A Novel Approach for

Computer-Assisted Template-Guided
Autotransplantation of Teeth With
Custom 3D Designed/Printed Surgical
Tooling. An Ex Vivo Proof of Concept
David Anssari Moin, DDS,* Wiebe Derksen, DDS,y J. P. Verweij, DDS, MD,z
Richard van Merkesteyn, DDS, MD, PhD,x and Daniel Wismeijer, DDS, PhDk
Purpose: The aim of this study was to introduce a novel method for accurate autotransplantation with
computer-assisted guided templates and assembled custom-designed surgical tooling and to test the feasi-
bility and accuracy of this method ex vivo.
Materials and Methods: A partially edentulous human mandibular cadaver was scanned with a cone-
beam computed tomography (CBCT) system and an intraoral scan system. The 3-dimensional (3D) data of
this cadaver were imported into specialized software and used to analyze the region of the recipient site
and the donor tooth was selected. Subsequently, congruent to the donor tooth, custom surgical tools and a
surgical guided template were designed and 3D printed. The guided osteotomy was performed and the
donor tooth was transplanted. To evaluate the planned position of the donor tooth in relation to the po-
sition of the transplanted donor tooth, the mandible with the transplanted donor tooth was rescanned
with the CBCT system and software matching was applied to measure the accuracy of the procedure.
Results: The angular deflection of the transplanted donor tooth in relation to the planned donor tooth
position was 3.1! . When comparing the 3D positions of the shoulder, there was a deviation of 1.25 mm and
an apical deviation of 0.89 mm.
Conclusion: With the use of currently available technology, it is feasible to accurately plan and create in a vir-
tual simulation a donor tooth position with congruent custom surgical tools and to transfer this to a clinical
setting with 3D printing. However, further research on multiple levels is needed to explore this novel approach.
! 2016 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 74:895-902, 2016

Autotransplantation is a relatively longstanding tech- trauma. Because of the alveolar and maxillofacial
nique with a well-recognized application for replacing bone growth of pediatric or adolescent patients, auto-
congenitally missing teeth or teeth lost because of transplantation can be a preferred treatment option

*PhD Resident, Department of Oral Implantology and Prosthetic
Dentistry, Academic Center for Dentistry Amsterdam (ACTA),
Research Institute Move, Amsterdam, The Netherlands.
yPhD Resident, Department of Oral Implantology and Prosthetic
Dentistry, Academic Center for Dentistry Amsterdam (ACTA),
Research Institute Move, Amsterdam, The Netherlands.
zPhD resident, Department of Oral and Maxillofacial Surgery,
Leiden University Medical Center, Leiden, The Netherlands.
xProfessor, Department of Oral and Maxillofacial Surgery, Leiden
University Medical Center, Leiden, The Netherlands.
kProfessor, Department of Oral Implantology and Prosthetic
Dentistry, Academic Center for Dentistry Amsterdam (ACTA),
Research Institute Move, Amsterdam, The Netherlands.
Address correspondence and reprint requests to Dr Anssari Moin:
Department of Oral Function, Academic Center for Dentistry
Amsterdam (ACTA), Gustav Mahlerlaan 3004, 1081 LA Amsterdam,
The Netherlands; e-mail: danssari@acta.nl
Received December 14 2015
Accepted January 21 2016
! 2016 American Association of Oral and Maxillofacial Surgeons
0278-2391/16/00125-7
http://dx.doi.org/10.1016/j.joms.2016.01.033

895
896 3D GUIDED AUTOTRANSPLANTATION OF TEETH

CoDiagnostiX

FIGURE 1. Virtual 3-dimesnional planning of donor tooth position. A, Analysis of anatomic and functional parameters of the recipient site. B,
Selection of donor tooth. C, Planning donor tooth position. D, Design of tooth-supported template.
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.

