Case Report/Clinical Techniques

Guided Autotransplantation of Teeth: A NovelMethod Using Virtually Planned 3-dimensionalTemplates

Georg D. Strbac, DDS, PhD,* Albrecht Schnappauf, DI,† Katharina Giannis, DMD,‡

Michael H. Bertl, DMD,§ Andreas Moritz, MD, DMD, PhD,‡k and Christian Ulm, MD, DDS, PhD*

Abstract

Significance

Using the latest techniques from guided implantsurgery, 3D printed templates can be predesignedto ensure a guided atraumatic approach in auto-transplantation. This could provide for better out-comes and fewer failures in the future.

Introduction: The aim of this study was to introduce aninnovative method for autotransplantation of teeth us-ing 3-dimensional (3D) surgical templates for guided os-teotomy preparation and donor tooth placement.Methods: This report describes autotransplantation ofimmature premolars as treatment of an 11-year-oldboy having suffered severe trauma with avulsion of per-manent maxillary incisors. This approach uses modifiedmethods from guided implant surgery by superimposi-tion of Digital Imaging and Communications in Medicinefiles and 3D data sets of the jaws in order to predesign3D printed templates with the aid of a fully digital work-flow. Results: The intervention in this complex casecould successfully be accomplished by performing pre-planned virtual transplantations with guided osteoto-mies to prevent bone loss and ensure accurate donorteeth placement in new recipient sites. Functional andesthetic restoration could be achieved by modifyingmethods used in guided implant surgery and prostho-dontic rehabilitation. The 1-year follow-up showed vitalnatural teeth with physiological clinical and radiologicparameters. Conclusions: This innovative approachuses the latest diagnostic methods and techniques ofguided implant surgery, enabling the planning and pro-duction of 3D printed surgical templates. These accuratevirtually predesigned surgical templates could facilitateautotransplantation in the future by full implementationof recommended guidelines, ensuring an atraumatic sur-gical protocol. (J Endod 2016;42:1844–1850)

Key Words3-dimensional printed template, guided autotransplan-tation, guided osteotomy, guided surgery, modern auto-transplantation, surgical template

From the *Division of Oral Surgery, ‡Division of Dental Studentodontology, School of Dentistry, Medical University of Vienna, Vien

Address requests for reprints to Prof PD Dr Georg D. Strbac, DivVienna, Austria. E-mail address: georg.strbac@meduniwien.ac.at0099-2399/$ - see front matter

Copyright ª 2016 American Association of Endodontists.http://dx.doi.org/10.1016/j.joen.2016.08.021

1844 Strbac et al.

Traumatic dental injuriesto permanent teeth are

most frequently seen atthe age of 8–12 yearsand may vary from crownor root fracture to avul-sion (1–3). Total toothdisplacement by avulsion

is present in 0.5%–3% of these injuries and should be treated by immediatereplantation (4–7). Although replantation may be successful, long-term survival ratesof these teeth may be jeopardized by a variety of consequent factors, resulting in progres-sive root resorption, endodontic problems, and tooth fractures, potentially causing loss ofthese teeth at a later time (3, 4).

Today, dental implants are commonly used in the area of esthetics, providing bet-ter outcomes compared with conventional fixed bridgework, resin-bonded restora-tions, and removable partial dentures (8, 9).

Although implantation is considered to be a superior choice compared with thepreviously mentioned alternative of fixed prosthetic restorations, this treatmentapproach is absolutely contraindicated in growing patients because it cannot followcraniofacial development and would remain in malocclusion during continuing growth(10, 11). In such complex cases of patients in their growth phase with missing anteriorteeth, only autotransplantation of immature teeth can provide a functional and estheticrehabilitation by not compromising remaining dentition and supporting continuingskeletal and dentoalveolar growth (1, 10, 11).

Tooth transplantation can be performed at an early age when incidence of traumais high, offering high tooth survival rates of up to 90% and providing for hard and softtissue results comparable with natural maxillary incisors (12, 13).

Although successful autotransplantation can offer promising results, compli-cations caused by documented risk factors may influence the outcome. The biolog-ical principles and wound healing are similar to avulsed teeth after replantation.Thus, mechanical injuries during extraction or traumatic press-fit placement inthe recipient alveolus and biochemical factors because of prolonged extra-alveolar duration may cause damage to dental structures, especially to the peri-odontal ligament, leading to progressive root resorption. Additionally, next tosufficient preparation of the recipient alveolus, root morphology and developmentappear to influence a negative outcome, causing pulp necrosis, ankylosis, rootresorption, and failure (10, 14–16).

