CLINICIAN'S CORNER
Autotransplantion of a displaced mandibular
second premolar to its normal position
Young-Seok Park,a Min-Ho Jung,b and Won-Jun Shonc
Seoul, Korea
The patient was a 13-year-old Korean girl who had a displaced mandibular second premolar. She was reluctant
to undergo a lengthy orthodontic treatment and opted instead for transplantation of the premolar to its usual site.
On the basis of computed tomography, a replica tooth model was manufactured to shorten the extraoral time,
and a root canal treatment was performed because root formation was complete. No negative signs or symptoms
were found during a 3-year follow up. Autotransplantation for this patient obviated the need for orthodontic trac-
tion and prosthetic therapy. (Am J Orthod Dentofacial Orthop 2013;143:274-80)
T
ransposing submerged or ectopically positioned
permanent teeth to their correct positions poses
diagnostic as well as treatment-planning di-
lemmas. Although orthodontic solutions might seem
to be the simplest and most successful remedies, they
sometimes have unfavorable results.1
After the third molars and the maxillary canines, the
most commonly impacted tooth is the mandibular sec-
ond premolar, with a reported impaction incidence of
2.1% to 2.7%.2 The frequency of intrabony distal migra-
tion for this tooth is 0.25%, and it occurs more often in
females than in males. Distal displacement and intrab-
ony migration of the mandibular second premolar are
idiopathic and have been reported to occur only unilat-
erally.3 The mechanisms that cause migration of teeth
are still obscure. A tooth is considered to have migrated
only after its normal eruption has been prevented and it
has left its normal site of development in the bone.4
Impaction can cause damage to the roots of neighboring
teeth, and the damage can be so severe that these
From the School of Dentistry, Seoul National University, Seoul, Korea.
a
Assistant professor, Department of Oral Anatomy and Dental Research Institute.
b
Clinical professor, Department of Orthodontics; private practice, Seoul, Korea.
c
Associate professor, Department of Conservative Dentistry and Dental Research
Institute.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Supported by the Basic Science Research Program through the National Research
Foundation of Korea funded by the Ministry of Education, Science, and Technol-
ogy (2010-0023586).
Reprint requests to: Won-Jun Shon, Department of Conservative Dentistry,
School of Dentistry, Seoul National University, 28, Yeongeuon-dong, Jongno-
gu, Seoul, 110-749, Korea; e-mail, anarobo@nate.com.
Submitted, July 2011; revised and accepted, November 2011.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2011.11.025
274
neighboring teeth are subsequently lost. Furthermore,
the tissue around these impacted teeth might undergo
cystic changes. The impaction of teeth can also lead to
esthetic problems.
Orthodontic treatment options for impacted and mi-
grated second premolars include open or closed surgical
exposure and subsequent alignment, which aims to
bring the tooth into occlusion.5 Management of this
kind is both time-consuming and expensive. Attempts
to rescue a deeply impacted and migrated second pre-
molar can also cause substantial risks to the roots of
adjacent teeth.6 Sometimes, interceptive extraction of
the deciduous tooth is performed to encourage sponta-
neous eruption, although definitive evidence to support
this procedure is still lacking. Observation and monitor-
ing of these teeth are often performed in case they are
grossly misplaced, and attempts to move or remove
them could cause damage to adjacent structures.7 Need-
less to say, extraction of these teeth is often the treat-
ment selected, whether by the recommendation of the
clinician or the patient's own choice.8
On the other hand, autotransplantation, which was
originally introduced in Scandinavian countries more
than 40 years ago, involves atraumatic surgical removal
of a tooth from its impacted or ectopic site, the creation
of a socket at the donor site, and reimplantation of the
tooth into the correct position in the alveolus.9 This
procedure is generally indicated for a missing tooth
with hopeless prognosis in a mouth where an appropriate
donor tooth can be used without negative effects be-
cause of its loss from its position in the arch.10 The 3
main indications suggested by Zachrisson et al11 for au-
totransplantation of developing premolars are unevenly
distributed multiple agenesis, agenesis of the mandibular
second premolars in low-angle face types with normal or
Park, Jung, and Shon
Fig 1. Pretreatment panoramic radiograph and intraoral radiograph. The patient had a retained second
deciduous molar and a severely displaced second permanent premolar in the right side of mandible.
