Autogeneic and allogeneic tooth transplants in the treatment of malocclusion

Autogeneic and allogeneic tooth transplants in the treatment of malocclusion Alfred

1. Baum,

D.D.S., M.S.D.,*

and

Robert

S. Hertz,

D.D.S., M.S.D.**

Los Angeles, Calif.

T

he problem of the young patient who presents with multiple teeth congenitally missing or with early loss of teeth can often be solved satisfactorily by orthodontic space-closing procedures. In fact, this has become routine treatment for congenital absence of premolars or prematurely lost first molars. In the case of the missing upper lateral incisor, unilateral or bilateral, Tuversonl has shown the fine results that can be achieved by placing the canine in the lateral incisor position, with appropriate modification in size and shape, and the similar adaptation of the first premolar to assume the canine’s function. In the opposing arch in these cases compensating tooth loss may be indicated, or an unconventional finished occlusion may be an acceptable compromise. In these circumstances, then, the orthodontist can produce an “intact” dentition with no need for prosthesis. There are, however, many cases in which either multiple teeth are missing or teeth are missing asymmetrically, so as to prevent purely orthodontic solutions to the problem. An attractive prospect in these cases might well be tooth transplantation. Categorically, two types of tooth transplant are possible : autogeneic (formerly called “autologous”), the transplantation of a tooth from one site to another in the same person, or allogeneic (formerly called “homologous”), the transplantation of teeth from one person to another. These two procedures will be discussed separately, and a case illustrating each will be presented. The surgical techniques for the transplantation of teeth are the same, regardless of whether the transplant is an autograft or an allograft. The host site must

386

Presented

before

*Clinical

Assistant

the

Professor

**Lecturer

in

Surgery,

Oral

European

College in

of

Orthodontists,

Orthodontics,

University

University of

California

Cannes, of School

France,

Southern of

June, California.

Dentistry.

1977.

puZ,“7%&‘4”

Tooth transplants

fig. 1. A, 6 and C, Models lower arch at completion right premolar area.

of Patient S.R. showing of treatment showing

in treatment

original upper

of malocclusion

387

makclusion. D, Photograph of premolar transplanted to lower

have adequate bone in all dimensions to accommodate the tooth. The host alveolar site must be prepared to conform as closely as possible to the donor tooth. The transfer from donor to recipient must be made as quickly as possible and with as few repeated attempts as can be achieved. Fixation of the graft is important to allow the surrounding bone to grow against the tooth graft without stimulating osteoclastic action. An immediate postoperative radiograph must be taken to act as a base line comparison upon which to judge such developments as root growth, osteoclasia, or root resorption. The

autogeneic

transplant

Autogeneic grafting should always be the first choice if available. Timing is important for optimum tooth development. The discretion of the oral surgeon should be a prime factor. In the opinion of most authorities, the ideal stage in root development appears to be when the root is half to two thirds complete, with the apices still wide open. This often necessitates the planning of orthodontic treatment around the most advantageous transplant time. The success of autogeneic transplants has been cited at from 50 per cent2 to as high as 95 per cent.3 Case

report

The trusion.

patient, an ll-year-old girl, had a Class I malocclusion The upper incisors showed hypopIastic enamel blanching.

with mild crowding and proThere was a bilateral buccal

388

Baurn and Hertz

Am. J. Orthod. October 1977

Tooth transplants

Fig.

3.

A,

Roentgenogram

showing

upper

right premolar area. B, Roentgenogram premolar. C, Roentgenogram showing orthodontic treatment. D and E, Follow-up transplanted years after

premolar. autograft.

