Beruflich Dokumente
Kultur Dokumente
Case repOrt
Autotransplantation as a technique for replacement of teeth was first reported in the 1950s when immature third Pre molars were used to replace decayed first molars1.Survival rates for auto transplantation of immaturepremolar teeth have been shown to be 95% over 5 years2. The auto transplanted tooth also has the capacity for functional adaptation and preservation of the alveolar ridge, which is advantageous when compared to ossointegrated implants that are stationary and do not erupt tocompensate for further growth. This is an important consideration when dealing with missing teeth, whether congenital or acquired, in the young patient. It is well documented that avulsed teeth recover optimal function and esthetics after replantation under ideal conditions. Favorable periodontal ligament [PDL] healing is the critical factor for success whether teeth are mature or immature. Pulp regeneration can be expected in immature (developing) teeth but not in mature teeth. Similar healing patterns can be expected in autotransplantation of teeth. In addition, bone induction is an interesting additional benefit of transplantation. Wound healing in autotransplantation of teeth is discussed below according to PDL healing, bone induction,
* Amrita School of Dentistry, AIMS, Kochi.
pulp healing and root development, respectively. Periodontal tissue healing Favorable healing of the PDL depends on how many viable cells are preserved on the root3. PDL cells can be damaged mechanically during extraction or bio-chemically due to various extra-oral conditions. PDL cells are easily injured under stressful conditions such as variable pH, osmotic pressure, dehydration, etc.4-7 If donor teeth are extracted with minimal mechanical damage to the PDL and are preserved in optimal condition extra-orally until the end of the surgical procedure, successful PDL healing should be expected. Optimal PDL healing is seen when a (avulsed) tooth is immediately replaced into its own socket. In this situation, reattachment occurs in 2 weeks between the connective tissues (PDL tissues) of the root surface and the recipient socket wall8-11. While not quite as predictable, extremely good PDL healing is expected in the case when a donor is immediately placed into the freshly extracted recipient socket12-15 However, PDL healing in the transplantation where the donor is placed into the newly (artificially) formed socket would need more time and the prognosis is a little poorer in comparison with the former two situations16. The slight difference in prognosis described above suggests that although viable cells on the root
surface are critical for successful healing, the importance of progenitor cells on the socket wall should not be overlooked. Another important factor to consider in regard to PDL healing is the repair of mechanically damaged root surface with new cementum and periodontal ligament17. The initial reaction to the trauma of the injury is always acute inflammation. If there is no additional stimulus to maintain this inflammatory response, healing will occur. The type of healing of a damaged root surface when a tooth is replanted or transplanted is dependent on the surface area of damaged root to be repopulated. If the area is small, cells with the potential to form new cementum and periodontal ligament are most likely to cover the damaged root. This type of healing is termed surface resorption or cementalhealing. However if a large area is to be healed, cells programmed to form bone will attach to some areas of the root. A physiologic process of bone turnover takes place as it does throughout the body. The root is resorbed (like the adjacent bone) but in the apposition stage bone (and not dentin) fills the (previously) resorbed area. In this way, the root is replaced by bone. This process has been termed ankylosis, replacement resorption or osseous replacement. Replacement resorption is irrevers-
16
donor tooth, trimming of flap is needed in some cases, and suturing of flap before the donor is positioned into the socket is recommended in every case. Tighter and closer adaptation between the flap and the donor tooth will be achieved by suturing before the donor positioning than after it. This technique is especially important distal to the transplant in the case when the impacted donor is transplanted into the adjacent second molar recipient site. If the donor is to be splinted using a suture, one string of each suture should be left long enough for this purpose. 9 Positioning and splinting of the donor tooth: The donor tooth is placed lightly into the recipient socket through the opening of the sutured gingival flap. Ideally, the gingival opening should be a little narrower than the donor diameter because a tight adaptation between the tooth and gingiva is desirable. Splinting by means of sutures is then performed. If the transplant is not stable after suture splinting or if much more occlusal adjustment is necessary, splinting is changed to one with wire and adhesive resin. If the transplant is not stable but no occlusal adjustment is needed, splinting with wire and resin can be delayed for 2 or 3 days after suture splinting because the former is time consuming and bleeding during the surgical procedure makes optimal results difficult. 10 Occlusal adjustment: The occlusion must be checked to ensure that no occlusal interference is present. If a suture is used for stabilization, ideally the occlusal contact should be reduced extra-orally prior to positioning of the donor, taking care not to damage the PDL. It could also be performed intraorally before the extraction of the donor. If a wire splint is used, occlusal adjustment can be done after placing the splint. Occlusal adjustment should be conservative, since a composite restoration will be needed after healing to adjust the occlusion and/or esthetic appearance of the crown of the tooth. 