Deep Bite And Orthopedic Bite Opening

(Section 2 of the Jaw Orthopedics Series)

In section 1, we discussed the incidence of a deep bite in growing children and its implications on the development and health of a child. A deep bite relates to the vertical length of the back part of the mandible (lower jaw), which also contains the growth (proliferation) zone for the proper development of the jaw. Functional jaw orthopedics allows this growth zone to be influenced.

A deep bite or a retruded (backward) lower jaw are not self-limiting, and children do not grow out of it. The reason is that they are trapped in a vicious circle. The more the teeth wear down, the more they will grind, and the process will perpetuate.  If functional influences have caused the current condition, then they have to be resolved with functional methods. There are two approaches:

  1. With functional appliances:  in children who have many jaw problems at the same time, such as a small jaw, crowding, a deep bite, etc.
  2. Without appliances: In children aged 5-8 with a deep bite, and in the event that there is no significant arch size crowding, or no retruded lower jaw, a very simple method of bite opening can be implemented without the use of appliances. It is also considered a form of interceptive jaw orthopedics, mainly because it repositions the jaw, and therefore causes an acceleration in the growth of the proliferation zones of the jawbone.

It involves adding material to the lower baby (or primary) molars. This will increase their height and allow the jaw to close at a vertically open position. This is achieved directly, by creating a jig to determine the amount of vertical opening, and adding composite on the lower primary teeth.

Another material which can be used is a ceramic polymer overlay on the same primary molars.  In the past, impressions were taken of the jaws. Today, we do this by digitally scanning the jaws with a wand, (for example, a CEREC procedure) and milling four overlays out of a more durable and biocompatible material. Parents who are concerned about “plastics” and “BPA-like” materials, this is the way to go. It is costlier, but a sound option.  After the overlays are bonded, permanent teeth that erupt will grow to the newly established vertical dimension. By the time the teeth with the overlays are shed (ages 10-12), the functional effect will already be achieved with permanent desired changes to the jawbone.

Q: WHAT ARE THE CONSEQUENCES IN ADULTHOOD IF THIS IS NOT ADDRESSED DURING CHILDHOOD?

A: Many teens and adults develop crowding, which by many orthodontists is resolved by extracting four healthy bicuspid teeth to make “room”.  This spells even more trouble as they hit middle age, since these adults develop Jaw-joint problems, have a flat face with no lip support, and their risk for sleep apnea is increased manifold.

Q: DOES MY CHILD AVOID BRACES IN THE FUTURE IF THIS EARLY INTERVENTION IS CARRIED OUT?

A:. Not necessarily, because there are other factors at play for needing braces. However, if needed, the time needed will be reduced significantly, and the end outcome will be much nicer. At this early stage we are concerned with the foundation of the jawbone, in three dimensions: vertical, lateral (sideways) and sagittal (forward).

More questions are answered at the following page:

Deep Bite And Childhood Sleep Apnea

FJOseries-17

(Section 1 of the Jaw Orthopedics Series)

An important aspect with children’s dentition is identifying their dental and jaw growth patterns, precisely during the rapid phase of growth.  Here we will concentrate on childhood sleep apnea and its relation to the vertical dimension. This is the arbitrary vertical distance between the upper and lower jaws. If one considers the teeth as the columns in a room holding up the roof, then we can appreciate that the higher the ceiling, the more room we have for the tongue and the airway.  A small and over-closed space inside the mouth and throat translates to less airway volume.

Airway means oxygen.
Oxygen means life and growth.

Many children under the age of 8 may exhibit a deep bite, and it is very easy for the parent or the pediatrician to identify this. 80% of jaw growth happens by age 8, therefore it is reasonable that this growth spurt window be utilized to treat a dysfunctional growth pattern.

Q:  HOW DO PARENTS IDENTIFY A DEEP VERTICAL BITE?

A:  Have the child bite down. You will see a deep bite and overlapping incisors:  how the front teeth come together when the child bites down.  If more than half of the height of the lower incisors are covered by the uppers, or if both upper and lower incisors have worn each other down,  the child has a deep and over-closed bite.

Q: WHAT SIGNS POINT TOWARDS THE RISK OF SLEEP APNEA IN A CHILD?

