Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824

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Asian Journal of Oral and Maxillofacial Surgery

journal homepage: www.elsevier.com/locate/ajoms

Clinical observation

Clinical study on root resorption of autotransplanted teeth with complete root

formation
Kanae Niimi a , Michiko Yoshizawa a, , Toshiko Sugai a , Tadaharu Kobayashi a , Kazuhiro Ono b ,
Ritsuo Takagi c , Takashi Okiji d , Chikara Saito a
a

Division of Reconstructive Surgery for Oral and Maxillofacial Region, Department of Tissue Regeneration and Reconstruction, Course for Oral Life Science, Niigata University Graduate
School of Medical and Dental Sciences, 2-5274, Gakkocho-Dori, Chuo-ku, Niigata 951-8514, Japan
b
Division of Dental Hygiene and Health Promotion, Department of Health and Welfare, Niigata University Faculty of Dentistry, Niigata 951-8514, Japan
c
Division of Oral and Maxillofacial Surgery, Department of Oral Health Science, Course for Oral Life Science, Niigata University Graduate School of Medical and Dental Sciences,
Niigata 951-8514, Japan
d
Division of Cariology, Operative Dentistry and Endodontics, Department of Oral Health Science, Course for Oral Life Science, Niigata University Graduate School of Medical and
Dental Sciences, Niigata 951-8514, Japan

a r t i c l e

i n f o

Article history:
Received 16 January 2009
Accepted 12 October 2010
Available online 26 January 2011
Keywords:
Tooth autotransplantation
Donor teeth
Replacement root resorption
Prognostic factors

a b s t r a c t
Introduction: The main reasons for the unsuccessful autotransplantation of teeth are the failure of initial
healing and root resorption. The aim of this study was to elucidate the relationship between donor teeth
factors and the prognosis of the transplants in which root resorption occurred.
Materials and methods: The study evaluated 110 patients with 117 transplants. The successful group
included the cases which healed well, with only minor problems. The unsuccessful group included the
cases with transplant-loss and progressive problems. The unsuccessful group and minor-trouble cases
were judged with the type of problems; i.e. failure of initial healing, root resorption, and others. Root
resorption was classied into 3 types; inammation resorption, replacement resorption and cervical root
resorption. The prognostic factors were evaluated to analyze the difference between rapidly progressing
root resorption and the stable resorption.
Results: There were 20 unsuccessful transplants. In the unsuccessful group, rapidly progressing replacement root resorption was observed in 11 transplants. In the successful group, minor problems such as
stable root resorption were found in 16 transplants. At least one of the atypical root shapes (divergent,
curve, and hypertrophy), probing pocket depth of more than 4 mm, and/or extrusion were signicantly
more frequent in the replacement root resorption cases compared to cases with no signicant ndings.
Probing pocket depth of more than 4 mm and/or extrusion, dental caries, history of restoration, root
canal treatment were signicantly more frequent in rapidly progressing replacement root resorption
cases compared to stable root resorption cases.
Conclusions: Abnormal root shape, deep periodontal pocket, dental caries, restoration and root canal
treatment of donor teeth are factors associated with progressive replacement root resorption after the
autotransplantation of teeth.
2010 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd.
All rights reserved.

1. Introduction
Tooth autotransplantation is one of the several useful treatments to solve occlusal problems after tooth-loss. The autologous
transplantation of root developing teeth is usually associated with
apexogenesis and revascularization of the pulp tissue [1]. However,
revascularization of the pulp is not be expected after the transplantation of teeth with complete root formation, therefore endodontic
treatment is indicated within 3 weeks after the surgical proce-

Corresponding author. Tel.: +81 25 227 2877; fax: +81 25 223 6516.
E-mail address: yoshi@dent.niigata-u.ac.jp (M. Yoshizawa).

dure when periodontal ligament healing had progressed to avoid

pulpal infection followed by inammatory root resorption [24].
The autotransplantation of completely root formed teeth has been
performed for many years and the surgical method is established,
consequently, the success rate of autotransplantation with complete root formed teeth was reported higher [5,6]. Nevertheless,
other types of root resorption, such as replacement root resorption
and cervical root resorption, seem to be still important factors that
inuence the prognosis of the transplantation of root formed teeth
[6].
More than 50 cases of tooth transplantation have been performed annually at Niigata University Medical and Dental Hospital
since 1994. Furthermore, tooth autotransplantation is performed

