Pacific Coast Society of Orthodontists Bulletin Summer 2020 - 48

Let's Talk About That

cleaned, there is no risk to the patient of decay
or decalcification. Injury to the soft tissues is
minimized because the patient can remove the
appliance if a sore spot develops.
With the TBA, there are no dire emergencies
where the patient must be seen right away. If the
TBA becomes distorted or is broken, the patient
simply leaves it out until a repair appointment
can be made during regular office hours.
Perhaps the outstanding advantage of the TBA
is its versatility in being able to correct skeletal
discrepancies in all planes of space simultaneously. While correcting the A-P discrepancy (overjet),
it can also open or close the vertical dimension as
needed by allowing or preventing eruption of the
mandibular molars. In contrast, the fixed functional appliances tend to block the maxillary and
mandibular first molars from erupting, so that
when the overjet correction has been achieved,
the patient has no contact in the molar region,
resulting in a very unstable bite situation that is
more prone to relapse.
The TBA can be used to retain the Class II correction while waiting to proceed with Phase II. Once
the overjet correction has been achieved, the
patient is typically weaned off the TBA gradually, wearing it 12 hours per day for a couple
of months, then reducing to night wear while
sleeping for a few more months, and eventually
wearing the appliance every second night for a
while. This provides a nice long stabilization period that allows for settling of the occlusion while
the skeletal correction is being held. The TBA
provides a very physiologic way of achieving and
holding the desired skeletal correction.
Similar to the fixed functional appliances, the TBA
is able to provide maxillary expansion to correct
any transverse skeletal disharmony. The TBA can
also be activated more on one side than the other
to correct a skeletal asymmetry of the mandible
and achieve harmonization of the maxillary and
mandibular midlines.

48	

5. How long does active treatment typically take?
Active treatment with the TBA in this particular
patient would be expected to take six to nine
months, assuming full-time wear of the appliance.
6. What is done at each appointment during this
treatment? At each monthly visit, I would check
the patient to ensure that the appliance is fitting
well, with adequate retention and no sore spots.
I would measure the overjet and the overbite,
with the expectation of the overjet decreasing by
1 mm each month and the overbite decreasing by
10% each month. I would also assess the transverse harmony of the maxillary and mandibular
dental arches to see if further widening of the
maxillary arch is needed by means of the expansion screw. I visually inspect the expansion screw
to ensure that it is in fact being opened correctly
by the patient.
It would not be unusual for the patient's rate
of overjet and overbite correction to slow down
as we get closer to our goal. Hitting a plateau is
usually an indication that the appliance needs to
be reactivated. This involves adding more acrylic
(2 mm) to the distal inclines of the bite blocks of
the lower TBA and 2 mm of acrylic to the occluding surfaces of the upper and lower blocks in the
premolar areas only. This will result in advancing
the mandible forward an additional 2 mm, and it
will also open the bite to allow for more eruption
of the mandibular first molars.
7. What will your occlusal treatment goal be? My
goal with this initial phase of TBA treatment will
be to achieve an edge-to-edge bite. The upper
and lower first molars should be occluding in a
"super Class I" relationship. I want to see overcorrection of both the overjet and overbite to allow
for some slight relapse as the patient transitions
from wearing the appliance full-time to wearing
it just at night. I also want to see harmony in
the transverse relationship of the maxillary and
mandibular arches. In addition, the maxillary and
mandibular midlines should be coincident.

PCSO Bulletin    Summer 2020



Pacific Coast Society of Orthodontists Bulletin Summer 2020

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