treatment of headaches and temporomandibular joint...
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Treatment of Headaches and
Temporomandibular Joint Problems
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Soft DietSuitable for Painful
Temporomandibular Join Conditions reducing the Stress on the Joints
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CounsellingSome Patients with
Temporomandibular Joint Problemshave varying degrees of Psychological
Problems
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CounsellingRanging from Treatment
of Mild Depression to Severe Psychological Problems
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PsycotherapySuitable for Patients with More Serious Psychological Problems
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• Anti-inflammatory Drugs• Antidepressants• Analgesics
Drug Therapy
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Drug Therapy• Muscle Relaxants• Steroid Injections• Cessation of Certain Drugs
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Occlusal Therapy• Appliance Therapy• Limited Occlusal Adjustment• Occlusal Equilibration• Removal of Teeth
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Occlusal Therapy• Orthodontic Treatment• Occlusal Reconstruction• Prosthetic Treatment
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Physical Therapy• Moist Heat• Ice• Vapocoolant and Stretch• Local Anaesthetic and Stretch
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Physical Therapy• Muscle Exercises• To Restrain• To Regain Mobility• To increase Muscle Strength
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Physical Therapy• Biofeedback• Microwave Therapy• Faradism• Relaxation Therapy
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OrthodonticTo correct Occlusaly Related Problems
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NeurologicalTo correct Neurologically Related
Problems
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Medical
To correct Medically Related Problems
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SurgicalShould be the last resort after all other Treatments have been tried and have
failedand where the Patients Symptom are
sufficiently Troublesome
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SurgicalIn some Circumstances
Surgical reattachment of an Anteriorly Displaced Disc
is Necessary
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No TreatmentIn Some Circumstances
No Treatment is the Best Option
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Sometimes TreatmentEither has No Effect
and the Patient eventually gets Betteror stays the Same
or gets worse
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Treatment ofNeuromuscular Dysfunction
( Myofascial Pain Dysfunction Syndrome M.P.D.S.)
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Lateral Pterygoid Isometric Exercises
to Strengthen the Lateral Pterygoid Muscles
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Physical Therapy• Palm of Hand under Chin• Support Elbow with Other Hand• Close Teeth together • Push up and back
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Physical Therapy• Separate Teeth Slightly• Open against Palm of Hand • Rotation only No Translation • Push Closed • 30 x 4 x Day for 4 weeks
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Appliance Therapy
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Uses of Appliances• To alter the Occlusion• To reposition the Jaw Relationship• To reposition Teeth
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Types of Appliances• Bite Raisers• Soft Appliances• Anterior Jigs• Posterior De-programmers
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Centric Relation Appliances with Posterior Disclusion
Upper or Lower
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Anterior Repositioners• Used to recapture Anteriorly
Displaced Discs• Permanent Repositioners
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Reasons for using Upper Appliances
• Better Appearance • Better Speech• More Comfortable• “My Guru taught Upper Appliances”
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Reasons for using Lower Appliances
• Better Appearance • Better Speech• More Comfortable• “My Guru taught Lower Appliances”
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Good Reasons for using Upper Appliances
• More Teeth Lost in Upper Jaw • Looser Teeth in Upper Jaw • Instanding Teeth in Lower Jaw
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Good Reasons for using Lower Appliances
• More Teeth Lost in Upper Jaw • Looser Teeth in Lower Jaw• Instanding Teeth in Upper Jaw• Very Uneven Lower Anterior Teeth
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The Tanner ApplianceA Lower Centric Relation Appliance
with Posterior Disclusion in Excursive Movements
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A Centric Relation Appliance
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Discluding Posteriorly in Excursive Movements
If an Occlusal Appliance is fitted and adjusted to occlude in Centric Relation
Patients tend to tap their teeth together in Centric Relation
This can be Verified by• Tapping the Patient in Centric
Relation on Articulating Paper• Then having the Patient tap rapidly
on a Different Coloured Paper
Case 1
Note the Red and Blue Dots coincide
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Given the OpportunityWhen Interferences are covered up with
an Appliance or if the Interferences are removed by
EquilibrationMost Patients will tap together
in Centric Relation
Tanner Appliance Construction
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Beading Wax place just below the Occlusal Surface
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Undercuts blocked out
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Tin Foil adapted to the Lower Model
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Cold Cure Acrylic
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The Acrylic Template Former
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Apply Vaseline to the Acrylic Template Former as a Separator
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The Acrylic Pressed onto the Template Former
