1. CASE PRESENTATION
Orthodontic correction prior to autotransplantation
of impacted permanent maxillary lateral incisor and
canine

2. Identification Data
Name
Age
Race
Sex
:A
: 19 years old
: Malay
: Male

3. History

The patient was a 19-years-old Malaysian boy
whose chief complaints were missing of the
upper front teeth since 5 years ago.

4. His mother claimed that there were no tooth erupted
at that area since primary teeth exfoliated.
 Patient defaulted dental check up several times since
2009 but presented back to HUSM with same
complaint since 3 years ago.
 One year ago, OPG and periapical radiograph for
tooth 22 and 23 were taken showed impacted teeth.
 Now, he was on regular appointment with
orthodontist for treatment.


5. 

Past medical history: No known medical illness
Past dental history:
– Done extraction, filling and scaling during primary
school

6. Clinical Examination

7. Fig 2: Pretreatment intraoral photograph
Problem list :
1. Missing left maxillary lateral incisor and canine
2. Median diastema
3. Rotated tooth 24 mesio-bucally
4. Upper midline shift 2mm to the left
5. Mandibular incisor crowding

8. Fig 3: Pretreatment dental cast

9. Fig 4: Pretreatment Orthopantomogram
OPG showed impacted maxillary left lateral incisor and canine with
minimal space available for both teeth eruption.

10. Table. Cephalometric measurements
Variable
Pretreatment
(0)
SNA
88
SNB
84
ANB
4
Maxillary incisor to
115
maxillary plane angle
Mandibular incisor to
94
mandibular plane
angle
Interincisal angle
120
Maxillary-mandibular
28
angle
Upper anterior facial
46.5 %
height
Lower anterior facial
53.5 %
Fig 5: Pretreatment lateral cephalograph
height
Normal
(0)
82 (+/-3)
79 (+/-3)
3 (+/-1)
108 (+/-5)
92 (+/-5)
133 (+/-10)
27 (+/-5)
45 %
55 %
The cephalometric analysis showed protrusive maxilla and mandible
noted with class I skeletal relationship. Maxillary incisor protruded but
normal inclination of mandibular incisor. Class 1 Bimax protrusion.

11. Treatment objectives
The objectives of the orthodontic treatment were to
(1) close the median diastema
(2) derotate tooth 24
(3) reduce lower anterior teeth crowding
(4) correct midline shift
(5) create space for the impacted teeth (ectopic maxillary left
lateral incisor and canine)
(6) replace missing teeth.

12. Treatment alternatives

Removable appliance

Orthodontic traction

Extraction
– Removable partial denture
– Fixed prosthodontic appliance (bridge)
– Implants
– Autotransplantation

13. 



Selection of treatment options were explained to patient –
extraction and autotransplantation.
However, the amount of space available estimated from
dental cast and radiograph was not sufficient to replace the
missing teeth.
Thus, fixed appliance was use for orthodontic correction and
space management prior to teeth substitutions.
Both the alignment and space acquired provides good
outcome for further management of teeth transplantation.

14. Treatment Progress
Fig 7. Fixed appliance on upper and lower teeth with open coil
spring between left upper central insicor and first premolar

15. Treatment results

Median diastema corrected

Derotated tooth 24

Upper midline corrected

Mandibular incisor was aligned

Sufficient space for autotransplantation

16. Discussion

Impaction of permanent teeth is a relatively common
occurrence that can involve any tooth in the dental arch. Highest
frequency of impaction is mandibular and maxillary third molars,
followed by maxillary canines and mandibular second molars.
(Aitasalo K, Lehtinen R, Oksala E. 1972)

About one third of impacted maxillary canines are positioned
labially or within the alveolus, and two thirds are located
palatally in dental arch.
(Johnston WD. 1969)

17.  Studies found that if a patient had a small or peg lateral
incisor there was approximately a one-in-ten probability
that the canine would be palatally placed; and if the
patient had a missing lateral incisor a one-in-twenty
probability.
(Jacobs SG.1996)
 This findings suggested that anomalous or missing lateral
incisors contributed towards palatal displacement of
canines initially by absence of guidance for the erupting
canine, and later by obstructing the misplaced canine's
attempt to rectify its position.
(Becker A, Smith P, Behar R. 1981)
 However, this case demonstrated impacted both lateral
incisor and canine which was a rare case that requires
better orthodontic and surgical approaches.

18. 
Treatment modalities in this patient include orthodontic
alignment and surgical repositioning.

Space analysis done on dental cast showed minimal space
available in the arch compared to space required for
autotransplatation of lateral incisor and canine

Thus, more spaces to be acquired in order to placed the missing
teeth back into position. The following alternatives were
considered for the space management:
(1) close median diastema
(2) derotate tooth 24 distobucally
(3) using open-coil spring between central incisor and first
premolar
(4) correct midline shift and alignment of maxillary and
mandibular teeth which provide more spaces

In considering these treatment outcome,fixed appliance was
taken into account.

