Tooth Transplantation to Bone Graft in Cleft Alveolus Soren Hillerurp

Tooth Transplantation to Bone Graft in Cleft Alveolus

Soren HiLLeRurp, D.D.S., Lic.opont. ERIK DAHL, D.D.S., DR.ODONT. OLE ScHwarTz, D.D.S., Lic.opont. ERIK Huorting-Hansen, D.D.S., DR.ODoONT.

Autotransplantation of teeth has developed from a last resort operation into a well tested and relatively predictable clinical procedure. This article documents four cases where autologous teeth were successfully transplanted into bone from the iliac crest grafted to an alveolar cleft. The possibility of tooth transplantation should be considered when planning dental rehabilitation for patients with cleft.

In recent years many questions concerning the alveolar part of a periodontal ligament, ap- surgical technique and timing of secondary bone parently as had it been jawbone. grafting in cases of cleft lip and palate have been clarified, and the procedure has been widely accepted as an integrated part of the rehabilita- MATERIAL AND METHODS tion (Jackson, 1972; Boyne and Sands, 1972, 1976; Harle, 1973; Koberg, 1973; Abyholm, 1981; Hall and Posnick, 1983; Freitag and Four patients with complete cleft lip and palate Fallenstein, 1984). When secondary bone graft- are described in which a tooth has been trans- ing is performed before eruption of the canine, planted into a bone grafted alveolar cleft. the teeth adjacent to the cleft can be seen to The primary surgical management consisted of migrate into the bone graft, or they may be closure of the clefts of the lip and the palate by aligned orthodontically (Eldeeb et al, 1982). conventional surgical methods within the first two However, in some cases, for various reasons, a years of life. Bone grafting was performed as a tooth will be missing in the cleft area. When late secondary procedure using cancellous bone planning the treatment for such patients it should from the iliac crest. be taken into account that tooth transplantation Tooth transplantation was performed under has developed into a safe and predictable proce- local anesthesia by the following procedure: ves- dure (Slagsvold and Bjercke, 1974; Kristerson tibular and palatal mucoperiosteal flaps were and Kvint, 1981; Schwartz et al, 1985a, 1985b). elevated in the bone grafted area. A socket was The present article describes four cases where prepared with a slowly rotating burr with con- autologous teeth were successfully transplanted tinuous irrigation of saline. The tooth selected for into bone from the iliac crest grafted to the transplantation was gently extracted with forceps alveolar cleft. Our aim with the paper is twofold: and immediately placed in the slightly over- extended socket prepared in the recipient area. 1. to introduce autologous tooth transplantation The tooth was fixated with a suture or splinted as a new treatment modality of dentoalveolar loosely to the neighboring teeth. Primary closure reconstruction in cleft patients, and was performed with interrupted silk 4-0 sutures. 2. to demonstrate that grafted bone from the The fixation was removed after 7 to 14 days. iliac crest has the capacity of forming the Endodontic treatment was performed in all cases but one. The treatment involved pulpec- tomy and deposit of calcium hydroxide to induce The authors are affiliated with the Royal Dental College apical closure. This was followed by a permanent and the University Hospital (Rigshospitalet), Copenhagen, root filling. Denmark. Dr. Dahl is Associate Professor, Department of The follow-up examinations comprised clinical Orthodontics; Dr. Hjgrting-Hansen is Professor and Chair- examination, i.e., inspection, gingival probing, man; Dr. Schwartz is Assistant Professor, and Dr. Hillerup is Associate Professor, Department of Oral and Maxillo- percussion and mobility test, and dental radio- facial Surgery. graphs. Observation time was from 1% to 4 years. 137 138 Cleft Palate Journal, April 1987, Vol. 24 No. 2

CASE STUDIES The follow-up examination showed satisfactory healing. Four years after transplantation the tooth was in Case 1 was a 16-year-old boy with a complete left- good position with gingival pockets 2 mm or less. The sided cleft lip and palate. The left upper lateral incisor radiologic examination showed obliteration of the pulp was missing (Fig. 1A, 1C). Orthodontic closure of the chamber and the root canal. The periodontal radio- space in the upper arch was considered inappropriate, lucency and the lamina dura appeared normal, and and it was decided to bone graft the alveolar cleft, there was no indication of ankylosis. await healing, and to transplant one of the lower Case 3 was a 15-year-old boy with complete unilater- second bicuspids which should be extracted for ortho- al cleft lip and palate. The alveolar cleft was bone graft- dontic reasons. ed at age 14 years. Four months after bone grafting, the left lower The lateral incisor was missing on the cleft side, and second bicuspid was transplanted into the cleft region. two mandibular bicuspids had to be extracted for ortho- Endodontic treatment was started 2 months later. dontic reasons. Fifteen months after bone grafting, the Follow-up examination showed healing with perio- lower left second bicuspid was transplanted into the dontal reattachment without pocket formation. The bone grafted region. radiologic examination revealed osseous healing of the Follow-up examination showed uneventful healing socket with normal periodontal radiolucency and and the tooth in good position with gingival pockets lamina dura. There was no sign of ankylosis. Figure of normal depth. The radiologic examination showed 1E shows the condition 2% years after tooth transplan- that the root formation had continued. The apex was tation. almost closed, but there was no evidence of pulp Case 2 was a 15-year-old girl with complete bilateral obliteration of the coronal part of the pulp. Electro- cleft lip and palate. Bone grafting to the right side was metric pulp test gave no reaction, and endodontic performed at age 14 years (Fig. 2A, 2B, 2C). Seven treatment was performed. Figures 3C and 3D show months later the cleft on the left side was grafted, and the condition 2 years after the transplantation; the tooth a left lateral incisor in palatal malposition was trans- has been given incisor shape by grinding and direct planted to the bone grafted area on the right side (Fig. bonding of a composite resin material. 2D, 2E, 2F). Case 4 was a 17-year-old boy with complete bilater-

