CASE REPORT

Mandibular premolar transplantation to

replace missing maxillary anterior teeth:
A multidisciplinary approach
Pawinee Tankittiwat,a Rungkarn Thittiwong,b Saowaluck Limmonthol,c Waraporn Suwannarong,d
Peerapong Kupradit,e Saengsome Prajaneh,d and Poonsak Piseka
Khon Kaen and Kanchanaburi, Thailand

One of the most challenging problems for orthodontists is that of multiple missing maxillary teeth in a growing
patient. In many patients, a good treatment option is autotransplantation. This case report describes the multi-
disciplinary treatment of an 11-year-old girl with regional odontodysplasia affecting the maxillary right and left
central incisors, and congenitally missing maxillary left lateral incisor and canine. Autotransplantation of the
mandibular second premolars to the affected area was combined with orthodontic space closure, and the trans-
planted premolars were reshaped and restored with a resin composite to be in line with the left central and lateral
incisors. After completion of the orthodontic treatment, gingivectomy was performed to obtain an even gingival
contour and symmetrical gingival tissue. Space closure of the maxillary anterior teeth was achieved. Autotrans-
plantation enabled the patient to retain her natural teeth rather than having a prosthesis or dental implant. The
autotransplanted tooth allows for alveolar bone growth in synchrony with neighboring teeth and the formation of
normal interdental papilla while adapting to functional stimuli and confers a high survival rate in the long term.
(Am J Orthod Dentofacial Orthop 2021;160:459-72)

R
egional odontodysplasia (RO), probably first Treatment goals of a RO combined with multiple
described by Hitchin in 1934, is a rare dental anterior missing teeth for patients during childhood
anomaly affecting primary and/or permanent include function and esthetic improvement, facilitation
teeth, most often in one quadrant.1 Clinical appearance of normal jaw growth, and reduction of the psycholog-
shows brown or yellowish soft teeth with clinical symp- ical impact.2,3 Possible treatment options are implants,
toms after eruption, such as gingival swelling, gingivitis, prosthesis, orthodontic space closure, autotransplanta-
or abscess; in some patients, a failure of tooth eruption tion, or a combination in any complicated cases.2,4
may occur.1,2 Radiographically, the affected teeth Dental autotransplantation is defined as the reposi-
appear as ghost teeth because the enamel and dentin tioning of a tooth from one site to a tooth extraction
are hypomineralized and hypoplastic, reducing radio- site or a surgically formed recipient site within the
density with wide pulp chambers and apical foramen.1 same person,5 which provides the possibility of a nat-
ural tooth rather than a prosthesis or implant to replace
missing teeth. It is an alternative approach suitable for
a
Division of Orthodontics, Department of Preventive Dentistry, Faculty of certain clinical situations, especially in young patients,
Dentistry, Khon Kaen University, Khon Kaen, Thailand.
b
for which a high success rate of .95% has been
Dental Department, Phaholpolpayuhasena Hospital, Kanchanaburi, Thailand.
c
Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, Khon Kaen demonstrated.6-8 A successful autotransplantation
University, Khon Kaen, Thailand. can induce bone formation, reestablish a normal
d
Division of Periodontology, Department of Oral Biomedical Sciences, Faculty of alveolar process and periodontal ligament, and
Dentistry, Khon Kaen University, Khon Kaen, Thailand.
e
Division of Operative Dentistry, Department of Restorative Dentistry, Faculty of permit tooth movement.5,9 Meanwhile, an implant
Dentistry, Khon Kaen University, Khon Kaen, Thailand. will not follow the adjacent incisors vertically during
All authors have completed and submitted the ICMJE Form for Disclosure of Po- tooth eruption at any age.6
tential Conflicts of Interest, and none were reported.
Address correspondence to: Poonsak Pisek, Division of Orthodontics, Depart- Our case report describes a multidisciplinary treat-
ment of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Khon ment carried out by an orthodontist, an oral maxillofa-
Kaen 40002, Thailand; e-mail, [email protected]. cial surgeon, a restorative dentist, and a periodontist
Submitted, December 2019; revised, May 2020; accepted, June 2020.
0889-5406/$36.00 to help a girl with RO at the maxillary right and left cen-
Ó 2021 by the American Association of Orthodontists. All rights reserved. tral incisors and congenitally missing maxillary left
https://doi.org/10.1016/j.ajodo.2020.06.035

