Exposure and Bracketing of 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 “Impacted Wisdom Teeth” under Procedures). Since there is rarely a functional need for these wisdom teeth, they are usually extracted if they develop problems.
Any tooth in the mouth can fail to erupt and may require treatment. The maxillary cuspids (upper eye teeth or canines) are the second most common teeth to be impacted. The cuspid tooth is a critical tooth in the dental arch and plays an important role in your “bite”. The cuspid teeth are very strong biting teeth which have the longest roots of any tooth in your mouth. 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 tight 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 teeth. 60% of these impacted eye teeth are located in 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 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 eye tooth will not erupt by nature’s forces alone. The American Association of Orthodontists recommends that a panorex radiograph and dental examination be performed on all dental patients at around the age of 7 years. This is to count the teeth and determine if there are problems with eruption of the adult teeth. The exam is usually performed by your general dentist who will refer you to an orthodontist if a problem is identified.
Treating such problems may involve an orthodontist placing braces to open spaces to allow for proper eruption of the adult 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 important canine teeth. The oral surgeon may also need to remove any extra teeth (supernumerary teeth) that are blocking tooth eruption.
By clearing the eruption path, there is a good chance the impacted canine tooth will erupt naturally. However, if the canine still does not erupt on its own (ages 13-14), then it may require assistance. In older patients, 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 erupt it into place. The only option at this point is to extract the impacted tooth and consider alternate replacement options (close the space orthodontically or a dental implant).
The orthodontist and oral surgeon will work together to get these impacted canine teeth to erupt. An orthodontist will place braces on the teeth. Then, the orthodontist will refer the patient to the oral surgeon to have the impacted tooth exposed and bracketed.
This is a relatively simple surgical procedure performed in our office. The gum on top of the impacted tooth will be lifted up to expose the hidden tooth underneath. Any baby teeth present may be removed at the same time. Once the tooth is exposed, the oral surgeon will bond a special orthodontic bracket to the exposed tooth. The bracket will have a thin chain attached to it. The oral surgeon will attach the chain back to the orthodontic arch wire.
Shortly after surgery the patient will return to the orthodontist. An elastic band will be attached to the chain to begin pulling on the impacted tooth. This is a carefully controlled, slow process that usually at least 6 months to complete. In some circumstances, especially those where the tooth was moved a long distance, there may be some minor “gum surgery” required. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation. On rare occasions the impacted tooth cannot be moved because it has fused to the surrounding bone known as ankylosis. If this occurs it will likely need to be removed.