Episode 88: Bite Collapse, Wear & Early Warning Signs

Eon Engelbrecht – E-Radio-SA (0:03 – 0:39) This is Save Your Money, Save Your Teeth, our podcast here on E-Radio SA with myself Eon and today’s episode features Dr Clifford Yudelman from OptiSmile diving into the dramatic sounding but all too real phenomenon of bite collapse. What does it mean when your bite starts to fail and how can you spot the early warning signs before it’s too late? If you care about your oral health, your facial appearance and avoiding costly dental emergencies, this episode really is a must listen.

Dr Clifford Yudelman – OptiSmile (0:40 – 1:19) Dr Yudelman, welcome back. Thanks. Thanks for having me back. And before we know it, it will be New Year’s. And maybe someone listening to this podcast today will get themselves a new bite for Christmas and the New Year or New Year’s resolution. You never know. I hope our podcasts have been helping people save their money and save their teeth. And today we’ll carry on with that. This will also form one of the chapters in the upcoming book with the same title Save Your Money, Save Your Teeth.

Eon Engelbrecht – E-Radio-SA (1:19 – 1:20) Awesome.

Dr Clifford Yudelman – OptiSmile (1:20 – 1:26) Yeah, we still got about another 20 or 30 good podcasts to go. So let’s keep at it.

Eon Engelbrecht – E-Radio-SA (1:26 – 1:39) Excellent. Now, Dr Yudelman, when you say bite collapse, it sounds really dramatic. I don’t even want to tell you about the mental picture I have. But what does it mean in practical terms?

Dr Clifford Yudelman – OptiSmile (1:39 – 2:52) Bite collapse occurs when the teeth lose significant height due to wear, erosion or missing support. And this reduces the vertical dimension of the face. And research shows that years of grinding or acid damage can shorten the teeth by several millimetres. But never mind research. I mean, we see that every day. I’ve got some dramatic cases where the patients had slowly worn away even more than half of their tooth. You know, if a tooth is nine millimetres long, they were down to four millimetres. And we built those up for them. You know, when the bite collapses, the lower third of your face, so there’s like three or there’s three thirds, you know, there’s always three thirds. You’ve got the sort of upper, the middle and the lower third of your face. So when your bite collapses, you basically, your chin gets closer to your nose. Like if you imagine someone who’s had dentures made and they take their dentures out, then the chin gets closer to the nose.

Eon Engelbrecht – E-Radio-SA (2:52 – 2:53) Oh, yeah.

Dr Clifford Yudelman – OptiSmile (2:53 – 3:03) When the bite collapses, chewing becomes inefficient and the temporomandibular joints, they compensate in unhealthy ways.

Eon Engelbrecht – E-Radio-SA (3:04 – 3:07) So doctor, what are the primary causes?