19. Discussion : Treatment options

Removable appliance

Orthodontic traction

Extraction
– Removable partial denture
– Fixed prosthodontic appliance (bridge)
– Implants
– Autotransplantation

20. Treatment options : Removable Appliance
Eg. Upper removable appliance with palatal finger
spring to close median diastema

21. Removable appliance
Fixed appliance
Only simple tipping movement
and few teeth can be moved at a
time; complex cases, tx is
prolonged.
Lower removable appliances are
not well tolerated.
Many types of tooth movements
can be produced and performed
simultaneously.
Uncooperative patients are
difficult to be managed because
they can removed the appliance
by them.
No need cooperation as the
appliance is rigidly attached to the
teeth.
Well tolerated because not
interfere with tongue.

22. Treatment options : Orthodontic Traction

Impacted teeth can be properly positioned with orthodontic
traction.
(Lin, Y. T. J. 1999)




However, several factors should be considered when making a
surgical procedure and orthodontic treatment plan for impacted
teeth.
In orthodontic traction treatment, consideration on the position,
direction and number of missing teeth are crucial.
OPG form this patient demonstrated rotated teeth position with
misplaced direction and a total of two impacted teeth presence.
This problems increase the difficulty in these treatment
modalities which indicate that the treatment is not effective

23. Eg. Orthodontic traction of tooth 13

24. Treatment options : Extraction




Many patients with impacted teeth are treated by
extraction and the teeth were replaced by implant, fixed
or removable partial denture.
In view of the patient's age, autotransplantation of the
maxillary lateral incisor and canine was thought to be a
good alternative compared to prosthodontic appliances.
Autotransplantation may provide a simplified and faster
treatment option or patient with ectopic teeth.
This is especially the case for adult who often reject the
idea of wearing the appliance to align the ectopic teeth,
yet would benefit from this teeth in the line of the arch.
(Thomas S, Turner SR, Sandy JR.1998)

25. Eg. Autotransplantation

26. Treatment options : Autotransplantation
 Autotransplantation has its applications in the repositioning of
malpositioned teeth and in substitution for missing teeth
(Slagsvold O, Bjercke B 1978)
 Autotransplantation is defined as the transplantation of teeth from
one site to another in the same individual into extraction sockets or
surgically prepared sites.
(Natiella JR, Armitage JE, Greene GW. 1970)
 Success rate of autotransplantation is influenced by a number of
preoperative and postoperative factors including root development,
position of the tooth and surgical technique.
(Schwartz O, Bergmann P, Klausen B 1985)
 At present, autotransplantation is advised for a suitable alternative
to conventional prosthetic rehabilitation or implant treatment.
(Mejare B, Wannfors K, Jansson L. 2004)

27. Conclusion

This case demonstrates the successful alignment of maxillary
and mandibular teeth prior to autotransplantation while
maintaining Angle class 1 occlusion that was successfully
achieved in less than a year.

The patient's compliance, esthetics, function, and age should
all be considered when deciding treatment options.

A diagnostic setup model and radiograpgh were effective and
important in determining the appropriate treatment plan for
our patient's impacted teeth.

Although many orthodontic treatment mechanics
encompassing different levels of complexity have been
described in the literature, autotransplatation was presented
here are a useful alternative.

28. References
 Aitasalo K, Lehtinen R, Oksala E. An orthopantomographic
study of prevalence of impacted teeth. Int J
Oral Surg 1972;1:117-20.
Johnston WD. Treatment of
palatally impacted canine teeth. Am J Orthod 1969;56:589-96.
 Jacobs SG. The impacted maxillary canine. Further
observations on aetiology, radiographic localization,
prevention/interception of impaction, and when to suspect impaction. Australian Dental Journal
1996;41:(5):310-16
 Becker
A, Smith P, Behar R. The incidence of anomalous maxillary lateral incisors in relation to palatallydisplaced cuspids. Angle Orthod 1981;51:24-9.
 Lin, Y. T. J. Treatment of an impacted dilacerated maxillary central incisor. Am J
Orthod Dentofacial
Orthop 1999;115:406–409.
 Slagsvold O, Bjercke
B. Applicability of autotransplantation in cases of missing upper anterior teeth.
American Journal of Orthodontics 1978;74: 410–21.
 Natiella JR, Armitage JE, Greene
GW. The replantation and transplantation of teeth. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology 1970;29:397–419
 Schwartz
O, Bergmann P, Klausen B.Autotransplantation of human teeth. International Journal of Oral
Surgery 1985;14: 245–58.
 Mejare
B, Wannfors K, Jansson L. A prospective study on transplantation of third molars with complete
root formation. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics
2004;97:231–38.

29. Thank you