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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 11  |  Issue : 4  |  Page : 168-174

Tooth transplantation and orthodontic movements


1 Dentist, Department of Orthodontics and Dentofacial Orthopedics, International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain
2 Professor Department of Orthodontics and Dentofacial Orthopedics, International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain
3 Dentist. International master of Oral Surgery. International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain
4 Dentist. Master of Endodontics. International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain
5 Chairman, Graduated Program, Department of Orthodontics and Dentofacial Orthopedics, International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain
6 Chairman of International Master of Oral Surgery, International University of Catalonia, Sant Cugat del Valles, Barcelona, Spain

Date of Submission15-Jul-2020
Date of Decision30-Sep-2020
Date of Acceptance05-Dec-2020
Date of Web Publication19-Jan-2021

Correspondence Address:
Dr. Ariadna Colom
C/de Josep Trueta, 08195, Sant Cugat del Vallès, Barcelona
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijor.ijor_26_20

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  Abstract 

Dental autotransplants have been performed successfully for many years, but little has been written about its relationship with orthodontics. This article is a review which analyses and highlights all the details about the orthodontic movement in autotransplanted teeth according to their root development. The inclusion criteria for the analysis were the following: human and animal model studies, retrospective and prospective clinical studies, case series, systematic reviews, any tooth type, minimum 20 transplants, languages of publication in Spanish and English, follow-up of at least 1 year, and publications between 1985 and 2017. After examining the titles and abstracts, 168 articles were evaluated, discarding those that were not within the inclusion criteria for agreement and relationship to the research topic.

Keywords: Autotransplantation, orthodontics autotransplantation and dental autotransplant, tooth autotransplantation


How to cite this article:
Colom A, la Iglesia FD, la Iglesia AD, Lucas-Taulé E, Llaquet M, Puigdollers A, Hernandez-Alfaro F. Tooth transplantation and orthodontic movements. Int J Orthod Rehabil 2020;11:168-74

How to cite this URL:
Colom A, la Iglesia FD, la Iglesia AD, Lucas-Taulé E, Llaquet M, Puigdollers A, Hernandez-Alfaro F. Tooth transplantation and orthodontic movements. Int J Orthod Rehabil [serial online] 2020 [cited 2021 Apr 19];11:168-74. Available from: https://www.orthodrehab.org/text.asp?2020/11/4/168/307438


  Introduction Top


The tooth autotransplantation is a treatment that consists of the placement of a tooth in an alveolus or edentulous receptor zone that has been previously surgically prepared. This involves transplanting an impacted or erupting tooth from one site to another in the same individual.[1] It is a treatment that has been shown to be effective in replacing missing teeth and success rates reported in the literature vary from 74% to 100%.[2],[3],[4]

It is a beneficial treatment for patients who are growing.[2] On the other hand, in adult patients, since there is no bone growth, it is more frequent for them to be treated with fixed tooth-supported prostheses and/or implants.[2],[5] Autotransplantation is a treatment option that provides clear advantages in terms of function, esthetics and cost of treatment, as well as good long-term prognosis.[1] It is indicated to do an autotransplantation in impacted teeth, in agenesias, in dental losses as a consequence of caries or periodontal and periodontal lesions, and in traumas.[2],[6] In general, a transplant is appropriate when a tooth cannot be restored, and when a third molar or a badly positioned tooth is not functioning.[1],[7] According to Tsukiboshi,[8] an autotransplant is chosen before placing an implant in the following cases: patients who are treated before pubertal growth and/or patients with nonrestorative tooth that require extraction and for which there are no ideal tooth donors.

To perform an autotransplant, a treatment sequence must be performed, requiring clinical and radiographic examination, precise diagnosis, treatment plan, surgical procedure, endodontic treatment, orthodontic treatment if necessary, restoration treatment, and follow-up.[1],[8]

During the surgical protocol of dental autotransplantation, one of the key factors for the success of the short- and long-term treatment will be the correct planning of 1the case.[1],[8] It will be crucial to take into account the dimensions of the donor tooth and the recipient site. Before starting the surgical procedure, measurements should be taken in the three axes of space in both the donor and recipient areas. If the donor tooth is too wide, space should ideally be opened by orthodontic treatment. If orthodontic treatment cannot be performed, the dimensions of the donor tooth can be reduced by ameloplasty without exceeding 2 mm of enamel. Orthodontic planning of autotransplant cases will be one of the keys to successful treatment.[9]

According to several authors such as Kim et al.,[10] in order to reduce the extraoral time of the donor tooth and prevent injuries to the periodontal ligament, a replica of the donor tooth is made in an acrylic model. Before placing the donor tooth in the new alveolus, the replica is tested to form the recipient alveolus and see the final position of the autotransplant.

