CLINICAL RESEARCH
Paweł Plakwicz, DDS, PhD,*
Dorota Cudziło, DDS, PhD,†
Ewa Monika Czochrowska,
DDS, PhD,‡ Katarzyna Gawron,
PhD, DSc,§
Małgorzata Kuc-Michalska,
DDS, PhD,k¶ and
Krzysztof Tadeusz Kukuła, DDS,
PhD#
SIGNIFICANCE
Partial resection of the root
during autotransplantation of a
mature canine enables pulp
revascularization after the
surgery. This allows to restore
the vitality of the pulp and to
avoid root canal treatment of
the transplant.
From the Departments of
*Periodontology, ‡Orthodontics, and
#
Oral Surgery, Medical University of
Warsaw; †Private Orthodontic Practice,
Warsaw; §Department of Molecular
Biology and Genetics, Medical University
of Silesia, Katowice; kOrthodontic and
Dental Private Practice, Zabrze; and
¶
Faculty of Humanities, University of
Silesia, Katowice, Poland
The authors deny any conflicts of interest
related to this study.
Address requests for reprints to Pawe1
Plakwicz, Department of Periodontology,
Medical University of Warsaw, ul.
Binieckiego 6, 02-097 Warsaw, Poland.
E-mail address: info@plakwicz.com
0099-2399
Copyright © 2023 The Authors. Published
by Elsevier Inc. on behalf of American
Association of Endodontists. This is an
open access article under the CC BY-NC-
ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/
j.joen.2023.03.006
478 Plakwicz et al.
Pulp Revascularization After
Autotransplantation of the
Mandibular Canines With
Partially Resected Roots:
Report of 5 Cases With Follow-
ups Between 26 and 80 Months
ABSTRACT
Introduction: Transmigrated (migrated through the midline) mandibular canines constitute a
treatment challenge. Advanced transmigration can be successfully treated by
autotransplantation. In developing canines, pulp revascularization is typical after
transplantation. On the contrary, the pulp of teeth with completed apex formation does not
undergo revascularization. In this case, root canal treatment becomes compulsory and
decreases the success of autotransplantation. The aim of this observational retrospective
study was to evaluate whether partial resection of the root (performed during the
autotransplantation of mature canines) would enable revascularization of the pulp after the
surgery. Methods: Five transmigrated mandibular canines with complete apex formation
before the surgery were evaluated. During the autotransplantation surgery, the resection of 2
to 4 mm of the root apex was performed to open the path for revascularization of the pulp after
surgery. The transplanted teeth were observed during healing after the surgery for the
presence of pulp obliteration. Clinical and radiographic examinations were performed.
Results: All treated canines survived the minimum observation period of 2 years (ranging
from 26 to 80 months, mean: 55 months) without pulp healing complications. The survival was
100%, and the success was 80%. In one canine, the external cervical root resorption was
diagnosed and treated 1 year after the surgery. At the final examination, transplanted canines
presented radiographic features of pulp obliteration, normal mobility, and healthy periodontal
tissues. Conclusions: The surgical protocol proved to be successful in promoting
revascularization to maintain pulp vitality, in all cases. The outcomes confirm that
autotransplantation, combined with the resection of the root, constitutes a valid treatment for
mature ectopic canines. (J Endod 2023;49:478–486.)
KEY WORDS
Ectopic canine; mandibular canine; partial root resection; pulp revascularization; tooth
autotransplantation; transmigration of canines
Autotransplantation of teeth has attracted special attention in the past decades. Successful outcomes for
specific protocols have been well documented and, as a result, more patients can benefit from this type of
treatment.