F, Roentgenogram

right

in treatwed

second

premolar

showing completion status of transplanted x-ray films showing of

transplanted

of malocclusior~

transplanted

to

389

lower

of root tip of transplanted premolar at completion of little change in status of the premolar

showing

status

13

open-bite (Fig. 1, A, B, and C). The upper left second premolar, the lower right first and setiond premolars, and the lower left second premolar were congenitally missing (Fig. 2). Jn October, 1963, the upper right second premolar wan transplanted to the lower right premolar area (Fig. 3, A). The case was fully banded. The transplanted tooth was banded 2 months lattbr and treatment was continued, nom as a symmetrical four-premolar-extraction case. Radiographically, the tooth completed its apical development, albeit atypically (Fig. 3, R). Treatment was completed uneventfully, and bands were removed in December, 1966. Radiographically, the tooth appeared much as it had 20 months earlier (Fig. 3, C) Clinically, the transplanted tooth appeared no different from the rest of the patient’s dentition except for its anatomy (Fig. 1, II). The retention period was routine. Roentgenograms taken periodically showed some rounding of the root end and narrowing of the pulp chamlwr Imt no impairment of function (Fig. 3, D and E). When the patient was last seen in January, 1976, about 1.X1/~ years after the autogeneic graft, the tooth was asymptomatic and functional (Fig. 3, P).

Am J. Orthod. Octobw 1977

__.

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of the kond

all tbzbuticcosnp!aints--arc 6mplc) b engages ti;at in in Teeth without dtnwpttrmks Tecfh with virgin

gualiiy, ,tm and

Fig. The

allogeneic

4. Advertisement

for

donors

for

tooth

transplants,

dated

1796.

transplant

Historically, tooth transplantation from one person to another has been attempted for literally hundreds of years. Pare described tooth transplantation in the sixteenth century.4 Fauchar@ and Hunter6 both enthusiastically embraced the procedure in the seventeenth and eighteenth centuries in Europe. Allogeneic tooth transplantation was widely practiced by early American dentists. Fig. 4 shows an advertisement for donors of “handsome and healthy live teeth” for “cash.” The allogeneic transplant falls into an entirely different category of tissue

Volume Number

72 4

Tooth transplants

in treatment

of wudocclusdon

391

management. Its history and implications were well described by Shulmans in 1972. The average survival time for allogeneic transplants has been estimated to be about 4 years. The genetic difference between the donor and the recipient is undoubtedly the most significant factor in determining the intensity and rate of allograft rejection.8 All transplanted tissue follows a definitive immunologic course as described by Mezrow,S with references to GuralnicklO and Shulman.ll Body tissues have genetically determined specific antigens which permit autografting but prevent homografting by an immune reaction known as the “homograft reaction,” an actively acquired immune response which results in ultimate rejection. After rejection, the host is further sensitized and a second graft from the same donor will elicit a more vigorous reaction and quicker rejection. This has been called the “second set reaction.” Histocompatibility can be tested by two methods, typing and matching. Both are involved and have not been extensively used in tooth transplantation. However, siblings and persons with closely related genetic backgrounds tend to show better compatibility prospects. In general, the current body of dental literature reflects a distinctly pessimistic attitude toward allogeneic tooth transplants. In the case that follows, involving a repeated allograft from brother to sister, the second set reaction did not occur. No matching or typing studies were done. The transplant is now more than 2 years old and appears unchanged. Case report The patient was first evaluated in 1970 at the age of 7. She had a well-repaired cleft lip and premaxilla on the left side. There was, however, a residual bony defect. The upper left lateral incisor and all four second premolars were congenitally missing (Fig. 5, a). All teeth showed relatively severe hypoplastic enamel blanching. Occlusion was Class I, with a severely displaced upper left central incisor (Fig. 6, B to E). Cephalometrically, the patient’s dentofacial pattern was not remarkable. The symmetrical absence of the four second premolars did not present a serious orthodontic problem. The space created by the absence of the upper left lateral incisor, however, could not be managed orthodontically by me&l movement of the canine because the premolar was missing. The patient’s younger brother was to lose four first premolars as a preliminary to orthodontic treatment. This fortuitous circumstance led to consideration of an allograft of a premolar to the upper left quadrant. Orthodontic treatment could then provide an intact dentition. The upper arch was banded in July, 19’72, and rotation of the upper left central incisor was begun. On April 30, 1973, the patient was referred to an oral surgeon to receive the tooth transplant from her brother. With the patient under intravenous sedation and local anesthesia, an alveolar socket was created in the maxillary left second premolar position. This socket was created with a dental drill. Attention was then directed to the brother. His maxillary left first premolar was extracted, wrapped in gauze soaked with the sister’s blood during the transfer, and easily placed into the newly created host site. Fixation was achieved by means of 25 gauge wire with acrylic reinforcing (Fig. 7, A). This fixation was removed on May 21, 1973. The postoperative course had been uneventful. The patient was instructed in the care of the allograft and given an appointment for a B-month recall. On Nov. 1, 1973, the patient returned. She was comfortable but noted that the allograft was mobile. A roentgenogram revealed extensive root resorption (Fig. 7, 73). On Nov. 12, 1973, the allograft was extracted. Healing was rapid and without complication. A discussion was held with the patient and her mother about the feasibility of repeating the allograft once again. Three of the brother’s premolara were still available for transplant. It,

