The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
667
Vertical Bone Growth Following Autotransplantation of the Developing Maxillary Third Molar to Replace a Retained Mandibular Permanent Molar: A Case Report Paweł Plakwicz, DDS, PhD1 Ewa Monika Czochrowska, DDS, PhD2 Anna Milczarek, DDS3 Małgorzata Zadurska, DDS, PhD4
A retained permanent mandibular first molar caused arrested development and a defect of the alveolar bone in a 16-year-old girl. Extraction of the ankylosed tooth was immediately followed by autotransplantation of the developing maxillary third molar. At the 3-year follow-up examination the interproximal bone level at the autotransplanted molar was equal to that of the neighboring teeth. Cone beam computed tomography showed bone at the labial aspect of the transplant. The eruption of the autotransplanted tooth stimulated vertical alveolar bone development and repaired the bone defect. Additionally, there was closure of the posterior open bite that was initially present at the ankylosed molar site. (Int J Periodontics Restorative Dent 2014;34:667–671. doi: 10.11607/prd.1984)
Clinical Assistant, Department of Periodontology, Medical University of Warsaw, Warsaw, Poland. 2Adjunct Professor, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 3Clinical Assistant, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 4Professor and Head, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 1
Correspondence to: Dr Paweł Plakwicz, ul. Górnos´la˛ska 5/19, 00-443 Warsaw, Poland; email: [email protected]. ©2014 by Quintessence Publishing Co Inc.
Eruption disturbance of a permanent mandibular first molar is a rare phenomenon and a challenge for dental professionals due to the bone defect it generates in a growing patient. Failure of permanent tooth eruption is rare, especially in the case of molars (excluding third molars).1,2 Physical barriers (eg, supernumerary teeth, odontomas, or a cyst) are local causes in mechanical failure of eruption. Metabolic changes, infection, or trauma are causative factors of the defect of the eruption mechanism itself, as in primary failure of eruption or secondary retention of permanent molars, ie, incomplete eruption of teeth without the influence of a physical barrier or a lack of space.3–7 Ankylosis of involved molars has been proven by electron microscopy.8 Extraction is often the only treatment of early ankylosis of a permanent tooth in a young patient.9 As a consequence, an orthodontic space closure (if acceptable) or a prosthetic replacement of the missing molar is required. In both cases the major concern is the alveolar bone defect at the extraction site, which may preclude implant placement and
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
668
Fig 1 Submergence of retained mandibular right first molar at the time of reevaluation of the treatment (May 2009).
jeopardize the periodontal status of adjacent teeth. According to the literature, the survival of autotransplanted molars is 50% when both mature and developing molars were considered as donors.10 However, transplantation of developing teeth has been proven to be a predictable treatment of missing teeth with the highest survival and success rates (90% to 98% and 75% to 93%, respectively).11–13 Thus, autotransplantation of teeth with incomplete root formation is the state of the art solution when aiming at healing of the pulp, periodontal ligament, and root growth after surgery.14–18 This case reports bone growth as a result of the eruption of a developing maxillary third molar that was autotransplanted to the site of the bone defect caused by a retained permanent mandibular molar.
Case report A 16-year-old girl reported for reevaluation of orthodontic treatment at the Department of Orthodontics,
Fig 2 Panoramic radiograph at the reevaluation of the treatment (May 2009). Concavity of the bone defect at the side of tooth submergence.