The crown of the displaced premolar was located nearly at the mesial root of the second molar.
weak facial profiles, and accidentally lost or congenitally
missing maxillary central and lateral incisors. The auto-
transplantation of developing premolars for replacement
of missing teeth, especially the maxillary incisors, is
a well-established procedure and has been demonstrated
to have a high survival rate.12-22 Although the available
information regarding the long-term stability of auto-
transplanted teeth with complete root formation is not
adequate, autotransplantation is a treatment modality
that has received increasing attention in recent years be-
cause of its innate advantages.23,24
This clinical example presents the successful auto-
transplantation of the mandibular second premolar to
its normal position by using computed tomography
and a computer-aided rapid prototyping model, conse-
quently obviating the need for orthodontic treatment.
CLINICAL EXAMPLE
The patient was a 13-year-old Korean girl with a chief
complaint of an ectopic mandibular right second premo-
lar. She was referred from a local orthodontic clinic to
our hospital for interdisciplinary treatment planning.
Originally, she was referred to the orthodontist from a lo-
cal general dentist, who found the malpositioned per-
manent tooth during a routine dental examination of
her retained deciduous molar with secondary caries
and an apical lesion. The patient had no peculiar preden-
tal history except for the fillings in both maxillary first
permanent molars. She had a retained second deciduous
molar with secondary caries under a stainless steel
crown. She had no orthodontic history but had good oc-
clusion and a good facial profile. The initial panoramic
radiographs (Fig 1) showed that her right second perma-
nent premolar was located deep under the root of the
mandibular right first and second molars and could
not be seen intraorally.
A treatment plan was established for the patient in
thorough discussions between the Departments of
Orthodontics, Oral and Maxillofacial Surgery, and
American Journal of Orthodontics and Dentofacial Orthopedics
275
Conservative Dentistry at Seoul National University in
Korea. It was decided that the girl would not undergo or-
thodontic treatment for several reasons. First, her pre-
molar was located so far from its original position and
so deep in the buccal vestibule that it would be difficult
to tract the tooth, although it was not impossible. In
other words, traction of the premolar might harm the
roots of the adjacent teeth, and the prolonged duration
of the orthodontic treatment might cause considerable
resorption of the tooth.25-27 Second, the patient and
her parent were not enthusiastic about the potentially
long duration of the orthodontic treatment since they
thought that the patient already had a good profile.
For these reasons, autotransplantation was chosen
for the patient as an alternative treatment plan. Because
her displaced premolar showed almost complete root
formation, the need for a root canal treatment and the
possibility of failure for this procedure was described
to the patient and her parent in detail before they gave
consent.
Three-dimensional computed tomography data were
used to fabricate a replica graft tooth, which enhanced
the preparation procedure and shortened the extraoral
time of the transplant (Fig 2). The computed tomogra-
phy system, Somatom Sensation 10 (Siemens, Pforz-
heim, Germany), was used, and the 3-dimensional
model was constructed by Vworks and OnDemand3D
(Cybermed, Seoul, Korea). The computed tomography
protocol used for this procedure involved a slit thickness
of 0.5 mm. Before the autotransplantation, the decidu-
ous second molar was extracted, and a healing period of
3 months was allowed because of the apical lesion.
On the day of the surgery, the recipient socket was
prepared with copious saline solution irrigation and
surgical burs for the implant (Friadent; Dentsply,
Mannheim, Germany), which was the approximate
size of the replica tooth (Fig 3). After confirming the
recipient socket with the replica tooth, the displaced
premolar was extracted carefully. The proximal surface
February 2013  Vol 143  Issue 2
276 Park, Jung, and Shon

Fig 2. Pretreatment computed tomography image and computer-aided rapid prototyping model of the
mandible and the premolar. From the computed tomography data, the target section of the patient's
mandible was fabricated to identify the 3-dimensional location of the premolar, and the premolar model
was fabricated separately to prepare the recipient site.

