Accepted Manuscript Immediate autotransplantation of third molars: An experience of 57 cases. Shakil Ahmed Nagori , BDS Ongkila Bhutia , BDS, MDS Ajoy Roychoudhury , BDS, MDS Ravinder Mohan Pandey , Ph.D PII:
S2212-4403(14)00479-9
DOI:
10.1016/j.oooo.2014.05.011
Reference:
OOOO 925
To appear in:
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Received Date: 3 May 2014 Accepted Date: 12 May 2014
Please cite this article as: Nagori SA, Bhutia O, Roychoudhury A, Pandey RM, Immediate autotransplantation of third molars: An experience of 57 cases., Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2014), doi: 10.1016/j.oooo.2014.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title page Title of the manuscript: Immediate autotransplantation of third molars: An experience of 57 cases. Authors:
RI PT
Shakil Ahmed Nagori*, BDS Junior resident Ongkila Bhutia*, BDS, MDS Additional professor
SC
Ajoy Roychoudhury*, BDS, MDS Professor and Head
M AN U
Ravinder Mohan Pandey+, Ph.D Professor and Head *Department of Oral and Maxillofacial surgery, All India Institute of Medical Sciences, New Delhi, India
Corresponding author:
TE D
+Department of Biostatistics All India Institute of Medical Sciences, New Delhi, India
AC C
EP
Dr. Ongkila Bhutia Additional professor, Department of oral and maxillofacial surgery, Centre for dental education and research, All India Institute of Medical Sciences, Ansari nagar, New delhi-110029, India. Email address: [email protected] Telephone number: +919313349564 Conflict of interest: None Financial Disclosure: None Word count: Abstract: 149
Text (body and legends to figures): 3303 No of figures: 10
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No of tables: 3
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EP
TE D
M AN U
SC
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No of references: 27
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Immediate autotransplantation of third molars: An experience of 57 cases Abstract
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Objective: We present our experience of success with immediate third molar transplantations in young individuals while secondarily assessing factors predicting failure.
Study Design: 57 cases of third molar transplantation with both open and closed apices were
SC
studied in individuals of 15-25 years of age. Factors influencing prognosis were analysed by univariate and multivariate analysis.
M AN U
Results: 17 maxillary (29.8%) and 40 mandibular molars (70.2%) were replaced. After a follow-up of 19.9±2.8 months, 49 cases (86%) were successful. 7 (12.3%) cases failed due to root resorption while 1 (1.7%) due to infection. Pulp revascularization was seen in all successful cases with open apices. Proximal grinding of donor tooth was significantly
TE D
associated with failure (Odds ratio: 12.5, p = 0.025)
Conclusion: Autogenous third molar transplantation is an excellent and viable treatment modality. Using proper case selection and minimizing damage to the donor tooth root high
AC C
Introduction
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success rates can be achieved.
Autotransplantation of teeth has become an established surgical procedure but with varying success rates1–10. Transplantation of immature teeth offers benefits of proprioception, pulp revascularization and continued root development11. Formation of periodontal ligament also allows for orthodontic tooth movement8. Transplantation of even completely formed donor teeth can be quite successful if endodontic treatment is carried out after the procedure. Autotransplantation has been used to replace avulsed anterior teeth12, to reposition impacted canines3 and to substitute non-restorable first or second molars1,2. The procedure is quite
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economical and is one of the best tooth replacement options if successful. However, technique sensitivity1, availability of donor teeth and misconceptions regarding the procedure has precluded its routine use in clinical practice13.
RI PT
While a large number of young individuals have premature loss of molars due to extensive caries, traditional fixed partial dentures are not routinely used in patients 3mm was defined as pathological. Mobility of the tooth was graded on follow-up visits as- grade 0- no abnormal mobility, grade 1- horizontal mobility of not more than 1mm,
RI PT
grade 2-abnormal horizontal mobility of more >1mm and grade 3-abnormal horizontal mobility of more >1mm with axial mobility. A pulp sensitivity testing using an electric pulp tester was carried out to evaluate the pulp status at the end of 6 months. In case root
SC
development of donor teeth was complete at the time of transplantation, root canal treatment was done after 3weeks.
M AN U
Criteria for success
The transplanted tooth was deemed successful if it fulfilled the following criteria at the end of follow-up period (Figures 8, 9 and 10):
1. The transplanted tooth functioning normally without excessive mobility, physiologic
TE D
mobility was allowed.
2. Clinically no discomfort on periodontal probing and pockets of no more than 3mm.
dura.
