|Year : 2020 | Volume
| Issue : 2 | Page : 91-94
Autotransplantation: An alternative treatment for horizontally impacted permanent incisors: A case report with review of literature
Ritesh R Kalaskar1, Priyanka Bhaje1, Ashita Ritesh Kalaskar2, Priyanka Sharma1
1 Department of Pediatric and Preventive Dentistry, Government Dental College and Hospital, Nagpur, Maharashtra, India
2 Department of Oral Medicine and Radiology, Government Dental College and Hospital, Nagpur, Maharashtra, India
|Date of Submission||28-Nov-2019|
|Date of Acceptance||21-Mar-2020|
|Date of Web Publication||08-Jul-2020|
Dr. Ritesh R Kalaskar
Department of Pediatric and Preventive Dentistry, Government Dental College and Hospital, Nagpur, Maharashtra
Horizontally impacted permanent maxillary incisors are rarely treated by surgical extraction due to their unfavorable position and traumatic extraction. Fixed prostheses such as fixed partial dentures and implants are contraindicated in children because of their growing age, as they adversely affect bone growth. In this case report, we have presented 18-month follow-up study of a 13-year-old child with a horizontally impacted permanent maxillary lateral incisor which was autotransplanted into its original position. To avoid interference in periodontal healing, intentional endodontic treatment was carried out followed by placement of a jacket crown.
Keywords: Autotransplantation, impaction, pathological obstruction, permanent incisors
|How to cite this article:|
Kalaskar RR, Bhaje P, Kalaskar AR, Sharma P. Autotransplantation: An alternative treatment for horizontally impacted permanent incisors: A case report with review of literature. SRM J Res Dent Sci 2020;11:91-4
|How to cite this URL:|
Kalaskar RR, Bhaje P, Kalaskar AR, Sharma P. Autotransplantation: An alternative treatment for horizontally impacted permanent incisors: A case report with review of literature. SRM J Res Dent Sci [serial online] 2020 [cited 2020 Aug 15];11:91-4. Available from: http://www.srmjrds.in/text.asp?2020/11/2/91/289173
| Introduction|| |
Impacted permanent maxillary incisors (either vertical or horizontal) pose a great challenge in speech, esthetics, malocclusion, and social interaction and also affect the self-esteem of children., Vertical impaction of permanent maxillary incisors is due to arch length deficiency, mucosal barrier, or overretained deciduous teeth, whereas horizontally impacted maxillary incisors are due to supernumerary teeth, cysts, or odontomas., Surgical extraction is the preferred treatment option due to their unfavorable position. The current case report describes autotransplantation as an alternative treatment option to manage horizontally impacted maxillary lateral incisors.
| Case Report|| |
A 13-year-old boy reported to the department of pediatric dentistry with the chief complaint of missing upper front tooth. Medical history was noncontributory with no previous history of trauma. Intraoral examination revealed a missing maxillary left lateral incisor and diffuse, nontender bony hard swelling in the same region [Figure 1]. The swelling was firm in consistency with no associated pus or blood discharge. On panoramic radiograph, a well-defined radiopaque lesion having density similar to the dentin was observed surrounding the crown of a horizontally impacted lateral incisor [Figure 2]. Provisional diagnosis of an odontoma was made. It was decided to surgically enucleate the odontoma followed by atraumatic removal of the horizontally impacted lateral incisor and its subsequent reimplantation in its anatomical position. The entire procedure was explained to the patient's parents in their own language, and consent for the treatment was taken.
|Figure 2: Panoramic radiograph showing impacted 22 displaced by odontome|
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Under local anesthesia (2% lignocaine with 1:20,0000 adrenaline), the calcified mass was removed without disturbing the underlying permanent maxillary left lateral incisor [Figure 3]a. The horizontally impacted permanent maxillary left lateral incisor was atraumatically extracted and reimplanted in its anatomical position within 5-min time [Figure 3]b. The tooth was stabilized using a composite splint for 1 week. Intentional root canal treatment was done to prevent the development of periapical infection. After 3-month follow-up, the permanent maxillary left lateral incisor showed no signs of failure such as mobility, tenderness, or gingival recession. Because the clinical crown height was not sufficient, it was decided to give post and core followed by a metal ceramic jacket crown. Eighteen-month clinical photograph did not show any signs of failure such as abscess, sinus, and swelling [Figure 4]a. Panoramic radiograph also did not show any signs of inflammatory or replacement resorption [Figure 4]b.
