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Multidisciplinary Approach for Autotransplantation and Restoration of a Maxillary Premolar into an Area of an Avulsed Anterior Tooth: A Case Report with a 6-Year Follow-up
Address requests for reprints to Prof Liran Levin, University of Alberta, School of Dentistry, Faculty of Medicine and Dentistry, 7-020K Katz Group Centre for Pharmacy and Health Research, 11361 87 Ave, Edmonton, Alberta, Canada T6G 2E1.
The loss of an anterior tooth because of avulsion has been reported in up to 3% of dental injuries. Management alternatives, such as implant-supported restorations and a fixed partial denture, are contraindicated in growing patients because of the continuous growth of the alveolar process. At the same time, orthodontic treatment for gap closure will result in asymmetry and will require adjustment of the adjacent healthy teeth. Therefore, restoring a missing tooth imposes a treatment challenge, especially in children and young adults. Tooth autotransplantation is a treatment modality with high reported survival and success rates that overcome these mentioned limitations. It might also help to preserve the alveolar bone and the soft tissues. This case report describes a multidisciplinary approach for managing a 13-year-old boy who lost his right maxillary central incisor because of a fall. Management included autotransplantation of the left maxillary second premolar to the site of the lost right maxillary central incisor, management of external inflammatory resorption with an endodontic treatment, orthodontic treatment, and aesthetic restoration of the area with composite resin crowns that can be adapted to the expected changes of the jaws during the craniofacial growing period. At the 6-year follow-up, the teeth demonstrated a positive outcome.
This case reports describes a successful outcome of an autotransplantation and restoration of a maxillary premolar into an avulsed anterior tooth area in a young patient with a long-term follow up of 6 years.
Adolescence (10–18 years old) is considered a high-risk age group for dental trauma
. The loss of a permanent anterior tooth in children and adolescents is a challenging condition to treat because the conventional restorative methods, such as an implant or a fixed partial denture, are not recommended in that age group because of their lack of adaptation to the continuous vertical growth of the patient’s jaws. Orthodontic closure of the gap and reshaping the adjacent teeth or tooth with a temporary restoration has limited indications and requires prosthetic restoration of adjacent teeth
. A long-term removable restoration during the teenage years is also not always desirable. Therefore, autotransplantation of a posterior tooth, such as a premolar, to the anterior region provides a viable management alternative that addresses some of these complex challenges
Autotransplantation is a treatment modality that has received increasing attention in recent years because it provides a vital periodontium and adaptation to the continuous vertical skeletal growth, thereby achieving functional adaptation with preservation of the alveolar ridge and the surrounding soft tissues
Autotransplantation of teeth to the anterior maxilla: a systematic review of survival and success, aesthetic presentation and patient-reported outcome.
. The survival rates ranged between 93% and 100% (weighted mean = 96.7%, median = 100%) after 9 months to 22 years of observation (median = 8.75 years)
Autotransplantation of teeth to the anterior maxilla: a systematic review of survival and success, aesthetic presentation and patient-reported outcome.
The purpose of this case report was to present a multidisciplinary management approach of a 13-year-old boy who lost an incisor in a skating accident. The management included autotransplantation of the left maxillary second premolar in place of the lost right maxillary central incisor, management of external inflammatory resorption with an endodontic treatment, orthodontic treatment, and aesthetic restoration of the area with composite resin crowns that can be adapted to the expected changes of the jaws during the craniofacial growing period. This case provides an example of cooperation between different disciplines, dealing with complications, and decision-making processes in complex clinical situations.
Case Description
A 13-year-old white male presented to the Periodontology Department, School of Dentistry Oral Health Clinic, University of Alberta, Edmonton, Alberta, Canada. His chief complaint was that he was missing a front tooth and avoided smiling. A valid informed consent for further evaluation was obtained from the patient and his mother. His medical history was reviewed and was noncontributory.
