Phillip G Cary, DDS
Nathan T Cary, DDS
CANANDAIGUA ORAL SURGERY, PC
500 North Main Street, Canandaigua, NY 14424, 585.394.3322
Exposure & Bracketing
n impacted tooth is a tooth that it is unable to erupt into function. Impaction implies when there is either insufficient space available for the tooth to erupt, or improper orientation of the tooth despite adequate space. The most commonly impacted teeth are third molars (wisdom) teeth. The maxillary (upper jaw) cuspid (canine or eye tooth) is the second most common tooth to become impacted. Any important teeth in the dental arch should be retained if possible. Exposure and bracketing is a surgical technique used so that orthodontic forces can be applied to erupt an impacted tooth.
Early recognition of impacted teeth is a key to successful treatment. The success in orthodontic eruption of impacted teeth diminished dramatically with advancing age, even if the space is available for the tooth to fit in the dental arch. The American Association of Orthodontists recommends panoramic dental imaging along with dental examination on all dental patients at around the age of 7 years
to count the teeth and determine if there are problems with eruption of the adult teeth.
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 extraction of over-retained baby teeth and/or selected adult teeth that are blocking the eruption of teeth in the proper sequence. If the eruption path is cleared and space opened up by age 11 or 12, there is a reasonable chance the impacted tooth will erupt with nature’s help alone. If the tooth is allowed to develop too much (age 13-14), it may not erupt by itself even with the space
cleared for its eruption. If the patient is over 25 years of age, there is a much higher chance the tooth will be fused in position. In these cases the tooth will move despite all the efforts of the orthodontist and oral surgeon to erupt it into place. The only option at this point would be to extract the impacted tooth and consider an alternate treatment to replace it in the dental arch (crown on a dental implant or a fixed bridge).
In cases where an impacted tooth does not erupt spontaneously, your orthodontist and our doctors will work together in the effort to help it erupt. While each case must be evaluated, the most common scenario will call for your orthodontist to place braces on the teeth. Space will then 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 us to have the impacted eyetooth exposed and bracketed. In an in-office surgical procedure, the gum covering the impacted tooth will be lifted up to expose the hidden tooth underneath. If there is a baby tooth present, it is generally removed at the same time. Once the tooth is exposed, we will bond an orthodontic bracket to it. The bracket will have a small gold chain attached to it. This chain will serve as a traction line for the Orthodontist to move the impacted tooth. Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by suturing the gum up high above the tooth. At other times, 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.
The surgery to expose and bracket an impacted tooth is a relatively straightforward procedure that is performed in the office. For many patients, it is performed using local anesthesia. In selected cases it will be performed under I.V. anesthesia. The procedure is generally scheduled for 45 minutes or so if one tooth is being exposed, longer if both sides require treatment.
You can expect a limited amount of bleeding from the surgical sites after surgery. Although there will be some discomfort after surgery, many patients find Tylenol or Advil to be adequate to manage any discomfort they may experience. Within 2-3 days after surgery there is usually little need for any medication. There may likely be swelling of the overlying tissues, which can be minimized by applying ice packs to the area. A soft diet is recommended at first, but you may resume your normal diet as soon as you feel comfortable chewing. It is best to avoid sharp food items like crackers and chips as they will irritate the surgical site if they jab the wound during initial healing.
Shortly after surgery (1-14 days) the patient will return to their Orthodontist. An elastic thread 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. 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. These basic principles can be adapted to apply to any impacted tooth in the mouth.