A Patient’s Guide to the Exposure of Unerupted Teeth

WHY IS IT NECESSARY?

Your orthodontist or dentist has referred you to see one of our surgeons for the surgical exposure of one or more teeth.

Teeth fail to erupt for a variety of reasons.  The most common reason is that the eruption path is blocked by another tooth due to dental crowding, or alternatively that the baby tooth (whose roots would normally dissolve allowing it to drop out) has not yet been lost and it is preventing the adult tooth from coming through.  If this is prevented for long enough, root growth on the adult tooth finishes, and there is nothing left to “push” it through the gum.

A tooth which should have erupted must not be left under the gum otherwise it can form a cyst around it, which can become infected or may even start to erode other teeth in the area, leading to their loss.

For this reason it has been suggested that your tooth should be surgically uncovered so that it can either erupt further by itself, or can be moved downwards into the correct position using an orthodontic plate or braces.

HOW IS IT DONE?

Your surgery can be performed either before or after your braces are fitted and in almost all cases, if the baby tooth has not been lost by this stage your dentist or orthodontist will request that it is removed at the same time.

It may be necessary to have further X-rays to establish whether the tooth is under the gum on the outside (near your cheek) or further towards the middle near the roof of your mouth or your tongue.  This is important, especially in the top jaw where the position of the tooth will determine whether surgical access is made via the roof of your mouth, or alternatively, the outside gum.

A tooth on the outside is uncovered by rolling the gum back and placing two stitches to hold it in position until the tooth erupts, bringing the gum with it. If the tooth is on the inside, however, it is usually necessary to remove a small piece of gum – about the size of a little fingernail – to uncover the tooth, and at the end of the operation the area is covered with a surgical pack – rather like putty – that is held in place with a stitch until it hardens.  This acts to protect the area (just like a band aid) and also to keep the gum from growing back over the tooth.  Thus, the healing of the gum occurs under the pack and when it is painlessly removed 2 to 3 weeks later, the gum around the now exposed tooth has completely regrown.  Of course it may be a little tender (as is all new skin) but will toughen up very quickly within a couple of days.  It is quite common for the stitch to become loose during this time span, and you can easily cut it off at the gum with small, clean scissors.  Likewise, small pieces of the pack may break away from the edges but there is no cause for alarm unless the whole pack becomes loose.

Usually your orthodontist or dentist will ask for a small ring to be glued to the tooth at the time of operation, to act as an attachment so that it can be pulled gently into position once the gum is healed.  When the tooth is starting to approach its correct position it can then be included into your braces, and the ring removed without any damage whatsoever to the enamel.

You will need to choose whether the procedure should be performed under a general anaesthetic where you will be asleep, or a local anaesthetic where you will be awake. In general, if the tooth is deeply buried, it is better to be asleep as it may take some time to uncover it.  If, however, a tooth is quite shallow it is a very quick and simple procedure and it will be recommended that it be performed under a local anaesthetic injection, while you are awake. In either case, there will be no pain for some hours post-operatively, and then the prescribed pain-relieving medication should be taken for two to three days.  In almost all cases there is virtually no swelling or bruising associated with this procedure and a normal lifestyle can be recommenced within 24 hours.

HOW LONG WILL IT TAKE?

The length of time it takes to pull the tooth into position depends firstly on how deeply it is buried, and whether there are any other teeth in the way; and secondly, whether the space for the tooth has closed up and needs to be reopened with orthodontic braces.  In most cases the tooth can be moved into position within 9 to 12 months, but it may take a little longer to perfectly align all the other teeth in the area.

WHAT CAN GO WRONG?

The vast majority of teeth treated in this way are successfully moved into their ideal position.  However, occasionally complications occur:

1.  Non-movement

In a small percentage of cases it is not possible to pull the tooth down into position, either because it will damage teeth which have moved into the way (and cannot be moved back out of the way) or because the tooth has been sitting under the gum for too long and has become fixed to the bone in that position.  Thus, if the tooth does not move within a reasonable period of time after it has been exposed, the options of either removal of the tooth (and replacement with either a false tooth, or closure of the gap with orthodontic treatment) or alternatively transplantation (surgical repositioning of the tooth) will be discussed with you.  This is a very rare occurrence if the buried tooth has been treated within 2 or 3 years of the time that it should have erupted through the gum.  Therefore, the sooner treatment of an unerupted tooth is undertaken, the better chance of success.

2. Damage to neighbouring teeth.

If the unerupted tooth has already formed a cyst by the time it is uncovered, it is possible that this may have already started to erode other teeth in the area.  In the vast majority of cases this heals without problems following orthodontic repositioning of the unerupted tooth.  Occasionally, damage can be so extensive, that a neighbouring tooth has to be root-filled, or may even be lost.  Equally rarely, the unerupted tooth is so close to the neighbouring tooth that the orthodontic movement through the gum can in itself cause some damage to the neighbouring tooth.  If this likely, you will be warned about the possibility before treatment starts.

3.  Other complications.

Very occasionally the surgical pack or stitches holding the gum back will be lost early, and the tooth may partially re-cover.  If this occurs it may be necessary to re-expose the tooth which involves minimal removal of the small piece of tissue which has re-covered it, or replacement of the ring if it has become unglued.

Post-operative bleeding and infection are virtually unknown with this procedure and so it is unlikely that post-operative antibiotics will be required.  Post-operative pain control will be prescribed according to the difficulty of the procedure and thus the amount of discomfort that is likely to be experienced.

To help you better understand the procedure, your surgeon can show you a computer simulation of how a tooth is moved into position, and if you wish, can put you in contact with patients who have previously undergone the procedure.

The exposure of an unerupted tooth is a predictably successful operation that is performed very frequently in this practice.  Once your tooth has been uncovered it can be moved into position resulting in the best possible bite and a beautiful smile!

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