An impacted tooth simply means that it is “stuck” and cannot 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 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 and have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together so they guide the rest of the teeth into the proper bite.
Normally, the maxillary canine teeth are the last of the “front” teeth to erupt into place. They usually come into place around the age of 11 or 12 and cause any space left between the upper front teeth to close together. If a canine tooth gets impacted, every effort is made to help 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. Ninety percent of these impacted canines are located on the palatal (roof of the mouth) side of the dental arch. The remaining impacted eye teeth are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.
Early Recognition Is The Key To Successful Treatment
The older the patient, the more likely an impacted canine 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 around the age of seven years to count the teeth and determine if there may be problems with eruption of the adult teeth. It is important to determine whether all the adult teeth are present or are some adult teeth are missing. Are there extra teeth present or unusual growths that are blocking the eruption of the canine? Is there extreme crowding or too little space available causing an eruption problem with the canine? This exam is usually performed by your general dentist who will refer you to an orthodontist if a problem is identified. Treating such a problem may involve an orthodontist placing braces to open spaces to allow for proper eruption of the adult teeth. Treatment may also require referral to an oral surgeon for extraction of over-retained baby teeth and/or selected adult teeth that are blocking the eruption of the all-important canines. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking the eruption of any of the adult teeth. If the eruption path is cleared and space is opened up by age 11-12, there is a good chance the impacted canine will erupt with nature’s help alone. If the canine is allowed to develop too much (age 13-14), the impacted canine will not erupt by itself even with the space cleared for its eruption. If the patient is too old (over 40), there is a much higher chance the tooth will be fused in position. In these cases, the tooth will not budge despite all the efforts of the orthodontist and oral surgeon to help it erupt into place. Sadly, the only option at this point is to extract the impacted tooth and consider an alternate treatment to replace it in the dental arch (crown on a dental implant or a fixed bridge).
What Happens If The Canine Will Not Erupt When Proper Space Is Available?
In cases where the canines will not erupt spontaneously, the orthodontist and oral surgeon work together to help these unerupted eyeteeth 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 (at least the upper arch). 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 has not fallen out already, it is usually left in place until the space for the adult canine is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted canine exposed and 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 bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature chain attached to it. The oral surgeon will attach the chain to the orthodontic arch wire with a suture or wire. Sometimes the surgeon will leave the now exposed impacted tooth completely uncovered by suturing the gum up high above the tooth or by 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.
Seven to fourteen days after surgery, the patient will return to the orthodontist. An elastic 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 several months to complete. Once the tooth has moved into the arch to its final position, the gum around it will be evaluated to make sure it is sufficiently strong and healthy to withstand 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.
Exposure and Bracketing of an Impacted Cuspid
These basic principles can be adapted to apply to any impacted tooth in the mouth. It is not that uncommon for both of the maxillary canines 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 bracket both teeth in the same visit so the patient only has to heal from surgery once.
Recent studies have revealed that with early identification of impacted canines (or any other impacted teeth other than wisdom teeth), treatment should be initiated. Once the general dentist 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 over-retained baby teeth and/or selected adult teeth. He will also remove any extra teeth or growths that are blocking the eruption of the developing adult teeth. Finally, he may be asked to simply expose an impacted canine without attaching a bracket and chain. This will hopefully encourage some eruption to occur before the tooth becomes totally impacted. By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the canine may have erupted enough that the orthodontist can bond a bracket to it and move it into place without needing to force its eruption. In the long run, this saves time for the patient and means less time in braces (always a plus for any patient!).
What To Expect From Surgery To Expose & Bracket An Impacted Tooth
The surgery to expose and bracket an impacted tooth is a very straightforward surgical procedure that is performed in the oral surgeon’s office. It is performed using laughing gas and local anesthesia or under IV anesthesia if the patient desires to be sedated. These options will be discussed in detail during your preoperative consultation with your doctor.
Please click here if you are interested in reviewing the post-operative instructions and learning more about what to expect after the procedure to expose and bracket an impacted tooth. As always, please notify the office if you have any questions or concerns.
Click here for Instructions for Exposure of An Impacted Tooth