Dr Clifford Yudelman – OptiSmile (3:08 – 6:36) There’s three main categories for this. So the one we’ve spoken about before is mechanical wear from grinding and clenching. And then we’ve also done episodes about chemical erosion from acidic foods or from reflux, gastroesophageal reflux disease or GERD. So that’s often undiagnosed. People that have chronic heartburn or people that are very overweight or have sleep apnea. You don’t have to be overweight or have sleep apnea to have GERD. I’ve had some fairly, I’d say, normal weight females that have reflux. It depends on your oesophagus and your valves and your diet, etc. And the other one is structural loss, like we just mentioned in the last question about people that have lost several teeth. And especially when you’ve got a handful of teeth on the upper that are missing and more than a handful on the lower and you don’t have any support at the back. And then the lower teeth cross over the upper teeth. We see that sometimes, you know, and the missing teeth or even a lot of patients come see us and they’ve got these old silver fillings or old white fillings that have been cracking and wearing down. And the dentists have just patched those fillings one at a time. And each time they patch it, you know, the bite has collapsed a little bit more, a little bit more. That’s sometimes called supervised neglect. Or there’s a word when a doctor or even a dentist doesn’t actually inform the patient or does something that’s harmful to the patient, that’s called iatrogenic. That’s a nice word as well. That’s, you know, if there’s actually damage to your bite because maybe the dentist put a big filling in and the filling wasn’t strong enough to maintain your bite. And over a few years, that tooth, you know, wore down. Maybe they should have told you that you need an onlay, definitely not a crown in those types of cases. We’ve discussed that about crowns versus onlays. That’s the third cause. And also, you know, studies on bruxism or tooth grinding show that the forces, remember we said they’re like 250 kilogrammes per centimetre, I believe we said last time, you know, these forces when you actually grind in your sleep can be up to six times higher during your sleep than normal chewing. And that explains why bite collapse often gets accelerated at night when people don’t wear a bite plate. A lot of people don’t wear a bite plate. You know, you make it for them, they don’t wear it. So I always make sure I say, you know, are you really going to wear this or are you just going to waste 6,000 rand because it is expensive to do a proper bite plate. So we’re not talking about one of those little vacuum-formed plastic sort of chew toys like a mouth guard. A proper bite plate has got balanced occlusion, et cetera. I think we maybe have to do, we did do and we did the bruxism one, we spoke about bite plates. So, you know, once the enamel weakens, the process just gets faster and faster. In fact, a lot of the patients that we see, the enamel is all worn away on the top and then you enter the dentine and the dentine is soft. It’s almost like wood, whereas enamel is like metal or glass.

Eon Engelbrecht – E-Radio-SA (6:36 – 6:44) Okay. And then, Doctor, what are the earliest warning signs that bite collapse is now actually starting?

Dr Clifford Yudelman – OptiSmile (6:45 – 10:57) So we often see it quite easily on the front teeth. If you look at a teenager, even we see some grinding in teenagers, but if you look at a newly formed tooth on an 8-year-old, the tooth has got rounded corners and a thin edge, but in a 35 or 40-year-old or older patient, those front teeth can be flattened or ground down and they got sharp corners at the edges. There’s small chips. They start chipping little bits out of the front or the back of those teeth, increased sensitivity. When you look at the top of a tooth, you can see like a little yellow sort of dent. That’s your dentine showing through. Gum recession is often a sign of like over… of your bite collapsing. You’ll get gum recession if your tooth is biting sideways and starts flexing and the whole smile starts to look shorter. We get patients that come in and when they’re talking to me, I think maybe they left their upper denture out because I don’t even see the upper teeth because when you get into your 50s and 60s, your upper lip gets a bit longer from gravity and your lower lip gets a bit more flappy and you see the lower teeth. These patients, when they force a smile or you put retractors in, then you can see, you know, a third or more of the tooth is missing because when at rest, you should show one or two millimetres of tooth without even smiling. You should see a little bit of tooth below your lip and if you look at pictures when you were younger, that might have been the case. So if it’s changing, that could be bite collapse. Some patients also find that they can’t really bite into an apple or something crusty because the teeth, they’re not sharp anymore. And these subtle changes, sometimes not so subtle, they’re significant because, you know, the evidence shows that early enamel wear predicts long-term occlusal instability. So the wear on your front teeth now could be the bite collapse in 10 or 15 years time. Yeah, I don’t want to scare people listening to this. You know, we always try and keep a level head. We’re not trying to scare everyone with a bit of wear or a few chips on their front teeth to go to the dentist and get the entire bite restored. You know, some dentists may take advantage of people like that, that can be a little bit paranoid and self-diagnosed. And like we always say, you know, don’t just listen to the podcast and then go and expect that treatment from your dentist. You always need to rely on your own dentist judgement. And if someone is telling you you need 10 or 20 crowns, always go and get a second opinion. I had a patient in like that earlier this week just to do one of those little bite adjustments that we mentioned before. But she came to us, she liked the dentist, and she’s got the funds to do crowns on the lower. She’s got all up to her sevens, her 12-year molars. So she’s got 14 lower teeth. She’s had some crowns on the upper six front teeth, but her dentist told her she needs crowns on all her lower teeth to open her bite. And in her case, she had a cross bite where the lower teeth were biting completely inside of the upper teeth. And we’re going to fix that with Invisalign. We won’t be drilling any teeth. So lucky for her, even though the cost was not an issue, she didn’t go for… a financial cost was not an issue, but she really didn’t want to file down her teeth. That’s the biologic cost that we’ve spoken about. And also, she’d had some bad luck with her upper. She’s got a couple of crowns on the upper, and I think there’s three crowns, and two of them have cracked more than once. So she thought, if I go and get 14 crowns, and I’ve had so much trouble with two, what’s going to happen with 14? So we’re very happy she came to see us, and we’re going to sort her out without any crowns, just some Invisalign.

