ARTICLE IN PRESS

Guidelines for autotransplantation of

developing premolars to the anterior
maxilla
Ewa Monika Czochrowska, and Pawe» Plakwicz

Loss of a permanent maxillary central incisor in a young patient is a thera-

peutic challenge for dental professionals. Autotransplanted developing pre-
molars replacing missing maxillary incisors provide predictable long-term
results and assure bone preservation during growth. Moreover, they can be
successfully transformed to the morphology of the missing incisors, which is
very important since these teeth are placed centrally in the esthetic zone.
Comprehensive interdisciplinary treatment planning is necessary, combining
a thorough evaluation of the occlusion and the profile, existing indications
for premolar removal, space conditions, and the optimal match between the
donor tooth and the recipient site. Orthodontic space management before
and after surgery is often needed to create favorable conditions for donor
accommodation, and to establish both normal occlusion and a good esthetic
result. Monitoring of pulpal and periodontal healing and root development
after transplantation of developing premolars is mandatory during follow-up
appointments. (Semin Orthod 2020; &:1–12) © 2020 Elsevier Inc. All rights
reserved.

Introduction The advantages of this method include immedi-

ate replacement of a missing tooth, good adapta-
ne of the most important indications for
O tooth autotransplantation is traumatic loss
of maxillary incisors in young patients. Upon the
tion of the transplanted tooth to growth changes,
and normal response to orthodontic forces.
These features are very important in children
loss of an upper anterior tooth, patients and
and young adolescents for whom dental implants
parents are usually very alarmed and seek expert
are generally contraindicated.6-8 Transplanted
help with the main request to explain all possible
developing premolars have a good potential for
treatment options, and to select the best solution
long-term preservation of hard and soft peri-
for the individual situation. Gaining informed
odontal tissues.3,9 Orthodontic mesialization of
consent after a thorough discussion with patients
lateral incisors, which is another viable alterna-
and parents/guardians about potential complica-
tive to replace a missing central incisor in a
tions and alternative solutions must precede the
young patient, is a long and complex treatment
initiation of any treatment.
after the eruption of all permanent teeth.10
Autotransplanation of developing premolars
Moreover, tooth width at the gingival level is usu-
has been reported to be a successful long-term
ally more favorable for premolars than for lateral
treatment alternative in growing patients with
incisors, which is an important factor for satisfac-
congenitally missing or traumatically lost teeth.1-5
tory esthetics of the restoration to resemble the
missing central incisor.10,11
Associate Professor, Department of Orthodontics, Medical Univer-
Developing premolars have good surgical
sity of Warsaw, Poland; Associate Professor, Department of Periodon-
tology, Medical University of Warsaw, Poland. access, which facilitates their gentle removal - a
Corresponding author: Ewa Czochrowska, Department of Ortho- crucial predictor for successful outcome.12-14 In
dontics, Medical University of Warsaw, ul. Binieckiego 6, 02-097 addition, premolars are frequently extracted for
Warsaw, Poland. E-mail: [email protected] orthodontic purposes, which is another reason
© 2020 Elsevier Inc. All rights reserved. why they can serve as tooth replacements in case
1073-8746/12/1801-$30.00/0
of need.15 When tooth transplantation is
https://doi.org/10.1053/j.sodo.2020.01.007

Seminars in Orthodontics, Vol &, No &, 2020: pp 1 12 1

 ARTICLE IN PRESS

2 Czochrowska and Plakwicz

considered as an alternative to replace traumati- Donor selection

cally lost maxillary incisors, developing premo-
Selection of a premolar as a donor tooth to
lars with 1/2 to 3/4 of the final root length are
replace a missing maxillary incisor, depends on:
the best donors for a successful outcome.16,17
Dental injuries often occur in children at the
- orthodontic indications for its removal,
time of incomplete premolar root development,
- surgical assessment of the optimal match
which may correspond well with the possibility of
between the donor tooth and the recipient site,
using these teeth as donors to replace trauma-
- long-term prognosis, and
tized incisors (Figs. 1 3).

