Impacted Teeth

What are impacted teeth?

An impacted tooth simply means that it is positioned incorrectly under the gum tissue or in the bone 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).

Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspid (canine or eye tooth) is the second most common tooth to become impacted. Cuspids are critical in the dental arch and play an important role in your bite. They are very strong biting teeth which 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 together. If a cuspid tooth  remains impacted, every effort is made to get it to erupt into its proper position in the dental arch.

Early recognition of impacted cuspid teeth is the key to successful treatment

The older the patient, the more likely an impacted eye tooth will not erupt by natures 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 to count the teeth and determine if there are problems with eruption of the adult teeth.

At this early age it is important to determine whether all the adult teeth are developing appropriately or whether some adult teeth missing. Are there extra teeth present or unusual growths 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 problems 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 retained baby teeth, teeth that are blocking eruption of the important cuspid (eye) teeth or for removal of any extra teeth (supernumerary teeth) or growths that are blocking eruption of the adult 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 cuspid (eye) tooth will erupt with nature’s help alone. If the cuspid tooth remains impacted into the mid or late teenage years, it is unlikely to come in by itself even with sufficient space cleared for its eruption. Once development of tooth is complete, there is a much higher chance the tooth will be fused (ankylosed) in the inappropriate 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 (dental implants and crown and bridge restorations)

What can be done if a tooth is delayed in it’s eruption?

In cases where teeth will not erupt spontaneously, the orthodontist and oral surgeon work together to achieve a successful outcome. Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral surgeon. Treatment will be customized for individual needs and circumstances but the most common scenario will call for the orthodontist to place braces on the teeth and open (optimal space for the impacted tooth to be moved into proper position. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eye tooth exposed and bracketed. When the space is optimal, the oral surgeon will perform the “expose and bond” procedure.

Through a small incision in the gum tissue, the surgeon will expose the hidden tooth and bond an special orthodontic bracket to it. From the surface of the bracket extends a miniature gold chain which is temporarily attached to the orthodontic arch wire.

Shortly after surgery (1-14 days) the patient will return to the orthodontist who will utilize the chain to 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 technique, often called forced or directed eruption, is a carefully controlled process that may take up to a full year to complete.

Exposure and Bracketing of an Impacted Cuspid

These basic principals can be adapted to apply to any impacted tooth in the mouth. It is not that uncommon for both of the upper 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. If your dentist or hygienist identifies a potential eruption problem, you should be evaluated by an orthodontist as soon as possible. Recent studies have revealed that outcomes are improved if treatment is initiated early. 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. He will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth. Finally, he 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). If delayed eruption is discovered early enough, the surgeon may be asked to simply uncover the problematic tooth (without bonding the bracket) to initiate the eruption process. Early intervention may save time, money, extra surgical procedures and time in braces.

What to expect with an expose and bond surgical procedure

The surgery is accomplished in the surgeon’s office under local anesthesia and IV sedation and takes one to two hours to complete. The procedure is generally scheduled for 60 minutes if one tooth is being exposed and bracketed. Details will be discussed at your preoperative consultation with your surgeon. You can also refer to Preoperative instructions under Surgical Instructions on this web site for a review of any details.

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