11 Radiographic evaluation: A radiograph is taken preoperatively, before and after splinting to evaluate the position of the donor tooth in the new socket. 12 Surgical dressing : Surgical dressing (periodontal packing) is applied to protect the transplant against infection during the first 23 days in the wound healing. This dressing is removed at about 34 days post surgery. The sutures are removed 45 days after the surgery Root-canal treatment of transplanted teeth Pulp healing can be expected in the transplantation of developing teeth. In such a case, a radiograph is taken every month for 3 months after the surgery to monitor inflammatory resorption or apical periodontitis
considering cost benefit and preservation of esthetic of the enamel. Bleaching can be performed before restoration on a root canal-treated anterior transplanted tooth. In the case of developing teeth, any preparation should be finished within enamel. The exposure of dentine may cause bacterial invasion and result in apical periodontitis. If dentine exposure is inevitable, immediate restoration must be performed. Transplants are natural teeth and any appropriate restorative treatment can be used with the correct indication. Maintenance Transplanted teeth that have healed normally have the same risks as any natural tooth with regards to caries and periodontal disease, etc. Thus, periodic follow up should be carried out with the same frequency as for the other teeth in the mouth. Compliance and maintenance is essential to ensure positive long term results Classification and clinical indications Autotransplantation can be classified into three groups: (1) conventional transplantation, (2) intra-alveolar transplantation, and (3) intentional replantation29. Conventional transplantation Conventional transplantation is moving teeth surgically from one site to another in the same individual. Autotransplantation is the term that is usually used to describe this procedure. This procedure is indicated when missing teeth with a hopeless prognosis are present in a mouth where an appropriate donor tooth can be used without any negative effects from its loss from its position in the arch. Good candidate donor teeth are those with simple root form, at the optimal stage of root development, easy extraction, and of sizes matching for recipient sites. Intra-alveolar transplantation Intra-alveolar transplantation is surgical intervention to move teeth within the original socket. Extrusion, rotation and/or uprighting can be performed surgically. Examples of indications include cases such as when the biologic width has been jeopardized due to deep caries, fractures or root resorption30, and when teeth have erupted in tilted direction and there are more advantages in uprighting them surgically than orthodontically31. Intentional replantation Intentional replantation is performed to solve an endodontic problem that cannot be solved by a conventional non-surgical or surgical approach. The sequence of the procedures is: the tooth is extracted; 3 mm of the apex is cut off; the root canal is prepared and retrofilled extra-orally; and then the tooth is replanted into the original socket without changing its original position32. Teeth with single, convex and conical shape root would give more predictable results than the ones with spread multi
19
this stage of root development, the prognosis is not as predictable37-41. When patients have an unrestorable tooth requiring extraction and an ideal donor tooth is present: Transplants have several advantages over implants in terms of function, esthetics, time and cost. Immediate transplantation with extraction at the recipient site is a procedure that provides significant time saving compared to implants. Healing is rapid and function is obtained almost immediately. The transplanted tooth has osteoinducing properties that results in bone regeneration of the bony defects around transplants without graft materials, significantly reducing time and cost compared to implants. Transplants have the potential for superior esthetic results, since the natural emergence profile and the natural beauty of enamel and crown form is maintained. Usually, the total cost of transplantation is much lower than implant treatment. When intra-alveolar transplantation or intentional replantation is indicated: Severely decayed teeth and crown-root fractured teeth can often be saved by surgical extrusion42-45. In addition, intentional replantation is a treatment option for teeth with endodontic disease that cannot be treated by conventional means. In clinical practice, it usually makes sense to maintain the use of natural teeth for as long as possible. With such procedures available, extractions can be avoided or at least delayed
COncLUsIOn
Autotransplantation is often not considered as a treatment option when teeth are lost. This is very unfortunate given that the biological principles for success are understood and the correct indications are present; it is an extremely successful treatment form with significant savings in time and cost compared to implants. From the patients perspective, the dentition is preserved using a natural tooth rather than a mechanical prosthesis. The dental practitioner should definitely have the knowledge to recommend and carry out this procedure to the appropriate patient. Autotransplantation of teeth based on science and the state of art will promise happiness and healthy smiles of patients for a long time.
