Exposure and Bracketing of an Impacted Tooth
An impacted tooth simply means that it is “stuck” and can not erupt into function. Patients frequently develop problems with impacted third molar (wisdom) teeth (see “Impacted Canines” under Services). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspid (upper eye tooth) is the second most common tooth to become impacted. The cuspid tooth is a critical tooth in the dental arch and plays an important role in your “bite”.
Normally, the maxillary cuspid teeth are the last of the “front” teeth to erupt into place, usually around age 13. 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.
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 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 7 years old to count the teeth and determine if there are problems with eruption of the adult teeth. 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 also 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. If the eruption path is cleared and the space is opened up by age 11 or 12, there is a good chance the impacted eye tooth will erupt with nature’s help alone. If the eye tooth is allowed to develop too much (age 13-14), the impacted eye tooth 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 erupt it 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 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 work together to get these unerupted eye teeth to erupt. 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. 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. (These basic principals can be adapted to apply to any impacted tooth in the mouth).
What to expect from surgery to expose and bracket an impacted tooth:
The surgery to expose and bracket an impacted tooth is a very straight forward surgical procedure that is performed in the oral surgeonâ’s office. This procedure is usually performed under IV sedation, however, laughing gas and local anesthesia may be used in some cases. This will be discussed in detail at your preoperative consultation with your doctor. You can also refer to “Preoperative instructions” under Surgical Instructions on this web site for a review of any details.
You can expect a limited amount of bleeding from the surgical sites after surgery. Although there will be some discomfort after surgery at the surgical sites, most patients find Tylenol or Advil to be more than adequate to manage any pain they may have. Your doctor may see you 7-10 days after surgery to evaluate the healing process. You should plan to see your orthodontist within 1-14 days to activate the eruption process by applying the proper rubber band to the chain on your tooth.