Impacted Canines / Teeth

An impacted tooth simply means that it is “stuck” and cannot erupt (break through the gums) into proper position or function like normal teeth. Patients frequently develop problems with impacted third molar (wisdom) teeth, which are the most commonly impacted teeth, as described in Wisdom Teeth under the Oral/Maxillofacial Services tab above. Any tooth can be impacted. Possible causes of impaction include abnormal tooth size and position, delayed development, inadequate size of the jaws, other teeth getting in the way, or even cysts or tumours preventing proper eruption. Impacted teeth can cause many problems, such as damage to other teeth, infections, pain, orthodontic tooth alignment problems, and even cysts or tumours. This is described in greater detail in the Wisdom Teeth section of this web site.

The maxillary cuspid (upper eye tooth, or “canine”) 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”. These teeth are very strong biting and tearing 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 final position 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 help it 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 are most commonly applied to the maxillary (upper jaw) 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 elevated position above the roots of the adjacent teeth or out to the lip side of the dental arch. Sometimes the position can be determined from examining and feeling that area in the mouth, but other times a special x-ray (3D CT scan) is recommended to better localize the exact position of the tooth within the bone in order to better assess the situation and to guide appropriate surgery.

The older the patient, the more likely an impacted eye tooth 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 panorex screening x-ray, 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 are some adult teeth 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 an eruption problem with 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 placing braces to open spaces to allow for proper eruption of the adult teeth.

Treatment may also require referral to an oral and maxillofacial surgeon for extraction of over-retained baby teeth and/or selected adult teeth that are blocking the eruption of the all-important eye teeth. The surgeon will also need to remove any extra teeth (supernumerary teeth) or growths that may be 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 eyetooth will erupt with nature’s help alone. If the eyetooth is allowed to develop too much (age 13-14), the impacted eyetooth will not erupt by itself even with the space cleared for its eruption. If the patient is too old (over 40), there is a much higher chance the tooth will be fused in its position and not responsive to orthodontic movement. In these cases the tooth will not budge despite all efforts of the orthodontist and surgeon. 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 (a dental implant, fixed bridge, or removable device). Occasionally an impacted tooth in an older patient can be left in place and monitored, but there are risks associated with this strategy.

Recent studies have revealed that with early identification of impacted canines (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 surgeon before braces are even applied to the teeth to simply expose an impacted eye tooth to encourage some eruption to occur before the tooth becomes totally impacted (stuck). In these cases, by the time the patient is at the proper age for the orthodontist to apply braces to the dental arch, the eye tooth will have hopefully erupted well enough on its own that the orthodontist can bond a bracket to it and move it into relatively easily. In the long run, this saves time for the patient and means less time in braces (always a plus for any patient!).

In cases where the eye tooth will not erupt spontaneously, the orthodontist and oral and maxillofacial surgeon work together to get the tooth into proper position within the dental arch. Each case must be evaluated on an individual basis. 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. If the baby eyetooth has not fallen out already, it is usually left in place until the space for the adult eye tooth is ready. Once the space is ready, the orthodontist will refer the patient to the surgeon to have the impacted tooth “exposed and bracketed”, as described here.

In a simple surgical procedure performed in our office, the gum covering the impacted tooth will be gently 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 surgeon will bond an orthodontic bracket or button to the exposed tooth. This bracket will usually have a miniature gold chain attached to it, which will be temporarily attached to the orthodontic arch wire that connects all of the braces together. Sometimes the surgeon will leave the exposed impacted tooth completely uncovered by repositioning the gum with sutures or by making a window in the gum covering the tooth (on selected cases located on the roof of the mouth). 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. Each case is different.

Within one to two weeks after surgery, the patient will return to the orthodontist. A rubber band will be attached to the chain 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 if it applies to your specific situation.

Any tooth may be impacted. These basic principals can be adapted to any impacted tooth in the mouth. Because the front teeth (incisors and cuspids) and the bicuspid teeth (the two teeth behind each eye tooth but in front of the molars) are small and have single roots, they are easier to successfully erupt with the above-described techniques if they get impacted than are the back 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, and more commonly need to be removed. In select patients the tooth can be left in place and monitored, but there are some risks with this strategy.

The surgery to expose and bracket an impacted tooth is a very straightforward procedure that is usually performed in the office. For most patients, it is performed with either local anaesthesia alone or IV sedation. If the patient desires to be completely asleep, or is so young that being asleep is the only way to predictably get cooperation, then general anaesthesia can be used, but this is generally not necessary. The procedure is generally scheduled for about 45 minutes to 1 hour per tooth to be exposed and bracketed. If the procedure only requires exposing the tooth with no bracketing, the time required will be shortened significantly. These issues will all be discussed further at your preoperative consultation with your doctor.

You can expect a limited amount of bleeding from the surgical sites after surgery. Although there will be some discomfort after surgery at the surgical sites, most patients find Tylenol or Advil/Motrin 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. Adult patients may have a lengthier recovery. There may be some minor swelling, which can be minimized by applying ice packs to the lip for the afternoon after surgery. Bruising is uncommon and though 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 sharp food items like crackers, chips and raw vegetables as they may directly irritate the surgical site during initial healing. Your will often be seen 7 to 10 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 1-14 days to activate the eruption process by applying the proper rubber band to the chain on your tooth.

The surgery to remove an impacted tooth is similar to that described above to expose and bracket it, except that the chances of swelling and bruising are increased. Depending on the clinical exam of your mouth, another x-ray (3D CT scan) may be recommended to evaluate the exact position of the tooth and proximity to adjacent structures, such as other teeth or nerves, in order to make the surgery safer and faster.

Risks of any surgery include bleeding, bruising, infection and allergic reactions to medications, but serious problems of this nature are very rare. Depending on the relationship of the impacted tooth to adjacent teeth or nerves, damage to these structures is sometimes unavoidable, which could result in needing root canals or possibly losing such damaged teeth, or in permanently altered sensation/feeling of an area of the mouth or lower lip. Luckily these are also very rare, and if you are at an elevated risk of such problems it is usually identifiable and discussed prior to any surgery. The vast majority of patients experience no complications.

Please review our section on post-operative instructions.