORT
(a) (b)

(c) (d)

Figure 6 Two-year postoperative stage (a) labial view, no recession or inflammation, (b) palatal
view, (c) 2-year follow-up radiograph, no bone loss or resorption evident and (d) normal probing
depth.

et al. 2009, Bae et al. 2010). This 1- to 2-week interval is important because if root
canal treatment is performed too early after autogenous tooth transplantation, additional
injury to the periodontal ligament may occur, whereas after 2 weeks, inflammatory
resorption may develop from the infected root canal (Tsukiboshi 2001, Amos et al.
2009, Bae et al. 2010). In this case, calcium hydroxide was used as an intracanal medi-
cament because it is expected to favour bone repair and inhibit root resorption because
of its high pH, providing an antimicrobial effect and stimulating the healing process
(Tronstad 1988). Also, long-term root canal treatment with calcium hydroxide is effec-
tive in preventing and treating inflammatory resorption (Tronstad 1988). Systemic antibi-
otics were given 1 h prior to surgery in the hope of protecting the pulp from infection
during the periodontal ligament healing phase (Andersson et al. 2010).
The stabilization period can vary from 2 weeks to 2 months depending on the mobil-
ity of transplant (Tsukiboshi 2001). Rigid splinting for prolonged periods should be
avoided as it may have adverse effects on periodontal healing (Pogrel 1987). In this
case, the splint was used for only 2 weeks so as to optimize periodontal healing whilst
not allowing for disuse atrophy. Transplanted teeth usually fail because of periodontal
detachment or due to root resorption (Andreasen 1981). Failure is generally attributed
to periodontal inflammation, inflammation in the alveolar socket or insufficient stabiliza-
tion of the transplant (Bae et al. 2010). The most common complications associated
with autotransplanted teeth are ankylosis and root resorption (Kvint et al. 2010). If the
transplanted tooth develops root resorption, this usually occurs within the first year
after surgery (Kristerson 1985). More specifically, the causes of tooth loss following
transplantation from most common to least common are inflammatory resorption,
replacement resorption (ankylosis), marginal periodontitis, apical periodontitis, caries
and trauma. Inflammatory resorption may become evident after 3 or 4 weeks, whilst
replacement resorption may not become evident until 3 or 4 months after transplanta-
tion (Schwartz et al. 1985).
Reduced root/crown ratio is one of the main disadvantages of transplanting mesio-
dens to replace a lost tooth. Also, as a mesiodens root can be narrow and have a
tapered form, satisfactory interproximal aesthetics can be difficult to achieve and could
result in poor contour in the embrasures and the emergence of ‘dark spaces’ postoper-
atively (Lee et al. 2014). In this case, gingival porcelain was used to re-establish the nat-
ural crown ratio and natural gingival profile.

624 International Endodontic Journal, 48, 619–626, 2015 © 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
Conclusion

CASE REPORT
This case demonstrates that autotransplantation of a mesiodens tooth to replace a cen-
tral incisor is a reliable and predictable procedure and should be considered as part of
the treatment plan. At a 2-year follow-up, the transplanted tooth was healthy and con-
tinued to satisfy aesthetic and functional demands.

Conflict of interest

The author denies any conflict of interest.

Disclaimer

Whilst this article has been subjected to Editorial review, the opinions expressed,
unless specifically indicated, are those of the author. The views expressed do not nec-
essarily represent best practice, or the views of the IEJ Editorial Board, or of its affili-
ated Specialist Societies.

