A long-term study of 370 autotransplanted premolars. Part III. Periodontal healing subsequent to transplantation

Autotransplantation of premolars to replace maxillary incisors: a comparison with natural incisors

The published literature contains no comprehensive studies that compare the outcome of premolar autotransplantation to the maxillary anterior region with natural incisors in the same patients. This article describes the gingival and periodontal conditions around premolars transplanted to the maxillary incisor region, subsequent to restoration. Forty-five premolars autotransplanted to the maxillary incisor region in 40 adolescent patients were evaluated after a mean observation period of 4.0 years. Mean age at surgery was 11.0 years. Established clinical criteria were used to assess tooth mobility, plaque and gingival indexes, probing pocket depth, and percussion. Recession and hyperplasia of interproximal gingival papillae were assessed according to a recently proposed index. Standardized radiography was used to evaluate presence of pathosis, pulp obliteration, root length, and crown-root ratios. Clinical variables for transplants did not differ from those of the natural incisors, except for increased mobility and more plaque in a few transplanted premolars. The interproximal gingival papillae adjacent to all transplanted teeth were normal or slightly hyperplastic. Radiographically, all transplants showed varying degrees of pulp obliteration, but no signs of pathosis. Crown-root ratios were similar for natural and transplanted teeth as were distances from cementoenamel junction to marginal bone. The overall status of the transplanted premolars and surrounding tissues indicated that this treatment modality may be recommended when maxillary incisors are missing in adolescents. In addition, tooth transplantation represents an inherent potential for bone induction and reestablishment of a normal alveolar process.

Periodontal health of orthodontically extruded impacted teeth. A split-mouth, long-term clinical evaluation

BACKGROUND

Impaction of front teeth (often upper canines) can result in esthetic, functional, and phonetic problems, in addition to root resorption and chronic or acute infections. Most impacted front teeth can be extruded orthodontically after minor periodontal surgery. The purpose of this retrospective study was to examine the periodontal outcome of surgically exposed and orthodontically extruded impacted teeth compared with the spontaneously erupted contralateral teeth.

METHODS

A total of 38 patients, who had been treated by a combined surgical and orthodontic approach (closed eruption technique by same periodontist and 2 associated orthodontists), underwent a periodontal re-examination after 4 to 10 years. Periodontal parameters (plaque and gingivitis indices, probing depth, bleeding on probing, gingival recession and width, bone level, and root resorption) of the orthodontically extruded teeth (test) were scored and compared with those of the contralateral naturally erupted teeth (control) in a masked set-up.

RESULTS

No significant differences could be detected between test and control teeth, except for the gingival width, which was 1 mm larger for the spontaneously erupted teeth.

CONCLUSIONS

The data indicate that orthodontic extrusion of impacted front teeth does not jeopardize their periodontal health. This procedure appears to be a satisfactory alternative to extraction and/or transplantation.

Treatment options for impacted teeth

BACKGROUND

A compilation of treatment options for impacted teeth is presented to assist dentists in discussing the sequelae of impacted teeth as well as the complications of treatment with their patients.

OVERVIEW

A differential diagnosis for an impacted tooth is not possible without clinical assessment. However, an ankylosed tooth or a tooth with failure of its eruption mechanism may be mistaken for an impacted tooth. This review of national and international dental texts, journals and publications concerning impacted teeth spans more than 50 years.

PRACTICE IMPLICATIONS

Treatment options for the management of impacted teeth are separated into four categories: observation, intervention, relocation and extraction. The indications, contraindications and complications of each option are presented. This information will help the clinician identify developmental conditions associated with an increased probability of tooth impaction and assess available treatment options.

Muco-gingival and periodontal health recovery following reimplantation of teeth

Reimplantation of avulsed permanent teeth following traumatic injuries is a widely accepted therapeutic measure; however, though periodontal healing is considered to be the major determinant of long-term survival of reimplanted teeth, the mucogingival reaction to reimplantation has never been assessed. In the present study, hygiene level and gingival inflammation of 13 reimplanted teeth were assessed according to the plaque index (PI) and the gingival index (GI) around both reimplanted and control teeth. The periodontal condition was evaluated by measuring probing depth and probing attachment level at the same location. The clinical parameters of the reimplanted teeth were compared with those of contralateral teeth with the help of the non-parametric Wilcoxon signed ranks test. There were no statistically significant differences in PI and GI scores at any points of measurements around both reimplanted and control teeth; neither did probing depths and probing attachment levels differ between reimplanted and contralateral teeth. The results of the present study indicated that the muco-gingival reaction following traumatic avulsion did not affect the long-term prognosis of the reimplanted teeth.

