Exposure of Impacted Teeth
What is an impacted tooth?
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 Wisdom Teeth under Procedures). 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 and plays an important role in your “bite”. 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. 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 eye teeth 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 are stuck in an elevated position above the roots of the adjacent teeth, or are 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 eye tooth will not erupt by natural forces alone, even if the space is available for the tooth to fit in the dental arch. A panoramic x-ray, along with a dental examination, will help determine whether all the adult teeth are present or if some adult teeth are missing. It is important to determine whether all the adult teeth are present or are some adult teeth missing. Are there extra teeth present or unusual growth that are blocking the eruption of the eye tooth? Is there extreme crowding or too little space available causing an eruption problem with the eye 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 spaces to allow for proper eruption of the adult teeth.
Treatment may require a 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 eye teeth. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking the eruption of any adult teeth.
Impacted tooth success by patient’s age:
- 11-12 years old – with space opened for eruption, good chance for success.
- 13-14 years old – the impacted eyetooth will not erupt by itself, even with the space cleared for its eruption.
- Over 40 years old – much higher chance that 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 erupt it into place. The only option is to extract the impacted tooth and replace it with a 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 eye teeth will not erupt spontaneously, the orthodontist and oral surgeon will work together to get these 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 (at least in the upper arch). A space will be opened to provide room for the impacted tooth to be moved into its position in the dental arch. If the baby eye tooth has not fallen out already, it is usually left in place until the space for the adult eye tooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eye tooth 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.
The goal is to erupt the impacted tooth and not to extract it. Once the tooth has moved into 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 a brushing. In some circumstances, there may be some minor “gum surgery” required to add bulk to the gum over the relocated tooth so it remains healthy during normal function. Your 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 form 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. 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.
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. For most patients, it is performed using laughing gas and local anesthesia. In selected cases it will be performed under IV sedation if the patient desires to be asleep, but this is generally not necessary for this procedure. If the procedure only requires exposing the tooth with no bracketing, the time required will be shortened by about one half. These issues will be discussed in detail at your preoperative consultation with your doctor.