Bite Opening in Children

Eighty percent of the jaws of a child develop before the age of 10. Modern trends in jaw and tooth development show that children still suffer from early childhood decay (ECC), and the jaws are not developing to their fullest potential during these critical early years. Basically, the genes we have for large jaws are not being properly expressed. Call it environmental influence, call it lack of proper diet and function, call it allergies. I will not discuss that issue here. However, I will discuss the terrible consequences as it relates to dental and general health.

First, an analogy.

Consider the room in the mouth as an actual room. The oral cavity of a child with a small jaw size (and consequently no spaces between baby teeth) can be compared to a small room where you find it hard to fit in or move around.

The oral cavity of a child, on the other hand, with worn down teeth and a deep bite can be compared to a room with a low ceiling. You can’t even walk in it upright.
A deep bite in children is confirmed if you cannot see the lower incisors when they bite down.

Who are we talking about? The tongue! The tongue grows to its genetically determined full size regardless of how much space is allowed within the oral cavity. Its functions, besides tasting, include phonetics (speech pronunciation), swallowing, and indirectly, keeping the airway open.

Place the tongue in a room with smaller dimensions (constricted jaw), OR a low ceiling (deep bite), OR both, it will not fit comfortably and cause serious long-term consequences.

Here is a list of these consequences as it relates to each of the tongue’s functions.

  1. Phonetics: children will tend to lisp due to a combination of insufficient space for the tongue and an altered programming of the muscles.
  2. Swallowing: Children will exhibit tongue thrust. The tongue just cannot find enough room to accommodate itself and protrudes between the teeth every time a child swallows – around 1000 to 2000 times a day. This repeated action causes the teeth to spread apart and develop a gap (open bite). This in turn will cause an occlusal (bite) probem not to mention bad esthetics.
  3. Airway: The most serious consequence of all, a blocked airway will result due to the tongue falling back and obstructing the already narrow airway in the back of the throat. This is known as childhood sleep apnea, which is hardly diagnosed by paediatricians or general dentists unless they know which signs to look for. The signs, ironically, to look for in children, are different than those in adults.
    1. increased hyperactivity with an inability to concentrate during the day,
    2. grinding of teeth at night
    3. dark circles under the eyes.
    4. bedwetting.
    5. frequent earaches.

Grinding and snoring in children is not normal. If the child is 4-7 years old, grinds and snores, and exhibits some of the abovementioned signs, and has a small jaw size, a deep bite, or worn down lower incisors, then the first step we take is to build up the vertical dimension on their baby molars. This in itself will be sufficient for this early age, without resorting to removable appliance therapy, to provide a sound solution for improving airway and function. It will have a permanent orthopedic effect on the jaw as the permanent teeth erupt to a restored vertical dimension and even alleviate some future crowding. After age 7, arch development can still be initiated with appliances if there is an arch deficiency.

Bite opening procedure: a bite key is constructed to fit behind the top incisor teeth. This is adjusted to create the desired vertical space between the back lower baby molars (two on each side). Their fissures are cleaned out t(to prevent future cavities), they are then primed and bonded with composite. Before the composite is cured, the child is instructed to bite into the upper key to mold the still soft composite into the correct shape and vertical dimension. After all composites are placed, they are adjusted and polished. These children adapt surprisingly fast to their new bite and by the time these baby teeth are lost, the jawbone and the permanent molars coming in behind them will have grown to consolidate that position.

Before (top) and after (bottom) the bite opening procedure

Front and side view after another bite opening procedure.

To read more about jaw development and jaw orthopedics, please read more in these links:

One-sided Crossbite in Children

The one-sided (unilateral) cross-bite in children, is a condition that should be immediately addressed or at least as early as possible. As a rule, the upper teeth should overlap the lower. When, however, the upper jaw does not develop properly, the upper arch holding the teeth will be smaller than normal. The lower teeth will not fit under the upper in the usual manner. In order to do so, the jaw, in an attempt to cause the maximum number of teeth to come together, will shift the jaw slightly to one side, causing a one-sided crossbite, in which only on one side the lower teeth are brought to overlap the upper teeth.

This condition should be addresses immediately, as the consequences are as follows:

  • Results in asymmetrical growth of the lower jaw, and thus the face.
  • Restricts the growth of the upper jaw.
  • Increases the risk for jaw joint (TMJ) problems in the future.
  • Causes insufficient space for the tongue, resulting in an increased risk for childhood sleep apnea and lisping.
  • Esthetically compromised appearance.

