Expose and Bond Surgery – Helping Impacted Teeth Into Position

What is an impacted tooth?

An impacted tooth is an adult tooth that has not come through the gum into its normal position. This may happen because the tooth is growing in the wrong direction, there is insufficient space, or another tooth is blocking its path.

The teeth most commonly affected are the upper canine teeth, sometimes called eye teeth. These usually come through between the ages of 11 and 13.

Occasionally, one or both canine teeth remain buried within the jawbone, sometimes in the roof of the mouth (palate) or towards the front of the gum.

Other teeth, such as premolars and incisors, can also become impacted.

An impacted tooth may remain completely hidden beneath the gum and cause no pain. However, it can sometimes affect the position of neighbouring teeth or damage their roots.

What is an expose and bond procedure?

An expose and bond is a minor surgical procedure that allows an orthodontist to move an impacted tooth into its correct position using braces.

The procedure involves uncovering the buried tooth and attaching a small orthodontic bracket or button to its surface. A fine gold-coloured chain is connected to the attachment.

Your orthodontist can then use this chain to apply gentle, controlled pressure to guide the tooth gradually into position.

The aim is to preserve your natural tooth rather than remove it.

Expose and bond surgery is usually carried out as part of a planned course of orthodontic treatment, with your surgeon and orthodontist working together.

Why might I need this procedure?

An impacted tooth may need treatment because:

It cannot erupt naturally: The tooth is trapped beneath the gum or bone.
It is affecting neighbouring teeth: An impacted canine can push against nearby teeth or cause damage to their roots.
There is a gap in your smile: The adult canine may be missing from its normal position.
It is affecting your bite: Canine teeth play an important role in the appearance and function of the bite.
Your orthodontist needs to align the tooth: Surgery may be required before braces can move the tooth into position.

Not every impacted tooth needs surgery. Your orthodontist will assess whether the tooth is likely to erupt naturally, whether it can be moved safely and whether an alternative treatment would be more suitable.

What happens at my consultation with Mr Maini?

Your surgeon will review your orthodontic treatment plan, examine your mouth and assess any X-rays or scans.

An X-ray helps identify the position of the impacted tooth and its relationship to neighbouring teeth.

In some cases, a cone beam CT (CBCT) scan may be recommended. This provides a three-dimensional view of the tooth and surrounding structures, which can be useful when the tooth is deeply buried or close to the roots of other teeth.

Your surgeon will discuss the surgical approach, the type of anaesthetic and any particular risks associated with your tooth.

What is the gold chain used for?

The gold chain is a small, delicate orthodontic attachment that is bonded to the impacted tooth.

Despite its name, the chain is not necessarily made of pure gold. It is a medical-grade orthodontic component designed to help move the tooth.

During surgery, the tooth is uncovered and a small metal button or bracket is glued to the tooth surface using dental bonding material. The chain is attached to this bracket.

The free end of the chain is left accessible in the mouth and may be secured temporarily to an orthodontic appliance or with a stitch.

Once healing has taken place, your orthodontist attaches the chain to your brace and uses it to apply gentle traction.

Over time, the tooth gradually moves through the bone and gum towards its intended position.

The chain does not pull the tooth into position immediately. Tooth movement is a gradual process and may take many months.

What is the difference between open and closed exposure?

There are two main techniques for exposing an impacted tooth.

The technique selected depends on the position of the tooth, its depth within the gum or bone, the amount and type of gum tissue surrounding it, and the orthodontic treatment plan.

1. Open exposure

With an open exposure, the surgeon removes or repositions a small area of gum covering the impacted tooth. A small amount of bone may also be removed if necessary.

The crown of the tooth is then left visible through an opening in the gum.

Sometimes a protective dressing or a small removable plate is used to prevent the gum from healing back over the exposed tooth.

Depending on the treatment plan, an orthodontic attachment may be bonded during surgery or at a later appointment.

This technique allows the orthodontist to access the tooth directly once the surgical site has healed.

Advantages of open exposure:

The exposed tooth can be accessed directly.
An orthodontic bracket can sometimes be attached or replaced without further surgery.
It may be suitable for certain teeth that are close to the surface, particularly some palatally impacted canines.

Possible disadvantages:

The exposed area may be uncomfortable while healing.
Food can collect around the exposed tooth.
The gum can occasionally grow back over the tooth.
This technique is not suitable for every impacted tooth.

2. Closed exposure with a gold chain

With a closed exposure, the surgeon lifts the gum to uncover the impacted tooth, removing a small amount of bone if necessary.

A small orthodontic bracket or button is bonded to the tooth and a gold chain is attached.

The gum is then repositioned and stitched back into place, covering the tooth again.

The free end of the chain passes through the gum or emerges near the gum margin so that it remains accessible to the orthodontist.

Once healing has taken place, the orthodontist uses the chain to gradually guide the tooth into its correct position.

Advantages of closed exposure:

The gum is repositioned over the tooth, allowing healing around the attachment.
The tooth can be moved gradually without leaving a large exposed area.
It is particularly useful for deeply impacted teeth and in situations where preserving the surrounding gum tissue is important.

Possible disadvantages:

The bracket or chain can occasionally become detached.
If the attachment fails, another surgical procedure may be needed.
The tooth may take many months to move into its correct position.