459
460 Tankittiwat et al

Fig 1. Pretreatment facial and intraoral photographs.

lateral incisor and canine achieve better dentition. The first molar was restored with a stainless steel crown
mandibular second premolars were autotransplanted because of previously treated dental caries. She had
to the affected area. normal gingiva and alveolar bone at the maxillary central
and lateral incisor area. The pretreatment dental casts
(Fig 2) presented the Angle’s Class II malocclusion: a
DIAGNOSIS AND ETIOLOGY spacing of 25.5 mm in the maxillary arch, crowding of
A girl aged 11 years and 1 month, with the chief 2 mm in the mandibular arch, and 3 mm deep curve of
complaint of esthetic concerns, underwent evaluation Spee.
of her maxillary anterior teeth. She was physically In the panoramic radiograph (Fig 3), all permanent
healthy with no contributing medical history. The pre- teeth aside from the left lateral incisor and canine were
treatment facial photographs (Fig 1) showed a convex visible. However, the maxillary right and left central in-
facial profile with a slightly protruded lower lip, low cisors had been impacted by abnormal formation, with
smile line, and absence of multiple maxillary anterior the appearance of ghost teeth and the formation of short
teeth. roots. In addition, cone-beam computed tomography
The pretreatment intraoral photographs (Fig 1) images (Fig 3) revealed the maxillary right central incisor
showed the clinical absence of the maxillary right and to be approximately 9 mm below the alveolar bone with
left central incisors, left lateral incisor, and canine. She a 5.6-mm diameter and 11-mm height, whereas the
had no active dental caries, although her maxillary left maxillary left central incisor was 12.6 mm below the

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Tankittiwat et al 461

Fig 2. Pretreatment dental casts.

alveolar bone with a 6.3-mm diameter and 6.6-mm and canine, respectively. The maxillary premolars were
height. These findings contributed to the diagnosis of substituted for the canines on both sides. Then, the
RO. mandibular second premolars with three fourths of
The pretreatment lateral cephalometric radiograph root length were transplanted to the maxillary left
(Fig 3) and analysis (Table) revealed a Class I skeletal central and lateral incisors. The teeth in the mandib-
pattern with orthognathic maxilla and mandible when ular arch were leveled and aligned with a slight
compared with the cranial base (SNA, 81.6 ; SNB, mandibular central incisor retraction to improve the
80.3 ; ANB, 1.3 ). She had an acceptable vertical skeletal lower lip position, relieve crowding, and correct the
relationship (MP-PP, 25.5 ) but slightly decreased lower deep curve of Spee. Moderate anchorage preparation
anterior facial height (ANS-Me, 58.1 mm). was carried out in both arches. This plan was advan-
tageous in that the patient’s natural teeth were used
TREATMENT OBJECTIVES instead of prostheses or implants, but the disadvan-
tages included the requirement for the patient to un-
The treatment objectives consisted of substitution for dergo surgery and a longer orthodontic treatment
the missing maxillary incisors and canine after removal period.
of the ghost teeth, using mandibular premolar trans- One treatment alternative was a dental implant or
plantation. prosthesis combined with orthodontic treatment to re-
To achieve the treatment objectives, a 3-dimensional move the maxillary right and left central incisors sur-
model setup was created with 3Shape Ortho Analyzer gically and to substitute the right central and lateral
software (3ShapeE2 lab scanner, Copenhagen, Denmark) incisors with the right lateral incisor and canine,
for communication and visualization among the clini- respectively. The maxillary premolars would be
cians, the patient, and her parents (Fig 4). substituted for the canines on both sides, maintaining
space at the left central and lateral incisors for pros-
TREATMENT ALTERNATIVES thetic treatment or dental implant placement after
The selected treatment plan for this patient was completion of the maxillary alveolar vertical growth
autotransplantation combined with orthodontic space process. The second premolars in the mandibular
closure. This plan involved surgical removal of the arch would be extracted to achieve slight retraction
maxillary right and left central incisors that had of the mandibular central incisors, improving the
been diagnosed with RO and substitution of the right lower lip position, relieving crowding, and correcting
central and lateral incisors with the right lateral incisor the deep curve of Spee. The advantages of this option