Parents, pediatricians, ENT specialists, and general physicians should be able to spot this condition and refer to a dentist or orthodontist who has experience in functional jaw orthopedics or appliance therapy. Treatment can be initiated as early as age 5, and involves a simple removable appliance that encourages growth of the upper jawbone (maxilla).

About the Biomimetic Principle

Biomimetics is a new concept in dentistry with one goal in mind; returning a tooth back to its natural state as much as possible.  This process involves the mimicking of a natural healthy tooth when performing a dental restoration.  According to Dr Magne, chairman of esthetic dentistry at USC and one of the foremost researchers in the area of bonded (non-metallic) restorations, “the physiological performance of intact (non-diseased) teeth is the result of an intimate and balanced relationship between biological, mechanical, functional, and aesthetic parameters.”  He explains that natural teeth, through the optimal combination of enamel (the hard outer coating) and dentin (the softer underlying organic structure) constitute the perfect and unmatched compromise between stiffness, strength, and resilience.  Alterations in the structural integrity of teeth due to restorative procedures and changes due to aging can easily violate this subtle balance, ultimately leading to increased failure.  By following biomimetic principles, we can strengthen teeth by increasing their resistance to crown deformation.  This is done by only removing diseased tooth structure and using modern advanced materials which imitate natural tooth mechanics much more closely than materials used in the past.

The biomimetic approach is not only tooth conserving, but it is also functionally and biologically sound.  It is in sharp contrast to the traditional crown technique, which renders the underlying tooth structure hypo-functional due to its stiffness and rigidity. It is important to note that hypo-functionality caused by the crown technique also leads to an increased incidence of pulpal deterioration resulting in avoidable root canal treatment.  A good analogy of this concept is having an arm weaken or atrophy due to being placed into a cast for a prolonged period of time.  In addition, we often notice gum irritation due to traditional crowns being placed under the gum to hide the metal edges.  These are all avoidable problems using biomechanically sound bonded restorations.

“The goal of biomimetics in restorative dentistry is to return all of the prepared dental tissues to full function by the creation of a hard tissue bond that allows functional stresses to pass through the tooth, drawing the entire crown into the final functional biologic and esthetic result.”

The biomimetic principles are very much in agreement with our existing treatment philosophies.  We are excited to integrate these principals in our office.

Out-of-state Patients

For all prospective clients wishing to visit our office and receiving treatment by Dr Sarkissian, rest assured that your trip may end up being a pleasant and lucrative one.

Since Dr Sarkissian provides a biologically-oriented comprehensive treatment plan considering all aspects of your health related to the mouth, the jaws and the teeth, your benefits from visiting us may outweigh the associated cost and time to travel out to Los Angeles. The meticulous planning and coordinating we offer will definitely serve to your advantage, in particular if you have a multitude of dental problems and work to accomplish. We will block out all your future visits and appointments once the treatment plan has been made, and will make sure that your treatment is relaxed, comfortable and smooth. We have a wonderful network of services and practitioners for your other needs, including naturopaths, homeopaths, massage therapy and body work, biocompatibility testing, acupuncture, and ultimately, a luxurious day spa. We can coordinate everything for you if we have ample notice.

To facilitate efficient handling, please use the following guidelines:

  1. Contact our office at least 1 month before your expected travel date.
  2. Obtain high-quality copies of X-rays pertinent to your case and mail them beforehand.
  3. Make a chronological list of dental treatment received, a chronological summary of health and medical history including dates of ONSET of specific problems or ailments, and a list of supplements, medications and remedies, including naturopathic or homeopathic remedies. Send these by mail.
  4. If you intend to start treatment on your first visit, please book a 3-hour appointment the first day, and plan to stay for a few days, as determined by the treatment plan. Our office will contact you to arrange further appointments. We can also assist you in finding a place to stay.
  5. Please download our forms, fill them out and mail them back to us. You find them in the main menu on the left under Forms.

Mouth Breathing

Mouth breathing is a serious matter. In children of growing age, it may have devastating effects on general health and growth. Many seemingly unrelated conditions are related to mouth breathing.

Chronic allergies, tonsil hypertrophy, nasal polyps, deviated nasal septum, constricted upper airways, a backward positioned lower jaw caused by thumb sucking, excessive pacifier use or insufficient suckling as an infant.