Which technique is best?

Neither technique is automatically better for every patient.

The choice depends largely on the position of the impacted tooth and the surrounding gum tissue, together with the planned direction of orthodontic movement.

For example, an impacted canine on the palate may be suitable for an open exposure, while a deeply buried canine or one on the outer side of the jaw may be better treated with a closed technique.

Your surgeon and orthodontist will recommend the most appropriate method for your individual circumstances.

What type of anaesthetic will I need?

What type of anaesthetic is needed?

Expose and bond surgery can be performed under:

Local anaesthetic: The area is numbed with an injection. You remain awake but should not feel sharp pain.
Local anaesthetic with sedation: Medication helps you feel more relaxed during the procedure.
General anaesthetic: You are asleep throughout the operation.

The choice depends on the position of the tooth, the complexity of surgery, your age, medical history and personal preferences.

Many procedures can be performed under local anaesthetic, although more complex cases, or procedures in younger patients, may be carried out under general anaesthetic.

Most patients can go home on the same day.

What are the risks of expose and bond surgery?

Expose and bond is a commonly performed procedure and most patients recover without significant problems.

However, all surgery carries some risks.

Pain, swelling and bruising

Some discomfort and swelling are normal after surgery, particularly during the first few days.

Bleeding or infection

A small amount of bleeding or blood-stained saliva is common initially. Occasionally, an infection can develop and require further treatment.

Damage to neighbouring teeth

An impacted tooth may lie very close to the roots of neighbouring teeth.

There is a small risk of damage during surgery, although careful assessment and planning help minimise this.

Failure of the gold chain or bracket

The bonded attachment may occasionally become loose or detach from the tooth.

If this happens, another procedure may be needed to reattach it.

Failure of the tooth to move

Sometimes an impacted tooth cannot be moved successfully, even with orthodontic treatment.

This may happen because the tooth is in an unfavourable position or because it is fused to the surrounding bone, a condition known as ankylosis.

In these circumstances, the treatment plan may need to change and removal of the impacted tooth may be recommended.

Damage to the gum or supporting tissues

Occasionally, orthodontic movement of an impacted tooth can be associated with gum recession or loss of supporting tissue.

Your surgeon and orthodontist will consider the position of the tooth and the surrounding gum when planning treatment.

Further surgery

Occasionally, further surgery is required if the gum heals over the tooth, the attachment fails or the impacted tooth does not progress as expected.

Your surgeon will explain the risks relevant to your individual case before treatment.

What can I expect afterwards?

Most people experience mild to moderate discomfort following the operation.

Some swelling, bruising or tenderness is common and usually settles within several days.

For the first few days, you should:

Take the recommended pain relief as directed.
Eat soft foods and avoid biting directly onto the surgical site.
Avoid hard, sticky or chewy foods that might catch or dislodge the gold chain.
Avoid vigorous exercise for the first 24–48 hours.
Avoid vigorous rinsing or spitting during the first 24 hours.
Keep your mouth clean, brushing carefully around the operated area.
Use warm salt-water rinses after the first 24 hours if advised.
Avoid smoking or vaping, as these can delay healing.

If stitches have been used, these are often dissolvable and usually disappear within one to three weeks. Occasionally, a stitch securing the chain or a protective dressing needs to be removed at a follow-up appointment.

Your surgeon will provide instructions specific to your operation.

When will my orthodontist start pulling the tooth?

Orthodontic traction usually begins after the initial surgical healing has taken place, often within a few weeks.

Your orthodontist will connect the gold chain to the brace and apply gentle pressure to encourage the tooth to move.

You will need regular orthodontic appointments so that the pressure can be adjusted and progress monitored.

How long does it take for the tooth to come through?

This varies considerably.

Some teeth move into position within a few months, while others may take a year or longer.

The overall orthodontic treatment may last considerably longer than this.

Factors that affect treatment time include:

The depth and position of the impacted tooth.
The direction in which the tooth is pointing.
Your age and the stage of dental development.
How far the tooth needs to move.
Whether there is sufficient space in the dental arch.
How the tooth responds to orthodontic traction.

It is important to attend regular orthodontic appointments throughout treatment.

What if the chain becomes loose?

The gold chain is delicate and may occasionally become detached from the tooth or its temporary securing point.

If the chain becomes loose, breaks or disappears beneath the gum, contact your orthodontist or surgeon for advice.

Do not try to pull the chain or reattach it yourself.

If the chain has simply come away from its temporary securing stitch but remains bonded to the tooth, it may be possible for your orthodontist to secure it again without further surgery.

However, if the bracket has detached from the tooth, another exposure and bonding procedure may be required.

What are the potential alternatives?

Depending on the position of the tooth, your orthodontist may discuss alternatives, including:

Observation: Monitoring the tooth if treatment is not currently necessary.
Creating space: Orthodontic treatment to create sufficient space and encourage eruption.
Removal of an obstruction: Occasionally, removing a retained baby tooth or another obstruction allows the permanent tooth to erupt.
Extraction: If the impacted tooth cannot be moved safely or successfully, removing it may be the most appropriate option.
Alternative orthodontic treatment: Closing the space or planning a replacement tooth where necessary.

The best option depends on your age, the position of the impacted tooth and the overall orthodontic treatment plan.