The general indication in orthodontics to perform an autotransplant is to replace the loss or agenesis of a tooth with a tooth from another region. The ideal situation occurs when the donor tooth does not have complete root development and is a premolar or a third molar.[7],[11] Almost all patients with autotransplanted teeth require orthodontic treatment to correct the malocclusion, as the transplanted tooth is often not in the ideal position. This movement must be carried out with care, as the orthodontic movement of a transplanted tooth results in some root shortening.[7],[12] The orthodontist is the most competent professional to identify available donor teeth since he or she previously evaluates the patient's general occlusal condition.[11]

The aim of this review will be to assess the success and survival of autotransplants and to analyze all the details about the orthodontic movement in autotransplanted teeth according to their root development.


  Materials and Methods Top


Sources of information and bibliographic search

In order to carry out this bibliographic review, a systematic review of studies related to dentistry, specifically orthodontics and autotransplantation was carried out. The literature was reviewed from articles found in Medline's PubMed electronic database, on the website of the journal “The Angle Orthodontist” and in the library of the International University of Catalonia. Some articles were published in journals such as Dental Traumatology, American Journal of Orthodontics and Dentofacial Orthopedics, Journal of Clinical Periodontology, and Dental Press Journal of Orthodontics. This literature search was conducted using a series of keywords such as: “tooth autotransplantation,” “autotransplantation,” “orthodontics autotransplantation,” and “dental autotransplant.”

Inclusion and exclusion criteria

The inclusion criteria for the analysis were the following: human and animal model studies, retrospective and prospective clinical studies, case series, systematic reviews, any tooth type, minimum 20 transplants, languages of publication in Spanish and English, follow-up of at least 1 year, and publications between 1985 and 2017.

The exclusion criteria were the following: vitro studies, case reports, and publications before 1985.


  Results Top


Selection of studies

The initial search using the keyword “Tooth Autotransplantation” in the previously mentioned available electronic databases resulted in a total of 1067 articles available, but only 649 articles published since 1985. After examining the titles and abstracts, 168 articles were evaluated, discarding those that were not within the inclusion criteria for agreement and relationship to the research topic. The first evaluation of these articles was carried out to determine their content. After this approach, 49 articles were discarded because they were clinical case reports and were not useful for the study, another 36 articles were discarded because they did not have a minimum simple of twenty transplants, 13 were discarded because they had another research objective and did not meet the inclusion criteria, another 15 articles were discarded because they had a follow-up of <1 year, and lastly, another 21 were discarded because they were in vitro studies. Finally, the remaining 34 articles that met the inclusion criteria were selected.

Survival rate

In the study by Andreasen et al.[13] they conducted a study with 370 autotransplanted teeth, with a follow-up period of 1–13 years. They achieved a survival rate of 95% in open apex and 98% in closed apex. Denys et al.[14] conducted a study of 137 autotransplanted teeth with a follow-up period of 4.9% years. The survival rate was 86.8%. Czochrowska et al.[15] conducted a study of 45 transplanted open apex premolars with a follow-up of 4 years. Achieving a 93% survival rate. In the 2002 study, a 90% survival rate was observed with a sample of 33 teeth with open apex transplanted with an average follow-up period of 26.4 years.[16] In the study by Plakwicz et al.,[9] a 100% survival rate is described in a sample of 23 transplanted premolars with open apex. Watanabe et al.[17] published a study of 38 teeth with closed apex transplanted with a survival rate of 86.8%, over a follow-up period of more than 6 years. In the Kokai et al.[18] study of 100 self-transplanted closed apex teeth, a survival rate of 93% was achieved [Table 1].
Table 1: Authors and their studies