EP
3. Radiographically no root resorption and presence of a normal PDL space and lamina
AC C
Data analysis and statistics
Factors affecting prognosis of the procedure were divided into two groups for the purpose of analysis. Age was classified as >20 years or ≤20 years and gender as male or female. Recipient site was either maxillary or mandibular. Peri-apical infection at the recipient site was noted as present or absent based on pre-operative radiographic evaluation. Donor tooth was classified as either from maxilla or mandible. Its eruption status was classified as erupted or unerupted while its position was classified after radiological examination as vertical or
ACCEPTED MANUSCRIPT
mesioangular since no third molars with distoangular or horizontal orientation were harvested. The root development stage of the third molar was also recorded according to Moorees staging. But for the purpose of analysis the root development was classified as
RI PT
complete or incomplete with open apex. Depending upon the number of roots, donor third molars were classified as single rooted or multi-rooted (with more than 1 root). Depending upon the extra-oral time of third molar, two groups were classified as those where third molar
SC
was exposed in the environment for >2mins or ≤2mins. Cases were classified as those which required proximal grinding of the donor tooth during transplantation and those which did not.
M AN U
Also depending upon stabilization method, the two groups were: sutures only and suture with splint.
Data was entered in Microsoft Excel 2010 and subjected to statistical analysis using STATA version 11 (Statacorp, College Station, TX, USA). The association between two categorical variables were analysed by Chi-square test/Fishers exact test as appropriate. The influence of
TE D
different parameters on failure was evaluated using univariate binary logistic regression analysis. All variables with p20 years
15 (88.2%)
2 (11.8%)
Male
12 (75%)
4 (25%)
Female
37 (90.2%)
4 (9.8%)
Maxillary
14 (82.4%)
3 (17.6%)
Mandibular
35 (87.5%)
5 (12.5%)
Present
15 (75%)
5 (25%)
Absent
34 (91.9%)
3 (8.1%)
Maxillary
15 (83.3%)
3 (16.7%)
Mandibular
34 (87.2%)
5 (12.8%)
Unerupted
36 (85.7%)
6 (14.3%)
Erupted
13 (86.7%)
2 (13.3%)
p-value
Unadjusted
95% confidence
odds ratio
interval
1.33
0.23, 7.69
Age
0.74
Gender
0.15
3.12
0.61
SC
0.08
3.84
TE D
Orientation of donor tooth
11 (78.6%)
3 (21.4%)
38 (88.4%)
5 (11.6%)
10 (83.3%)
2 (16.7%)
39 (86.7%)
6 (13.3%)
24 (82.8%)
5 (17.2%)
25 (89.3%)
3 (10.7%)
>2mins
14 (82.3%)
3 (17.7%)
≤2mins
35 (87.5%)
5 (12.5%)
3 (50%)
3 (50%)
46 (90.2%)
5 (9.8%)
Suture+splint
10 (83.3%)
2 (16.7%)
Suture
39 (86.7%)
6 (13.3%)
0.31, 7.14
0.8, 1.81
(reference)
M AN U
Eruption stage of donor tooth
Vertical
1.5
(reference)
Peri-apical infection
Donor Tooth type
0.6, 14.2
(reference)
Recipient Site
Mesioangular
RI PT
(reference)
0.7
1.36
0.28, 6.66
(reference)
0.92
1.08
0.19,6.05
(reference)
0.37
2.07
0.42-10.07
(reference)
Root development of donor tooth Complete
EP
Incomplete
0.77
1.31
0.22, 7.69
(reference)
Number of roots of donor tooth
Multirooted
AC C
Single
0.47
1.75
0.37, 8.33
(reference)
Extra-oral time
0.61
1.5
0.31, 7.13
(reference)
Proximal grinding
Yes No
0.02
10
1.47, 100
(reference)
Fixation method
0.77
1.3 (reference)
0.22,7.44
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Table 3: Multivariate logistic regression analysis for factors predicting failure of tooth transplantation
Adjusted odds ratio
p-value
95% confidence
RI PT
Variable
interval
Proximal grinding
12.5
0.025
4.54
0.11
7.69
0.04
1.36, 100
Peri-apical infection
Gender
AC C
EP
TE D
(Male)
M AN U
(yes)
0.7, 33.3
SC
(yes)
1.05, 100
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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TE D
M AN U
SC
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TE D
M AN U
SC
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SC
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TE D
M AN U
SC
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SC
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SC
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Statement of clinical relevance: Autotransplantation is being seldom used in routine practice. Our experience demonstrates it to be an excellent treatment modality. Proper case selection and minimal damage to donor
AC C
EP
TE D
M AN U
SC
RI PT
tooth would ensure high success.
