Efficient, Effective Herbst Treatment by Dr. Mike DePascale

Efficient, Effective Herbst Treatment 

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by Dr. Mike DePascale


Treating complex cases simply and effectively is one of my greatest passions as an orthodontist. Who wouldn’t love that, right? I believe mastery is most shown when one can perform and communicate difficult things in a simple way, digestible by all practitioners, parents and patients alike. In my opinion, if I can do that, then I’m worth listening to. Read on and you’ll find an example of how we do that every day at Kozlowski DePascale Orthodontics.

There have been a tremendous array of advancements since the profession of orthodontics began in the 1800s. Some of the most notable have come to fruition only within the past 50 years. The Herbst appliance was invented in the early 1900s by Dr. Emil Herbst to treat excessive overjet with retrognathic mandibles, focusing primarily on chin deficiency at the time. There have been myriad changes to the appliance since then, thanks to the help of several amazing orthodontists. I would be remiss if I didn’t mention the late Dr. Terry Dischinger here, to whom we owe so much because of the advancement of this appliance in his development of the AdvanSync molar-to-molar version. I couldn’t even begin to guess how many lives have been changed in a positive way as a result of Dischinger’s knowledge and dedication to his craft.

Today, in our office, we use a cantilever version of this appliance (Figs. 1 and 2). Instead of the advancing arms attaching directly to the lower first molar crowns, they connect to a housing on a cantilever arm positioned horizontally and mesially, ending approximately at the mesial edge of the lower first premolar. (More details on that to come.)

Efficient, Effective Herbst Treatment
Fig. 1
Efficient, Effective Herbst Treatment
Fig. 2


Diagnosis is key— and comprehensive
The first question to be answered is: How do we decide which patients receive Herbst treatment and which don’t? Diagnosis is critical to excellence in orthodontics, and not just clinical diagnosis. When we see a patient for a consultation, it’s important that we take into account not just the skeletal and dental classification but also the patient’s (and often parents’) goals, desires and expectations.

For example, what do you do if someone appears skeletally Class II with minimal chin projection and lower lip eversion but has a dental presentation of 2.5–3 mm of overjet? Is this something that you should treat with elastics, a Herbst appliance, or some other Class II correction appliance?

For us, the answer is almost never black and white, so to speak. If we have the ability to use braces and elastics, distalization with aligners, or a mandibular advancement appliance, which is correct? I’d argue they may all be correct; the decision comes down to the aforementioned factors. Goals and expectations are crucial. If said patient or parent has no concerns with the appearance or profile, and the patient has no signs or symptoms of TMD and no signs or symptoms of a constricted anatomical airway secondary to mandibular retrognathia, we would very likely choose elastics with braces or aligners. If that same patient presented with positive signs of TMD or known airway issues, the conversation changes. The key concept is you have to treat the whole person, not just the teeth and not just the jaw.


The treatment plan begins
Once we’ve decided the Herbst appliance is the appropriate treatment for a patient, our diagnosis is complete. The basics of our Herbst treatment plan are always the same, but the specifics for each individual patient depend on several factors:
  • Upper incisors: Is the patient Class II, Division 1 with flared upper incisors, or Class II, Division 2 with retroclined upper incisors?
  • Lower incisors: Does the patient have mandibular spacing or crowding?
  • Are there any specific spacing requirements for the upper anterior teeth, such as missing laterals that will be restored, or planned restorative work on U3–3?
The first step of our treatment involves bonding U4–4 with Damon brackets. As always, torque selection is important for our mechanics. If the patient has severe flaring and spacing, high torque will maximize torque expression during initial space closure, and if the patient is Class II, Division 2, it will allow for torque expression when alleviating crowding. High torque also can minimize retroclination of the upper incisors during some of the known distalization you’ll get with the Herbst appliance mechanics, as well as maximize overjet for mandibular advancement. If flaring and spacing is moderate, standard torque is sufficient. This patient (Fig. 3) was bonded with standard torque.
Efficient, Effective Herbst Treatment
Fig. 3