Figure 1. A 9-year old boy sought orthodontic treatment for his unerupted maxillary left central incisor and
reverse overjet (A, B). The panoramic radiograph evidenced an impacted, dilacerated maxillary incisor on the left
side (C), which was scheduled for extraction due to its unfavorable crown-to-root angulation. Due to the patient’s
Class III tendency, autotransplantation of the unerupted mandibular left first premolar (circle) was planned to
substitute the dilacerated incisor The transplanted premolar did not erupt 8 months after the transplantation and
therefore orthodontic extrusion was performed to confirm the presence of ankylosis (D), which was not clearly vis-
ible on the intraoral radiograph (E). The panoramic radiograph taken after confirmation of ankylosis of the trans-
plant, showed that the mandibular right first premolar was still unerupted (circle) and that its root development
was favorable for a second premolar transplantation (2/3 root growth completed) (F). The ankylosed transplant
was extracted and the second transplantation was performed. The transplanted mandibular premolar erupted
spontaneously into occlusion after 4 months (G). Radiographic signs of pulp obliteration and root growth were
detected (H, I). Space opening was performed before reshaping of the transplant in order to secure an optimal
match between its width and the width of the adjacent natural central incisor (J). A direct composite build-up was
placed following the long axis of the transplant and matching the length of the reference incisor (K). After ortho-
dontic treatment normal overjet and overbite were achieved (L). Pulp obliteration of the transplanted premolar is
present 2 years after the surgery (M).
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Guidelines for autotransplantation of developing premolars to the anterior maxil 3

Figure 1. Continued

- careful weighing of all pros and cons com- While maxillary second premolars are a good
pared with other treatment modalities. choice in patients with Class II malocclusion, man-
dibular premolars are the better choice in patients
Comprehensive interdisciplinary evaluation with Class III malocclusions (Fig. 1). In patients
of a prospective candidate is mandatory to with dental Class I relationships and missing maxil-
select the donor tooth, which will have the lary central incisors, it is advantageous to choose
most favorable prognosis for successful heal- the upper second premolars, because space closure
ing, satisfactory esthetics, and good function in in the lower arch is more difficult, even if skeletal
the long term. temporary anchorage devices (TADs) are utilized.
Sometimes, after removal of the maxillary second
premolars, the remaining spaces close spontane-
Orthodontic indications
ously by mesialization and rotation of the first
Comprehensive evaluation of the individual char- molars around their palatal root. For each patient
acteristics of each patient include: occlusion and radiological examination using cone-beam com-
profile, space conditions, the number of teeth miss- puted tomography (CBCT) is mandatory to evalu-
ing, the availability of suitable donors, post-treat- ate individual morphological variations of the
ment stability and patient’s expectations. premolars in order to assess the best match
Preferably, extraction of a donor tooth should also between the donor and the recipient site.
be indicated from the orthodontic perspective, Unilateral replacement of a central incisor
and not only because of incisor loss.18 In this case, requires management of the asymmetry created
the general indications for the selection of a donor in the dental arch after removal of a donor pre-
premolar to replace a missing maxillary central molar from one quadrant. Compensatory extrac-
incisor are the same as orthodontic indications for tions or the use of TADs are effective treatment
premolar extraction. Upper first premolars are less strategies to assist orthodontic tooth movements,
appropriate as donors because of their morphology and to obtain normal dental relationships after
and the arising difficulty to accommodate a dou- premolar transplantation for substitution of a sin-
ble-rooted premolar in the anterior maxilla. gle incisor loss. If spontaneous space closure at
Reportedly, these teeth have a lower potential for the donor site is intended, upper second premo-
successful healing after autotransplanation.19,20 lars are usually the best choice.
 ARTICLE IN PRESS