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Roller used to flatten the Acrylic
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The Acrylic Tanner Sheet
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The Acrylic Tanner Sheet pressed over the Lower Model
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Trim back some of the Excess before the Acrylic is set
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The Acrylic Tanner Sheet pressed over the Lower Model
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The Centric Markings
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The Excess Acrylic Trimmed away
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The Cold Cure Acrylic applied to the under-surfaced of the Tanner
Appliance
This is best done in Three SegmentsNot All in one go
There is Less Likelihood of the Appliance becoming Stuck
Start with the Right Side• Apply Soft Acrylic to the Under
Surface of the Right Side • Fit the Appliance in the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the
Acrylic is set
Do Not allow the Acrylic to set in the Mouth
to remove the Appliance if it becomes Set in Place
would require cutting out This is a Difficult Procedure
Remove and trim away Excess Acrylic
Continue with the Lower Front• Apply Soft Acrylic to the Under
Surface of the Lower Front• Insert into the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the
Acrylic is set
Continue with the Lower Front• Remove and trim away Excess Acrylic
Continue with the Lower Left Side• Apply Soft Acrylic to the Under
Surface of the Lower Left Side• Insert into the Mouth• Press down Firmly into Place• Repeatedly lift the Left Side until the
Acrylic is set
Continue with the Lower Front• Remove and trim away Excess Acrylic
Equilibrate the Appliance in Centric Relation
Then remove All Posterior Excursive Contacts
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Centric Stops
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Lack of Centric Stops
In Some Cases it is Necessary to add Soft Acrylic to the Occlusal
Surface
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The Acrylic added to the Occlusal Surface of the Tanner Appliance
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The Final Centric Stops
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Centric Stops
If the Patient taps their Teeth together
The Marking Ink may be cleared from the Centre of a Marking
This is known as a “Halo”
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Halos
A Halo indicates a Definite Contact rather than a False Marking
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Lateral Excursions
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Lateral Excursions
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Protrusive Excursions
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Posterior Lateral Excursion Movements marked in Red
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Posterior Lateral Excursion Movements marked in Red
All Posterior Excursive Markings should be removed
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All Posterior Lateral Excursion Movements removed
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Grooves added to aid eating
The Patient experienced Pain when chewing
The Appliance relieved the Symptoms
The Appliance may cause Sores on Soft Tissues
Apply Zinc Oxide Impression Pasteto the Fitting Surface
to indicate the Tight Area
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Ease the Tight Surface
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An Alternative Lower Appliance
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Occlude used to detect the Tight Fit
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Occlude used to detect tight Fit
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Upper Appliances
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Upper Appliance
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Anterior Guidance
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Centric Contacts
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Centric Contacts
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Centric Contacts
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Centric Contacts
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Centric Contacts
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Centric Contacts
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Centric Contacts
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Lingually placed First Premolar
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A Lower Appliance would impinge on the Tongue
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An Upper Appliance was fitted
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An Upper Appliance
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An Upper Appliance
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Anterior Jigs
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Place some Soft Acrylic behind the
Anterior Teeth
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Overlap the Incisal Edges
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Have the Patient bite into the Soft Acrylic
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Remove the Some of the Palatal Surface
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Flatten the Biting Surface
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Treatment of Anterior Displaced Discs
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Treatment of Anterior Displaced Discs
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At Rest the Disc is displaced Anteriorly
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The Closed Position
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Opening
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The Disc bunches up in Front of the Head of the Condyle
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The Disc clicks into Place
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There is a Late Click on Opening
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Closing
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The Disc has clicked off Anteriorly again