It has been proven that autotransplantation of developing teeth had better outcomes regarding
survival and success, when compared with teeth autotransplanted with complete root development1,2. In
developing teeth with widely open apices, the revascularization of the pulp is expected within the first
weeks after the surgery. In teeth with complete root development, pulp does not undergo
JOE  Volume 49, Number 5, May 2023
revascularization and root canal treatment
(RCT) becomes compulsory. Therefore, the
success of autotransplantation of mature teeth
is additionally dependent on the outcome of
the RCT of the transplants. The study by
Murtadha and Kwok3, showed that even
though postsurgical RCT was not performed,
some mature autotransplanted teeth
presented pulp obliteration. However, the
authors concluded that routine RCT should be
considered after transplantation of mature
donors. In 2015, revascularization of a
maxillary incisor transplanted from an ectopic
position was described despite detachment of
its root apex during the surgery4. In 2018,
Jakse et al.5 demonstrated the technique of
resection of the apical part of a premolar’s root
to promote revascularization of pulp. This
phenomenon was previously described in an
animal study6. Furthermore, in 2019, the
“fragile fracture technique” was applied to
assist autotransplantation of a mature
premolar. The dentine was abraded to
produce an external groove in the root surface,
without invading the root canal. Later, the
fragile fracture root-end resection was
performed using a dental elevator, maintaining
the apical pulp tissue intact. Successful pulp
revascularization was later observed7. Until
now, only 1 study reported several patients
who have undergone partial root resection
performed during autotransplantation of a
mature tooth8. Pulp revascularization and
obliteration after the surgery was found in 4 of
9 resected teeth.
After a standard surgical procedure
(without resection of the root end) the healing
outcomes for different groups of donor teeth
have different predictability for normal
postsurgical healing. Autotransplanted
premolars have the highest survival, followed
by molars and canines with 75%, 50%, and
25% survival, respectively9,10.
The incidence of impaction of
permanent canines in the mandible ranges
from 0.3% to 1.35% and is lower than in the
maxilla11,12. Once diagnosed, ectopic or
migrated mandibular canine constitutes a
major challenge and usually requires a
multidisciplinary treatment approach.
Autotransplantation may also be considered
as one of the treatment options13. The choice
of the treatment of migration depends on age,
orthodontic indications, and severity of
migration. It includes surgical exposure of the
affected tooth followed by orthodontic
extrusion, autotransplantation, and extraction
or conditional observation14. Transmigrated
mandibular canines (canines that have
migrated across the mandibular midline) are
particularly difficult regarding orthodontic
treatment planning. In contrast to slightly
JOE  Volume 49, Number 5, May 2023
migrated canines (which can be aligned in the
dental arch after forced orthodontic eruption),
advanced transmigration can be successfully
treated by autotransplantation or the canine
must be extracted. Furthermore, severely
migrated or transmigrated canines are usually
diagnosed after complete maturation of their
roots. In these cases, RCT is necessary to
avoid pulp necrosis after transplantation
because revascularization of pulp cannot be
expected. RCT is associated with additional
costs, increased treatment time, and frequent
appointments with a specialist. In addition,
some patients relate RCT to pain, discomfort,
and complications, which can occur as well.
As a result, most patients’ families and dentists
abandon the option of transplantation of a
mature tooth and the removal of a canine
remains the only solution.
In agreement with the preceding
findings, the aim of this observational
retrospective study was to evaluate whether
partial resection of the root (performed during
the autotransplantation of mature canines)
would enable revascularization of the pulp after
the surgery. Donor teeth were treated with
partial resection of the root, which was
performed during autotransplantation of the
canine from its ectopic to the normal position in
the dental arch. Resection of the root end was
performed to remove the apical constriction to
widen the apical diameter and allow
revascularization of the pulp.
MATERIALS AND METHODS
The Ethical Committee of the Medical
University of Warsaw approved the study
(AKBE/86/14). A total of 127 patients with
ectopic position of the mandibular canine were
diagnosed from 2007 to 2018 in the oral
surgery practice, which specializes in tooth
impactions and autotransplantation. In 50
patients, the impacted canines had developing
roots and in 77 patients, the root development
was complete (stage 7 according to Moorrees
classification; Moorrees et al.)15. Orthodontic
and surgical consultations were performed for
all patients and different treatment options
were presented to the patients and their legal
guardians. Figure 1 presents the diagram of
enrollment, the selection criteria, the number of
surgeries performed, dropouts, and the final
number of the autotransplanted mature
canines included in the study. The inclusion
criteria were as follows: patients with
transmigration of the mandibular canine with
complete apex formation who underwent
autotransplantation with partial resection of the
root apex and minimum observation time of 2
years after the surgery. Exclusion criteria were
incomplete data after the surgery or absence
Revascularization After Partial Root Resection.
on the follow-up visits. Nine patients
underwent transalveolar autotransplantation of
the canine with the partial resection of a root
during the transplantation surgery. These
canines had complete root development and,
therefore, the surgical protocol was modified in
relation to the developing canines (when root
resection was not performed). In 1 patient, the
decision of canine extraction was made at the
time of the surgery due to iatrogenic
traumatization during removal from its ectopic
position. Finally, after applying inclusion and
exclusion criteria, 5 autotransplanted canines
with complete root development and partial
root resection (at the time of
autotransplantation) were evaluated.