4 Czochrowska and Plakwicz

It is inadvisable to select the donor premolar patients with a natural substitute may support
from the same quadrant as the lost maxillary the choice of premolar transplantation, even if
incisor, because this would worsen the initial premolar extraction is not indicated from the
problem in case of failure. If the transplant fails, orthodontic perspective. When autotransplanta-
mesializiation of maxillary lateral incisors still tion of developing premolars is considered in
remains an alternative solution. When two max- older children, selection of an optimal donor
illary central incisors are missing, the mandibu- (an unerupted premolar), might be limited
lar premolars should be selected as donors because of advanced root formation (Fig. 2).
(Fig. 2). Selection of a mandibular premolar in Therefore, treatment planning including auto-
patients with dental Class I and II relationships transplanation of developing premolars should
to replace missing central incisors will increase be initiated as early as possible following
the orthodontic problem, and necessitates trauma. Timely planning of premolar transplan-
either optimum patient collaboration with full- tation, when all premolars are still unerupted,
time wear of Class II elastics, or the use of TADs helps to select the optimal donor tooth from an
or Herbst-type anchorage reinforcement appli- orthodontic perspective, to secure a good match
ances for space closure in the lower arch. between the stage of root development and the
(Fig. 2). However, the overwhelming advantages recipient site, and to promote successful healing
of replacing a missing maxillary incisor in young and a good esthetic outcome.

Figure 2. A 10-year old boy with an increased overjet and severe traumatic injury of his maxillary central incisors
was scheduled for extraction of the compromised teeth. Autotransplantation of both mandibular second premo-
lars was performed to replace the missing incisors, as these were the only unerupted premolars present (A). Nor-
mal healing after transplantation with pulp obliteration, eruption of the transplants, and continuous root
development could be radiographically evidenced (B-D). Orthodontic treatment with fixed appliances and a Class
II corrector (Forsus, 3M Unitek) was started two years after transplantation with the aim to correct the overjet and
to close the lower extraction spaces (E-J). After closing the spaces in the lower arch, the premolar brackets were
removed and the transplants were reshaped using direct composite build-ups without any enamel grinding. The
incisor brackets were subsequently bonded (K, L). Satisfactory occlusal relations and closure of the extraction
spaces were achieved after the orthodontic treatment (M-Q). Intraoral radiographs confirmed normal root devel-
opment after transplantation including pulp obliteration (R, S).
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Guidelines for autotransplantation of developing premolars to the anterior maxil 5

Figure 2. Continued

Surgical planning of autotransplantation  the morphology of all potential donor premo-

lars indicated by the orthodontist,
Two major issues need to be addressed at the
 the space between teeth adjacent to the recipi-
time when surgical autotransplantation of a
ent site and bone conditions.
developing premolar to the anterior maxilla is
planned. They include:
 ARTICLE IN PRESS

6 Czochrowska and Plakwicz

The morphology of developing premolars and selection of an alternative donor tooth or