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462 Tankittiwat et al

Fig 3. Pretreatment radiographs: A, lateral cephalometric; B, cephalometric tracing; C, panoramic ra-

diographs were taken 2 months before stainless steel crown treatment of the maxillary left first molar
and cone-beam computed tomography images of RO; D, sagittal view of the maxillary right central in-
cisors; E, sagittal view of the maxillary left central incisors; F, axial view

included a shorter orthodontic treatment period; the incisor, and the canine. The advantages of this option
disadvantage was the need to insert prostheses or were nonextraction, the elimination of excessive ortho-
implants. dontic movement, and a shorter treatment period, but
Another alternative treatment was the nonextraction the disadvantage was more proclined maxillary and
of the mandibular premolars, with slight proclination of mandibular incisors, resulting in protruded lips. More-
the mandibular incisors to correct crowding and the over, this option would create a long edentulous area,
deep curve of Spee. Space would be created in the maxil- requiring long-span dental prosthesis or implants,
lary arch for dental implants or prosthetic replacements higher costs, and unpredictability in terms of long-
of the right and left central incisors, the left lateral term efficacy.

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Tankittiwat et al 463

orthodontic archwire and a resin composite (Fig 5, E).

Table. Cephalometric measurements
The transplanted premolar tooth was placed in infraoc-
Variables Thai norm Pretreatment Posttreatment clusion, and the cusp was ground to avoid any pressure
Skeletal or occlusal interference and prevent injury of the perio-
Maxilla to cranial dontium; moreover, the tooth was rotated 90 to achieve
base
the ideal cervical width when compared with the contra-
SNA ( ) 84.0 6 3.6 81.6 80.9
Mandible to lateral tooth and for higher favorability in restoration10
cranial base with sufficient bone support in the transverse direction
SNB ( ) 81.0 6 3.6 80.3 79.3 of the alveolar process.11 Histologic examination of the
Maxillomandibular impacted maxillary central incisors showed tiny tooth-
ANB ( ) 3.0 6 2.5 1.3 1.6
like structures consisting of tubular dentin, interglobular
Wits appraisal (mm) 2.0 6 3.5 N/A 0.6
Vertical dentin, disorganized amorphous material, and pools of
MP-SN ( ) 30.0 6 5.6 30.3 32.9 enamel matrix, thus confirming the RO diagnosis. The
FMA (MP-FH) ( ) 22.7 6 5.4 28.2 30.4 2-month follow-up periapical radiograph showed a
MP-PP ( ) 20.9 6 5.3 25.5 26.0 thick periodontal ligament (PDL) space, normal alveolar
ANS-Me (mm) 68.1 6 5.0 58.1 60.0
bone level, large pulpal size, and nearly completed root.
N-ANS: ANS-Me (%) 45:55 44:56 45:55
S-Go:N-Me (%) 67.0 6 5.0 65.8 64.6 The transplanted tooth was subsequently further ground
Dental to relieve interference during orthodontic tooth move-
Maxillary dentition ment (Fig 6) and was bonded with a lateral incisor
U1-NA ( ) 22.0 6 5.9 N/A 21.4 bracket in the same position as the contralateral tooth.
U1-NA (mm) 5.0 6 2.1 N/A 2.9
Leveling was started with a 0.014-in nickel-titanium
SN-U1 ( ) 108.0 6 6.1 N/A 101.3
Mandibular dentition wire 3 months after surgery.
L1-NB ( ) 30.0 6 5.0 26.1 28.2 After the transplanted tooth had moved to the left
L1-NB (mm) 6.0 6 2.0 5.1 3.2 lateral incisor position by using the 0.016-in stainless
L1-FH ( ) 60.0 6 6.0 60.0 56.0 steel wire and elastic chain to create space at the left cen-
L1-MP ( ) 97.0 6 6.0 91.8 93.7
tral incisor, the 0.016-in Australian wire and V-bend me-
Soft tissue
LL to E-line (mm) 2.0 6 2.0 3.4 0.6 chanics were used in the mandibular arch to carry out
UL to E-line (mm) 1.0 6 2.0 0.7 0.7 mandibular anterior teeth intrusion and posterior teeth
