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Inga Mollen, Thomas Bernhart, Andreas Filippi

Transplantation of teeth after traumatic tooth loss

Inga Mollen,
Dr med dent
Center of Dental
Key words premolar, primary canine, transplantation, trauma Traumatology,
Department of Oral Surgery,
Oral Radiology and Oral
Trauma to the anterior teeth is a frequent reason for tooth loss in children and adolescents. The Medicine,
transplantation of teeth is an established and biological therapy for replacing missing anterior teeth School of Dental Medicine,
University of Basel,
in these age groups. Premolars and primary canines are suitable for replacing anterior teeth in the Basel, Switzerland
maxilla due to their root anatomy and the corresponding emergence prole. This article gives an Thomas Bernhart,
overview on the indications of tooth transplantation in the anterior maxilla, the surgical procedure Prof Dr med dent
Department of Oral Surgery,
and a short survey of the developments in current literature. School of Dental Medicine,
University of Vienna,
Vienna, Austria

Andreas Filippi,
Prof Dr med dent
Introduction Indications Center of Dental
Departement of Oral
The transplantation of teeth is an established bio- There are various reasons for tooth loss in children Surgery, Oral Radiology and
Oral Medicine,
logical treatment option after tooth loss, for exam- and adolescents (Table 1). Trauma is one of the most School of Dental Medicine,
ple through traumas or agenesis of permanent teeth common reasons for missing teeth in the anterior University of Basel,
Basel, Switzerland
particular in children and adolescents. Because there maxilla. If central or lateral incisors are lost due to
are more common procedures, the dentist may in accidents, an extensive dental treatment and at- Correspondence to:
Inga Mollen
many cases not consider tooth transplantation im- tempts to preserve that tooth may have taken place. Center of Dental
mediately. There is a variety of different therapies In these cases, the main objective will be the re- Traumatology,
Department of Oral Surgery,
to the problem of tooth loss; their selection being generation of hard and soft tissue, which was pre- Oral Radiology and Oral
dependent on patient related factors as age, compli- viously lost due to trauma. The transplantation of Medicine,
School of Dental Medicine,
ance and individual preferences. Gaps can be closed autologous teeth, unlike a dental implant, offers the University of Basel,
Hebelstrasse 3
by orthodontic treatment, by placing dental implants potential of generating new bone formation1. Al- CH-4056 Basel, Switzerland
or using xed prosthesis (resin-bonded or conven- though sometimes the lack of hard tissue requires Email:
tional). Especially in children and young adults the a more apical or oral positioning of the donor tooth
element of growth should be kept in mind, which in the recipient site, this location will be corrected
can inuence lasting treatment success. In this age by orthodontic treatment after a new formation of
group the replacement of teeth should not interfere periodontal ligament. Because of their anatomical
with jaw growth. Therefore, tooth transplantation characteristics, premolars of the mandible or maxilla
may represent the therapy of choice, which however or even primary canines are suited for replacement of
might be limited by the availability of an appropriate maxillary incisors. Which tooth complies with the re-
donor site. quirements for transplantation best depends on the
patients age and the stage of root development. In
children between the ages of 10 to 14 years, rst and

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302 Mollen et al Transplantation of teeth after traumatic tooth loss

Table 1 Causes for tooth loss or common locations of tooth agenesis3.

Disease Trauma Agenesis

Destruction by caries or apical periodontitis Avulsion with impossible replantation Maxillary or mandibular premolar
Localised juvenile periodontal disease Post-traumatic resorption Lateral maxillary incisor
Endodontic complication Vertical root fracture Other
Unsuccessful combined orthodontic surgical Ankylosis
therapy in retained maxillary canine