0915-6992/$ see front matter 2010 Asian Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd.All rights reserved.
doi:10.1016/j.ajoms.2010.10.005

K. Niimi et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824

with a medical team consisting of not only oral surgeons, but

also specialists in endodontics, periodontics, prosthodontics and
orthodontics in 2001. An evaluation of the postoperative course and
the prognostic factors of autotransplanted teeth with complete root
formation conducted from 1997 to 2004 was done, and the main
reasons for unsuccessful transplants are the failure of the initial
healing and root resorption [7]. The age of the patient, type of donor
tooth, the probing pocket depth, and history of having dental caries
and/or restoration and/or root canal treatment showed signicant
relevance to transplant loss in a single factor analysis. Multivariate
analysis showed a pocket depth of the donor tooth of equal to or
more than 4 mm showed to be factor of signicant inuence for the
prognosis [8].
It had been described that the causes of replacement root
resorption after transplantation are lack of cementum, loss of precementum and cementoblasts, resulting from root surface injury
[2,911]. Drying of the root surface is also a cause of replacement root resorption [11]. On the other hand, Hammarstrm and
Lindskog reported that toxins from the infected pulp maintain an
inammatory reaction in the periodontal tissue, and substances
from the infected pulp may directly stimulate resorbing cells [12].
Furthermore, Kristerson reported that both damage to the periodontal ligament and the combination of damage to the periodontal
ligament and pulp tissue are important in progressive root resorption [2]. We have realized that root resorption progresses rapidly in
some cases, but is stable in others, and considering the prognosis of
the root resorption cases in the present study, progressive replacement root resorption is suspected to be one of the most serious
types of root resorption of transplanted root formed teeth. However, the relationship between the preoperative status of donor
teeth and progressive root resorption comparing stable root resorption after transplantation has not been yet determined, although
the risk factors with root resorption after autologous transplantation have been analyzed in many cases. The aim of the present study
was to elucidate the relationship between donor tooth factors and
the prognosis of transplants in which root resorption occurred after
the transplantation of teeth with complete root formation.

2. Materials and methods

2.1. Patients
All patients signed an informed consent form under the approval
of the institutional review board of Niigata University Dental School
before their treatment. The study evaluated 117 teeth of 109
patients, whose complete root formed teeth were transplanted dur-

19

Fig. 1. Distribution of patients age and sex.

ing 20012004 in Niigata University Medical and Dental Hospital.

The patients included 68 females and 41 males, ranging in age at the
time of surgery from 11 to 75 of age, with a mean age of 38.9 years
(Fig. 1). Type of donor teeth and distribution of recipient sites are
shown in Figs. 2 and 3, respectively.
2.2. Methods
The usual course of tooth transplantation is based on the system
reported by Andreasen in 1990 [9]. Pre-examination of the donor
teeth and the recipient sites was made according to the protocol
(Table 1). Autotransplantation was performed based on an evaluation by a medical team. The team included not only oral surgeons
but also endodontic, periodontic, prosthodontic and orthodontic
specialists.
2.2.1. Surgical technique
Eighteen oral surgeons carried out surgery with the following
standardized surgical technique: the donor tooth was carefully
extracted, taking care not to injure the root surface and then placing it in either tooth storage solution or sterile saline while the
recipient site was prepared. The donor tooth was positioned in the
prepared socket and the aps were sutured with 40 silk sutures.
Almost all transplanted teeth were stabilized with an orthodontic wire and resin or 40 silk sutures. The sutures were removed
7 days after surgery and the wire splint was removed 3 weeks postoperatively. Throughout the surgical process, variable factors were
recorded (Table 1).

Fig. 2. Type of donor teeth.

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K. Niimi et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824

Fig. 3. Distribution of recipient sites.

Table 1
Pre-designed protocol for tooth transplantation.