Eon Engelbrecht – E-Radio-SA (10:57 – 11:03) And how does bite collapse affect your long-term oral health?

Dr Clifford Yudelman – OptiSmile (11:03 – 11:56) We mentioned before that increases the risk of cracked teeth. Your fillings will break. You’re going to end up with a lot more root canals. If you split a tooth, maybe a split tooth, which would lead to an extraction. You can’t root canal a split tooth. You have to pull it out. You get joint inflammation when you touch your joints, or when you yawn, your joint is sore. A collapsed bite can overload the remaining teeth and create a cycle of emergencies. And the jaw joints may click or pop with pain. If you get clicking or popping, in general, it’s not a big deal, but it should get looked at. But if you have pain, that’s a problem. And the muscles often work harder, and that leads to chronic fatigue in the jaw and in the neck and in your temples and gives you headaches.

Eon Engelbrecht – E-Radio-SA (11:57 – 12:00) It changes your facial appearance, like you mentioned earlier.

Dr Clifford Yudelman – OptiSmile (12:00 – 13:07) For sure. The loss of vertical dimension changes those proportions. Your lips can appear thinner. You get more wrinkles around the mouth. Often when we open someone’s bite or restore their bite, their lips are supported, far less wrinkles. They look so much younger. I mean, I’m not trying to sell a magic treatment, but people go and spend money on fillers and Botox and skin peels and even facelifts. Meantime, the problem is the bite has collapsed and they just need their bite restored and their teeth made longer. Of course, it’s cosmetic, but it also is functional. And the whole lower part of the face can look more sunken, like we mentioned. And studies in aesthetic dentistry has actually proven that when you restore the bite, it rejuvenates the facial appearance without surgery. I think that’s a good takeaway there. You know, patients definitely look younger after they’ve had bite correction.

Eon Engelbrecht – E-Radio-SA (13:08 – 13:14) And tell us, doctor, how do you diagnose bite collapse there at OptiSmile?

Dr Clifford Yudelman – OptiSmile (13:15 – 14:55) We combine the digital scans. We do high resolution photography. There’s 3D bite simulations. We assess your muscles, your joint movement. We check the balance of your bite forces. The digital dentistry lets us compare the patient’s current teeth to an ideal expected anatomy. In fact, with all of the scanners now, there’s something called time lapse. So if we’re not sure if maybe most of the wear was in your previous phase in your life, maybe in your 20s, you were drinking a lot of Red Bulls and grinding your teeth. And now you’re married with two kids and you chilled maybe on anti-anxiety meds and you’re sleeping well. You know, maybe you treated your reflux. Maybe this wear that we see is more stable. So in cases like that, we don’t rush to go and open everyone’s bite or fix a bite, you know, moderate or mild collapse. We scan you and then we can scan you a year later and compare the two scans like a heat map where the heat map will show us, oh, you’ve lost a tenth of a millimetre here or this is chipped off or you’ve lost up to half a millimetre here. I mean, if you’ve got current wear, if your teeth are wearing down and it’s going faster and faster, there’s ways to actually scientifically measure that too with great accuracy. And that’s where we’re seeing a leading digital dentist, which is our trademark as I mentioned before at OptiSmile. Digital dentistry is really it’s here and it’s now and that can really help.