In the study, panoramic radiographs
confirmed unilateral transmigration of the
mandibular canine and pattern 1 of
transmigration according to classification
proposed by Mupparapu16. Migration of
canines was advanced to the stage in which
the crown tips of the canines were at the site of
the roots of the lateral incisors on the opposite
side of the arch. All transmigrated canines
were located labially to the roots of mandibular
incisors, which was confirmed on the cone-
beam computed tomography (CBCT)
examination. Four patients had previous
orthodontic treatment of opening the space
between a lateral incisor and a first premolar on
the affected side. Space opening was
performed to facilitate a spontaneous eruption
of the migrated canine; however, it was
unsuccessful and there was no improvement
in canine eruption before the surgery. One
patient had no orthodontic treatment before
the surgery. In 4 patients, there were no
primary canines at the migration site. In 1
patient, the primary canine was present until
the autotransplantation surgery. The
demographic data of study patients are given
in Table 1.
According to the regular protocol for
transplantation of mature teeth, all mature
canines would be scheduled for RCT a few
weeks after the surgery. This would be
required to avoid pulp complications because
revascularization after transplantation was not
expected in teeth with mature apices. All
patients’ families disliked the necessity of RCT
and preferred to remove the canine to avoid
having a nonvital tooth after treatment.
Consultations with pediatric dentists and
orthodontists were provided to discuss all
potential treatment options with patients’
families. To save the vitality of the migrated
canines and to minimize the risk of mandibular
fracture, the decision was made to perform a
resection of the apex of canines during
autotransplantation to widen the apical
foramen and to enhance the revascularization
479

FIGURE 1 – Diagram of enrollment, selection, dropouts, and follow-up of patients in the study.
of the pulp after surgery. Informed consent had a favorable chance of successful
was obtained for the surgical procedure, periodontal healing after transplantation. In
follow-up appointments, and orthodontic every case, an individual decision was made to
treatment in the future. continue the procedure of transplantation with
resection of an apex and not to extract the
Surgical Procedure canine. During apex resection, the canine’s
The surgeries were performed under local crown was kept in the surgeon’s fingers to
anesthesia (articaine with epinephrine; avoid trauma of the PDL from sharp
1:200,000) deposited in the area between the instruments. When the 2- to 4-mm apical part
first mandibular premolars. In all cases, the of the canine’s root (containing apical
surgical procedure was the same. The full- constriction) was resected with a diamond bur
thickness flap was raised with at least 1 vertical in a contra-angle handpiece at 3000 rpm, the
incision at the sites of the first premolars on the root of the canine was continually hydrated
vestibular side of the alveolus. The with saline administered by syringe. Then, the
transmigrated canine was carefully exposed canine was stored in saline to avoid drying of
from the buccal bone which covered their the PDL until the artificial root socket was
crowns. Afterward, the canine was gently prepared at the recipient site between the
removed from its initial location in the way to lateral incisor and the first premolar. The
avoid trauma to the periodontal ligament of the surgical socket at the recipient site was
root. The intrasurgical assessment of prepared after removal of the migrated canine
complexity of the canine removal and the from its crypt. This was due to the presence of
status of the periodontal ligament (PDL) was the canine’s root below the recipient site,
individually performed. This inspection of the which could be traumatized if the recipient
root allowed for the assessment of any socket was prepared first. The preparation of
damage to the root surface and that the tooth the socket, according to the measurements