Signs in Mouth Breathers

  • Long, narrow face
  • Difficulty breathing through nose
  • Retarded physical growth
  • Dry lips
  • Dark circles under eyes
  • Excessive creases between lower lip and chin
  • Allergies
  • Smaller jaws with crowded teeth
  • Swollen tonsils

Consequences of Mouth Breathing

  • Jaw deformity
    The jaws and subsequently the whole facial structures grow in an altered fashion, resulting in long faces, constricted arches, tooth crowding, a narrowed nasal airway passage, and an altered head posture. The lower jaw remains too far behind in its growth, producing a small chin, dental malocclusion, a large overjet, and an unfavorable profile. If the mouth breathing is addressed, these children can often be treated for their malocclusions and skeletal growth discrepancies by a dentist or orthodontist who follows a functional-orthopedic approach.
  • Compromised airway
    Caused by: 1. the lower jaw being positioned too far back, along with the tongue, thereby constricting the upper airway. 2. Enlarged tonsils and adenoids due to chronic allergies may be the primary cause for mouth breathing, however mouth breathing in itself will also cause a further increase in tonsil size, thus constricting the airway to such an extent, that normal nasal breathing becomes an impossibility.
  • Altered head, neck and body posture
    The unnatural and unphysiological process of breathing through the mouth, which in many children looks like they are “gasping” for air, produces a reflex forward head posture. This puts a large load on the upper back and neck muscles, which if sustained, will cause permanent posture changes, such as abnormal curvatures in the cervical and thoracic vertebrae, and an altered shoulder posture. Ultimately, we see a domino effect affecting hips, knees and feet. In adults, Jaw joint dysfunction (TMJ problems).
  • Bad breath and gum disease
    Caused by the shift in the bacterial flora in the mouth.
  • Lowered immune system and poor health
    Nasal breathing produces a tissue hormone that regulates normal blood circulation. It also filters, warms and moisturizes the air. The lack of oxygen in mouth breathers, who usually snore at night and struggle for air, weakens the immune system, disrupts deep sleep cycles, and interferes with growth hormone production.
  • Obstructive sleep apnea (OSA)
    In newborns, this is thought by many researchers to be related to SIDS, or Sudden Infant Death Syndrome. In children, this is manifested as snoring, bed-wetting, poor quality of sleep, obesity, and ultimately behavioral symptoms resembling ADHD.
    In adults, OSA is a silent killer. Snoring is a manifestation of a blocked airway, which in essence is a milder version of sleep apnea. Most snorers, however, may not be aware that they may be suffering from OSA. On average, snorers are more likely to suffer from cardiovascular disease and stroke, and carry an increased risk for obesity, high blood pressure, stroke, severe obstructive sleep apnea, and diabetes.
  • Poor performance
    The same lack of oxygen and other hormonal factors make these children tend to be overweight, tired, and not perform well at school. Physically they are not athletic.

Mouth breathing in children should be addressed as soon as possible by consulting a physician, a dentist, a myofunctional therapist or an ENT specialist, who are experienced in treating this condition.

For recommendations to handle mouth breathing please view and download the article Recommendations for Mouth Breathers.

Guidelines to a Beautiful Smile

L.A. Health News

Who does not know that a beautiful smile with healthy-looking, naturally white and proportionately shaped and sized teeth is a precursor to an esthetically pleasing image that we strive to create in our lives. Not only is it a trademark of health, beauty, and young age, but it also plays a significant role in our social, business and sexual interactions.

In this modern era, many possibilities exist, using a blend of artistic creativity and science, to create the dental image that we are longing for. Important is, however, before embarking on such a metamorphosis, to determine the limiting factors. Is the image you want to create technically feasible? Does it conform to your facial type? Is it too invasive? Most of the time, given the right circumstances, it does not have to involve harrowing sessions in the dental chair, nor does it have to be as invasive as you might think.

In evaluating our dental appearance, we tend to overlook some other factors compromising esthetics. If the lips are too thin with pronounced wrinkles at the corners of the mouth, and the teeth do not show enough upon smiling, it means that the vertical relationship between the upper and lower jaws has been diminished through poor dental work or heavy wear. Likewise, past orthodontic therapy, where teeth have been extracted, many times produce a flat face with small arches, retruded teeth and thus, flat, thin lips. TMJ symptoms are not uncommon in such scenarios.

