Herbst Appliance Reference Manual - Specialty … Appliance Reference Manual ... removable...

Herbst ApplianceReference Manual

Herbst Appliance Overview

Herbst Designs

Laboratory Overview

Clinical Management

Herbst Removal

Patient and Parent Education

Troubleshooting

About Specialty AppliancesSpecialty Appliances is a full service orthodontic laboratory located inAtlanta, Georgia. Founded in 1981 as a functional appliance laboratory,Specialty has developed a complete product line that includes retainers andspring retainers, metal appliances, functional appliances, splints, and labialand lingual indirect bonding services. We pride ourselves on the quality ofour laboratory work, which is complemented by outstanding customerservice. We invite your practice to try Specialty Appliances for yourlaboratory requirements.

Specialty Appliances and the Herbst ApplianceSpecialty Appliances has fabricated the Herbst since 1981. Over the years,we have worked with numerous leading clinicians in Herbst designs andimprovements. In addition, our many Herbst customers are continuallyproviding us with feedback and suggestions on design improvements. Ourlong-term experience and extensive clinical interaction have moved us tothe forefront in Herbst technology and have enabled our laboratorypersonnel to become an extremely valuable resource for practices that areeither using the Herbst or are considering this unique appliance.

Specialty’s Herbst Educational MaterialIn addition to providing laboratory services, Specialty has become aneducational resource for the Herbst. We have been instrumental insponsoring seminars on the Herbst, as well as producing a comprehensiveeducational videotape on the Herbst that features Dr. Terry Dischinger andhis “team.” This manual is another of the outstanding educational piecesour customers have come to expect from Specialty. Our goal with thismanual is to provide a reference source on the Herbst for the entirepractice, including the clinician, clinical staff, and laboratory members.Our experience with the Herbst, as well as with other appliances, hasshown that providing educational information to our clients helps improvethe working relationship for all parties involved.

About Specialty Appliances LaboratoryAbout Specialty Appliances Laboratory

IntroductionIntroduction

Table of ContentsTable of Contents

Overview of the Herbst Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Evolution of the Herbst Appliance Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Herbst Appliance Parts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

The Acrylic Splint Herbst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

The Banded Herbst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

The Stainless Steel Crown Herbst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

The Cantilever Herbst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11

“How to” Sequence Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Steps in the Practice Prior to Sending the Herbst to the Laboratory . . . . . . . . . . . . . . 13-15

Overview of Laboratory Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16-17

Clinical Delivery of the Herbst Appliance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18-29

Patient and Parent Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31

Clinical Adjustment of the Herbst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32-37

Herbst Removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38-39

Herbst Troubleshooting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40-46

Herbst Appliance Designs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47-67

© 1998 Specialty Appliances Inc. all rights reservedThis book, or parts thereof, may not be reproduced in any form without permission of

Specialty Appliances Inc.

Herbst ™ Dentaurum

Introduction to this ManualThis manual is designed to guide the practice through the basic steps involved insuccessfully implementing the Herbst appliance into their practice. The material ispresented in the order that a practice would generally follow in the overalltreatment sequence. In addition to the clinical steps outlined in using the Herbst,supplemental sections provide valuable information on Herbst appliance design,and Herbst troubleshooting.

We suggest practices refer to the Specialty Appliances Internet site atwww.specialtyappliances.com for additional information on the Herbst Appliance.

Overview and Benefits of the Herbst Appliance The Herbst appliance is one of the most popular functional appliancesused in the United States today. It is designed to correct a Class IImalocclusion by advancing the lower jaw. Class II correction occurs via acombination of dental and skeletal changes, with the net result being apredictable Class I occlusion. Over the past few years, the Herbst hassurpassed appliances such as the Bionator and Frankel in terms of overalluse. This is due to the non-removable aspect of the appliance. Unlikeremovable appliances, the Herbst can be fixed to the teeth. This reducesthe need for active patient cooperation. This is an advantage not only forthe orthodontic practice, but also for the patient and parents. Byeliminating the potential negative implications associated with lack ofpatient cooperation, the practice can concentrate on and reinforce thepositive factors involved in the orthodontic care.