A: Many of the following signs by themselves may not implicate sleep apnea. However, the more they occur simultaneously, the higher the risk for sleep apnea.
Snoring at night, large tonsils, hyperactivity, dark rings under the eyes, bedwetting, tooth crowding, a reduced vertical bite (see above) and nighttime grinding. Grinding in children is a sign of oxygen deficiency at night. From the perspective of jaw orthopedics, these children will also tend to have a retruded (backward) lower jaw, future crowding, and as they grow up, an unfavorable profile and TMJ problems.

Q: WHAT CAN WE DO IF WE SUSPECT SLEEP APNEA IN OUR CHILD?

A: Many conditions discussed above are not self-limiting, and children will not grow out of them.  A constricted dental arch, a vertically closed bite, and a retruded lower jaw do not reverse as a child grows.  If the child is treated early enough, between 5 and 8, functional jaw orthopedics will solve most of their jaw problems.  In the case of hypertrophic tonsils and adenoids, these may shrink over the years, but do we take the chance? They are the main culprit in most cases.  An ENT specialist has to evaluate the condition and remove them if needed. Many parents swear by it that this procedure has changed the life of their child overnight.

FJOseries-18
More resources on childhood sleep apnea and jaw orthopedics:

  1. Sleep Apnea Treatment
  2. Functional Jaw Orthopedics
  3. Early Intervention
  4. Bite Opening
  5. Sleep Dentistry

Abnormal Frenum Attachments In Children

The tight ligament that attaches the upper lip to the gums is called the labial frenum. The one attaching the tongue to the base of the mouth is the lingual frenum.

The labial frenum should be attached at least 4 mm above the gum crest of the front teeth and should not limit the lip movements Almost 10% of children will have labial frenum attachments that penetrate the papilla, or the triangular gum tissue between the central incisor teeth. These usually need intervention, as they do not resolve with age.

The consequences of a tight or low-attaching frenum are:

  • NURSING and SUCKLING problems in infants – a serious complication, as it prevents normal latching on to the nipples, and may even produce undernourishment.
  • DIASTEMA FORMATION: Due to the fibrous extension of these ligaments extending down in-between the upper front teeth, spaces between them usually do not close, and form what we know as a gap, or a diastema.
  • RECESSION: As the lip moves, it makes the frenum continually tug on the papilla  (the triangular gum tissue filling the space between the upper incisors). In the future, the risk for recession and gum pockets on these teeth is higher.
  • OPEN MOUTH POSTURE: The tight ligament limits lip function and prevents it from adapting with the lower lip, or forming a “lip seal”, which is an integral part of healthy nose breathing. Therefore, these children have a higher risk of open mouth posture and mouth breathing, leading to detrimental effects on jaw growth and airway development.
  • PLAQUE, DECAY AND GINGIVITIS: Studies show that a higher lip posture due to the tight frenum is associated with more plaque retention, decay, and gum inflammation.

The lingual frenum should allow for free movement of the tongue, particularly in its role in swallowing, speech, and tooth and jaw development. In severe cases, it is called “ANKYLOGLOSSIA”.

A child with a tight lingual frenum is also called “tongue tied”.  One sign is a “heart-shaped” tongue as the child opens the mouth wide and extends the tip of the tongue upwards. Consequences are as follows:

  • LOW TONGUE POSITION: The tongue lies lower in the mouth, therefore causing abnormal growth of the lower jaw, and insufficient growth of the upper jaw. This causes severe orthodontic problems in the future as well as a tendency for sleep apnea.
  • SWALLOWING DYSFUNCTION: Upon swallowing, the tongue should rest against the upper palatal vault. If its frenum is tied, it will rest lower, and insert between the teeth. This is called tongue thrust. Orthopedic effects are insufficient growth of the upper jaw, and an open bite if there is an associated tongue thrust.
  • SPEECH PROBLEMS AND LISPING: Due to improper tongue positioning, lisping is a common occurrence. Generally, the “r” cannot be rolled and some consonants cannot be properly pronounced.

TREATMENT:

Surgically releasing the frenum is called frenectomy. Conventional treatment involves a procedure where the frenum is cut with a blade or scissors, with or without sutures to reposition its attachment. Another method is using an electric device called an “electrosurge”, which is fast, but painful, and it creates a zone of “burnt” tissue which not only heals slow, but heals with more scarring, therefore defeating the purpose.

Today, in some offices, including ours, we employ a procedure called “laser frenectomy” in which the waterlase is used to zap the frenum with laser pulse, gently severing it from its attachment. A few drops of anesthetic makes the area numb enough so even a 6-year old can tolerate it.

