Case Report/Clinical Techniques
Thus, as in dental implant treatment, accurate clinical and radio-
logic examination can enhance treatment planning, ensuring an atrau-
matic and minimally invasive procedure for autotransplantation.
Modern diagnostic techniques, such as 3-dimensional (3D) imaging,
not only allow imaging of anatomic structures for accurate diagnosis
and treatment planning but are also used for the fabrication of surgical
models and the construction of surgical templates in guided implant
surgery (17–20). The application of 3D radiologic data is also being
used for the fabrication of tooth replica as single tooth-sized models
and for model-based produced surgical guides in autotransplantation
(2, 16, 21–23).
The aim of this report was to introduce a novel surgical technique
using virtually planned 3D printed surgical templates for guided osteot-
omy preparation of recipient sites and safe placement of donor teeth. By
the implementation of traditional and recognized guidelines, this
method could ensure an atraumatic and precise surgical approach
for future autotransplantation of teeth.
Case Report
An 11-year-old boy was referred after having suffered a maxillofa-
cial trauma 1 month previously, with an avulsion of his permanent
maxillary central incisors. Replantation was not possible because the
2 missing teeth could not be found.
Clinical and radiologic examinations revealed a prominent ver-
tical and horizontal deficiency of alveolar bone and soft tissue (Fig. 1A
and B, Supplemental Figures S1 and S2 are available online at www.
jendodon.com). 3D radiographic examination (Somatom Sensation
4; Siemens, Erlangen, Germany [voxel size 0.2 ! 0.2 ! 0.5 mm,
120 kV, 512 matrix]) was performed at the Division of Radiology
to ensure accurate treatment planning, rule out fractures of remaining
teeth, and exclude any fractured particles of missing teeth in hard or
soft tissues. A 3D assessment revealed no remaining dental structures
but recorded a complete loss of buccal plates of the alveolar ridge.
In further examinations, the patient presented with a changing denti-
tion, 1/4 class II molar relations, and a reduced overbite and overjet
(0 mm each). Leeway space analysis showed only 0.5 mm of access
space on each side of the lower arch. The lateral cephalogram
showed the lower incisors to be slightly protruded (97" to the
mandibular plane) with a skeletal class III tendency (ANB = 0" ,
Wits appraisal = #3 mm, APDI = 84.7). Because of the class III ten-
dency, mesialization in the upper arch was not considered a viable
treatment option. Because the tooth buds of the lower wisdom teeth
Figure 1. (A) Panoramic radiography of the 11-year-old patient showing missing maxillary central incisors after dentoalveolar trauma; because of class III ten-
dency, mesialization in the upper arch was not considered as a viable treatment option. Thus, transplantation of 2 mandibular premolars into the upper incisor
region followed by orthodontic space closure in the lower arch was conceived as the final treatment plan. (B) A clinical view presenting vertical and horizontal
deficiency of alveolar bone and soft tissue.
JOE — Volume 42, Number 12, December 2016
were clearly visible on panoramic radiography, transplantation of
mandibular premolars into the upper incisor region was considered.
After the final interdisciplinary consultation, autotransplantation of
the 2 mandibular second premolars into the anterior maxillary re-
gion, following esthetic restoration and orthodontic treatment
after the eruption of canines to correct malocclusion and space
closure in the lower arch, was conceived as the appropriate treatment
plan (10, 24).
Initially, Digital Imaging and Communications in Medicine files
were imported into surgical planning software designed for guided
implant surgery (coDiagnostiX Version 9.6; Dental Wings, Montreal,
Canada). Within the segmentation mode, the right and left second
mandibular premolars were selected as the most suitable donor teeth.
Their segmented stereolithography (STL) files were transferred to the
planning mode (Fig. 2A and B). Furthermore, STL files of scanned
dental models (7 Series dental model and impression scanner, Dental
Wings) and intraoral scans of the jaws (iTero; Align Technology, San
Jose, CA) were imported to fabricate precise surgical templates.
