What are Impacted Canines?
When we say "impacted tooth," all we mean is that the tooth is stuck and unable to erupt out of your gums and perform its roles as a tooth! It's common for patients to have developed problems with impacted third molar (wisdom) teeth. Often, these teeth get “stuck” in the back of the jaw and cause painful infections and annoyances among other problems. Most people don't need their wisdom teeth, so it's common to have them removed once they start causing problems.
The most common tooth to become impacted is the maxillary cuspid (upper eye tooth). This tooth plays a critical role in the dental arch and your "bite." The cuspid teeth are strong biting teeth and have the longest roots of any human teeth. By design, these teeth are the first teeth to touch when your jaws close together; therefore, they guide the rest of the teeth into the proper bite.
In most cases, the maxillary cuspid teeth are the last of the “front” teeth to erupt out of the gums and into place. This usually happens around age 13, and their eruption can cause any leftover space between the upper front teeth to close together tightly.
If a cuspid tooth gets impacted, every effort is made to get it to erupt into its proper position in the dental arch. While 60% of 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. They are 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
For older patients, it is more likely that an impacted eye tooth will need a little extra help to erupt, even if there is plenty of space for it in the dental arch. The American Association of Orthodontists recommends that a panorex screening x-ray and dental examination be performed on all dental patients at around the age of 7. This helps us count the teeth and find any problems with adult tooth eruption quickly.
It is important to determine whether any adult teeth are missing. Are there extra teeth present? Do we see any unusual growths that are blocking the eruption of the eye tooth? Is there extreme crowding or too little space available? Your general dentist or hygienist will typically perform this exam and refer you to an orthodontist if they find any problems. A common treatment method to address these types of problem is to have an orthodontist place braces to open spaces and accommodate for proper eruption of the adult teeth. Treatment may also require a referral to an oral surgeon. An oral surgeon can extract over retained baby teeth and/or selected adult teeth that may be blocking the eruption of the eye teeth. The oral surgeon will also remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any of the adult teeth.
If patients' guardians are proactive and clear the eruption path by age 11 or 12, there is a good chance the impacted eye tooth will erupt with no extra help. Alternatively, if the eye tooth develops too much (around ages 13-14), the impacted eye tooth likely will not erupt by itself even if it has adequate space. If the patient is over 40, there is a much higher chance the impacted tooth will be fused into position. In these cases, the tooth will not budge despite all efforts of the orthodontist and oral surgeon to erupt it, and the only option is to extract the impacted tooth. When this happens, patients may consider an alternate treatment to replace the tooth in the dental arch (for instance, a crown on a dental implant or a fixed bridge).
What happens if the eye tooth will not erupt when proper space is available?
In cases where the eye teeth will not erupt on their own, the orthodontist and oral surgeon work together to erupt these stubborn teeth. While each case is unique, treatment typically involves the following: the orthodontist places braces to open space in the mouth and provide room for the impacted tooth to be moved into its proper position in the dental arch. If the baby eye tooth has not yet fallen out, it is usually left in place until the space for the adult eye tooth is ready. When the space is ready, the orthodontist will refer the patient to an oral surgeon, who will expose and bracket the impacted eye tooth.
The surgical procedure at the oral surgeon's office is simple. We lift up the gum on top of the impacted tooth in order to expose the hidden tooth underneath. We remove the baby tooth, if present, and then bond an orthodontic bracket to the exposed tooth. The bracket has a miniature chain on it, which the oral surgeon will guide back to the orthodontic arch wire, where it will be temporarily attached. In some cases, 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. In most cases, the surgeon will return the gum to its original location and suture it back with only the chain remaining visible as it exits a small hole in the gum.
Shortly after surgery (about 7 days), the patient will return to the orthodontist. Their orthodontist will attach a rubber band to the chain and put a light eruptive pulling force on the impacted tooth. This begins the process of moving the tooth into its proper place within the dental arch. This carefully controlled, slow process can take up to a full year to complete. Remember, the goal is to erupt the impacted tooth and not to extract it!
Once your tooth moves into the arch in its final position, your doctor will evaluate the surrounding gum to ensure it is sufficiently strong and healthy to withstand a lifetime of chewing and tooth brushing. In some circumstances, especially when the tooth had to be moved a long distance, patients may require some minor “gum surgery” to add bulk to the gum tissue over the relocated tooth and keep it healthy. If applicable to your case, your dentist or orthodontist will explain this situation to you.
These basics can be applied across most cases of impacted teeth. For some patients, both of their maxillary cuspids may 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. The anterior teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, which makes them easier to erupt if they get impacted than the posterior molar teeth. The molar teeth are much bigger teeth and have multiple roots, which makes them more difficult to move. These teeth may require more advanced orthodontic maneuvers because of their location in the back of the dental arch.
Early identification of impacted eye teeth and treatment initiated at a younger age give patients the best outcome. Once your general dentist or hygienist identifies a potential eruption problem, you should be referred to the orthodontist for early evaluation. In some cases, you may skip the orthodontist and go straight to the oral surgeon before braces are even applied to your teeth. The surgeon will remove over retained baby teeth and/or selected adult teeth as well as remove any extra teeth or growths that are blocking eruption of the developing adult teeth. In some cases, the surgeon may expose an impacted eye tooth without attaching a bracket and chain to it. This simpler procedure encourages some eruption to occur before the tooth becomes completely impacted. With this treatment, the patient's eye tooth should have erupted enough by the time they reach the proper age for braces, that the orthodontist can bond a bracket to the effected tooth and move it into place without excess force. This procedure saves both time and money for the patient in the long run!
What to expect from surgery to expose and bracket an impacted tooth?
The surgical solution that exposes and brackets an impacted tooth is straightforward and performed in the oral surgeon’s office. For most patients, it is performed using laughing gas and local anesthesia. In select cases, patients may receive IV sedation if they desire to be asleep, but IV sedation is not generally necessary for this procedure. Patients can expect for their procedure to take approximately 75 minutes if one tooth is being exposed and bracketed or about 105 minutes if both sides require treatment. If the patient needs only to expose their tooth and not bracket it, they can expect their approximate procedure time to be halved. Your doctor will discuss these specifics at length and answer any questions in your preoperative consultation.
After surgery, most patients will experience a small amount of bleeding from the surgical sites as well as some discomfort. Most patients find that Tylenol or Advil are more than helpful in managing the slight pain they experience while healing. Within 2-3 days after surgery, most patients are able to stop taking medicine for pain management. You may experience some swelling as a result of holding the lip up to visualize the surgical site. Minimize this swelling by applying ice packs to the lip for the afternoon after surgery. Bruising may occur but is uncommon. We recommend a soft, bland diet at first, but patients are able to resume their normal diets as soon as they feel comfortable chewing. Avoid sharp food items such as crackers and chips as these can irritate the surgical site and hinder your healing.
Your Midtown OFS doctor will see you 7-10 days after surgery to evaluate the healing process and ensure you are maintaining good oral hygiene. Plan to visit your orthodontist within 7 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 reached after hours if any problems should arise after surgery. Simply call Midtown Oral & Facial Surgery at 601-261-2611 if you have any questions.