Impacted Teeth

Impacted Teeth: Exposure & Bonding

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. Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspid (upper eyetooth) is the second most common tooth to become impacted. The cuspid tooth is a critical tooth in the dental arch. The cuspid 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 cuspid teeth are the last of the “front” teeth to erupt into place. They usually come into place around age 13 and cause any space left between the upper front teeth to close tighter together. If a cuspid 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 cuspid (upper eye) teeth. Sixty percent of these impacted eyeteeth 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 Of Impacted Eye Teeth Is The Key To Successful Treatment

The older the patient, the more likely an impacted canine will not erupt spontaneously even if 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 all the adult teeth are present. Your general dentist usually performs this exam 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 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 canine teeth. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any of the adult teeth. If the eruption path is cleared and the space is opened up by age 11-12, there is a good chance the impacted eyetooth will erupt spontaneously. If the canine is allowed to develop too much (age 13-14), the impacted eyetooth 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 usually not respond to orthodontic attempts to facilitate eruption. 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 Eye Tooth Will Not Erupt When Proper Space Is Available?

In cases where the eyeteeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these “unerupted canines” 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 eyetooth 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 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 (on selected cases located on the roof of the mouth). 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 (1-14 days) 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.

Why Expose and Bond?

Normally all permanent teeth have erupted by the early teenage years. Occasionally, some teeth do not make it all the way into the mouth and become impacted, or stuck in the jaw. When this occurs it is important to guide these teeth into the mouth or they will be permanently impacted. This condition occurs most frequently in the upper cuspids but could occur in any location. In addition to wanting all teeth in the mouth for function and aesthetics, leaving a tooth impacted can lead to resorption of adjacent teeth and the development of cysts and tumors. Bringing the tooth into the mouth is extremely important.

What's Involved?

An impacted tooth can have a bracket-bonded attachment applied enabling the orthodontist to guide the tooth safely into the mouth. The patient can be either awake or asleep depending upon the desires of the patient and complexity of the procedure. The tooth is exposed and the bracket is bonded just as normal orthodontic brackets are bonded to the front surface of the tooth. The bracket typically has a gold chain attached to it, which will be brought out of the gum tissue and tied to the adjacent orthodontic appliances. After healing, the patient returns to the orthodontist for traction on the gold chain to guide the tooth into the mouth. Depending on the depth of impaction, the tooth is often erupting in just a few months. On rare occasions, the impacted tooth will be "ankylosed" (fused with the bone and rendering it totally immobile) but the tooth is brought into the mouth successfully in over 97% of the cases.

Your Recovery

After the bonding procedure, the gums around the bonded tooth will be tender and chewing should be avoided in this area. Healing normally progresses rapidly and pain medicine is only required the first 24-48 hours. If sutures are required, we often use the kind that dissolves which means you would not need to return for follow up visits. As always, we welcome post-operative questions or calls and we are happy to see you anytime a question arises.