Similar to virtual planning of dental implants, correct angulation,
rotation, and accurate positioning of the donor teeth were predefined
with 2 surgical pins and with the aid of STL files of donor teeth. Their
exact 3D positions were selected in relation to anatomic space and
adjacent dental structures and according to their optimal prosthetic
relationship to teeth in the lower arch to ensure ideal esthetic and
functional restoration after surgical intervention (Fig. 2C–G). In
this case, the narrow ridge, caused by the severe trauma, necessitated
ridge expansion in the buccopalatinal plane. This was virtually
planned using rotatory, piezoelectric, and manual surgical instru-
ments. Technical STL files of piezoelectric instruments (Piezomed In-
struments, Piezomed, W&H Dentalwerk, Buermoos, Austria) and
bone-condensing osteotomes (Ø 2.2-, 2.8-, 3.5-, and 4.2-mm osteo-
tomes [Osteotome instrument kit for bone condensation; Straumann,
Basel, Switzerland]) were imported into planning software to achieve
predefined and precise osteotomies. In addition, preexisting files of
surgical burs and dental implants (Guided Implant Surgery Bone
Level; Straumann, Basel, Switzerland) could be visualized and super-
imposed onto the osteotomy plan to facilitate final treatment planning.
According to virtually preplanned positions and dimensions of donor
teeth, surgical templates for guided osteotomy were designed within
the software (Fig. 2H–K). To ensure precise positioning throughout
surgical intervention, 3 additional surgical templates with attached
segmented teeth were virtually designed, showing the appropriate
occlusal location of each graft (Fig. 2L). Finally, all surgical templates
Guided Autotransplantation of Teeth 1845

Thus, as in dental implant treatment, accurate clinical and radio-
logic examination can enhance treatment planning, ensuring an atrau-
matic and minimally invasive procedure for autotransplantation.
Modern diagnostic techniques, such as 3-dimensional (3D) imaging,
not only allow imaging of anatomic structures for accurate diagnosis
and treatment planning but are also used for the fabrication of surgical
models and the construction of surgical templates in guided implant
surgery (17–20). The application of 3D radiologic data is also being
used for the fabrication of tooth replica as single tooth-sized models
and for model-based produced surgical guides in autotransplantation
(2, 16, 21–23).
The aim of this report was to introduce a novel surgical technique
using virtually planned 3D printed surgical templates for guided osteot-
omy preparation of recipient sites and safe placement of donor teeth. By
the implementation of traditional and recognized guidelines, this
method could ensure an atraumatic and precise surgical approach
for future autotransplantation of teeth.
Case Report
An 11-year-old boy was referred after having suffered a maxillofa-
cial trauma 1 month previously, with an avulsion of his permanent
maxillary central incisors. Replantation was not possible because the
2 missing teeth could not be found.
Clinical and radiologic examinations revealed a prominent ver-
tical and horizontal deficiency of alveolar bone and soft tissue (Fig. 1A
and B, Supplemental Figures S1 and S2 are available online at www.
jendodon.com). 3D radiographic examination (Somatom Sensation
4; Siemens, Erlangen, Germany [voxel size 0.2 ! 0.2 ! 0.5 mm,
120 kV, 512 matrix]) was performed at the Division of Radiology
to ensure accurate treatment planning, rule out fractures of remaining
teeth, and exclude any fractured particles of missing teeth in hard or
soft tissues. A 3D assessment revealed no remaining dental structures
but recorded a complete loss of buccal plates of the alveolar ridge.
In further examinations, the patient presented with a changing denti-
tion, 1/4 class II molar relations, and a reduced overbite and overjet
(0 mm each). Leeway space analysis showed only 0.5 mm of access
space on each side of the lower arch. The lateral cephalogram
showed the lower incisors to be slightly protruded (97" to the
mandibular plane) with a skeletal class III tendency (ANB = 0" ,
Wits appraisal = #3 mm, APDI = 84.7). Because of the class III ten-
dency, mesialization in the upper arch was not considered a viable
treatment option. Because the tooth buds of the lower wisdom teeth
Figure 1. (A) Panoramic radiography of the 11-year-old patient showing missing maxillary central incisors after dentoalveolar trauma; because of class III ten-
dency, mesialization in the upper arch was not considered as a viable treatment option. Thus, transplantation of 2 mandibular premolars into the upper incisor
region followed by orthodontic space closure in the lower arch was conceived as the final treatment plan. (B) A clinical view presenting vertical and horizontal
deficiency of alveolar bone and soft tissue.
JOE — Volume 42, Number 12, December 2016
Case Report/Clinical Techniques
were clearly visible on panoramic radiography, transplantation of
mandibular premolars into the upper incisor region was considered.
After the final interdisciplinary consultation, autotransplantation of
the 2 mandibular second premolars into the anterior maxillary re-
gion, following esthetic restoration and orthodontic treatment
after the eruption of canines to correct malocclusion and space
closure in the lower arch, was conceived as the appropriate treatment
plan (10, 24).
