Abstract
A 10-year-old female patient with a fibula transplant in her left hemimandible due to ameloblastoma treatment was referred for combined orthodontic and surgical planning and treatment to observe and prevent expected asymmetric facial development and malocclusion, because the premolars and molars on the left side of the mandible were missing. The patient had an Angle Class II malocclusion and arch length discrepancy in the upper jaw. The two second premolars in the maxilla were transplanted into the neomandible to create occlusion on the left side and retention for orthodontic treatment. Clinical and radiological examination 3 months postoperatively showed good integration of both premolars without pocket formation. After 4 months, active orthodontic treatment with fixed appliances was started to create sufficient arch space in the upper jaw for both canines to erupt and to extrude and for the transplanted premolars in the lower jaw to rotate and align into the planned positions. This case report demonstrates that autotransplantation of premolars into a fibula transplant can be a successful dental rehabilitation procedure.
High survival rates (79–98%) have been reported for autotransplantation surgery. In young patients, age is an important indication for using autologous teeth to replace missing teeth. The most common indication for autotransplantation in these young patients is agenesis of premolars with a Class II malocclusion . The best time for transplantation is before apexification. The transplanted teeth can easily be aligned with orthodontic therapy. Successful cases of autotransplantation in an autologous augmented alveolar process, for example in cleft patients, have been reported .
Unicystic ameloblastoma (UA) is a benign epithelial odontogenic tumour of the jaws with aggressive potential. This cystic odontogenic neoplasm is generally asymptomatic and can be identified during routine radiography. UA is a rare pathological condition in children, of all the ameloblastomas its estimated frequency in children below 10 years of age is 0.8–2% .
Enucleation treatment can be considered in ameloblastomas, especially in children, but resection is inevitable with larger tumours . Several reconstructive procedures, such as free vascularized fibular graft, can be considered after mandibular resection .
Reports of autotransplantion of teeth in free vascular bone grafts have not published previously. This study reports a case of dental autotransplantation in a 10-year-old child after surgical ameloblastoma treatment on the left side of the mandible, which was resected and reconstructed with a microvascular free fibular transplant.
Case report
A 10-year-old female patient was referred with a fibula transplant on the left side of the mandible due to hemimandibulectomy and primary reconstruction with a free vascularized fibula graft, because of an ameloblastoma. The patient was referred to the combined orthodontic–surgical clinic for observation and treatment to prevent expected asymmetric facial development and malocclusion, because the premolars and molars on the left side of the mandible were missing. Extraction of the premolars to achieve coordinated arches was indicated.
One year before presentation, the patient underwent segmental resection of the left mandible, with preservation of the left condyle, and reconstruction with a free vascularized double-barrel fibular graft, because of a unicystic ameloblastoma ( Fig. 1 ). Her medical history was uneventful.
Intraoral examination revealed a Class II malocclusion, crowding in the upper jaw, a lack of arch space for the permanent canines to erupt, and no occlusion of the premolars and molars in the upper left jaw because of missing antagonists. There was a slight overeruption of these posterior maxillary teeth. Radiographic examination showed impaction of both superior permanent canines and incomplete root formation (approximately 80%) of the superior premolars. A bony union of the vascularized double-barrel fibular graft was observed ( Fig. 1 b).
Staged surgical and orthodontic treatment was initiated to restore occlusion, prevent further overeruption, treat the maxillary arch length discrepancy, and produce dental anchorage for interceptive orthodontic treatment. This treatment can be commenced if the bony transplant is osseointegrated and the transplanted teeth show incomplete root formation (preferably 50–75%).
The ventral 2.0 mm of the mini-osteosynthesis was removed transorally under general anaesthesia. Both second premolars in the upper jaw were extracted and transplanted in the infra-occlusal position, with a 90° axial rotation in the neomandible, because of the small bucco-lingual distance of the neomandible. During the extraction the premolars were gently removed. Care was taken to prevent damage to the periodontal ligament. The teeth were preserved in saline while a neo-alveolus was prepared with a bur. The alveolus was fashioned until the premolars fitted with slight occlusal pressure just caudally of the occlusal plane. The postoperative recovery was uneventful.
The patient attended follow-up visits after 1, 3, 6 weeks and 2 and 3 months postoperatively. Clinical and radiological examination 3 months postoperatively showed good integration of both premolars without pocket formation (Figs. 1 b and 2 ). After 4 months, active orthodontic treatment with fixed appliances was started to create sufficient arch space in the upper jaw for both canines to erupt and to extrude and for the transplanted premolars in the lower jaw to rotate and align into the planned positions ( Fig. 2 ). The teeth were not discoloured and had no radiological signs of peri-apical pathology. Sulcus depth was 1–3 mm, without bleeding on probing. The second premolar showed a slight recession of the lingual part of the second transplanted premolar, mostly due to the missing attached gingiva on the fibula transplant. At first, a slight pocket was found, but meticulous oral hygiene reduced the pocket and revealed a healthy gingiva. Percussion sounds were normal and both teeth responded normally on orthodontic activation. periodontic, orthodontic, and radiological investigation revealed uneventful healing, and the procedure was considered to be a functional success. Orthodontic treatment will continue for another few years. Follow-up will continue every 3 months for the first year and afterwards during routine orthodontic follow-up.