rather than a titanium implant.1,2 Autotransplantation
has numerous advantages because it is an autogenic
biological approach for tooth replacement.1-3
Research has documented variable long-term results
that depend on various factors.4,5 There are 3 factors
that have the greatest negative influence on the
survival of the donor tooth6-10: 1) damage to the
periodontal ligament (PDL) of the donor tooth by
trying to fit the donor tooth into the new alveolus at
the recipient site; 2) extended extra-alveolar time
that traumatizes viable PDL cells on the donor tooth;
and 3) distance between the new alveolus and the
root of the donor tooth. The method commonly
used to minimize these negative influences is chal-
lenging and relies mostly on a surgeon’s expertise
and intuitive flair for adapting the recipient site to be
as congruent as possible with the root of the donor
tooth in the least achievable amount of tries
and time.10
With recent developments in cone-beam computed
tomography (CBCT) and additive manufacturing tech-
nology, different approaches have been suggested to
plan and create custom donor tooth templates and sur-
gical guides to assist in and increase the survival of the
autotransplant by minimizing extra-alveolar time,
number of insertion efforts, and the distance from
the new alveolus to the donor tooth.11-13
Hypothetically, the ability to precisely virtually plan,
execute, and transfer the plan to the clinical situation
to have a new alveolus accurately congruent to the
donor tooth at the desired predefined recipient loca-
tion would be ideal.
Case Report/Clinical Techniques
Guided Autotransplantation of Teeth: A Novel
Method Using Virtually Planned 3-dimensional
Templates
Georg D. Strbac, DDS, PhD,* Albrecht Schnappauf, DI,† Katharina Giannis, DMD,‡
Michael H. Bertl, DMD,§ Andreas Moritz, MD, DMD, PhD,‡k and Christian Ulm, MD, DDS, PhD*
Abstract
Introduction: The aim of this study was to introduce an
innovative method for autotransplantation of teeth us-
ing 3-dimensional (3D) surgical templates for guided os-
T raumatic dental injuries
teotomy preparation and donor tooth placement.
Methods: This report describes autotransplantation of
immature premolars as treatment of an 11-year-old
boy having suffered severe trauma with avulsion of per-
manent maxillary incisors. This approach uses modified
methods from guided implant surgery by superimposi-
tion of Digital Imaging and Communications in Medicine
files and 3D data sets of the jaws in order to predesign
3D printed templates with the aid of a fully digital work-
flow. Results: The intervention in this complex case
could successfully be accomplished by performing pre-
planned virtual transplantations with guided osteoto-
mies to prevent bone loss and ensure accurate donor
teeth placement in new recipient sites. Functional and
esthetic restoration could be achieved by modifying
methods used in guided implant surgery and prostho-
dontic rehabilitation. The 1-year follow-up showed vital
natural teeth with physiological clinical and radiologic
parameters. Conclusions: This innovative approach
uses the latest diagnostic methods and techniques of
guided implant surgery, enabling the planning and pro-
duction of 3D printed surgical templates. These accurate
virtually predesigned surgical templates could facilitate
autotransplantation in the future by full implementation
of recommended guidelines, ensuring an atraumatic sur-
gical protocol. (J Endod 2016;42:1844–1850)
Key Words
3-dimensional printed template, guided autotransplan-
tation, guided osteotomy, guided surgery, modern auto-
transplantation, surgical template
From the *Division of Oral Surgery, ‡Division of Dental Student Training and Patient Care, §Division of Orthodontics, kDivision of Conservative Dentistry and Peri-
odontology, School of Dentistry, Medical University of Vienna, Vienna, Austria; and †Software Research, Dental Wings, Chemnitz, Germany.
Address requests for reprints to Prof PD Dr Georg D. Strbac, Division of Oral Surgery, School of Dentistry, Medical University of Vienna, Sensengasse 2a, A-1090
Vienna, Austria. E-mail address: georg.strbac@meduniwien.ac.at
0099-2399/$ - see front matter
Copyright ª 2016 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2016.08.021
1844 Strbac et al.
to permanent teeth are
most frequently seen at
Significance
Using the latest techniques from guided implant
surgery, 3D printed templates can be predesigned
the age of 8–12 years
to ensure a guided atraumatic approach in auto-
and may vary from crown
transplantation. This could provide for better out-
or root fracture to avul-
comes and fewer failures in the future.
sion (1–3). Total tooth
displacement by avulsion
is present in 0.5%–3% of these injuries and should be treated by immediate
replantation (4–7). Although replantation may be successful, long-term survival rates
of these teeth may be jeopardized by a variety of consequent factors, resulting in progres-
sive root resorption, endodontic problems, and tooth fractures, potentially causing loss of
these teeth at a later time (3, 4).
Today, dental implants are commonly used in the area of esthetics, providing bet-
ter outcomes compared with conventional fixed bridgework, resin-bonded restora-
tions, and removable partial dentures (8, 9).
Although implantation is considered to be a superior choice compared with the
previously mentioned alternative of fixed prosthetic restorations, this treatment
approach is absolutely contraindicated in growing patients because it cannot follow
craniofacial development and would remain in malocclusion during continuing growth
(10, 11). In such complex cases of patients in their growth phase with missing anterior
teeth, only autotransplantation of immature teeth can provide a functional and esthetic
rehabilitation by not compromising remaining dentition and supporting continuing
skeletal and dentoalveolar growth (1, 10, 11).
Tooth transplantation can be performed at an early age when incidence of trauma
is high, offering high tooth survival rates of up to 90% and providing for hard and soft
tissue results comparable with natural maxillary incisors (12, 13).
Although successful autotransplantation can offer promising results, compli-
cations caused by documented risk factors may influence the outcome. The biolog-
ical principles and wound healing are similar to avulsed teeth after replantation.
Thus, mechanical injuries during extraction or traumatic press-fit placement in
the recipient alveolus and biochemical factors because of prolonged extra-
alveolar duration may cause damage to dental structures, especially to the peri-
odontal ligament, leading to progressive root resorption. Additionally, next to
sufficient preparation of the recipient alveolus, root morphology and development
appear to influence a negative outcome, causing pulp necrosis, ankylosis, root
resorption, and failure (10, 14–16).
JOE — Volume 42, Number 12, December 2016
ANSSARI MOIN ET AL 897