S2212-4403(14)00479-9
DOI:
10.1016/j.oooo.2014.05.011
Reference:
OOOO 925
To appear in:
Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology
Received Date: 3 May 2014 Accepted Date: 12 May 2014
Please cite this article as: Nagori SA, Bhutia O, Roychoudhury A, Pandey RM, Immediate autotransplantation of third molars: An experience of 57 cases., Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2014), doi: 10.1016/j.oooo.2014.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Title page Title of the manuscript: Immediate autotransplantation of third molars: An experience of 57 cases. Authors:
RI PT
Shakil Ahmed Nagori*, BDS Junior resident Ongkila Bhutia*, BDS, MDS Additional professor
SC
Ajoy Roychoudhury*, BDS, MDS Professor and Head
M AN U
Ravinder Mohan Pandey+, Ph.D Professor and Head *Department of Oral and Maxillofacial surgery, All India Institute of Medical Sciences, New Delhi, India
Corresponding author:
TE D
+Department of Biostatistics All India Institute of Medical Sciences, New Delhi, India
AC C
EP
Dr. Ongkila Bhutia Additional professor, Department of oral and maxillofacial surgery, Centre for dental education and research, All India Institute of Medical Sciences, Ansari nagar, New delhi-110029, India. Email address: [email protected] Telephone number: +919313349564 Conflict of interest: None Financial Disclosure: None Word count: Abstract: 149
Text (body and legends to figures): 3303 No of figures: 10
ACCEPTED MANUSCRIPT
No of tables: 3
AC C
EP
TE D
M AN U
SC
RI PT
No of references: 27
ACCEPTED MANUSCRIPT
Immediate autotransplantation of third molars: An experience of 57 cases Abstract
RI PT
Objective: We present our experience of success with immediate third molar transplantations in young individuals while secondarily assessing factors predicting failure.
Study Design: 57 cases of third molar transplantation with both open and closed apices were
SC
studied in individuals of 15-25 years of age. Factors influencing prognosis were analysed by univariate and multivariate analysis.
M AN U
Results: 17 maxillary (29.8%) and 40 mandibular molars (70.2%) were replaced. After a follow-up of 19.9±2.8 months, 49 cases (86%) were successful. 7 (12.3%) cases failed due to root resorption while 1 (1.7%) due to infection. Pulp revascularization was seen in all successful cases with open apices. Proximal grinding of donor tooth was significantly
TE D
associated with failure (Odds ratio: 12.5, p = 0.025)
Conclusion: Autogenous third molar transplantation is an excellent and viable treatment modality. Using proper case selection and minimizing damage to the donor tooth root high
AC C
Introduction
EP
success rates can be achieved.
Autotransplantation of teeth has become an established surgical procedure but with varying success rates1–10. Transplantation of immature teeth offers benefits of proprioception, pulp revascularization and continued root development11. Formation of periodontal ligament also allows for orthodontic tooth movement8. Transplantation of even completely formed donor teeth can be quite successful if endodontic treatment is carried out after the procedure. Autotransplantation has been used to replace avulsed anterior teeth12, to reposition impacted canines3 and to substitute non-restorable first or second molars1,2. The procedure is quite
ACCEPTED MANUSCRIPT
economical and is one of the best tooth replacement options if successful. However, technique sensitivity1, availability of donor teeth and misconceptions regarding the procedure has precluded its routine use in clinical practice13.
RI PT
While a large number of young individuals have premature loss of molars due to extensive caries, traditional fixed partial dentures are not routinely used in patients 3mm was defined as pathological. Mobility of the tooth was graded on follow-up visits as- grade 0- no abnormal mobility, grade 1- horizontal mobility of not more than 1mm,
RI PT
grade 2-abnormal horizontal mobility of more >1mm and grade 3-abnormal horizontal mobility of more >1mm with axial mobility. A pulp sensitivity testing using an electric pulp tester was carried out to evaluate the pulp status at the end of 6 months. In case root
SC
development of donor teeth was complete at the time of transplantation, root canal treatment was done after 3weeks.
M AN U
Criteria for success
The transplanted tooth was deemed successful if it fulfilled the following criteria at the end of follow-up period (Figures 8, 9 and 10):
1. The transplanted tooth functioning normally without excessive mobility, physiologic
TE D
mobility was allowed.
2. Clinically no discomfort on periodontal probing and pockets of no more than 3mm.
dura.