His dental history revealed a fall on the ground in a skate park; he landed on his face, resulting in a traumatic dental injury and laceration of the chin and the right upper lip 4 weeks before the examination. Initial immediate emergency therapy was provided at the University of Alberta Emergency Hospital Department and included suturing of the chin laceration and referral to the University of Alberta Hospital Dental Clinic where dental examination and treatment were provided. The right maxillary central incisor was avulsed without reimplantation (the patient did not know where it was). The left maxillary lateral incisor was extruded; it had a complicated crown fracture with a pinpoint pulpal exposure. It was treated with direct pulp capping. The right maxillary lateral incisor and canine were both extruded; they had an uncomplicated crown facture and an uncomplicated crown-root fracture correspondingly. The patient did not have the fragments of any of the fractured teeth, and composite restorations were placed on the exposed dentin on all the teeth mentioned previously. The right maxillary first premolar had an extrusion. There are no records regarding the degree of extrusion or the material used for pulp capping. A semirigid splint was placed from the right maxillary first molar to the left maxillary canine, and the patient was referred to the University of Alberta School of Dentistry Oral Health Clinic for continued care. Two weeks later, the splint was removed, and slight horizontal mobility was recorded on the left maxillary central incisor and the right maxillary lateral incisor. There were no abnormal extraoral findings recorded. All teeth on the maxillary arch had a normal response to cold (1,1,1,2-tetrafluoroethane [Endo-Ice; Coltène/Whaledent Inc, Cuyahoga Falls, OH]). Slight palpation sensitivity was recorded in the buccal vestibule near the right maxillary canine and the left maxillary lateral incisor. There was no percussion sensitivity or palpation sensitivity on other teeth. All teeth had a diagnosis of “normal pulp” with “normal apical tissues” apart from the right maxillary canine and the left maxillary lateral incisor, which had a diagnosis of “normal pulp” with “symptomatic apical periodontitis.” Periodontal probing depths were not evaluated because of the early stage after the trauma.
Two weeks after the trauma, the patient presented to the periodontal clinic at the University of Alberta. His chief concern was that he was missing a front tooth. After a multidisciplinary discussion, including an orthodontic and periodontal evaluation, the recommended treatment plan was formulated. The plan was to extract and transplant the left maxillary second premolar (which had an open apex and about 3/4 of the root length as shown in Fig. 1) into the space of the missing right maxillary central incisor. This would follow by functional and aesthetic reshaping of the crown of the transplanted tooth and a future orthodontic treatment to address the patient’s class II occlusion as well as gaps. Because the right side (right maxillary first premolar) was involved in the trauma, it was decided that the left maxillary premolar was a better candidate for extraction and autotransplantation. If future orthodontic extractions to correct class II occlusal relations are needed, the traumatized right maxillary first premolar could be extracted. Other management options including a temporary removable denture until the completion of growth and future implants and no treatment and their advantages and potential risks were discussed with the patient and his mother, and informed consent for the treatment was obtained.
Figure 1A panoramic radiograph on the day of the trauma. The digital panoramic radiograph was acquired as part of the patient’s initial evaluation after the trauma. The yellow arrow points to the area of the missing right maxillary central incisor, which was lost because of avulsion. Crown fractures are evident in the right maxillary canine, lateral incisor, and the left maxillary central incisor; the left maxillary second premolar (red circle) was selected for extraction and autotransplantation to replace the missing right maxillary central incisor.
Under local anesthesia, the recipient site of the missing right maxillary central incisor (Fig. 2A) was prepared (Fig. 2B); the left maxillary second premolar was atraumatically extracted using surgical forceps, avoiding damage to the periodontal ligament (PDL). The recipient site was prepared according to the measurements acquired from preoperative cone-beam tomographic imaging using implant osteotomy burs. The transplant was immediately and carefully inserted into the previously prepared site of the missing right maxillary incisor (Figs. 2C and 3A). Primary stability of the transplanted tooth was achieved by suturing and splinting for 1 week using a semirigid splint (Fig. 2D). The palatal aspect of the transplanted premolar was adjusted with a diamond bur with water spray coolant to allow the patient to bite with no interference. A soft diet was recommended for 2 weeks as well as the avoidance of contact sports. Chlorhexidine mouth rinse 0.12% (Peridex Oral Rinse; ANB Canada, Ontario, Canada) was recommended for 1 week. The importance of oral hygiene to the success of the treatment was explained to the patient, and instructions were given.
