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Orthodontics/eyetooth has never came down

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QUESTION: Hi Dr.Supan at one time I had a baby eyetooth that never fell out eventualy the tooth broke and I went to the dentist who took a xray and did a examination. He told me my baby tooth needed to be pulled and that my permanent tooth was sitting against the other tooth and it might come down on it's own or it might not there is a huge bulge in my gum where the tooth is sitting and can be felt but it's been year since I saw him and the tooth still hasn't came down. I would like to know what the procedure is for bringing my tooth down and into place as I have a gap that is very embarrassing but I'm also fearful because I have had terrible experiences in the past with dentists who have caused me pain. I also had a bad reaction to laughing gas have tachycardia and have  been told that bringing the tooth down is brutal! any info you can give me would be greatly appreciated.

ANSWER:
Dear Heather,

Thank you for a very I interesting  question.  Un-erupted and impacted adult canines present a challenge which I deal with very often.  Again, what I write here are only my opinions based on limited information. No X-rays or images were included. Any comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  As you know Heather, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person and who have had an opportunity to take and analyze proper diagnostic records.

Now, in your question you asked several things. Let me parse the question into three more easily digestible parts.  You  wrote:

#1  You wrote:

“  Hi Dr. Supan at one time I had a baby eyetooth that never fell out eventually the tooth broke and I went to the dentist who took a X-ray and did a examination. He told me my baby tooth needed to be pulled and that my permanent tooth was sitting against the other tooth and it might come down on it's own or it might not.   “

Heather there are a number of reasons a baby canine tooth is retained and the adult canine tooth does not erupt.  Please visualize that any tooth basically has a crown and a root. The white part that you see in the mouth when you smile is the “root”.  The part of the tooth that anchors the tooth into the bone is the root.  In the case of a canine, visualize an upside down vanilla ice cream cone. The white scoop is the crown, and the brown cone is the tooth.

Okay with that visual in mind, now try to imagine a billiard table and the white cue ball hitting another billiard ball. In certain ways, an adult tooth , if properly aligned,  will knock up against the baby tooth much like a white cue ball hitting up against another billiard ball. In so doing the baby tooth is “pushed” out, in what a lay person may call “ losing a baby tooth”.  The picture in your mind should be of one adult tooth colliding and pushing out the baby tooth. In the case of your upper canines, envision two inverted ice cream comes. The upper inverted cone coming down and colliding with the lower inverted cone.

A second process that occurs is that the adult canine tooth, as it is hitting up and pushing against the baby canine tooth, will actually cause resorption of the baby tooth root.  That is, the “cone or root “ portion of the baby tooth will dissolve a bit as the adult tooth collides against it.

Now Heather, regarding the retained baby tooth, you wrote that  “ the tooth broke  “ . It could very well be that all that remains of the baby tooth in your mouth is the crown and a small portion of the remaining root ( or “cone section” ). If this is the case, then an extraction of the baby tooth would be very simple, and subsequent eruption of the adult canine may follow through shortly.

“ May “ is the important word here, because it depends on several important factors. First of all, the adult canine is wider and larger than the baby canine. If there is enough room in the space left after the baby tooth is lost, then the adult canine may erupt uneventfully. If there is not enough space the canine may come in poorly oriented or could even end up impacted, and not erupt at all.

A second important factor is the inclination and orientation of the adult canine. Again, envisioning an inverted ice cream cone, the adult canine needs to be properly positioned in a more or less vertical orientation. If the canine is vertical, then the it may drop down into the vacated space. If the canine however is say angulated at a 45 degree angle, and NOT vertical, the tooth will not maneuver into the space. The canine may in fact collide against the upper lateral incisor.

The available space and the orientation of the adult canine are the two critical factors in your case Heather.

#2  You also wrote:

“   there is a huge bulge in my gum where the tooth is sitting and can be felt but it's been year since I saw him and the tooth still hasn't came down. I would like to know what the procedure is for bringing my tooth down and into place as I have a gap that is very embarrassing but I'm also fearful because I have had terrible experiences in the past with dentists who have caused me pain. I also had a bad reaction to laughing gas have tachycardia and have  been told that bringing the tooth down is brutal! any info you can give me would be greatly appreciated.  “

The fact that there is a “bulge” there is encouraging. This may mean that the un-erupted adult canine is very core to emerging. I am going to assume that the baby tooth is in fact gone. The fact that a year has gone by and the tooth still has not emerged means it may in fact be impacted.  Waiting another year may not necessarily change anything.  You specifically asked what you should consider doing.  That is outlined below:

1)   Consider asking your dentist to take an updated “periapical” x-ray of the area  of the “Bulge”. This will give you an updated diagnosis of the position and orientation of the adult canine.

2)   If the adult canine is favorably oriented more or less vertically, and there is enough space for the tooth to come in, then perhaps waiting a little more is worth considering. Your dentist or a Periodontist can also offer to “expose” the canine by slightly incising into the overlying tissue. Again, check with your dentist.

3)   If the canine is deemed to be unable to erupt on its own, a referral to an Orthodontist may be helpful.  Often even an angulated impacted canine that has insufficient space to erupt can be addressed with orthodontics.  The canine is exposed, and a small bracket can be placed onto the tooth. The tooth can then be dragged down, exposed, and then positioned into place. Yes, this involves orthodontic treatment.

4)   I would recommend consulting with your dentist, and if deemed appropriate, a Periodontist and Orthodontist.   I have done many many such cases Heather, and because the adult upper canine is such an important tooth in affecting the smile and in providing proper lip support and a balanced facial profile

I hope my comments have been helpful. As you know Heather,  the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your impacted canine and the coming consultations. If you would like to submit a follow up question complete with an X-ray, I would be happy to answer in more detail.

Heather, thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.


---------- FOLLOW-UP ----------

QUESTION: Dear Dr.Supan just wanted to let you know the dentist did pull my broken baby tooth the same day he xrayed it and yes there was a little bit of the root still attached to the baby tooth and there is plenty of room for the adult tooth to come down but the xray showed the tooth sitting against the other tooth. I will do as you say and follow up with the orthodontist I was referred to and again thank you for your help. Sincerely Heather Cook.

Answer

Hi Heather and thank you for the follow up email. It is not so much a question as a follow up report regarding your actions. I am glad that it worked out for you.  

Canine situations like your are such a challenge, for both the patient and the Orthodontist. Nature has her way of  doing things, and occasional impacted canines are part of all this grandeur.

I wish you the best Heather. You have the advantage in 2016 of modern dentistry which often can literally deliver miracles.


Heather, thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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