Why Teeth Shift as Adults

Eon Engelbrecht – E-Radio-SA:
Welcome again to Save Your Money, Save Your Teeth, the go-to podcast where curiosity meets dentistry straight from the experts. I’m Eon Engelbrecht – E-Radio-SA, and I’m joined once again by Dr Clifford Yudelman – OptiSmile, taking a deep dive into the world of dental care from a consumer’s perspective. Whether you’re looking to brighten your smile or protect your wallet, this podcast has got you covered with practical advice and the latest insights.

Dr Clifford Yudelman – OptiSmile:
Yeah, great, thanks for having me back and I really enjoyed last week’s podcast about jaw problems and clicking and looking forward to today about why my teeth are shifting or why my teeth are getting skew, so I’m ready, ready for you.

*(01:13 – 01:21) Eon Engelbrecht – E-Radio-SA: So Dr Yudelman, what exactly do we mean when we say that my teeth are shifting or going skew and why should our listeners care about it?

Dr Clifford Yudelman – OptiSmile:
Well, we get a lot of enquiries at OptiSmile, a lot of people, their main complaint is my teeth used to be straight and now they’re getting skew or my teeth are shifting. So teeth shifting or teeth getting skew, we talk about the gradual movement of one or more teeth, sometimes it can be a few teeth next to each other from their original aligned position, even if no orthodontic work was done and we can liken this to books on a shelf, slowly leaning over as the shelf settles, the bone and the periodontal ligament, that’s the little ligament that holds the tooth in and the soft tissue is constantly remodelled and adapt and listeners should care because what appears to be purely cosmetic can actually signal early changes in a functional bite relationship or periodontal health or even long-term stability, issues that if ignored can often lead to more extensive and more costly treatment later.

*(02:28 – 02:35) Eon Engelbrecht – E-Radio-SA: And doctor, is it genuinely normal for teeth to move as we get older and what’s happening in the mouth to cause this change?

Dr Clifford Yudelman – OptiSmile:
Yeah, so adult bone is a dynamic living tissue that undergoes continuous remodelling, there’s little cells called osteoclasts, they cause resorption and then there’s other cells called osteoblasts, which cause bone deposition and that’s how orthodontics, how Invisalign or braces works. So after around age 30, bone formation slightly lags behind bone resorption unless there’s a robust mechanical loading and nutrition. The periodontal ligament that connects each tooth to the alveolar bone is under constant micro-strain from normal chewing forces from your lip and tongue pressure and over months or years, this can permit a subtle tipping or a rotation, especially if your teeth were straightened with braces or Invisalign and you’re not wearing retainers, which I think we’ll get into a little bit later.

So the gingival tissues underlying the bone can recede and remodel with time and particularly if your gum health is not optimal and this removes some of the support that keeps the teeth upright. And you know, in short, a little bit of physiological drift, some drifting can be expected, but that degree of movement varies widely depending on your genetics, your bone density and your daily oral forces.

*(04:16 – 04:29) Eon Engelbrecht – E-Radio-SA: That’s very interesting and how big a role do parafunctional habits like grinding or clenching play in the tooth movements? Can they really make everything drift?

Dr Clifford Yudelman – OptiSmile:
Yeah, parafunctional forces which we’ve discussed before, bruxism, clenching, lip biting and so on, often generate up to several hundred pounds of pressure and that chronic overload stresses the PDL and it causes the repeated inflammatory remodelling and over time, these cycles will push the teeth out of ideal alignment, similar to braces or Invisalign. Grinding can accelerate gum recession at specific sites, which will reduce bone support on one side or another and can be uneven and this can encourage tipping or rotation of adjacent teeth and if the occlusal contacts, which is your bite, where your teeth bite together, become uneven due to worn enamel or fractured cusps, as is common when people grind their teeth, some teeth begin to get more load than others and they shift to accommodate a new path of least resistance. In short, parafunctional habits and parafunction can be one of the single greatest accelerators of adult teeth drifting, often silent but relentless.

*(05:44 – 05:58) Eon Engelbrecht – E-Radio-SA: And when we look beyond parafunctional habits, doctor, are there any other everyday factors or anatomical issues like wisdom teeth or orthodontic history that contribute to tooth shifting as well?

Dr Clifford Yudelman – OptiSmile:
Yeah, so look, some dentists believe that wisdom teeth that are partially or impacted can put pressure on the second molar and then that can transmit force through the arch. Myself and the dentists at OptiSmile, we don’t believe that. We see this happening even in patients who have their wisdom teeth out.