Figure 2(A–D) The autotransplantation procedure 1 month after avulsion and the loss of the right maxillary central incisor. (A) The occlusal view showing the recipient site of the missing right maxillary lateral central incisor. Fractured crowns of the right maxillary cuspid and lateral incisor and the left maxillary incisor can be observed as well. (B) The occlusal view showing socket preparation at the site of the missing right maxillary central incisor for transplantation of the left maxillary second premolar. (C) The occlusal view showing the left maxillary second premolar inserted into the previously prepared transplantation site replacing the missing right maxillary central incisor. (D) The left maxillary second premolar transplanted in the previously prepared site of the missing right maxillary incisor, showing initial stabilization with sutures and splint immediately after autotransplantation.
Figure 3(A–F) Radiographic follow-up of an autotransplantation of the left maxillary second premolar in place of the missing right maxillary central incisor. The digital periapical radiographs were acquired as part of the endodontic periodic follow-up, and the digital panoramic radiograph was acquired as part of the patient’s dental treatment. The radiographs were evaluated by an endodontist and a periodontist on a computer screen. (A) The periapical radiograph taken immediately after transplantation of the left maxillary second premolar to the prepared site of the missing right maxillary central incisor. (B) The periapical radiograph showing a periradicular radiolucency associated with the roots of the right maxillary central (transplant) and lateral incisors (red arrows). (B) A radiolucent lesion is also seen on the distal aspect in the midroot of the transplant, corresponding to an external inflammatory root resorption (yellow arrow). (C) The periapical radiograph showing intracanal medication with calcium hydroxide paste in the right maxillary incisors. (D) The 1-year after transplantation follow-up periapical radiograph showing healing of the periradicular radiolucent lesions that were associated with roots of the right maxillary lateral and central incisors. Normal PDL is seen around the root of the right maxillary lateral incisor. The transplant showed no progression of the external inflammatory resorption on the distal aspect of the root. (E) The 3-year, (F) 4-year, (G) 5-year, and (H) 6-year follow-up after trauma demonstrating normal periradicular tissues during orthodontic treatment.
The patient was seen for follow-ups at 1 week (splint removal and slight reshaping of the teeth with composite), 3 weeks, and 6 weeks after the autotransplantation. During the follow-up visits, the transplanted left maxillary second premolar (will be addressed as “the transplant” from now on) had no response to cold or electric pulp testing. The transplant and the adjacent right maxillary lateral incisor were sensitive to percussion and palpation in the buccal vestibule. The other anterior maxillary teeth all had a normal response to cold and electric pulp testing, and all other clinical tests were within normal limits. Radiographic examination of a periapical radiograph at 3 weeks after the transplantation revealed no evidence of root resorption and no significant increase in the size of the radiolucent lesion around the transplant.
On a follow-up 2 and a half months after the surgery, external inflammatory root resorption was diagnosed on the periapical radiograph on transplant as well as a radiolucent periradicular lesion around the apices of both the central and the adjacent lateral incisor (Fig. 3B). Both these teeth were diagnosed with “pulp necrosis” and “symptomatic apical periodontitis.” Therefore, endodontic therapy was initiated on both. For all the endodontic treatments, the teeth were isolated with a rubber dam, and an operative microscope was used. To control the external root resorption in the transplant, calcium hydroxide paste intracanal dressing was used (Fig. 3C). After the clinical signs and symptoms were resolved and there was no evident radiographic progression of the resorptive lesion on the transplant (4 months after the initiation of endodontic therapy), the endodontic treatment was completed. Mineral trioxide aggregate (White ProRoot MTA; Dentsply Sirona, Johnson City, TN) was placed in the apical third to control the irregular shape of the root and the canal in the area of resorption of the transplanted tooth. Gutta-percha (GP) and AH Plus (Dentsply DeTrey, Konstanz, Germany) were used with combined cold lateral technique (using a GP master cone, accessory cones, and finger spreaders) and vertical warm compaction in the coronal portion of the canal (using a heat tip and hand pluggers) for obturation of the right maxillary lateral incisor. The coronal portions of the canals of both teeth as well as the pulp chamber and access cavities were sealed with self-cure composite resin (BisFil 2B; Bisco, Schaumburg, IL), and the patient’s bite was checked and adjusted.
