An impacted tooth simply means that it is “stuck” in the jawbone and cannot erupt properly. 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 or other problems (see Impacted Wisdom Teeth under Procedures). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary cuspids (upper eyeteeth) are the second most common teeth to become impacted. They are critical to the dental arch and play an important role in your “bite.” The cuspid teeth are very strong biting teeth and have the longest roots of any human teeth. They are designed to be the first teeth that touch when your jaws close together, and a a result, 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 tighter 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 (upper eye) teeth. Sixty percent of these impacted cuspids are located on the palatal (roof of the mouth) side of the dental arch. The remainder are in the middle of the supporting bone but stuck in an elevated position above the roots of adjacent teeth or out to the facial side of the dental arch.
Early Recognition Of Impacted Cuspids Is The Key To Successful Treatment
The older the patient, the more likely an impacted cuspid will not erupt by nature’s forces alone, even if 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 around the age of seven years 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. It is important to determine whether all the adult teeth are present. On occasion, extra teeth or unusual growths may block the eruption of the cuspids. Extreme crowding or insufficient space can also cause an eruption problem. Treating such a problem may involve an orthodontist placing braces to open space for proper eruption of adult teeth. Treatment may also require referral to an oral surgeon for extraction of over-retained baby teeth and/or selected adult teeth that are blocking the eruption of the cuspids. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths. If the eruption path is cleared and the space is opened up by age 11-12, there is a good chance the impacted cuspids will erupt with nature’s help alone. If the cuspids are allowed to develop too much (age 13-14), they will not erupt on their own, even with adequate space. 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 Cuspid Will Not Erupt When Proper Space Is Available?
In cases where the cuspid will not erupt spontaneously, the orthodontist and oral surgeon work together to achieve eruption. Each case must be evaluated on an individual basis, but treatment will usually involve a combined effort between the orthodontist and the oral surgeon. 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. If the baby cuspid has not fallen out already, it is usually left in place until the space for the adult cuspid is ready. The patient is then referred to the oral surgeon to have the impacted cuspid 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 tooth. The bracket will have a miniature 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 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 its final position, the surrounding gum 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.
Exposure and Bracketing of an Impacted Cuspid
These basic principals can be adapted to any impacted tooth in the mouth. It is not 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. 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. Because the anterior teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, they are easier to erupt than the posterior molar teeth. The molar teeth are much larger and have multiple roots making them more difficult to move. 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 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. The oral surgeon may simply expose an impacted tooth without attaching a bracket and chain to it. 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 cuspid 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 means less time 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 straightforward surgical procedure that is performed in the oral surgeon’s office. For most patients, it is performed using laughing gas and local anesthesia. In selected cases it will be performed under IV sedation if the patient desires to be asleep, but this is generally not necessary. The procedure is generally scheduled for 75 minutes if one tooth is being exposed and bracketed and 105 minutes if both sides require treatment. These issues will be discussed in detail at your preoperative consultation. You can also refer to Preoperative Instructions under Surgical Instructions on this website 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, most patients find Tylenol or Advil to be more than adequate to manage any pain they may have. Within two to three days after surgery there is usually little need for any medication at all. Swelling can be minimized by applying ice packs to the lip after surgery. Bruising is not a common finding at all 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 seven to ten 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.