Impacted Cuspid (Canine) Teeth, Pasadena, CA
In addition to Wisdom Teeth, other teeth can become impacted. An impacted tooth simply means that it is “stuck” and cannot erupt into a functional and cleansable position.
The maxillary (upper jaw) cuspid (canine or eyetooth) 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, and the protection of such. The cuspid teeth are very strong biting teeth and have the longest roots of all 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 into place. They usually come into place around age 13 and cause any space left between the upper front teeth to close tighter together. If a cuspid tooth becomes 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, but most commonly are applied to the maxillary cuspid teeth. Sixty percent of these impacted cuspids are located on the palatal (roof of the mouth) aspect of the dental arch. The remaining impacted cuspid teeth are found in the middle of the supporting bone but stuck in an elevated position above the roots of the adjacent teeth or out to the facial (lip) side of the dental arch.
Early Recognition Of Impacted Maxillary Cuspids Is The Key To Successful Treatment
The older the patient the more likely an impacted cuspid 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 radiograph, along with a dental examination, be performed on all dental patients at around the age of seven 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 whether some adult teeth are missing. In some situations, extra teeth (supernumerary teeth) or cystic growths are present, blocking the eruption of the cuspid tooth. In other situations, extreme crowding or too little space is available, causing an eruption problem with the cuspid.
Your general dentist usually performs this examination and then refers you to an orthodontist if a problem is identified. Treating such a problem may involve an orthodontist using braces to open spaces, which allows for proper eruption of the adult teeth. Treatment may also require referral to an oral & maxillofacial surgeon for extraction of retained baby teeth and/or selected adult teeth that are blocking the eruption of the all-important cuspid teeth. The oral & maxillofacial 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 11-12, there is a good chance the impacted cuspid will erupt naturally. If the cuspid is allowed to develop too much (age 13-14), it will have less chance to erupt by itself even with the space cleared for its eruption.
The older the patient, the much higher the chance the tooth will be fused in position. In these cases the tooth will not budge despite all the efforts of the orthodontist and oral & maxillofacial 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 (removable partial denture, dental implant, or a fixed bridge).
What Happens If The Cuspid Tooth Will Not Erupt When Proper Space Is Available?
In cases where the cuspids will not erupt spontaneously, the orthodontist and oral & maxillofacial surgeon work together to move these teeth into the dental arch. Each case must be evaluated on an individual basis but treatment will usually involve a combined effort between the orthodontist and the oral & maxillofacial 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 cuspid to be moved into its proper position in the dental arch. If the baby cuspid has not fallen out yet, it is usually left in place until the space for the adult cuspid is ready. Once the space is ready, the orthodontist will refer the patient to the oral & maxillofacial surgeon to have the impacted adult cuspid exposed and bracketed.
In a simple surgical procedure performed in the surgeon’s office, the gum tissue on top of the impacted tooth will be lifted up to expose the hidden tooth underneath. If there is a baby tooth present, it will be removed at the same time. Once the adult cuspid tooth is exposed, the oral & maxillofacial surgeon will bond an orthodontic bracket to the exposed tooth. The bracket will have a small gold chain attached to it. The 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 tissue up high above the tooth or making a window in the gum covering the tooth (in selected cases located on the roof of the mouth). Most of the time, the gum tissue 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 (7-14 days) the patient will return to the orthodontist. A rubber band (orthodontic elastic), spring, or other appropriate device 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 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 tissue 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 it remains healthy during normal function. Your dentist or orthodontist will explain this situation to you if it applies to your specific situation.
Exposure and Bracketing of an Impacted Cuspid
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.
Recent studies have revealed that with early identification of impacted cuspid teeth (or any other impacted tooth other than wisdom teeth), treatment should be initiated at a younger age. Once the general dentist or hygienist identifies a potential eruption problem, the patient should be referred to the orthodontist for early evaluation. In some cases the patient will be sent to the oral & maxillofacial surgeon before braces are even applied to the teeth. As mentioned earlier, the surgeon will be asked to remove retained baby teeth and/or selected adult teeth. The surgeon will also remove any extra teeth or growths that are blocking eruption of the developing adult teeth.
Finally, he may be asked to simply expose an impacted eyetooth without attaching a bracket and chain to it. In reality, this is an easier surgical procedure to perform than having to expose and bracket the impacted tooth. This will encourage some eruption to occur before the tooth becomes totally impacted (stuck). By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the cuspid will have erupted enough so that the orthodontist can bond a bracket to it and move it into place without needing to force its eruption. In the long run, this saves time for the patient and means less time in braces.
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 oral & maxillofacial surgeon’s office. In some cases, it is performed with local anesthesia. Nitrous oxide sedation (laughing gas) can be use in addition to local anesthesia to minimize anxiety. In most cases though, it is performed with monitored intravenous anesthesia when the patient desires to be asleep. The procedure is generally scheduled for 45 – 60 minutes if one tooth is being exposed and bracketed. If the procedure only requires exposing the tooth with no bracketing, the time required will be shorter. These issues will be discussed in detail at your preoperative consultation with your doctor. You can also refer to “After Exposure of an Impacted Tooth” under Surgical Instructions on this website for a review of any details.
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 or Advil to be more than adequate to manage any pain they may have. Within two to three days after surgery there is usually little need for any medication at all.
There may be some swelling to the general area but applying ice packs to the area on the face for the afternoon after surgery can minimize significant swelling. Bruising is not a common finding 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. It is advised that you avoid hard crunchy food items like crackers and chips, as they will irritate the surgical site during initial healing. We will see you seven to ten days after surgery to evaluate the healing process and make sure you are maintaining good oral hygiene. You should plan to see your orthodontist within 7-14 days to activate the eruption. Your orthodontist may start the process by applying the proper rubber band to the chain on your tooth. As always Drs. Elias and Jun are available at the office or can be reached after hours if any problems should rise after surgery.