Table of Contents    
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 273-277  

Immediate replacement of nonrestorable molar with impacted third molar: An experimental study


1 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli, India
2 Department of Oral and Maxillofacial Surgery, YMT Dental College and Hospital, Kharghar, Maharashtra, India
3 Department of Public Health Dentistry, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli, India

Date of Web Publication20-Jun-2018

Correspondence Address:
Mahesh Ravindra Khairnar
Department of Public Health Dentistry, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnsbm.JNSBM_29_18

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   Abstract 

Background: Autogenous transplantation of impacted third molars in place of nonsalvageable first or second molars can prove to be a good option. Hence, the present study evaluated the replacement of maxillary or mandibular nonrestorable molars with immediate autotransplantation of impacted third molar. Materials and Methods: Forty-two impacted third molars having complete root formation were extracted and autotransplanted into the extraction socket of nonrestorable first or second molars on 42 participants in the age range of 22–50 years. Follow-up period for the study was of 1 year at regular intervals. Participants were analyzed for pain, tooth mobility, ankylosis, and root resorption at follow-up intervals. Data obtained were analyzed using SPSS software. Results: Out of the 42 participants, 9 participants required extraction of autotransplanted tooth due to resorption and Grade 2 mobility. One tooth showed ankylosis. Success rate of the autotransplantation was 78%. Conclusion: It was concluded that immediate autotransplantation is a successful and more economical tooth replacement option provided that proper case selection and procedure should be followed.

Keywords: Ankylosis, autotransplantation, resorption


How to cite this article:
Shinde SU, Deshmukh A, Khairnar MR. Immediate replacement of nonrestorable molar with impacted third molar: An experimental study. J Nat Sc Biol Med 2018;9:273-7

How to cite this URL:
Shinde SU, Deshmukh A, Khairnar MR. Immediate replacement of nonrestorable molar with impacted third molar: An experimental study. J Nat Sc Biol Med [serial online] 2018 [cited 2018 Jul 20];9:273-7. Available from: http://www.jnsbm.org/text.asp?2018/9/2/273/234726


   Introduction Top


Fixation of a single tooth from one bony slot to another in oral cavity in the same individual is called autogenous transplantation.[1] Hale was the first person who documented autogenous tooth transplantation.[2] It is suitable option for cases such as tooth loss because of severe dental caries, tooth agenesis, and traumatic tooth fracture.[3],[4],[5]

Available literature shows that non-impacted third molars have also been used for autogenous transplantation.[6] Furthermore, this therapy is relatively simple and prevents the space loss. It maintains the anatomy of the alveolus after extraction and proprioception feeling.[3],[7] Autotransplantation allows for orthodontic tooth movement which is impossible in case of metal dental implants.[8] The futile tooth can be changed with an efficient one with the help of autotransplantation with a good prognosis. It gives natural tooth appearance and effective chewing ability with good postoperative success rate for longer duration.[9]


   Materials and Methods Top


Ethical approval was obtained from institutional ethical committee before starting the study. A detailed case history of the patient and an informed consent regarding the surgical procedure were obtained. A total of 42 participants with impacted maxillary or mandibular third molars and nonrestorable maxillary or mandibular first or second molars were selected. All the participants had undergone routine blood investigations. All the surgical procedures were done under local anesthesia (Lignox 2% A; Indoco Remedies Ltd, Mumbai, India), with the same type of instruments by the same operative surgeon.

Surgical technique

Preoperative orthopantomograms (OPGs) were taken for every case to know more about measurements of the donor and recipient tooth and anatomical variations and for procedure planning [Figure 1]a. All the participants were prepared as per the routine surgical protocol. Inferior alveolar, lingual, and long buccal nerve blocks were given using 2% lignocaine hydrochloride with 1:80,000 adrenaline. Reflection of the full-thickness mucoperiosteal flap was done with the help of ward incision. The incision began at a point down in buccal sulcus. The anterior limb of the incision was made from distobuccal line angle of the second molar at the gingival margin with the blade pressed firmly down progressing anteriorly. Then, the incision was passed cervically behind the second molar to the middle of its distal surface. From this point, the incision was taken backward and buccally along the external oblique ridge. The ward incision was avoided in few simple cases in which extraction of the third molar was easy.
Figure 1: (a) Preoperative photographs: radiograph showing impacted third molar and nonrestorable molar. (b) Extraction socket of nonrestorable tooth(47) with adjoining soft-tissue impacted third molar (48). (c) Transplant positioned at or slightly below the occlusal plane so as to avoid premature occlusal contacts. (d) Transplanted tooth in new position with crossover suturing with 3–0 silk. (e) One-year postoperative radiograph

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Extraction of the nonrestorable tooth was done [Figure 1]b. In all the cases, there was a need of elimination of interradicular bone for easy adaptation of donor tooth in recipient site. A straight handpiece (Kavo Straight Handpiece 500; KaVo Kerr Group, Mumbai, India) with a HP10 round and 703 straight fissure burs was used with ample saline irrigation to ready the recipient slot for donor tooth. Additional removal of the bone beyond the apex was done in every case for maintaining tension-free zone at the apex.