|Figure 3: Surgical procedure (a) Surgically removed calcified mass. (b) Surgical site showing destruction of the labial alveolar bone|
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|Figure 4: Eighteen-month follow-up of autotransplantation. (a) Intraoral photograph showing metal ceramic jacket crown in place. (b) Panoramic radiograph showing no signs of inflammatory or replacement resorption|
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| Discussion|| |
Impaction of permanent maxillary incisors may be due to pathological obstruction (supernumerary tooth, cysts, and odontomas), tooth malformation, ectopic eruption, ankylosis, endocrine abnormalities, bone diseases, and physical barrier to eruption (mucosal barriers),,, which interfere with normal speech, occlusion, esthetics, and social interaction., Majority of the impacted permanent maxillary incisors are vertically placed, therefore they can be either extracted or treated by orthodontic traction. Horizontally impacted permanent maxillary incisors pose a great difficulty in orthodontic traction due to their unfavorable position; therefore, surgical extraction is the preferred choice of treatment. In a growing patient, following extraction, a removable partial denture (fixed partial denture [FPD]) can be given, but it is hardly used nowadays because of patient's compliance issue, hygiene maintenance, and thinning of alveolar ridge. Fixed prosthesis and implants are contraindicated in children because of their growing age and incomplete alveolar bone growth., In the current case, autotransplantation was a better option to bridge the time until FPD or implant can be placed. Autotransplantation is a surgical method, in which a tooth is repositioned within the same patient. The most commonly autotransplanted teeth are premolars followed by molars and canines.,, Literature search revealed that erupted or vertically impacted (ectopic eruption) teeth are only most commonly autotransplanted for agenesis of permanent tooth or in the place of cariously extracted tooth or for avulsion. However, in the current case, horizontally impacted permanent maxillary left lateral incisor was surgically extracted and autotransplanted into its original position. Autotransplantation of horizontally impacted tooth into its original position offers several advantages such as the teeth can be moved orthodontically, it induces alveolar bone growth during tooth eruption, formation of functional periodontal cells, bone deposition at deficient site, improved gingival contour, and psychological satisfaction of natural tooth. However, the long-term outcome of such tooth is questionable due to difficulties in the removal of tooth from the donor site. Irreversible damage to the neurovascular bundle and periodontal ligament cells interferes with the healing process of autotransplantation. However, knowledge and skill of surgical procedure can prevent damage to periodontal tissue, pulpal tissue, alveolar bone, and adjacent tooth, improving the long-term successful outcome. In the current case report, after removal of odontome, the crown of the impacted permanent incisor was carefully exposed without damaging to the periodontal ligaments, thus preventing irreversible damage to the neurovascular bundle and periodontal ligament cells.
Apart from surgical skills, there are other factors that are perceived as important factors for a successful autotransplantation. Pulp healing in autotransplantation is strongly related to the apical diameter of root. The wider the apical foramen, lesser is the risk of pulpal necrosis, whereas the narrower the apical foramen, higher is the risk of pulpal necrosis. Ok and Yilmaz presented a bilateral autotransplantation in a 13-year-old child and documented that immature teeth are the best teeth for autotransplantation. However, van Westerveld et al. in a follow-up study of 20 years stated that even a mature tooth should be considered for autotransplantation. Horizontally impacted autotransplanted teeth carry a potential risk of pulpal necrosis irrespective of the apical diameter. Furthermore, these teeth are subjected to develop surface resorption, thereby increasing the risk of inflammatory resorption if the infected pulp tissue comes in contact with the exposed dentinal tubule., Therefore, to improve prognosis in the current case, intentional endodontic treatment was planned after autotransplantation.
Ankylosis is another commonly encountered complication, caused due to the injury to the root surface during surgery of donor tooth. In such conditions, the root of the autotransplanted tooth starts resorption, and simultaneously, there is deposition of bone in the resorbed areas. Such tooth has to be monitored with periodic imaging for replacement resorption phenomenon; infection can lead to inflammatory resorption which is a sign of failure. Long-term outcomes of autotransplantation are still a concern. Tsukiboshi et al. in their follow-up study for 30 years stated that autotransplantation done in immature teeth had a higher tendency toward success.
The quality of alveolar bone (bucco-palatal width and height) is also an important factor for the long-term successful outcome of autotransplanted tooth. It has been stated that stem/progenitor cells in the periodontal ligament and alveolar bone can differentiate into mature cells, including fibroblasts, osteoblasts, and endothelial cells, which infill the tissue in need. In children, the alveolar bone is spongy and more cellular, which favors differentiation of these cells., Considering these advantages, in spite of the destruction of labial alveolar bone, we transplanted a maxillary permanent lateral incisor in its anatomical position. Eighteen-month follow-up showed healing of the periodontal tissue and alveolar bone. Although the current case report had a successful follow-up of 18 months, long-term follow-up is required to use this treatment option in horizontally impacted tooth.
| Conclusion|| |
Autotransplantation can be an alternative treatment option for the management of horizontally impacted permanent incisors if removed atraumatically.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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