Eon Engelbrecht – E-Radio-SA (14:55 – 15:02) Doctor, what happens if someone ignores these early signs of bite collapse? What’s going to happen?

Dr Clifford Yudelman – OptiSmile (15:03 – 16:35) So the wear accelerates. A slightly worn tooth can become a fractured tooth. A cracked filling can become a crown or an onlay or we mentioned a split tooth can become a future implant. The weakened enamel surface then exposes the dentine and dentine is the yellow part of which wears up to seven times faster and then eventually people reach a point where a full mouth rehabilitation becomes the only option. So early intervention prevents this. That’s really where we’re at OptiSmile. We do have a prosthodontist that does a lot of full mouth rehabilitations on patients where they’ve been to their dentist and the dentist can see that they’re beyond any kind of Invisalign or anything. And they literally need every tooth in their mouth ground. There are cases like that. And I would say that very few general dentists, even myself included, have the experience to do a full mouth rehabilitation to the level of a prosthodontist. There are some dentists in Cape Town and in Joburg. But if your dentist is suggesting 28 crowns, I would get a second opinion with a prosthodontist. That’s a person that is specialised an extra four years or more at university just in bite collapse and putting crowns on teeth. There’s your save your money and save your teeth tip for today.

Eon Engelbrecht – E-Radio-SA (16:36 – 16:43) Doctor, can you take us through some of the treatment options that exist for bite collapse?

Dr Clifford Yudelman – OptiSmile (16:43 – 20:21) Mild to moderate cases can often be treated with clear aligners. We use Invisalign and we’re now starting to use some 4D printed aligners. They look very promising. It’s still in the sort of guinea pig phase on staff and family members. Basically, we can reposition the bite and combine it with composite bonding, injection moulded composite and rebuild the worn surfaces. So that’s very common for us. We’ve done some extensive cases that I don’t think that many other dentists wouldn’t maybe even attempt or think was possible. And we’re seeing very nice results. Even six years later, a lot of cases without even any chipping or further wear. Just a disclaimer there. These patients are wearing retainers every night. They never sleep without protecting their teeth from the grinding that originally caused the problem. More severe cases may require ceramic restorations or a full mouth rehabilitation like I mentioned. It’s always better if possible to go for partial coverage restoration like an inlay or onlay or they call it like a crown veneer where it covers the top and the outside of the tooth. You’re not filing the whole tooth down. A lot of dentists these days I see just go straight to zirconia crowns where they basically turkey teeth, all of your teeth, they file them down. You remove 60% of your tooth when you go all the way around with a drill to put a crown on. And some people, the public are misled that that’s really the way to go and they’ll never break and they’ll never come out. But you get lots of those teeth end up with root canals. There’s a big cost to replacing them. If you get cavities underneath, you can often lose a tooth and end up with an implant. And you just, in many cases, unless it was done properly or by a prosthodontist, you’re looking for a lifetime of more expense and problems. So conservative is always the way to go. That’s the main theme behind our podcast, even behind the name, Save Your Money, Save Your Teeth. And the goal is to rebuild the vertical height, restore the functional guidance, and all the evidence supports that restoring the bite reduces muscle overactivity and protects the teeth in the long term. Just an aside, my son-in-law, he used to grind his teeth terribly and bite his nails. And I’ve had lots of experience repairing his bonding. It was one of the first injection moulded composite bonding cases I did. And he just kept chipping and breaking them. They can chip and break if a patient doesn’t wear a bite plate or retainer. And then just recently, we 3D printed six onlays, three on each side, no drilling or anything. We just scanned his teeth, 3D printed all six in about 10 minutes and polished them and glued them on. The whole visit was less than three hours, as I said, no drilling. And that was a good three, four months ago. And he hasn’t chipped a single tooth because we addressed his collapsed bite. And that was with 3D printing. And I believe that you actually may have a question for me about 3D printing.

Eon Engelbrecht – E-Radio-SA (20:22 – 20:29) Yes, I actually want to ask you, where does digital dentistry and 3D printing fit into the whole process, doctor?