Luxation of the donor tooth with the straight elevator employing minimum force without sectioning before the extraction was done in every case. Only those cases were selected in which the third molar extraction could be done without bone removal so that there would be less trauma. Saline irrigation was used to remove all the debris from wound. The tissue margins were freshened up. After extraction, impacted tooth had to be transferred to a new socket position within 18 min.[10] If the donor tooth could not be adjusted in the recipient site, elimination of the bony hindrance from the recipient site was performed. During this time, the donor molar was kept between two gauze pads soaked in normal saline solution. Any root damage of donor tooth was avoided. Transplanted molar was examined and kept out of occlusion to avoid occlusal trauma [Figure 1]c.

Fixation of the transplanted third molar was done with 3–0 black braided silk suture so that it will cover the occlusal surface and avoid undue movement [Figure 1]d. The donor molar was covered all around by gingival flap with the help of firm sutures. Extraction socket of the donor tooth was also closed with sutures. Fixation with the help of wire was required for mobile tooth after autotransplantation.

Postoperative care

All participants were given oral antibiotics and analgesic. Instructions about oral hygiene had been given to the participants, and the participants were kept at a full liquid diet for 2 days postoperatively and on a semi-liquid diet for next 2 weeks. A soft diet was suggested for further 2 weeks.

Suture and wire were removed after 7 days postoperatively. Root canal treatment was performed 1 month after transplantation instead of doing on the same day of surgery to reduce the damage of the periodontal ligaments during handling of the tooth. Follow-up was scheduled 2 weeks, 1 month, 3 months, 6 months, and 1 year thereafter.

Assessment of pain, mobility, and ankylosis

Pain and mobility were assessed clinically while resorption of tooth and ankylosis were assessed radiographically [Figure 1]e. Pain was examined and noted on visual analog scale (VAS) (0 = no pain, 1 = slight pain, 2 = mild pain, 3 = severe pain, 4 = very severe pain, and 5 = extremely severe pain) on the 1st postoperative day (POD1), POD2, and POD7.

Mobility was graded clinically. Tooth was held between the handles of two metallic instruments or with one metallic instrument and one finger and graded according to the tooth movement direction and extends of tooth.

  • Grade 0 – mobility within physiological limit
  • Grade 1 – slight mobility
  • Grade 2 – moderate mobility in horizontal direction
  • Grade 3 – severe mobility both in mesiodistal and buccolingual direction with vertical displacement.


Ankylosis was seen radiographically as obliteration of periodontal ligament space and the absence of lamina dura. It was recorded as present – p and absent – a, on 1 month, 3 months, 6 months, and after 1 year postoperatively. Resorption was seen radiographically as radiolucency on root surface. It was recorded as present – p and absent – a, on 1-month, 3-month, 6-month, and after 1-year POD.

Statistical analysis

Data collected were analyzed using SPSS version 17 (SPSS, Inc., Chicago, IL, USA) software. Mean pain score at regular intervals was analyzed using Friedman's test and Wilcoxon signed-rank test. Mobility, resorption, and ankylosis were analyzed using Chi-square test. Level of significance was kept at P ≤ 0.05.


   Results Top


A total of 42 teeth were transplanted in the present study. Eight teeth were lost during the follow-up period due to Grade 2 mobility and root resorption, whereas one tooth showed ankylosis. Success rate of autotransplantation was 78%.

Comparison between mean pain scores at different time intervals was performed. Mean pain score reduced from POD1 to POD7. The differences in mean pain scores were statistically significant (P< 0.001) [Table 1]. Differences in mean pain scores were significant for all the comparisons at different time intervals [Table 1]. There was a reduction in the mobility of the teeth as time progressed which was statistically significant (P< 0.001) [Table 2]. Out of 42 teeth, only one tooth showed ankylosis. This difference in ankylosis was not statistically significant (P = 0.999) [Table 3]. At the end of 1 year, 34 teeth showed no signs of resorption (P = 0.045) [Table 3].
Table 1: Comparison of pain score

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Table 2: Comparison of mobility at different intervals

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Table 3: Comparison of ankylosis and resorption at different intervals

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   Discussion Top


The nonrestorable, nonfunctional molar can be replaced by a functional tooth with the help of autotransplantation procedure. Recipient site can be adjusted to accept the donor tooth.[11] Autogenous transplantation has more rapid healing when compared to implant procedure, and donor tooth can function like normal tooth.[12] Success of the present study was evaluated with the help of criteria which have been widely mentioned in literature.[8],[13],[14] The transplanted tooth was supposed to be successful if it showed following things at the end of study:

  1. Normal functioning tooth without excessive mobility
  2. Radiographically transplanted tooth should be without root resorption and the absence of abnormal periodontal ligament space and the presence of continuous lamina dura around the root.