Initially, Digital Imaging and Communications in Medicine files
were imported into surgical planning software designed for guided
implant surgery (coDiagnostiX Version 9.6; Dental Wings, Montreal,
Canada). Within the segmentation mode, the right and left second
mandibular premolars were selected as the most suitable donor teeth.
Their segmented stereolithography (STL) files were transferred to the
planning mode (Fig. 2A and B). Furthermore, STL files of scanned
dental models (7 Series dental model and impression scanner, Dental
Wings) and intraoral scans of the jaws (iTero; Align Technology, San
Jose, CA) were imported to fabricate precise surgical templates.
Similar to virtual planning of dental implants, correct angulation,
rotation, and accurate positioning of the donor teeth were predefined
with 2 surgical pins and with the aid of STL files of donor teeth. Their
exact 3D positions were selected in relation to anatomic space and
adjacent dental structures and according to their optimal prosthetic
relationship to teeth in the lower arch to ensure ideal esthetic and
functional restoration after surgical intervention (Fig. 2C–G). In
this case, the narrow ridge, caused by the severe trauma, necessitated
ridge expansion in the buccopalatinal plane. This was virtually
planned using rotatory, piezoelectric, and manual surgical instru-
ments. Technical STL files of piezoelectric instruments (Piezomed In-
struments, Piezomed, W&H Dentalwerk, Buermoos, Austria) and
bone-condensing osteotomes (Ø 2.2-, 2.8-, 3.5-, and 4.2-mm osteo-
tomes [Osteotome instrument kit for bone condensation; Straumann,
Basel, Switzerland]) were imported into planning software to achieve
predefined and precise osteotomies. In addition, preexisting files of
surgical burs and dental implants (Guided Implant Surgery Bone
Level; Straumann, Basel, Switzerland) could be visualized and super-
imposed onto the osteotomy plan to facilitate final treatment planning.
According to virtually preplanned positions and dimensions of donor
teeth, surgical templates for guided osteotomy were designed within
the software (Fig. 2H–K). To ensure precise positioning throughout
surgical intervention, 3 additional surgical templates with attached
segmented teeth were virtually designed, showing the appropriate
occlusal location of each graft (Fig. 2L). Finally, all surgical templates
Guided Autotransplantation of Teeth 1845
Case Report/Clinical Techniques

coDiagnostiX

Figure 2. (A) Visualization of Digital Imaging and Communications in Medicine files showing complete loss of buccal plate in anterior maxilla; within the seg-
mentation mode of the software program, the right and left second mandibular premolars were selected as donor teeth (green color). (B) One pair of donor teeth
was virtually segmented according to existing immature root formation (green color), and 1 pair of donor teeth was virtually modified by implementing soft tissue
formation and the width of the Hertwig epithelial sheath (gray color) from the 3D data set to protect the vulnerable apical structures of the donor teeth during
intervention and to ensure postoperative revascularization and root development. (C) Within the software planning mode, virtual transplantation of donor teeth in
their predefined 3D positions could be performed with the aid of 2 surgical planning pins and importation of the modified STL files of the donor teeth. (D) STL files
of the upper and lower jaws were superimposed with Digital Imaging and Communications in Medicine data in order to visualize soft and hard tissue structures, to
ensure optimal surgical and prosthodontic 3D relationships of donor teeth, and to allow fabrication of precise computer-guided surgical templates. (E) A coronal
slice from the radiographic examination showing a complete loss of the buccal plate and imported STL files of the upper and lower jaws for virtual planning. (F)
Virtual autotransplantation of the second premolar with the aid of an imported STL file of the segmented donor tooth; the illustration presents vertical and horizontal
deficiency of soft and hard tissue in the recipient area. (G) Correct surgical and prosthodontic positioning of donor teeth can be achieved with 2 surgical pins,
comparable with the virtual planning of dental implants, and with the help of virtually preselected and individually segmented donor teeth. (H) An illustration of the
first virtually designed surgical template for guided osteotomy preparations (Ø 2.2 mm). (I) The second surgical template for Ø 2.8-mm guided osteotomies

1846 Strbac et al. JOE — Volume 42, Number 12, December 2016
 Case Report/Clinical Techniques

Figure 3. (A) STL files of all virtually designed surgical templates and models for final 3D printing. (B) 3D printed surgical templates for guided osteotomies (Ø
2.2, 2.8, 3.5, and 4.2 mm). (C) 3D printed supplementary surgical templates with attached donor teeth showing the ideal 3D position of each tooth.