FIGURE 2. Schematic drawing of the guided sequence to create the new alveolus. The drills and osteotome have identical guiding segments
corresponding to the sleeve diameter with predetermined depth and position. Measurements are in millimeters.
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.

The aim of this study was to introduce a novel
method for accurate autotransplantation with
computer-assisted guided templates and assembled
custom-designed surgical tools and to test the feasi-
bility and accuracy of this method ex vivo.
Materials and Methods
THREE-DIMENSIONAL DATA ACQUISITION: OPTICAL
SCAN AND RADIOGRAPHIC SCAN
One partially edentulous human mandibular
cadaver not identified by age, gender, or ethnic group
was obtained from the functional anatomy depart-
ment. The cadaver was sectioned at the mid-ramus
level, fixed in formalin, and stored. A declaration was
obtained from the functional anatomy department
that this material could be used for research purposes.
Full-arch intraoral scanning of this mandible was
performed using the 3M TrueDefinition Scanner (3M
ESPE, Seefeld, Germany). The scan files were exported
and stored in standardized triangulation language
(STL) file format.
The mandible was scanned with the 3-dimensional
(3D) Accuitomo 170 CBCT system (90 kVp, 5 mA,
30.8 seconds, 10- " 10-cm field of view; Morita Inc,
Kyoto, Japan). The scan position was with the occlusal
plane parallel to the floor according to the manufac-
turer’s recommendations. The scan volumes were ex-
ported in Digital Imaging and Communications in
Medicine (DICOM) 3 format.
For measurement of accuracy and precision of the
donor tooth position after insertion into the new alve-
olus, the mandible with the donor tooth transplanted
was rescanned with the 3D Accuitomo 170 CBCT sys-
tem using the exact same scan settings and stored in
STL format.
VIRTUAL SURGICAL PLANNING AND 3D MODEL
DESIGN OF CUSTOM IMPLANT AND TOOLING
The DICOM files were imported into CoDiagnostiX
9 software (Dental Wings GmbH, Ghemnitz, Ger-
many). The CBCT scan was analyzed, the donor tooth
was selected, and the anatomic and functional param-
eters for the recipient region of the missing tooth were
measured (Fig 1A). Based on this analysis, it was
decided that the lower left canine would serve as the
donor tooth. Using the method described by Anssari
Moin et al,14 the lower left canine was segmented
and stored as an STL file. STL files of the intraoral
scan and donor tooth were imported into

FIGURE 3. Three-dimensional printed surgical tooling (left to right): guided template, sleeve, 4 drills, and osteotome.
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.
898 3D GUIDED AUTOTRANSPLANTATION OF TEETH

FIGURE 4. Clinical process of template-guided autotransplantation. A, Fitting of guided template. B, Guided creation of the new alveolus by
drilling. (Fig 4 continued on next page.)
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.

