Other Impacted Teeth
(Non-Third Molar Impacted Teeth)
An impacted tooth simply means that it is “stuck” and cannot 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. Other teeth than the wisdom can remain stuck under the gum and are impacted.
The cuspid (eyetooth) is the second most common tooth to become impacted. Please see the Impacted Canine section of this website for information on management of these teeth.
Teeth other than the impacted canines and wisdom teeth can remain “stuck” in the jaw and exhibit failure of eruption. Patients can have baby teeth that are not naturally lost or baby teeth that are fused to the bone. These retained baby teeth can prevent the permanent teeth from erupting into place. Patients can have extra teeth called supernumerary teeth that block the eruption of the permanent teeth. Patients can also have pathology in the jaws that interfere with eruption of adjacent teeth. Some permanent teeth for unknown reasons simply fail to erupt even though the baby teeth have been lost.
Early Recognition Of Impacted Teeth Is The Key To Successful Treatment
The older the patient, the more likely an impacted 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 panorex screening x-ray, along with a dental examination, be performed on all growing patients 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 permanent tooth? Is there extreme crowding or too little space available causing an eruption problem with the tooth? Your general dentist usually performs this examination and 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 referral to an oral surgeon for extraction of over-retained baby teeth and/or selected adult teeth if needed. 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 an early age, there is a good chance the impacted tooth will erupt with nature’s help alone. If the impacted tooth is allowed to develop too much, the impacted tooth may not erupt by itself even with the space cleared for its eruption. If the patient is older, there is a much higher chance the tooth will be fused in position. In these cases the tooth may not erupt 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 with a dental implant or a fixed bridge.
What Happens If The Tooth Will Not Erupt When Proper Space Is Available?
In cases where the teeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these unerupted 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. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eyetooth exposed and possibly bracketed.
In a 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. Bone may have to be removed if it covers the impacted tooth in order to make it easier for the tooth to erupt. If there is a baby tooth present, it will be removed at the same time. Once the tooth is exposed, Drs. Blecha and Jandali may bond an orthodontic bracket to the exposed tooth. The bracket will have a miniature gold chain attached to it. Drs. Blecha and Jandali will guide the chain back to the orthodontic arch wire where it will be temporarily attached. Sometimes Drs. Blecha and Jandali 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 this case, a bracket and chain may not be placed. This will allow the tooth to possibly erupt naturally for a while. In this way, the orthodontist can place the bracket in their exact preferred position.
Shortly after surgery (7-14 days) the patient will return to the orthodontist. An orthodontic elastic 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 months to 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 a need for a soft tissue graft to provide the proper type of 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. Of course our objective is to avoid the soft tissue graft if possible.
These basic principals can be adapted to apply to any impacted tooth in the mouth, even molar teeth. 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. For difficult cases, the orthodontist may suggest use of orthodontic anchors or additional procedures to help teeth that are resistant to eruption erupt in normal position.
When second molars are impacted and do not erupt, we may be wise to remove the wisdom tooth and surgically expose the second molars. Orthodontic treatment may or may not be used in these cases.
Surgical procedures that are performed to help impacted teeth erupt usually work. However, we cannot guarantee that these procedures will always work. Some teeth may not erupt or may erupt partially but then stop erupting. Additional surgical treatment may be necessary in a small number of such cases to re-expose the tooth or to do other treatment to stimulate the tooth to erupt. Rarely, it is even possible that we cannot obtain the final eruption of the tooth and the tooth may need to be removed.
It is useful to obtain a CT scan on many of these unerupted teeth in order to better evaluate the problems in erupting an impacted tooth. Drs. Blecha and Jandali will advise you of these problems before any treatment is rendered. He will work closely with your general dentist and orthodontist to achieve an excellent result.
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 office. For most patients, it is performed using intravenous anesthesia. The procedure usually takes about an hour to perform. These issues will be discussed in detail at your preoperative consultation with your doctor.
There is usually some bleeding from the surgical sites after surgery, though it is usually not a problem. There will be some discomfort after surgery at the surgical sites. You will probably need to take some prescription pain medicine. Hopefully within two to three days after surgery there is little need for any medication at all. There may be some swelling. Applying ice packs to the area for the afternoon after surgery can help in minimizing swelling. Bruising is not a common finding after these cases but could occur.
A soft diet with some bulk is recommended on the first day, and this is possible if you take one half of the normal bite size so you can confine your chewing to the opposite side. If treatment is rendered on both sides of the mouth, patients should still be able to eat mashed potatoes, oatmeal, and ground up meats on the first day. You may resume your normal diet as soon as you feel comfortable chewing.
Patients should avoid eating on the surgical area, and also should avoid playing with the tissue in this area or with the dissolvable sutures with their lip, fingers, or tongue. 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.