Click here to view


Success rate

In the study by Lundberg and Isaksson[19] a success rate of 94% at the open apex and 84% at the closed apex is described. Denys et al.[14] conducted a study of 137 autotransplanted teeth with a follow-up period of 4.9 years. The success rate was 65.4%.[14] Czochrowska et al.[15] conducted a study of 45 transplanted open apex premolars with a follow-up of 4 years. Achieving a 93% success rate.[15] In the study carried out in 2002, a success rate of 79% was observed for 33 teeth with open apex transplanted with an average follow-up period of 26.4 years.[16] In the study by Plakwicz et al.,[9] a success rate of 91.3% is described in a simple of 23 transplanted premolars with open apex. Watanabe et al.[17] published a study of 38 teeth with closed apex transplanted with a success rate of 63.1%, over a follow-up period of more than 6 years. In the Kokai et al.[18] study of 100 self-transplanted closed apex teeth, a success rate of 71% was achieved [Table 1].

Orthodontic movement

Lennart Lagerström et al.[12] apply an orthodontic 6 months movement after transplantation of teeth with open apex. Czochrowska et al.[15] also describe that the ideal time to initiate orthodontic movement in teeth with an open apex is approximately 6 months after surgery. However, authors such as Paulsen[20] initiate orthodontic movement 3-0 months after autotransplantation of teeth with open apex.

On the other hand, in autotransplants with closed apex, Watanabe et al.[17] apply orthodontic movement 2 months after the tooth transplant. Moreover, in the study by Kokai et al.,[18] orthodontic strength begins 1–2 months after transplantation of fully developed teeth. On the other hand, there are studies such as Jonsson and Sigurdsson[21] that do not differentiate between the open and closed apex and initiate orthodontic movement 4 months after transplantation. Neither in the article by Mensink et al.[2] differentiate between the open and closed apex and orthodontic movement begins 3 months after surgery. Finally, Denys et al.[14] believe that orthodontic movement in both open and closed apex transplantation should begin 3–9 months after autotransplantation [Table 1].


  Discussion Top


In order to understand and classify an autotransplant as successful, authors Schwartz et al.,[22] Kristerson and Lagerström et al.,[23] and Kugelberg et al.[24] described and referred to the following three criteria described by Czochrowska et al.[16] in their articles:

  • The hard and soft periodontal tissues adjacent to the transplanted tooth should remain normal and unchanged
  • Absence of progressive root resorption
  • Coronoradicular ratio <1, therefore, the supraosseous part shorter than the infraosseous part.


In our opinion, we agree with several other authors such as Schawartz et al.,[22] Kristerson y Lagerström et al.,[23] Kugelberg et al.,[24] Czochrowska et al.,[15],[16] Kokai et al.,[14],[18],[25] and Denys et al.,[14] since they take into account the soft tissues, the development of the root of the transplanted tooth, and mobility, that there is no ankylosis or apical infection, and above all emphasize the fact of a coronoradicular relationship <1. This last criterion is necessary to keep the tooth in the mouth.[18]

Andreasen et al.[4],[13],[26] state that donor teeth in the early stages of root development are more likely to stop root growth than those with more mature roots but open root apex.[27],[28] As Czochrowska et al.[15],[16] comment in their article, autotransplantation of teeth with fully formed roots reduces success rates. Articles corroborate that the success of autotransplantation decreases when the donor teeth have fully formed roots and also indicates that the ideal time for transplantation is when the donor tooth has half or three-quarters of the root formed. We especially like classifications that regardless of the radiographic success criteria, the teeth are in the mouth without any apparent problem. We have to base ourselves on the fact that there are no signs or symptoms, and that the tooth is in the mouth and does not show any type of symptomatology.[14],[18],[22],[23],[25],[29]

According to most articles on autotransplantation of teeth with open apex, we should wait for the pulp to regenerate, as it has been observed that the apical foramen influences the revascularization of the pulp. As Andreasen et al.,[13] Tsukiboshi,[1],[8] and Rocha et al.[14] state that a pulp cure will be achieved when the diameter of the apical foramen is at least 1 mm. Root canal treatment should be performed promptly when inflammatory resorption of the root is suspected or if irreversible pulpitis is diagnosed.[30] On the other hand, all the authors of this review state that in the case of teeth with a closed apex, root canal treatment should always be carried out after transplantation, as there will be no regeneration of the pulp.[1],[8],[14] We have observed that a higher success rate is obtained if endodontics is performed at 2 weeks postoperatively than not at 4 weeks.[8],[10],[14],[31],[32]