TABLE 1 - Demographic Data of Study Patients at the Time of the Surgery
Patient Patient Patient Patient Patient
1 2 3 4 5 appointment (ie, 1, 2, 3, 5, 7, 9, 12, 18, and
Gender Female female female female female
Age at the surgery 12 y/4m 12 y 12 y/1m 13 y/7m 14 y
Tooth number 22 27 22 22 22
Stage of root development* 7 7 7 7 7
Pattern of transmigration† 1 1 1 1 1
Previous orthodontic treatment Yes yes yes yes no
*Root development was assessed according to the Moorrees classification.15
†
Pattern of transmigration established based on description given by Mupparapu.16
480 Plakwicz et al.
taken from the initial CBCT examination, was
complete when an adequate width and height
of the socket was achieved to accommodate
the resected canine and to avoid the damage
to the adjacent teeth. The preparation was
performed with surgical carbide round burs at
1000 rpm under copious saline rinsing. To
keep a safe distance from the roots of the
lateral incisor and the first premolar, the new
socket was prepared more labially than the
normal position of the canine’s root. The
preparation of the socket created a bone
dehiscence at the labial side of the alveolar
bone. The dehiscence was left to heal
spontaneously by labial bone apposition on the
transplanted canine’s root after surgery, as
previously described in a case report17. The
cumulative extraoral time of root resection and
preparation of the surgical socket did not
exceed 7 minutes. The canine was loosely
placed in the prepared socket with 1-mm free
space around the root surface and apically to
the resected root. There were no repeated
attempts to accommodate the canine in the
sockets to avoid damage of the PDL. The
space filled spontaneously with blood after
positioning of the transplant and before
suturing. The stabilization of canines in the
socket was obtained only by suturing the soft
tissues. The canine’s crown did not reach the
opposite teeth to avoid occlusal contacts that
could disturb early healing. The intraoral
radiograph was taken before suturing to
confirm adequate position of the transplanted
canine. The mucoperiosteal flap was
repositioned and stabilized with 5-0 resorbable
sutures (Fig. 2; Clinical photographs were
taken with a Canon EOS 40D with the Macro
LED ring light/flesh and 100-mm f/2.8 Macro
lens). All patients were prescribed amoxicillin
(500 mg every 8 hours for 5 days) to reduce the
risk of postoperative infection and
development of root resorption18-20.
Follow-up
The healing was uncomplicated in all cases,
with no signs of edema or inflammation and
sutures were removed 10 to 14 days after
surgeries. All treated patients were monitored
from 26 to 80 months after surgery (mean
follow-up was 55 months). The intraoral
radiographs were taken at each follow-up
24 months after surgery and then annually).
The criteria of success included the
following:
 Normal periodontal healing (ie, an absence
of pathology within the PDL, and normal
canine eruption and mobility).
 Pulp healing (ie, pulp revascularization
observed as presence of progressing
JOE  Volume 49, Number 5, May 2023
FIGURE 2 – Clinical photographs from the representative surgery performed in study patient 1. Preparation of a full-thickness flap (A ) exposure of labial bone for gentle removal of the
ectopic canine (B ), measurements of the apical part of the apex before resection (C, D ), resection on apical part with the use of diamond bur (E ), measurements after resection (F, G ),
placement of canine in the surgical socket (H ), and final stabilization of the transplanted canine and sutures (I ). (Adjustment of brightness was performed.)

obliteration combined with an absence of
any type of inflammatory root resorption
associated with pulp necrosis).
 Presence of a healthy bone around the left
part of the root. Root development was not
expected because the apical part of the
root (which contained Hertwig’s epithelial
root sheath) was intentionally resected
during autotransplantation surgery.
RESULTS
All transplanted canines were present in the
oral cavity after an observation period. The
survival was 100%.
Spontaneous eruption of the
autotransplanted canines toward occlusal
contact was observed in all cases and before
including the transplanted canines to the
orthodontic appliance.
Orthodontic alignment of transplanted
canines was performed between 2 and 10
months after the surgery and was completed
before the final examination. The periodontal
tissues were healthy and pocket probing
depths were between 2 and 4 mm with no
bleeding on probing. A normal clinical
attachment level and a wide keratinized gingiva
were present around the teeth (Fig. 3). Canines
presented normal mobility and responded to
vitality tests within normal limits.
Extraoral periapical radiographs
confirmed clinical observation of an eruption
and reestablishment of lamina dura of the
alveolar socket. No pathology of alveolar bone
or the root of the transplant was found within
the first year. One transplant presented an
external cervical resorption (ECR) of the root at
the follow-up 1 year post surgery.
Progressive pulp obliteration was
detected on radiographs in all
autotransplanted canines. Initial pulp
obliteration was detected between 5 and 7
months after the surgery. It consisted of a
partial narrowing of the pulp space, which was
uniform along the length of the remaining root.
Obliteration progressed gradually and at the
final radiographic examination, 3 of 5 canines
presented complete pulp obliteration. Two
teeth had only partial obliteration even after 2
years of observation (Fig. 4).
