British Journal of Oral and Maxillofacial Surgery (2005) 43, 31—35

Success rate of autotransplanted teeth without

stabilisation by splints: a long-term clinical and
radiological follow-up
Murat Akkocaoglu∗, Oguzcan Kasaboglu

Department of Oral and Maxillofacial Surgery, Hacettepe University, Faculty of Dentistry, Turkey

Accepted 9 August 2004

KEYWORDS Summary The purpose of this retrospective study was to assess the results after
Autotransplantation; a follow-up of 10 years of autotransplantation of canines and third molars without
Canine; the use of any apparatus for stabilisation. A total of 96 teeth were transplanted and
Third molar 83 were successful (86%). The technique is easy, reliable, and effective.
© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Introduction gical technique) are important factors that affect

Autotransplantation is reliable and has a good prog-
nosis for donor teeth that have both open and
closed apices.1 The indications include the replace-
ment of unrestorable molars, of missing premo-
lars or upper incisors, and repositioning of im-
pacted maxillary canines.2—6 The two most common
transplantations are of impacted canines, when or-
thodontics is not feasible, and of impacted third
molars to substitute for first or second molars.7 Pro-
gressive absorption of roots, necrosis of pulp, anky-
losis, and infraocclusion are the commonly reported
problems after autotransplantation.3,8
The age at transplantation, the type of donor
tooth, and the stage of eruption (as well as the sur-
* Corresponding author. Tel.: +90 312 305 2276;
fax: +90 312 310 4440.
E-mail address: makkocao@hacettepe.edu.tr
(M. Akkocaoglu).
the success rate of autotransplantation.
Various techniques of autotransplantation have
been reported.1,14 Careful manipulation of the root
and socket, stabilisation of the implanted tooth and
postoperative care are important for the success of
the operation.2,11 Various methods of stabilisation
have been reported.5,6
We now report long-term results of autotrans-
plantation of maxillary canines and mandibular
third molar teeth without stabilization.
Patients and methods
A total of 78 patients aged between 18 and 24 teeth
had autotransplanted between the years 1994 and
2003. All teeth had their apexogenesis completed or
near to completion, as verified by periapical radio-
graphs. Teeth with open apices were not included

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2004.08.010
32 M. Akkocaoglu, O. Kasaboglu

Table 1 Details in 47 patients in whom canines were transplanted.

Sex Age (years) Recall period (months)
18—19 20—21 21—24 Range Median
Men 8 7 8 6—120 84
Women 9 8 7 12—120 84
Total 17 15 15 6—120 84

Table 2 Details of 49 patients in whom molars were transplanted.

Sex Age (years) Recall period (months)

18—19 20—21 21—24 Range Median

Men 7 8 8 8—93 84
Women 8 9 9 12—120 96
Total 15 17 17 8—120 96

in the study. All these patients have been followed
up regularly, apart from seven who failed to attend
(Tables 1 and 2). Indications for autotransplanta-
tion were limited to permanent first molars that
were unlikely to respond to restorative treatment,
and to impacted permanent canines (Table 3).
Surgical technique and postoperative
management
The technique was standard. Before operation, the
mesiodistal dimensions of the donor tooth and of
the recipient area were measured on periapical
radiographs taken with a parallel technique. Par-
ticular attention was paid to select teeth with
mesiodistal dimensions similar or equal to those of
the transplantation site.
To reposition impacted canines, the decidu-
ous canine was first extracted and the palatally-
impacted permanent canine was removed by an
atraumatic technique. The donor tooth was stored
in its original position or in sterile saline until
it was repositioned. The recipient area was ad-
justed, if needed, by a root-form surgical drill (No-
bel Biocare, Goteborg, Sweden) as close in shape
as possible to the permanent canine tooth. The
transplanted canine tooth was then checked for
occlusion, and adjustments in the position of the
tooth were made if necessary (Fig. 1).
Transplantations of third molars were done to
replace hopeless first permanent molars. After ex-
traction of the first molar, the impacted or erupted
third molar was implanted in the recipient area,
which, if necessary, was shaped with implant burs.
As in the canine operations, transplants were posi-
tioned slightly below the occlusal plane (Fig. 2).1
In both groups the initial stability of the im-
planted teeth was maintained by frictional reten-
tion with the neighbouring teeth. The recipient
socket was prepared to provide maximum contact
with the root of the donor tooth. No orthodontic
or prosthodontic splints were used either position-
ing or for stabilisation. All patients were given oral
antibiotics, anti-inflammatory drugs, and mouth
rinses containing chlorhexidine, and they were also

Table 3 Data are number (%).

Indication n %
Aplasia 9 9
Poor prognosis to conservative treatment 47 49
Canine impaction 40 42 Figure 1. Postoperative view of autotransplanted perma-
nent canines.
Success rate of autotransplanted teeth without stabilisation by splints 33

The criteria for failure included the presence of

pulpal or apical disease, advanced mobility, and
progressive internal or external absorption of the
root (even after endodontic treatment) that would
cause loss of the transplanted tooth.
Success was judged by the modified criteria of
Chamberlin and Goerig:10 the tooth was fixed in
its socket without discomfort; chewing was satis-
factory and without discomfort; the tooth was not
mobile; no pathological condition was seen on the
radiograph; the lamina dura appeared normal on
the radiographs; and the depth of the sulcus, gin-
gival contour, and gingival colour were normal.
Statistical tests were used to establish the dif-
ferences in success and vitality between men and
women, and between canine and molar groups, us-
ing the chi-square test at a confidence level of 95%.

