Impacted Canines

An impacted tooth simply means that it is “stuck” and can not erupt into function. Patients frequently develop problems with impacted third molars (wisdom) teeth. These teeth get “stuck” in the back of the jaw and can develop painful infections as well as 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 before they create problems. The maxillary cuspid (upper eye tooth) is the second most common tooth to become impacted. The cuspid tooth is a critical tooth in the dental arch acting as the “corner stone” and plays an important role in the occlusion. The cuspid teeth are very strong with the longest roots of any human teeth. In an ideal position the cuspid teeth help guide the bite during function and protect other teeth from excess wear.

Normally, the maxillary cuspid teeth are the last of the “front” teeth to erupt into place. They normally erupt into place by age 13. Since they are the last of the front teeth to erupt, in a small or crowded arch, they may get stuck while attempting to descend into position. If there is not enough space for the cuspid to descend by the time the root finishes formation, much of its eruptive power may be lost and the tooth will not complete its descent into the arch. These teeth may be observed for a short time if space is created for them to erupt, however, often the tooth will not descend without external forces to assist its movement. Surgical exposure and attachment of a small orthodontic bracket is usually the best solution. The orthodontist can then apply an eruptive force to the impacted tooth so that it may complete its journey into 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 tooth). Most of these impacted eye teeth are located on the palate (roof of the mouth) side of the dental arch. The remaining impacted eye teeth are found in the middle of the supporting bone often stuck in an elevated position above the roots of the adjacent teeth or out to the lip side of the dental arch.

Early recognition of impacted eye teeth is the key to successful treatment

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. 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 7–8 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 are some adult teeth missing. Are there extra teeth present or unusual growths that are blocking the eruption of the eye tooth? Is there extreme crowding or too little space available causing an eruption problem with the eye 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 or appliances to open spaces and allow for proper eruption of the adult teeth. Treatment may also require a referral to an oral surgeon for extraction of over retained baby teeth and/or selected adult teeth that are blocking the eruption of the all important eye teeth. The oral 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 developing eye tooth will erupt naturally. There is little reason to delay treatment to assist a cuspid once the root has completed formation and the tooth has failed to erupt into an arch with adequate space. The decision to assist a cuspid is normally made by your dentist or orthodontist by age 13.

Once a cuspid becomes impacted, as a patient gets older, it is more difficult to expose and bracket assist eruption. In adult patients, there is a much higher chance the tooth may be fused to bone in its impacted position. In many of these cases the tooth will not budge despite efforts of the orthodontist and oral surgeon to erupt it into place. Impacted cuspid teeth in adults may be left in place and followed periodically with xrays. Alternatively, when there is a need to replace the cuspid prosthetically, a patient may consider alternative treatments with bridgework or a dental implant.

What happens if the eye tooth will not erupt when proper space is available?

In cases where the eye teeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these unerupted eye 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. A space will be opened to provide room for the impacted tooth to be moved into its proper position in the dental arch. An exposure and bracketing procedure by the oral surgeon will then allow the orthodontist access to apply an eruptive force to the cuspid.

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. The baby canine tooth is often present and either removed early or at the same time the surgeon exposes the cuspid. 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. On the more difficult, highly impacted canines, a second surgical procedure may be necessary to reattach the bracket in a different location. There are also circumstances when a secondary gum graft is necessary to and healthy attached gum tissue around the collar of the repositioned cuspid tooth. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.

These basic principals can be adapted to apply to any impacted tooth in the mouth. It is not that 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 if they get impacted than the posterior 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.

What is the Surgical experience like?

The surgery to expose and bracket an impacted tooth is a very straight forward surgical procedure that is performed in the office of Dr. Rissolo. For most patients, it is performed with using laughing gas and local anesthesia. In selected cases it will be performed under I.V. sedation if the patient desires to be less aware, but this is generally not necessary. You can also refer to “Preoperative instructions” under Surgical Instructions on this web site for a review of any details.

You can expect a limited amount of bleeding from the surgical sites after surgery, often times there is none. Some post-operative discomfort is expected, although most patients find Tylenol or Advil to be adequate to manage any pain. Early and frequent dosing (every 3-4 hours) before pain sets in is best. Within a few 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. Post-operative oral hygiene is important. It is best to clean the surgical site and adjacent teeth twice daily with a mix of 3% Hydrogen peroxide and water on a Q-tip. After one week, most patients return to brushing the teeth in the surgical area. Your doctor will see you 7-10 days after surgery to evaluate the healing process and make sure you maintain good oral hygiene. You should plan to see your orthodontist soon after surgery 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 after hours if any problems should arise from surgery. Simply call Oral Surgeons Associates at 203-853-0500 if you have any questions.