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There is a Late Click on Closing
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Diagnosing Anterior Displaced Disc
A Late Click on Openingfollowed by a Late Click on Closing This is known as a Reciprocal Click
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Anterior RepositionersUsed to recapture Anteriorly
Displaced Discs
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Add some Greenstick Compound• to the Front of a Flat Occlusal
Appliance• Insert the Appliance• have the Patient open until they click
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• Have them move their jaw forwards and start to close
• Before they close onto the Soft Compound
• have the Patient move their jaw backwards until They almost click
• then ask them to close
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• Remove the Appliance • Add soft Cold Cure Acrylic to the
Posterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Greenstick
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The Anterior Greenstick Compound
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The Acrylic
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• Remove the Greenstick• Add soft Cold Cure Acrylic to the
Anterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Posterior
Acrylic
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• Remove the Appliance• Remove any Sharp Projections • Insert the Appliance • Have the Patient open until they click• Then have them Open and Close
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Their Disc has been recaptured with the Appliance in
They will not click on opening and closing
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On removing the Appliance On closing the Patient will click
The Disc has fallen off the Head of the Condyle
The Reciprocal Click now has returned
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The Anterior Appliance with Grooves for chewing
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Making an Anterior Repositioning
Appliance using a Relined Tanner Shell
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The Tanner Shell
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Add some Greenstick Compound• to the Appliance• Insert the Appliance• have the Patient open until they click• Have them move their jaw forwards • and start to close
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Before they close onto the Soft Compound
• have the Patient move their jaw backwards until They almost click
• then ask them to close
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• Remove the Appliance • Add soft Cold Cure Acrylic to the
Posterior Biting Surface• Insert the Appliance • Have the Patient open until they click• Have them close into the Greenstick
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• Remove the Greenstick• Add More Soft Cold Cure• Insert the Appliance • Have the Patient open until they click• Have them close into the Posterior
Acrylic
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• Remove the Appliance• Remove any Sharp Projections • Insert the Appliance • Have the Patient open until they click• Then have them Open and Close
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The Final Repositioner
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Converting Complete Dentures into
an Anterior Repositioning Appliance
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The Original Dentures
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The Original Dentures
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HistoryThis Patient’s Wife complained about his Loud Clicking Joints
when He was eating
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On ExaminationThe Patient had a Late Click on Opening
and a Late Click on Click on ClosingThis is known as a Reciprocal Click
This a Diagnostic of an Anterior Displaced Disc
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The Back of the Second Molar flattened Vertically
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Greenstick Compound was added• to the Premolar Area of a Flat Occlusal
Appliance• The Appliance was fitted• The Patient opened until he clicked• moved his Jaw Forwards
and started to close
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Before closing onto the Soft Compound
• The Patient move his jaw backwards until he almost clicked
• He was then asked to close• Remove the Appliance
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Soft Cold Cure Acrylic was added to the Posterior Biting Surface
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The Soft Cold Cure Acrylic added
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• The Appliance was inserted• The Patient opened until he clicked• Then closed into the Greenstick
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• The Greenstick was removed• Soft Cold Cure Acrylic was added
to the Gap• The Appliance inserted• The Patient opened until He clicked• Then closed into the First Set Acrylic
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• The Appliance was removed• The Added Acrylic Flattened • A Wedge Posteriorly to keep
the Mandible Forward• This stops the Disc slipping of the
Head of the Condyle
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The Posterior Wedge
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The Repositioning Appliance
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The Patient’s Clicking during eating was eliminated
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Gelb AppliancesThe Use of Gelb Appliance Therapy
is Controversial It involves the Use of Kinesthesiology
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Treatment of a Patient with a Posterior Open Bite
after wearing a Tanner Appliance
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Posterior Open Bite
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Tanner Appliance was cut back Posteriorly
To allow the Second Molars to erupt
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Tanner Appliance was then cut back Posteriorly
To allow the First Molars to erupt
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The Back Teeth were then in Occlusion
The EndThe End