N/A, Not applicable. extrusion.
Five months after the first autotransplantation, the
same technique was used to transplant the mandibular
TREATMENT PROGRESS
left second premolar with three fourths of root length
As a first treatment step, a 0.022 3 0.028-in slot, to the site of the maxillary left central incisor (Fig 7). Af-
straight-wire appliance (MBT prescription; 3M Unitek, ter 1 month, the periapical radiograph showed a thick
3M Dental Products, Monrovia, Calif) was placed in PDL space, normal alveolar bone level, large pulpal
both arches. All first molar teeth were banded, and the size, but the remaining three fourths of root length
bite was opened for prevention of occlusal interference (Fig 8). The tooth had started to move 3 months after
during autotransplantation with a composite raised bite. the operation (Fig 9).
In the aligning and leveling phase, the orthodontist In the movement and contraction phase, we used
started with a 0.016-in nickel-titanium wire in the a 0.016 3 0.022-in stainless wire and corrected the
maxillary and mandibular arches and then used a maxillary dental midline with a light open-coil
0.016-in Australian wire in the maxillary arch and a tis- spring. Meanwhile, the mandibular teeth were cor-
sue guard to maintain the maxillary anterior space. Two rected with an elastic chain placed from the left first
months after the transplantation site had been prepared, molar to the right first molar. In the finishing phase,
the first operation involved surgical removal of the bracket repositioning and a 0.017 3 0.025-in beta-
maxillary central incisors (Fig 5, A and B), and the titanium wire with minor wire bending were chosen
mandibular right second premolar with three fourths for detailing the occlusion. The patient was then
of root length was transplanted to the site of the maxil- referred to a restorative dentist for temporary resto-
lary left lateral incisor. To address root exposure through ration with a resin composite at the maxillary ante-
a bone defect, particulate bone grafting from the chin rior teeth, using Bolton analysis. This aimed to
was placed over the exposed root (Fig 5, C and D), fol- improve orthodontic closure and normalize overjet
lowed by gingival flap suturing and fixation, using an and overbite (Fig 10).

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Fig 4. Diagnostic model setup with 3D Ortho Analyzer software for space preparation of autotrans-
planted teeth and guiding of orthodontic tooth movement: the maxillary right lateral incisor and canine
moved slightly mesially to replace the maxillary right central and lateral incisors, whereas the maxillary
left premolar moved mesially to replace the maxillary left canine, creating space for 2 transplanted pre-
molars. In the mandibular arch, the second premolars were removed for transplantation, the mandib-
ular incisors moved lingually, and the mandibular molars moved slightly mesially, obtaining a molar
Class I relationship.

Fig 5. Autotransplantation: A, surgical removal of the maxillary central incisors; B, malformation of the
maxillary central incisors; C, particulate alveolar bone grafting from chin to recipient site; D, transplan-
tation of the mandibular right second premolar in the recipient site by rotating the tooth and placing the
bone grafting; E, gingival flap suturing and stabilization with the orthodontic archwire. Courtesy of Khon
Kaen University Dental Journal (KDJ). Vol. 18, No. 2 July–December, 2015.29

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Tankittiwat et al 465

Fig 6. Intraoral photographs and a periapical radiograph 2 months after the first operation, showing a
thick PDL space, normal alveolar bone level, large pulpal size, and nearly completed root.