Fig 3. Preparation of the recipient site. A surgical bur of the approximate size of the replica tooth was
chosen for preparation. After preparation, the recipient site was checked to accommodate the replica
tooth properly.

of the extracted premolar was contoured slightly be-
cause there were interferences of the contact points
of the adjacent teeth that tilted toward the extraction
site. The premolar was fitted in the prepared trans-
plantation site (Figs 4 and 5). The external exposure
time of the premolar was about 3 minutes. No
additional bone graft was needed. Tight and close
adaptation of the flaps was achieved by sutures. A sur-
gical dressing was applied to protect the transplant
against infection. The transplant was fixed with
a wire and resin splint, and the occlusal interference
was corrected.

February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Park, Jung, and Shon
Fig 4. Extraction of the premolar. After flap elevation, the premolar was carefully removed so as not to
damage the periodontal ligament.
Fig 5. Positioned transplant. The donor tooth was fitted in the prepared site after slightly contouring the
proximal surface because of interference.
Fig 6. First day of root canal treatment. The root canal
was filled with calcium hydroxide.
Two weeks later, the root canal treatment was initi-
ated. On the first day of the endodontic treatment, the
canal was opened, cleaned, and filled with a creamy
mix of calcium hydroxide spun into the canal with a len-
tulo spiral (Fig 6). At the next visit, the canal was filled
with gutta-percha and sealer after complete canal
instrumentation (Fig 7). Restorative treatment began 2
months after the root canal treatment. A definitive
restoration was made of ceramic zirconia. During the
treatment period, no specific symptoms were observed,
except for pain on the day of surgery.
Follow-up appointments were made at 6, 18, and 36
months after the autotransplantation procedures (Figs 8
American Journal of Orthodontics and Dentofacial Orthopedics
277
Fig 7. Completion of the root canal treatment. At the sec-
ond visit for endodontic treatment, the canal was filled
with gutta-percha and sealer.
and 9). The transplant was evaluated by radiographs,
periodontal probing, and visual inspections. The trans-
plant met the success criteria28 adapted from Schwartz
et al,29 Kristerson and Lagerstr€ om,16 and Kugelberg
et al, up to the final follow-up visit.
17
According to a lateral cephalogram (Fig 10) taken at
the recall visit at 36 months, the tooth demonstrated
clinically good occlusion, and the patient had an accept-
able facial profile, although it was not perfect. Cephalo-
metric analysis showed an SNA of 80.71 , an SNB of
79.79 , an ANB of 0.93 , a Bj€ork sum of 395.91 , and
an interincisal angle of 115.32 . The clinical
February 2013  Vol 143  Issue 2
278
Fig 8. Intraoral photos at the 3-year follow-up. The patient and the parent were satisfied with the result.
Fig 9. Panoramic radiograph at the 3-year follow-up. The
transplant showed no pathology and no symptoms.
examination showed bilateral Angle Class II molar rela-
tionships and a 1-mm overbite and a 1.5-mm overjet.
DISCUSSION
In the clinical decision-making process, treatment
planning should be established after considering every
aspect of the resources from the clinical and basic
science researchers, clinicians, and patient. In this way,
the treatment will reflect patient-centered care.30 The
questions confronting each clinician are when to apply
each treatment modality and how to use these therapeu-
tic approaches to their maximum benefit for the pa-
tient.31 Although our treatment planning was based
on the concrete evidence, even the best evidence some-
times has different meanings to each interdisciplinary
decision maker.32
Autotransplantation is a well-documented, evi-
dence-based dental practice, and its efficiency has
been internationally proven.33 For the patient described
in this report, no other alternative treatment except
orthodontics could be considered preferentially because
the patient was too young to accommodate a single
implant treatment. An osseointegrated implant is anky-
losed to the bone; thus, it cannot follow the vertical
movements of the neighboring teeth.11 In contrast,
a transplanted tooth has a normal periodontal
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Park, Jung, and Shon
Fig 10. Cephalometric radiograph at the 3-year follow-
up. An acceptable facial profile was seen on the radio-
graph. The patient and her parent stated that they
believed that orthodontic treatment was unnecessary.