At the follow-up appointments during the first 6 months after surgery, it was evident that the gingival margin of the transplanted tooth migrated coronally (Fig. 4A and B). Nine months after the trauma, during a follow-up appointment, the left maxillary central incisor was diagnosed with “pulp necrosis” with “symptomatic apical periodontitis.” Therefore, endodontic treatment was initiated, calcium hydroxide paste intracanal dressing was used as an intra-appointment medicament, and the root canal treatment was completed 2 weeks later at the second appointment after the symptoms resolved. For obturation, GP and AH Plus sealer were used with combined lateral and vertical warm compaction.
Figure 4(A–F) The clinical follow-up of an autotransplantation of the left maxillary second premolar in place of the missing right maxillary incisor. (A) Two weeks after autotransplantation. (B) Six months after autotransplantation; note the migration of the gingival margin of the transplanted tooth coronally relative to the adjacent right maxillary lateral and the left maxillary central incisors. (C) Similarly, at the 1-year follow-up, no ankylosis was evident. (D) Two and a half years after the autotransplantation, orthodontic treatment was planned to correct the class II occlusal relations and try to move the transplant in place of the right maxillary central incisor coronally because infraocclusion was noticed. (E) The 3-year follow-up shows an acrylic bracket bonded to the cervical third of the labial surface of the transplant as part of the attempt to extrude the tooth coronally because infraocclusion was noticed. (F) The 5-year follow-up shows the transplant responding to the orthodontic forces applied as part of the orthodontic treatment the patient was undergoing to correct his class II occlusion and the infraocclusion of the transplant.
Restorative treatment included a mock-up technique to demonstrate to the patient the contours of his final restorations on the maxillary central incisors as well as on the right maxillary lateral incisors. The crown of the transplanted premolar was shaped as a central incisor on all its aspects. The final impression was taken with CEREC chairside digital dentistry (Densply Sirona, CA). The restorations were milled with Cerasmart (GC America Inc, Alsip, IL) blocks (flexible resin nanoceramic). This material provides the characteristics of a high-strength ceramic and a composite allowing adjustment of the restorations while the patient is growing. The crowns were etched internally with hydrofluoric acid (9%), and 1 layer of GC Ceramic Primer II (GC America Inc) was applied to their internal surface before the final cementation with G-CEM LinkForce (GC America Inc), a dual-cure adhesive resin cement (Fig. 4C).
One year after the trauma, good oral hygiene was evident, and the patient was asymptomatic and pleased with the appearance of his restorations (Fig. 4C). The autotransplanted tooth in place of the right maxillary central incisor demonstrated normal mobility, periodontal probing depth up to 2 mm, and no sensitivity to percussion or palpation. Radiographic examination revealed healing of the periradicular bone around the right maxillary central and lateral incisors with a minimal area of radiolucency on the middistal aspect of the root of the right maxillary central incisor where the active inflammatory resorption was present in the past. No progression of the resorption lesion was evident (Fig. 3D). The lower anterior teeth had no pathological radiographic findings, and all clinical tests were within normal limits.
Two and a half years after the autotransplantation, orthodontic treatment was recommended to the patient to correct his class II occlusal relation, and it was decided to move the transplant coronally (Fig. 4D). During the 3-, 4-, 5-, and 6-year follow-ups, the patient has been undergoing an orthodontic treatment to correct his occlusal relations, and the autotransplanted tooth, in place of the right maxillary central incisor, was responding to the orthodontic forces as well (Fig. 4E and F). During the follow-up visits, up to 6 years after the autotransplantation, the patient had no concerns regarding his anterior maxillary teeth, mandibular anterior teeth, or the affected right first maxillary premolar. All clinical examination findings were within normal limits, and no pathological radiographic changes were evident (Fig. 3E–H). The gap of the open site of the extracted transplant was closed during orthodontic treatment.
Discussion
This case report adhered to the Preferred Reporting Items for Case reports in Endodontics 2020 guidelines, which were developed through a consensus-based methodology
Retrospective evaluation of endodontic case reports published in the International Endodontic Journal and the Journal of Endodontics for their compliance with the PRICE 2020 guidelines.
