Exposure of Unerupted Teeth

In cases where the eyeteeth will not erupt spontaneously, the orthodontist and periodontist work together to get these unerupted eyeteeth to erupt.  Each case must be evaluated on an individual basis, but treatment usually involves a combined effort between the orthodontist and the periodontist.  The most common scenario calls 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 periodontist to have the impacted eyetooth exposed and bracketed.

The upper cuspid (upper canine/eyetooth) is the second most common unerupted tooth.  The cuspid tooth is a critical tooth in the dental arch and plays an important role in your “bite.”  The cuspid 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 upper 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 remains unerupted, 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 unerupted tooth in the upper or lower jaw, but most commonly they are applied to the upper cuspid (upper canine/eyetooth).  

Prior to exposure, it is very important to determine the exact location of the teeth.  The periodontist or orthodontist will use several x-rays to determine if the location is on the outside surface or the inside surface of the bone.

In a simple surgical procedure performed in the periodontist’s office, the gum on top of the unerupted 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 periodontist will bond an orthodontic bracket to the exposed tooth.  The bracket will have a miniature gold chain attached to it.  The periodontist will guide the chain back to the orthodontic arch wire where it will be temporarily attached.

Shortly after surgery (1-14 days) or on the same day, 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 unerupted 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 one full year to complete.  Remember, the goal is to erupt the tooth and not to extract it!  Once the tooth is moved into its final position in the arch, 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.  This will add bulk to the gum tissue over the relocated tooth so it remains healthy during normal function.  Your periodontist or orthodontist will explain this to you if it applies to your situation.

These basic principals can be adapted to any unerupted tooth in the mouth.  It is not that uncommon for both of the upper cuspids to be unerupted.  In these cases, the space in the dental arch form will be prepared on both sides at once.  When the orthodontist is ready, the periodontist will expose and bracket both teeth in the same visit, so the patient only has to heal from surgery once.  Because the front teeth (incisors and cuspids) and the bicuspid teeth are small and have single roots, they are easier to erupt 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 unerupted molar tooth can be more complicated due to its location in the back of the dental arch.

Recent studies have revealed that with early identification of unerupted eyeteeth (or any other unerupted 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 periodontist before braces are even applied to the teeth.  The periodontist 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 unerupted tooth.  This will encourage some eruption to occur before the tooth becomes totally unerupted (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 (always a plus for any patient!).