selection of the best donor tooth changing the feature that prevents transplanta-
tion to the recipient site need to be considered.
Based on occlusal conditions and patient needs,
the orthodontist indicates the potential donor
tooth/teeth for autotransplantation. Premolars Key aspects of the surgical procedure
differ not only in shape and size, but also in
According to a recent study of Jakobsen,21 the
inclination in the alveolar process during erup-
success of transplantation does not depend on
tion, which is an important feature from the sur-
the experience of the surgeon. This is contrary
gical perspective. Impacted premolars are
to the findings of a previous study by Schwartz
generally more difficult, if not impossible, to
et al.,13 who reported that the surgeon’s experi-
remove gently, which is a prerequisite for suc-
ence improves treatment outcomes.
cessful healing. Upper first premolars have usu-
Surgery may be performed under local or gen-
ally two clearly separate roots and their
eral anesthesia depending on the patient’s coop-
cumulative bucco-palatal dimension may
eration and psychological status, and on the
exclude their accommodation within the vol-
operator’s experience. However, general anesthe-
ume of the alveolus along the entire root length.
sia with nasal intubation is reasonable for more
Upper second premolars are often smaller since
complex cases (e.g. transplantation of two or
their roots are often close to each other, making
more premolars). If the deciduous molar is still
them the preferable donors for maxillary auto-
present over its premolar successor, it is simply
transplantation compared to first maxillary pre-
extracted with a forceps; if ankylosis is detected,
molars. Mandibular premolars, both first and
the tooth must be separated into fragments and
second, are usually the smallest and the easiest
gently removed. The buccal and coronal part of
ones to remove from their alveolar crypt and to
the bone over the donor’s crypt is removed until
accommodate in the recipient site in the ante-
the premolar can be easily reached.
rior maxilla, and for this reason surgically pre-
Special effort should be made to avoid direct
ferred as replacement of maxillary incisors. The
contact of any instrument with the surface of the
downside is that orthodontic indications for
donor root, which requires that the inner thin
their removal are not easy to find. In cross-sec-
layer of bone that stays in direct contact with the
tion, mandibular premolars are less oval and
periodontal ligament of the root, is not drilled
more rounded when compared to the maxillary
with a bur, but only gently deflected from the
premolars, and the lingual cusp is less pro-
root surface with a small elevator. Most studies
nounced, requiring less grinding when the final
describe preparation of the recipient site with
shaping of the incisor is performed.
rotary instruments (straight or contra-angled
handpieces with either round or conical burs of
large diameter), chisels, or more recently, piezo-
Space and bone conditions at the recipient site
surgery has been proposed.
The amount of space at the recipient site If the traumatized incisor is still present, prep-
should ensure safe preparation of the new arti- aration of the new socket can be mostly per-
ficial socket, which is created parallel between formed without elevation of a flap, which allows
the roots of the adjacent teeth. The size of the easy adaptation of the soft tissues around the
new socket should be wider then the cross-sec- transplant. However, preparation of the flapless
tion of the root, providing approximately 1 mm socket without increasing the risk of trauma to
of space around the entire surface of the root. the adjacent teeth is more difficult due to the
The oval cross-section of the artificial socket extremely limited visual control of the adjacent
corresponding to the morphology of most roots structures. In most cases, the initial size of the
of premolars differs from the triangular or socket must be enlarged for ensuring a loose
round cross-section of the existing incisor alveo- accommodation of the donor within the walls of
lus, especially in the vestibulo-palatal dimension the new artificial bed. Since the premolar root is
at the coronal part of the root. When the char- usually bigger than the root of an incisor, osteot-
acteristics of the donor tooth and the recipient omy involves the removal of labial alveolar bone
site do not match, other options in terms of of about 1/3 to 1/2 of the coronal socket height,
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Guidelines for autotransplantation of developing premolars to the anterior maxil 7

deliberately creating a labial bone dehiscence. bone and adjacent roots (Fig. 3A-B). In patients
The artificial socket should also provide 2-3 mm with pre-existing horizontal bone atrophy, the
of extra- space apically to accommodate the soft socket is usually a three-wall defect with a labial
tissues of the donor root apex. dehiscence created during surgery (Fig. 3C).
In cases with a time lag between incisor loss Once the socket is ready, the donor tooth is
and transplantation surgery, a significant vertical removed from the crypt with forceps or elevators,
and horizontal bone defect might be detected at which should only contact the coronal portion of
the recipient site. In these situations, flap prepa- the tooth, clearly distant from the periodontal
ration becomes necessary. The mucosal tissue ligament covering the root in presence of the
covering the resorbed buccal and marginal bone dental follicle. Should the dental follicle still sur-
is deficient, the keratinized gingiva is narrow, round the donor crown, it can be gripped with
and scars are present, which makes flap handling surgical forceps and extracted together with the
difficult. For this reason, the flap is usually tooth inside. The donor should be directly trans-
extended to at least one adjacent tooth on each ferred to the recipient socket without any delay.
side, and vertical releasing incisions are per- Because of the labial dehiscence, the buccal root
formed to ensure better visual inspection of surface of the premolar may partially lack bony