The Moorrees et al. classification[12],[18],[21],[33] is based on the evaluation of the stages of root development and is divided into seven groups. The stages that are most suitable for the success of a dental autotransplant are between stages 3 and 6 of Moorrees. A grade higher than 4, at least three quarters of the length of the root formed, will ensure a sufficiently long root that can be preserved if no root development occurs after transplantation.[26],[28] Ideally, the aim is to transplant a tooth that is at its maximum degree of root development and that has revascularization potential (apex opening >1 mm radiographically).[28] For an autotransplant to be successful, the following must be taken into account: the healing of the pulp, the healing of the periodontal ligament, and the optimum root length. It has been seen that there is better pulp healing in initial stages, since the apex is open and is going to revascularize, that not in stages such as 7 that the apex is already closed and the pulp is not going to revascularize, but we will have to perform endodontics. We observed that the exact opposite happens with the optimum root length, which causes that we are going to have more success in the last stages and less success in the first stages, as there will be less root development. Finally, we observed that the healing of the periodontal ligament remains quite stable. Therefore, we observed that the ideal time for autotransplantation is when these three variables are at their best, specifically between stages 3 and 5.[12],[18],[34]

We have noticed that there is a relationship between the orthodontic movement of a transplanted tooth and the reabsorption of the root, but that has little clinical relevance.[12] Lagerström and Kristerson et al.[12] and Paulsen[20] state that there is a minimal difference between the length of the final root of treated and nonorthodontically treated autotransplanted teeth. In the study by Lagerström and Kristerson et al.,[12] it is observed that the final root length of transplanted teeth without application of an orthodontic movement is 13.24 ± 2.75, whereas the final root length of transplanted teeth with the orthodontic application is 13.08 ± 2.10. The authors have found no differences, and therefore, these forces can be used in transplants.[12] We can conclude that combined surgical and orthodontic treatment is a viable alternative in cases of agenesis, as there will be no clinical difference between whether they are treated with orthodontics or not. The main factor causing root resorption is periodontal ligament trauma during donor tooth transplantation.[10],[14],[20]

Some clinical or experimental studies have suggested that prior application of mechanical stimuli to donor teeth may widen the periodontal ligament and facilitate extraction, which may reduce damage to the periodontal ligament that occurs during extraction of the donor tooth while decreasing the risk of root resorption after transplantation. Suzaki et al. conducted a study with rats to investigate the effect of a previous application of orthodontic forces to donor teeth and to evaluate the results before and after replanting. After 7 days of applying an orthodontic force, it was observed that the area of the periodontal ligament in the buccal and palatal was wider in the experimental group than in the control group. It was also observed that the apical zone of the alveolus was wider in the experimental group. This procedure increases the width of the periodontal ligament around the root of the tooth to be transplanted; therefore, preapplication of an orthodontic force to the donor tooth may be advantageous for autotransplantation.[11],[25]

According to the bibliographic review, we have carried out we see that there are many articles that do not differentiate the moment of initiating orthodontic movement between a transplanted tooth with an open or closed apex. Some of the authors who do not differentiate between open and closed apex are Denys et al.,[14] Jonsson and Sigurdsson,[21] and Mensink et al.[2] Others, such as Mensink et al.[2] initiate orthodontic movement 3 months after transplantation and achieve a success rate of 98%.

We can conclude that the ideal moment to start the orthodontic movement before a tooth with an open apex varies depending on the author. According to Lagerström et al.,[12] we should start the orthodontic movement 6 months after the autotransplant. Paulsen[20] also recommends starting orthodontic movement 3–9 months after transplantation. And finally, Czochrowska et al.[15] recommend starting orthodontic movement 6 months after the surgical procedure. In our opinion, when we transplant a tooth with an open apex, we will start the orthodontic movement around 6 months after the autotransplant. We must wait a while to avoid interfering with the root development of the donor tooth. It is best to perform the movement after periodontal healing and before complete obliteration of the pulp duct. Periodontal healing occurs about 8 weeks after transplantation, so we should wait at least 2 months before starting the orthodontic movement. We assume that in a tooth with an open apex, we should wait longer for greater root development and pulp healing. The longer we wait to apply the force, the more the root will form and the more good results we will have.[12],[15],[17],[20] We can see that the success rate of the study by Czochrowska et al.[15] applying an orthodontic movement 6 months after the transplant of a tooth with an open apex is 93%.