Presurgical diagnostics
A successful transplantation depends on exact ana-
lysis und individual planning prior to surgery. It is a
multidisciplinary approach including orthodontists,
oral surgeons and dentists. The patient should show
good physical conditions. Severe diseases, diseases
with compromised wound healing or blood-clotting
disorders are contraindications for tooth transplanta-
Fig 1 Progressive infraposition in a 25-year-old female tion. The patients compliance should be sufcient
patient 7 years after implant placement.
to perform the surgical intervention in local anaes-
thesia. In case of follow-up interventions (e.g. en-
dodontic treatment, failure of the transplant, ortho-
second premolars have usually reached 50 to 75% dontic treatment), sufcient cooperation for an
of root development and offer good prognosis for outpatient treatment is necessary. Precise analysis of
transplantation. In patients younger than 10 years the available space in the recipient site matching the
with loss of permanent incisors, primary canines crown width of the donor tooth has to be performed
may represent an alternative if premolars are not before transplantation. This has to be carried out
available. This treatment can only be performed clinically and radiologically. In the case of retained
when there are no pronounced signs of physiologic teeth or unclear bone conditions seen in two-di-
root resorption. Compared to transplantation of mensional radiographs, cone beam computed tom-
permanent teeth, revascularisation cannot be ex- ography (CBCT) can be valuable. The interocclusal
pected. Therefore, a titanium post is recommended space and the jaw relation have to be regarded. If the
for retrograde cementation into the root canal of gap for transplantation is not sufcient, space needs
primary canines. This technique is additionally seen to be created through orthodontic treatment. If the
as an extension of the root for a better crown-to- space matches nearly the diameter of the trans-
root-ratio. plant, a tooth stripping can be considered within the
In children and adolescents, the placement of meaning of a gentle reduction in tooth enamel of
dental implants to replace missing teeth is contrain- about 0.5 mm. Dentine exposure should be strictly
dicated in growing parts of the maxilla and mandi- avoided, because of the high risk of invasion of mi-
ble. Especially in the anterior region of the maxilla, croorganisms resulting in pulp necrosis.
implants represent a major risk for aesthetic failure The transplant should also possess a vital peri-
and complications in young people ( 30 years) odontal ligament (PDL). A better prognosis for
(Fig 1). Jemt et al2 stated that movements of teeth the transplant can be seen with teeth that show
could be seen in the anterior maxilla adjacent to an open apical foramen of about 2 mm diameter.
single implants. Females with a long face anatomy The root should have reached a length of approxi-
show the highest risk for tooth movements next to mately 50 to 75%4. Elective treatments like tooth
implants. This nding may be explained by a signi- transplantations require a careful and detailed elu-
cant increase of anterior face height and mandibular cidation. The patient or the parents should sign a
clockwise rotation. detailed informed consent form including risks, po-

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Mollen et al Transplantation of teeth after traumatic tooth loss 303

Table 2 Choice of transplants and their possible destination with the corresponding SAC-classication.

Transplant Possible location for transplantation SAC-classication

Maxillary third molar Maxillary molars (same side) Straightforward
Mandibular premolars Advanced
(Maxillary molar opposite side) Complex
Mandibular third molar Mandibular molars Straightforward
(same side, opposite sides)
Mandibular premolars Advanced
(maybe 90 degree rotation)
Maxillary molars Complex
(maybe 90 degree rotation)
Maxillary primary canine Maxillary incisor Complex
(maybe 180 degree rotation)
Maxillary premolars Other premolars Straightforward
Maxillary incisors Advanced-Complex
(maybe 90 degree rotation)
Mandibular premolars Other premolars Straightforward
Maxillary incisors Advanced-Complex

tential subsequent treatments and possible failure of Surgery

the transplant.
Tooth transplantation is a surgical therapy, which is
mostly done in young patients. The maximum dose
SAC-classication of local anaesthetics needs to be considered by tak-
ing the patients body weight into account. There are
In oral implantology the SAC-classication devel- no reports about adrenalin-containing local anaes-
oped by the ITI (International Team for Implantol- thetics showing negative side effects on success rate
ogy) in 2007 provides guidelines for the clinicians of tooth transplantation.
to categorise implant cases with different levels of An antibiotic therapy (e.g. amoxicillin and cla-
complexity: Straightforward (S), Advanced (A), and vulanic acid) starting prior to surgery should be
Complex (C)5. In analogy, according to Filippi this discussed on an individual basis. Depending on in-
classication can also be used in tooth transplanta- dividual case-related circumstances, the rst steps
tion (Table 2). A Straightforward example is, for of the surgical treatment are a gentle removal of
instance, a transplantation of a maxillary third molar the tooth that is not preservable as well as removal
with immature roots within the same quadrant into of the transplant. A apless approach including a
the position of a rst molar with sufcient bone vol- sharp incision with a microsurgical scalpel (no peri-
ume in all three dimensions. The category Advanced otome) should be carried out. This procedure allows
includes transplantation of maxillary third molars a fast healing of the gingival tissue supported by
into the place of a mandibular premolar as well as primary connection of the blood vessels. To prevent
the placement of a maxillary or mandibular premolar damage to the recipient region, there are tissue pre-
to replace a central maxillary incisor, if there is suf- serving extraction systems available (e.g. Benex, Lu-
cient bone and no occlusal interferences. Complex zern, Switzerland; Zalex, Hohenwarthe, Germany)
cases include transplants of a premolar into the pos- that offer a gentle removal. In erupted teeth with
ition of a central maxillary incisor with interocclusal a single root, a rotational extraction technique may
interferences and/or with bone or tissue deciency, preserve the alveolar bone better than tooth removal
of a third molar into another toothed quadrant than under extensive orofacial movements. Retained or
the donor site, primary canine transplantation (Figs impacted transplants should be as carefully removed
2 to 5), transplantation of teeth to replace a lateral as possible. It has to be ensured that the PDL is
incisor and multiple side-by-side transplantations. not damaged during surgery or during osteotomy.
In selected cases, piezo-surgery may be advisable.