Autotransplantation as a treatment option after loss of a maxillary permanent incisor tooth. A case report

A case is described of the management of a maxillary left permanent incisor, damaged by several traumatic injuries, in a 13-year-old girl. The traumatized incisor tooth required extraction and as part of an orthodontic treatment plan, a mandibular left second premolar was surgically transplanted to the prepared extraction socket at the maxillary anterior alveolus. After splinting, the transplanted tooth underwent endodontic treatment, because of pulpal necrosis. Orthodontic treatment commenced 3 months post-transplantation. Permanent root obturation was provided after orthodontic treatment and a porcelain veneer was placed to restore aesthetic appearance. The case emphasizes the importance of correct case selection, a multidisciplinary approach to treatment planning, and regular follow-up for transplanted teeth.

Tissue characteristics of root resorption areas in transplanted maxillary canines

The aim of the present study was to describe some histopathologic features of tissues collected from root resorption areas of maxillary canines after transalveolar transplantation surgery. In 8 of 101 transplanted canines, complications including cervical root resorption occurred between 6 and 11 years after treatment. The resorptive processes were located at the supra-alveolar portions of the distal and/or mesial aspects of the teeth and were scheduled for treatment involving surgical exploration. The resorption cavities, which extended from the cementoenamel junction to a position immediately below the bone crest, were filled with a granulation tissue. In four of the diagnosed complication cases, this granulation tissue was carefully excised concomitant with the adjacent gingival tissue after flap elevation and placed in a buffered fixative. After proper soft-tissue healing, the cavities were filled with a glass-ionomer material. The collected biopsy specimens were, after fixation and, in one case, decalcification in ethylenediaminetetraacetic acid, dehydrated and embedded in Epon. Sections 3 microns thick were produced, stained in periodic acid-Schiff and toluidine blue, and used for histometric and morphometric analyses. The histologic analysis showed that the dissected tissue harbored well-encapsulated areas of inflammatory infiltrates. The lesions comprised a relatively low volume of collagen and a large number of inflammatory cells, predominantly lymphocytes.

Intra-alveolar surgical uprighting of impacted teeth: a case report

Although orthodontic repositioning of impacted teeth is widely used, the treatment has its limitations. Autotransplantation or intra-alveolar surgical repositioning of teeth is an alternative therapy that may be used in selected cases of desperate impactions, when orthodontic extrusion is unsuccessful or when orthodontic treatment is rejected by the patient. A case report is presented to stress both the indications and limitations of a modified technique of intra-alveolar surgical uprighting of impacted teeth.

Autotransplantation of premolars and molars in patients with tooth aplasia

OBJECTIVES

The purpose of this study was to investigate retrospectively a group of patients who had undergone autotransplantation of teeth.

METHODS

The study group comprised 29 patients who had had a total of 31 teeth autotransplanted (22 premolars and nine molars). Seventeen premolars and one molar were moved from the upper to the lower jaw. The remaining premolars and molars were moved within the same quadrant. Twenty-three teeth were transplanted in cases of agenis, two in cases of ectopic eruption, and six after loss of the first molar. The observation period varied from 3 to 16 years (average 8 years). The patients were examined clinically, and radiographs were taken of the autotransplanted teeth. In addition, the patients were asked to complete a questionnaire.

RESULTS

By the end of the observation periods, four autotransplanted teeth had been extracted due to root fracture, caries, or external root resorption. In three of the patients who had lost their transplanted teeth and where no replacement had been inserted, the dentition had remained stable without tipping, rotations, or elongation. Most of the patients were happy with the autotransplantation and satisfied with the information that they had received in connection with the surgery.

CONCLUSION

Although not a frequent procedure, it was concluded that autotransplantation had a good prognosis after an (average) observation period of 8 years.

A clinical follow-up study of 278 autotransplanted teeth

This open study was undertaken to investigate the outcome of autotransplanted teeth over a 6-year period. The subjects were 296 patients who underwent autotransplantation in the 6-year period September 1986-August 1992 and outcome was measured by considering root formation, occlusion, endodontal and periodontal complications. 18 patients were excluded because of inadequate notes or radiographs (n = 3) or because they were lost to follow-up (n = 15). The groups were divided into open apex and closed apex, and duration of follow up was 6 months-5 years. Aplasia was the indication for operation in 158 (77 percent) of the open apex group but only 10 (14 percent) of the closed apex group, whereas caries and associated disease was the most common in the latter (n = 45, 61 percent compared with 20, 10 percent). There were 24 complete failures, 12 in each group (p <0.01). Only 7 teeth in total developed full roots, and 159 showed incomplete growth. In the open apex group 112 teeth were in occlusal contact and 4 were extracted for severe infraocclusion. In the closed apex group there were 10 cases of mild infraocclusion, none of which required treatment. There were 7 cases of pulp necrosis in the open apex group, 4 of which required extraction. Two teeth in the closed apex group were extracted for endodontic reasons. Only 1 tooth (in the closed apex group) had to be extracted for periodontal reasons. Autotransplantation is a reliable method with a good prognosis for donor teeth with both open and closed apexes. The technique is applicable whatever the aetiology of the agenesis, and is worthy of consideration should there be a suitable donor tooth.