On the other hand, we have observed that the ideal moment to perform an orthodontic movement of a transplanted tooth with a closed apex will be 2 months after having performed the surgery. According to Kokai et al.,[18] the orthodontic movement should be started from 4 to 8 weeks after the transplant. On the other hand, according to Watanabe et al.,[17] it should be started 2 months after the transplant when it has healed periodontally. In our opinion, we see that the two authors agree quite a lot, and we come to the conclusion that the ideal time would be 2 months after transplantation once periodontal healing has taken place. In the study by Kokai et al.,[18] a success of 71% is achieved by applying an orthodontic movement from 1 to 2 months after the tooth transplant with a closed apex. Moreover, in the study of Watanabe et al.,[17] a success of 65.4% is obtained by applying an orthodontic force 2 months after the transplant. This percentage difference may be due to the different sample, follow-up time, or the success criteria required. There is a lot of variability in the results due to the different samples that are published. This difference in results could be due to the size of the sample or the type of tooth transplanted, the variations in the follow-up periods, the different success criteria demanded by each author, etc. In addition, there are few articles that mention the ideal moment to start an orthodontic movement in a transplanted tooth.

When a transplant is performed, the new alveolus receptor is placed in infraocclusion in relation to the rest of the adjacent teeth. According to Lundberg and Isaksson[19] teeth with closed apices are placed slightly below the occlusal plane, and teeth with open apices are placed a little more in infraocclusion. We believe that the ideal would be, since it no longer has eruptive power, to place it just in infraocclusion so that it does not disturb and that it allows a certain degree of the eruption. In addition, it would be prudent to let the tooth erupt on its own, without forcing it by applying an orthodontic extrusion movement. In this way, a more natural eruption of the tooth is obtained and time is given for the periodontal ligament to be consolidated. Ideally, wait until the transplanted tooth erupts to the occlusal level of the remaining teeth before starting an orthodontic movement. For this reason, we cannot determine exactly when to start the orthodontic movement, as this process of extrusion of the tooth itself will depend on each case. Although according to the articles studied, we can say that we will apply an orthodontic movement 2 months after the transplant in a closed apex, and 6 months after the transplant in an open apex, the eruption of the transplanted tooth must be taken into account in order to determine at what moment the force of the application should start.

Finally, it should be borne in mind that when performing an autotransplant at the time of extraction, the periodontal ligament may be damaged. If this happens to us, there is a better chance that the transplant will end up ankylosing. If ankylosis of the tooth is expected due to damage to the periodontal ligament during the surgical procedure, we should consider initiating orthodontic movement earlier than mentioned above. Ankylosis can be improved by the patients' chewing during periodontal healing or by extruding previously dislocated teeth orthodontically. A tooth that is ankylosed should not be applied an orthodontic movement without having been previously dislocated.


  Conclusion Top


Autotransplantation is a good treatment option, as it has multiple advantages over other alternatives such as implants or other types of prosthetic restorations. The advantages are biocompatibility, high long-term success rate, low economic cost, as well as good dental and gingival esthetics.

In order to be successful with autologous transplants, it is necessary to follow an action protocol:

  • Three-dimensional planning and orthodontics before the case
  • Atraumatic surgical procedure
  • Pulp vitality of the donor tooth and root length consideration in order to be successful. Tooth with open apex wait for it to revascularize. Instead, tooth with closed apex perform root canal 2 weeks after transplant
  • Monitoring the case
  • Application of orthodontic force in an open apex around 6 months after the autotransplant. On the other hand, the ideal moment to perform an orthodontic movement in a closed apex will be 2 months after having performed the surgery. In addition, we have to take into account the eruption of the transplanted tooth to finish determining when we begin to apply the force.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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