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Dual transplantation of third molar teeth
DUAL TRANSPLANTATION
OF THIRD MOLAR TEETH
Report of a Case GEORGE J. COLLINGS,
D.M.D., PORTLAND, ORE.
T
HIS report describes the successful dual transplantation of third molar teeth in the same individual. A. W., a white youth, aged 14, was admitted to the dental clinic on Jan. 3, 1948, with the chief complaint of a severe ache in the upper right lateral tooth which had a carious exposure beyond help. It was removed at this time. The other teeth were in a very bad condition. In particular the crowns of the lower and upper right first molars were decayed to the gingiva; the patient did not complain of pain associated with these teeth. The extent of decay is seen in Figs, 1 and 2. This case seemed to offer an excellent opportunity for the transplantation of unerupted third molars to replace the first molars already destroyed. The remaining treatment of this patient was done in the general clinic.
Preoperative Treatment On March 30, 1948, the patient was prepared for surgery as follows: pentobarbital sodium (11/e gr.) one hour in advance, atropine sulfate (&e gr.) orally thirty minutes later.
Operation The face was thoroughly cleansed with soap and water and then washed with alcohol. The patient rinsed his mouth thoroughly with a 1 :l,OOO solution After draping the of potassium permanganate for a period of one minute. operative area as in a tonsillectomy the lingual, inferior dental, and long buccal nerve were anesthetized with 2 per cent Novocaine containing 1:50,000 epinephrine. The impacted lower right third molar was removed first. This was accomplished by making two incisions, the first of which went distally and buccally 1.5 cm. from the distal lingual cusp of the second molar; the other started immediately posterior to the second molar downward to a point 5 mm. below the free gingiva and thence forward 1 cm. (Fig. 3). Next the mucoperiosteal flap was retracted and the mandible exposed (Fig. 4). A vertical cut distal to the distobuccal cusp of the second molar was made with a chisel. Then the bone overlying the occlusobuccal and distal portions of the impacted tooth was carefully removed to avoid injury to Nasmyth’s membrane. The third molar was lifted from its place and wrapped in sterile gauze moistened with physiological saline until ready for use. The lower right first molar was then extracted with minimal trauma to the gingival tissue. A crypt was formed by removal of inter- and intraseptal bone from this socket. This
work
was
done
in
the
Department
of 1211
Surgery,
llniversity
of
Oregon
Dental
School.
DUAL
TRANSPLASTATIOX
OF THIRD
MOLAR
1215
TEETH
The third molar was sprinkled with sulfanilamide powder and placed in this crypt. An interrupted silk suture from buccal to lingual gingiva held the transplanted tooth firmly in place. Sutures were also placed in the area formerly occupied by the third molar (Fig. 3).
Fig.
Fig.
Fig.
1.
3.
2.
Fix.
4.
Postoperative Care Postoperative medication consisted of codeine sulfate ($Ls gr.) plus empirin compound (6 gr.) every four hours or whenever needed for relief of pain. The patient was also instructed to place cold packs on the right side of the face for thirty minutes alternately for the next six to eight hours. Hot boric acid compresses were applied the next day until the swelling subsided. Hypotonic saline mouth irrigation was prescribed every three hours for five days starting the day after surgery. On the fifth operat,ive day the patient’s face was still slightly swollen; the transplanted tooth was somewhat mobile but not painful. The sutures were removed, the operated areas swabbed with 2 per cent gentian violet and irrigated with hypotonic saline. On the tenth postoperative day no swelling or pain was present. The tooth was st,ill slightly mobile on digital pressure.