Figure 3. Surgery in a 10 year-old patient is described in Figure 2. Autotransplantation of the mandibular right
and left second premolars to replace both traumatized central incisors; incision and flap elevation (A) after extrac-
tion of the resorbed central incisors - note the existing labial fenestration over the left incisor (B), surgical labial
bone dehiscences created during preparation of new sockets (C), second mandibular premolars placed in new
sockets with labial exposure of the coronal parts of their roots (D), suturing of the flap over the premolar crowns
(E). The status of the soft tissues at the time of suture removal 3 weeks after surgery, (F).Cone Beam Computed
Tomography scans performed 5 years later prove regeneration of a normal labial cortical plate (G,H, I).
 ARTICLE IN PRESS

8 Czochrowska and Plakwicz

coverage, but the apical portion should be control examinations upon the removal of the
placed within the alveolus (Fig. 3D). Depending suture (7-10 days), after 2, 6, 12, 18, 24 months,
on the stage of root development, the transplant and then annually. In cases of uncertain healing,
may be placed at the level of marginal gingiva or the follow-up appointments are scheduled every
in a more advanced eruption stage. Different month until healing is established. The clinical
protocols for stabilization of the transplant have examination includes assessment of tooth mobil-
been described; however, most studies support ity, eruption and percussion sound. The radio-
the finding that flexible splinting with sutures logical examination includes periapical
alone (Fig. 3E) decreases the risk of complica- radiographs of the transplanted premolar in
tions of periodontal healing.22,23 order to monitor the healing of bone at the
In patients with a short anterior maxilla (due recipient site, root development, pulp oblitera-
to the individual growth pattern or significant tion of the transplanted premolar, and signs of
posttraumatic atrophy of the alveolus), smaller different types of resorption.
premolars with shorter roots (1/2 instead of 3/4 Horizontal growth of the new alveolar bone is
root development) should be selected. expected several months after surgery.24,25
In order to prevent bacterial infection during Regeneration of the labial cortical plate was
early stages of healing, systemic antibiotic is rec- reported even in sites where significant bone
ommended after surgery. Additionally, according dehiscence was present at the time of surgery
to a systematic review by Chung et al.,23 antibiotic (Fig. 3G-I).26,27
prophylaxis reduces the risk of inflammatory, Most complications of transplanted teeth with
infection-related root resorption, and postopera- developing roots can be detected within the first
tive failure rate. year after surgery, however a longer observation
The patient is advised to take non-steroidal period is always more reliable (Fig. 1A-F). Anky-
anti-inflammatory drugs for 2-3 days, and to losis is one of the most common complications
apply a chlorhexidine gel on the operated area after tooth transplantation, and is suspected
until the sutures/splinting is removed two weeks when the transplant presents lack of normal
after surgery (Fig. 3F). Subsequently, the patient mobility and a high metallic sound on percus-
can resume normal masticatory function regard- sion. Ankylosis of the transplant is confirmed
less of the transplanted tooth. when orthodontic force application does not
move the tooth, while the adjacent teeth are tilt-
ing towards the transplant. Radiological exami-
Follow-up after transplanation
nation of the root surface of the ankylosed tooth
Monitoring after tooth transplantation is neces- is usually not conclusive, because spot ankylosis is
sary to evaluate periodontal healing, postsurgical often not visible on radiographs (Fig. 1E-F).
root development, and to detect any signs of
pathology. After transplantation of developing
Management of complications
teeth, typical parameters to evaluate include
pulp obliteration, tooth eruption (for donors Impaired healing of the transplanted tooth is
which were placed at the level of gingiva or sub- usually related to the surgical procedure, namely
gingivally to continue their eruption after sur- to the injury to the surface of the developing
gery), and ongoing root formation (Figs. 1H, 1I, root and manifests itself typically as cervical root
2B-C, 2R).17,19,20 Pulp obliteration is a common resorption or replacement resorption (ankylo-
finding in transplanted developing teeth. It is a sis). Based on the authors’ clinical experience,
sign of preserved pulp vitality and does not ankylosis is the most serious complication after
require endodontic therapy. In presence of a nat- autotransplantation of developing premolars to
ural, contralateral premolar, comparing root the anterior maxilla. In case of complications,
development of the transplanted and non-trans- alternative solutions may include transplantation
planted premolar is very helpful to assess root of another developing premolar (second trans-
formation. Periodic clinical and radiological plantation), or orthodontic mesialization of the
examinations are necessary at least during the neighboring lateral incisor after extraction of the
first 12 months after surgery. The protocol after failed transplant (Fig. 1G-I).10 If a contralateral
transplantation of developing teeth includes premolar is anyhow scheduled for extraction in
 ARTICLE IN PRESS

