When jaw pain is a bite problem, it is a prosthodontic problem.

There is no shortage of "TMJ specialists" on this side of town. Look closely and most are general or cosmetic dentists offering a night guard and a course of adjustments. Some sell a philosophy. Very few can tell you, before touching a tooth, whether your bite is the cause of your pain, a contributor to it, or nothing to do with it.

Prosthodontics is the dental specialty concerned with how teeth meet and function together, covering the diagnosis, planning, rehabilitation and maintenance of oral function, comfort, appearance and health. When a jaw problem is driven by where the teeth meet, by a collapsed bite, or by restorative work that put the bite in the wrong place, it is prosthodontic work.

That distinction is the whole job, and it is what prosthodontists are trained for. Dr. Reshad's background in this subject is not a weekend course:

— Former Chairman of Fixed Prosthodontics and Operative Dentistry, Herman Ostrow School of Dentistry of USC, the department that teaches occlusion to the next generation of dentists.

— Author of The Influence of Posterior Occlusion When Restoring Anterior Teeth (Journal of the California Dental Association, 2008), on the exact mechanism behind most bite-driven jaw problems.

— Author of the textbook chapter Occlusion, Posterior Support, and Occlusal Overload in Implant Dentistry (forthcoming), which sets out the protocol described on this page, and of the chapter on full-arch framework design, material selection and clinical protocols in Full-Mouth Implant Reconstruction (Quintessence Publishing).

— Editorial board, Journal of Esthetic and Restorative Dentistry; clinical editor, Spectrum Dental Teamwork. Fellow of the International College of Dentists.

— Trained at King's College London and the Eastman Dental Institute (MSc with Distinction), then advanced prosthodontics at USC. Practices limited to prosthodontics in Los Angeles and London.

— Runs an international mentorship program in which dentists travel to Los Angeles to observe his cases.

In plain terms: the dentists who treat bites learned it from textbooks and departments he has contributed to. When the case is complicated, this is where it should start.

This is the mechanism Dr. Reshad published on in 2008 and has since written the textbook chapter on, and it explains the majority of bite-driven cases we see.

Back teeth are built to take the vertical load of closing. Front teeth are built to guide the jaw sideways and forward, and to separate the back teeth the moment you move. When back teeth wear, break, drift or are lost, that load transfers forward onto front teeth that were never designed to carry it. The upper front teeth are pushed outward, the bite opens at the front, and the height of the lower face closes down.

The jaw now rests where it was not designed to rest. The muscles work harder to hold it there. The joint is loaded at an angle it does not tolerate well. Patients describe pain in front of the ear, tightness through the temples, headaches on waking, clicking, and a jaw that is tired by evening.

This is a functional diagnosis, not a count of teeth. A mouth with a full complement of teeth can have lost its posterior support if those teeth are worn, drifted or periodontally weakened. The signs are specific: widening of the ligament space around a tooth on an x-ray; front teeth that shiver or move under a firm bite; restorations that fracture repeatedly in the same place; teeth drifting, or gaps opening between them; heavy or uneven wear.

Two or more together make the diagnosis. One alone does not, and a dentist who diagnoses a collapsed bite from a single worn tooth is guessing.

How much support is enough? The working baseline is eight back-tooth contacts, four each side, with a molar counting as two and a premolar as one. Some patients need considerably more: younger patients, heavy grinders, and anyone with weakened gum support. Some older patients function well with less, and the evidence supports leaving a shortened arch alone when nothing else is planned. The distinction that matters is this: a bite that is adequate for a mouth left as it is may be entirely inadequate for a mouth about to receive veneers, crowns or implants at the front. That is the calculation made before any of that work is offered here.

One rule follows from it, and it governs everything on this page: definitive front-tooth work does not proceed until posterior support is resolved. Veneers, crowns or implants placed at the front of an unsupported bite are taking forces they were never designed for, and they fail early. That sequence is not a preference. It is the reason cases last.

Temporomandibular disorders are not one condition. Some are muscular, some inflammatory, some arise in the joint itself, some are driven by the bite, and many are a mixture. A bite altered before it is understood is very difficult to put back, so the examination comes first and it is thorough.

It covers the joints and muscles; how far and how symmetrically the jaw opens; where the teeth meet and which teeth meet first; the wear pattern on each tooth; the height of the lower face; and whether you clench or grind in your sleep, which is asked about directly and looked for in the teeth. A stable, repeatable jaw position is established and verified. Models of your teeth are mounted on an instrument that reproduces your jaw movement so the bite can be studied outside the mouth, and imaging is taken where it will change the plan.

The jaw is a tripod. It rests on three points: the two joints at the back and the front teeth. All three have to be stable at the right height. If the front teeth do not meet firmly, or a back tooth hits first and deflects the jaw, one leg of the tripod is missing and the joints and muscles carry the difference. Establishing that stable position is the first thing done, and in a collapsed bite it is often the hardest, because the muscles have learned to hold the jaw somewhere it should not be and have to be unlearned first.

The examination answers one question before any other: is the bite driving this, contributing to it, or incidental to it?

When the answer is that the bite is not the cause, you will be told so and referred to the clinician whose field it is. Orofacial pain is a recognized specialty of its own. Saying "this is not a bite problem" is part of the job, and it is said here without a treatment plan attached.