Medical University of Warsaw, Warsaw, Poland. The patient had already been wearing an orthodontic appliance on the maxillary and mandibular teeth for 6 months. The initial treatment plan was focused on orthodontic forced eruption of a retained mandibular right first molar. At the time of the reevaluation, an intraoral examination revealed Class II malocclusion and posterior open bite on the right side, Class I on the left side, and the mandibular midline shifted to the right. The mandibular right first molar was retained (Fig 1). The tooth had no mobility and presented a high metallic sound during a percussion test. The radiographs revealed a complete permanent dentition apart from the submergence of the mandibular right first molar. Radiographic signs of root resorption were found in the interradicular area, and a distinct concave bone defect was found surrounding the affected tooth. The bottom of the defect was located several millimeters below the cementoenamel junction (CEJ) of the adjacent teeth (Fig 2). The patient
had all third molars with developing roots that were two-thirds the final root length (see Fig 2). There was no history of tooth retention in the patient’s family. The patient did not suffer from any general disease. No progress in the eruption of the mandibular right first molar was observed at the referral (6 months after starting the orthodontic treatment), thus confirming the ankylosis and the indication for extraction of the tooth.9 The new treatment plan included extraction of the ankylosed mandibular right first molar and autotransplantation of the developing maxillary right third molar to fill the space and, at minimum, preserve the existing bone level for a potential implant placement in the future. Informed consent was obtained for the treatment.
Surgical technique
The surgery was performed under local anesthesia (4% articaine with epinephrine 1:200,000). A horizontal incision was made along the
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
669
Fig 3 Autotransplanted maxillary right third molar stabilized in the mandibular right first molar position (October 2009).
gingival margin. A single vertical incision at the second premolar allowed creation of a triangular full-thickness flap. Then, the retained first molar was divided into fragments and extracted. The root socket was reshaped with burs to provide space to accommodate donor roots with an additional 1 mm around it. The transplanted tooth (maxillary right third molar) was carefully and gently removed to save the dental follicle, cementum, and Hertwig epithelial root sheath; placed in the socket a few millimeters from the occlusal plane; and stabilized with sutures and steel wire with composite (Fig 3). The time between the removal of the transplant tooth and its stabilization in the new position was less than 1 minute. After the surgery, the patient was prescribed 500 mg of amoxicillin every 8 hours for 1 week and 200 mg of ibuprofen every 8 hours for 2 days. The healing was uneventful, with no signs of edema or inflammation. The sutures and wire stabilization were removed 9 days after the surgery.
Fig 4 Normal occlusion at affected site 3 years after the surgery (November 2012).
Follow-up and results
The patient was examined every month during the first year and then 2 and 3 years after the surgery. Three months after the transplantation orthodontic treatment was resumed in the mandible. After 2 years of orthodontically assisted eruption, the transplanted tooth reached the occlusal plane and was aligned in the dental arch. The final clinical examination (3 years after the surgery; 1 year after the completion of the orthodontic treatment) included an electric pulp sensitivity test, recordings of probing depth (PD), clinical attachment level, mobility, and the percussion test. The radiologic examination (intraoral radiographs using the long cone paralleling technique with film holders) allowed assessment of the degree of pulp obliteration, new socket formation, the level of the marginal alveolar bone, the absence of root resorption, and the progress of root development. In addition, cone beam computed tomography (CBCT) was
performed to evaluate the bone at the buccal and lingual aspect of the transplanted molar 44 months after the surgery. The transplant demonstrated features that were typical for vital teeth: a response to the electric pulp tests within normal limits and the pulp obliteration. The tooth erupted to the occlusal plane and showed normal mobility. The marginal periodontal tissues were healthy (PD did not exceed 2 mm), and a wide band of keratinized gingiva was present around the transplant. No gingival recessions or attachment loss were detected (Fig 4). The radiographs did not reveal any replacement or inflammatory root resorption of the transplant, and its root continued developing. The interproximal bone regained its normal level along with transplant eruption (Figs 5a to 5c). In addition, the CBCT showed the presence of bone at the labial and lingual aspect of transplanted molar (Fig 6).