Pre-operation

Donor tooth

Recipient cite
Operation

Donor tooth

Recipient cite

Post-operation

1 week postoperation
3 weeks postoperation
3 months postoperation

6 months postoperation

1 year postoperation

Variable factors

Examination

Age
Sex

Intraoral photographs
Study model
Interocclusal record
Radiographs (panoramic and periapical)

Tooth type
Pocket depth
Status of eruption
Restored tooth
Dental caries
Ectopia
Occluded tooth
Endodontic treatment had performed
Position
Duration of missing teeth
Atypical root morphology: curve or not
Atypical root morphology: hypertrophy or not
Atypical root morphology: divergent or not
Root fracture at removal
Number of socket bone wall
Fixation (orthodontic wire or suture)
Need for adjustment of donor tooth to t recipient site
Initial healing
Initial healing
Duration of endodontic treatment
Root resorption
Delay of bone regeneration
Pocket depth
Root resorption
Delay of bone regeneration
Pocket depth
Root resorption
Delay of bone regeneration
Pocket depth

2.2.2. Endodontic treatment

Endodontic treatment was started 3 weeks after the operation
by an endodontic specialist. The treatment included debridement
of the root canal system followed by interim root canal lling with
calcium hydroxide, which was replaced at 2 weeks to 3 months
intervals. All cases were lled with thermoplasticized gutta-percha
when no sign of failure was seen clinically and radiographically.
2.2.3. Postoperative examination and evaluation of prognosis
The patients were followed up regularly at 1, 2 and 3 weeks and
at 3, 6, 9 and 12 months clinically and radiographically according to
the protocol (Table 1). Thereafter the patients were followed up at
intervals of 6 months to 12 months. All transplants were evaluated
clinically and radiographically by two oral surgeons and then were

Periapical radiograph
Periapical radiograph

Periapical radiograph

Periapical radiograph

classied into 2 groups according to the postoperative course. The

successful group included all cases whose transplants healed into
the recipient site well and the cases whose transplants had only
minor problems and the unsuccessful group included both cases of
transplant-loss and cases whose transplants have had progressively
major problems. Root resorption was diagnosed by clinical ndings
and dental X-ray lms and classied into 3 types: inammatory
resorption, replacement resorption and cervical root resorption.
Inammatory resorption was observed with periradicular radiolucency, while replacement resorption was observed with no clinical
mobility, high tone of percussion and the disappearance of the
periodontal space radiographically, and cervical root resorption
observed with a radiolucency extending over the cementenamel
junction. The donor tooth-prognostic factors of the transplants

K. Niimi et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824
Table 2
Postoperative course of 117 transplanted teeth.
Cases (rate)
Unsuccessful group
20a (17.1%)

Successful group
97 (82.9%)

Problems

Cases

Rapidly progressing replacement

root resorption
No initial healing
Others

11

Stable replacement root resorption

Other types of stable root
resorption
Periodontal inammation
Failure of initial healing
Delay of bone regeneration
No signicant ndings

11
5

5
4

5
4
2
70

Thirteen teeth lost.

in which root resorption occurred were evaluated clinically and

radiographically to analyze any differences between the rapidly
progressing root resorption cases and the stable resorption cases.
An evaluation of the postoperative course and the prognostic
factors of autotransplanted teeth with complete root formation
conducted in Niigata University Medical and Dental Hospital from
1997 to 2004 was done before, and the main reasons for unsuccessful transplants are the failure of the initial healing and root
resorption [7]. After this study, the prospective study of the factors that affect the prognosis of autotranted teeth with complete
root formation from 2001 to 2004 at Niigata University Medical
and Dental Hospital was also done [8]. The results were that the
age of the patient, type of donor tooth, the probing pocket depth,
and history of having dental caries and/or restoration and/or root
canal treatment showed signicant relevance to transplant loss in a
single factor analysis. Multivariate analysis showed a pocket depth
of the donor tooth of equal to or more than 4 mm showed to be factor of signicant inuence for the prognosis. Therefore, we picked
up these factors, such as the probing pocket depth, history of having dental caries and/or restoration and/or root canal treatment of
donor teeth to analyze any differences between the rapidly progressing root resorption cases and the stable resorption cases. We
also chose the atypical root shape as a factor because it was very
important factor for root resorption according to our data [8].
2.2.4. Statistical analysis
Univariable analysis of the factors of donor teeth was performed
compared replacement root resorption cases to no-signicantnding cases (Pearsons chi-square test). Analysis was also
performed compared rapidly progressing replacement root resorption cases to stable replacement root resorption cases. Analysis was
performed with a computerized statistical package, SPSS (release
11.0, SPSS, Inc., Chicago, IL, USA). The results were considered statistically signicant at P-value of <0.05.
3. Results
There were 97 transplants in the successful group (82.9%), while
20 transplants were unsuccessful (17.1%). Thirteen transplants
were lost (11.1%). In the unsuccessful group, rapidly progressing
replacement root resorption was observed in 11 transplants (55.0%)
and failure of the initial healing was observed in 5 transplants
(25.0%). In the successful group, minor problems were found in 28
transplants: stable replacement root resorption in 11 transplants,
other types of stable root resorption in 5 transplants, periodontal
inammation in 5 transplants, failure of initial healing in 4 transplants and a delay of bone regeneration in 2 transplants (Table 2).
An abnormal root shape (divergent, curve, and hypertrophy) was
observed in donor teeth in almost all transplants in which root