If one studies photos of beautiful models, one will notice that, apart from large, white teeth,

  1. They have a broad smile with full visibility of their teeth supported by a broad dental arch.
  2. Their teeth follow a curve line parallel to the lower lip line.
  3. They have a convex profile with fully supported lips, meaning that there was adequate forward growth of the bone structures supporting the front teeth, and the teeth themselves are inclined forward, rather than backward.

Today, in children between the ages of 6 – 12, some dentists intervene with functional orthopedic appliances to encourage a pattern of growth, that will produce an esthetically pleasing profile. In adults, however, who have ceased growing, and who do not intend to undergo extensive brace therapy, there are still ways to improve function and esthetics by rebuilding teeth to approach the esthetic standards mentioned above.

Modern porcelain materials and sophisticated bonding agents allow us to rebuild teeth using minimal tooth reduction and no metals. In a coordinated sequence of treatments, failing silver fillings and leaking crowns and bridges are removed, and decay is cleaned out using lasers. In this process, healthy tooth structure is conserved, and the gum-line is not violated. Restorations are made using porcelains that resemble natural tooth. Unfilled teeth, if needed, are left untouched by the drill, and are overlaid with porcelain, just like veneers.
A newer understanding of the dynamics of jaw and neuromuscular function, along with a stepwise technique allow us to keep a healthy and harmonious bite relationship, even after regaining the lost vertical relationship between the teeth. This slight “bite opening” creates enough leeway space for reconstructing a completely new chewing surface with proper tooth anatomy on the back teeth, and at the same time allows us to later design longer veneers for the front teeth, enhancing the smile even more.

Health-conscious Dentistry for the Future Generation

L.A. Health News

Today, we as parents, most of us are spending tens of thousands of dollars to fix your teeth, and most of it to repair dental work done (or often not done) during your childhood. Tomorrow, as our children grow into adults, and face the challenge of repairing their past dental work, that amount will rise ten-fold, as dental fees skyrocket and insurances pay less. It is a known fact, that most costly dental treatment in adults involves teeth that have been treated throughout the ages 8-18.

When a tooth with a neglected cavity is restored, many times its integrity is invaded, thereby starting a sequential downward cascade of re-filling with a larger filling, root canal, crown, extraction, bridge, partial denture. Along this path, heavy expenses, time away from work, pain, gum disease, TMJ, long-lasting anxiety and fear, health problems. Sounds familiar?

A filling is really not just a “filling”. A tooth’s restoration may range between a 10-minute, indiscriminate, “grind and pack”, to a detailed, conservative, bonded tooth-colored filling. The live tooth structure can be ground away at a startling speed of 400,000 RPM, or with the gentler electric drill at 40,000 RPM, or nowadays, with the ultimate in technology, the tooth-friendly LASER, which removes decay without even physically touching the tooth. All these, and many other factors, will determine how far along that downward cascade a certain tooth will follow, and how much misery and expense it will cost your child in adulthood.

We have entered the era of prevention, cosmetics, and laser micro-dentistry. Many dentists are now trained in extremely conservative and tooth-friendly ways to restore a tooth. Advances in diagnosing and filling early cavities, high magnification, lasers, and advanced bonding and filling materials should eliminate outdated restorative options for the new generation.

Most parents nowadays are eager to have their children get braces. Believe it or not, there are many options even for orthodontic therapy. In many cases, fixed braces can be avoided altogether, if removable appliance therapy is implemented earlier on in childhood, as early as 7. Between this age and the end of the pre-teen growth spurt, which ranges between the ages of 11-14, a lot can be achieved by appliances. These influence and steer the natural craniofacial growth patterns of the jawbones, to create larger arches, more space for all the permanent teeth, and a harmonious spatial relationship between the jaws and the skull. Mainstream orthodontics, on the other hand, may align teeth, but sometimes at the expense of four healthy teeth, small dental arches, stunted roots, a higher risk of decay, and retruded upper and lower jaws, resulting in a flat profile. Other problems that only manifest years later may be in the form of “TMJ”, premature wear of teeth, and sleep apnea.