membrane. Therefore, it can not only erupt in synchrony
with the others, but also be used in orthodontic treat-
ment afterward.34 In addition, a transplanted tooth re-
covers its proprioceptive function, and the patient
retains a natural chewing sensation.37 There have been
numerous reports demonstrating the superiority of
autotransplantation over resin-retained bridge or con-
ventional fixed bridge treatment.8,28,34-40
Transplantation is not usually the first line of treat-
ment for patients with impacted teeth and should not
be, because there are usually more predictable ortho-
dontic treatments for most patients. However, trans-
plantation could be an option in specific situations:
eg, for teeth that are markedly displaced or for patients
who are reluctant to wear orthodontic appliances or
undergo prolonged treatment.8 Other factors must be
considered: adequate space for the transplant, the prog-
nosis of the transplant, the potential for atraumatic
removal, and so on. To our regret, the displaced premo-
lar in our patient was discovered so late that its root de-
velopment was complete. The pulp in fully developed
transplants cannot regenerate.41 Therefore, we had no
Park, Jung, and Shon
choice but to perform root canal treatment. Watanabe
et al42 recommended that tooth transplantation should
be performed before the completion of root develop-
ment, since they demonstrated that the survival rate of
transplants with complete root formation was inferior
to that of transplants with incomplete root formation,
although it was still as high as 86.8% for a mean obser-
vation time of 9.2 years. They also stated that the quality
of root filling was important for the prognosis of a trans-
plant, since inadequate root fillings were found in most
failed transplants or in transplants with pathology.
Several reports have demonstrated the importance of
limiting the extraoral time of donor teeth, especially ma-
ture teeth.24,43 Lee et al43 introduced the computer-
aided rapid prototyping model in autotransplantation.
In addition to saving operation time, they underlined
the importance of preventing unnecessary damage to
a donor tooth that can occur during checking for fit in
the prepared site. Honda et al44 also explained the ad-
vantages of using a replica graft tooth to shorten the
time of the procedure. For this reason, we used a replica
tooth for our patient; this seemed to decrease the expo-
sure time to about 3 minutes. Clear-cut segregation of
the 3-dimensional donor tooth shell from the embedded
jaw bone is important for the reproducibility of the
model. Before surgery, the detailed position and the
available bone volume of the recipient site were carefully
assessed on the computer-aided rapid prototyping
model of the mandible. This procedure also allowed
the operator to practice real bone contouring of the re-
cipient site before the actual surgery.
CONCLUSIONS
The treatment results for this patient indicate that au-
totransplantation of a displaced premolar obviated the
need for orthodontic treatment, although the follow-
up time was not sufficient for a definitive conclusion.
Andreasen et al33 stated that autotransplantation
appears to be the most biologic approach apart from or-
thodontic gap closure for missing teeth. Baviz11 pointed
out that this procedure is generally undervalued but not
for good reasons. The lack of regard for autotransplanta-
tion might be due to the different experiences of dentists
themselves or the biases of teachers or peers with whom
orthodontists have discussed this procedure.42 However,
autotransplantation should be considered as an option
in specific cases of ectopic teeth, as shown by the clinical
and experimental evidence for more than 40 years.
REFERENCES
1. Spieker RD. Submerged permanent teeth: literature review and
case report. Gen Dent 2001;49:64-8.
American Journal of Orthodontics and Dentofacial Orthopedics
279
2. Oikarinen VJ, Julku M. Impacted premolars. An analysis of 10,000
orthopantomograms. Proc Finn Dent Soc 1974;70:95-8.