EP
3. Radiographically no root resorption and presence of a normal PDL space and lamina
AC C
Data analysis and statistics
Factors affecting prognosis of the procedure were divided into two groups for the purpose of analysis. Age was classified as >20 years or ≤20 years and gender as male or female. Recipient site was either maxillary or mandibular. Peri-apical infection at the recipient site was noted as present or absent based on pre-operative radiographic evaluation. Donor tooth was classified as either from maxilla or mandible. Its eruption status was classified as erupted or unerupted while its position was classified after radiological examination as vertical or
ACCEPTED MANUSCRIPT
mesioangular since no third molars with distoangular or horizontal orientation were harvested. The root development stage of the third molar was also recorded according to Moorees staging. But for the purpose of analysis the root development was classified as
RI PT
complete or incomplete with open apex. Depending upon the number of roots, donor third molars were classified as single rooted or multi-rooted (with more than 1 root). Depending upon the extra-oral time of third molar, two groups were classified as those where third molar
SC
was exposed in the environment for >2mins or ≤2mins. Cases were classified as those which required proximal grinding of the donor tooth during transplantation and those which did not.
M AN U
Also depending upon stabilization method, the two groups were: sutures only and suture with splint.
Data was entered in Microsoft Excel 2010 and subjected to statistical analysis using STATA version 11 (Statacorp, College Station, TX, USA). The association between two categorical variables were analysed by Chi-square test/Fishers exact test as appropriate. The influence of
TE D
different parameters on failure was evaluated using univariate binary logistic regression analysis. All variables with p20 years
15 (88.2%)
2 (11.8%)
Male
12 (75%)
4 (25%)
Female
37 (90.2%)
4 (9.8%)
Maxillary
14 (82.4%)
3 (17.6%)
Mandibular
35 (87.5%)
5 (12.5%)
Present
15 (75%)
5 (25%)
Absent
34 (91.9%)
3 (8.1%)
Maxillary
15 (83.3%)
3 (16.7%)
Mandibular
34 (87.2%)
5 (12.8%)
Unerupted
36 (85.7%)
6 (14.3%)
Erupted
13 (86.7%)
2 (13.3%)
p-value
Unadjusted
95% confidence
odds ratio
interval
1.33
0.23, 7.69
Age
0.74
Gender
0.15
3.12
0.61
SC
0.08
3.84
TE D
Orientation of donor tooth
11 (78.6%)
3 (21.4%)
38 (88.4%)
5 (11.6%)
10 (83.3%)
2 (16.7%)
39 (86.7%)
6 (13.3%)
24 (82.8%)
5 (17.2%)
25 (89.3%)
3 (10.7%)
>2mins
14 (82.3%)
3 (17.7%)
≤2mins
35 (87.5%)
5 (12.5%)
3 (50%)
3 (50%)
46 (90.2%)
5 (9.8%)
Suture+splint
10 (83.3%)
2 (16.7%)
Suture
39 (86.7%)
6 (13.3%)
0.31, 7.14
0.8, 1.81
(reference)
M AN U
Eruption stage of donor tooth
Vertical
1.5
(reference)
Peri-apical infection
Donor Tooth type
0.6, 14.2
(reference)
Recipient Site
Mesioangular
RI PT
(reference)
0.7
1.36
0.28, 6.66
(reference)
0.92
1.08
0.19,6.05
(reference)
0.37
2.07
0.42-10.07
(reference)
Root development of donor tooth Complete
EP
Incomplete
0.77
1.31
0.22, 7.69
(reference)
Number of roots of donor tooth
Multirooted
AC C
Single
0.47
1.75
0.37, 8.33
(reference)
Extra-oral time
0.61
1.5
0.31, 7.13
(reference)
Proximal grinding
Yes No
0.02
10
1.47, 100
(reference)
Fixation method
0.77
1.3 (reference)
0.22,7.44
ACCEPTED MANUSCRIPT
Table 3: Multivariate logistic regression analysis for factors predicting failure of tooth transplantation
Adjusted odds ratio
p-value
95% confidence
RI PT
Variable
interval
Proximal grinding
12.5
0.025
4.54
0.11
7.69
0.04
1.36, 100
Peri-apical infection
Gender
AC C
EP
TE D
(Male)
M AN U
(yes)
0.7, 33.3
SC
(yes)
1.05, 100
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
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Statement of clinical relevance: Autotransplantation is being seldom used in routine practice. Our experience demonstrates it to be an excellent treatment modality. Proper case selection and minimal damage to donor
AC C
EP
TE D
M AN U
SC
RI PT
tooth would ensure high success.
