Exposing & Bracketing of an Impacted Tooth

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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 cuspid (upper canine tooth) is the second most common tooth to become 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 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 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 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 canine) 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 but stuck in an elevated position above the roots of the adjacent teeth or out to the facial side of the dental arch.

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 surgeon work together to get these unerupted canine teeth to erupt.  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 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 surgeon to have the impacted canine 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.  Once the tooth is 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 surgery would be performed following the completion of orthodontics.