Pulp and periodontal healing, root development and root resorption subsequent to transplantation and orthodontic rotation: a long-term study of autotransplanted premolars

One hundred and eighteen premolars transplanted at a stage with 3/4 to 4/4 root development with a wide open apical foramen were followed with standardized clinical and radiographic techniques for signs of pulpal and periodontal ligament healing and root development. Pulp healing, evaluated first by radiographic presence of pulp canal obliteration, appeared to be an earlier sign of pulp healing than the detection of pulp vitality with an electrometric test. Continued root growth of premolars was seen in some cases. Complete arrest of root development was usually followed by development of the missing root structure at the donor site, indicating a separation of the Hertwig's epithelial root sheath. Orthodontic rotation performed on 11 premolars induced slight surface resorption and a significant shortening of tooth length (mean 1.2 mm), compared with nontreated but transplanted control teeth. However, the extent of the apical root resorption is of minor clinical importance, and is equivalent to what has been found in previous investigations of orthodontic treatment of nontransplanted premolars. Late pulp necrosis occurred in 2 of the 11 treated cases 6 years after transplantation and 5 years after orthodontic rotation. To prevent late pulp necrosis, orthodontic rotation is recommended after periodontal healing and before total pulp canal obliteration has taken place, i.e., 3 to 9 months after transplantation.

Transplanting teeth successfully: autografts and allografts that work

This article suggests tooth transplantation as an alternative to other restorative options. The 10-year success rates for autografts--teeth moved from one location to another in a patient's mouth--range from 60 percent to 95 percent. Allografts, teeth moved from one person to another, are less successful. The authors report on one case of each type of transplant.

Conservative surgical and orthodontic management of a child with central giant cell granuloma

Differential diagnosis and treatment modalities of giant cell granulomas have been a controversial matter since Jaffe first distinguished true giant cell tumours (TGCG) from central giant cell granulomas (CGCG). CGCG is a slowly growing and painless tumour usually treated by simple curettage but denotes a strong tendency to recurrence. A case report is presented to describe conservative therapy of CGCG in the maxilla of a young child: surgical enucleation of the tumour at the age of 11 years, though successful, was followed by progressive impaction of the maxillary right permanent canine. Orthodontic treatment aligned the maxillary teeth to accommodate autotransplantation of the impacted tooth. Clinical and radiographic evaluation of the patient 5 years after the initial surgical treatment showed good bony and periodontal healing around the transplanted canine and no recurrence of the CGCG. As the literature shows that distinction of the two tumours is difficult even by histological means, various clinico-pathologic factors involved in prognostic evaluation are discussed.

Teeth and tooth nerves

(1) Although our knowledge on teeth and tooth nerves has increased substantially during the past 25 years, several important issues remain to be fully elucidated. As a result of the work now going on at many laboratories over the world, we can expect exciting new findings and major break-throughs in these and other areas in a near future. (2) Dentin-like and enamel-like hard tissues evolved as components of the exoskeletal bony armor of early vertebrates, 500 million years ago, long before the first appearance of teeth. It is possible that teeth developed from tubercles (odontodes) in the bony armor. The presence of a canal system in the bony plates, of tubular dentin, of external pores in the enamel layer and of a link to the lateral line system promoted hypotheses that the bony plates and tooth precursors may have had a sensory function. The evolution of an efficient brain, of a head with paired sense organs and of toothed jaws concurred with a shift from a sessile filter-feeding life to active prey hunting. (3) The wide spectrum of feeding behaviors exhibited by modern vertebrates is reflected by a variety of dentition types. While the teeth are continuously renewed in toothed non-mammalian vertebrates, tooth turnover is highly restricted in mammals. As a rule, one set of primary teeth is replaced by one set of permanent teeth. Since teeth are richly innervated, the turnover necessitates a local neural plasticity. Another factor calling for a local plasticity is the relatively frequent occurrence of age-related and pathological dental changes. (4) Tooth development is initiated through interactions between the oral epithelium and underlying neural crest-derived mesenchymal cells. The interactions are mediated by cell surface molecules, extracellular matrix molecules and soluble molecules. The possibility that the initiating events might involve a neural component has been much discussed. With respect to mammals, the experimental evidence available does not support this hypothesis. In the teleost Tilapia mariae, on the other hand, tooth germ formation is interrupted, and tooth turnover ceases after local denervation. (5) Prospective dental nerves enter the jaws well before onset of tooth development. When a dental lamina has formed, a plexus of nerve branches is seen in the subepithelial mesenchyme. Shortly thereafter, specific branches to individual tooth primordia can be distinguished. In bud stage tooth germs, axon terminals surround the condensed mesenchyme and in cap stage primordia axons grow into the dental follicle.(ABSTRACT TRUNCATED AT 400 WORDS)

Indications of autotransplantation of teeth in orthodontic problem cases

Autotransplantations of teeth have been widely used in orthodontics, mainly in cases of severe impactions, early loss of permanent teeth, or congenital aplasia. In specific clinical situations, indication of extractions or supernumerary teeth may provide donor teeth for transplantations avoiding prosthetic or implant therapy. Two cases are presented to illustrate the topic, and prognostic factors of autotransplantation are discussed.