E FIGURE 1 Case 1: A and B, cleft region before and after tooth transplantation; C, radiograph before tooth transplantation; D, 3 months after; and E, 2% years after tooth transplantation. Hillerup et al, TOOTH TRANSPLANTATION TO BONE GRAFT 139

FIGURE 2 Case 2; A, cleft region after secondary bone grafting to right side; B and C, malposed left lateral incisor; D and E, dental arch after transplantation of palatally malposed left lateral incisor to right side; and F, healing with root canal obliteration 4 years postopera- tively.

FIGURE 3 Case 3: A, open cleft with unerupted canine and malformed lateral incisor with internal resorption to be extracted; B, right canine being aligned before bone grafting; C and D, lower left second premolar in position in bone graft 2 years after transplantation.

140 Cleft Palate Journal, April 1987, Vol. 24 No. 2 al cleft lip and palate. Bone grafting was carried out teeth in general, and bearing in mind that trans- at age 15 years. Both upper lateral incisors were miss- planted teeth are at greatest risk of resorption and ing, and 20 months after bone grafting a severely mal- loss during the first year, we expect three of the positioned maxillary second bicuspid was trans- four transplanted teeth discussed in this study to planted into the bone grafted region on the right side. serve in function for a number of years to come. The clinical healing was uneventful in spite of damage to the periodontal ligament during the extraction. After the first four cases documented in this ar- Radiologic follow-up initially showed normal perio- ticle we have autotransplanted another five teeth dontal healing and no signs of ankylosis. Endodontic into bone grafts in patients with cleft palate, all treatment was started with a deposit of calcium hydrox- with a favorable outcome. One of these teeth was ide and the tooth was root filled. However, suspicion extracted during the bone grafting operation, of ongoing external root resorption was raised at the cryopreserved in a special storage medium in radiographic check after 1% years (Fig. 4B). liquid nitrogen for a period of 7 months awaiting healing of the bone graft, and successfully transplanted back into the cleft region. Schwartz et al DISCUSSION (19852) showed that more than 50 percent of au- The four cases of tooth autotransplantation totransplanted one-rooted teeth were still in func- documented in this article were carried out at 4, tion after 20 years. Adding known favorable 7, 15, and 20 months after bone grafting, all with prognostic factors-such as tooth type (one- successful clinical healing, and they have been rooted tooth), stage of root development (open followed up for a period ranging from 18 months apex), age of patient (<15 years), and surgical to 4 years. Three of the cases exhibited no signs technique (no extraoral storage of tooth, ex- of morbidity to give expectation of future loss of perienced surgeon-autotransplantation of teeth the transplants, i.e., progressive inflammatory appears as a safe and predictable clinical proce- root resorption or ankylosis. In Case 4, the 1% dure (Slagsvold and Bjercke, 1974; Kristerson and year follow-up dental x-ray film raised suspicion Kvint, 1981; Andreasen, 1981; Kristerson and An- of external root resorption, possibly caused by dreasen, 1984; Schwartz et al, 1985a, 1985b). the damage to its periodontal ligament during sur- Apart from solving the problem of a missing gery. The clinical and radiologic appearance of tooth in the cleft area, a tooth transplantation to the periodontal attachment to the grafted iliac the bone graft may even provide the new alveo- bone was indistinguishable from that of teeth in lar bone with functional stimulation and prevent jawbone in general, indicating that a grafted tooth atrophy of the grafted bone, as otherwise often with its dental part of the periodontal ligament happens (Freitag and Fallenstein, 1984). is capable of inducing a fully formed alveolar Dental treatment planning in patients with periodontal ligament in an incorporated iliac bone cleft-in particular extraction policy-should be graft. This observation is interesting considering conducted with the possibility of tooth trans- the different histomorphogenesis of jawbone plantation in mind. Cryopreservation of extract- formed by intramembranous ossification and iliac ed teeth for later transplantation into the bone bone formed by endochondral ossification. There grafted cleft alveolus is a future treatment alter- is no indication that transplanted teeth with clin- native of surgical dental rehabilitation. The ical and radiologic healing into grafted bone have method is now under investigation (Schwartz et a prognosis that differs from that of transplanted al, 1985; Schwartz, 1986).

FIGURE 4 Case 4: bone grafted cleft, A, before and B, after tooth transplantation. The radiolucency indicated by arrow is in- terpreted as external inflammatory root resorption.

Hillerup et al, TOOTH TRANSPLANTATION TO BONE GRAFT 141

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