Dr Clifford Yudelman – OptiSmile (20:30 – 23:38) Good question, especially since I might have already answered it. So digital design allows us to plan the ideal bite before we touch the tooth. So we can preview the proposed results. We can print test models. We can refine the design. So when I say that my son-in-law came in and we printed these things and glued them on, we did a test run. We actually put special wax between his teeth and to the thickness that we wanted to open his bite and then scanned him in that position and then transferred that into the dental software. And then we designed the new tops for his teeth with that in mind. And we tested them on a model. And we can refine the design. It reduces risks and it improves precision. And the modern materials, such as these nanohybrid composites that have up to 60% or 70% filler, high-strength filler, allows us to restore teeth with more longevity. Traditionally, milling an inlay or an onlay, even from Emax, on the top of the tooth, you need a minimal thickness of a millimetre for these milled restorations. And they can sometimes crack because sometimes there’s areas like in the grooves that are thinner. Whereas with 3D printing, we can print as thin as 100 microns, which is one layer that’s thinner than a hair. So we can print a restoration for the top of your tooth. And you’ve got to keep in mind, well, not keep in mind, just I’ll tell you a little interesting fact. If we make, like on my son-in-law, like some inlays or onlays that we glue on the top of the back teeth, and they’re even a half a millimetre thick at the front, your front teeth will be opened by a factor of four, which means that now he’s got a gap. He actually can’t bite his nails. We would have to now build up his lower front teeth, which are very worn down. They’re like little stubby teeth. And we were never able to build those up before because of his bite being collapsed. So the digital 3D printing and that is amazing. And it’s here now. There are some dentists in South Africa that have a fair amount of experience in it. Some of them even more than me. I’ve just bought two courses from overseas at a cost of 20,000 rand a course. I finished the first one on the inlays and the onlays before I did my son-in-law’s teeth. And I’m busy working my way through the 3D printed veneer. And the sort of partial crown one, and then there’ll be, you know, family and friends and staff members, a bit of a guinea pig phase for that. But all the research and everything, it’s not experimental. It’s more for us to get up to speed with the technique because it is a very new technique, new materials that are well researched and look amazing, especially for wear like this and collapsed bites.

Eon Engelbrecht – E-Radio-SA (23:38 – 23:44) What is the single most important takeaway for our listeners today?

Dr Clifford Yudelman – OptiSmile (23:44 – 24:34) Don’t ignore any small chips anywhere. When you look, if you see those little yellow sort of ditches in the back teeth, you know, jaw tension. These are not only cosmetic issues, although there might be cosmetic issues, but they’re also mechanical warnings. Bite collapse, complete bite collapse is preventable when diagnosed early. A digital assessment can identify problems long before any symptoms develop and monitoring them or wearing a bite guard, a night guard, bruxism splint, like in one of our earlier podcasts and or correcting them with Invisalign and bonding and 3D printing, or maybe some onlays if that’s called for. All of this will protect your smile, your comfort and your quality of life.

Eon Engelbrecht – E-Radio-SA (24:34 – 24:40) There we go, Dr. Yudelman. Thank you so much for another great edition of Save Your Money, Save Your Teeth.

Dr Clifford Yudelman – OptiSmile (24:40 – 24:45) Thank you. And yeah, looking forward to next week.

Eon Engelbrecht – E-Radio-SA (24:45 – 25:33) Absolutely. And that wraps up our deep dive into bite collapse and the early signs that you shouldn’t ignore. As Dr. Yudelman emphasised, small chips, wear or jaw tension are not just cosmetic. They’re mechanical warnings that deserve attention. So early intervention can protect your smile, your comfort and your quality of life as well. Thanks for joining us on Save Your Money, Save Your Teeth. Remember, while we strive to provide valuable insights, always consult with your own dental professional for advice tailored to your personal health. Now, don’t forget to subscribe and share this podcast for more expert advice and practical tips for lifelong dental health. We’ll see you next time.

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