Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

December 27, 2017

A case of collapsed bite


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Hi Dr. Hall,
I really hope you can help me.

I am not sure if my issue is related to my lips, teeth, or jaw, but I absolutely can’t stand my smile. It feels very forced to be able to show my upper teeth. When my mouth is in repose it is just empty space and you cannot see my teeth (especially my upper) and it makes me extremely self-conscious.

I also have jaw pain and wear a night guard and when I wear it my mouth feels more comfortable and I feel like it supports my lips better. It also gives an impression of upper tooth show that I would very much like. I also find I have difficulty pronouncing certain words especially when it’s cold, almost as if my jaw tightens and I can’t open it properly to speak. P and T words are especially uncomfortable.

Are my only options veneers? Do I even have any options?

It’s very frustrating for me. I can attach pictures as well if need be.
– Laura from Ontario

Laura,
I’m glad you’re emailing me now, before going to a dentist to have this fixed. It’s painful to have to write back to people after a problem like yours and the dentist messed up their mouth.

This is a very difficult problem and you need to be very careful in picking a dentist to treat this for you. While I can’t tell for sure just with your description, it sounds like you may have a collapsed bite plus some other complicating TMJ issues (TMJ disorder). Veneers wouldn’t be the answer, at least not as a sole treatment. Opening your bite with crowns could solve your problem, but it would need to be done methodically by a dentist with experience in full-mouth reconstruction.

The proper way to open a bite is to do it reversibly first, with some type of provisional restoration. When that provisional is successful, then permanent restorations should be made that duplicate what was done provisionally. By successful I mean that you are out of pain, are happy with your appearance, show your upper teeth normally, and have no speech difficulties. That’s a tall order, but a dentist with adequate training should be able to do this.

It’s a small minority of dentists who have the training needed to address this type of situation. There are several training institutes in the United States that train dentists in this level of complex restorative dentistry. Those would be the L.D. Pankey Institute and the Dawson Academy in Florida, and the Las Vegas Institute for Advanced Dental Studies in Nevada. There are others, but these are the best known. I don’t believe there are any such institutes in Canada.

To help cement this idea of being careful in picking a dentist to do this, you may want to visit other blog posts I wrote for patients where the dentist opened their bite and caused more problems than they started with.

I will email you privately with a dentist recommendation for you. It will involve some travel, but you need to get this done right.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

June 23, 2016

Follow-up on trouble speaking with new veneers


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This is a follow-up to the previous post, where Susan emailed Dr. Hall telling about problems she was having speaking with her new porcelain veneers.

Susan commented at the bottom of the post:

Thank you for the reply. I think I am going thru a bad nightmare. After complaining about my speech and bite, the dentist took off the front four permanent veneers, to replace them. As he was taking them off he broke #9 [the upper left central incisor] after which I had to have the tooth pulled and an implant put in. I am currently 2 months with the implant temporary. I have to wait three months for it to heal. I asked him to make a matrix of the temporary veneers and the final veneers to see what is wrong. He said all the molars are each side were made too short and the lab made the mistake by using my original bite. Right now I have 9 temporaries in my mouth with the implant. He didn’t replace the 1st molars because he claims they are fine. My temporary veneers were 12.4 length for #9 and #10. Now they 11.8 and hitting my lip. Could it be those back 1st molars being too short? Or should I just run and find a new dentist?

And here is my answer:

Susan,

Again, I do have to qualify what I answer here by saying that not being able to see exactly what is going on, I may be missing something, but I CAN tell that something isn’t right here.

The molars being made too short—that would definitely explain your speech problems. But passing the mistake off onto the lab saying they used the wrong bite? No, that doesn’t work for me. It’s not the lab’s fault. The dentist gives instructions to the lab and the issue isn’t your bite, it’s the vertical dimension. And that has the potential to cause long-term problems. It is called bite collapse. You absolutely need to have your bite opened to its original position. What is starting out as just speech problems can easily progress to TMJ disorder with possible chronic headaches and jaw pain.

