Orthotown May 2024 - 25

Fig. 5
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
Fig. 6
One of the biggest things to be
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.
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
MAY 2024 | 25 | ORTHOTOWN.COM
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
http://www.ORTHOTOWN.COM
Orthotown May 2024

Table of Contents for the Digital Edition of Orthotown May 2024