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
670
a
b
c
Fig 5 (a) Cropped panoramic radiograph before the treatment (May 2009). Concaved margins of bone defect around the retained mandibular right first molar are located several millimeters apical to the adjacent teeth. (b) Intraoral radiograph 3 months after autotransplantation of the maxillary right third molar. (c) Intraoral radiograph 3 years after the surgery (November 2012). Lines connect the levels of the CEJ of the transplanted molar and the adjacent teeth. Interproximal bone regained its normal level. Fig 6 (a to c) CBCT scans 44 months after the surgery (January 2013). Arrows indicate bone at the labial and lingual aspects of the transplanted molar.
a
b
Discussion The treatment of the eruption disturbances of permanent molars depends mostly on the severity of the infraocclusion, the number of teeth involved, and the age of the patient at the time of referral. In the described case, secondary retention of first molar eruption due to ankylosis (detected on radiographs) was recognized since there were no physical barriers (present in mechanical failure of eruption), and the second molar at the affected side was not involved in the submergence (typical for primary failure of eruption).3 According to some authors, extraction should be performed when early ankylosis of a permanent molar is diagnosed on the basis of progressive
c
infra occlusion that is unavoidable during the growth spurt.9 Extraction may prevent the adjacent teeth from further tipping and a loss of space; otherwise, severe marginal ridge discrepancy will develop as a result of the growth spurt. Luxation before forced orthodontic extrusion of an ankylosed molar often results in recurrence of ankylosis and eventual failure.9 If ankylosis occurs late (causing only slight infraocclusion), the mandibular molar might be left for observation and restored with a composite, onlay, or crown. In the presented case, the extraction was performed because of progressive submergence of the retained tooth in a young patient. As a consequence, the patient required one of the following treatments: orthodontic space closure, mainte-
nance of space for prosthetic restoration postponed until after growth cessation (implant-supported crown or partial denture), or tooth autotransplantation. Autotransplantation was chosen due to contraindications for orthodontic space closure and unfavorable conditions for implant placement (bone defect and patient age). The presence of adequate bone at the recipient site was deemed essential for the performance of the autotransplantation surgery.19 However, in the described case the transplantation was performed to a vertical bone defect caused by the retention of a tooth and its removal. Initial radiography performed before the treatment (see Figs 2 and 5a) and that performed directly after the surgery (see Fig 5b) document a bone defect below the
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
671 line connecting the CEJs of adjacent teeth. As a result of this defect, at the time of the surgery, the transplant was placed several millimeters inferior to the occlusal plane. Three years after the surgery the transplanted molar fulfilled the criteria for successful healing, ie, pulp vitality, absence of resorption, and progress of root growth.13 The periodontal tissues were healthy, and radiographs revealed typical features for vital transplanted teeth.11 However, the most important finding was the marginal bone level of the transplanted molar, which was equal to that of the adjacent teeth. It was observed that during eruption of the transplant, the alveolar bone grew interproximally and consequently repaired the bone defect initially caused by the disturbed eruption of the first molar (see Fig 5c). In addition, the CBCT performed 44 months after the surgery proved the presence of normal bone at the buccal and lingual aspects of transplant (see Fig 6). This is in line with another case report that described bone growth around autotransplanted teeth.20 This unique finding suggests that autotransplantation of developing teeth may be a viable option for treating local bone growth defects caused by retained permanent molars when alternative treatment options are not available.
Conclusions The presented case describes vertical bone growth accompanied by the eruption of the developing maxillary third molar, which was autotransplanted to the bone defect.
Should further studies confirm the above findings, this may imply that regeneration of vertical bone defects in sites of tooth infraposition is possible through autotransplantation of a developing tooth. This opens new prospects for the treatment of growing patients with defects caused by tooth eruption disturbances, in whom other treatments are often contraindicated.
Acknowledgments The authors reported no conflicts of interest related to this study.