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304 Mollen et al Transplantation of teeth after traumatic tooth loss

Fig 2 Case 1: 8-year-old male patient with a vertical Fig 3 Case 1: Two weeks after removal of tooth 11 and
crown- and root fracture of tooth 11 due to trauma. transplantation of the left primary canine (tooth 63).

Fig 4 Case 1: Radiograph taken 4 months after transplan- Fig 5 Case 1: Clinical situation 8 years after transplantation
tation (left side) and nearly 6 years following transplantation and reconstruction with composite of the primary canine 63
of tooth 63 into the position of the right central incisor. into the position of the right central incisor.

Special forceps with diamond grit reduce ipping of If there has been damage to the root surface of
the tooth during removal. the transplant during surgery, a local therapy with
The removed transplant should be stored im- corticosteroids (no resorb) can be applied. The os-
mediately in a moist and physiologic medium to teoclast activity, which usually is responsible for root
maintain the metabolism of vital cementoblasts and resorption, can be reduced by this approach9. The
broblasts on the root surface. These cells are ne- coronal part of the transplant should be inspected for
cessary in order to avoid ankylosis of the transplant. dentine exposition, if a surgical removal with oste-
Physiological depositories are nutrient cell culture otomy was necessary. Exposed dentinal tubuli offer
media (e.g. Dentosafe, Zahnrettungsbox, Medice, an entry for microorganisms, which can rapidly lead
Iserlohn, Germany; SOS Zahnbox, Zahnrettungs- to pulp necrosis and apical periodontitis in trans-
box, miradent, Duisburg, Germany) to which 1 mg planted teeth.
doxycycline and 1 mg dexamethasone (no resorb, If the recipient site has already healed, there
Medcem, Weinfelden, Switzerland) can be added6. will be the need for preparing a root correspond-
Nutrient cell culture media may help to ush out ing pseudo alveolar socket. This can be performed
toxic breakdown products of tissue and bacteria7. using root-shaped implant burs or surgical round
The above-mentioned approach of applying nutrient burs corresponding in length and width to the root
cell culture medium with additional doxycycline can of the donor tooth. In distinction to implant prepar-
help to improve incorporation of vital tissue through ation, this preparation should be wider in diameter
an open apical foramen into the pulp chamber. This and length than the root of the transplant. There
procedure can duplicate the chance of revascularisa- should be a lateral distance about 0.5 mm to 1 mm
tion of the pulp8. around the transplant towards the alveolar socket.

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Mollen et al Transplantation of teeth after traumatic tooth loss 305

Fig 6 Case 2: Clinical situation immediately after surgery Fig 7 Case 2: The clinical situation 6 weeks following
and xation of the transplant (tooth 44) with a titanium transplantation of tooth 44 and removal of the TTS shows a
trauma splint (TTS). bland dento-gingival healing.

Fig 8 Case 2: Clinical situation approximately 2 years fol- Fig 9 Case 2: Clinical situation 7 years following transplan-
lowing transplantation with a xed orthodontic appliance in tation of tooth 44 to replace the right central incisor, suc-
situ. The transplant was reconstructed using composite ma- cessful orthodontic treatment and composite reconstruction.
terial. The two lateral incisors are missing due to agenesis.