A pharmacy night guard, or a soft guard made in a general office, is a cushion. It absorbs grinding. It does not diagnose anything and it can make some joint problems worse.

A stabilization splint is a precisely made appliance that gives the jaw one stable, reproducible position to close into. It protects teeth and restorations from clenching and grinding, and it is diagnostic: a corrected bite position can be tested and adjusted over weeks, in your own mouth, before a single tooth is touched. If symptoms settle on the splint, that is real information. If they do not, that is also real information, and it usually means the bite is not the answer.

For many patients a well made splint, worn and adjusted properly, is the entire treatment. That is the outcome we aim for first.

Where teeth are too worn, broken or few to hold the corrected position, the bite is rebuilt to it. The starting point is the position proven on the splint, not the collapsed one the teeth currently occupy.

That sequence is the point. A reconstruction designed from a collapsed bite rebuilds the collapse in a stronger material, and the patient pays twice. Instead, the lower jaw is stabilized early so it is not loaded unpredictably while everything else heals, posterior support is restored first, guidance is designed onto that support, and only then is anything made permanent.

If you are considering a full-mouth reconstruction, implants across an arch, or a large number of veneers or crowns, the bite is not settled at the end of the case. It is what the case is built on. This is the subject of Dr. Reshad's textbook chapter on full-arch implant reconstruction, and these are its principles in plain language.

Implants have no shock absorber, so the bite has to be one. A natural tooth sits in a ligament that moves under load, dissipates force, and senses pressure finely. An implant is fused to bone. It moves a few microns, absorbs nothing, and feels very little. Force goes straight into bone and overload can go unnoticed until something breaks. Occlusal design has to compensate, which makes it structural rather than cosmetic.

Back teeth take the load, front teeth do the steering. Posterior teeth accept vertical force when you close. Anterior teeth guide the jaw sideways and forward and separate the back teeth the moment you move. That division protects both ends, and it is the first thing lost when support fails.

Guidance has to be shallow. Steep front-tooth guidance, common in deep bites, drives the muscles harder and concentrates force on the very teeth carrying the smile. The consequences are chipped ceramic, debonded restorations, loosened screws and accelerated wear. Flattening it is often the single most protective change available, and it changes the design: the amount the upper front teeth overlap the lower ones is set deliberately, at roughly a fifth of the lower tooth's height, not left to whatever looks longest in the mirror.

Two bites in particular cause trouble. A deep bite with the upper teeth far ahead of the lower ones produces steep, high-force guidance. A deep bite with the upper teeth clamped tightly over the lower ones, common in certain jaw patterns, builds a fence the jaw cannot move past without forcing it: the muscles work against it, the joints load up, and the backs of the upper front teeth wear away. Both are corrected by reshaping the guidance, and both have to be diagnosed before implants are placed, because the corrected front-tooth position decides where those implants belong.

Lengthening front teeth has a cost. Longer upper front teeth are often the whole point of a smile makeover. Beyond a certain length they steepen the guidance and load the front of the mouth. There is a line, it can be calculated, and it is respected here even when a longer tooth would photograph better.

The teeth are designed before the implants are placed. An implant in the wrong position will still integrate, but it will never be the right foundation for the restoration you planned. The intended bite dictates where implants go, not the other way round.

Distribution beats quantity, and cantilevers are minimized. Implants spread strategically across an arch manage force better than more implants clustered together, and any extension beyond the last implant lengthens the lever arm working against it.

Your grinding is part of the prescription. Nocturnal clenching and grinding amplify every force in the mouth and are an independent risk factor: even well designed guidance can fail under it. It changes the material chosen, the occlusal design, whether teeth can be loaded immediately, and what protection you go home with. Where sleep is implicated, it is assessed rather than assumed.

When in doubt, over-engineer. A tooth of doubtful prognosis that is kept "just in case" and then fails takes the reconstruction built on it down with it. Decisions about what to save and what to remove are made early and definitively, in favor of predictable support.

Everything is proven in a provisional first. Bite, speech, comfort and appearance are tested in a provisional worn for at least four weeks, then copied digitally into the final so that what was proven is what is delivered. A screw loosening or a provisional chipping during that phase is information, usually that the guidance is too steep, and it is far better learned then.

None of this shows in a photograph of a finished smile. All of it decides whether that smile is still there in fifteen years.

A significant part of this practice is patients who arrive after the fact: veneers that keep chipping, implants restored to a bite that was never established, a full-mouth case that looks right and hurts. The pattern is nearly always the same. The appearance was designed first and the bite was left to chance.

Patients often arrive here after the fact, some after they have already spoken to lawyers, asking whether failed work can be rescued. It almost always can. It is always harder than planning it correctly the first time. These cases are taken on, and they are approached the same way as any other: diagnosis first, position proven on a splint, support restored, then the definitive work. What was done before is assessed candidly and you will be told what can be kept and what cannot.

If your treatment involves the bite, see the prosthodontist first. If you already have, and it went wrong, see this one.

Dr. Reshad accepts referrals for the restorative and occlusal component of temporomandibular problems: patients whose occlusion is implicated, whose previous restorative work altered their occlusion, who have lost posterior support, or who require a bite rebuilt to a position established in splint therapy.

Cases come from general dentists, periodontists, orthodontists and oral surgeons. A written report goes back to the referring office at each stage, and the referring clinician retains the patient for general care. Where a case belongs to another specialty, it is referred on with a report.