Progress On July 16, 1948, three and one-half months after transplantation, the alveolar bone was firmly adherent to the transplanted tooth which was firm and
Y
DUAL
TRANSPLANTATION
OF T&IRD
MOLAR
TEETH
1217
not painful during mastication (Fig. 5). Aug. 20, 1948, four and one-half months after transplantation, the root was seen beginning to develop and the tooth was erupting into normal occlusion (Fig. 6). On Oct. 7, 1948, six months after operation, the tooth was firm; it was growing into occlusion; it was developing satisfactorily (Fig. 7). On April 27, 1949, thirteen months postoperatively, the tooth was in occlusion but did not react to the electric pulp tester. The roots had grown considerably in this period (Fig. 8). On Feb. 24, 1950, twenty-five months after transplantation, the tooth was still unresponsive to pulp test. The bone structure was normal, and the roots had developed to the point that periodontal membrane and lamina dura were easily visible (E’ig 9). On Aug. 20, 1950, after twenty-six mont,hs, the tooth was in occlusion, reacted to the electric pulp tester, and was caries free. The surrounding bone was normal (Fig. 10). The pat,ient w&s well satisfied and the tooth appeared functional in every respect. Second Transplantation On May 1, 1948, the unerupted upper third molar was transplanted to the The procedure was the same as described upper right first molar position. previously.
Fig.
15.
Progress On Oct. 27, 1948, six months later, the tooth was firm but not in occlusion since it appeared crowded between second premolar and second molar (Fig. 11) , On April 27, 1949, one year after transplantation, the roots showed development, though the tooth was still not in occlusion (Fig. 12). On Feb. 21, 1950, twenty-one months postoperatively, the tooth remained firmly in place. It was not painful during mastication. The periodontal membrane was present. Distal angulation was causing resorption at the mesial surface of the second molar. (Fig. 13.) On April 26, 1950, twenty-five months after operation, the tooth reacted to the electric pulp tester. The lamina dura appeared to be present. A sepa-
Fig.
18.
DUAL
TRANSPLAST.\TIOS
OF THIRD
3IOI,i\H
TEETH
1219
rating wire was inserted between the transplanted tooth and the second molar in the hope that it would push the transplanted tooth anteriorly to allow normal occlusion. (Fig. 14.) The case is best summarized by including Bite-Wing radiographs taken at twenty-five months after the second transplantation to show the relationship and appearance of these teeth (Figs. 15, 16, and 17). Summary The successful dual transplantation of two molar teeth in the same individual with progress notes over twenty-five months is described.
OF THIRD MOLAR TEETH
Report of a Case GEORGE J. COLLINGS,
D.M.D., PORTLAND, ORE.
T
HIS report describes the successful dual transplantation of third molar teeth in the same individual. A. W., a white youth, aged 14, was admitted to the dental clinic on Jan. 3, 1948, with the chief complaint of a severe ache in the upper right lateral tooth which had a carious exposure beyond help. It was removed at this time. The other teeth were in a very bad condition. In particular the crowns of the lower and upper right first molars were decayed to the gingiva; the patient did not complain of pain associated with these teeth. The extent of decay is seen in Figs, 1 and 2. This case seemed to offer an excellent opportunity for the transplantation of unerupted third molars to replace the first molars already destroyed. The remaining treatment of this patient was done in the general clinic.
Preoperative Treatment On March 30, 1948, the patient was prepared for surgery as follows: pentobarbital sodium (11/e gr.) one hour in advance, atropine sulfate (&e gr.) orally thirty minutes later.
Operation The face was thoroughly cleansed with soap and water and then washed with alcohol. The patient rinsed his mouth thoroughly with a 1 :l,OOO solution After draping the of potassium permanganate for a period of one minute. operative area as in a tonsillectomy the lingual, inferior dental, and long buccal nerve were anesthetized with 2 per cent Novocaine containing 1:50,000 epinephrine. The impacted lower right third molar was removed first. This was accomplished by making two incisions, the first of which went distally and buccally 1.5 cm. from the distal lingual cusp of the second molar; the other started immediately posterior to the second molar downward to a point 5 mm. below the free gingiva and thence forward 1 cm. (Fig. 3). Next the mucoperiosteal flap was retracted and the mandible exposed (Fig. 4). A vertical cut distal to the distobuccal cusp of the second molar was made with a chisel. Then the bone overlying the occlusobuccal and distal portions of the impacted tooth was carefully removed to avoid injury to Nasmyth’s membrane. The third molar was lifted from its place and wrapped in sterile gauze moistened with physiological saline until ready for use. The lower right first molar was then extracted with minimal trauma to the gingival tissue. A crypt was formed by removal of inter- and intraseptal bone from this socket. This
work
was
done
in
the
Department
of 1211
Surgery,
llniversity
of
Oregon
Dental
School.