The resected roots of the canines were
not associated with any pathology on
radiographs. At the intraoral radiographs,
taken immediately after the resection, the roots
had sharp edges (Fig. 4, P1surg–P5surg),
which gradually tapered with time (P1-1year–
P5-1 year). At the final radiographs (Fig. 4, from
26 to 80 months), their resected ends were
smoothed and surrounded by a normal PDL
space.
Four of 5 transplanted canines
successfully healed according to the
established criteria. One transplanted canine
(in patient 4) developed ECR, which was
detected and successfully treated 1 year after
surgery. The small reflection of marginal
gingiva was performed under local anesthesia.
The granulation tissue was removed with

JOE  Volume 49, Number 5, May 2023 Revascularization After Partial Root Resection. 481

FIGURE 3 – The clinical presentation of the mandible of 5 patients (P1–P5) at the final examination are presented in the
left column. A normal contour of the alveolus with no gingival recession and an adequate width of the keratinized gingiva
is present at the sites of the autotransplanted canines (black arrows ). The long clinical crown of the transplant in the fifth
patient is present but the root is not exposed. Sagittal scans from cone-beam computed tomography examinations
performed after the surgery in patients are presented in the right column. The normal appearance of the alveolar bone
and the labial plate is visible. White arrow in panel/row 4 (P4) indicates the presence of external cervical resorption of the
root at the lingual side of the transplanted canine. (Adjustment of brightness was performed.)
excavators and the resorption lacuna was filled
with Geristore (Den-Mat Holdings, Lompoc,
CA, USA). The gingiva was sutured with
resorbable material. No recurrence was
observed afterward. Success was confirmed
in 4 of 5 autotransplanted canines. All treated
patients were satisfied with the treatment and
had no complaints regarding the outcomes.
CBCT was performed after the surgery.
It was limited to the operated area and served
to evaluate the position of the canines’ roots
during or after the orthodontic treatment. At
each site of the autotransplanted canine, the
labial plate of the alveolar bone was present at
the CBCT examination and covered most of
the root (Fig. 3, right column), even though the
labial dehiscence was created at the time of
the surgery (Fig. 2H).
482 Plakwicz et al.
Because of the small number of canines
in the study, the statistical analyses were
considered inappropriate. Instead, Table 2
presents intrasurgery data, information about
orthodontic treatment and healing, and
survival/success of the transplanted canines.
DISCUSSION
The presence of a permanent mandibular
canine is important for the shape of a lower
arch and the occlusal conditions, especially
regarding the canine guidance also known as
the canine protected occlusion21.
In case of migration or impaction of a
mandibular canine, different treatment options
are available. Most of them are associated with
duration and high cost of the treatment and
possibility of various complications. Surgical
removal of an impacted mandibular canine is
the most frequently performed treatment22.
For this reason, autotransplantation is an
option to save migrated mandibular canines. It
decreases the time of the treatment and avoids
complications related to the adjacent teeth.
The migrated canines in the study had
complete root development. The patients were
selected from the 127 cases diagnosed with
mandibular canine migration. In the presented
cases, the impaction could not be treated with
orthodontic exposure and bonding of an
orthodontic bracket followed by gradual
orthodontic traction. Orthodontic traction was
not possible because it could pose a threat to
the roots of the adjacent teeth.
Autotransplantation was the only alternative
treatment option to save the affected canine.
For the 9 patients who participated in the
surgery, 1 patient had the canine removed
instead of being autotransplanted, because
the canine’s root was seriously traumatized
during removal from the bone. This
demonstrates that, in some cases, removal of
an intact canine may not be possible despite a
labial position of impacted canine. Another 2
canines did not fulfill the inclusion criterion of
the 2-year observation period, which was
considered the minimum time to reliably
assess the pulpal healing and treatment
outcomes.
Autotransplantation of the tooth
requires a gentle technique of removing the
transplanted tooth from its initial location,
careful handling and placing the transplant in
the recipient site. Avoiding trauma to the
periodontal ligament and cementum of the root
is crucial to prevent complication of healing
after surgery. For this reason, manipulation of
the transplant is usually limited to the direct
contact with the coronal part of the donor (this
includes elevation from the donor site, handling
during transfer, and accommodation within the
recipient site) while all efforts are made to avoid
any contact with the root surface. In these
cases, the contact with the canines’ root could
not be avoided because the root apices were
resected during the extraoral handling of the
canines. The resection of the apices was
performed under copious irrigation with saline
and the canines were stored in saline during
preparation of the surgical sockets, which
prevented from drying of the periodontal
ligament and cementum.