CoDiagnostiX 9 and the donor tooth position at the
recipient site was determined (Fig 1B, C). Subse-
quently, the intraoral surface scan and CBCT scan
were superimposed and a tooth-supported template
based on the donor tooth position was designed
(Fig 1C, D). Within the template, a precalculated space
was preserved for fitting a custom-designed sleeve
aimed at guiding the drills and osteotome during the
creation of the new alveolus. The guided template
design was stored as an STL file.
Accordingly, based on the premeditated positions of
the donor tooth and sleeve, a set of surgical tools was
custom designed with SolidWorks 2015 SP3 software
(Dassault Syst!emes, V"elizy, France) to create a new
alveolus congruent to the root shape of the donor
tooth and stored as STL files (Fig 2). The custom-
designed tools consisted of a sleeve, 4 drills with incre-
ments in diameter, and an osteotome whose final
shape was analogous to the root of the donor tooth
(Fig 2). All osteotomy tools consisted of a cutting and
shaping segment and a guiding segment correspond-
ing to the sleeve design.
3D PRINTING OF GUIDED TEMPLATE, SURGICAL
TOOLS, AND IMPLANT
Additive manufacturing techniques were used to
fabricate the guided template, surgical tools, and
implant from their respective STL files (Fig 3).
The guided template was 3D printed through a ster-
eolithographic procedure in which an ultraviolet laser
ANSSARI MOIN ET AL 899

FIGURE 4 (cont’d). C, Guided shaping of the new alveolus by the osteotome. D, Transplantation of the donor tooth in the new alveolus.
(Fig 4 continued on next page.)
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.

