Orthotown May 2024 - 24

Figs. 1 and 2
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.)
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
Fig. 3
Fig. 4
* Lower incisors: Does the patient
have mandibular spacing or
crowding?
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?
MAY 2024 | 24 | ORTHOTOWN.COM
* 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.
We don't bond the U5s because
the crowns on U6s are designed with
a tube (Fig. 4) that extends mesially
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Orthotown May 2024

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