Underneath the root apex, a 2 mm-distance should plants supports the periodontal healing10. A rigid
be maintained towards the alveolar bone. The trans- splint increases the risk for ankylosis of the tooth
planted tooth should be positioned in the socket in and can inuence the revascularisation of pulp tissue
consideration of the optimal adaption of gingival negatively11. The root length in autotransplants with
tissue. To achieve a tight dento-gingival seal around a rigid xation is signicantly negatively inuenced
the transplant, remnants of the dental follicle can be compared to suture splinting. The titanium trauma
left around it. Also the emergence prole has to be splint (TTS) offers an adequate intraoral xation,
evaluated during this positioning. It should be con- which allows physiologic tooth mobility. The design
sidered that sometimes an improved position could of TTS allows a simple application and removal12.
be achieved through rotating the transplant of about Crossing sutures to x a transplant should only be
90 or 180 degrees. The terminal occlusion should used when primary stability is sufcient. This tech-
be inspected after positioning the tooth into the al- nique has been often used for transplantation of
veolar socket. The transplanted tooth should be set premolars, as their crown shape permits a good x-
in slight occlusal contact to the antagonistic teeth or ation by crossing sutures.
in minimal inferior position. A exible metallic splint Emdogain (Straumann, Basel, Switzerland), which
(e.g. TTS; Medartis, Basel, Switzerland) is xed ad- is successfully used during regenerative periodontal
hesively with phosphoric acid gel, bonding and com- therapy, can replace localised acellular cementum13.
posite to the neighbouring teeth for 2 to 6 weeks There is little scientic evidence about the application
(Figs 6 to 9). The duration of splinting depends on of Emdogain in replanted or transplanted teeth, due
the clinical parameters (percussion sound, periotest to lack of randomised controlled trials and clinical
values). The functional occlusal impulse on trans- controlled trials14. In cases of tooth transplantation

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306 Mollen et al Transplantation of teeth after traumatic tooth loss

Fig 10 Case 2: 10-year-old

male patient; series of radio-
graphs: (a) Initial situation
after loss of tooth 11 due
to avulsion; (b) Situation
after transplantation of the
donor tooth 44 into the
position of the right central
incisor (c) nearly 6 years
following transplantation;
pulp obliteration is a sign of
revascularisation of the pulp

with traumatic removal of the transplant or damage tion of teeth is generally acknowledged as a treat-
to the root surface, Emdogain might improve the ment success15,16. Pulp obliteration can also be seen
outcome of the transplantation1. The root surface 3 to 6 months after transplantation (Fig 10)1. In case
must not be conditioned with EDTA. signs of pulp necrosis become apparent, root canal
treatment should be initiated immediately. In im-
mature teeth with incomplete formed roots, calcium
Recall and prognosis hydroxide should be applied as an intracanal dress-
ing to enable apexication. Endodontic complica-
Paracetamol or non-steroidal anti-inammatory tions show better response to treatment than peri-
drugs (NSAIDs) are advisable for approximately a odontal infections. For the comparison of literature,
few days after surgery. A systemic antibiotic treat- it is important to dene and to clarify the terms of
ment shows no signicant inuence on the outcome survival and success rate. The survival rate implies
of tooth transplantation and is therefore not manda- that the transplant is still in situ, whether or not signs
tory4. During postsurgical recall, the patient should of complications like ankylosis, apical periodontitis or
maintain ideal oral hygiene as plaque accumulation root resorption are present. In contrast, the success
degrades periodontal healing. Subsidiary chemical rate excludes transplanted teeth with periodontal
plaque control should be performed with a 0.2% or endodontic complications. There are several het-
chlorhexidine mouth rinse. Sutures can be removed erogeneous publications of success and survival of
about 7 days after surgery. Immature transplanted transplanted teeth differing in the kind of tooth as
teeth especially should be evaluated regularly during well as the area of reception and different xation
the rst postsurgical months. techniques.
Periotest values can demonstrate the develop- Mendoza et al reported a success rate of 80%
ment of periodontal healing and bone formation. after a 1-year-follow-up of transplantation of pre-
These values can be compared to those of the neigh- molars to substitute maxillary central incisors. Teeth
bouring dentition. A clear sign for ankylosis are de- with two-thirds root development showed the best
creasing periotest values of 0 or less. Radiographs results. Additionally, a positive correlation between
to control root development or signs for resorption, complete pulp obliteration and further root forma-
clinical evaluation and sound of percussion are rec- tion and viability of the transplanted tooth was de-
ommended annually after a successful healing pro- scribed by Mendoza et al17. Factors affecting the
cess. Evaluation of pulp regeneration takes more success of transplantation of teeth with complete
time than periodontal healing. Approximately after 3 root formation were examined by Sugai et al18. They
to 6 months, there might be a positive pulp sensitiv- found an average 5-year-survival rate of 84%. It was
ity test or radiographic signs of further root develop- stated that patient age above 40 years, molar teeth
ment that demonstrates successful revascularisation. as donor, probing pocket depth of 4 mm or more,
In the literature, pulp obliteration after transplanta- root canal treatment of the graft, teeth with more