. Traumatic injuries that result in the loss of an incisor at a young age impose a treatment challenge because of the continued vertical development of the growing jaws
; however, in this case, the avulsed tooth was lost and not found by the patient in the trauma scene. The autotransplanted tooth in place of the missing right maxillary central incisor provides an aesthetic and functional solution for the missing tooth. It is the only tooth substitute with a PDL that can allow normal growth of the jaws during adolescence
. Because the transplanted tooth had an open apex, it was monitored to determine if and when endodontic treatment would be needed. Elective endodontic treatment was not performed to allow possible revascularization of the root, which was replanted immediately after extraction. If the apex of the transplant had been closed before transplantation, then endodontic treatment could have been completed before transplantation, before extraction, or extraorally as long as it did not extend the extraoral time too much and compromise the vitality of the PDL cells on the transplant or increase the risk of ankylosis. In the presented case, the autotransplanted tooth was diagnosed with pulp necrosis and inflammatory root resorption 2.5 months after autotransplantation. The reported incidence of inflammatory resorption in autotransplanted teeth is 4.8%, and it is usually diagnosed 1–2 months after transplantation
. In the current case, the root was incompletely formed and therefore had a relatively decreased risk of developing resorption. A significant increase in the frequency of inflammatory resorption has also been reported when more than 25% of the PDL was damaged at the time of transplantation and when a narrow alveolus with apparent physical contact between the tooth and the alveolar bone was evident
. In this case, the tooth was atraumatically extracted followed by a gentle and passive insertion into a preprepared socket, avoiding pressure or direct tight contact. Despite this, the transplanted left maxillary second premolar was diagnosed with pulp necrosis inflammatory resorption. The required modification of the crown shape to fit occlusion and the external arch might have contributed to the development of pulp necrosis and subsequent inflammatory root resorption in the present case. The resorption was controlled by removing the infected pulp and intracanal medication with calcium hydroxide
The right maxillary lateral incisor which had an extrusion and uncomplicated crown fracture and the left maxillary central incisor which had an extrusion and pinpoint pulp exposure, both with mature roots at the time of the trauma, were diagnosed with pulp necrosis 2.5 and 9 months after trauma, respectively. In teeth after extrusion with mature root development, the overall risk of pulp necrosis was reported to increase from 56.5% to 76.5% in the case of a concomitant crown fracture
Combination injuries 3. The risk of pulp necrosis in permanent teeth with extrusion or lateral luxation and concomitant crown fractures without pulp exposure.
. In this case, direct pulp capping without pulpotomy was performed. Placing direct capping without partial removal of the exposed pulp might have spread the inflammation to the deeper layers and increased the chance of pulp necrosis. In a study analyzing 369 teeth, there was no difference in the percentage of autotransplanted teeth that developed root resorption, whether orthodontically moved or not
. Currently, there is no consensus in the literature regarding the optimal timing of the initiation of orthodontic treatment after autotransplantation.
Conclusion and Clinical Implications
The current case report demonstrates a multidisciplinary approach (periodontal, endodontic, restorative, and orthodontic) frequently necessary to achieve favorable results in complex trauma cases in young adults. Autotransplantation, although presenting rather high success rates, requires frequent follow-up and control of possible complications, such as inflammatory resorption, as shown in this case. When interdisciplinary treatment is performed in a manner in which the end result is anticipated, the overall outcome is biologically favorable, aesthetic, and functional.
Acknowledgments
The authors deny any conflicts of interest related to this study.
References
Lin S.
Levin L.
Goldman S.
Peleg K.
Dento-alveolar and maxillofacial injuries: a 5-year multi-center study. Part 1: general vs facial and dental trauma.
Autotransplantation of teeth to the anterior maxilla: a systematic review of survival and success, aesthetic presentation and patient-reported outcome.
Retrospective evaluation of endodontic case reports published in the International Endodontic Journal and the Journal of Endodontics for their compliance with the PRICE 2020 guidelines.
Combination injuries 3. The risk of pulp necrosis in permanent teeth with extrusion or lateral luxation and concomitant crown fractures without pulp exposure.
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