applied to a vat of liquid photopolymer cures layers of
25-mm thickness to build the requested design (Im-
plantec GmbH, Amstetten, Germany).
The custom-designed surgical instruments were 3D
printed using a proprietary high-end selective laser
melting machine equipped with an ytterbium-fiber laser
(30 mm thickness) in a biocompatible titanium alloy
grade 5 (LayerWise, 3Dsystems, Leuven, Belgium).
SURGICAL PROCEDURE
The guided template with the sleeve incorporated
was positioned and optically checked through de-
signed fenestrations for good fit (Fig 4A). Subse-
quently, guided osteotomy was performed at the
recipient site by drilling and shaping was finished by
gentle tapping with a hammer on the custom-printed
osteotome (Fig 4B, C). Rotational osteotome position
was controlled through exact alignment of the equal
sign on the guided template with the guiding groove
on the osteotome (Fig 4C). Then, the donor tooth
was carefully removed and transplanted into the new
alveolus at the recipient site (Fig 4D, E). Stability of
the donor tooth was achieved and checked
by palpation.
EVALUATION OF PREOPERATIVE PLANNING OF
DONOR TOOTH POSITION AND POSTOPERATIVE
DONOR TOOTH POSITION
The pre- and postoperative DICOM files were im-
ported into CoDiagnostiX 9 for analysis of accuracy
900
FIGURE 4 (cont’d). E, Transplantation of the donor tooth in the
new alveolus.
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral
Maxillofac Surg 2016.
of the donor tooth position. The incorporated evalu-
ation tool in the software was used to match the pre-
operatively planned donor tooth position and the
postoperative donor tooth position. The following
deviations were measured (Fig 5): 3D offset, position
of the apex of the tooth, and angulation of the tooth.
Results
Good stabilization and fit of the surgical guide was
achieved and checked through the designed fenestra-
tions (Fig 4A). The drilling process was uneventful;
however, the final shaping with the guided osteotome
was relatively complicated and required constant
adjustment because there is rotational freedom in
the transversal plane (Fig 4C). During removal of the
donor tooth, the crown of the tooth fractured owing
to the brittleness of the formaldehyde-stored state of
the mandible. The crown was temporarily glued for vi-
sual purposes only (Fig 4D, E).
The angular deflection with the planned donor
tooth position was 3.1! (Fig 6). When comparing
the bodily 3D positions, there was a deviation of
1.25 mm and an apical deviation of 0.89 mm
(Fig 6).
3D GUIDED AUTOTRANSPLANTATION OF TEETH
Discussion
This experiment was performed as a first step to-
ward guided autotransplantation with a computer-
assisted guided template and custom-designed surgical
tools. With the combined use of 3D data acquisition
with CBCT and intraoral scanning technology, virtual
3D planning software, 3D design software, and high-
end 3D printing technology, it was possible to trans-
plant through guided surgery, with acceptable accu-
racy, a donor tooth into the new alveolus.
Preoperatively fabricated tooth replicas and stereoli-
thographic guides to simplify and increase the success
rate of autotransplantation have been proposed in the
literature.13,15,16 A study by Shahbazian et al13 sug-
gested the benefits of the CBCT planned surgical guide
as decreasing the surgical time and being a less inva-
sive technique, causing fewer failures than a conven-
tional approach. In this study, the CBCT-based
surgical template served as a guide for the drilling pro-
cedure and then the final shaping of the new alveolus
was performed by free-hand preparation. However,
the question arises as to how accurate alignment of
the bony wall of the new alveolus, as proposed in
this research, might influence the clinical outcome.
In implant dentistry, computer-assisted template-
guided insertion of implants has been extensively re-
searched. Methods described in these studies for
increasing accuracy of the guided implant placement
are to a certain extent applicable to this approach.
Comparing accuracy data of this study with the
currently available data on accuracy of computer-
aided implant placement is incongruous because these
are based on conventional screw-type implants in-
serted by conventional surgical tools. Nonetheless,
for a general comparison, it is noteworthy to appre-
ciate that the result of this particular experiment is
within the range of positional and angular deviations
for guided implant placement described in a meta-
analysis by Van Assche et al.17 This meta-analysis re-
ported mean deviations of 0.99 mm (range, 0 to
6.5 mm) for the entry point and 1.24 mm (range,
0 to 6.9 mm) for the apex and a mean angular deflec-
tion of 3.81! (range, 0! to 24.9! ).
Final shaping of the new alveolus is performed by a
custom-printed osteotome in the shape of the donor
tooth’s root and is of critical importance for an accu-
rate fit of the donor tooth. The shape of this specific
osteotome is designed through a combination of
segmentation of the root of the donor tooth and
computer-assisted designed reprocessing and
designing of the osteotome. Previous research has
shown that 3D surface reconstructions based on
CBCT segmentations can vary from the actual shape,
resulting in an over- or underestimation of the actual
root shape depending on selected threshold values
902
FIGURE 6. Evaluation of matching procedure. A, Frontal and B, sagittal cross-sections.
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.
Acknowledgments
The authors thank Hugo Waars for his contribution and knowl-
edge in the field of 3D designing.
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3D GUIDED AUTOTRANSPLANTATION OF TEETH
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ANSSARI MOIN ET AL 901

FIGURE 5. Matching procedure for measuring accuracy of the transplanted donor tooth position versus planned donor tooth position. The
parameters used were 3-dimensional offset (a), position of the tooth apex (b), and angulation of the tooth (a).
Anssari Moin et al. 3D Guided Autotransplantation of Teeth. J Oral Maxillofac Surg 2016.

and CBCT scan settings.15,18,19 Especially toward the
more apical areas, segmentation of the root becomes
increasingly difficult because of the increase in
bone mass.18
This novel approach has hypothesized benefits on
the prognosis of the transplanted tooth. Decreasing
extraoral time and number of insertion efforts of the
transplanted tooth have well-known positive effects
on the vitality of the PDL.5-7,10 Furthermore, as a
general rule, it has been stated that a shorter
distance between the new alveolus and the donor
tooth will provide more favorable revascularization
of the PDL and apex. However, with this approach, a
near exact alveolus congruent to the donor root
shape can be created instead of a closely contoured
recipient site, thus raising questions concerning
optimal bone-to-root distances for autotransplanta-
tion, as stated earlier. Nonetheless, more evidence
on many levels for this guided autotransplantation
approach is needed. Future studies can focus on
evaluating the accuracy, fine-tuning the process, and
assessing the success of this guided autotransplanta-
tion with custom 3D designed and printed
surgical tooling.