A lot of the time, it’s used to scare people to get wisdom teeth out when their wisdom teeth don’t really need to come out and or people come to us, they want their teeth straightened but the last dentist said before they straighten them, they need to get all their wisdom teeth out. We’ve done hundreds of cases where we haven’t taken the wisdom teeth out unless we need to move a second molar backwards to make more space which is very unusual. The main thing is past orthodontic treatment without adequate retention.

And I think I should say that again, if you’ve ever had orthodontic treatment and you don’t wear a retainer, your teeth will move. You need to wear a retainer for the rest of your life. There’s like an elastic memory of your periodontal ligament and remember your tongue and your lip and everything hasn’t changed dramatically after your teeth are straightened and your teeth naturally want to go back to where they were.

And if you don’t wear your retainers, then relapse is almost guaranteed. So we get patients that have Invisalign and their teeth stay straight for four, five, six years and then they lose their retainer and they don’t wear it for three or four months and they come and see us. And it’s funny the teeth have remembered where they used to be and they can start moving back into that position.

That’s amazing. Quite quickly. Yeah.

And so much of the Invisalign treatment that we do at OptiSmile, our patients that used to, that had braces, they know what straight teeth look like and they had a wire that fell off and they didn’t get replaced or sometimes even worse, a wire breaks and a wire that’s partially connected and then acts like a spring and can actually move lower teeth into very unusual positions. That’s a very dangerous situation. If you think your wire behind your lower front teeth is broken, you should see your dentist right away, get that wire replaced.

And we use something called Vivera retainers or Essex retainer. So these are made with a 3D scan to fit over your teeth and you just got to wear them every night. It’s not something you got to wear 24-7.

So minor trauma or tooth loss. So when you lose a molar because it’s extracted, the neighbouring teeth will drift into the newly vacated space and this can over time open interdental gaps and crowns can tip into these spaces at unnatural angles and opposing teeth can over-erupt. So that is something that will start causing a domino effect literally like, I don’t want to over-exaggerate and say like a game of Jenga.

But I just thought of that now. We say dominoes but I think Jenga is more dramatic. If you pull the wrong, you just pull out that one tooth and everything starts caving in.

Restorative changes. So yeah, if a dentist does a new crown for you and maybe the bite is high and you put up with it rather than going back and getting it adjusted, that can cause your whole bite to shift and then often you can lose your ideal alignment. That doesn’t happen too often.

And then like new habits, maybe all of a sudden you started chewing on a pen or pencil that you never did or you started lip biting or all of a sudden started biting your nails when you didn’t do it before. Maybe it’s that new girlfriend. It’s time to have a word with her.

I think we should cut that bit out. Maybe keep it in. Boyfriend, should I say.

Maybe it’s that new partner. It’s that new stress in your life. Call your mom.

Eon Engelbrecht – E-Radio-SA:
Okay.

Dr Clifford Yudelman – OptiSmile:
Call your mom.

*(10:26 – 10:42) Eon Engelbrecht – E-Radio-SA: Dr Yoruman, now let’s say someone notices their front teeth overlapping a bit or the bite line is shifting a bit. What are the real world consequences of leaving drifting untreated? Will they just drift out of your mouth or what’s going to happen?

Dr Clifford Yudelman – OptiSmile:
Yeah, so in this particular case, they won’t drift out of your mouth. This is more like when they start overlapping, which is quite common or this midline shift that has a big aesthetic impact. If your teeth are once straight and they start getting crooked in the front, that’s very noticeable.

And all that orthodontics that you had before is basically now going to waste. It may begin as a minor cosmetic nuisance, but often it can snowball psychologically where it really starts to bug you and you’re not smiling in photos and it affects your confidence. And each couple of millimetres that your teeth move, it just means an extra four or an extra eight aligners if you’re getting Invisalign or other aligners.

Every time your teeth need to move a millimetre, that’s like four aligners. So if you wait another year or two, your treatment could just take longer. And the same with braces, the braces would take longer to work as well.

So don’t wait. If you do notice this happening, it can be quite quick and easy to fix earlier on. So aside from aesthetic impact that we just discussed, there’s occlusal and functional complications.