References 1. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420–425. 2. Chintakanon K, Boonpinon P. Ectopic eruption of the first permanent molars: Prevalence and etiologic factors. Angle Orthod 1998;68:53–60. 3. Proffit WR, Vig KW. Primary failure of eruption: A possible cause of posterior open bite. Am J Orthod 1981;80:173–190. 4. Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofacial Orthop 2004;126: 432–445. 5. Raghoebar GM, Boering G, Jansen HW, Vissink A. Secondary retention of permanent molars: A histologic study. J Oral Pathol Med 1989;18:427–431. 6. Nagpal A, Sharma G, Sarkar A, Pai KM. Eruption disturbances: An aetiologicalcum-management perspective. Dentomaxillofac Radiol 2005;34:59–63. 7. Baccetti T. Tooth anomalies associated with failure of eruption of first and second permanent molars. Am J Orthod Dentofacial Orthop 2000;118:608–610. 8. Raghoebar GM, Jansen HW, Jongebloed WL, Boering G, Vissink A. Secondary retention of permanent molars: An assessment of ankylosis by scanning electron and light microscopy. Br J Oral Maxillofac Surg 1992;30:50–55.
9. Kurol J. Impacted and ankylosed teeth: Why, when, and how to intervene. Am J Orthod Dentofacial Orthop 2006; 129(suppl 4):S86–S90. 10. Schwartz O, Bergmann P, Klausen B. Autotransplantation of human teeth. A lifetable analysis of prognostic factors. Int J Oral Surg 1985;14:245–258. 11. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-term study of 370 autotransplanted premolars. Part II. Tooth survival and pulp healing subsequent to transplantation. Eur J Orthod 1990; 12:14–24. 12. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: Survival and success rates 17–41 years posttreatment. Am J Orthod Dentofacial Orthop 2002;121:110–119. 13. Kristerson L. Autotransplantation of human premolars. A clinical and radiographic study of 100 teeth. Int J Oral Surg 1985; 14:200–213. 14. Watanabe Y, Mohri T, Takeyama M, et al. Long-term observation of autotransplanted teeth with complete root formation in orthodontic patients. Am J Orthod Dentofacial Orthop, 2010;138:720–726. 15. Skoglund A, Tronstad L, Wallenius K. A microangiographic study of vascular changes in replanted and autotransplanted teeth of young dogs. Oral Surg Oral Med Oral Pathol 1978;45:17–28. 16. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A long-term study of 370 autotransplanted premolars. Part IV. Root development subsequent to transplantation. Eur J Orthod 1990;12:38–50. 17. Andreasen JO, Paulsen HU, Yu Z, Schwartz O. A long-term study of 370 autotransplanted premolars. Part III. Periodontal healing subsequent to transplantation. Eur J Orthod 1990;12:25–37. 18. Plakwicz P, Wojtowicz A, Czochrowska EM. Survival and success rates of autotransplanted premolars: A prospective study of the protocol for developing teeth. Am J Orthod Dentofacial Orthop 2013; 144:229–237. 19. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer T, Schwartz O. A longterm study of 370 autotransplanted premolars. Part I. Surgical procedures and standardized techniques for monitoring healing. Eur J Orthod 1990;12:3–13. 20. Plakwicz PW, Wojtaszek J, Zadurska M. New bone formation at the site of autotransplanted developing mandibular canines: A case report. Int J Periodontics Restorative Dent 2013;33:13–19.
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
667
Vertical Bone Growth Following Autotransplantation of the Developing Maxillary Third Molar to Replace a Retained Mandibular Permanent Molar: A Case Report Paweł Plakwicz, DDS, PhD1 Ewa Monika Czochrowska, DDS, PhD2 Anna Milczarek, DDS3 Małgorzata Zadurska, DDS, PhD4
A retained permanent mandibular first molar caused arrested development and a defect of the alveolar bone in a 16-year-old girl. Extraction of the ankylosed tooth was immediately followed by autotransplantation of the developing maxillary third molar. At the 3-year follow-up examination the interproximal bone level at the autotransplanted molar was equal to that of the neighboring teeth. Cone beam computed tomography showed bone at the labial aspect of the transplant. The eruption of the autotransplanted tooth stimulated vertical alveolar bone development and repaired the bone defect. Additionally, there was closure of the posterior open bite that was initially present at the ankylosed molar site. (Int J Periodontics Restorative Dent 2014;34:667–671. doi: 10.11607/prd.1984)
Clinical Assistant, Department of Periodontology, Medical University of Warsaw, Warsaw, Poland. 2Adjunct Professor, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 3Clinical Assistant, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 4Professor and Head, Department of Orthodontics, Medical University of Warsaw, Warsaw, Poland. 1
Correspondence to: Dr Paweł Plakwicz, ul. Górnos´la˛ska 5/19, 00-443 Warsaw, Poland; email: [email protected]. ©2014 by Quintessence Publishing Co Inc.
