Guidelines for

autotransplantation of
developing premolars to the
anterior maxilla

Dr. Masooma ali

Autotransplantation
• Autotransplantation is the surgical movement of a tooth from one
location in the mouth to another in the same individual.
• It is also known as autogenous tooth transplantation
 Introduction
• Autotransplanation of developing premolars has been reported to be
a successful long-term treatment alternative in growing patients with
congenitally missing or traumatically lost teeth
• The advantages of this method include
1. Immediate replacement of a missing tooth,
2. Good adaptation of the transplanted tooth to growth changes
3. Normal response to orthodontic forces
4. Transplanted developing premolars have a good potential for long-term
preservation of hard and soft periodontal tissues
 Orthodontic indications
Comprehensive evaluation of the individual characteristics of each
patient includes:
• Occlusion and profile,
• Space conditions,
• The number of teeth missing,
• The availability of suitable donors,
• Post-treatment Stability and
• Patient’s expectations.
 Occlusion and Profile
• Class II malocclusion: maxillary
second premolars are a good
choice
• Class III malocclusions:
mandibular premolars are the
better choice in patients
• Class I relationships and missing
maxillary central incisors, it is
advantageous to choose the
upper second premolars
The number of teeth missing
• Single incisor
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
• Both central incisors
The mandibular premolars should
be selected as donors
 Donor selection
• Selection of a premolar as a donor tooth to replace a missing
maxillary incisor, depends on:
1. Orthodontic indications for its removal,
2. Surgical assessment of the optimal match between the donor tooth
and the recipient site,
3. Long-term prognosis, and
4. Careful weighing of all pros and cons compared with other
treatment modalities.
 Surgical planning of autotransplantation
• Two major issues need to be addressed at the time when surgical
autotransplantation of a developing premolar to the anterior maxilla
is planned. They include:
1. The morphology of all potential donor premolars indicated by the
orthodontist, and
2. The space between teeth adjacent to the recipient site and bone
conditions.
The morphology of developing premolars and
selection of the best donor tooth
• Shape, size and inclination in the alveolar process are important
feature from the surgical perspectives
• 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 anterior maxilla
• Maxillary 2nd premolar
 Space and bone conditions at the recipient
site
• The amount of space at the recipient site should ensure safe
preparation of the new artificial socket, which is created parallel
between the roots of the adjacent teeth
• The oval cross-section of premolars differs from the triangular or
round cross-section of the existing incisor alveolus, especially in the
vestibulo-palatal dimension at the coronal part of the root.
• When the characteristics 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 transplantation
 Key aspects of the surgical procedure
• Surgery may be performed under local or general anesthesia
(complicated case) depending on the patient’s cooperation and
psychological status, and on the operator’s experience.
• 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.
• If the traumatized incisor is still present, preparation of the new socket
can be mostly performed without elevation of a flap, which allows easy
adaptation of the soft tissues around the transplant
• 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,
osteotomy involves the removal of labial alveolar bone of about 1/3
to 1/2 of the coronal socket height 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
• 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,
• The donor should be directly transferred to the recipient socket
without any delay
• The transplant may be placed at the level of marginal gingiva or in a
more advanced eruption stage and then suture it.
• In order to prevent bacterial infection during early stages of healing,
systemic antibiotic is recommended after surgery and NSAID for pain.
 Follow-up after transplanation
• Monitoring after tooth transplantation is necessary to evaluate
1. Periodontal healing,
2. Postsurgical root development,
3. To detect any signs of pathology
4. Pulp obliteration, (Pulp obliteration is a common finding in
transplanted developing teeth. It is a sign of preserved pulp vitality
and does not require endodontic therapy)
5. Tooth eruption
• 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.
• Radiological examinations (PA x ray to monitor the healing of
bone at the recipient site, root development, pulp obliteration
of the transplanted premolar, and signs of different types of
resorption.)
• Ankylosis 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
percussion.
• Ankylosis of the transplant is confirmed when orthodontic
force application does not move the tooth, while the adjacent
 Management of complications
• Complications: impaired healing and ankylosis
• In case of complications, alternative solutions may include
transplantation of another developing premolar (second
transplantation), or orthodontic mesialization of the neighboring
lateral incisor after extraction of the failed transplant
• If a contralateral premolar is any how scheduled for extraction in
order to achieve dental arch symmetry, it can then serve as a suitable
donor for a second transplantation
 Post-surgical orthodontics
• Most patients who have undergone autotransplantation of developing
premolars to replace missing maxillary incisors need orthodontic
treatment after surgery in order to:
1. Close the space in the dental arch after removal of the donor
premolar,
2. Align the transplanted premolar in the dental arch,
3. Level the gingival margins,
4. Position the transplant for optimal reshaping to mimick the
morphology of a natural incisor, or
5. Correct a concomitant malocclusion.
 Orthodontic repositioning for optimal
reshaping
• Orthodontic repositioning of the transplanted premolar usually
includes tooth alignment and levelling of the gingival margin between
the transplanted premolar and the neighboring teeth
• It is often better to reshape the transplanted premolar before
orthodontic repositioning
• The optimal position of the zenith should be defined and respected.
 Reshaping transplanted premolars in the
anterior maxilla
• Contemporary techniques for reshaping autotransplanted premolars
include the use of
• Direct and indirect composite restorations or
• Porcelain laminate veneers (PLV)
• A 9-year old boy sought orthodontic treatment for his unerupted
maxillary left central incisor and reverse overjet
• The panoramic radiograph evidenced an impacted, dilacerated
maxillary incisor on the lef side 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 which was not clearly visible on
the intraoral radiograph
• The panoramic radiograph taken after confirmation of ankylosis of the
transplant, 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)
• The ankylosed transplant was extracted and the second
transplantation was performed. The transplanted mandibular
premolar erupted spontaneously into occlusion after 4 months.
• Radiographic signs of pulp obliteration and root growth were
detected
• 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
• A direct composite build-up was placed following the long
axis of the transplant and matching the length of the
reference incisor
• After orthodontic treatment normal overjet and overbite
were achieved
• M: Pulp obliteration of the transplanted premolar is
• The maxillary right second premolar was
transplanted to replace the traumatically
injured maxillary left central incisor in a 9-
years old girl
• 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
• Four years after transplantation, the
composite restoration was replaced by a
feldspatic porcelain veneer to improve
dental esthetics
• The patient was satisfied with her smile
after placement of the veneer
 Conclusions
• Autotransplanation of developing premolars is a viable treatment option for
replacing missing maxillary central incisors in children and adolescents.
• 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.
• Surgical damage to the root surface of the transplanted premolar must be
avoided, and presurgical orthodontic space opening is frequently necessary.
• After surgery, healing and root development of the transplanted teeth
requires periodic monitoring in order to detect early signs of failure.
• 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.
• Cooperation is important for achieving a successful long-term outcome
Theme : Autotransplantation
Sub theme : Guidelines for autotransplantation of
developing premolars to the anterior maxilla
level:
Q: A 10 year boy was treated by autotranplantion of upper right central incisor,
which was lost by trauma 7 months back. Patient came for post surgical
orthodontics but On examination transplanted was not erupted, ankylosis was
diagnosed by clinical and radiological examination. Patient has class II profile. 2nd
autotranplsntation is planned , which tooth is preferable for him?
a. Upper right 2nd premolar
b. Upper left 2nd premolar
c. Upper right 1st premolar
d. Lower left 2nd premolar
e. Lower left 1st premolar
 Module
OBJECTIVE KNOWLEDGE
Autotranplantation
SKILLS ATTITUDE TEACHING AND ASSESMENT
LEARNING
METHODS

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