3. Shapira Y, Kuftinec MM. Intrabony migration of impacted teeth.
Angle Orthod 2003;73:738-43.
4. Shapira Y, Borell G, Kuftinec MM, Stom D, Nahlieli O. Bringing im-
pacted mandibular second premolars into occlusion. J Am Dent
Assoc 1996;127:1075-8.
5. Thilander B, Thilander H. Impacted premolars. Trans Eur Orthod
Soc 1976;1:167-75.
6. Kyung SH, Hwang CJ. Diagnosis and treatment plan of maxillary
impacted canine. Korean J Orthod 1993;23:165.
7. Ericson S, Kurol PJ. Resorption of incisors after ectopic eruption of
maxillary canines: a CT study. Angle Orthod 2000;70:415-23.
8. Patel S, Fanshawe T, Bister D, Cobourne MT. Survival and success
of maxillary canine autotransplantation: a retrospective investiga-
tion. Eur J Orthod 2011;33:298-304.
9. Harzer W, R€ uger D, Tausche E. Autotransplantation of first premo-
lar to replace a maxillary incisor—3D-volume tomography for eval-
uation of the periodontal space. Dent Traumatol 2009;25:233-7.
10. Tsukiboshi M. Autotransplantation of teeth: requirements for pre-
dictable success. Dent Traumatol 2002;18:157-80.
11. Zachrisson BU, Stenvik A, Haanaes HR. Management of missing
maxillary anterior teeth with emphasis on autotransplantation.
Am J Orthod Dentofacial Orthop 2004;126:284-8.
12. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R, Bayer T, Schwartz O.
A long-term study of 370 autotransplanted premolars. Part I. Sur-
gical procedures and standardized techniques for monitoring heal-
ing. Eur J Orthod 1990;12:3-13.
13. 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.
14. Andreasen JO, Paulsen HU, Yu Z, Schwartz O. A long-term study of
370 autotransplanted premolars. Part III. Periodontal healing sub-
sequent to transplantation. Eur J Orthod 1990;12:25-37.
15. Andreasen JO, Paulsen HU, Yu Z, Bayer T. A long-term study of
370 autotransplanted premolars. Part IV. Root development sub-
sequent to transplantation. Eur J Orthod 1990;12:38-50.
16. Kristerson L, Lagerstr€om L. Autotransplantation of teeth in cases
with agenesis or traumatic loss of maxillary incisors. Eur J Orthod
1991;13:486-92.
17. Kugelberg R, Tegsjo U, Malmgren O. Autotransplantation of 45
teeth to the upper incisor region in adolescents. Swed Dent J
1994;18:165-72.
18. Paulsen HU, Andreasen JO, Schwartz O. Pulp and periodontal
healing, root development and root resorption subsequent to
transplantation and orthodontic rotation: a long-term study of
autotransplanted premolars. Am J Orthod Dentofacial Orthop
1995;108:630-40.
19. Lundberg T, Isaksson S. A clinical follow-up study of 278 auto-
transplanted teeth. Br J Oral Maxillofac Surg 1996;34:181-5.
20. Paulsen HU, Andreasen JO. Eruption of premolars subsequent to
autotransplantation. A longitudinal radiographic study. Eur J Or-
thod 1998;20:45-55.
21. Stenvik A, Zachrisson BU. Orthodontic closure and transplantation
in the treatment of missing anterior teeth. An overview. Endod
Dent Traumatol 1993;9:45-52.
22. Marcusson KA, Lilja-Karlander EK. Autotransplantation of premo-
lars and molars in patients with tooth aplasia. J Dent 1996;24:
355-8.
23. Sugai T, Yoshizawa M, Kobayashi T, Ono K, Takagi R, Kitamura N,
et al. Clinical study on prognostic factors for autotransplantation
February 2013  Vol 143  Issue 2
280
of teeth with complete root formation. Int J Oral Maxillofac Surg
2010;39:1193-203.
24. Bae JH, Choi YH, Cho BH, Kim YK, Kim SG. Autotransplantation of
teeth with complete root formation: a case series. J Endod 2010;
36:1422-6.