Eruption disturbance of a permanent mandibular first molar is a rare phenomenon and a challenge for dental professionals due to the bone defect it generates in a growing patient. Failure of permanent tooth eruption is rare, especially in the case of molars (excluding third molars).1,2 Physical barriers (eg, supernumerary teeth, odontomas, or a cyst) are local causes in mechanical failure of eruption. Metabolic changes, infection, or trauma are causative factors of the defect of the eruption mechanism itself, as in primary failure of eruption or secondary retention of permanent molars, ie, incomplete eruption of teeth without the influence of a physical barrier or a lack of space.3–7 Ankylosis of involved molars has been proven by electron microscopy.8 Extraction is often the only treatment of early ankylosis of a permanent tooth in a young patient.9 As a consequence, an orthodontic space closure (if acceptable) or a prosthetic replacement of the missing molar is required. In both cases the major concern is the alveolar bone defect at the extraction site, which may preclude implant placement and
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
668
Fig 1 Submergence of retained mandibular right first molar at the time of reevaluation of the treatment (May 2009).
jeopardize the periodontal status of adjacent teeth. According to the literature, the survival of autotransplanted molars is 50% when both mature and developing molars were considered as donors.10 However, transplantation of developing teeth has been proven to be a predictable treatment of missing teeth with the highest survival and success rates (90% to 98% and 75% to 93%, respectively).11–13 Thus, autotransplantation of teeth with incomplete root formation is the state of the art solution when aiming at healing of the pulp, periodontal ligament, and root growth after surgery.14–18 This case reports bone growth as a result of the eruption of a developing maxillary third molar that was autotransplanted to the site of the bone defect caused by a retained permanent mandibular molar.
Case report A 16-year-old girl reported for reevaluation of orthodontic treatment at the Department of Orthodontics,
Fig 2 Panoramic radiograph at the reevaluation of the treatment (May 2009). Concavity of the bone defect at the side of tooth submergence.
Medical University of Warsaw, Warsaw, Poland. The patient had already been wearing an orthodontic appliance on the maxillary and mandibular teeth for 6 months. The initial treatment plan was focused on orthodontic forced eruption of a retained mandibular right first molar. At the time of the reevaluation, an intraoral examination revealed Class II malocclusion and posterior open bite on the right side, Class I on the left side, and the mandibular midline shifted to the right. The mandibular right first molar was retained (Fig 1). The tooth had no mobility and presented a high metallic sound during a percussion test. The radiographs revealed a complete permanent dentition apart from the submergence of the mandibular right first molar. Radiographic signs of root resorption were found in the interradicular area, and a distinct concave bone defect was found surrounding the affected tooth. The bottom of the defect was located several millimeters below the cementoenamel junction (CEJ) of the adjacent teeth (Fig 2). The patient
had all third molars with developing roots that were two-thirds the final root length (see Fig 2). There was no history of tooth retention in the patient’s family. The patient did not suffer from any general disease. No progress in the eruption of the mandibular right first molar was observed at the referral (6 months after starting the orthodontic treatment), thus confirming the ankylosis and the indication for extraction of the tooth.9 The new treatment plan included extraction of the ankylosed mandibular right first molar and autotransplantation of the developing maxillary right third molar to fill the space and, at minimum, preserve the existing bone level for a potential implant placement in the future. Informed consent was obtained for the treatment.