The success rate with autogenous third molar transplantation in the present study was 78% since out of 42 cases, 8 cases were failed due to Grade 2 mobility and resorption. One case showed ankylosis. The success rate was higher as compared to the study conducted by Watanabe et al.,[15] Kallu et al.,[16] and Huth et al.[17] (63.1%, 68%, and 74%, respectively). Inferior success rate in the study conducted by Watanabe et al. can be attributed to inadequate root canal obturation as compared to the present study where root canal treatment was performed by trained endodontist to reduce chances of failure.[15] Kallu et al. mentioned lower patient response rate as a reason for lower success rate. They also mentioned case selection, surgical technique, and surgeon's skills as the factors affecting final outcome of the transplantation.[16] Huth et al. included participants with smoking habits which influenced the outcome of their study.[17]

The mean age of the participants was 36 (age range: 22–50 years) with 15 males and 27 females. In one case, mandibular nonrestorable molar was autotransplanted by maxillary third molar. For the ease of procedure, only vertical and mesioangular impacted third molars were considered as donor tooth.

Evaluation of the pain perception by the participants was done with VAS scale which showed that the pain reduced as the time progressed. Donor tooth which showed more stability after immediate transplantation showed better prognosis. This is because stability of the autotransplanted tooth provides more anchorage and better healing.[12] Available literature shows that wire splinting and acid-etch composite are the most commonly used tooth stabilizing, splinting methods.[18] As per Kasaboglu, there is no requirement of any fixation if mesiodistal dimension of the donor tooth is similar to that of the recipient area, enough space between donor tooth root and recipient bone slot and enough adjacent crown frictional stability.[14] In our experience, stability can be achieved if the mesiodistal dimension of the donor tooth is similar to that of the recipient area. Suture or wire fixation was done to achieve enough stability in some cases due to anatomical variations and removed it after 1 week. Kristerson and Andreasen concluded that rigid splinting for more than 1 week should be avoided for better prognosis.[19] In 2002, Bauss autotransplanted 76 immature third molars and concluded that suture splinting for 1 week had lower chances of ankylosis and pulp necrosis as compared to rigid fixation for 4 weeks.[20] Tooth mobility of autotransplanted tooth was measured according to grade system (0–3).[21] Results showed that mobility decreased with time. In the present study, 8 autotransplanted teeth showed Grade 2 mobility after 3 months, out of which 4 teeth were extracted at 3-month interval and 4 teeth were extracted at 6-month interval.

After autotransplantation, revascularization of the donor tooth having complete root formation is difficult. Pulp necrosis leading to inflammatory root resorption is the common complication.[22] Tsukiboshi advocated root canal treatment in such cases before the surgery which was difficult in the present study due to impacted nature of the donor molar. Hence, the case root canal treatment was recommended 2 weeks after the surgery for such cases.[12] However, in the present study, root canal treatment was done 1 month after transplantation instead of doing at the same time or doing after 2 weeks so as to reduce the damage of the periodontal ligaments during handling of the tooth and subsequently increasing the chances of root resorption.[3]

Resorption was seen radiographically as radiolucency on the root surface. A total of eight autotransplanted teeth got extracted due to resorption in the present study which was responsible for lowering the success rate. Ankylosis was seen radiographically as obliteration of periodontal ligament and periodontal ligament space and the absence of lamina dura. Transplanted tooth shows the absence of root resorption and the presence of noninterrupted lamina dura on radiographs. Ankylosis is directly proportional to root damage. Transplantation of tooth with root damage leads to ankylosis.[3] According to Akiyama et al., periodontal ligament on root cementum plays an important role in ankylosis. Undamaged healthy periodontal ligament leads to transplantation without ankylosis.[23] Therefore, for successful transplantation, surgeon must preserve periodontal ligament by performing atraumatic extraction without root damage. Time plays a crucial role from the moment; the extraction of the donor tooth is done till it gets implanted into the recipient site. As this period gets increases, damage to the periodontal ligament also increases which may ultimately lead to ankylosis of the tooth.[10] Therefore, root canal treatment was done after transplantation to reduce this time to get healthy periodontal ligament. Tsukiboshi suggested tight closure of the gingival flap around the tooth to avoid bacterial contamination into the blood in periodontal space and for reattachment of periodontal ligament to the tooth.[12] In the present study, one tooth was ankylosed, but it showed good prognosis postoperatively. A patient was satisfied with the prognosis.