Antibiotic prophylaxis was administered
after surgery to all operated patients to reduce
the risk of infection. Antibiotic use can
potentially improve the outcome of
autotransplantation, as the failure rate has
been reported to be 2.5 times higher in studies
that report not using systemic antibiotics when
JOE  Volume 49, Number 5, May 2023
FIGURE 4 – Radiographic examination of the patients: presurgical cropped panoramic radiographs (5 patients: P1–P5); resection at the surgery (P1s–P5s); 1 year follow-up (P1y–
P5y); and final status of root healing (P1f–P5f) on periapical radiographs. Additional information: in 1 patient, Geristore (Den-Mat Holdings) restoration was placed after cleaning the
external cervical resorption lacuna and is visible at the cervical level (P4f, white arrow ).

compared with those when antibiotics were
administered18-20.
Final clinical and radiographic
examinations of the canines were performed
between 26 and 80 months after the surgery,
which is enough time to conclude healing
outcomes.
Revascularization of the pulp of
autotransplanted teeth is desired to maintain
vitality of transplants after the surgery. This
phenomenon can prevent potential
complications faced by the presence of
nonvital teeth, including discoloration, fracture,
or secondary inflammation in the future. Pulp
revascularization is normally observed in
autotransplanted developing teeth that have
open apices at the time of surgery21,23.
Progressive obliteration of the pulp is a
radiographic feature that confirms the
revascularization of the pulp. The first signs of
obliteration are usually detected several weeks
after autotransplantation of immature teeth
with gradual partial or complete obliteration of
the canal, and the coronal part of the pulp24.
The revascularization does not occur in mature
teeth, in which apical constriction prevents
ingrowth of vessels in most mature
transplants.
Only a few studies suggested incidence
of revascularization and presence of pulp
obliteration in mature teeth3. It is extremely rare
in mature teeth and, consequently, RCT is
routinely performed (before or a few weeks
after transplantation of mature teeth) to avoid
inflammatory complications9,20,25. In the
experimental study on dogs, Skoglund6
documented that revascularization is possible
after resection of an apex of the root during
surgery. According to the study finding, the
vessels from the trabecular bone, adjacent to
the end of the resected root, entered the root
canal and the replacement of the necrotic pulp
by a well-vascularized connective tissue was
documented 3 months after the surgery. The
results were recently confirmed in an
experimental study in mice26. The treatment
described in the present study was aimed at
investigating whether autotransplantation of
the mature impacted canines with root
resected during the surgery would bring
benefit in terms of pulp revascularization.
The resection of the apical part of the
root was performed to make revascularization
more likely. Pulp obliteration was documented
in all cases and demonstrated complete
revascularization of the pulp after the surgery,
contrarily to the results published by Raabe

JOE  Volume 49, Number 5, May 2023 Revascularization After Partial Root Resection. 483
TABLE 2 - Intrasurgery Data, Follow-up Observations, and Survival/Success of Canines
Extraoral time during surgery
(in 0.9% saline/in min)
Observation period after surgery (in mo)
CBCT after surgery (in mo)
Start of the orthodontic mobilization of the
transplant after surgery (in mo)/length of the
postsurgical orthodontics (in mo)
First signs of pulp obliteration after the
surgery (in mo)
Type of final obliteration of the pulp
(“full” or “partial”)
Periapical pathology/resorption of the apical part
of the root
Pocket probing (in mm)/bleeding (“yes” or “no”)
Complications (time of detection in mo)
Survival
Success (established criteria)
et al.8, in which only 4 of 9 teeth presented
signs of obliteration. No pathology related to
the remaining root end was clinically or
radiologically diagnosed. Root growth after
transplantation was not expected as a natural
consequence of the removal of the tip of the
root that contained Hertwig’s epithelial root
sheath.
The clinical examination of the canines
after the surgery showed typical features of
successful autotransplantation: spontaneous
eruption after the surgery, normal mobility,
submission to the orthodontic forces (features
that proved the absence of an ankylosis), and
pocket probing depths within normal ranges.