Guidelines for autotransplantation of developing premolars to the anterior maxil 9

order to achieve dental arch symmetry, it can development can affect the development of their
then serve as a suitable donor for a second trans- hard tissues. If premolars are transplanted dur-
plantation. Consequently, it is very important to ing later stages of their root formation (about 3/4
carefully monitor transplanted teeth after sur- of the final root length), it is usually recom-
gery, because early detection of complications mended to wait 3-6 months after surgery to ascer-
usually provides a better chance for a second tain undisturbed healing.28 On the other hand,
transplantation (Fig. 1G-I). Preservation of an orthodontic mobilization shortly after transplan-
ankylosed transplant in the anterior maxilla in tation (at about six weeks) was reported to
young children is usually not advisable, because decrease the risk for ankylosis after transplanta-
of the unpredictable long-term prognosis and tion of more mature teeth.
impaired smile esthetics.
Orthodontic repositioning for optimal reshaping
Post-surgical orthodontics Orthodontic repositioning of the transplanted pre-
Most patients who have undergone autotrans- molar after surgery significantly improves the
plantation of developing premolars to replace esthetic outcome and should be recommended to
missing maxillary incisors need orthodontic the patient and parents/caregivers before surgery.11
treatment after surgery in order to: Orthodontic repositioning of the transplanted
premolar usually includes tooth alignment and
- close the space in the dental arch after levelling of the gingival margin between the trans-
removal of the donor premolar, planted premolar and the neighboring teeth, and
- align the transplanted premolar in the dental should be performed using light forces, consider-
arch, ing the transplant a traumatized tooth.
- level the gingival margins, It is often better to reshape the transplanted
- position the transplant for optimal reshaping premolar before orthodontic repositioning, if
to mimick the morphology of a natural inci- the position of the transplant and its long axis
sor, or need to be adjusted to the neighboring incisors.
- correct a concomitant malocclusion. Sometimes, extra space is needed to match the
width of the transplant with the natural central
If the selection of a donor premolar is predom- incisor. In this case, it is necessary to bond a pre-
inantly based on the optimal stage of root devel- molar bracket on the unrestored transplanted
opment rather than on orthodontic indications, premolar, and to open an adequate space for its
anchorage control must be supplemented. TADs reshaping (Figs. 1J, 2K). The optimal position of
or Herbst-type Class II correctors may be helpful the zenith should be defined and respected.
to assist planned tooth movements (Fig. 2). Alter- After the adequate space for reshaping is
native treatment options after removal of a donor achieved, the premolar bracket is removed, and
premolar usually include prosthodontic substitu- the morphology of the transplanted premolar is
tion of the donor tooth with either partial fixed adapted to that of the central incisor using indi-
dentures (PFD) or dental implants after the end rect or direct techniques. If further orthodontic
of growth.7,8 Transplantation of developing wis- repositioning of the reshaped transplant is neces-
dom teeth constitutes another good option which sary, a corresponding central incisor bracket is
may be performed before the cessation of growth bonded, and the orthodontic treatment is contin-
depending on their root development. ued until satisfactory alignment is obtained
Orthodontic alignment of the transplanted (Figs. 1K, 2L). It is usually easier to perform a
premolar should preferably start after comple- good direct composite restoration of the trans-
tion of the post-surgical healing phase. If donor planted premolar, if some mesial and distal space
premolars were transplanted at the earlier stages excess has been created (Fig. 1J-K). The palatal
of root development, it is necessary to wait until cusp of the transplanted premolar does not
root development reaches at least 3/4 of the final require grinding, because occlusal interferences
root length. Orthodontic repositioning of trans- can be avoided by palatally directed orthodontic
planted premolars at earlier stages of root tooth movement (Fig. 2K).
 ARTICLE IN PRESS