We don’t bond the U5s because the crowns on U6s are designed with a tube (Fig. 4) that extends mesially across the facial aspect of the second premolar and prevents bracket placement in that area. The design here is very specific—there is approximately 3 mm of mesiodistal width between the end of the housing and tube. This allows for enough area to cinch a 0.019-by-0.025-inch beta titanium (TMA) upper archwire while maximizing stability of the cantilever section of this arm. Too little distance and you won’t be able to cinch this wire, increasing the chance of distalization of 6s, which we want to minimize. Too large of a distance and you’ll increase the chance of appliance breakage.
Efficient, Effective Herbst Treatment
Fig. 4

One of the biggest things to be aware of in diagnosis is retroclined upper incisors that would prevent full activation of the Herbst (or require you to create a significant Class III dental presentation temporarily, which can be uncomfortable for the patient and introduce other issues). If the patient presents with severe upper crowding, we might choose low torque for any or all incisors, but this situation is exceedingly rare.

When a patient presents with significant flaring or spacing of the lower incisors, we bond the lower arch at the same time to consolidate space before activation while controlling retraction and uprighting of anterior teeth. As with the above remark on upper incisor torque, you’ll want to maximize the mandibular advancement without introducing significant Class III overjet, and that will be inhibited if the lower spacing is not addressed.

If the patient has lower crowding, it is rare that any brackets need to be placed on the lower arch during the Herbst phase of treatment. An instance that might require this is creating space for a blocked-out canine during the appliance usage. Because you’ll need to bond and level the lower posterior teeth after Herbst removal anyway, often there is little to nothing to gain with lower anterior brackets during activation.

Lastly, if there are specific space requirements on the upper, such as a missing lateral incisor, we typically will make that space before Herbst placement—again, to maximize advancement. Depending on restorative plans, the details of this aspect of treatment can vary greatly, but the premise remains the same.

In the patient shown in Fig. 5, there are mildly flared upper incisors with mild to moderate spacing and minimal lower spacing that does not require bonding at this stage. In this situation, which is how most of our patients present, the protocol is as follows:
  1. Bond U4–4 with standard-torque Damon brackets.
  2. Scan for Herbst appliance.
  3. Four weeks later, place separators where needed for crown placement— usually between 5/6s and 6/7s if 7s are erupted enough.
  4. One week after separator placement, deliver upper Herbst crowns and lower Herbst crowns with lingual holding arch (LLHA) and cantilever arms on the buccal extending to the mesial aspect of the L4s. The LLHA has occlusal rests on the lower 4s to prevent mesial tip of the lower 6s (Fig. 6). The largest wire possible will be engaged into the upper crowns at this visit. This is usually a 0.016-by-0.025-inch CN or 0.018-by-0.025-inch CN, but can be a 0.018 CN depending on alignment of anterior teeth and the orientation of the tube on the 6s when cemented. Cementing the crowns properly angulated to be in line with the mesial tube extension is crucial to avoiding an unnecessary interim wire and minimize unwanted rotation or intrusion of the U6s. Note: The LLHA is used to minimize forward tipping of the cantilever arms that can cause breakage and/or unwanted intrusion of upper and lower molars. This is also a key concept for minimizing side effects.
  5. Six to eight weeks later, place either a 0.018-by-0.025-inch CN (only if not able to place a 0.016-by-0.025-inch or 0.018-by-0.025-inch CN initially) or a 0.019-by-0.025-inch TMA wire, cinched directly against the distal aspect of the upper 6 tubes. Once the wire is placed, the advancing arms can be delivered at that same visit. Our advancing arms are custom made and have some activity built into them, but you must decide if any activation is desired on delivery based on initial positioning (Fig. 7). Note: If the wire is not cinched directly against the distal aspect of the tube, the 6s will distalize, space will develop and you will not maximize the desired effect of the appliance. Some distalization is expected.
  6. Every 8 to 12 weeks after this, add 1- to 3-mm shims per side as needed. Appointments are scheduled out approximately at 1 mm-per-month intervals (for example, a 3-mm activation would produce a 12-week appointment interval).
  7. Continue activation for six to 12 months. Activation is complete when molars are approximately 1–2 mm into dental Class III. This amount of “rebound” is expected when the appliance is removed.
  8. Remove the Herbst and schedule bonding of remaining brackets two to three weeks later. This allows for reduction of gingival inflammation and promotes tissue healing before bonding posterior teeth.
  9. Bond all remaining upper teeth and 7–7 on lower, assuming the 7s are erupted (Fig. 8). Start Class II elastics bilaterally full time—typically, these are quail elastics, 3⁄16-inch, 2-ounce, from U4s to L6s. Note: Shorter elastics are chosen to create a more vertical effect than horizontal to correct any previous molar intrusion, as well as level the lower curve of Spee while maintaining the anterior-posterior correction.
  10. Continue elastics and switch to full Class II elastics as needed.
  11. Once both arches are leveled and Class I occlusion is achieved, plan scan/repo. In our office, this is a 3D iCat FLX low-dose CBCT scan.
  12. Scan/repo appointment to reposition braces as needed (Fig. 9).
  13. Finishing and detailing. Often we use “V” elastics at this stage—U6s to L4s to upper post between U2/3s for settling.
Efficient, Effective Herbst Treatment
Fig.5
Efficient, Effective Herbst Treatment
Fig.6