and models were exported as STL files and sent to a 3D printer for
fabrication (Objet260 Connex 3, Material MED610; Stratasys, Minne-
apolis, MN) (Fig. 3A–C).
Surgery was performed under general anesthesia according to
guidelines for autotransplantation with the aid of 3D printed surgical
templates (Supplemental Figures S3–S6 are available online at www.
jendodon.com). The first surgical template with drilling sleeve of Ø
2.3 mm was positioned, and initial preparation was performed with a
guided surgical round bur Ø 1.4 mm marking precise locations for os-
teotomies. To avoid any loss of residual alveolar bone, piezoelectric in-
struments were additionally used (B7, P1, and S2, Piezomed
Instruments) to enlarge initial preparations and to initialize ridge
expansion. The initial osteotome, Ø 2.2 mm, was used manually with
the first surgical template following osteotomy paths and ridge
morphology (Supplemental Figures S7–S12 are available online at
www.jendodon.com). The second and the third surgical template

=
(illustration showing 2 surgical pins from the preplanning procedure). (J) The third surgical template for Ø 3.5-mm safeguard osteotomies (illustration showing 2
planning pins and STL files of donor teeth). (K) The final surgical template for Ø 4.2-mm preplanned osteotomies (illustration showing the superimposed intraoral
scan from the fabrication process of surgical templates). (L) The supplementary template with attached segmented teeth implementing preplanned 3D positions
according to the ideal relationship to anatomic space, adjacent dental structures, and occlusal position.

JOE — Volume 42, Number 12, December 2016 Guided Autotransplantation of Teeth 1847
Case Report/Clinical Techniques
were positioned after Ø 2.8-mm and Ø 3.5-mm safeguarded osteoto-
mies by conserving all remaining bone to its final drilling depths. To
maintain a straight path, the last surgical template was inserted, and final
osteotomies were performed with a Ø 4.2-mm osteotome to preplanned
osteotomy depths (Supplemental Figures S13–S20 are available online
at www.jendodon.com). Supplementary templates with the attached
segmented teeth and 3D tooth replicas were inserted to verify the final
preparation of the recipient site and, where necessary, to slightly spread
buccal and lingual plates by fully conserving osseous tissues
(Supplemental Figures S21–S24 are available online at www.
jendodon.com).
Atraumatic uncovering was performed using surgical elevators to
preserve dental structures of donor teeth. Transplantation was
achieved using diamond-coated forceps placing the grafts into the pre-
planned infraocclusal positions. Initially, both transplanted teeth were
mesially and distally stabilized with sutures, and a nonrigid suture fix-
ation was performed across the occlusal plane to ensure stability after
surgery (Supplemental Figures S25–S31 are available online at www.
jendodon.com).
Oral antibiotics and chlorhexidine mouth rinse were prescribed
for 1 week. Sutures were removed 10 days postoperatively. There
were no postoperative complications, and the healing process was un-
eventful.
Six months after surgery, intraoral scans of the jaws were per-
formed, and composite laminate veneers were virtually designed
(DWOS Crown & Bridge CAD Software, Dental Wings) without need
of surface reduction because they had been preoperatively planned.
The placement of CAD/CAM-processed composite laminate veneers
(S2 Impression, Dental Milling Machines; vhf camfacture, Ammerbuch,
Germany) with adhesive cement (Variolink Esthetic LC; Ivoclar Viva-
dent, Schaan, Liechtenstein) completed the functional and esthetic
rehabilitation (Supplemental Figures S32–S39 are available online at
www.jendodon.com).
At the 12-month follow-up, the patient and his parents were very
satisfied with the functional and esthetic reconstruction. In clinical and
radiologic examinations, the transplanted teeth showed physiological
periodontal parameters and no signs of pathology or root resorption
and responded positively to thermal vital pulp tests (Fig. 4A–C).
Discussion
In recent decades, state-of-the-art dentistry has mainly gained
from newly developed radiologic imaging techniques. Such new devices
do not only improve diagnosis and treatment planning, but they may
also help in developing treatment procedures, such as guided implant
surgery, using templates for an enhanced surgical and prosthodontic
Figure 4. (A) The clinical view of the patient 12 months after autotransplantation. (B) The panoramic radiograph after 12 months showing second premolars
transplanted into the upper incisor regions. (C) The intraoral radiograph at the 12-month recall documenting further root development and obliteration of the
pulp, physiological periodontal ligament space, and lamina dura.