Fig 7. Second operation: the mandibular left second premolar was transplanted in the recipient site by
rotating the tooth and gingival flap suturing. Courtesy of Khon Kaen University Dental Journal (KDJ).
Vol. 18, No. 2 July–December, 2015.29

After orthodontic treatment was completed, a wrap- (Figs 11 and 12). The profile was acceptable, and the pa-
around retainer was placed, and the patient was referred tient’s satisfaction had improved. Moreover, the cortical
to a periodontist for frenectomy and gingivectomy of the bone had formed with a normal PDL space and alveolar
maxillary anterior teeth because of high frenulum bone level. Both transplanted premolar roots had
attachment, asymmetry of tooth length, and inconsis- continually developed, and the apical end of both roots
tent gingival margin. were completely closed but total pulp obliteration. How-
ever, there was neither sign of inflammatory root resorp-
tion nor pulp necrosis. Root canal treatment was not
TREATMENT RESULTS
necessary.12 (Figs 13 and 14).
Three years and 9 months after starting the ortho- From the posttreatment cephalometric radiograph
dontic treatment, Class I canine and molar relationships (Fig 13) and analysis (Table), the patient still maintains
were achieved; the maxillary midline shifted slightly to a Class I skeletal pattern with orthognathic maxilla and
the right relative to the mandibular midline, and the mandible (SNA, 80.9 ; SNB, 79.3 ; ANB 1.6 ). In addi-
extraction spaces were closed without prosthesis need tion, she has a normal vertical skeletal relationship

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466 Tankittiwat et al

(MP-PP, 26.0 ), slightly decreased lower anterior facial

height (ANS-Me, 60.0 mm), and a good proportion of
upper and lower anterior facial height (N-ANS: ANS-
Me, 45:55). The maxillary incisors have a normal inclina-
tion and position (U1-NA, 21.4 ; U1-NA, 2.9 mm), and
the mandibular incisors are normally inclined but slightly
retruded (L1-NB, 28.2 ; L1-NB, 3.2 mm). In terms of soft
tissue, her upper and lower lips are positioned normally
compared with the E-line (UL to E-line, 0.7 mm; LL to
E-line, 0.6 mm).
The cephalometric superimposition shows pretreat-
ment conditions represented by the black line without
central incisors and posttreatment conditions repre-
sented by the red line, with right and left central incisors
Fig 8. A periapical radiograph, 1 month after the second substituted with the right lateral incisor and left trans-
operation, showing a thick PDL space, normal alveolar planted premolar. The image reveals favorable growth,
bone level, and large pulpal size for the remaining three slight anterior teeth retraction in centric occlusion, and
fourths of root length.

Fig 9. Intraoral photographs taken 3 months after the second operation.

Fig 10. Direct resin composite restoration of the maxillary anterior teeth.

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Tankittiwat et al 467

Fig 11. Posttreatment facial and intraoral photographs.

good anchorage control as planned (Fig 15). The func- 18-20 years, surgical crown lengthening and bone re-
tional analysis showed that incisor-protected protrusion constructing should be performed to achieve biological
and group function lateral excursions were established, width (Figs 16 and 17).
and the substituted teeth were reshaped to the central
and lateral incisors through adjustment of palatal cusps DISCUSSION
and incisal edge so that they made contact at the same Treatment of patients with RO and multiple congen-
time when the jaw was moved forward. The substituted itally missing teeth is controversial and requires a multi-
canines were also adjusted so that the palatal cusps disciplinary approach.2,3 Surgical removal should be
made simultaneous contact with the posterior teeth dur- considered a treatment option if the affected teeth
ing lateral jaw movement on the working side, thus facil- inhibit tooth eruption or orthodontic tooth movement
itating the distribution of occlusal loading. or if it can help retain uninfected teeth to preserve the
A frenectomy was performed to correct the frenulum alveolar bone.2,3
attachment, and a gingivectomy procedure at the maxil- Several treatment options are available for growing
lary anterior teeth decreased excessive gingival tissue patients with congenitally missing teeth, including ortho-
display, useful in improving smile esthetics. Finally, if dontic closure of the space, replacing the teeth with im-
the patient is diagnosed with altered passive tooth erup- plantation after growth is complete, fixed prostheses,
tion of maxillary anterior teeth when she is aged removable partial dentures, or autotransplantation.6,7,9

