Practitioner’s
Practitioner’s
Jim Janakievski (JJ): The term auto means within the same
patient , so tooth autotransplantation is a surgical procedure
where a tooth is extracted from one site and replanted to an-
other site, or repositioned within the same socket, on the same
patient. It can be considered in cases of displaced or impacted
teeth and unilateral agenesis of premolars. Autotransplantation
can also be utilized for tooth replacement of traumatized maxil-
lary incisors.
 TM: Is there any research that has evaluated the long-term outcomes of tooth autotransplantation?
JJ: There are many studies on tooth autotransplantation. It has
been most extensively studied in Scandinavia. A recently  pub-
lished long-term review of cases  had a follow-up range of 17 to
41 years.1 The success rate was over 90%, which is similar to
that of dental implant-supported restorations.
 TM: What factors should be considered when plan- ning this type of treatment?
JJ: The stage of root development of the transplant tooth is
very important. Studies have evaluated the success of auto-
transplantation looking at both development of the periodontal
attachment and pulpal survival.2,3 Success rates are highest
when the root development is two-thirds to full root length with
an open apex. So timing is critical when planning this type of
treatment. This stage of root development occurs between the
DR. TERRY MCDONALD INTERVIEWS
Dr. McDonald 
 Y  ou receive a call from a frantic mother informing you that her 10-year-old daughter has been in a bicycle accident;
one of her upper front teeth has been knocked out; and the tooth cannot be located. You see Mom and daughter at your office shortly thereafter, calm them both down, confirm that there are no other dental injuries, and inform Mom of the options for replacing the lost tooth. One of those options might be one that is seldom used in the United States but is quite common in many Scandinavian countries. This is autotransplantation—a technique in which the lost or extracted tooth is replaced with one of the patient’s own teeth, which is later restored to the size, shape, and color of the missing tooth. This modality of treatment requires a team approach involving a periodontist or oral surgeon, an orthodontist, and a restorative dentist.
 Jim Janakievski, the interviewee for this issue of the Bulletin, is not an orthodontist but an experienced periodontist who has mastered the skills required to accomplish this somewhat delicate procedure and describes for us in detail how it is done.
Dr. Janakievski 
 
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ages of 9 and 12 years. Most traumatic injuries to anterior
teeth seem to occur during this same period, making auto-
transplantation a good option for these patients ( Figure 1).
 TM: Which tooth is most commonly selected for  transplantation in a patient with an ankylosed or avulsed maxillary central incisor?
JJ: In a child who has had trauma to the maxillary incisors
with resultant ankylosis or loss of a tooth due to avulsion,
we begin by selecting the tooth to be transplanted. Consid-
eration is given to the stage of root development and the size
of the crown. Measuring the contralateral incisor or the space
available will assist in the selection. Usually we choose the
mandibular first or second premolar. In most cases the second
premolar is wider and may be more appropriate in mesiodistal
dimension to replace a central incisor.
 TM: Is this treatment most applicable in patients  who will require bicuspid extractions for orthodon-  tic management?
JJ: Of course this would be the ideal patient, but we can con-
sider autotransplantation for nonextraction cases as well. The
posterior space that results from the harvesting of the pre-
molar can be closed by unilateral protraction of the posterior
teeth, either with traditional or with mini-implant anchorage
mechanics. This way, no future implant treatment to replace
the bicuspid will be needed.
 TM: Can you describe the surgical procedure?
JJ: The surgical treatment begins with the preparation of an
osteotomy using burs, much like implant site preparation. The
transplant tooth is then harvested and carefully transferred to
the recipient site. It is usually secured in place with sutures or
a wire splint. After initial stabilization, the tooth is monitored
for root development and eruption (Figure 2).
 TM: When can an orthodontist apply force to the  transplanted tooth?
JJ: To answer this question, you must understand how a peri-
odontal ligament heals.
In the case of a traumatic avulsion and replantation, both the
tooth and the socket are lined with periodontal ligament, and
there is an intimate fit when the avulsed tooth is inserted into
the socket. In such a case, the ligaments reattach, and this
Figure 1
 