Training and Patient Care, §Division of Orthodontics, kDivision of Conservative Dentistry and Peri-na, Austria; and †Software Research, Dental Wings, Chemnitz, Germany.ision of Oral Surgery, School of Dentistry, Medical University of Vienna, Sensengasse 2a, A-1090

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Case Report/Clinical Techniques

Thus, as in dental implant treatment, accurate clinical and radio-

logic examination can enhance treatment planning, ensuring an atrau-matic and minimally invasive procedure for autotransplantation.Modern diagnostic techniques, such as 3-dimensional (3D) imaging,not only allow imaging of anatomic structures for accurate diagnosisand treatment planning but are also used for the fabrication of surgicalmodels and the construction of surgical templates in guided implantsurgery (17–20). The application of 3D radiologic data is also beingused for the fabrication of tooth replica as single tooth-sized modelsand for model-based produced surgical guides in autotransplantation(2, 16, 21–23).

The aim of this report was to introduce a novel surgical techniqueusing virtually planned 3D printed surgical templates for guided osteot-omy preparation of recipient sites and safe placement of donor teeth. Bythe implementation of traditional and recognized guidelines, thismethod could ensure an atraumatic and precise surgical approachfor future autotransplantation of teeth.

Case ReportAn 11-year-old boy was referred after having suffered a maxillofa-

cial trauma 1 month previously, with an avulsion of his permanentmaxillary central incisors. Replantation was not possible because the2 missing teeth could not be found.

Clinical and radiologic examinations revealed a prominent ver-tical and horizontal deficiency of alveolar bone and soft tissue (Fig. 1Aand B, Supplemental Figures S1 and S2 are available online at www.jendodon.com). 3D radiographic examination (Somatom Sensation4; Siemens, Erlangen, Germany [voxel size 0.2 � 0.2 � 0.5 mm,120 kV, 512 matrix]) was performed at the Division of Radiologyto ensure accurate treatment planning, rule out fractures of remainingteeth, and exclude any fractured particles of missing teeth in hard orsoft tissues. A 3D assessment revealed no remaining dental structuresbut recorded a complete loss of buccal plates of the alveolar ridge.In further examinations, the patient presented with a changing denti-tion, 1/4 class II molar relations, and a reduced overbite and overjet(0 mm each). Leeway space analysis showed only 0.5 mm of accessspace on each side of the lower arch. The lateral cephalogramshowed the lower incisors to be slightly protruded (97� to themandibular plane) with a skeletal class III tendency (ANB = 0�,Wits appraisal =�3 mm, APDI = 84.7). Because of the class III ten-dency, mesialization in the upper arch was not considered a viabletreatment option. Because the tooth buds of the lower wisdom teeth

Figure 1. (A) Panoramic radiography of the 11-year-old patient showing missingdency, mesialization in the upper arch was not considered as a viable treatment opregion followed by orthodontic space closure in the lower arch was conceived asdeficiency of alveolar bone and soft tissue.

JOE — Volume 42, Number 12, December 2016

were clearly visible on panoramic radiography, transplantation ofmandibular premolars into the upper incisor region was considered.After the final interdisciplinary consultation, autotransplantation ofthe 2 mandibular second premolars into the anterior maxillary re-gion, following esthetic restoration and orthodontic treatmentafter the eruption of canines to correct malocclusion and spaceclosure in the lower arch, was conceived as the appropriate treatmentplan (10, 24).