25. Segal GR, Schiffman PH, Tuncay OC. Meta-analysis of the
treatment-related factors of external apical root resorption. Or-
thod Craniofac Res 2004;7:71-8.
26. Reitan K. Initial tissue behavior during apical root resorption. An-
gle Orthod 1974;44:68-82.
27. Mirabella AD,  Artun J. Risk factors for apical root resorption of
maxillary anterior teeth in adult orthodontic patients. Am J Orthod
Dentofacial Orthop 1995;108:48-55.
28. Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of
tooth transplantation: survival and success rates 17-41 years post-
treatment. Am J Orthod Dentofacial Orthop 2002;121:110-9.
29. Schwartz O, Bergmann P, Klausen B. Resorption of autotrans-
planted human teeth: a retrospective study of 291 transplanta-
tions over a period of 25 years. Int Endod J 1985;18:119-31.
30. Schouten BC, Eijkman MA, Hoogstraten J. Information and partic-
ipation preferences of dental patients. J Dent Res 2004;83:961-5.
31. Fugazzotto PA. Evidence-based decision making: replacement of
the single missing tooth. Dent Clin North Am 2009;53:97-129, ix.
32. Bauer J, Spackman S, Chiappelli F, Prolo P. Interdisciplinary re-
sources optimize evidence-based dental practice. J Evid Based
Dent Pract 2005;5:67-73.
33. Andreasen JO, Schwartz O, Kofoed T, Daugaard-Jensen J. Trans-
plantation of premolars as an approach for replacing avulsed teeth.
Pediatr Dent 2009;31:129-32.
34. Ghassemi M, Jamilian A, Fritz U, Riediger D, Ghassemi A. Ortho-
dontic treatment after autotransplantation. Angle Orthod 2011;
81:721-5.
35. Priest GF. Failure rates of restorations for single-tooth replace-
ment. Int J Prosthodont 1996;9:38-45.
February 2013  Vol 143  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Park, Jung, and Shon
36. Baviz JB. Autotransplantation of teeth: a procedure that gets no
respect. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;
110:441.
37. Czochrowska EM, Stenvik A, Album B, Zachrisson BU. Autotrans-
plantation of premolars to replace maxillary incisors: a comparison
with natural incisors. Am J Orthod Dentofacial Orthop 2000;118:
592-600.
38. Salinas TJ, Block MS, Sadan A. Fixed partial denture or sin-
gle-tooth implant restoration? Statistical considerations for
sequencing and treatment. J Oral Maxillofac Surg 2004;62:
2-16.
39. Djemal S, Setchell D, King P, Wickens J. Long-term survival char-
acteristics of 832 resin-retained bridges and splints provided in
a post-graduate teaching hospital between 1978 and 1993. J
Oral Rehabil 1999;26:302-20.
40. Holm-Pedersen P, Lang NP, Muller F. What are the longevities of
teeth and oral implants? Clin Oral Implants Res 2007;18(Supp 3):
15-9.
41. Kim E, Jung JY, Cha IH, Kum KY, Lee SJ. Evaluation of the
prognosis and causes of failure in 182 cases of autogenous tooth
transplantation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2005;100:112-9.
42. Watanabe Y, Mohri T, Takeyama M, Yamaki M, Okiji T, Saito C,
et al. Long-term observation of autotransplanted teeth with
complete root formation in orthodontic patients. Am J Orthod
Dentofacial Orthop 2010;138:720-6.
43. Lee SJ, Jung IY, Lee CY, Choi SY, Kum KY. Clinical application of
computer-aided rapid prototyping for tooth transplantation.
Dent Traumatol 2001;17:114-9.
44. Honda M, Uehara H, Uehara T, Honda K, Kawashima S,
Yonehara Y. Use of a replica graft tooth for evaluation before
autotransplantation of a tooth. A CAD/CAM model produced using
dental-cone-beam computed tomography. Int J Oral Maxillofac
Surg 2010;39:1016-9.