Impacted Tooth Exposure and Extractions for Orthodontics

When a tooth is “impacted” it means that it is “stuck”, and cannot erupt into function. Patients frequently develop problems such as this with impacted third molars (wisdom teeth). These teeth get “stuck” in the back of the jaw and can develop painful infections, damage to adjacent teeth, etc. (see Impacted Wisdom Teeth under Procedures). Since there is rarely a functional need for wisdom teeth, they should usually be removed once it has been determined that they do not have enough room to completely erupt.

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 and plays an important role in your “bite”. The cuspid teeth are very strong biting teeth and 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 . They usually come into their proper place by age 13, and cause any space left between the upper front teeth to close. If a cuspid tooth becomes impacted, every effort should be made to get it to erupt into its proper position. 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) teeth. Sixty percent 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 position above the roots of the adjacent teeth, or out to the facial side of the dental arch.

Early Recognition of an Impacted Maxillary Cuspid is the Key To Successful Treatment

The older the patient, the more likely an impacted eye-tooth will not erupt by naturally even if the space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends that a panoramic x-ray and a dental examination be performed on all patients at seven years old, in order to count the teeth and determine if there are any problems with the eruption of the adult teeth. It is important to determine whether all the adult teeth are present, or some are 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 a problem with the eruption of 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 who can place braces to create space 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 that are blocking the eruption of the important eye-teeth. The oral surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that are blocking eruption of any adult teeth. If the eruption path is cleared and the space is opened by age 11-12, there is a good chance the impacted eye-tooth will erupt naturally. If the eye-tooth is allowed to develop too much (age 13-14), the impacted eye-tooth will probably not erupt by itself even there is space available. If the patient is too old (over 40), there is a chance the tooth will be fused to the adjacent bone. In these cases the tooth will not budge despite the efforts of an orthodontist and/or an oral surgeon. Sadly, the only option at this point is to extract the impacted tooth and consider an alternate treatment to replace it (a dental implant supported crown or a fixed bridge).

What happens if the Eye-tooth does not erupt when adequate space is available?

In cases where an eye-tooth will not erupt spontaneously, the orthodontist and oral surgeon can work together to get the eye-tooth to erupt. Although each case must be evaluated on an individual basis, treatment will usually involve a combined effort between the orthodontist and the oral surgeon. The most common scenario is for the orthodontist to place braces on the teeth and open a space to provide room for the impacted tooth to be moved into its proper position. If the baby eye-tooth has not fallen out, it is usually left in place until the space for the adult eyetooth is ready. Once the space is ready, the orthodontist will refer the patient to the oral surgeon to have the impacted eye-tooth exposed and an orthodontic attachment bonded to the eye-tooth while it is uncovered. The orthodontic attachment usually has a gold chain connected to it. After 7 to 10 days the patient will return to the orthodontist, and a small elastic band is threaded through a link in the gold chain to exert some light traction on the eye-tooth. This will start moving the eye-tooth toward its proper position. As the eye-tooth starts to move, the gold chain is shortened once every few weeks and the elastic is placed through the next link on the chain. The eye-tooth will eventually be moved into its final position.

These basic principles can be adapted to apply to any impacted tooth in the mouth. It is not uncommon for both maxillary cuspids to be impacted. In these cases space will be created on both sides, and Dr. Vecchione can expose and place orthodontic attachments on both teeth during the same visit.

In some patients the lower second molar is not incompletely erupted, and may also be tipped forward. The molar teeth are bigger and have multiple roots making them more difficult to move. For this reason the orthodontic maneuvers needed to reposition them can be more difficult.

Extractions and other Oral Surgery for Orthodontics

During orthodontic treatment it may be necessary for patients to an Oral Surgeon for any of the following:

To remove over-retained primary teeth (baby teeth)
To remove selected adult teeth due to severe crowding or malposition
To remove impacted wisdom teeth to prevent crowding
To remove an impacted third molar (wisdom tooth) to re-position the adjacent second molar
To remove an impacted third molar (wisdom tooth) to allow continued eruption of an impacted second molar
To remove supernumerary (extra) teeth, or growths, which are preventing the eruption of developing adult teeth
To remove the muscle attachment (frenum) between the upper front teeth in order to close a space between them