So misaligned teeth often create uneven contacts and you get accelerated wear on certain teeth and chipping and fractures that can start messing up your TMJ, your temporomandibular joint because you got strain as your lower jaw adapts to the new tooth positions and even being not able to inefficient chewing where you can’t chew properly. Your gum health can deteriorate when you get crowding and tipping, you get retention of plaque in certain areas and gingivitis can progress to periodontitis and it’s not good for your gums to have crowded or difficult to clean teeth. And financial implications, early shifting, like I mentioned earlier, can be fixed quite quickly with some several aligners rather than a whole course of aligners.

Delaying treatment just makes things a lot more expensive and take longer.

*(13:06 – 13:18) Eon Engelbrecht – E-Radio-SA: Retainers, let’s talk about retainers. How do they work and at what point should someone consider them? Are we talking about full-time wear forever or are there more flexible options, Dr Yudelman?

Dr Clifford Yudelman – OptiSmile:
Yeah, so the traditional type of retainer was called a Hawley, I think after Dr Hawley, that’s H-A-W-L-E-Y. That’s like an acrylic plate with a wire. We used to make them at dental school.

So you don’t see a lot of Hawley retainers these days after braces. Generally, the orthodontist will do a fixed bonded retainer. It’s a thin wire that’s bonded behind your lower front teeth.

A fixed bonded retainer, thin wire bonded behind your teeth, usually from canine to canine. It demands meticulous cleaning and it’s quite difficult to clean. And the most common one that we use is a clear vacuum-formed retainer or a 3D-printed retainer called a Vivera or other type of retainer.

These are virtually invisible. They’re easy to make. You wear them at night.

So the wearing of these things, you wear full-time for the first few months to stabilise the PDL, the periodontal ligament. We go quite quickly from full-time to overnight plus two hours in the morning, two hours in the evening. And then you go to nighttime only.

And you can miss a couple of nights a week, but we just recommend wearing them every night. If you do miss one or two nights a week, it’s not a big deal, but you do want to keep wearing them for the rest of your life. And you should always wear a retainer immediately after any orthodontics, especially if you’re waiting to have any other treatment done.

In the meantime, we’re very careful to make patients even temporary retainers. If they’re waiting to get some injection-moulded bonding or some crowns or inlays, if you’ve got any shifting, if you’ve had braces years ago and you haven’t had retainers for a long time and all of a sudden you start to see a bit of shifting or rotation, it’s time to get a retainer immediately before they move further. And for people with low bone levels or gum disease, a retainer can really help.

*(15:23 – 15:36) Eon Engelbrecht – E-Radio-SA: And what about Invisalign? How can clear aligners fix these minor shifts without full orthodontics? And are there age or bone density limitations?

Dr Clifford Yudelman – OptiSmile:
Each Invisalign or aligner is digitally designed to move teeth, specific teeth, by about 0.25 millimetre per stage, which means every four aligners will move teeth about a millimetre and uses gentle and controlled forces and a full series of trays, sequential trays, will move your teeth from the relapse position back into an ideal alignment. Ideal candidates are adults with mild to moderate relapse, single tooth rotation, slight crowding, small midline deviations. The digital software allows for precise visualisation and staging of each movement.

Having said that, we do very complicated cases that can go on for a year or more and fix almost every type of problem. There are some new types of aligners coming out now that are 3D printed and they can actually move teeth even more than, say, traditional Invisaligns and they’ve got shape memory. The plastic has got shape memory and that’s something that we’re looking into at OptiSmile.

It’s not yet available in South Africa, but we will be the first to offer it should we be able to get it in South Africa. So that’s an interesting development. It doesn’t mean to say we’ll stop doing Invisalign, but there will be cases that we’ll be able to use this shape memory.

Bone density considerations, patients with osteopenia, which means low bone density or osteoporosis, may have to wear their aligners for longer. If somebody has severe gum disease, they can still be treated, but more gradually. In some cases, I’m treating a patient at the moment from Stellenbosch where she had one of those retainers that made her tooth go skew where the root was almost sticking out of the bone.

We’re working with a periodontist who’s monitoring, but we’re using the aligner to actually push that root back into the bone so that her gum will be healthy in that area. Compliance and retention, you have to wear your aligners 20 to 22 hours a day. In fact, we recommend 22 hours a day with Invisalign.

These newer shape memory plastics may allow a shorter wear time, like 18 to 20 hours, which will give more flexibility for some people. Upon completion, one has to go into a retainer like a Vivera. If you don’t do your retention, then undermining any success, any straightness, any perfection that we achieved will definitely go backwards.