392

Am. J. Orthod. October 1977

Baum and Hertz

Fig. 5. A, Roentgenogram incisor

of Patient congenitally

Panographic upper left

x-ray film lateral incisor

at completion area; upper

upper

first

upper

left

left

lateral

premolar

in canine

L.S. before missing, of left

treatment with bony

showing second defect in repaired

orthodontic treatment canine in contact with

premolars and cleft area. 6,

showing bony defect central incisor; allografted

in

position.

was agreed that the tooth allograft should be repeated after waiting a period of time for healing of the extraction site and to allow osteoclastic activity to subside. The patient returned to the orthodontist. During the following year, the adjacent first premolar erupted. Orthodontic treatment continued. The canine was moved mesially in contact with the central incisor to replace the congenitally missing lateral incisor. For mechanical reasons, it was orthodontically advantageous to move the first premolar distally to replace the missing second premolar. As a result, the original allograft site was now occupied by the first premolar. The endentulous site was now in the first premolar alveolus. On Dec. 2, 1974, the patient and her brother were prepared for the second tooth allograft. An alveolar socket was prepared in the maxillary left first premolar area by the same technique

Tooth transplants

Volwne Number

72 4

Fig. 6. allograft

A to E, Pretreatment

models

of

Patient

in treatment

L.S. F, Finish

models

of malocclusion

of

Patient

393

L.S. showing

in place.

as in the previous transplant. The brother and transplanted to the host developed than the first transplanted apex was still open (Fig. 7, C). Wire On Dec. 17, 1976, 2 years after recalled for evaluation. Orthodontic

maxillary right first premolar was extracted from the site of the sister. The root of the transplant was further tooth because of the additional year of growth, hut, the fixation was used. the second allograft had been placed, the patient was treatment had been completed. The patient stated that

394

Fig. 7. A, Roentgenogram Roentgenogram of failing from

Am. J. O&hod. October 1977

Baum and Hertz

patient’s

brother.

of Patient first allograft. D,

Roentgenogram

L.S. showing first C, Roentgenogram showing

allograft

allograft from her of repeated premolar at

completion

brother. 8, allograft of

treatment.

the transplanted tooth felt and functioned as if it were her own tooth. Vitality tests were performed with a vitalometer and ice. These tests were nonconclusive, as none of the premolars, including the transplant, responded to these tests. Clinically, the transplanted tooth appeared as one of the patient’s own premolars except for its slightly larger size (Fig. 8). A roentgenogram of the allograft revealed a first premolar with an intact root. The apex remained open at the same stage of development as when transplanted (Fig. 7, D). A panoramic x-ray film revealed the status of the dentition in December, 1976 (Fig. 5, B). The dentition was continuous, with all spaces closed. The residual bony defect in the cleft area was evident between the roots of the upper left central incisor and canine. The finished case is shown in Fig. 6, F.