21

resorption occurred. In addition, the presence of either a donor

tooth with a periodontal pocket deeper than 4 mm, dental caries,
a history of restoration, or a history of root canal treatment of
donor teeth was found in all transplants where rapidly progressing replacement root resorption was observed. These factors were
not present in almost all of the transplants in which root resorption did not progress rapidly. All root resorption cases are shown in
Tables 3 and 4 with factors that were determined to be the causes
of troubles. Cases with progressive root resorption and stable root
resorption are shown in Figs. 4 and 5.
At least one of the atypical root shapes (divergent, curve, and
hypertrophy), probing pocket depth of more than 4 mm, and/or
extrusion were signicantly more frequent in the replacement root
resorption cases compared to cases with no signicant ndings
(Table 5). Moreover, probing pocket depth of more than 4 mm
and/or extrusion, dental caries, history of restoration, root canal
treatment were signicantly more frequent in rapidly progressing
replacement root resorption cases compared to stable root resorption cases (Table 6).

4. Discussion
We evaluated the postoperative course and the prognostic
factors of autotransplanted teeth with complete root formation
conducted from 1997 to 2004, and revealed that the main reasons
for unsuccessful transplants are the failure of the initial healing and
root resorption. From these results we revealed that the atypical
root shape as a important factor for root resorption and speculated
that root resorption is one of the risk factors of loosing transplanted
teeth [7]. The prospective study with the cases of autotranted teeth
with complete root formation from 2001 to 2004 at Niigata University Medical and Dental Hospital was also done [8]. Single factor
analysis showed that the age of the patient, type of donor tooth, the
probing pocket depth, and history of having dental caries and/or
restoration and/or root canal treatment showed signicant relevance to transplant loss. Multivariate analysis showed a pocket
depth of the donor tooth of equal to or more than 4 mm showed
to be factor of signicant inuence for the prognosis [8].
In the current study, the atypical root shape (divergent, curve,
and hypertrophy) was most signicantly frequent in the replacement root resorption cases, and the presence of either donor tooth
with a periodontal pocket deeper than 4 mm, dental caries, a history
of restoration, or a history of root canal treatment of donor teeth
was found in all transplants where rapidly progressing replacement
root resorption was observed. On the other hand, these factors were
not present in almost all of the transplants in which root resorption did not progress rapidly. On the point of root shape, at least
one of the atypical root shapes (divergent, curve, and hypertrophy)
was observed in donor teeth in almost all transplants with replacement root resorption. The reasons of root resorption might be the
lack of periodontium and cementum, and lack of periodontal tissue
might have occurred during extraction as root shape was abnormal. Mejre et al. described that adverse root shape resulted in
loss of buccal bone coverage of the transplanted teeth and subsequent loss of periodontal integrity [6]. However, root resorption did
not progressed in cases without pocket deeper than 4 mm, dental
caries, a history of restoration, or a history of root canal treatment
of donor teeth, and this might be because those donor teeth are
not contaminated with bacteria. Finucane and Kinirons reported
that a combination of bacteria in the root canal and cemental
damage results in inammatory root resorption [13] and Schwartz
and Andreasen reported that inammatory root resorption is initiated and maintained by necrotic pulp and the resorption can
extend into the areas that have developed replacement root resorption [3]. Andreasen and Andreasen [14] told that ankylosis of the

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K. Niimi et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824

Table 3
Factors of donor teeth in unsuccessful cases with root resorption.
Cases

1
2
3
4
5
6
7
8
9
10
11

Age

43
54
63
61
60
65
42
44
62
73
26

Sex

Donor teeth

F
F
M
F
F
M
M
M
M
M
M

27
47
18
17
48
18
18
48
38
48
28

Recipient sites

36
16
47
46
16
47
16
37
47
36
37

Contamination of root
surface

Characteristic root
shape of donor teeth

Contamination of root canal

and/or dental tubules

Divergent

Curve

Hypertrophy

Pocket depth
4 mm

Extrusion



























History of root
canal
treatment















History of
restoration







Dental
caries

R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.