Surgical technique
The surgery was performed under local anesthesia (4% articaine with epinephrine 1:200,000). A horizontal incision was made along the
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
669
Fig 3 Autotransplanted maxillary right third molar stabilized in the mandibular right first molar position (October 2009).
gingival margin. A single vertical incision at the second premolar allowed creation of a triangular full-thickness flap. Then, the retained first molar was divided into fragments and extracted. The root socket was reshaped with burs to provide space to accommodate donor roots with an additional 1 mm around it. The transplanted tooth (maxillary right third molar) was carefully and gently removed to save the dental follicle, cementum, and Hertwig epithelial root sheath; placed in the socket a few millimeters from the occlusal plane; and stabilized with sutures and steel wire with composite (Fig 3). The time between the removal of the transplant tooth and its stabilization in the new position was less than 1 minute. After the surgery, the patient was prescribed 500 mg of amoxicillin every 8 hours for 1 week and 200 mg of ibuprofen every 8 hours for 2 days. The healing was uneventful, with no signs of edema or inflammation. The sutures and wire stabilization were removed 9 days after the surgery.
Fig 4 Normal occlusion at affected site 3 years after the surgery (November 2012).
Follow-up and results
The patient was examined every month during the first year and then 2 and 3 years after the surgery. Three months after the transplantation orthodontic treatment was resumed in the mandible. After 2 years of orthodontically assisted eruption, the transplanted tooth reached the occlusal plane and was aligned in the dental arch. The final clinical examination (3 years after the surgery; 1 year after the completion of the orthodontic treatment) included an electric pulp sensitivity test, recordings of probing depth (PD), clinical attachment level, mobility, and the percussion test. The radiologic examination (intraoral radiographs using the long cone paralleling technique with film holders) allowed assessment of the degree of pulp obliteration, new socket formation, the level of the marginal alveolar bone, the absence of root resorption, and the progress of root development. In addition, cone beam computed tomography (CBCT) was
performed to evaluate the bone at the buccal and lingual aspect of the transplanted molar 44 months after the surgery. The transplant demonstrated features that were typical for vital teeth: a response to the electric pulp tests within normal limits and the pulp obliteration. The tooth erupted to the occlusal plane and showed normal mobility. The marginal periodontal tissues were healthy (PD did not exceed 2 mm), and a wide band of keratinized gingiva was present around the transplant. No gingival recessions or attachment loss were detected (Fig 4). The radiographs did not reveal any replacement or inflammatory root resorption of the transplant, and its root continued developing. The interproximal bone regained its normal level along with transplant eruption (Figs 5a to 5c). In addition, the CBCT showed the presence of bone at the labial and lingual aspect of transplanted molar (Fig 6).
Volume 34, Number 5, 2014 © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
670
a
b
c
Fig 5 (a) Cropped panoramic radiograph before the treatment (May 2009). Concaved margins of bone defect around the retained mandibular right first molar are located several millimeters apical to the adjacent teeth. (b) Intraoral radiograph 3 months after autotransplantation of the maxillary right third molar. (c) Intraoral radiograph 3 years after the surgery (November 2012). Lines connect the levels of the CEJ of the transplanted molar and the adjacent teeth. Interproximal bone regained its normal level. Fig 6 (a to c) CBCT scans 44 months after the surgery (January 2013). Arrows indicate bone at the labial and lingual aspects of the transplanted molar.