10 Czochrowska and Plakwicz

Reshaping transplanted premolars in the central incisors, which have the highest inci-
anterior maxilla dence of traumatic loss. A matching cervical
width of the transplant and the lost incisor is
Transplanted teeth replacing traumatically lost critical, as only limited preparation of the
maxillary incisors should not only have a good transplant is possible during restorative treat-
potential for successful healing, but also a ment. Third molars, which are often consid-
favorable tooth form to match incisor morphol- ered as donor teeth, are mostly unsuitable for
ogy, as these teeth are placed in the center of reshaping to maxillary incisors.29 Occasionally,
the esthetic zone. Premolars have a compara- supernumerary lateral incisors can be trans-
ble morphology to the width of maxillary planted to the anterior maxilla.9

Figure 4. The maxillary right second premolar was transplanted to replace the traumatically injured maxillary left
central incisor in a 9-years old girl (A). The transplanted premolar was reshaped to the incisor morphology with a
direct composite build-up and orthodontic treatment was performed in order to align the transplanted tooth and
to obtain normal occlusal relations (B). Four years after transplantation, the composite restoration was replaced
by a feldspatic porcelain veneer to improve dental esthetics (C). The patient was satisfied with her smile after
placement of the veneer (D).
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Guidelines for autotransplantation of developing premolars to the anterior maxil 11

Contemporary techniques for reshaping auto- necessary. After surgery, healing and root develop-
transplanted premolars include the use of direct ment of the transplanted teeth requires periodic
and indirect composite restorations or porcelain monitoring in order to detect early signs of fail-
laminate veneers (PLV) (Figs. 1, 2, 4). The ure. Post-surgical orthodontic repositioning of the
bonded restoration should not include any den- transplanted premolar and reshaping or restoring
tine preparation, because the presence of tertiary them to incisor morphology is often indicated to
dentine in transplanted developing teeth may ensure the best esthetic treatment result. Close
lead to different types of root pathology. Prefera- interdisciplinary cooperation is imperative for
bly, enamel reduction should also be avoided achieving a successful long-term outcome.
(Fig. 1J-L). Extensive grinding of premolars can
interfere with pulp healing after surgery.28
If unerupted donor premolars are trans- References
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development and erupt similarly to normal devel- tion of 45 teeth to the upper incisor region in adoles-
oping teeth, hence the final restoration should cents. Swed Dent J. 1994;18:165–172.
only be placed after their full eruption. 3. Czochrowska EM, Stenvik A, Album B, et al. Autotrans-
Post-surgical root development of a trans- plantation of premolars to replace maxillary incisors. A
comparison with natural incisors. Am J Orthod Dentofacial
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its root development upon surgery and may take 4. Mendoza-Mendoza A, Solano-Reina E, Iglesias-Linares A,
more than two years in less mature premolars. et al. Retrospective long-term evaluation of autotrans-
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Endod J. 2012;45(1):88–97.
clinical inspection, and evaluation of a good
5. Stange KM, Lindsten R, Bjerklin K. Autotransplantation
quality intraoral radiograph of both the trans- of premolars to the maxillary incisor region: a long-term
plant and the control contralateral tooth, if pres- follow-up of 12-22 years. Eur J Orthod. 2016;38:508–515.
ent, is mandatory. €
6. Odman J, Gr€
ondahl K, Lekholm U, et al. The effect of
Most frequently, the transplanted premolars osseointegrated implants on the dento-alveolar develop-
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Eur J Orthod. 1991;13:279–286.
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cent teeth. An 8-year follow-up study. Clin Oral Impl Res.
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