These features enhanced normal alveolar bone
development and for that reason were crucial
in young patients, in which alveolar bone
development was still expected. A normal
bone level was detected in all operated
patients, both at the proximal sites of
transplants and at the labial and lingual
surfaces of their roots. These findings were in
agreement with the study published in 1998
and more recently in 2021, which documented
maintenance of the alveolar bone at the sites of
autotransplanted teeth27,28.
Four of 5 transplanted teeth presented
periodontal healing without any complications
during the observation period. ECR was
observed in 1 canine. The development of ECR
is usually associated with damage to the
periodontal ligament on the root surface during
the surgery and not due to the status of the
pulp29. The lesion was detected at the cervical
part of 1 canine, which was considered a
typical place of occurrence of ECR. The lesion
did not correlate to the apex resection
procedure performed during transplantation,
but rather to iatrogenic trauma to the cervical
region during autotransplantation surgery.
484 Plakwicz et al.
Patient 1 Patient 2 Patient 3
5 5
26 80
25 31
5/19 completed 10/18 completed 3/35 completed
5 6
Partial Full
— —
2–4/no 2–3/no 2–3/no
— —
1 1
1 1
ECR also can be triggered with orthodontic
treatment. The orthodontic treatment in a
traumatized tooth is usually not recommended
for at least 6 months after different types of
traumatic injuries30. Autotransplantation of a
tooth may be considered as a controlled
trauma to the donor. Both periodontal and
pulpal healing are monitored afterward with the
possibility of developing some complications.
From this point of view, the orthodontic
movement of a transplanted canine could be
considered only at a minimum of 6 months
after the surgery. In a single patient diagnosed
with ECR, the orthodontic movement of the
canine was initiated 2 months after the
autotransplantation. In retrospect, it may have
been carried out too early. ECR is occasionally
found in the transplanted teeth but can be
treated if it is detected early. Successful
treatment of resorption lacunae was previously
described in cases of ECR in the
autotransplanted teeth31. Similarly, the
treatment of the lesion was performed in the
affected canine and a stable satisfactory
outcome was observed after 1 year.
Radiographic examination of the
canines was based on the periapical
radiography technique and allowed to
periodically monitor the healing of the pulp and
periodontal ligament without unnecessary
exposure to larger doses of radiation, which
are associated with other techniques such as
panoramic radiographs or CBCT. The use of
the periapical radiography technique proved its
effectiveness in early detection of ECR in 1 of
the transplanted canines.
The small sample size is the main
limitation of this study. The limited number of
cases occurred, first, due to the relatively small
number of patients with indication for this type
of treatment, and second, because
Patient 4 Patient 5
6 5 7
65 64 43
25 12 36
2/24 completed 4/32 completed
5 7 6
Full Partial Full
— — —
2–4/no 2–3/no
— ECR (12) —
1 1 1
1 - 1
autotransplantation with root resection was
quite a novel approach. In fact, the description
of this technique was first published by Jakse5
3 years after the first patient was treated in the
presented study.
Until now, the typical protocol for the
autotransplantation of mature teeth included
RCT performed before or shortly after the
surgery, because revascularization of the pulp
in transplanted mature teeth was deemed
impossible or at least not expected.
For this reason, a technique allowing
revascularization in mature transplanted teeth
would potentially play an important role in
increasing the likelihood of survival of vital
transplants without pulpal complications. The
limitations related to autotransplantation of
teeth with complete root development could
be overcome by modification of the standard
surgical protocol. Future studies should focus
on determining if other types of mature teeth
can undergo revascularization after
autotransplantation with partial root resection.
CONCLUSIONS
The mature autotransplanted canines, with
partially resected roots, presented radiological
features of pulp obliteration, which indicated
revascularization of the pulp after the surgery.
No bone or root pathology associated with
inflammatory root resorption or pulp necrosis
was detected. The surgical protocol proved to
be successful in protecting the PDL in 4 cases.
One complication related to the root surface
was detected. The outcomes of the study
demonstrate that root resection at the time of
autotransplantation may maintain the vitality of
mature ectopic canines and possibly other
types of mature teeth.
JOE  Volume 49, Number 5, May 2023
ACKNOWLEDGMENTS editing of the manuscript. The authors have no
conflict of interest regarding the study and
The authors gratefully acknowledge Ms. Agata
have nothing to disclose.
Malinowski , BSc, for her help in language

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