1848 Strbac et al.
approach (25, 26). Currently available software programs alter the
fabrication process of these templates by implementing STL files of
dental models or intraoral scans, reducing scheduling time as well as
treatment costs, and preventing radiation exposure because no
additional radiologic assessment is needed (26–28). These latest
developments, generating precise 3D printed surgical templates, were
customized for the present clinical report to deploy a novel treatment
planning technique, implementing all recommended guidelines and
surgical methods, for a modern approach to autotransplantation.
As proposed in complex cases, tooth replica models fabricated
preoperatively from 3D radiographic imaging should be used as surgi-
cal tooth guides during autotransplantation of immature or mature
grafts to facilitate the preparation process of recipient sites. Addition-
ally, this may reduce the extra-alveolar time of grafts and minimize
the number of fitting attempts, thus preventing injury of vital dental
structures. These latest enhancements in autotransplantation could
improve the success and survival rate by preserving the periodontal lig-
ament and the apical structures of the donor teeth; hence, this could
avoid replacement and inflammatory resorptions of the grafts and
would ensure orthodontic movement of these vital teeth after interven-
tions (2, 16, 21, 29–32). Furthermore, it was also shown recently that
these 3D rapid prototyped teeth may also shorten the general surgical
procedure time in the future (31).
Through our modification of the software program for this new sur-
gical approach, a novel tooth replica model was virtually designed ac-
cording to the immature root formation but additionally including the
development of the Hertwig epithelial sheath. The intention of this adap-
tation process was to avoid iatrogenic damage to the vulnerable apical
structures and press-fit compressions, especially to the apical part dur-
ing surgery, thus ensuring vital grafts with postoperative revasculariza-
tion of the pulp and continuous root development, consequently
reducing future postoperative endodontic treatments (1, 14–16, 33).
This approach not only allows for a selection of the most suitable
donor tooth according to tooth morphology and root development but
may also show the ideal 3D position and the required dimensions of the
new alveolus during surgery. Moreover, if there is inadequate space
during the planning process on the mesial and distal side of the graft,
an orthodontic space opening could be performed before surgery to
prevent stripping of dental structures. Consequently, 1- or 2-stage pro-
cedures could be achieved with this approach (14, 15, 21, 24).
Occlusal interference, causing jiggling contacts between donor teeth
and opposing teeth, could also be avoided, and infraocclusal position
and physiological mobility placement could be planned before
intervention (2, 14, 24). By importing STL files of the jaws and
superimposing them with the radiographic data set, the adapted
planning process allows for the donor tooth to be positioned as an
JOE — Volume 42, Number 12, December 2016
ORAL AND MAXILLOFACIAL RADIOLOGY
670 Shahbazian et al.
Fig. 4. A, Stereolithographic tooth replica and surgical guides
fabrication according to segmentation of the donor tooth,
recipient site and B, study model.
procedure began with the preparation of the socket in
the recipient area (open procedure). The surgical guides
and replica were used for proper shaping of the recipient
site. The first step allowed preparation of the recipient
site by using the stereolithographic drill guide and tooth
replica for a matching socket preparation (Figure 5).
After preparation of the recipient region, the donor
tooth was carefully extracted avoiding injury to the
periodontal ligament, and then it was immediately
reimplanted in the recipient site. The extra-alveolar time
of the donor tooth was monitored as well as the number
of repositioning attempts and total surgery time. Any
surgical complications were recorded as well. The
follicle was, if possible, kept intact when the tooth germ
was transplanted. All donor teeth were placed in
infraocclusion position to avoid any occlusal interfer-
ence during the first few weeks after surgery. Almost all
transplants were initially stabilized with splints.
Splinting was carried out with a flexible orthodontic
wire, which was attached using composite to the buccal
surfaces of the transplanted and adjacent teeth.
All patients were prescribed antibiotics for 1 week
postoperatively.
OOOO
May 2013
Fig. 5. Preparation of recipient site in tooth auto-
transplantation; A, guide adjustment; B, preparation of
recipient area with bur and drilling guide; C, tooth replica in
position.
Postoperative clinical and radiographic assessment
In the control group the clinical and radiographic
information were collected from the medical records of
the patients and in the last follow-up examination
clinical and radiographic evaluation (CBCT imaging)
were performed.
In the study group the postoperative clinical and
radiographic examination included periapical radio-
graphs at 1, 4-6 and 12 months postoperative and
CBCT 1 year after surgery. As a part of the clinical
evaluation of the transplanted teeth, the following