Advantages:

  1. Healing time is reduced drastically. Full healing with new skin is evident within 10 days.
  2. The actual procedure takes 3-5 minutes
  3. There is no burning or cutting, therefore the laser frenectomy can be performed wider and deeper, thus improving the final results. The new frenum attachment is at least 5 mm higher up, clearing the gums and releasing the tongue or the lip respectively.

AFTER-CARE

Homeopathic Arnica and Hypericum in 30C potency is given half an hour apart, three times a day for three days. The area is gently dabbed with gauze soaked in a calendula/glycerin tincture (non-alcoholic). Otherwise, rinse with a strong sea-salt solution. For the next two weeks post-operatively the child and parents are instructed to perform, any chance they get, stretching exercises on the lip (grabbing the lip and moving it in all directions) to allow the re-attachment of the fibers as far away from the gums as possible.

How To Keep a Chipped Tooth Alive

This young boy came in with a very common trauma, a blow to the front teeth with a large chip. The nightmare of parents.
Boy with chipped front tooth

Provided the visit to the dentist is as soon as possible, and a laser is utilized, chances of the tooth surviving are excellent. The small nerve exposure along with the whole dentine surface is lasered with the Waterlase and disinfected.
Disinfecting chipped tooth with laser

MTA ( a highly biocompatible cement) is applied as a dressing over the exposed nerve. Over this layer the tooth is bonded with a self-etching bonding agent.
Dressing chipped tooth with MTA

The tooth is built up with composite …
Build up chipped tooth

… following aesthetic bonding principles.
aesthetic bonding of chipped tooth

The tooth is polished and as good as new.
Chipped tooth good as new

Three years after this procedure was done, the tooth is still alive and vital. This kid was spared a root canal.

How to get your crown the same day

We all know the procedure when it is time to get a crown or an onlay:

After the tooth is prepared an impression is taken with a tray.  This one may be needed to be taken multiple times and sometimes requires separate molds to be taken for the opposing teeth. This can be overwhelming for some patients, especially those with an enhanced gag reflex.

Not a very comfortable procedure.

Then a temporary provisional is made to cover and protect the tooth. Most of us know how inconvenient that is for the next two weeks.

The impression is sent to the dental lab. Two weeks later the final crown or onlay is back, and we make a second appointment to seat it. Time off work or family, traffic, a new shot to numb the area, painstakingly removing the provisional cover and disinfecting the tooth once again.

Wouldn’t it be great if we could come in and all this would be done the SAME DAY without the discomfort and inconvenience of impressions and temporaries?

Dr. Sarkissian can now offer you exactly that! You come in for a procedure that requires any indirect porcelain restoration and leave the same day – all done. No gagging on the impression, no mess, no second shot, no temporaries dislodging.

All this is made possible by the CEREC scanner and a milling machine by Sirona. This is German technology at its finest. Its latest model makes it appear the 21st century has finally arrived. This combination of 3D scanning and milling basically allows Dr. Sarkissian to create bio-compatible ceramic inlays, onlays and crowns during your visit – all in one day.

omnicam

The Omnicam scanner is used to digitally scan your teeth in 3D. The data collected is directly sent to a sophisticated software program that builds a digital 3D model of your jaw.  This is then used to model the crown, onlay, inlay or veneer with unmatched precision.  Dr. Sarkissian manipulates the design on the computer screen to his liking, and once the exact digital model of the restoration is designed, one click of a button sends it to a CAD-CAM milling machine a few rooms away.

4_cerec

This device mills your crown, inlay, onlay or veneer out of a block of a desired ceramic material right in front of your eyes. After some polishing and glazing, Dr. Sarkissian is now ready to bond it on your tooth. As the precision of this process is so high, hardly any adjustments will be necessary.

milling

If you are in the greater Los Angeles area you should not miss this experience. You can find the contact information for Dr. Sakissian here…

How to address Tooth Grinding and Jaw Clenching

Bruxism is the term describing nighttime tooth grinding or jaw clenching. This can result in tooth wear, gum recession, and morning headaches or stiff muscles. Most of the time we are not aware that we clench or grind at night. Jaw-joint symptoms will get worse if clenching is not addressed.

After continued bruxism the teeth will wear down and the jaw-joint can be damaged over time

After continued bruxism the teeth will wear down and the jaw-joint can be damaged over time.

A lot of times you may hear about the warning signs from your hygienists, if they are trained to look for these symptoms.