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468 Tankittiwat et al

Fig 12. Posttreatment dental casts.

Fig 13. Posttreatment radiographs and cephalometric tracing.

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Tankittiwat et al 469

Fig 14. Periapical radiographs from pretreatment to posttreatment: A and B, pretreatment radiograph;
C and D, postorthodontic treatment.

Fig 15. Superimposition of pretreatment and posttreatment cephalometric tracing.

Fig 16. Intraoral photographs: A, frenectomy; B, design of gingival margin for gingivectomy; C, gingi-
vectomy.

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Fig 17. Final intraoral photographs at follow-up 1 month after gingivectomy.

The combination of multiple treatment options in to fourth fifths16 or one half to three fourths of the final
complicated cases is often most appropriate. root length.8,13,17 If the root has developed by less than
In growing patients, implant placement is a contrain- half, the treatment may be too traumatic and interfere
dication because the implant does not erupt along with with further root development. In contrast, if a tooth
adjacent teeth, and there is a risk of infraocclusion post- with complete root formation is transplanted, it will
adolescence.6,9,13 Long-term follow-up has also found require root canal therapy.5 In open apex teeth, the
this treatment option to be unfavorable in terms of pulp can revascularize through capillary vessel growth
esthetic appearance because of minor marginal bone at the apex.18 In this case report, autotransplantation
loss, especially at the unilateral maxillary incisor was carried out with proper timing because three fourths
implant.14,15 Use of a conventional fixed bridge in of the root had formed in the patient’s mandibular sec-
adolescent patients should be delayed because of large ond premolars.
pulpal size, a lengthy site maintenance process, and Long-term studies have shown the positive effects of
the need for irreversible tooth preparation. In addition, autotransplantation,10-12 with survival rates at over 90%
removable dentures may be disadvantageous; for and success rates of .79%.16,17,19 According to a sys-
example, their temporary nature requires them to be tematic review,8 survival and success rates for tooth au-
replaced periodically during growth.9 In contrast, totransplantation with incomplete root formation were
autotransplantation is a beneficial treatment option, also high (.95%), with a low rate of complication
especially for young patients who can retain their natural (\5%). Complications that did occur resulted from con-
teeth rather than needing a prosthesis or dental implant. ditions such as ankylosis, severe infection, or root
Potential benefits include bone induction, promotion of resorption.17,19 Although these problems have not
a normal alveolar process and PDL development, and the been presented in this patient, follow-up evaluations
fact that an autotransplanted tooth can be moved ortho- will be necessary. Moreover, the most successful proced-
dontically in the same way as any other tooth. Even if the ures have involved transplantation of premolars to the
treatment fails in the future, the bone and implant maxillary anterior region, with reported success rates
placement will have been preserved after facial develop- of 82%-100%.4,13,20,21 The optimal premolars to trans-
ment is complete.6,9 For these reasons, autotransplanta- plant to the maxillary anterior region are the second
tion was the most appropriate option for this patient. mandibular premolars because of their root anatomy,
The stage of the donor tooth’s root development is and longitudinal studies have demonstrated their favor-
one of the most important factors determining the suc- able long-term results.9
cess of autotransplantation. Some authors recommend Normally, bone grafting is unnecessary between
an ideal root of the premolar tooth from three fourths bone walls and transplant roots. However, if the donor’s