DUAL
TRANSPLASTATIOX
OF THIRD
MOLAR
1215
TEETH
The third molar was sprinkled with sulfanilamide powder and placed in this crypt. An interrupted silk suture from buccal to lingual gingiva held the transplanted tooth firmly in place. Sutures were also placed in the area formerly occupied by the third molar (Fig. 3).
Fig.
Fig.
Fig.
1.
3.
2.
Fix.
4.
Postoperative Care Postoperative medication consisted of codeine sulfate ($Ls gr.) plus empirin compound (6 gr.) every four hours or whenever needed for relief of pain. The patient was also instructed to place cold packs on the right side of the face for thirty minutes alternately for the next six to eight hours. Hot boric acid compresses were applied the next day until the swelling subsided. Hypotonic saline mouth irrigation was prescribed every three hours for five days starting the day after surgery. On the fifth operat,ive day the patient’s face was still slightly swollen; the transplanted tooth was somewhat mobile but not painful. The sutures were removed, the operated areas swabbed with 2 per cent gentian violet and irrigated with hypotonic saline. On the tenth postoperative day no swelling or pain was present. The tooth was st,ill slightly mobile on digital pressure.
Progress On July 16, 1948, three and one-half months after transplantation, the alveolar bone was firmly adherent to the transplanted tooth which was firm and
Y
DUAL
TRANSPLANTATION
OF T&IRD
MOLAR
TEETH
1217
not painful during mastication (Fig. 5). Aug. 20, 1948, four and one-half months after transplantation, the root was seen beginning to develop and the tooth was erupting into normal occlusion (Fig. 6). On Oct. 7, 1948, six months after operation, the tooth was firm; it was growing into occlusion; it was developing satisfactorily (Fig. 7). On April 27, 1949, thirteen months postoperatively, the tooth was in occlusion but did not react to the electric pulp tester. The roots had grown considerably in this period (Fig. 8). On Feb. 24, 1950, twenty-five months after transplantation, the tooth was still unresponsive to pulp test. The bone structure was normal, and the roots had developed to the point that periodontal membrane and lamina dura were easily visible (E’ig 9). On Aug. 20, 1950, after twenty-six mont,hs, the tooth was in occlusion, reacted to the electric pulp tester, and was caries free. The surrounding bone was normal (Fig. 10). The pat,ient w&s well satisfied and the tooth appeared functional in every respect. Second Transplantation On May 1, 1948, the unerupted upper third molar was transplanted to the The procedure was the same as described upper right first molar position. previously.
Fig.
15.
Progress On Oct. 27, 1948, six months later, the tooth was firm but not in occlusion since it appeared crowded between second premolar and second molar (Fig. 11) , On April 27, 1949, one year after transplantation, the roots showed development, though the tooth was still not in occlusion (Fig. 12). On Feb. 21, 1950, twenty-one months postoperatively, the tooth remained firmly in place. It was not painful during mastication. The periodontal membrane was present. Distal angulation was causing resorption at the mesial surface of the second molar. (Fig. 13.) On April 26, 1950, twenty-five months after operation, the tooth reacted to the electric pulp tester. The lamina dura appeared to be present. A sepa-
Fig.
18.
DUAL
TRANSPLAST.\TIOS
OF THIRD
3IOI,i\H
TEETH
1219
rating wire was inserted between the transplanted tooth and the second molar in the hope that it would push the transplanted tooth anteriorly to allow normal occlusion. (Fig. 14.) The case is best summarized by including Bite-Wing radiographs taken at twenty-five months after the second transplantation to show the relationship and appearance of these teeth (Figs. 15, 16, and 17). Summary The successful dual transplantation of two molar teeth in the same individual with progress notes over twenty-five months is described.