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happens rapidly, usually within a few weeks. In the case of an
autotransplanted tooth, the periodontal ligament is only on the
harvested tooth root, and there is more space around it within
the osteotomy site. Bone and periodontal ligament formation
requires more time in this situation. Healing is monitored ra-
diographically and is typically complete at about 3 to 4 months.
At this time the transplant can be moved orthodontically, much
like any other tooth (Figure 3).
 TM: When can  the premolar be restored to look like a cen-  tral incisor?
JJ: Certainly
incisor, it must be very specifi-
cally positioned to allow for ideal
restoration. For the incisogingival
position, the orthodontist must
use the cemento-enamel junc-
incisor as a guide. Positioning the
transplanted tooth so that the CEJ
is lined up with the adjacent central incisor minimizes the risk
of developing uneven gingival margins as passive eruption oc-
curs. In order to minimize future prosthetic tooth preparation,
positioning must also take into consideration both the form of
the transplanted tooth and the restorative procedure (bonding,
veneer, crown) that will be used to normalize it. Since a central
incisor has a straighter mesial contour and a more curved distal
contour than a premolar, the tooth must be positioned with
two-thirds of the residual space to the distal. To minimize the
amount of enamel reduction that needs to be done on the facial,
the transplant should be positioned slightly palatal on the ridge.
Various restorative techniques or materials can then be utilized
to change the morphology of this tooth (Figure 4).
Figure 3a 
2 MONTHS
Figure 3d 
 
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 TM: What is the advantage of using this technique  for ectopic impactions?
JJ: In the case of an impacted tooth, consideration should first
be given to the techniques often used for surgical exposure
and orthodontic eruption . However, we may be faced with a
patient in whom the impacted tooth position would present a
challenge for traditional orthodontic mechanics (Figure 5). For
this patient, the central incisor was autotransplanted to a more
natural orientation. With this approach, the orthodontic treat-
ment was simplified and the overall treatment time reduced.
 TM: What are the risks of tooth autotrans- plantation?
JJ: The risks include pulpal necrosis with development
of inflammatory resorption and ankylosis or replacement
resorption. Careful planning and meticulous treatment
execution by the dental team can minimize these risks.
Autotransplantation can simplify and reduce orthodontic
treatment time for patients with impacted teeth. For patients
with traumatized incisors, it can provide a functional and
natural tooth replacement during their early growth phase
and eliminate the need for a removable appliance. Indeed,
tooth autotransplantation is another option, that we should
consider when treatment planning our young patients.
 TM: Are there courses available in the United States, should our readers desire more information on this topic?
JJ: There are no courses available at this time. I have been
invited to present on this topic to several study clubs and
academies. We are hoping to put together a course in the next
Figure 4a 
Practitioner’s
 
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Corner 2 years that would cover the surgical, orthodontic, and restor-
ative aspects of autotransplantation.
 TM: What is the future of tooth autotransplantation?
JJ: I view tooth autotransplantation as a precursor to what will
be available in the near future. Research has been evaluating
the process of biomineralization in tooth formation and its
application to regenerative models in dentistry. 4 It has recently
been demonstrated that a bioengineered scaffold shaped like a
tooth can attract stem cells and grow a tooth in vivo.5 Certainly
Figure 5d 
2 MONTHS
Figure 5e
1 YESR
Figure 5f 
DAY OF
regeneration becomes available to our patients.
References
Outcome of tooth transplantation: survival and success rates
17-41 years posttreatment. Am J Orthod   Dentofac Orthop.
2002;121(2):110-119.
2. Andreasen JO, Paulsen HU, Yu Z, Ahlquist R,  Bayer T, Schwartz
O. A long-term study of 370 autotransplanted premolars,
III:periodontal healing subsequent to transplantation.  Eur J Or-
thod . 1990;12(1):25-37.
3. Andreasen JO, Paulsen HU, Yu Z, Bayer T, Schwartz O. A long-
term study of 370 autotransplanted premolars, II:tooth survival
and pulp healing subsequent to transplantation.  Eur J Orthod. 
1990;12(1):14-24.
4. Rauth RJ, Potter KS, Ngan AY, et al. Dental enamel: genes define
biomechanics.  J Calif Dent Assoc. 2009;37(12):863-868.
5. Kim K, Lee CH, Kim BK, Mao JJ. Anatomically shaped tooth
and periodontal regeneration by cell homing.  J Dent Res.
2010;89(8):842-847.
University of Toronto, 1995, and completed a general-practice
residency, at St. Clare’s Hospital, Schnectady, New York,
in 1996.
Washington, where he received a certificate in periodontol-
ogy with an MSD degree and a fellowship in prosthodontics.
 He is a Diplomate of the American Board of Periodontology,
serves as an affiliate assistant professor in the Department of
Periodontology at the University of Washington, and maintains
a private practice in Tacoma, Washington.
    S