Exposure and Bracketing of Impacted Canines

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 Wisdom Teeth under Procedures) (link to Wisdom teeth section). Since there is rarely a functional need for wisdom teeth, they are usually extracted if they develop problems. The maxillary canine or cuspid (upper eyetooth) is the second most common tooth to become impacted. The canine tooth is a critical tooth in the dental arch and plays an important role in your “bite”. The canine 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 canines are the last of the “front” teeth to erupt into place. They usually come into place around age 11. If a canine 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.

The older the patient, the more likely an impacted canine will not erupt by natural forces alone, even if space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends that a panoramic x-ray, along with a dental examination, be performed on all dental patients at the age of seven to count the teeth and determine if there are problems with eruption of the adult teeth. If teeth do not erupt at their normal time, x-rays should be taken to evaluate the situation and determine the cause. Often, crowding of the dental arch is the cause and treatment may involve expansion, extractions, or expose and bracketing. Treating teeth that fail to erupt normally into position involves an orthodontist placing braces. Treatment may also require referral to an oral surgeon for extraction of baby teeth that failed to fall out or to remove any extra teeth (supernumerary teeth) or growths that are blocking the eruption of any adult teeth. The surgeon may need to uncover the impacted tooth and remove bone that is interfering with eruption.

In a surgical procedure performed in the surgeon’s office, the gum on the top of the impacted tooth will be lifted 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 and impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth. 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 has 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 that it remains healthy during normal function. Your dentist or orthodontist will explain this procedure to you if it applies to your specific situation.

These basic principles can be adapted to apply to any impacted tooth in the mouth. Molar teeth are much bigger 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. Dr. Reynolds developed a “piggyback” arch-wire technique to erupt second molars.

What To Expect from Surgery to Expose and Bracket an Impacted Tooth

The surgery to expose and bracket an impacted tooth is a very straightforward surgical procedure that is performed in the oral surgeon’s office. For most patients, it is performed using IV sedation but can sometimes be performed with local anesthesia only. Please see Pre-Operative Instructions for anesthesia.

You can expect a limited amount of bleeding from the surgical sites after surgery. Although there will be some discomfort after surgery, most patients find Tylenol and ibuprofen to be more than adequate to manage pain they may have. Within two or three 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 cool packs to the lip for the afternoon after the surgery. A soft, bland diet is recommended at first. Please see our post operative instructions for Expose and Bond.

Your surgeon will see you seven to ten days after surgery to evaluate the healing process. You should plan to see your orthodontist within 1-14 days to reactive the eruption process (applying the proper rubber band to the chain on your tooth). As always, your surgeon is available at the office and can be contacted after hours if any problems should arise after surgery.