Initially, Digital Imaging and Communications in Medicine fileswere imported into surgical planning software designed for guidedimplant surgery (coDiagnostiX Version 9.6; Dental Wings, Montreal,Canada). Within the segmentation mode, the right and left secondmandibular premolars were selected as the most suitable donor teeth.Their segmented stereolithography (STL) files were transferred to theplanning mode (Fig. 2A and B). Furthermore, STL files of scanneddental models (7 Series dental model and impression scanner, DentalWings) and intraoral scans of the jaws (iTero; Align Technology, SanJose, CA) were imported to fabricate precise surgical templates.Similar to virtual planning of dental implants, correct angulation,rotation, and accurate positioning of the donor teeth were predefinedwith 2 surgical pins and with the aid of STL files of donor teeth. Theirexact 3D positions were selected in relation to anatomic space andadjacent dental structures and according to their optimal prostheticrelationship to teeth in the lower arch to ensure ideal esthetic andfunctional restoration after surgical intervention (Fig. 2C–G). Inthis case, the narrow ridge, caused by the severe trauma, necessitatedridge expansion in the buccopalatinal plane. This was virtuallyplanned using rotatory, piezoelectric, and manual surgical instru-ments. Technical STL files of piezoelectric instruments (Piezomed In-struments, Piezomed, W&H Dentalwerk, Buermoos, Austria) andbone-condensing osteotomes (Ø 2.2-, 2.8-, 3.5-, and 4.2-mm osteo-tomes [Osteotome instrument kit for bone condensation; Straumann,Basel, Switzerland]) were imported into planning software to achievepredefined and precise osteotomies. In addition, preexisting files ofsurgical burs and dental implants (Guided Implant Surgery BoneLevel; Straumann, Basel, Switzerland) could be visualized and super-imposed onto the osteotomy plan to facilitate final treatment planning.According to virtually preplanned positions and dimensions of donorteeth, surgical templates for guided osteotomy were designed withinthe software (Fig. 2H–K). To ensure precise positioning throughoutsurgical intervention, 3 additional surgical templates with attachedsegmented teeth were virtually designed, showing the appropriateocclusal location of each graft (Fig. 2L). Finally, all surgical templates

maxillary central incisors after dentoalveolar trauma; because of class III ten-tion. Thus, transplantation of 2 mandibular premolars into the upper incisorthe final treatment plan. (B) A clinical view presenting vertical and horizontal

Guided Autotransplantation of Teeth 1845

Figure 2. (A) Visualization of Digital Imaging and Communications in Medicine files showing complete loss of buccal plate in anterior maxilla; within the seg-mentation mode of the software program, the right and left second mandibular premolars were selected as donor teeth (green color). (B) One pair of donor teethwas virtually segmented according to existing immature root formation (green color), and 1 pair of donor teeth was virtually modified by implementing soft tissueformation and the width of the Hertwig epithelial sheath (gray color) from the 3D data set to protect the vulnerable apical structures of the donor teeth duringintervention and to ensure postoperative revascularization and root development. (C) Within the software planning mode, virtual transplantation of donor teeth intheir predefined 3D positions could be performed with the aid of 2 surgical planning pins and importation of the modified STL files of the donor teeth. (D) STL filesof the upper and lower jaws were superimposed with Digital Imaging and Communications in Medicine data in order to visualize soft and hard tissue structures, toensure optimal surgical and prosthodontic 3D relationships of donor teeth, and to allow fabrication of precise computer-guided surgical templates. (E) A coronalslice from the radiographic examination showing a complete loss of the buccal plate and imported STL files of the upper and lower jaws for virtual planning. (F)Virtual autotransplantation of the second premolar with the aid of an imported STL file of the segmented donor tooth; the illustration presents vertical and horizontaldeficiency of soft and hard tissue in the recipient area. (G) Correct surgical and prosthodontic positioning of donor teeth can be achieved with 2 surgical pins,comparable with the virtual planning of dental implants, and with the help of virtually preselected and individually segmented donor teeth. (H) An illustration of thefirst virtually designed surgical template for guided osteotomy preparations (Ø 2.2 mm). (I) The second surgical template for Ø 2.8-mm guided osteotomies

Case Report/Clinical Techniques

1846 Strbac et al. JOE — Volume 42, Number 12, December 2016

Figure 3. (A) STL files of all virtually designed surgical templates and models for final 3D printing. (B) 3D printed surgical templates for guided osteotomies (Ø2.2, 2.8, 3.5, and 4.2 mm). (C) 3D printed supplementary surgical templates with attached donor teeth showing the ideal 3D position of each tooth.

=

Case Report/Clinical Techniques

and models were exported as STL files and sent to a 3D printer forfabrication (Objet260 Connex 3, Material MED610; Stratasys, Minne-apolis, MN) (Fig. 3A–C).