Efficient, Effective Herbst Treatment
Fig. 7

Efficient, Effective Herbst Treatment
Fig. 8

Efficient, Effective Herbst Treatment
Fig. 9


Conclusion

The patient shown here used this protocol and finished in 24 months with 15 appointments (Figs. 10 and 11). It’s important to note that while some steps along the way may vary for the reasons covered earlier, the core of the mechanics remain the same.

Efficient, Effective Herbst Treatment
Fig. 10
Efficient, Effective Herbst Treatment
Fig.11


One of our goals in the practice has always been and will always be to deliver a high-quality result in a comfortable, convenient way for our patients. This is one of the reasons our Herbst treatment is completed in the three-step process referenced above—it allows the patient to adapt to the feeling of braces, then get used to having the crowns of the appliance cemented, and finally adjust to the feeling of the activation arms. It requires that we pay close attention to every step we are taking at each visit, making sure there is always forward progress.

Doing everything we can at every visit is one of the many methods we employ to reduce the total number of appointments in treatment while still achieving clinical excellence, and there are so many ways to do this. Our profession still averages approximately 24 visits to finish treatment. Here you can see an example of how, even in complex situations, there are effective methods to reduce that.

I was fortunate to be guided by one of the best in the profession on clinical efficiency, Dr. Jeff Kozlowski. Together we’ve been able to successfully treat thousands of patients this way, leaving them with healthy, happy, confident smiles in a way that we’re all proud of. I believe that’s something we all want for our patients, and it’s even more rewarding when we can do it for those who have a malocclusion severe enough to require Herbst treatment. For some of these patients, this is life-changing without requiring any external appliances or surgical intervention. It’s something we are very proud of being able to deliver on a consistent basis.

If nothing else, I hope there is some detail in here that you can take home with you and apply to your own protocols to help elevate your results and patient experience. After all, that’s why we do what we do! Do more. Be more. Smile more.


Author Bio
Dr. Mike
DePascal A New Jersey native, Dr. Mike DePascale received his orthodontic master’s degree at the University of Maryland in Baltimore. In 2017, he joined the team at Kozlowski Orthodontics, a practice that matched his dedication to high-quality treatment, innovation, efficiency and education.

When DePascale is not in the office, you can find him in his garage gym or coaching CrossFit at a local gym, where he puts to use his passion for personal growth, leadership and commitment to others. (You may see him there throwing weights around, too!) He believes in pushing boundaries, doing what you love and sharing that with the world.




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