Results

A total of 105 teeth were transplanted in 78 pa-

Figure 2. Postoperative view of the autotransplanted
third molar.
given instructions about oral hygiene and a soft diet
during the first postoperative week was provided.
The first postoperative radiographs were taken a
week later and patients were ask to attend for clin-
ical and radiographic examinations at 1, 3, 6, and
12 months. Occlusal contacts, ankylosis, dental mo-
bility, external and internal absorption, necrosis,
periodontal disease, and vitality of the pulp were
tested at each recall. By the end of the third month,
endodontic treatment was started in the autotrans-
planted teeth if any complications such as absorp-
tion of the root, discoloration, necrosis, sensitivity
on percussion, apical rarefactions, or pulpal infec-
tions were found.
tients, but 6 patients were excluded because of lack
cooperation or inadequate documentation, leaving
72 patients and 96 teeth for statistical analyses
(Table 4).
In the canine group, 42/47 transplantations were
successful (89%) was after a median of 84-months
follow-up. Twenty-two (47%) of the transplanted
canines required endodontic treatment after 3
months for discolouration, sensitivity, or delayed
response in electrical pulp tests. The remaining 20
canines remained vital with no clinical or radio-
graphic signs of failure.
In the molar group, 41/49 operations were suc-
cessful (84%) after a median of 96 months. For
reasons similar to those of the canine group, 12
transplanted third molar teeth required endodontic
treatment 3 months postoperatively. The remaining

Table 4 Success rates in 96 transplanted teeth after 9 years.

Number of Number (%) of Number of teeth calling for Number of vital Success rate
implanted teeth lost endodontic treatment teeth after 3 (%)
teeth months
Men
Canine 21 1 (5) 12 8 95
Molar 21 3 (14) 5 13 86
Women
Canine 26 4 (15) 10 12 85
Molar 28 5 (18) 7 16 82
Total
Canine 47 5 (11) 22 20 89
Molar 49 8 (16) 12 29 84
34
Table 5 Reasons for failure of 13 transplants (data
are number).
Diagnosis
External resorption 5
Internal resorption 3
Necrosis/endodontic complication 5
29 of molars maintained their vitality throughout
the follow-up period.
There were no significant differences between
men and women in terms of success (91% in men
and 83% in women, p = 0.3) or vitality (50% in men
and 52% in women, p = 0.9). The percentage of suc-
cesses was similar in the canine (42/47, 89%) and
molar (41/49, 84%) groups and the difference was
not significant (p = 0.4). The difference in vitality
between the canine (20/47, 43%) and molar (29/49,
59%) groups was not significant (p = 0.1).
Thirteen transplanted teeth (14%) were lost
(Table 5). None were lost from either infraocclusion
or periodontal disease. The two most common rea-
sons for failure were necrosis or endodontic compli-
cations (Fig. 3) and external root absorption, which
caused the loss of 5 teeth (6%) each. These were
extracted in the first postoperative year. Internal
absorption of a root caused the loss of 8 teeth. This
was seen first in the third month and continued pro-
gressively (Fig. 4) together with symptoms of pain
and hypersensitivity. Patients with non-progressive
replacement absorption had endodontic treatment
and were not considered as failures.
Figure 3. Periapical radiograph showing an autotrans-
planted third molar, which failed because of periapical
infection that led to further periodontal and endodontic
treatment.
M. Akkocaoglu, O. Kasaboglu
Figure 4. Radiographic view of internal and external ab-
sorption in an autotransplanted molar.
Discussion
The percentage of successes depends on several
factors such as the age of the patients, the oper-
ation done, and the use of a splint.9 Another im-
portant factor is the stage of physiological apical
closure at the time of transplantation. Schwartz et
al. reported that a donor tooth with an open apex
at the time of transplantation had a better chance
of survival than a tooth with a closed apex.8 In our
series, however, teeth with closed apices were in-
cluded, and the operation was successful in 85%
without initial stabilisation. These results confirm
those of Waikakul et al.9
According to Andreasen and Hjortiting-Hansen, it
is not necessary to start any endodontic treatment
immediately if a tooth with a negative electric pulp
test has good clinical and radiological findings.11
Endodontic treatment should be started only when
a tooth becomes symptomatic or when bone le-
sions develop.11 The pulpal response in the electri-
cal pulp test indicates the presence of nerve fibres
carrying sensory impulses. This does not provide
any information about the vascular supply, which
is the real determinant of vitality of the pulp.12,13
We found that 49 (51%) of the 96 transplanted teeth
maintained their vitality and showed no clinical
or radiological disturbances. Assessment of these
teeth should therefore be based on clinical signs
and symptoms such as discolouration, sensitivity
tests, tenderness on percussion, and signs of inflam-
mation, together with radiological findings includ-
ing periradicular pathology and root absorption.
Various techniques have been described to sta-
bilise transplanted teeth, including fixation with
orthodontic brackets, ligatures, sutures, and com-
posite resins.1,14—16 In all these studies, the authors
have defend of their technique as useful methods if
Success rate of autotransplanted teeth without stabilisation by splints
the patient and the tooth are chosen correctly. The
reported long-term success rate varies between 74%
and 100%.16 This is in accordance with our results.
The surgeon should therefore choose the method of
stabilization that is easiest to use and inexpensive.
We suggest that the mesiodistal dimension of the
tooth be transplanted should be similar to that of
the recipient area, frictional stabilisation with the
adjacent teeth should be secure and there should
be good adaptation of the root with recipient bone;
this will result in good long-term clinical success.
Our results indicate that autotransplantation of
teeth without primary splint stabilisation is a reli-
able treatment in selected cases with good prog-
nosis for impacted canines and third molars with
closed apices in both sexes.
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