The consideration of tooth transplantation should not be neglected in orthodontic treatment planning. In both of these cases the finished result was a continuous dentition without a prosthesis, a worthwhile objective in our opinion. The definitions of success of both the autograft and the allograft must be taken into account in the planning of these procedures. Even should a graft fail in later life and be lost, the prosthodontist has then a more mature dentition to deal with, and the patient has experienced a growing period without the encumbrance of the removable prosthesis usually prescribed for an immature dentition. We further would like to call for a more critical evaluation of the recently pro-

Volume Number

72 4

Tooth trampla~~ts

Fig. 8. Photograph canine in contact

Fig.

of with

9. X-ray

upper central

film

in trentment

dentition at completion incisor; allografted left

of recent

autograft

of third

of first

orthodontic premolar

molar

395

of malocclusion

treatment. in place.

to first

molar

Note

left

position.

posed early third molar enucleation in children between ‘7 and 9 years of age based on the thesis that, with contemporary mandibular growth prediction techniques, it is possible to determine whether or not there will be space in the adult dental arch to accommodate third molars. I2 It would seem prudent to maintain to early adulthood even those third molars for which a lack of space is predicted as an autogeneous tooth bank for possible transplant should the patient suffer the loss of a first or second molar. Fig. 9 shows a case in point in which a lost lower first molar has been replaced by a 23-year-old woman’s own third molar.

Many orthodontic problems are complicated by the asymmetrical congenital absence of permanent teeth. Autogeneic or allogeneic transplantation of teeth should be considered in these cases. A case of each type of transplant is presented. REFERENCES

1. Tuverson, Donald: lateral incisors, AM.

Orthodontic J. ORTHOD.

treatment 58: 109-127,

using 1970.

canines

in

place

of

missing

maxillary

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Am J. Orthod. October 1977

Baum and Hertz

2. Kruger,

3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Gustav 0.: Textbook of oral surgery, ed. 4, St. Louis, 1974, The C. V. Mosby Company, p. 280. Apfel, H.: Transplantation of the unerupted third molar tooth, Oral Surg. 9: 96, 1956. Kusek, J. C.: A brief history of tooth transplantation, Dent. Students Mag., p. 662, May, 1963. Fauchard, P.: Le Chirurgien, Paris, 1746, P. J. Mariette, p. 375. Hunter, J.: The natural history of human teeth, London, 1771, J. J. Johnson. Taylor, J. A.: History of dentistry, Philadelphia, 1922, Lea & Febiger, pp. 31, 70. Shulman, Leonard B.: Allogeneic tooth transplantation, J. Oral Burg. 30: 395, 1972. Mezrom, Ralph Raymond: Homologous viable tooth transplantation, Oral Surg. 17: 375, 1964. Guralnick, W. C.: Autogenous and allogeneic tooth transplantation, J. Oral Surg. 28: 575, 1970. Shulman, Leonard B.: The transplantation antigenicity of tooth homografts, Oral Surg. 17: 389, 1964. Ricketts, Robert, et al. : Third molar enucleation: Diagnosis and technique, J. Cal. Dent. A. 4: 52-57, 1976.

THE JOURi’JAL 60 YEARS AGO October,

1917

How the New Income Taxes Hit Your Pocket tax, the

This table, prepared for beginning with the rates new war revenue bill.

Income Married Men $1,000.. . . 2,000. . . . . . 3,000. . . . . 4.000. . . . 5,000. ... . 6,000.. . 7,000.. . , .

. . . . .

Normal Tax (Old Law) Exempt Exempt Exempt Exempt 2% on $1,000 2%on 2.000 2%on 3,000

the New York Tribune, shows how to compute under the law of 1916, and adding the taxes

Additional Normal Tax (New Law ) Exempt Exempt 2% on $1,000 2%on 2.000 2%on 3,000 2%on 4,000 2%on 5,000

surtax (Old Law) Exempt Exempt Exempt Exempt Exempt Exempt Exempt

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7,000

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An

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unmarried man pays a tax on his income $1,000 under the new law. An unmarried man with an income of $5,000 law and an additional 2 per cent on $4,000 under

beyond

your income provided by

Additional Surtax (New Law) Exempt Exempt Exempt Exempt Exempt 1% on $1,000 i%on 2,000

Total Tax None None $20 40 80 130 180

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pays 2 per cent the new law.

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