Impacted Canines

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 “Oral Surgery”). 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 one front teeth to erupt into place. They usually come into place around age 13 and cause any space left between the upper front teeth 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 commonly they applied to the maxillary cuspid teeth. 60% 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 or out to the facial side of the dental arch.

Early recognition of the impacted eye teeth is key in to a successful treatment; The older the patient, the more likely the impacted eye tooth will not erupt by nature’s forces alone. The American Association of Orthodontists recommends that patient at the 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 exams are usually 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 and extra teeth (supernumerary teeth) or growths are blocking tooth eruption.

By clearing the eruption path, the space is opened up by the age 11 or 12 and there is a good chance the impacted tooth canine tooth will erupt naturally. However, if the canine is allowed to develop further ages (13-14) it may not erupt by itself and requires assistance (See Below). 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 an alternate replacement options (crown on a dental implant or a fixed bridge).

What happens if the canine tooth will not erupt when the proper space is available?

The orthodontist and oral surgeon will work together to get these impacted canine teeth to erupt. The most common scenario will call for the orthodontist to place braces on the teeth. A space will be opened to provide room for the impacted tooth to move 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. 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.

Once the tooth (teeth) is/are 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.

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. Recent studies have revealed that with early identification of impacted eye teeth (or any other impacted tooth other than wisdom teeth); treatment should be initiated at a younger age. Once the general dentist or hygienist 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 and will also remove any extra teeth or growths that are blocking eruption of the developing. Finally, the surgeon may be asked to simply expose an impacted eye tooth without attaching a bracket and chain to it. In reality, this is an easier surgical procedure to perform than having to expose and bracket the impacted tooth. This will encourage some eruption to occur before the tooth becomes totally impacted (stuck). By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the eye tooth will 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 expose and bracket an impacted tooth surgery?

The surgery to expose and bracket an impacted tooth is a very straight forward surgical procedure that is performed in the oral surgeon’s office. For most patients, it is performed with laughing gas and local anesthesia. In selected cases, it will be performed under I.V. sedation, if the patient desires to be asleep, but this is generally not necessary for this procedure. The procedure is generally scheduled for 30 minutes for one tooth being exposed and bracketed, whereas 45 minutes if both sides require treatment. 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.

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. Within 2-3 days after surgery, there is usually little need for any medication at all. There may be some swelling from holding the lip up to visualize the surgical site; it can be minimized by applying ice packs to the lip for the afternoon after surgery. Bruising is not a common finding after these cases.

A soft, bland diet is recommended at first, but you may resume your normal diet as soon as you feel comfortable chewing. It is advised that you avoid sharp food items like crackers and chips, as they will irritate the surgical site if they jab the wound during initial healing. Your doctor will see you 7-10 days after surgery to evaluate the healing process and make sure you are maintaining good oral hygiene.

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. As always, your doctor is available if any problems should arise after surgery. Simply call our office if you have any questions.