Exposure and Bracketing of an Impacted Tooth

An impacted tooth simply means that it is “stuck” and can’t erupt into function. Patients frequently develop problems with impacted third molar (wisdom) teeth. These teeth get “stuck” in the back of the jaw and can develop painful infections among a host of other problems (see “Impacted wisdom teeth” under Procedures). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary canine (upper eye tooth) is the second most common tooth to become impacted. The canine tooth is a critical tooth in the dental arch and plays an important role in your “bite”. The canine teeth are very strong biting teeth which have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together, guiding the jaws and the other teeth into position.

Normally, the maxillary canine teeth are the last of the “front” teeth to erupt into place. They usually come into place around age 10 to 12, and cause any space left between the upper front teeth to close tightly together. If a canine tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch. The techniques involved to aid eruption can be applied to any impacted tooth in the upper or lower jaw, but most commonly they are applied to the maxillary canine teeth.

Early recognition of impacted canines is the key to successful treatment:

The older the patient, the more likely an impacted canine tooth will not erupt by nature’s forces alone, even if the space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends that a panorex screening x-ray along with a dental examination be performed on all dental patients at around the age of seven years to count the teeth and determine if there are problems with eruption of the adult teeth. It is important to determine whether or not all the adult teeth are present and erupting properly. Are there extra teeth present or unusual growths that are blocking the eruption of the canine tooth? Is there severe crowding or too little space available causing an eruption problem with the canine tooth? This exam is usually performed by your general dentist or hygienist who will refer you to an orthodontist if a problem is identified. Treating such a problem may involve an orthodontist placing braces to open up spaces wide enough to allow proper eruption of the adult canine teeth. Treatment may also require a referral to an oral surgeon for extraction of retained baby teeth and/or selected adult teeth that are blocking the eruption of the all-important canine. The oral surgeon may also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of adult teeth. If the eruption path is cleared and the space is opened up by age 11 or 12, there is a good chance the impacted canine will erupt with nature’s help alone. If the eye tooth is allowed to develop for too long (age 13-14), the impacted eye tooth may not erupt by itself even after space is cleared for its eruption.

What happens if the canine tooth will not erupt when proper space is available?

In cases where the canine teeth will not erupt on their own, the orthodontist and oral and maxillofacial surgeon work together to get these canine teeth to erupt. Each case must be evaluated on an individual basis, but treatment will usually involve a combined effort between the orthodontist and the oral surgeon. The most common scenario will call for the orthodontist to place braces on the teeth. A space will be opened to provide room for the impacted tooth to be moved into its proper position in the dental arch. If the baby canine tooth has not fallen out already, it is usually left in place until the space for the adult canine tooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted canine tooth exposed and possibly bracketed.

In a simple surgical procedure performed in the surgeon’s office, the gum on top of the impacted tooth will be lifted up to expose the hidden tooth underneath. If there is a baby tooth present, it will be removed at the same time. Once the tooth is exposed, the oral surgeon will often bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature gold chain attached to it. The oral surgeon will guide the chain back to the orthodontic arch wire where it will be temporarily attached. Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth. Most of the time, the gum will be returned to its original location and sutured back with only the chain remaining visible as it exits a small hole in the gum.

Shortly after surgery, the patient will return to the orthodontist. A rubber band will be attached to the chain to put a light eruptive pulling force on the impacted tooth. This will begin the process of moving the tooth into its proper place in the dental arch. This is a carefully controlled, slow process that may take up to a full year to complete. Remember, the goal is to erupt the impacted tooth and not to extract it! Once the tooth is moved into the arch in its final position, the gum around it will be evaluated to make sure it is sufficiently strong and healthy to last for a lifetime of chewing and tooth brushing. In some circumstances, especially those where the tooth had to be moved a long distance, there may be some minor “gum surgery” required to add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.

These basic principals can be adapted to apply to any impacted tooth in the mouth. It is not that uncommon for both of the maxillary cuspids to be impacted. In these cases, the space in the dental arch will be prepared on both sides at once. When the orthodontist is ready, the surgeon will expose and often bracket both teeth in the same visit so the patient only has to heal from surgery once. Because the anterior teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, they are easier to erupt if they get impacted than the posterior molar teeth. The molar teeth are much bigger teeth and have multiple roots making them more difficult to move. The orthodontic maneuvers needed to manipulate an impacted molar tooth can be more complicated because of their location in the back of the dental arch.

Recent studies have revealed that with early identification of impacted canine teeth (or any other impacted tooth other than wisdom teeth), treatment that is initiated at a younger age may be more predictable. Once the general dentist or hygienist identifies a potential eruption problem, the patient should be referred to the orthodontist for early evaluation. In some cases, the patient will be sent to the oral surgeon before braces are even applied to the teeth. As mentioned earlier, the surgeon will be asked to remove retained baby teeth and/or selected adult teeth. He/She will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth. Finally, he/she may be asked to simply expose an impacted eye tooth without attaching a bracket and chain to it.

What to expect from surgery to expose and bracket an impacted tooth:

The surgery to expose and bracket an impacted tooth is a straightforward procedure that is performed in the oral surgeon’s office. For most patients, it is performed with under I.V. sedation, but this is not always necessary.

You can expect slow bleeding or blood-tinged saliva for 12-24 hours after surgery. Although there will be some discomfort after surgery at the surgical sites, most patients find Tylenol or Advil to be adequate to manage any pain they may have. Within 2-3 days after surgery, there is usually little need for any medication at all. There may be some swelling, but this can be minimized by applying ice packs to the lip for the afternoon after surgery. A soft, bland diet is recommended at first, but you may resume your normal diet as soon as you feel comfortable chewing. It is advised that you avoid sharp food items like crackers and chips as they can irritate the surgical site during initial healing. Your doctor will see you 7-10 days after surgery to evaluate the healing process and make sure you are maintaining good oral hygiene. You should plan to see your orthodontist to apply the proper rubber band to the chain on your tooth if applicable. As always your doctor is available at the office or can be reached after hours if any problems should arise after surgery. Simply call Davis OMFS at (530) 753-0550 if you have any questions.