A night guard is a thin piece of hard plastic molded according to an impression of your teeth that is placed on the upper teeth while you sleep. The night guard is hard enough to be durable but it is softer than teeth and protects them from wear. A night guard protects your teeth and jaw from the detrimental effects of nighttime teeth grinding. The pressure created by grinding can eventually wear your teeth down to nothing! Other warning signs that you may be grinding your teeth at night include headaches (sometimes severe) and jaw pain when you wake up in the morning.

A conventional hard BPA-free nightguard, which is our favorite.

A conventional hard BPA-free nightguard, which is our favorite.

The Food and Drug Administration (FDA) has recently approved the NTI Tension Suppression System (NTI) as a drug-free alternative to reducing headache pain and migraine-related episodes that affects 28 million Americans. This safe and effective device is simple to use, requires no surgery and has no side-effects.

The NTI is much smaller, and where indicated, works great for bruxism when associated with headaches.

The NTI is much smaller, and where indicated, works great for bruxism when associated with headaches.

In a multi-center trial of the NTI device, 82% of sufferers had a 77% reduction within 8 weeks. Just a single visit to our office could make migraine suffering a thing of the past.

Sleep Dentistry

Obstructive Sleep Apnea and Sleep Dentistry

There is probably, in my opinion, no other condition that impacts general health as much as sleep apnea does. Imagine that during your sleep someone chokes you for a whole minute, and repeats this every 5 minutes throughout the whole night. Worst of all, you are not aware of this happening.

In our office we take sleep apnea very seriously, mainly because it seems to be an underlying factor for many conditions. Furthermore, I have noticed that most of my patients who have had braces as teenagers after having had four sound teeth extracted for the purpose of “creating space,” invariably suffer from a multitude of deleterious effects, such as excessive tooth wear, orthodontic relapse, stunted jaw growth, jaw-joint dysfunction, a mid-face deficiency, flat face with lack of proper lip support, insufficient jaw sizes to accommodate proper tongue position, snoring, and sometimes sleep apnea. Many times sleep apnea is an accompanying condition in these patients, due to the fact that the smaller jaws will just not accommodate the tongue, which tends to fall back and obstruct the airway during sleep. As dentists we have to be able to identify the incidence of this serious disorder, and offer treatment after obtaining a diagnosis by a physician.

ADULT SLEEP APNEA FACTS:

  • Obstructive Sleep Apnea, or OSA for short, afflicts 20 million Americans. 9% of men and 4% of women have OSA.
  • Statistically, most heart attacks happen in the early morning hours. Many of these can be blamed on O.S.A.
  • The Anales Medicina de Interna reported in 1999 that patients with untreated sleep apnea have a 37% chance of dying within 8 years.
  • Nasal breathing and an ample oxygen supply encourages nasal and sinus epithelium to produce Nitric Oxide, a tissue mediator which prevents the blood from clotting, protects arteries and dilates blood vessels.

 

CHILDHOOD SLEEP APNEA FACTS:

  • Most growth hormone is produced during the first few hours of sleep.
  • 90% of growth and tissue repair happens during NREM stage 4 sleep.
  • According to the American Academy of Pediatrics, all children should be screened for sleep apnea and treated immediately.
  • Chronic tonsil and adenoid enlargement is the most common cause of childhood sleep apnea
  • Since enlarged tonsils and adenoids are a major cause of sleep apnea and mouth breathing in children, consequentially smaller jaws and dental crowding are also common findings.
  • A survey in the journal Pediatrics from 2001 determined that children who snored during early childhood tended to show poor performance in middle school.

HIGH RISK FACTORS FOR O.S.A.

  • Being overweight
  • Snoring (not all snorers are sleep apneics)
  • Small or underdeveloped jaws
  • Lower jaw too far back in relation to the upper jaw.
  • Narrow upper airway diameter
  • Increasing age
  • Alcohol/tobacco/sedative use

SIGNS OF O.S.A.

  • Snoring, intermittent, with occasional gasping for air
  • Excessive daytime sleepiness
  • Non-refreshing sleep
  • Fatigue and irritability
  • Morning headaches
  • Gastro-esophageal reflux

CONSEQUENCES OF O.S.A. – sleep apnea is considered an independent risk factor for the following conditions

  • Poor memory
  • Increased auto and work-related accidents
  • Poor performance
  • Depression
  • Decreased quality of life
  • Heart problems, increased chances for developing high blood pressure, arrhythmias or stroke
  • Increased risk for adult type II diabetes

Diagnosis of OSA

Because OSA is a life-threatening medical condition, a multidisciplinary approach is necessary to address it. A physician should be involved in diagnosing the presence and degree of sleep apnea. A physician should also conduct an examination to determine if other correlated health conditions exist, such as hypertension, cardiovascular disease, diabetes and chronic fatigue.

