Mandibular premolar transplantation to replace missing maxillary anterior teeth: A multidisciplinary approach

One of the most challenging problems for orthodontists is that of multiple missing maxillary teeth in a growing patient. In many patients, a good treatment option is autotransplantation. This case report describes the multidisciplinary treatment of an 11-year-old girl with regional odontodysplasia affecting the maxillary right and left central incisors, and congenitally missing maxillary left lateral incisor and canine. Autotransplantation of the mandibular second premolars to the affected area was combined with orthodontic space closure, and the transplanted premolars were reshaped and restored with a resin composite to be in line with the left central and lateral incisors. After completion of the orthodontic treatment, gingivectomy was performed to obtain an even gingival contour and symmetrical gingival tissue. Space closure of the maxillary anterior teeth was achieved. Autotransplantation enabled the patient to retain her natural teeth rather than having a prosthesis or dental implant. The autotransplanted tooth allows for alveolar bone growth in synchrony with neighboring teeth and the formation of normal interdental papilla while adapting to functional stimuli and confers a high survival rate in the long term.


  • Patients with RO and multiple congenital missing teeth pose a challenge for orthodontists.

  • Autotransplantation with orthodontic treatment is a beneficial treatment option, especially for young patients.

  • A multidisciplinary team is a key factor in achieving all treatment objectives.

  • Multidisciplinary treatment was performed by an orthodontist, oral maxillofacial surgeon, restorative dentist, and periodontist.

  • After treatment, the patient was more satisfied, the cortical bone had formed, and the transplanted roots were continually evolving without the need for root canal.

Regional odontodysplasia (RO), probably first described by Hitchin in 1934, is a rare dental anomaly affecting primary and/or permanent teeth, most often in one quadrant. Clinical appearance shows brown or yellowish soft teeth with clinical symptoms after eruption, such as gingival swelling, gingivitis, or abscess; in some patients, a failure of tooth eruption may occur. , Radiographically, the affected teeth appear as ghost teeth because the enamel and dentin are hypomineralized and hypoplastic, reducing radiodensity with wide pulp chambers and apical foramen.

Treatment goals of a RO combined with multiple anterior missing teeth for patients during childhood include function and esthetic improvement, facilitation of normal jaw growth, and reduction of the psychological impact. , Possible treatment options are implants, prosthesis, orthodontic space closure, autotransplantation, or a combination in any complicated cases. ,

Dental autotransplantation is defined as the repositioning of a tooth from one site to a tooth extraction site or a surgically formed recipient site within the same person, which provides the possibility of a natural tooth rather than a prosthesis or implant to replace missing teeth. It is an alternative approach suitable for certain clinical situations, especially in young patients, for which a high success rate of >95% has been demonstrated. A successful autotransplantation can induce bone formation, reestablish a normal alveolar process and periodontal ligament, and permit tooth movement. , Meanwhile, an implant will not follow the adjacent incisors vertically during tooth eruption at any age.

Our case report describes a multidisciplinary treatment carried out by an orthodontist, an oral maxillofacial surgeon, a restorative dentist, and a periodontist to help a girl with RO at the maxillary right and left central incisors and congenitally missing maxillary left lateral incisor and canine achieve better dentition. The mandibular second premolars were autotransplanted to the affected area.

Diagnosis and etiology

A girl aged 11 years and 1 month, with the chief complaint of esthetic concerns, underwent evaluation of her maxillary anterior teeth. She was physically healthy with no contributing medical history. The pretreatment facial photographs ( Fig 1 ) showed a convex facial profile with a slightly protruded lower lip, low smile line, and absence of multiple maxillary anterior teeth.

Fig 1
Pretreatment facial and intraoral photographs.

The pretreatment intraoral photographs ( Fig 1 ) showed the clinical absence of the maxillary right and left central incisors, left lateral incisor, and canine. She had no active dental caries, although her maxillary left first molar was restored with a stainless steel crown because of previously treated dental caries. She had normal gingiva and alveolar bone at the maxillary central and lateral incisor area. The pretreatment dental casts ( Fig 2 ) presented the Angle’s Class II malocclusion: a spacing of 25.5 mm in the maxillary arch, crowding of 2 mm in the mandibular arch, and 3 mm deep curve of Spee.