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Mollen et al Transplantation of teeth after traumatic tooth loss 307

than one root and suture xation were signicantly 5. Dawson A, Chen S. The SAC Classication in Implant Den-
tistry Straightforward - Advanced Complex. Quintessence
related with unsuccessful results of transplantation. Publishing, 2009; 59.
The main reasons for transplant failure were insuf- 6. Pohl Y, Filippi A, Kirschner H. Results after replantation of
avulsed permanent teeth. II. Periodontal healing and the
cient initial healing and replacement root resorption role of physiologic storage and antiresorptive-regenerative
associated with periodontal inammation. Other therapy. Dent Traumatol 2005;21:93101.
7. Pettiette M, Hupp J, Mesaros S, Trope M. Periodontal
possible risk factors published by Yoshino et al were healing of extracted dogs teeth air-dried for extended pe-
a reduced dentition of 25 or less teeth after surgical riods and soaked in various media. Endod Dent Traumatol
intervention, as well as tooth loss due to periodontal 1997;13:113118.
8. Yanpiset K, Trope M. Pulp revascularization of replanted
disease next to the transplanted tooth. According immature dog teeth after different treatment methods.
to their ndings, in most cases the circumstance of Endod Dent Traumatol 2000;16: 211217.
9. Sae-Lim V, Metzger Z, Trope M. Local dexamethasone im-
adjacent tooth loss led to further attachment loss proves periodontal healing of replanted dogs teeth. Endod
at the transplant site19. Kim et al20 found a failure Dent Traumatol 1998;14: 232236.
10. Mine K, Kanno Z, Muramoto T, Soma K. Occlusal forces
rate of 4.5% in short to intermediate observation promote periodontal healing of transplanted teeth and
period. Another study conducted by Czochrowska et prevent dentoalveolar ankylosis: an experimental study in
rats. Angle Orthod 2005;75:637644.
al16 who analysed mainly premolars as donor teeth, 11. Bauss O, Schilke R, Fenske C, Engelke W, Kiliaridis S.
showed a long-term transplant survival rate of 90% Autotransplantation of immature third molars: inuence
of different splinting methods and xation periods. Dent
and a success rate of 79%. Traumatol 2002;18:322328.
12. von Arx T, Filippi A, Buser D. Splinting of traumatized teeth
with a new device: TTS (Titanium Trauma Splint). Dent
Traumatol 2001;17:180184.
Conclusion 13. Hammarstrm L. Enamel matrix, cementum dexelopment
and regeneration. J Clin Periodontol 1997;24:658668.
14. Wiegand A, Attin T. Efcacy of enamel matrix derivatives
Overall, tooth transplantation offers the possibility (Emdogain) in treatment of replanted teeth a sys-
to replace a missing tooth in a biological way. Espe- tematic review based on animal studies. Dent Traumatol
cially in cases of traumatic tooth loss in children and 15. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A
adolescent during jaw growth, it may represent a long-term study of 370 autotransplanted premolars. Part II.
Tooth survival and pulp healing subsequent to transplanta-
good alternative for prosthodontics or orthodontic tion. Eur J Orthod 1990;12:1424.
therapy. A thorough diagnostic and treatment plan- 16. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU.
Outcome of tooth transplantation: survival and success
ning is essential for treatment success. rates 17-41 years post-treatment. Am J Orthod Dentofacial
Orthop 2002;121:110119.
17. Mendoza-Mendoza A, Solano-Reina E, Iglesias-Linares A,
Garcia-Godoy F, Abalos C. Retrospective long-term evalu-
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