In cases where the eyeteeth will not erupt spontaneously, the orthodontist and oral surgeon work together to get these un-erupted eyeteeth 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. If the baby eyetooth has not fallen out already, 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 eyetooth exposed and bracketed.
In a simple 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. 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 impacted tooth completely uncovered by suturing the gum up high above the tooth or making a window in the gum covering the tooth (on selected cases located on the roof of the mouth). 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 (one to 14 days) the patient returns 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 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 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.
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, 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 impacted, than the posterior molar teeth. The 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.
Recent studies have revealed that with early identification of impacted eyeteeth (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 surgeon before braces are applied to the teeth. The surgeon will be asked to remove over-retained baby teeth and/or selected adult teeth. The surgeon removes any extra teeth or growths that are blocking eruption of the developing adult teeth. Finally, the surgeon 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, or stuck. By the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the eyetooth will have erupted enough 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.