Surgery was performed under general anesthesia according toguidelines for autotransplantation with the aid of 3D printed surgicaltemplates (Supplemental Figures S3–S6 are available online at www.jendodon.com). The first surgical template with drilling sleeve of Ø2.3 mm was positioned, and initial preparation was performed with a

(illustration showing 2 surgical pins from the preplanning procedure). (J) The thirdplanning pins and STL files of donor teeth). (K) The final surgical template for Ø 4.2scan from the fabrication process of surgical templates). (L) The supplementary teaccording to the ideal relationship to anatomic space, adjacent dental structures,

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guided surgical round bur Ø 1.4 mm marking precise locations for os-teotomies. To avoid any loss of residual alveolar bone, piezoelectric in-struments were additionally used (B7, P1, and S2, PiezomedInstruments) to enlarge initial preparations and to initialize ridgeexpansion. The initial osteotome, Ø 2.2 mm, was used manually withthe first surgical template following osteotomy paths and ridgemorphology (Supplemental Figures S7–S12 are available online atwww.jendodon.com). The second and the third surgical template

surgical template for Ø 3.5-mm safeguard osteotomies (illustration showing 2-mm preplanned osteotomies (illustration showing the superimposed intraoralmplate with attached segmented teeth implementing preplanned 3D positionsand occlusal position.

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Case Report/Clinical Techniques

were positioned after Ø 2.8-mm and Ø 3.5-mm safeguarded osteoto-mies by conserving all remaining bone to its final drilling depths. Tomaintain a straight path, the last surgical template was inserted, and finalosteotomies were performed with a Ø 4.2-mm osteotome to preplannedosteotomy depths (Supplemental Figures S13–S20 are available onlineat www.jendodon.com). Supplementary templates with the attachedsegmented teeth and 3D tooth replicas were inserted to verify the finalpreparation of the recipient site and, where necessary, to slightly spreadbuccal and lingual plates by fully conserving osseous tissues(Supplemental Figures S21–S24 are available online at www.jendodon.com).

Atraumatic uncovering was performed using surgical elevators topreserve dental structures of donor teeth. Transplantation wasachieved using diamond-coated forceps placing the grafts into the pre-planned infraocclusal positions. Initially, both transplanted teeth weremesially and distally stabilized with sutures, and a nonrigid suture fix-ation was performed across the occlusal plane to ensure stability aftersurgery (Supplemental Figures S25–S31 are available online at www.jendodon.com).

Oral antibiotics and chlorhexidine mouth rinse were prescribedfor 1 week. Sutures were removed 10 days postoperatively. Therewere no postoperative complications, and the healing process was un-eventful.

Six months after surgery, intraoral scans of the jaws were per-formed, and composite laminate veneers were virtually designed(DWOS Crown & Bridge CAD Software, Dental Wings) without needof surface reduction because they had been preoperatively planned.The placement of CAD/CAM-processed composite laminate veneers(S2 Impression, Dental Milling Machines; vhf camfacture, Ammerbuch,Germany) with adhesive cement (Variolink Esthetic LC; Ivoclar Viva-dent, Schaan, Liechtenstein) completed the functional and estheticrehabilitation (Supplemental Figures S32–S39 are available online atwww.jendodon.com).

At the 12-month follow-up, the patient and his parents were verysatisfied with the functional and esthetic reconstruction. In clinical andradiologic examinations, the transplanted teeth showed physiologicalperiodontal parameters and no signs of pathology or root resorptionand responded positively to thermal vital pulp tests (Fig. 4A–C).

DiscussionIn recent decades, state-of-the-art dentistry has mainly gained

from newly developed radiologic imaging techniques. Such new devicesdo not only improve diagnosis and treatment planning, but they mayalso help in developing treatment procedures, such as guided implantsurgery, using templates for an enhanced surgical and prosthodontic

Figure 4. (A) The clinical view of the patient 12 months after autotransplantationtransplanted into the upper incisor regions. (C) The intraoral radiograph at the 1pulp, physiological periodontal ligament space, and lamina dura.

1848 Strbac et al.

approach (25, 26). Currently available software programs alter thefabrication process of these templates by implementing STL files ofdental models or intraoral scans, reducing scheduling time as well astreatment costs, and preventing radiation exposure because noadditional radiologic assessment is needed (26–28). These latestdevelopments, generating precise 3D printed surgical templates, werecustomized for the present clinical report to deploy a novel treatmentplanning technique, implementing all recommended guidelines andsurgical methods, for a modern approach to autotransplantation.

