Exposure of an Impacted Tooth
IMPACTED TOOTH/TEETH, FRISCO, TX, ORAL SURGEON, Dr. Mark Davis
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. 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 Procedures). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary canine (upper eye tooth) is the second most common tooth to become impacted. The canine tooth is a critical tooth in the dental arch and plays an important role in your bite. The canine teeth 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 upper canine 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 tight together. If a canine tooth becomes impacted (stuck), every effort is made to help 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 canine (upper eye) teeth. About 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 but stuck in a position above the roots of the adjacent teeth or out to the lip side of the dental arch.
Early recognition of impacted canine teeth is the key to successful treatment:
The older the patient, the more likely an impacted canine 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 panoramic 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. It is important to determine whether all the adult teeth are present, or if some adult teeth are missing. Are there extra teeth present or unusual growths that are blocking the eruption of the canine tooth? Is there extreme crowding or too little space available causing an eruption problem with the canine tooth? This exam is usually performed by your general dentist 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 & maxillofacial surgeon for extraction of retained baby teeth and/or selected adult teeth that are blocking the eruption of the all important canine teeth. The oral & maxillofacial surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any 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 canine tooth will erupt with natures help alone. If the canine tooth is allowed to develop too much (age 13-14), the impacted canine tooth will not usually erupt by itself even with the space cleared for its eruption. If the patient is older (over 40), there is a significantly higher chance the tooth will be fused (stuck) in position. In these cases the tooth will not budge despite all the efforts of the orthodontist and oral & maxillofacial surgeon to help 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 canine tooth will not erupt when proper space is available?
In cases where the canine teeth will not erupt spontaneously, the orthodontist and oral & maxillofacial surgeon work together to get these unerupted canine teeth to erupt into the mouth. Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral & maxillofacial 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 canine tooth has not fallen out already, it is usually left in place until the space for the adult canine tooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral & maxillofacial surgeon to have the impacted canine tooth is surgically exposed and bracketed.
In a common surgical procedure performed in the surgeons office, the gum tissue 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 surgeon will bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature gold chain attached to it. The 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 tissue up high above the tooth or making a window in the gum tissue covering the tooth (on selected cases located on the roof of the mouth). Most of the time, the gum tissue 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 tissue.
Exposure and Bracketing of an Impacted Cuspid
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 dental arch in its final position, the gum tissue 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.
These basic principals can be adapted and applied to any impacted tooth in the mouth. It is not uncommon for both of the upper ca
nines 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 front teeth (incisors and canines) and the premolar teeth are small and have single roots, they are easier to erupt if they get impacted than the back molar teeth. The molar teeth are much bigger teeth 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 canine teeth (or any other impacted tooth other than wisdom teeth), treatment should be initiated at a younger age. Once the general dentist 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 & maxillofacial surgeon before braces are even applied to the teeth. As mentioned earlier, the surgeon will be asked to remove retained baby teeth and/or selected adult teeth. The surgeon will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth. Finally, the surgeon may be asked to simply expose an impacted canine 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 canine tooth will have erupted adequately 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 after surgery to expose and bracket an impacted tooth: The surgery to expose and bracket an impacted tooth is, in most cases, a straight forward surgical procedure that is performed in the oral & maxillofacial surgeons office. Again, there are also many options for anesthesia and patient comfort, that will be discussed with Dr. Davis at the consultation appointment.
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 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 surgeon 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 attached chain on your tooth. As always, your doctor is available at the office or can be beeped after hours if any problems should arise after surgery. Simply call Dr. Davis at Frisco Oral & Dental Implant Surgery Phone Number 972-335-8717 if you have any questions.