References
1. Apfel H. Autoplasty of enucleated prefunctional third molars.J Oral Surg 1950;8:189200. 2. Andreason J, Paulsen H, Yu Z, Bayer T, Schwartz O. A longtermstudy of 370 autotransplanted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Eur JOrthod 1990;12:1424. 3. Lee S-J, Jung I-Y, Lee C-Y, Choi SY, Kum K-Y. Clinicalapplication of computer-aided rapid prototyping for tooth transplantion. Dent Traumatol 2001;17:1149.
19 Le H, Waerhaug J. Experimental replantation of teeth in dogs and monkeys.Arch Oral Biol 1961;3: 17684. 20. Najleti CE, Caffesse RG, Castelli WA, Hoke JA. Healing after tooth reimplantation in monkeys.A radioautographic study. Oral Surg 1975;39: 36175. Links 21. Andreasen JO. A time-related study of periodontal healing and root resorption activity after replatation of mature permanent incisors in monkeys.Swed Dent J 1980;4: 10110 22. Proye MP, Polson AM. Repair in different zones of the periodontium after tooth reimplantation. J Periodontol 1982;53: 37989 23. Shimada T. Effect of periodontal ligament curetted in alveolar socket for autotransplantation of tooth in adult monkeys. J JpnSoc Oral Implantol 1998;11: 492500[in Japanese 24. Andreasen JO. Periodontal healing after replantation and autotransplantation of incisors in monkeys.Int J Oral Surg 1981;10: 5461. 25. Andreasen JO. Analysis of topography of surface and inflammatory root resorption after replantation of mature permanent incisors in monkeys.Swed Dent J 1980;4: 13544 26. Andreasen JO. Analysis of pathogenesis and topography of replacement resorption (ankylosis) after replantation of mature permanent incisors in monkeys.Swed Dent J 1980;4: 23140 27. Andreasen JO. Relationship between cell damage in the periodontal ligament after replantation and subsequent development of root resorption.ActaOdontolScand 1981;39: 1525.33. 28. Andreasen JO, Kristerson L. The effect of limited drying or removal of the periodontal ligament.Periodontal healing after replantation of mature incisors in monkeys.ActaOdontolScand 1981;39: 113.[PubMed link]Links 29. Andreasen JO, Skougaard MR. Reversibility of surgically induced dental ankylosis in rats. Int J Oral Surg 1972;1: 98102.35. 30. Andreasen JO. Histometric study of healing of periodontal tissues in rats after surgical injury. I. Design of a standardised surgical procedure. Odontol Revy 1976;27: 11530 32. Andreasen JO. Histometric study of healing of periodontal tissues in rats after a surgical injury.Healing events of alveolar bone, periodontal ligaments and cementum.Odontol Revy 1976;27: 13144. 33. Yoshida M. An experimental study on regeneration of cementum, periodontal ligament and alveolar bone in the intradentinal cavities in dogs.The ShikwaGakuho 1976;76: 1179222[in Japanese]. 34 Andreasen JO. Review of root resorption systems and models. Etiology of root resorption and the homeostatic mechanisms of the periodontal ligament. In: The biological mechanisms of tooth eruption and root resorption. Birmingham, Alabama: EBSCO Media; 1988. 921. 35. Atrizadeh F, Kennedy J, Zander H. Ankylosis of teeth following thermal injury. J Periodontal Res 1971;6: 15967 36 Cvek M, Lindvall A. External root resorption following 21
22