As proposed in complex cases, tooth replica models fabricatedpreoperatively from 3D radiographic imaging should be used as surgi-cal tooth guides during autotransplantation of immature or maturegrafts to facilitate the preparation process of recipient sites. Addition-ally, this may reduce the extra-alveolar time of grafts and minimizethe number of fitting attempts, thus preventing injury of vital dentalstructures. These latest enhancements in autotransplantation couldimprove the success and survival rate by preserving the periodontal lig-ament and the apical structures of the donor teeth; hence, this couldavoid replacement and inflammatory resorptions of the grafts andwould ensure orthodontic movement of these vital teeth after interven-tions (2, 16, 21, 29–32). Furthermore, it was also shown recently thatthese 3D rapid prototyped teeth may also shorten the general surgicalprocedure time in the future (31).

Through ourmodification of the software program for this new sur-gical approach, a novel tooth replica model was virtually designed ac-cording to the immature root formation but additionally including thedevelopment of the Hertwig epithelial sheath. The intention of this adap-tation process was to avoid iatrogenic damage to the vulnerable apicalstructures and press-fit compressions, especially to the apical part dur-ing surgery, thus ensuring vital grafts with postoperative revasculariza-tion of the pulp and continuous root development, consequentlyreducing future postoperative endodontic treatments (1, 14–16, 33).

This approach not only allows for a selection of the most suitabledonor tooth according to tooth morphology and root development butmay also show the ideal 3D position and the required dimensions of thenew alveolus during surgery. Moreover, if there is inadequate spaceduring the planning process on the mesial and distal side of the graft,an orthodontic space opening could be performed before surgery toprevent stripping of dental structures. Consequently, 1- or 2-stage pro-cedures could be achieved with this approach (14, 15, 21, 24).Occlusal interference, causing jiggling contacts between donor teethand opposing teeth, could also be avoided, and infraocclusal positionand physiological mobility placement could be planned beforeintervention (2, 14, 24). By importing STL files of the jaws andsuperimposing them with the radiographic data set, the adaptedplanning process allows for the donor tooth to be positioned as an

. (B) The panoramic radiograph after 12 months showing second premolars2-month recall documenting further root development and obliteration of the

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Case Report/Clinical Techniques

implant, not only according to its best surgical position but also againstthe adjacent and contralateral tooth, consequently in its optimalprosthodontic position. Therefore, this fully implemented digitalworkflow may also offer greater accuracy than model-based surgicaltemplates (1, 2, 26). Ideal esthetic and functional position can alsobe preplanned and, hence, as presented in this case, no-prep veneerreconstructions of the immature donor teeth could be achieved by anaccurate virtual predesign according to the 3D position of the graftsto avoid preparations and postoperative endodontic treatments (10,11, 12, 14).

The production of surgical templates is achieved by the superim-position of corresponding surgical burs, dental implants, or donor teethin their recipient sites. Similar to treatment planning of dental implants,this method not only offers guided preparation of an osteotomy pathwith a pilot drill but also graduated drilling to the final width, and dril-ling depth can also be preplanned and performed using correspondingguided surgical burs or instruments (2, 32, 34). Using fully virtualvisualization of circumstances, this digital work flow approach couldsignificantly facilitate autotransplantation procedures, even incomplex cases and for surgeons with less experience.

Finally, modified tooth replica models can be used to assess thedrilling progress and also to support the ultimate preparation processin apical and buccopalatinal planes. These adapted tooth models intheir optimal position can also be attached to custom-made templates,showing exact 3D preplanned positions and preferred occlusal locationduring surgery following the recommended guidelines (14, 34–38).

The innovative technique presented for the first time offers a fullyimplemented digital work flow for precise pretreatment planning andguided osteotomy during autotransplantation. This approach couldimplement all suggested guidelines and surgical techniques with theaid of novel surgical templates ensuring an atraumatic treatmentapproach by preserving soft and hard tissues and preventing injury tovulnerable dental structures. By using accurate 3D printed templates,this method could help to accomplish highly complex surgical andprosthodontic procedures, consequently ensuring greater success ratesin future autotransplantations.

AcknowledgmentsThe authors wish to thank Professor Dr Ale�s Celar for referring

the patient and for his efforts in the interdisciplinary consultation.Also, they want to thank ZTM Stefan Remplbauer for printing the 3Dtemplates and the team of the Division of Radiology and the team ofprofessional photographers of the Division of Oral Surgery, Univer-sity of Dentistry, Medical University of Vienna for their continuedsupport and backing over the years.

The authors deny any conflicts of interest related to this study.

Supplementary MaterialSupplementary material associated with this article can be

found in the online version at www.jendodon.com (http://dx.doi.org/10.1016/j.joen.2016.08.021).

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