Unlike yesterday, there are many options in treatment and materials, and parent education and informed consent on all procedures, material compatibility and durability, is and should be a part of all treatment of minors. With the big issue of mercury in silver amalgams, and a higher incidence of chemical sensitivities in the population, a biological and naturopathic approach to dental issues is a necessity not only for dentists, but also for all physicians, including pediatricians. The right choices we make today for the growing generation will be only appreciated later.

yesterday, there are many options in treatment and materials, and parent education and informed consent on all procedures, material compatibility and durability, is and should be a part of all treatment of minors. With the big issue of mercury in silver amalgams, and a higher incidence of chemical sensitivities in the population, a biological and naturopathic approach to dental issues is a necessity not only for dentists, but also for all physicians, including pediatricians. The right choices we make today for the growing generation will be only appreciated later.

The Benefits of Biological Therapies in Dentistry

Today homeopathy is an often used system of medicine which is not only safe, but also has no harmful side-effects. It involves remedies chosen on a highly individual basis. In the dental field it offers surprisingly effective therapies for toothaches, gum disease, abscesses, ulcers, children’s teething problems, dental fear and anxiety, etc. Since homeopathy acts on an energy level, it acts extremely well on children especially, because of their high energy, vitality and purity.

Herbal remedies can be used as teas which stimulate the body’s immune system and its detoxification mechanisms, and also as natural constituents in mouthwashes and toothpastes. Some herbs are not suitable for children, pregnant women, for those on anti-depressive or other drugs, or with liver damage. Please consult your physician before using herbs internally.

Aromatherapy, hypnosis, acupuncture, bioresonance, low level laser, biomeridian and bioenergetic therapy, applied kinesiology, osteopathic therapy and nutritional therapy can all have applications in dentistry. A biological dentist uses a multidisciplinary approach in utilizing these services, or referring a patient to specialists in complementary therapies, thus benefiting the patient as a whole.

Lasers in Dentistry

L.A. Health News, December 2004

The laser has now ultimately infiltrated the world of dentistry. This amazing technology, which has been the centerpiece of futuristic and science fiction myths, has actually found numerous applications in medicine over the past three decades. Nowadays, it is an everyday reality in an increasing number of dental offices. There are many types of dental lasers, but I will refer mainly to the ones that can be used on hard tissue such as teeth. Developed into streamlined machines and equipped with efficient delivery systems, these can be used to prepare cavities, sterilize root canals, treat periodontal pockets, trim gums, and assist in soft and hard tissue surgeries. Many of them work by emitting pulses of laser energy, which excite the water molecules on the surface of the target tissue, making them break away in microscopic layers. This is termed “hydrokinetic energy”, and since it does not involve heat and vibration, there is hardly any pain in most procedures.

Examples of their uses in dentistry are as follows:

  1. Preparing tooth cavities for placement of bonded fillings. Used in place of the drill, it gently removes tooth structure layer by layer, without even touching the tooth. Children love it. Used correctly, it is safer than the drill, in spite of misconceptions over the word “laser”. In fact, this piece of equipment is one of the safest gadgets used in the mouth. As the cavity is cleaned out, there is a simultaneous sterilization in effect, and a surface is created which produces a superior bond with bonding agents.
  2. Fissure sealants: It is a well-known fact that along with cosmetics, preventative procedures will lead the way in modern dentistry. Along with improved oral hygiene programs, cleaning out the deep grooves, or “fissures”, on the chewing surfaces of teeth, and placing bonded sealants in them, constitutes a significant measure in the prevention of dental cavities. The laser is ideal for this purpose, as it obliterates the soft, decalcified and decayed enamel, along with bacteria and organic matter – namely the precursors of cavities – found in the microscopic depths of these fissures.
  3. Preventing root canals: Most root canals arise after bacteria from deep cavities invade and infect the nerve chamber. Many times, however, the process of using a drill to clean out decay so close to a live, but compromised nerve, will irreversibly traumatize it through high-frequency vibrations, or even crush the dentine and drive bacteria deeper into the nerve. This by itself may be the last straw, and cause a root canal. The laser, on the other hand, causes no vibration, structural damage, or heat. It will gently remove infected tooth structure in close proximity to the nerve and kill bacteria, thereby greatly reducing chances of a root canal treatment.
  4. Debriding and disinfecting root canals prior to placement of the filler material. The laser beam unclogs the dentinal tubules and kills bacteria.
  5. Treatment of gum disease. Today there is irrefutable evidence that people with gum disease run a higher risk of heart disease and diabetes. Conventional deep cleanings of infected gum pockets often result in millions of bugs entering the bloodstream and causing havoc. The laser is used as part of a thorough gum treatment protocol to safely disinfect pockets, and stimulate the diseased epithelium before undertaking more invasive measures.