Generally, an impacted tooth means that it is “stuck” and can not fully erupt into function in the mouth. Impacted third molar teeth (commonly known as wisdom teeth) are frequent problems that we see with our patients. These molars will get “stuck” in the back of the jaw and can eventually develop painful infections, as well as a variety of other problems (see “Impacted wisdom teeth” under Procedures). Wisdom teeth are teeth that typically serve no purpose, so it’s not uncommon for them to be extracted. The second most common tooth to become impacted is the maxillary cuspid (upper eye tooth). The cuspid tooth plays an important role in your “bite” and is also critical to the dental arch. The cuspid teeth are very strong biting teeth which have the longest roots of any human tooth, and 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.
The maxillary cuspid teeth are usually the last of the “front” teeth to appear in place. They can be expected to come into place around age 13 and will cause any space left between the upper front teeth to close tightly together. If a cuspid tooth becomes impacted, we make every effort to get it to appear in its proper position in the dental arch. The techniques involved to aid this process 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. 60% of these impacted eye teeth are located on the palatal (roof of the mouth) side of the dental arch. The impacted teeth that remain are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.
Early recognition of impacted eye teeth is the key to successful treatment
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. 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, so it is important to determine whether all the adult teeth are present or if some of the adult teeth are missing. It can also be determined if there are extra teeth present or unusual growths that are blocking the eruption of the eye tooth. Additionally, you can also then determine if there is extreme crowding or too little space available causing an eruption problem with the eye tooth. This particular exam is typically performed by your general dentist or hygienist who can then refer you to an orthodontist if a problem is uncovered. Treatments for this range from being seen by an orthodontist who can place braces on the teeth to open up spaces to allow for the proper eruption of the adult teeth. You may also be referred to an oral surgeon for the extraction of any over retained baby teeth and/or selected adult teeth that are blocking the eruption of the all important eye teeth. If needed, the oral surgeon can also remove any extra teeth (supernumerary teeth) or growths that are blocking the eruption of any of the adult teeth. If you clear the eruption path and the space is opened up by age 11 or 12, there is a higher likelihood that the impacted eye tooth will erupt with nature’s help alone. If the eye tooth is allowed to develop too much (by age 13 or 14), the impacted eye tooth will likely not erupt by itself even with the space cleared for its eruption. If the patient is too old (over the age of 40), there is a much higher chance the tooth will be fused in position. In these particular cases the tooth will not move despite all the efforts of the oral surgeon and orthodontist to erupt it into place. Unfortunately, the only feasible option at this point is to extract the impacted tooth and consider an alternative treatment plan 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 the particular cases where the eye teeth will not erupt by themselves, the oral surgeon and orthodontist will make it a team effort to get these unerupted eye teeth to erupt. Each individual case must be evaluated based on their own specific needs, but treatment will typically involve a collaborative effort between the oral surgeon and the orthodontist. The most likely scenario for treatment will be for the orthodontist to place braces on the teeth (or at least on the upper arch). Then, a necessary space will be opened up in order to provide the room needed for the impacted tooth to be successfully moved into its proper 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 then refer the patient to the oral surgeon to have the impacted eye tooth exposed and bracketed.
In a simple surgical procedure performed right in the surgeon’s office, the gum that appears on top of the impacted tooth will then be lifted up to expose the hidden tooth underneath. If indeed 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 by taking a small gold chain and attaching it to it. The oral surgeon will then carefully guide the chain back to the orthodontic arch wire where he will temporarily attach it. Occasionally the oral 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.
Soon after surgery (within 1 to 14 days) the patient will return to the orthodontist, where then a rubber band will then be attached to the chain to put a small eruptive pulling force on the impacted tooth, which can then begin the process of moving the tooth up into its proper place in the dental arch. This process is a carefully controlled, slow methodical process that may take up to a year to fully complete. Keep in mind that the goal is to erupt the impacted tooth and to not to extract it. Once it is clear that the tooth has moved into the arch in its final position, the gum around it will then be evaluated to be certain that it is sufficiently strong and healthy in order for it to last a lifetime of tooth brushing and chewing. In certain circumstances, especially those situations where the tooth has to be moved a long distance, there may be some minor gum surgery that is required to add bulk to the gum tissue over the relocated tooth so it remains healthy while it functions normally. If this particular procedure is needed, your dentist or orthodontist can fully explain it to you if it applies to your specific situation.
These simple principals can always be adapted to apply to any impacted tooth in the mouth. It’s not that uncommon for both of the maxillary cuspids to be impacted. In these particular cases, the space in the dental arch form will be prepared on both sides at the same time. When the orthodontist is ready, the surgeon will expose and bracket both teeth in the same visit so the patient has to recover from only one surgery. Since the anterior teeth (cuspids and incisors) and the bicuspid teeth are small and have single roots, they are much more simple to erupt if they become impacted than the posterior molar teeth. The bigger molar teeth have multiple roots making them more difficult to move, since the orthodontic procedures that are needed to manipulate an impacted molar tooth can be far more complicated because of their specific location in the back of the dental arch.
Several recent studies have revealed that with early detection of impacted eye teeth (or any other impacted tooth other than wisdom teeth), treatment should begin 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 it was discussed 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 the eruption of the developing adult teeth. Lastly, he may be asked to expose an impacted eye tooth without attaching a bracket and chain to it because in reality, this is a much easier surgical procedure to perform than having to expose and bracket the impacted tooth. This will then encourage some eruption to occur before the tooth becomes completely impacted. 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 just enough that the orthodontist can then safely bond a bracket to it and move it into place without needing to force its eruption. Ultimately, this saves the patient time and also means less time having to be spent in braces.
What to expect from surgery to expose & 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 surgeon’s office. For the majority of patients, it is performed by using laughing gas and a local anesthesia, but can also be performed under I.V. sedation if the patient desires to be completely asleep. However, I.V. sedation is typically not necessary as this is a fairly simple procedure. It typically takes about 75 minutes to complete the procedure if one tooth is being exposed and bracketed, and around 105 minutes if both sides require treatment. If the procedure only requires exposing the tooth with no bracketing, the time required will be cut in half. These issues 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 these details, as well.
You can expect a limited amount of bleeding from the surgical sites once the surgery is complete. Although there will likely be some discomfort experienced after surgery at the surgical sites, most patients find Tylenol or Advil to be sufficient to manage any pain they are experiencing. Swelling from holding the lip up to visualize the surgical site can be minimized by applying ice packs after the surgery. Bruising is uncommon. We initially recommend a soft, bland diet at first, but you may resume your normal diet as soon as you feel comfortable chewing. To avoid irritating the surgical site, we advise that you avoid sharp food items like crackers and chips since they might end up jabbing the wound during the healing process. It’s likely that your doctor will see you within seven to ten days after surgery to evaluate the healing process and make sure that you are maintaining good oral hygiene. You should also plan to see your orthodontist within 1 to 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 at the office or can be paged after hours if any problems should arise after surgery. Call Dr. Reisman at (303) 665-2377 if you have any questions or concerns that need to be addressed.