References

Amos MJ, Day P, Littlewood SJ (2009) Autotransplantation of teeth: an overview. Dental Update
36, 102–13.
Andersson L, Tsukiboshi M, Andreasen JO (2010) Autotransplantation of teeth. In: Andersson L,
Kahnberg KE, Pogrel MA. Oral and Maxillofacial Surgery, Ist edn. Oxford, UK: Wiley Blackwell,
pp. 289–90.
Andreasen JO (1981) Relationship between surface and inflammatory resorption and changes in the
pulp after replantation of permanent incisors in monkeys. Journal of Endodontics 81, 294–301.
Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O (1990) A long-term study of 370 autotrans-
planted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Euro-
pean Journal of Orthodontics 12, 14–24.
Bae JH, Choi YH, Cho BH, Kim YK, Kim SG (2010) Autotransplantation of teeth with complete root
formation: a case series. Journal of Endodontics 36, 1422–6.
Bosco AF, Neto MS, Nagata MJH, Pedrini D, Sundefelde MLMM (2000) Evaluation of the periodon-
tal tissues of the mature teeth autotransplanted to either newly prepared or initial healing alveoli:
histologic study in monkeys. Revista de Odontologia da UNESP 29, 9–29.
Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU (2002) Outcome of tooth transplantation:
survival and success rates 17-41 years posttreatment. American Journal of Orthodontics and
Dentofacial Orthopedics 121, 110–9.
Day PF, Lewis BR, Spencer RJ, Barber SK, Duggal M (2012) The design and development of surgical
templates for premolar transplant in adolescents. International Endodontic Journal 45, 1042–52.
Demir T, Ates U, Cehreli B, Cehreli ZC (2008) Autotransplantation of a supernumerary incisor as a
replacement for fused tooth: 24-month follow-up. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology and Endodontology 106, e1–6.
Kallu R, Vinckier F, Politis C, Mwalili S, Willems G (2005) Tooth transplantations: a descriptive retro-
spective study. International Journal of Oral and Maxillofacial Surgery 34, 745–55.
Kristerson L (1985) Autotransplantation of teeth: influence of different factors on periodontal and
pulpal healing (Thesis). Stockholm, Sweden: Karolinska institute.
Kvint S, Lindsten R, Magnusson A, Nilsson P, Bjerklin K (2010) autotransplantation of teeth in 215
patients: a follow up study. Angle Orthodontist 80, 446–51.
Lee S-J, Jung I-Y, Lee C-Y, Choi SY, Kum K-Y (2001) Clinical application of computer-aided rapid
prototyping for tooth transplantation. Dental traumatology 17, 114–9.
Lee Y, Chang SW, Perinpanayagam H et al. (2014) Autotransplantation of mesiodens for missing
maxillary lateral incisor with cone-beam CT-fabricated model and orthodontics. International End-
odontic Journal 47, 896–904.

© 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 48, 619–626, 2015 625
 Lon LF, Cerci BB, Baboni FB, Maruo H, Guariza-Filho O, Tanaka OM (2009) Root formation of an
CASE REPORT

autotransplanted tooth. Dental Traumatology 25, 341–5.

Lundberg T, Isaksson S (1996) A clinical follow-up study of 278 autotransplanted teeth. British Jour-
nal of Oral and Maxillofacial Surgery 34, 181–5.
Nethander G (1994) Periodontal conditions of teeth autogenously transplanted by a two-stage tech-
nique. Journal of Periodontal Research 29, 250–8.
Park JH, Tai K, Hayashi D (2011) Tooth autotransplantation as a treatment option: a review. Journal
of Clinical Pediatric Dentistry 35, 129–36.
Pogrel MA (1987) Evaluation of over 400 autogenous tooth transplants. Journal of Oral and Maxillo-
facial Surgery 45, 205–11.
Schwartz O, Bergmann P, Klausen B (1985) Autotransplantation of human teeth: a life-table analysis
of prognostic factors. International Journal of Oral Surgery 14, 245–58.
Tanaka T, Deguchi T, Kageyama T, Kanomi R, Inoue M, Foong KWC (2008) Autotransplantation of
28 premolar donor teeth in 24 orthodontic patients. Angle Orthodontist 78, 12–9.
Tronstad L (1988) Root resorption-etiology, terminology and clinical manifestations. Dental Trauma-
tology 4, 241–52.
Tsukiboshi M (2001) Autotransplantation of teeth. Tokyo: Quintessence publishing, pp. 10–8.
Tsukiboshi M (2002) Autotransplantation of teeth: requirements for predictable success. Dental
Traumatology 18, 157–80.

626 International Endodontic Journal, 48, 619–626, 2015 © 2014 International Endodontic Journal. Published by John Wiley & Sons Ltd
This document is a scanned copy of a printed document. No warranty is given about the
accuracy of the copy. Users should refer to the original published version of the material.