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Tankittiwat et al 471

teeth are placed in the recipient site with insufficient adjacent to the transplanted teeth appeared normal,
buccopalatal width, roots can protrude through a bone and patients were left feeling satisfied. In the present
defect, resulting in an increase in replacement root case, the patient received interim restoration with
resorption and ankylosis. A previous study reported direct composite buildup, and final restoration was
that bone coverage of less than two thirds of the buccal conducted after facial development was complete.
surface was significantly more frequent in lost trans- After orthodontic treatment and to improve es-
plants and was correlated with pathologic mobility.22 thetics, the patient was referred to further treatment of
Therefore, bone grafting should be placed over the frenectomy and gingivectomy because of high frenulum
exposed root for bone regeneration, especially in pa- attachment and asymmetry of gingival tissue. However,
tients with large bone defects after the removal of uner- in adolescent patients, gingivectomy of anterior teeth
upted teeth.18,23 For the patient in the present case, for esthetic purposes should be postponed and reeval-
alveolar bone grafting was required after removing the uated in early adulthood because the gingival contour
RO in the maxillary right and left central incisors. The in an adolescent is not stable, and a cervical displace-
defect caused incomplete bone coverage of the buccal ment takes place during growth. Adolescents (aged
root surface at the transplanted premolar teeth. Bone 14-18 years) and adults (aged 20-51 years) show a
grafting was performed during autotransplantation mean apical displacement of gingival margin of
with no negative effect.23-25 0.51 mm and 0.13 mm, respectively, related to a second-
After autotransplantation, the orthodontic force can ary eruption of the incisors and a slowed increase in
be applied. However, the timing for such treatment re- facial height.27 In contrast, a study that conducted a
mains controversial. Although some studies generally 1-year follow-up to a surgical crown lengthening found
recommend delaying orthodontic treatment until that the amount of tooth structure immediately after
6 months after the surgical procedure,7,10,20 Stenvik surgery had decreased to 0.5 mm at interproximal sites
and Zachrisson26 recommend that orthodontic move- and 1.2 mm at buccal and lingual sites. This indicates
ment of transplants be postponed for about 6-9 months. that the marginal periodontal tissue has a tendency to
For the patient in the present case, the orthodontist grow in a coronal direction and relates to the gingival
started orthodontic movement 3 months after the oper- phenotype and the patient’s healing response.28
ation, as recommended by Andreasen et al16 and Tsuki- Therefore, gingival surgery in the present study should
boshi.18 They suggest initiating active orthodontic be reconsidered when the patient reaches the age of
treatment 3-9 months after periodontal healing but 18-29 years.
before pulp canal obliteration.
Another consideration is that autotransplanted
CONCLUSIONS
teeth do not match the natural contralateral incisor;
for example, there tends to be a color mismatch and In growing patients with multiple congenitally
asymmetry in crown width. Such features can be missing teeth, autotransplantation combined with or-
improved with tooth rotation during surgery to thodontic treatment is an alternative treatment option,
achieve the ideal cervical crown width.11 Zachrisson and a multidisciplinary team is a key factor in achieving
et al6 recommends reshaping the premolar crown to all objectives.
resemble incisor morphology. In their study, they
initially made a direct resin composite buildup and ACKNOWLEDGMENTS
later replaced it with porcelain laminate veneer. How- The authors express gratitude to the postgraduate
ever, establishing normal incisor width using compos- students, Dr Siriwannapa Kawsamer from the Depart-
ite buildup is difficult and the material tends to ment of Restorative Dentistry, and Dr Thananya Tara-
discolor with time. Furthermore, the use of prosthetic sena from the Department of Periodontology, Khon
crowns in adolescents is avoided because the large Kaen University, for making this case report possible.
pulp chambers limit preparation, and the gingival
retraction over time can lead to unaesthetic root
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or radiographic parameters other than pulp oblitera- 3. Cho SY. Conservative management of regional odontodysplasia:
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September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics