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welcome to the University of Michigan.dentistry podcast series promoting or.health care worldwide.the purpose of today's discussion is to.discuss a close analysis and examination.the patient close analysis as the.examination and understanding the mask.of Story system and its functional and.dysfunctional relationship since this.system is not a single organ but is made.up of several individual units which.ideally function harmoniously we must.examine each part individually and then.together as a do function we must.determine what is normal for that.particular individual if it is less than.normal and we see or find evidence of.damage we call it trauma from occlusion.what is normal for one individual may.not necessarily be normal for another to.be normal is to be within the adaptive.potential of the individual in order to.determine the range of normalcy as well.as find dysfunctional factors in the.mass Kotori system some systematic.scheme of examination should be.developed purpose of today's talk is to.guide you through such a scheme now the.first thing we'd like to do is have our.patient seated comfortably we'd ask her.to remove her glasses and her lipstick.and now we'd like to make sure that our.head is well supported on the occipital.bone and that there's no stretching or.discomfort in the neck region so that.she has complete relaxation the whole.purpose of course is to have your.patient relaxed so they can cooperate.with you and they will follow your.guidance as you try to guide them.through this examination and you can.relax your patient by talking to them.some people become our naturally relaxed.other people are very tense in this.situation so if they are extremely tense.of course you may have to depend on some.drug therapy or so on to help them relax.and one of the ways you can check to see.if this patient is relaxed is to.observer as you cedar and talk with them.and watch the muscles in the cheek and.the cedar muscle and see what happens.are they a person that they said here.this muscle begins to contract and if we.watch this patient Y we can see that.there's a little contraction of muscle.which might indicate that she has some.problem with and bruxism or clenching.one of the problems that we run into.with patients that does create at times.trauma from occlusion but not.necessarily but so we kind of observe.them as we talk to them and see if the.patient does do this the next thing we.might do is ask them about their dental.care what are they had in the past and.how many teeth have you had out are you.missing any teeth now or that you know.you are could we just take a peek and.see okay just on a quick examination.here we can see she has a bridge to.indicate she has a tooth missing here.and also we don't see any third molar so.these been extracted or yes so you had.some oral surgery done you're familiar.with that so she does have at least four.teeth missing that we can tell by this.examination and other than that why I.don't see any thing that would indicate.that she's had any problem the chances.are this second molar was extracted then.the bridge was made from the third molar.to the first molar the other thing we'd.like to check now is one of the chief.signs of trauma from occlusions if the.teeth are mobile and so by taking a.young instrument such as your mirror and.by putting that against the tooth and.pressing in this manner you can check if.there's mobility on the teeth now we.won't do all the teeth but we would.expect you to and if you see some very.slight mobility on the anterior teeth we.could probably consider that normal but.if it's more than very slight or if you.see mobility on the posterior teeth and.we begin to wonder if there is a cause.so.we would use a mirror and your finger in.that manner and try to determine if you.have any mobility and then by using the.same instrument but you can come along.and slightly perk us or tap the teeth.and by this we mean taking and not a.hard blow but just a you can hear it now.if you listen you hear me tapping the.tooth.sounds like a good solid sound and one.of the another sign of trauma from.occlusion of course is if you tap a.tooth and it has a dull thud sound the.way you might be concerned about the.tooth this is one of the more difficult.things that you have to learn to do as.you go along so after we've tapped the.teeth and so on why we would go all over.and if we have any we discover any loose.teeth or any teeth that are sensitive.percussion we would of course make a.note of that on our records now the.other thing we like to do at this time.is have our patient bite real tight.together just bite your teeth together.and then if you like to turn your head.slightly we would notice the.relationship of the teeth one to another.are they in what we might consider a.fairly normal relationship or do we have.cross bites where the upper teeth or the.maxillary teeth happen to go on the.inside the mandibular teeth and car.cessation doesn't have such a situation.but this is one of the things that we.would check for to see if there is a.cross bite relationship which may.indicate some other problem then now.another thing that we'd like to discuss.with the patient asketh ever have any.pain and discomfort in the area in front.of the ears or the temporal mandibular.joint area have you ever had discomfort.or pain yes were you treated in any way.for this what did they do for you um.they did someone just ingesting on your.teeth or ground on your teeth I'm going.to stand behind you and I'm going to.palpate the joint and I wonder do you.have any discomfort up in here now is.that sore none at all no no soreness.none okay now would you open real wide.and do it rather slowly now why did you.can stretch yourself okay is there any.discomfort back there when you do that.cane I'll bite up slowly again now I can.feel as she does that that there's a.slight clicking or jumping of the joint.I'm going to have her turn her head to.slightly like this and I mean we can get.a good view in this area and then I.won't ask you now if you would to open.it real wide open as wide as you can.real real wise now close very slowly.very slowly okay would you do that again.do that several times open real wide and.then we watch this area there oops now.go back and do it again and if you're.careful if you watch closely at this.area right here and now you will see.that you know she doesn't do it every.time so we're do it once more and see we.can pick it up stretch real wide and.then close slowly and see if we can see.that little there we go.and that's the sign that there are some.been some disturbance in that area you.know it's perhaps been corrected by this.time by her close little adjustments and.she doesn't have any pain or discomfort.at this time now another thing we would.like to do is to watch the midline and.see that when she opens why does this.deviate from either side so I'm going to.ask you again to open real wide.now watch the point of her chin and.let's see if she has any deviation give.him very slight you notice just before.she causes she has a slight movement and.we do it once more now watch just as she.comes almost together see how the jaw.goes a little to the left and back into.the midline so this is probably related.somewhat the same problem she had.originally now another thing we want to.do so the is to check their chewing.pattern in order to do this we actually.will just give her a piece of green wax.and ask her to chew it.and as she chews it we will observe her.and we watch her little muscle spasms.that may occur and if you watch closely.she does she's slightly disoriented.sometimes when she chews she has a.little muscle spasm in this area how.could you chew it on the other side -.some people have difficulty chewing on.both sides and I think she's one she.first to chew on the right side can you.shift it to the left side and two on the.other side the other side that seemed.comfortable to you.would you prefer to chew on this side.both feel both feel comfortable fine she.seems to like to chew on one side there.are times when people have a restricted.or unilateral pattern of mastication and.they just absolutely can't chew on the.other side and some of this is habit due.to the early problems with their.dentition and other times it's a matter.of preference sometimes there's pain.involved and so on but actually she does.a pretty good job of chewing on it and.and I think she could chew on both sides.but I think she shows preference for.here although she does have a little.slight muscle spasm in her chin when she.does chew which might indicate some.disorientation and so on now another.thing we like to do is to check and see.if we can pick up at this stage and.course you're an experienced at this.stage so we don't expect you to be able.to do everything but you should be.training yourself to check for.interferences in what we call the.working and the balancing and pro Trucy.and the way we do this is we ask our.patient here to just bite together.tightly now and bite tight and then.we'll just slide your chin towards me.just keeping your teeth no not.straightforward now this is one of the.problems you run into and examining.patients you say do this or do that and.they don't always they can always follow.your direction so now what I really want.to do is tell her I want our chin to.come this way and I'll touch your cheek.and then we have her bite tight together.now would you slide your cheek toward.your chin towards me they're fine now.you'll notice that when she does that.she has a tendency to stick her chin a.little bit I'm going to ask her to bite.up tight in and now come straight.towards me side.now notice the difference but she does.have some interference on her anterior.teeth when she comes into this area now.we'd ask you to do by tight and go over.to this side on the other side the.opposite so there notice the difference.now she rides more on the canine tooth.and so on but she still has some.interference again we'd like you to come.straight forward as far straight chin.straight out this direction.staying woman right there now if we look.inside at this time if you can see in.there you notice all the pressures on.her front teeth she's not able to have.any pressure in the back teeth and this.is called a producing movement and of.course it's ideal when they come into.protrusion that bent back teeth do dis.occlude we don't want them to be an.occlusion however all of her pressures.on our incisors and as you get further.into this business of course you realize.those are weaker teeth it would be ideal.if she had some pressure on our canines.or her cuspid teeth so we'd make this.note we'd write in our record that this.does occur that she doesn't have.particularly when she comes towards the.right she has her guidance on her and to.your teeth now the next thing we're.going to do is to measure what we call.the vertical rest position with a.freeway space and the way that we will.do this action is we put a couple dots.on her face one right under her nose and.one on the point of her chin which is a.fairly immovable part of her face and.then by asking her to say the word.Mississippi or getting her to relax.completely so that she sits here her.teeth will not be touching which is the.way is a vertical rest position I then.we measure that and see how much closer.freeway space she has so I'm going to.put a dot now right here and another one.right here now this isn't this is a.gross measurement under much finer ways.of doing this but for our purpose today.is demonstrating and for you to learn.how to do this.or this suffice is now what I want you.to do is get completely relaxed let.yourself completely relaxed and I'll.just kind of say the word very slowly.Mississippi Mississippi and then as you.get at the end of the word why just let.your jaw stay in that position I just.hold it now can you get completely.relaxed okay and we can do it two or.three times.okay now that shows 41 millimeter now.would you bite tight together and she.comes up live more than two millimeters.let's do it once more distant.Mississippi completely relaxed.Mississippi Mississippi.no biting.and she comes up about two millimeters.each time which means then that she has.approximately two millimeters freeway.spaces so and she is sitting completely.relaxed or standing relaxed why her.teeth are really about two millimeters.apart then when she goes into maximum.and or digitation or centric occlusion.they come together so we have that.amount of space and between the T now we.want to go ahead and check a few other.things here and we talked about maximum.interdigitating the next thing we'd like.to do is to place her in what we.consider centric relation where the.joint is in the posterior of the hinge.position and we're going to do this.again by gonna to relaxed and guiding.her chin and then we'll have her bite so.she has a first contact and then after.the first contact why we have her.squeeze again and we'll see if there's.any change any difference between.centric relation the most posterior.position our centric occlusion which is.maximum on or digitation and if she has.a slide which I would anticipate she.might we're trying to pick it up by.showing the movement of two so know what.I really am going to do is ask you to.get completely relaxed and what we'd.like to do is make your make your your.jaw in this thing so just just to hinge.so when I shake it it it goes like that.and and I will guide it with.my thumb and my sum first you come and.you just touch my thumb and then I'll.slip my some other way and we go all the.rest away now don't squeeze the first.contact I'd like you to stop so we're.going to practice now and you just let.your job become just like a hinge and.she does it quite well.he never going to go up just relax now.keep it completely relaxed so it's.completely relaxed.just complete now you're tightening at.home yeah.yes just don't think about it because.when you think about it while you have a.tendency to want to help me so we're.doing once more now and it's fine there.okay I'll just do a little more closed.let it go you know you can see where my.thumb is stops the bite now just keep.coming up all right okay just a little.more till you find for the first contact.fine now squeeze together okay now I can.see from where I'm sitting that she does.have a a slight anterior and a little.bit to the left slide I think what we're.do is I'm going to try and do it again.and maybe we can catch this again now on.I want you to stay real relaxed now I.won't put my thumb in this time but so.we can see better this relaxed now let.you know.keep going shot okay now go up to your.teeth just barely touch I know you're.fighting yes there we go.okay it's not your teeth come together.ain't no squeeze see how she comes.anterior though that I don't let me pick.that up but she has a slight slide I'm.guessing it's a millimeter millimeter.and a half and I don't think we can.measure it because the way that her.anterior teeth she has a great amount of.overlap vertical overlap it would be.difficult for us to get a ruler and to.measure that but this is something that.you have to work on you have to practice.with your patient and again they may not.be able to do this the first time and.there are ways of helping them one of.course again is to go back to some type.of relaxant drug sometimes we put them.on a bike plane splint to help them get.the muscles relaxed and so on and so.don't be discouraged it the first time.you try it it doesn't work.some matter of you practicing with the.patient the patient learning to relax.when you go along and do that type of.thing now we've talked a lot about the.examination and we gone over quite a few.little features examination but we want.to show the difference now between what.we call the border movements of the.mandible the maximum movements of the.mandible and then we're going and show.the actual envelope of function how much.movement the mandible actually does go.through when you're chewing and so on so.what I'm going to ask you to do now is a.similar to the thing we did the first.time is just let your teeth go together.and I want you to come toward me very.slowly just keep coming - fine now stop.right there just a little more a little.more a little more now you can see this.time we got our chin back and she.actually does have function here now.would you like to come towards me just.as far as you can so I keep now you.notice see she's way over here and of.course the guidance has gone back to her.anterior teeth so go up slowly again.they're not she comes in and you're.notice at this time that she has a.spacing between the canine and the.lateral incisor and we refer to this as.a diastema and that's something you.might note there is some spacing in.there now would you like to go up tight.again right tight together would you.like to turn your head toward me I'll.try to keep my fingers out of the way so.we can always ask you to go this side as.far as you can but slowly keep slowly.you notice on the canine stop right.there she has function now go as far as.you can well no you noticing you can go.way beyond those are the extreme.movements of the mandible on the right.and left direction of course it's.limited by the ramus in the back I'm.sure she can feel pressure when you get.out there and it stops you now would you.like to look straight ahead and we're.going to measure the patru civ now and.what we'd like you to do is to put your.jaw forward just as far as you can away.way out and I'm going to take our.millimeter rule.and we're just seeing how would you like.to go back in position bite uptight.okay and now side your lower teeth.straight forward all the way as far as.you can keeps hiding further yet they're.fine.and I come about five millimeters to six.millimeters so she has quite a bit of /.to see movement okay now the other.maximum border movement of the mandible.is how white she can open so I'm going.to ask you to open as white as you can.and then we're measure from one incisal.edge to the other and she has a very.nice wide opening for us and it's.somewhere in the neighborhood of 36 to.38 millimeters so that's those are the.maximum border movements what we want to.demonstrate to you now is that people.really don't go into the the maximum.border movements but before we do that.they don't go in the maximum border.movements during function I should say.but when they before we do that I'd like.to look at the occlusal surfaces and see.if we can see any facets aware that.maybe beyond those we'd anticipate for.function and we'll just take our mirror.now and and background that the teeth.and see if we see any extreme facets.aware any place and either the teeth or.the restorations she has just a little.shiny spot on an amalgam back here which.I don't think you can see very well but.which would mean that perhaps she does.at times very where we can see it then.we come on forward now let's check the.upper posterior teeth and again we don't.see any extreme wear patterns out beyond.those we might anticipate and then the.lower anterior teeth and if you notice.on this tooth the lateral mandibular.central incisor she does have some.extreme wear right in this area this.where may be due to some type of rock.scene habit or perhaps she's had some.training by a dentist on some.or anterior teeth but this is in an.extreme fast set of wear now since you.have seen the extreme border movements.of the mandible we're going to ask her.to choose some wax again unless you.choose this wax I'm going to try and.part our lips so you can if you watch.particularly the central incisors and.the lower and the mandible your see that.that all the chewing is really done in a.very neural pattern and this is called.the envelope of function or envelope of.motion so would you I'm gonna let you.chew it for a second to get it softened.up and just - normally and then I'm.going to reach in and I just take your.lips apart slightly so they can see once.you get thick.wax off normal chewing pattern now you.just keep chewing and we're just trying.just keep chewing you notice how she.chews if you watch this chew again if.you notice in the chewing habit why she.has a tendency to chew on this right.side and also she has a tendency to go.to the right so she is falling kind of a.unilateral pattern however I'm sure that.she probably could learn to chew on both.sides now I think with what we've shown.you today really what we want you to do.is to go to the clinics and labs now and.do the same type of thing on each other.and begin to get some experience in the.occlusal analysis and an examination of.a patient you've been listening to a.presentation from the University of.Michigan's School of Dentistry which is.dedicated to supporting open learning.and open educational resources this.recording is licensed under the Creative.Commons it may be reused and.redistributed for nonprofit use.please attribute materials to the.University of Michigan's School of.Dentistry and redistribute under this.same license for more information on how.this and other university of michigan.school of dentistry recordings may be.used visit.

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How do you realign a bite?

Remove all the fasteners. Have someone help you hold the gutter if necessary. Determine the high point and attach the gutter there as high as it can go on the fascia. Put a 2' or 4' level in the gutter. For proper pitch to a downspout the bubble should be on the line that is toward the high point. Using this method, take a reading and put a fastener every six feet. Reinstall flashing and hangers. I like to use 2" coated deck screws.

What causes your bite to shift?

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How do you know if you need to fill out a 1099 form?

The w9 is what an employer uses to get your social security or taxpayer ID. This is perfectly legal. The w2 is what he gives you after he gets the SSN to do yearly reporting to you and IRS of taxes withheld and wages earned

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