a
b
Discussion The treatment of the eruption disturbances of permanent molars depends mostly on the severity of the infraocclusion, the number of teeth involved, and the age of the patient at the time of referral. In the described case, secondary retention of first molar eruption due to ankylosis (detected on radiographs) was recognized since there were no physical barriers (present in mechanical failure of eruption), and the second molar at the affected side was not involved in the submergence (typical for primary failure of eruption).3 According to some authors, extraction should be performed when early ankylosis of a permanent molar is diagnosed on the basis of progressive
c
infra occlusion that is unavoidable during the growth spurt.9 Extraction may prevent the adjacent teeth from further tipping and a loss of space; otherwise, severe marginal ridge discrepancy will develop as a result of the growth spurt. Luxation before forced orthodontic extrusion of an ankylosed molar often results in recurrence of ankylosis and eventual failure.9 If ankylosis occurs late (causing only slight infraocclusion), the mandibular molar might be left for observation and restored with a composite, onlay, or crown. In the presented case, the extraction was performed because of progressive submergence of the retained tooth in a young patient. As a consequence, the patient required one of the following treatments: orthodontic space closure, mainte-
nance of space for prosthetic restoration postponed until after growth cessation (implant-supported crown or partial denture), or tooth autotransplantation. Autotransplantation was chosen due to contraindications for orthodontic space closure and unfavorable conditions for implant placement (bone defect and patient age). The presence of adequate bone at the recipient site was deemed essential for the performance of the autotransplantation surgery.19 However, in the described case the transplantation was performed to a vertical bone defect caused by the retention of a tooth and its removal. Initial radiography performed before the treatment (see Figs 2 and 5a) and that performed directly after the surgery (see Fig 5b) document a bone defect below the
The International Journal of Periodontics & Restorative Dentistry © 2014 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
671 line connecting the CEJs of adjacent teeth. As a result of this defect, at the time of the surgery, the transplant was placed several millimeters inferior to the occlusal plane. Three years after the surgery the transplanted molar fulfilled the criteria for successful healing, ie, pulp vitality, absence of resorption, and progress of root growth.13 The periodontal tissues were healthy, and radiographs revealed typical features for vital transplanted teeth.11 However, the most important finding was the marginal bone level of the transplanted molar, which was equal to that of the adjacent teeth. It was observed that during eruption of the transplant, the alveolar bone grew interproximally and consequently repaired the bone defect initially caused by the disturbed eruption of the first molar (see Fig 5c). In addition, the CBCT performed 44 months after the surgery proved the presence of normal bone at the buccal and lingual aspects of transplant (see Fig 6). This is in line with another case report that described bone growth around autotransplanted teeth.20 This unique finding suggests that autotransplantation of developing teeth may be a viable option for treating local bone growth defects caused by retained permanent molars when alternative treatment options are not available.
Conclusions The presented case describes vertical bone growth accompanied by the eruption of the developing maxillary third molar, which was autotransplanted to the bone defect.
Should further studies confirm the above findings, this may imply that regeneration of vertical bone defects in sites of tooth infraposition is possible through autotransplantation of a developing tooth. This opens new prospects for the treatment of growing patients with defects caused by tooth eruption disturbances, in whom other treatments are often contraindicated.
Acknowledgments The authors reported no conflicts of interest related to this study.
References 1. Grover PS, Lorton L. The incidence of unerupted permanent teeth and related clinical cases. Oral Surg Oral Med Oral Pathol 1985;59:420–425. 2. Chintakanon K, Boonpinon P. Ectopic eruption of the first permanent molars: Prevalence and etiologic factors. Angle Orthod 1998;68:53–60. 3. Proffit WR, Vig KW. Primary failure of eruption: A possible cause of posterior open bite. Am J Orthod 1981;80:173–190. 4. Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis, diagnosis, and treatment. A literature review. Am J Orthod Dentofacial Orthop 2004;126: 432–445. 5. Raghoebar GM, Boering G, Jansen HW, Vissink A. Secondary retention of permanent molars: A histologic study. J Oral Pathol Med 1989;18:427–431. 6. Nagpal A, Sharma G, Sarkar A, Pai KM. Eruption disturbances: An aetiologicalcum-management perspective. Dentomaxillofac Radiol 2005;34:59–63. 7. Baccetti T. Tooth anomalies associated with failure of eruption of first and second permanent molars. Am J Orthod Dentofacial Orthop 2000;118:608–610. 8. Raghoebar GM, Jansen HW, Jongebloed WL, Boering G, Vissink A. Secondary retention of permanent molars: An assessment of ankylosis by scanning electron and light microscopy. Br J Oral Maxillofac Surg 1992;30:50–55.
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