Fig 2
Pretreatment dental casts.

In the panoramic radiograph ( Fig 3 ), all permanent teeth aside from the left lateral incisor and canine were visible. However, the maxillary right and left central incisors had been impacted by abnormal formation, with the appearance of ghost teeth and the formation of short roots. In addition, cone-beam computed tomography images ( Fig 3 ) revealed the maxillary right central incisor to be approximately 9 mm below the alveolar bone with a 5.6-mm diameter and 11-mm height, whereas the maxillary left central incisor was 12.6 mm below the alveolar bone with a 6.3-mm diameter and 6.6-mm height. These findings contributed to the diagnosis of RO.

Fig 3
Pretreatment radiographs: A, lateral cephalometric; B, cephalometric tracing; C, panoramic radiographs were taken 2 months before stainless steel crown treatment of the maxillary left first molar and cone-beam computed tomography images of RO; D, sagittal view of the maxillary right central incisors; E, sagittal view of the maxillary left central incisors; F, axial view

The pretreatment lateral cephalometric radiograph ( Fig 3 ) and analysis ( Table ) revealed a Class I skeletal pattern with orthognathic maxilla and mandible when compared with the cranial base (SNA, 81.6°; SNB, 80.3°; ANB, 1.3°). She had an acceptable vertical skeletal relationship (MP-PP, 25.5°) but slightly decreased lower anterior facial height (ANS-Me, 58.1 mm).

Cephalometric measurements
Variables Thai norm Pretreatment Posttreatment
Maxilla to cranial base
SNA (°) 84.0 ± 3.6 81.6 80.9
Mandible to cranial base
SNB (°) 81.0 ± 3.6 80.3 79.3
ANB (°) 3.0 ± 2.5 1.3 1.6
Wits appraisal (mm) −2.0 ± 3.5 N/A −0.6
MP-SN (°) 30.0 ± 5.6 30.3 32.9
FMA (MP-FH) (°) 22.7 ± 5.4 28.2 30.4
MP-PP (°) 20.9 ± 5.3 25.5 26.0
ANS-Me (mm) 68.1 ± 5.0 58.1 60.0
N-ANS: ANS-Me (%) 45:55 44:56 45:55
S-Go:N-Me (%) 67.0 ± 5.0 65.8 64.6
Maxillary dentition
U1-NA (°) 22.0 ± 5.9 N/A 21.4
U1-NA (mm) 5.0 ± 2.1 N/A 2.9
SN-U1 (°) 108.0 ± 6.1 N/A 101.3
Mandibular dentition
L1-NB (°) 30.0 ± 5.0 26.1 28.2
L1-NB (mm) 6.0 ± 2.0 5.1 3.2
L1-FH (°) 60.0 ± 6.0 60.0 56.0
L1-MP (°) 97.0 ± 6.0 91.8 93.7
Soft tissue
LL to E-line (mm) 2.0 ± 2.0 3.4 0.6
UL to E-line (mm) −1.0 ± 2.0 0.7 −0.7

N/A, Not applicable.

Treatment objectives

The treatment objectives consisted of substitution for the missing maxillary incisors and canine after removal of the ghost teeth, using mandibular premolar transplantation.

To achieve the treatment objectives, a 3-dimensional model setup was created with 3Shape Ortho Analyzer software (3ShapeE2 lab scanner, Copenhagen, Denmark) for communication and visualization among the clinicians, the patient, and her parents ( Fig 4 ).

Fig 4
Diagnostic model setup with 3D Ortho Analyzer software for space preparation of autotransplanted teeth and guiding of orthodontic tooth movement: the maxillary right lateral incisor and canine moved slightly mesially to replace the maxillary right central and lateral incisors, whereas the maxillary left premolar moved mesially to replace the maxillary left canine, creating space for 2 transplanted premolars. In the mandibular arch, the second premolars were removed for transplantation, the mandibular incisors moved lingually, and the mandibular molars moved slightly mesially, obtaining a molar Class I relationship.
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Oct 30, 2021 | Posted by in Orthodontics | Comments Off on Mandibular premolar transplantation to replace missing maxillary anterior teeth: A multidisciplinary approach
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