Cases like yours where the vertical dimension is altered need to be approached with great care, and a dentist needs more training than what they receive in dental school to pull this off. The dentist will replicate your bite on a machine called an articulator where he or she can carefully study all your bite movements. He or she will establish a vertical dimension by testing it in your mouth with temporary restorations, and then will send your case to the laboratory on the articulator with careful instructions on how to reconstruct your mouth.

And then I’m aghast at what happened to your front tooth. When you take off veneers, the way to do that is to grind them off. You can’t “pop them off” or remove them in any way like that if they’re bonded on properly. They become like a second enamel and the only way is to grind them off, which is a gentle process that is similar to preparing the teeth in the first place. I am again suspecting that he didn’t actually do porcelain veneers but did porcelain crowns and called them veneers. But even then, with front teeth, crowns should also be ground off, and there is no excuse for breaking a tooth.

I would not let this dentist touch your teeth any more—this is getting worse every time he sees you.
Actually, I do know an excellent cosmetic dentist in northern New Jersey. I will send you the name. I know her personally and have absolute confidence in her. She is AACD-accredited, which is no mean achievement, and a Master of the Academy of General Dentistry, and I believe she is one of the best cosmetic dentists in the entire state.

A couple of additional points:
1. You need to get tough with this dentist. As I said, not seeing your case personally I’m at a little bit of a disadvantage, but based on what you are telling me he has violated the standard of care and is very vulnerable legally. He seems to have got in way over his head and has done multiple things wrong. If I were you I would call him and say that you’re going to be nice and not take him to court where you could sue him out the wazoo, but to avoid that he needs to pay for everything that this new dentist needs to do to fix you up. Go to the new dentist first, confirm the details of what has been done wrong, and then confront him.
2. I can’t imagine that your bite and vertical dimension are the only problems with your case. You haven’t said anything about how your teeth look, but it is rare for functional incompetence in dentistry to be blended with artistic excellence. In my mind’s eye right now I can’t imagine that you have a beautiful smile. But based on what you have told me, your case needs to be completely re-done. That is your silver lining. The new dentist, in re-doing this, can give you a beautiful smile.

– Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

December 6, 2012

Dentist said everything was fine – but she grinds her teeth, so it’s not fine

Filed under: TMJ — Tags: , , , , , — mesasmiles @ 8:39 am

Hello Dr. Hall, I was hoping you could help and provide a little insight. I have been grinding my teeth for some time now while I sleep. My last dental cleaning and checkup was 8 months ago and everything was fine. I have recently been feeling pain from my lower back teeth. The dull pain lasts for 2 secs and then stops. It feels like someone is pulling at my back tooth and letting go. I feel this pain on both sides of the mouth (all back lower teeth). I have never had a cavity before so I don’t know what to expect. Does this seem like cavities? Or could it be something else? could it be from clenching teeth while asleep? What should I do to help my situation, I feel this pulling sensation and it’s very hard to describe. Hope you can help.
– Mona from New York

Mona,

Your two statements seem to contradict each other. You said that in your checkup everything was fine, but then you said you’ve been grinding your teeth in your sleep for some time now. If you have a grinding problem, then everything is not fine.

I’m not sure what is wrong with your teeth because I don’t have all the details – like what brings this pain on. And it would be helpful to see the x-rays and actually see your mouth and check things like tooth mobility. But I’m worried that your dental examination may not have been as thorough as it should have been, just from your comment that everything was fine in your checkup. Now I don’t know this for sure, not having been there, but I know this is a common problem in much dental care – a focus on cavities and fillings, and not paying much attention to other important dental problems like TMJ, gum disease, or occlusion. You get this in budget dental clinics and chain practices. I think you should get another opinion from a dentist who is possibly more thorough.

Having said that, your pain doesn’t sound like it comes from tooth decay. It sounds like the pain some people get when they have gum disease. Or it could be from the trauma of your grinding. I would find out, because either of these problems could be serious. If it’s gum disease, by the time you start having pain you could have significant bone loss. If it’s the grinding, you can literally grind your teeth away, and the solution could be as simple as wearing a nightguard.

Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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