Tsukiboshi suggested that if donor molar is not fitted in the first attempt of transplantation due to mismatching of dimensions, then 0.5 mm proximal side stripping of the donor molar is mandatory.[12] This technique has never been followed because of chances of damage to root cementum and periodontal ligaments.

Impacted third molars covered by follicle or in developing condition are easy to extract. Completely developed impacted third molar requires rotary and bur which may damage the tooth.[24] Koszowski et al. used piezosurgery for transplantation of the third molar to reduce the damage.[25] Teeth which were either vertical or mesioangular in position and easy to extract without sectioning were transplanted. Due to these reasons, case selection is very important in transplantation of teeth.


   Conclusion Top


Immediate autogenous transplantation of the impacted third molar is a good alternative to replace nonrestorable molars with prosthesis which requires cutting of noncarious adjacent teeth. The authors concluded that the third molar transplantation is a very beneficial tooth replacement option using proper case selection and proper technique. For better success rate, root canal treatment should be done 1 month after transplantation.

.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
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2.
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Josefsson E, Brattström V, Tegsjö U, Valerius-Olsson H. Treatment of lower second premolar agenesis by autotransplantation: Four-year evaluation of eighty patients. Acta Odontol Scand 1999;57:111-5.  Back to cited text no. 5
    
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Czochrowska EM, Stenvik A, Bjercke B, Zachrisson BU. Outcome of tooth transplantation: Survival and success rates 17-41 years posttreatment. Am J Orthod Dentofacial Orthop 2002;121:110-9.  Back to cited text no. 9
    
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Tsukiboshi M. Autotransplantation of teeth: Requirements for predictable success. Dent Traumatol 2002;18:157-80.  Back to cited text no. 12
    
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Yan Q, Li B, Long X. Immediate autotransplantation of mandibular third molar in china. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:436-40.  Back to cited text no. 13
    
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Akkocaoglu M, Kasaboglu O. Success rate of autotransplanted teeth without stabilisation by splints: A long-term clinical and radiological follow-up. Br J Oral Maxillofac Surg 2005;43:31-5.  Back to cited text no. 14
    
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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.  Back to cited text no. 15
    
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Kallu R, Vinckier F, Politis C, Mwalili S, Willems G. Tooth transplantations: A descriptive retrospective study. Int J Oral Maxillofac Surg 2005;34:745-55.  Back to cited text no. 16
    
17.
Huth KC, Nazet M, Paschos E, Linsenmann R, Hickel R, Nolte D, et al. Autotransplantation and surgical uprighting of impacted or retained teeth: A retrospective clinical study and evaluation of patient satisfaction. Acta Odontol Scand 2013;71:1538-46.  Back to cited text no. 17
    
18.
Bauss O, Schwestka-Polly R, Schilke R, Kiliaridis S. Effect of different splinting methods and fixation periods on root development of autotransplanted immature third molars. J Oral Maxillofac Surg 2005;63:304-10.  Back to cited text no. 18
    
19.
Kristerson L, Andreasen JO. The effect of splinting upon periodontal and pulpal healing after autotransplantation of mature and immature permanent incisors in monkeys. Int J Oral Surg 1983;12:239-49.  Back to cited text no. 19
    
20.
Bauss O, Schilke R, Fenske C, Engelke W, Kiliaridis S. Autotransplantation of immature third molars: Influence of different splinting methods and fixation periods. Dent Traumatol 2002;18:322-8.  Back to cited text no. 20
    
21.
Newman M, Takei H, Klokkevold P, Carranza F. Clinical diagnosis. Carranza's Clinical Periodontology. 12th ed., Ch. 29. St. Louis, Missouri: Elsevier Saunders; 2014. p. 357-74.  Back to cited text no. 21
    
22.
Trope M. Clinical management of the avulsed tooth: Present strategies and future directions. Dent Traumatol 2002;18:1-1.  Back to cited text no. 22
    
23.
Akiyama Y, Fukuda H, Hashimoto K. A clinical and radiographic study of 25 autotransplanted third molars. J Oral Rehabil 1998;25:640-4.  Back to cited text no. 23
    
24.
Goyal M, Marya K, Jhamb A, Chawla S, Sonoo PR, Singh V, et al. Comparative evaluation of surgical outcome after removal of impacted mandibular third molars using a piezotome or a conventional handpiece: A prospective study. Br J Oral Maxillofac Surg 2012;50:556-61.  Back to cited text no. 24
    
25.
Koszowski R, Morawiec T, Bubiłek-Bogacz A. Use of the piezosurgery technique for cutting bones in the autotransplantation of unerupted third molars. Int J Periodontics Restorative Dent 2013;33:477-81.  Back to cited text no. 25
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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