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Autotransplantation

inside view of a delicate procedure

ou receive a call from a frantic mother

informing you that her 10-year-old
daughter has been in a bicycle accident;
one of her upper front teeth has been knocked
out; and the tooth cannot be located. You see
Mom and daughter at your office shortly
thereafter, calm them both down, confirm that
there are no other dental injuries, and inform
Mom of the options for replacing the lost tooth.
One of those options might be one that is
seldom used in the United States but is quite
common in many Scandinavian countries. This
is autotransplantationa technique in which the
lost or extracted tooth is replaced with one of
the patients own teeth, which is later restored
to the size, shape, and color of the missing
tooth. This modality of treatment requires a
team approach involving a periodontist or oral
surgeon, an orthodontist, and a restorative
dentist.
Jim Janakievski, the interviewee for this issue
of the Bulletin, is not an orthodontist but an
experienced periodontist who has mastered the
skills required to accomplish this somewhat
delicate procedure and describes for us in detail
how it is done.

Dr. McDonald

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2010 PCSO Bulletin

Dr. Terry McDonald Interviews

Dr. Jim JanakievskI
Terry McDonald (TM): What is tooth autotransplantation?
Jim Janakievski (JJ): The term auto means within the same
patient, so tooth autotransplantation is a surgical procedure
where a tooth is extracted from one site and replanted to another site, or repositioned within the same socket, on the same
patient. It can be considered in cases of displaced or impacted
teeth and unilateral agenesis of premolars. Autotransplantation
can also be utilized for tooth replacement of traumatized maxillary incisors.
TM: Is there any research that has evaluated the
long-term outcomes of tooth autotransplantation?
JJ: There are many studies on tooth autotransplantation. It has
been most extensively studied in Scandinavia. A recently published long-term review of cases had a follow-up range of 17 to
41 years.1 The success rate was over 90%, which is similar to
that of dental implant-supported restorations.
TM: What factors should be considered when planning this type of treatment?
JJ: The stage of root development of the transplant tooth is
very important. Studies have evaluated the success of autotransplantation looking at both development of the periodontal
attachment and pulpal survival.2,3 Success rates are highest
when the root development is two-thirds to full root length with
an open apex. So timing is critical when planning this type of
treatment. This stage of root development occurs between the

Dr. Janakievski

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ages of 9 and 12 years. Most traumatic injuries to anterior
teeth seem to occur during this same period, making autotransplantation a good option for these patients (Figure 1).

TM: Is this treatment most applicable in patients

who will require bicuspid extractions for orthodontic management?
JJ: Of course this would be the ideal patient, but we can consider autotransplantation for nonextraction cases as well. The
posterior space that results from the harvesting of the premolar can be closed by unilateral protraction of the posterior
teeth, either with traditional or with mini-implant anchorage
mechanics. This way, no future implant treatment to replace
the bicuspid will be needed.

Figure 1
Panograph

TM: Can you describe the surgical procedure?

TM: Which tooth is most commonly selected for

transplantation in a patient with an ankylosed or
avulsed maxillary central incisor?
JJ: In a child who has had trauma to the maxillary incisors
with resultant ankylosis or loss of a tooth due to avulsion,
we begin by selecting the tooth to be transplanted. Consideration is given to the stage of root development and the size
of the crown. Measuring the contralateral incisor or the space
available will assist in the selection. Usually we choose the
mandibular first or second premolar. In most cases the second
premolar is wider and may be more appropriate in mesiodistal
dimension to replace a central incisor.

JJ: The surgical treatment begins with the preparation of an

osteotomy using burs, much like implant site preparation. The
transplant tooth is then harvested and carefully transferred to
the recipient site. It is usually secured in place with sutures or
a wire splint. After initial stabilization, the tooth is monitored
for root development and eruption (Figure 2).
TM: When can an orthodontist apply force to the
transplanted tooth?
JJ: To answer this question, you must understand how a periodontal ligament heals.
In the case of a traumatic avulsion and replantation, both the
tooth and the socket are lined with periodontal ligament, and
there is an intimate fit when the avulsed tooth is inserted into
the socket. In such a case, the ligaments reattach, and this

Figure 2a

Figure 2b

Figure 2c

Transplantation of mandibular premolar

Osteotomy preparation

Transplantation of mandibular premolar

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Figure 3a
2 months

happens rapidly, usually within a few weeks. In the case of an

autotransplanted tooth, the periodontal ligament is only on the
harvested tooth root, and there is more space around it within
the osteotomy site. Bone and periodontal ligament formation
requires more time in this situation. Healing is monitored radiographically and is typically complete at about 3 to 4 months.
At this time the transplant can be moved orthodontically, much
like any other tooth (Figure 3).
TM: When can
the premolar
be restored to
look like a central incisor?