Watch-PAT100

We are proud to carry this FDA approved, compact and ambulatory system of sleep monitoring.

In the comfort of your own home, it is a welcome alternative to a stressful and expensive hospital-based sleep study. Based on the results of this study, an on-line pulmonologist’s diagnosis is obtained which allows us to implement treatment much sooner.

Treatment of OSA

For mild to moderate cases of OSA, a dentist may fabricate an oral appliance to allow the airways to remain open for sufficient air to flow into the lungs during sleep. This treatment is far more tolerable than the conventional CPAP machine, which many patients of OSA find very cumbersome to use. (A CPAP is still a requirement for severe sleep apnea cases). In our office, we conduct a thorough evaluation of the multiple contributing factors and signs of sleep apnea, including daytime sleepiness and nighttime sleep evaluation scores. Homeopathic and naturopathic treatment many times provides additional support in improving sleep quality or addressing the hormonal, biochemical and physiological ravages of this condition.

Sleep hygiene

Among other things, the following habits should be implemented to improve sleep quality.

  1. Do not eat dinner within 3 hours preceding bedtime.
  2. Follow a regular sleep routine by not staying up late and not oversleeping.
  3. Cut back on alcohol, soda and caffeine.
  4. Take an herbal supplement or a hot herbal relaxing tea half an hour before bedtime.
  5. Take a warm bath before bedtime.
  6. Do not eat snacks, watch TV or read in bed.
  7. Follow a light and individualized exercise routine, preferably in the morning, and one hour before dinner.
  8. Do not engage in activities that are stressful or mentally challenging before bedtime.
  9. Shut off all lights.

Teeth Bleaching (internal/external)

A tooth may discolor after trauma, if the nerve dies, or even some time after a root canal treatment.  It looks unsightly, especially if it is a front tooth.

The office of Dr. Sarkissian offers a procedure to bleach a tooth simultaneously externally and internally. During the procedure the chamber is opened to allow the bleach to be applied from the inside as well as the outside.

An unattractive tooth like this

Internal-External-Bleaching-01

can be transformed into this Internal-External-Bleaching-09allowing the patient to show a wide smile again.

Get more details about the procedure to whiten a discolored tooth elsewhere on this blog.

Jaw Orthopedic – Bite Opening In Adults

Bite and Normal Jaw
The lower jaw (pink) is a double-hinged bone that is suspended between two joints. Its distance from the skull is technically determined by the height of the teeth, just like columns holding up a roof. The “columns” are high, the jaw-joint is healthy and the tongue has room to fit inside the mouth.

Normal jaw relationship

Bite and Normal Jaw – Facial Profile
The esthetically pleasing profile usually reflects the healthy jaw and teeth with full lip support, and a forward positioned mouth. The face reflects harmony.

Bite and Normal jaw (2)

Collapsing Bite
The teeth are worn down (the columns are shortened) and the jaw has approached the skull. The TMJ (jaw-joint) is under strain and the lips have collapsed inwards.

Collapsed bite adult tx ( 0)

Collapsed Bite
The Jaw-joint has been jammed deeper and backwards into the skull. The delicate disc is usually popping in and out of place every time the mouth opens and closes, creating that characteristic “click”.

Collapsed bite adult tx (2)

Collapsed Bite – Reposition Jaw
An orthotic that fits over the lower teeth will allow the jaw to vertically reposition itself and function in a physiologically corrected position. It takes at least 3 months for the jaw-joint and the muscles to adapt to this position. During this phase certain symptoms such as muscle spasms, tenderness, and headaches will generally improve.

Collapsed bite adult tx (3)

Collapsed Bite – Teeth Build-Up
As symptoms improve, and the patient is comfortable functioning in the open position, the bite is restored to the new vertical dimension. The orthotic is sequentially cut back and the teeth built up with onlays or overlays.

Collapsed bite adult tx (4)

Collapsed Bite Restored
Eventually all the teeth are restored and the orthotic is discontinued. The jaw-joint is in a physiologically corrected position and the teeth have been restored to full anatomy.

Collapsed bite adult tx (5)Collapsed bite adult tx (6)Collapsed bite adult tx (7)