Table 4
Factors of donor teeth in successful cases with root resorption.
Cases

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Age

33
72
17
35
36
49
23
45
11
11
34
24
14
14
15
54

Sex

F
F
M
M
F
F
F
F
F
F
M
M
F
M
F
F

Donor teeth

18
38
45
28
38
18
37
38
14
24
34
14
44
35
34
14

Recipient sites

37
37
25
36
37
35
36
37
45
35
11
47
15
22
21
36

Characteristic root
shape of donor teeth

Contamination of root
surface

Contamination of root canal

and/or dental tubules

Divergent

Curve

Hypertrophy

Pocket depth
4 mm

Extrusion

Dental
caries



















History of
restoration






root surface rst occurs with or without root surface resorption

and the presence of bacteria on the root surface and a non-vital
periodontal ligament or a defect in the cementum may activate
an osteoclast attack prior to bone apposition. Furthermore, they
also reported that once ankylosis is established, it becomes an ini-

History of root
canal treatment
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R.
R.R., I.R.
R.R., I.R
I.R.
I.R.
C.R.

tial part of the continuous bone remodeling and when ankylosis

exposes infected dentinal tubules, a combination of inammatory
and replacement root resorption occurs where inammatory root
resorption is more aggressive [10]. These reports are consistent
with the current results. In the rapidly progressive replacement

Fig. 4. A case with progressive root resorption. (a) Mandibular left rst molar is missing and upper left second molar is transplanted to mandibular left rst molar site. (b)
Extracted donor tooth before transplantation. Root canal lling and restoration have already been done. (c) 1 week after transplantation. (d) 9 months after transplantation.
Replacement root resorption is seen (arrows). (e) 5 years after transplantation. Root resorption has progressed (arrows) and bone resorption can also be seen (arrowheads).

K. Niimi et al. / Asian Journal of Oral and Maxillofacial Surgery 23 (2011) 1824

23

Fig. 5. A case with stable root resorption. (a) Mandibular left second molar was extracted and mandiblar left third molar is transplanted into the original location of mandibular
left second molar. (b) The extracted donor tooth before transplantation. Hypertrophy of root is seen. (c) 1 week after transplantation. (d) 4 months after transplantation.
Replacement root resorption is seen at the root apex (arrows). (e) 1 year after transplantation. Root resorption has not progressed, although replacement root resorption is
still seen.

Table 5
Comparison of replacement root resorption cases to no-signicant-nding cases.

Atypical root shape

Probing pocket depth of more than
4 mm, and/or extrusion
Dental caries, history of restoration
with/without root canal treatment

Replacement root resorption (n = 22)

No signicant ndings (n = 70)

Pearsons chi-square test

22
10

55
15

P = 0.018*
P = 0.027*

12

29

P = 0.280
P < 0.05*

p < 0.09.

Table 6
Comparison of rapidly progressing root resorption cases with stable root resorption cases.
Rapidly progressing root resorption (n = 11)
Probing pocket depth of more than
4 mm, and/or extrusion
Dental caries, history of restoration
with/without root canal treatment

Stable root resorption (n = 11)

Pearsons chi-square test

P = 0.001*

10

P = 0.001*
P < 0.05*

p < 0.05.

root resorption cases, it is possible that the infection of dentinal

tubules and/or root surface could have occurred because of dental
caries, restoration, root canal treatment and periodontal disease
of donor teeth before the operation. The bacteria may have been
preoperatively present in dentinal tubules of donor teeth due to
dental caries, restoration and root canal treatment. Moreover, there
may have been bacteria, as well as a lack of periodontium and
cementum, on the root surface of donor teeth due to periodontitis. These results suggest that replacement root resorption after
transplantation must have progressed rapidly simultaneously with
infection.
These results indicate the necessity to examine donor teeth carefully before transplantation if the following factors are present; a
periodontal pocket deeper than 4 mm, dental caries, a history of
restoration, or a history of root canal treatment. If these factors
are observed, then other suitable teeth of the patient should be
considered and if the teeth with these factors are transplanted,
then careful observations must be carried out after transplantation.

Acknowledgment
This work was supported in part by a Grant-in-Aid for Development of Highly Advanced Medical Technology B from the
Ministry of Education, Culture, Sports, Science, and Technology of
Japan.

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