Severe complication after autotransplantation of bilateral palatal impacted maxillary canines: a lesson to learn

Abstract

Background

Autogenous tooth transplantation of impacted maxillary canines can be considered in cases where traditional treatment options are prone to failure. We report a clinical case of autogenous tooth transplantation of bilateral impacted maxillary canines with adverse outcome and failure of treatment.

Methods

Clinical and radiographic data of a fifteen years old girl was collected over a 12-months period.

Results

This case demonstrates difficulties and possible adverse outcomes that can be faced when performing this surgical technique. Lack of proper presurgical planning and training in the specific autotransplantation procedure, and inadequate use of the surgical technique may not only be followed by failure of treatment and loss of the transplanted teeth but can also jeopardize neighboring healthy teeth, thus complicating further treatment.

Conclusions

This case report of a 15-year old patient with severe complications after autotransplantation of bilateral impacted maxillary canines calls for the need of proper presurgical planning and training with regard to the specificities of the treatment strategy and surgical technique when performing this type of surgery.

Highlights

  • Autogenous tooth transplantation may be a valid treatment option in selected cases.

  • Proper case selection should be followed by meticulous presurgical planning.

  • The surgical technique necessitates surgical experience with proper training regarding the autotransplantation of teeth, to avoid complications.

  • Care should be taken to avoid neighboring healthy teeth suffering irreversible damage.

  • In case of severe complications, further treatment planning can be complicated.

Introduction

Autotransplantation is the positioning of a tooth in the same individual, from a donor site to an extraction site or a surgically prepared socket. Impacted maxillary canines may present themselves in a wide three-dimensional range of variations with a corresponding difference in treatment difficulty [ ].

Untreated partially erupted or impacted canines may result in several complications such as displacement and loss of vitality of the adjacent incisors, follicular cysts, ankylosis, internal resorption, external resorption of the canine and adjacent teeth, or combinations of these factors [ , ]. Traditional treatment options are interceptive removal of the deciduous canine, surgical exposure with or without orthodontic traction, no treatment, autotransplantation or removal of the permanent canine and prosthetic or restorative treatment [ ]. Only when surgical exposure and orthodontic traction are considered too difficult or impossible autotransplantation can be considered as an alternative to the removal of the tooth [ ]. High positioning or an angulation larger than 45° relative to the occlusal plane are known selection criteria of autotransplantion [ ]. Long-term studies have shown a good overall success and survival rate. However, since long-term complications as progressive root resorption and ankylosis with replacement resorption can occur, the clinician should always consider the emotional cost, oral health related improvement in quality of life, treatment fatigue with having to endure the current procedure and possibly even another one in the future [ ].

With the present case report, the authors aim to report a disastrous end result after autotransplantation treatment of bilateral maxillary impacted canines in a 15-years old female patient. By doing so, the authors aspire to recommend caution and use of carefully prepared treatment plan, with a dedicated surgical technique performed by an adequately trained maxillofacial surgeon.

Presentation of case

A 15-year-old Caucasian female was referred to the department of Oral and Maxillofacial Surgery by her orthodontist because of persisting deciduous canines and bilateral high horizontal impaction of maxillary canines. The patient was in good health and was a non-smoker. She had a Class I skeletal and molar relationship with proclination of the upper incisors. The upper right and left deciduous canines were still present in the arch ( Fig. 1 ). A panoramic view and cone beam CT-scan (CBCT) were performed which showed a complete overlap of the canines with the root of the central incisors and the crowns positioned in the apical 1/3 of the central incisors. CBCT revealed complete root formation of both impacted canines and bilateral root resorption of the lateral and central incisors ( Fig. 2 ).

Fig. 1
Clinical photograph, right anterolateral, anterior, left anterolateral, upper and lower view. Note the class I molar dental relationship with normally inclined lower incisors and proclination of the upper incisors.

Fig. 2
A. Panoramic radiograph. Note that the canines show a complete overlap with the root of the central incisors and the crowns are positioned in the apical 1/3 of the central incisors. B. Cone beam CT. This revealed complete root formation of both impacted canines and bilateral root resorption of the lateral and central incisors.

Considering the patient’s age, the underlying malocclusion , and the patient’s will to maintain her natural teeth, it was decided to try to resolve the canine impaction. At this stage of development the first treatment option would be to surgically expose the impacted canine and apply orthodontic traction. Nevertheless, the position of the impacted canine and the already existing root resorption of the incisors, discouraged this option. Indeed, when aiming to put the canines under traction from the palatal side would be accompanied by an unacceptable risk of further root resorption of lateral and central incisors. It was therefore opted to remove the primary canines followed by autotransplantation of both impacted maxillary canines.

In this specific case, a palatal incision was made from the sulcus of the right maxillary canine to contralateral to gain surgical access. An osteotomy of the overlying bone was performed and both impacted canines were exposed. This was followed by luxation of both teeth. The deciduous canines were removed, and a vestibular flap was raised for exposure. Both acceptor sites were shaped with 3D printed dummies and the donor teeth were atraumatic removed and autotransplanted at the recipient site. Temporary splinting was done with the orthodontic arch and composite. Root channel treatment was performed 4 weeks after the removal of the splint. Already at the 1-week follow-up consultation we could observe delayed wound healing and wound dehiscence at the palatal incision. Intra-oral radiographs showed signs of inflammatory root resorption ( Fig. 3 ). Antibiotic treatment (Amoxicilline 500mg 4 times a day for 7 days) and hydrogen peroxide mouth wash 3% were started.

Aug 8, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Severe complication after autotransplantation of bilateral palatal impacted maxillary canines: a lesson to learn
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