Apical root resorption in orthodontically treated subjects: analysis of edgewise and light wire mechanics

Of the several modes of tooth movement, pressure from intrusive forces seems the most likely to cause external apical root resorption (EARR). This has been demonstrated for incisors in human beings and molars in laboratory animals. The present study examined full-banded adolescent patients and scored the degrees of in-treatment root resorption throughout the dentition. Just Class I cases with four first premolar extractions were used. Equal samples of conventional Begg and Tweed treated cases were examined with 1:1 sex ratios (total n = 83). No difference between the Begg and Tweed techniques and no sex difference was found in any of the 30 univariate tests, even though power analysis indicated a strong likelihood of finding a difference if one existed. By using multiple linear regression, significant decreases in length (EARR) were found for those roots systematically intruded in this Class I malocclusion, notably the mesial root of the maxillary first molar and the distal root of the mandibular first molar. Even though some of the present cases had been in "active" treatment up to 6 years, we found no significant association between duration of treatment and degree or amount of EARR.

A clinical and radiologic study of autotransplanted impacted canines

The aim of the present study was to evaluate the clinical and radiologic results of 20 autotransplantations of impacted canines performed in the Orthodontic and Pedodontic Department of the University of Geneva between 1979 and 1988. The sample, divided into two different age groups (group A: 13-20 years; group B: 20-48 years), demonstrated persistence of pulp vitality in 80% of the cases in group A, whereas routine endodontic treatment was instituted in all cases of group B. Periodontal healing was noted in 90% of the cases in group A, and in 70% of the cases in group B. The present clinical and radiologic data indicate that impacted canines can be transplanted at any age with good prognosis and are an alternative to orthodontic repositioning in selected cases of canine impaction.

Autotransplantations and loss of anterior teeth by trauma

The loss of anterior teeth by trauma has usually been corrected by orthodontic or prosthetic means. In some specific cases, however, the skeletal and dental relationship may contraindicate the use of space-closure mechanics. Autotransplantation of teeth, successfully depicted in many clinical studies, can help to reduce the severity of orthodontic cases complicated by traumatized anterior teeth. A case report is presented to stress both the indications and limitations of such treatment.

Long-term clinical and radiologic evaluation of autotransplanted teeth

The purpose of the present study was to investigate the radiologic results of 40 autotransplantations (20 molars and 20 premolars) performed in the orthodontic department of the University of Geneva between 1979 and 1990. The sample demonstrated persistence of pulp vitality and continuous root development, followed, however, in most cases by replacement root resorption. The data were in accordance with previously published studies and point to an ideal developmental stage for molar and premolar transplantation to ensure pulpal and periodontal survival.

Patterns of incisor root resorption before and after orthodontic correction in cases with anterior open bites

External root resorption is a frequent iatrogenic consequence of orthodontic treatment, particularly in the maxillary anterior teeth. Since resorption also occurs is a normal function of aging and since altered behaviors such as bruxism and chronic nailbiting accelerate resorption even in the absence of treatment, it was hypothesized that the long-term orthopedic forces of tongue thrusting leading to anterior open bites would also enhance the rates of clastic activity. In a series of 32 adolescents with open bites, the roots of permanent maxillary central incisors were significantly shorter and exhibited higher modal grades of periapical resorption than a matched series with deep bites before treatment. The open bite group also had less facial bony support for these teeth. Both series experienced discernible resorption during full-banded treatment but to comparable extents so that, after active treatment, the open bite series continued to possess significantly greater degrees of resorption. Consequently, the oral forces leading to apertognathia are themselves destructive of root integrity and merit early recognition and interception.

Treatment of traumatic dental injuries. Shift in strategy

A more conservative approach to the treatment of traumatic dental injuries has been made possible by knowledge concerning the pathogenesis of external root resorption, increased knowledge about wound healing processes in the pulp and periodontium, as well as by advances in restorative dentistry (reattachment of crown fragments with a dentin bonding system, the use of adhesive bridges, and advances in autotransplantation and implantation). However, a rethinking by the public, clinicians, and third-party payers is necessary for these procedures to gain wider acceptance. The present article describes the state of the art of treating dental trauma in the hope that these advances can become an accepted part of the dental trauma armamentarium and not merely scientific curiosities.