*(18:36 – 18:45) Eon Engelbrecht – E-Radio-SA: Are there non-orthodontic preventative measures beyond retainers that our listeners can adopt if they’re worried about future drifting?

Dr Clifford Yudelman – OptiSmile:
We’ve spoken about night guards for people that brux or grind their teeth at night. These are those custom fitted hard acrylic occlusal splints which distribute the grinding forces evenly across the arch and they protect your periodontal ligaments and prevent microtrauma from causing your teeth to shift. A soft, chewy one or one that you get from the chemist or like a sports mouth guard won’t do the trick.

In fact, it can make things worse. You want to have optimal oral hygiene, daily flossing, interdental brushing, six monthly professional cleanings, reducing any gum inflammation. Firm, healthy gums will help to anchor your teeth more securely and resist any unwanted movement.

Keep an eye on the wisdom teeth for infections and so on by all means, but I wouldn’t be so quick to pull out wisdom teeth. I’ve done a whole podcast about wisdom teeth and when you should take them out and when you shouldn’t, but if you’re over 30 and they’re completely buried and they don’t give you trouble and they’re not bothering anything, don’t go and get them surgically removed thinking your teeth will magically straighten because they won’t. Avoid harmful habits like we mentioned before a few times, chewing on ice, pens, nails, opening bottles with your teeth.

All of these things, they all add up and it just pushes teeth one way or another and they’re going to move. Of course, your routine dental checkups and we do something annually called a retainer check where patients come and see Dr Harris. They bring their retainers, we check that it fits and we recommend changing your retainer every year.

Eon Engelbrecht – E-Radio-SA:
Okay, and doctor, are there situations where shifting teeth hinted something a bit more serious going on in your mouth?

*(20:52 – 21:01) Eon Engelbrecht – E-Radio-SA: And then finally, Dr Yudelman, if a listener wants to be proactive right now, what are three simple steps they can take this week to protect their smile from unwanted shifting?

Dr Clifford Yudelman – OptiSmile:
So book a retainer check or retention check. If you’ve ever had braces or aligners, schedule an appointment to confirm your retainer is still in place or your clear retainers haven’t gone soft and they still fit properly. If the wire is loose or damaged or your plastic retainer looks all grotty and it’s gone all soft, then get your dentist or orthodontist or OptiSmile to make your new vacuum form retainer or 3D printed retainer as soon as possible because early intervention costs far less than retreating severe relapse.

Identify and minimise any parafunctional habits. Now that we’ve done our three podcasts on parafunctional habits, people know when I say parafunctional habits, they know what I’m talking about. Yeah, so clenching, grinding, any stressful phone calls, you know, tense meetings, etc.

Replace those habits with something more relaxing. And if you suspect nighttime bruxism, ask your dentist about a night guard or a bruxism splint and upgrade your oral hygiene, maybe add some interdental brushes, make sure you’re flossing. If you’re not flossing, then try to learn how to use little brushes.

Focus on areas that are tight or overlapping because those are areas that will definitely get inflamed and you could reduce your bone support there and that could lead to bigger problems in the future. And that’s it for shifting or skew teeth.

Eon Engelbrecht – E-Radio-SA:
And it was very interesting, Dr Yudelman. Thank you so much once again for your time and information that you share with us. We really appreciate it.

Dr Clifford Yudelman – OptiSmile:
It’s a pleasure and look forward to speaking to you on another interesting topic next week.

Eon Engelbrecht – E-Radio-SA:
Absolutely. And also a big thank you to our listeners for joining us. And remember, while we strive to provide valuable insights with this podcast, always consult with your own dental professional for advice tailored to your personal health.

Subscribe to the podcast, also share it with your friends and family and join us again next time for more enlightening discussions as we continue to explore the fascinating intersection of dental health and financial savvy with Dr Clifford Yudelman – OptiSmile. Until then, keep smiling and taking great care of your teeth.

[Speaker 3] (26:30 – 27:14)
Discover the world of dental excellence with OptiSmile. Join us for a weekly podcast featuring Dr Clifford Yudelman, a seasoned expert with 40 years of dental experience across four continents. Gain unique insights and expert dental advice by visiting OptiSmile.co.za for articles that illuminate the path to optimal oral health. If you’re seeking unparalleled dental care in Cape Town, get in touch with OptiSmile or book directly online on OptiSmile.co.za. OptiSmile, where global expertise meets local care.