Figure 3b
4 months

Figure 3c
7 months

Figure 2d

JJ: Certainly
the next phase
of treatment will
involve coordination between the
orthodontist and
the restorative
dentist. Since the premolar is
usually smaller than a central
incisor, it must be very specifically positioned to allow for ideal
Figure 3e
restoration. For the incisogingival
RDUOGRAPH
7 MONTHS
position, the orthodontist must
use the cemento-enamel junction (CEJ) of the contralateral
incisor as a guide. Positioning the
transplanted tooth so that the CEJ
is lined up with the adjacent central incisor minimizes the risk
of developing uneven gingival margins as passive eruption occurs. In order to minimize future prosthetic tooth preparation,
positioning must also take into consideration both the form of
the transplanted tooth and the restorative procedure (bonding,
veneer, crown) that will be used to normalize it. Since a central
incisor has a straighter mesial contour and a more curved distal
contour than a premolar, the tooth must be positioned with
two-thirds of the residual space to the distal. To minimize the
amount of enamel reduction that needs to be done on the facial,
the transplant should be positioned slightly palatal on the ridge.
Various restorative techniques or materials can then be utilized
to change the morphology of this tooth (Figure 4).
Figure 3d

Radiograph
day 1
transplant

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Figure 4a

Figure 4b

bEFORE
RESTORATION

rESTORATION
WITH COMPOSITE VENEER

TM: What is the advantage of using this technique

for ectopic impactions?
JJ: In the case of an impacted tooth, consideration should first
be given to the techniques often used for surgical exposure
and orthodontic eruption . However, we may be faced with a
patient in whom the impacted tooth position would present a
challenge for traditional orthodontic mechanics (Figure 5). For
this patient, the central incisor was autotransplanted to a more
natural orientation. With this approach, the orthodontic treatment was simplified and the overall treatment time reduced.

Figure 5a
Description

TM: What are the risks of tooth autotransplantation?

JJ: The risks include pulpal necrosis with development
of inflammatory resorption and ankylosis or replacement
resorption. Careful planning and meticulous treatment
execution by the dental team can minimize these risks.
Autotransplantation can simplify and reduce orthodontic
treatment time for patients with impacted teeth. For patients
with traumatized incisors, it can provide a functional and
natural tooth replacement during their early growth phase
and eliminate the need for a removable appliance. Indeed,
tooth autotransplantation is another option, that we should
consider when treatment planning our young patients.
TM: Are there courses available in the United
States, should our readers desire more information
on this topic?

Figure 5b
rADIOGRAPH
PRE-OP

Figure 5c
eXPOSURE
OF CENTRAL
INCISOR

JJ: There are no courses available at this time. I have been

invited to present on this topic to several study clubs and
academies. We are hoping to put together a course in the next

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2 years that would cover the surgical, orthodontic, and restorative aspects of autotransplantation.

the knowledge and skills developed by clinicians performing

tooth autotransplantation will be of benefit when tooth
regeneration becomes available to our patients.

TM: What is the future of tooth autotransplantation?

JJ: I view tooth autotransplantation as a precursor to what will
be available in the near future. Research has been evaluating
the process of biomineralization in tooth formation and its
application to regenerative models in dentistry.4 It has recently
been demonstrated that a bioengineered scaffold shaped like a
tooth can attract stem cells and grow a tooth in vivo.5 Certainly

References
1. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU.
Outcome of tooth transplantation: survival and success rates
17-41 years posttreatment. Am J Orthod Dentofac Orthop.
2002;121(2):110-119.
2. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer T, Schwartz
O. A long-term study of 370 autotransplanted premolars,
III:periodontal healing subsequent to transplantation. Eur J Orthod. 1990;12(1):25-37.

Figure 5d
2 MONTHS

3. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A longterm study of 370 autotransplanted premolars, II:tooth survival
and pulp healing subsequent to transplantation. Eur J Orthod.
1990;12(1):14-24.
4. Rauth RJ, Potter KS, Ngan AY, et al. Dental enamel: genes define
biomechanics. J Calif Dent Assoc. 2009;37(12):863-868.
5. Kim K, Lee CH, Kim BK, Mao JJ. Anatomically shaped tooth
and periodontal regeneration by cell homing. J Dent Res.
2010;89(8):842-847.

Figure 5e
1 YESR

Jim Janakievski, DDS, MSD received his DDS from the

University of Toronto, 1995, and completed a general-practice
residency, at St. Clares Hospital, Schnectady, New York,
in 1996.
He completed his postgraduate training at the University of
Washington, where he received a certificate in periodontology with an MSD degree and a fellowship in prosthodontics.
He is a Diplomate of the American Board of Periodontology,
serves as an affiliate assistant professor in the Department of
Periodontology at the University of Washington, and maintains
a private practice in Tacoma, Washington.

Figure 5f
dAY OF
SURGERY
AND
1 YEAR

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