Lori B. was a 34-year-old flight attendant who lived in Marina Del Rey. All of her friends considered her very pretty, but Lori never felt that way. Ever since she was a teenager, she was always self-conscious about her smile. She always felt that her front teeth were “too small” and in 1992 she came to my dental office for a consultation about having some cosmetic dentistry done.
Upon evaluating her teeth, I agreed with her that the size of her upper front teeth were not in proportion with her face and that made her teeth look too small. We determined that she needed some bleaching to whiten all of her teeth, and that with ten upper porcelain veneers she could have the smile that she always dreamed of.
Once the veneers were placed, both Lori and I were very happy with the results, and she received many compliments about how beautiful her smile was from her friends, family and even strangers.
Lori’s Veneers: A Clue To a Bigger Problem
About a month after completing Lori’s cosmetic dentistry, I got a frantic call from Lori who had a veneer on her front tooth fall off while she was working on a flight to Atlanta. I told her to come into the office as soon as she got back to L.A. and I would recement it for her. Over the next 2 years, the veneer on that same front tooth came off four times, and 3 other veneers came off between one and three times each.
At first, I thought that the veneer had come off because of some faulty cement, or that the tooth we were cementing to had become contaminated with saliva, disrupting the bond of the veneer to the tooth. But after four different veneers came off eleven times in twenty four months, I began to think there was something that I was missing.
You Don't Know What You Don't Know
One thing I noticed about Lori’s smile was that when she bit together, her upper front teeth almost completely covered up her lower front teeth. In dentistry, this is known as a “deep bite,” and I knew that it was not normal, but didn’t really know if this might be one of the reasons her veneers kept popping off.
The study of the way that the upper and lower teeth come together is called “occlusion.” It is a subject that is not taught very well in dental school, so most dentists do not know very much about it when they graduate and unless they go out on their own and seek post doctoral education in occlusion, it is one of those things that is confusing to dentists and not easily understood.
I decided that if I was going to provide high quality dentistry, I was going to have to learn about occlusion, so that restorations I placed in my patients’ mouths lasted a long time and did not fall out. Little did I know at that time, that I was beginning a life long journey that was initially very frustrating, but is now extremely fulfilling and the reason I enjoy doing dentistry so much today.
TMJ Symptoms, and the Perfect Bite
I started my journey learning about what makes a bite good and what makes a bite bad by going to a series of continuing education classes in Northern California put on by a group that had sent a flyer in the mail to my office. It struck me as I sat in their classes that they kept talking about all of these different philosophies on occlusion and how theirs was the only right one and everyone else’s were wrong.
A couple of years later, I went to a very famous dental teaching center in Scottsdale, Arizona and found out that they taught a completely different philosophy on Occlusion than the one I had learned in Northern California. They also insisted that their philosophy was correct and that what everyone else taught was wrong.
I continued on a path, going to different post doctoral teaching institutes learning different philosophies on how to construct the “perfect bite,” each time coming back to my practice in Marina Del Rey and trying out what I had learned. For the most part, the different things I learned partially worked, but nothing I learned worked all of the time.
About 10 years into my journey I began to notice that a lot of my patients whose bites were off also were complaining of grinding their teeth, popping and clicking of their jaw joints, headaches, neck aches and even migraines. I knew that these were the symptoms of TMJ (temporomandibular joint disorder). As I began to treat these patients with the occlusal techniques I had learned, almost none of them had their TMJ symptoms go away. I knew that I was missing something, but I didn’t know what it was.
The Connection Between Proper Bite and TMJ Symptoms
In early 2001, I had heard of this new Post Doctoral Teaching Institute in Las Vegas that was teaching about not only cosmetic dentistry, but also about occlusion. I thought that this might be a place that would put the two things together in such a way as to explain why Lori’s veneers kept coming off. I went to the Las Vegas Institute for Advanced Dental Studies (LVI) and what I learned there has changed not only my life, but the lives of my TMJ patients forever.
I learned at LVI about NEUROMUSCULAR Dentistry. This is a philosophy that believes that patients have pain because the MUSCLES in the head and neck that attach to the jaws become sore when a patient has a bad bite. All of the other occlusal philosophies I had previously learned were focused exclusively on either the teeth or the position of the ball inside the socket of the jaw joints. None of them EVER talked about the muscles. It made sense to me that if people have pain of muscular origin (headaches, neck aches and migraines), that if I could help my patients muscles relax, I could help to alleviate the symptoms they were complaining of.
Neuromuscular dentistry is not the majority point of view on occlusion in my profession today, but I believe it is the correct philosophy of occlusion based on the successes I have had treating my TMJ patients using neuromuscular principles.
Although I still practice regular dentistry today (fillings, cleanings, crowns, etc.), almost 50% of my practice is devoted to the treatment of patients with TMJ, craniofacial pain, neuromuscular orthodontics, jaw joint dysfunction (popping and clicking of the jaw joints), sSleep disordered breathing (snoring and sleep apnea) and postural disorders.
In future posts I plan on explaining how a patient’s bite can affect their jaw joints, muscles, central nervous system, speaking/singing/voice, cardiac/heart, gastrointestinal system/stomach, sinuses/allergies, eyesight, ears, airway/breathing and posture.
If you have any questions for me on these subjects, or any other questions about dentistry in general, please post them below and I will try to answer as many of them as I can.
Stay on trajectory,
Scott L. Tamura DMD, LVIF