Case Presentation
A 19-year-old man presented to the dental office with pain and swelling around tooth 4.6. The tooth had a history of an initial root canal treatment, 5 years ago, due to a diagnosis of symptomatic irreversible pulpitis. The tooth was retreated two times by endodontists, due to continued symptomatic apical periodontitis.
Intraoral examination revealed a temporary crown, class III mobility, pain to percussion and palpation. Swelling was evident on the disto-lingual portion of the tooth, with a pocketing depth of 15 mm in that area. Teeth 4.5 and 4.7 responded normally to testing.
A periapical radiograph showed an amalgam core and root canal treatment that was overextended at the apex of the distal root. A periapical radiolucent lesion was seen 10 mm in diameter surrounding tooth 4.6. A CBCT showed penetration of the lesion through the buccal and lingual cortical plates, and approximating the inferior alveolar nerve canal. An acute apical abscess was diagnosed, and a vertical fracture was also suspected.
Treatment
Day 1
- Tooth 4.6 was extracted and a vertical root fracture was confirmed.
- A delicate curettage and drainage was performed, due to the proximity of the lesion to the IAN canal.
- Mucograft (Geistlich Biomaterial, Germany) was placed and sutured with 6-0 nylon sutures to increase keratinized tissue width.
Day 2
- 9 weeks after the first treatment day, tooth 4.8 (partially impacted and immature) was surgically extracted, as a crestal incision and full-thickness mucoperiostreal flap was raised. With buccal bone removal, tooth 4.8 was delivered with forceps.
- Tooth 4.8 was immediately implanted in the healing socket of 4.6, with an extra-oral time of under one minute. Since the socket of 4.6 was at the osteoid stage of healing, the area was fairly soft and no preparation of the area was needed.
- The transplanted tooth was splinted with stainless steel wires for 2 weeks, in an infra-occlusion position.
| Follow up The patient had a follow up schedule of 2 weeks, 1 month, 3 months, and 1 year. At the 1-year follow up, the tooth had normal mobility, no pain on percussion or palpation, and responded normal to cold testing. The soft tissue was within normal limits, with probing depth of 3 mm all around. There was no change in the distal root dimension, however the mesial root – there was a development of root length and closing of the apex. |
| Autotransplantation can be a viable option for replacing a missing tooth, in addition to implants or a bridge. This is especially true in children or adolescents, as implants are contraindicated due to the continuous growth of the alveolar process – posing a risk of severe infrapositioning of the implant. What is critical for any autotransplantation case is positioning and splinting the donor tooth for 2-3 weeks, following a minimal extraoral time of the transplanted tooth. And if the donor tooth is a mature tooth, root canal treatment should be performed extraorally or within 2 weeks of the transplantation. Although most reported cases of autotransplantation show a healthy recipient site, in this case we saw a site with a large periradicular lesion. The postponed autotransplantation by 9 weeks was done to allow for soft tissue repair and bone regeneration. The bone regeneration process has two phases. The first 4-8 weeks following extraction is the progressive osteogenic phase, showing the growth of osteogenic cells and immature bone. 8-12 weeks following extraction, osteogenesis slows down and new trabeculae undergo maturation. 9 weeks was chosen for this case, as it would be time where the recipient site would be inflammation free and have immature osteogenic bone. And as was seen in this case, no site preparation or osteotomy was needed. Replanting immature teeth gives us a significant advantage. As the apical foramen is open, the tooth has a high chance of revascularization as blood capillaries invade the apical foramen, and if the Hertwig epithelial root sheath is preserved, pulp cell differentiation should be expected. |
| This case was completed and reported by Dr. Y. Arbel, Dr. A. Lvovsky, and Dr. H. Azizi. |