The Herbst Offers Predictable TreatmentThe 24-hour wear of the fixed Herbst appliances generates predictableresults. Without question, a predictable treatment outcome is linked tomore profitable overall results. The Herbst appliance allows practices toestimate-with a high degree of accuracy-the length of time necessary forClass II correction, and therefore, the time required to treat the entiremalocclusion. Reducing treatment overruns leads to enhancedproductivity, which enables the orthodontist to be more competitive intoday’s marketplace. This has been a major advantage for orthodontistsusing the Herbst, and another reason why the Herbst has seen a dramaticacceptance in new practices, as well as an increase in overall applianceapplication.

Multifaceted Treatment Effects with the HerbstMany of the Herbst used today include accessories added to the basicdesign to increase the effectiveness of the appliance. Expansion screws towiden the arches, archwire tubes to combine fixed appliances and othermodifications extend the treatment effects of the Herbst beyond Class llcorrection. The ability to simultaneously correct multiple factorscontributing to the malocclusion has also increased the widespread use ofthe Herbst.

Benefitsof the Herbst

Overview of the Herbst ApplianceOverview of the Herbst Appliance

The Original Banded HerbstThe original banded Herbst was developed by Emil Herbst inthe early 1900s. It was reintroduced by Dr. Hanz Pancherz inthe late 1970s. Pancherz employed orthodontic bands on thelower first bicuspids and upper first molars. Due to the learningcurve that was necessary to correctly fabricate this design,many of the early banded appliances made in the United Statesdid not withstand the forces in the mouth. Even though thoseinitial attempts met with limited success, the overall promise ofusing the Herbst kept several clinicians involved in developingalternative designs. The banded designs that are in use todayare able to withstand the forces of the mouth. SpecialtyAppliances offers many designs that are widely used byclinicians today.

The Acrylic Splint Herbst The Acrylic Splint Herbst was originally designed to be bondedto the teeth. However, a large percent of clinicians experiencedproblems with this appliance. First, there was a leakageproblem in the bonding system that increased the potential fordecalcification. Another major problem arose when it cametime to remove the bonded splints. The procedure was timeconsuming and actually posed a risk to the teeth due to theforces required to remove the bonded appliances. Due to theseproblems, the acrylic Herbst did not achieve widespreadacceptance in the market.

The Stainless Steel Crown HerbstClinicians using the Stainless Steel Crown Herbst have seen themost favorable results in terms of ease of clinical application,patient acceptance, and appliance removal. Many advocates ofthe crown Herbst have added accessories such as expansionscrews and archwire tubes, and have established protocols tocombine the Herbst with traditional fixed appliances. This hasled to improvements in terms of the overall treatmentsequencing, as well as a reduction in the overall length oftreatment when the Herbst appliance is used.

Evolution of the Herbst Appliance DesignsEvolution of the Herbst Appliance Designs

The Herbst SystemThe Herbst system is composed of several components. TheHerbst mechanism is made up of rods, tubes, screws, and pivots.

The Herbst Rods and Tubes The terminal ends of the rods and tubes are fabricated with ahole that fits over each pivot. The rods slide freely inside thetubes (there are right and left side tubes) and the patient is freeto open their mouth. The size of the hole on the rods and tubesis larger than the corresponding pivot, which allows lateralmovement due to the “play” in the system.

The Herbst Screws and Pivots The Herbst screws have a small hex head that assists in insertingthem into the pivots. It takes three to four turns to fully engageand seat the screws. The suggested method to secure them intoplace in the pivots is to use a small drop of Ceka Bond on theends of the screws. Ceka Bond is a material designed to holddental implants. Note: The hex screws are interchangable with the slot screwsfrom Specialty.

The Herbst Anchorage Appliance The Herbst anchorage system is the appliance-using bands,crowns, or splints-that attaches the mechanism to the teeth. Thisappliance is custom fabricated at Specialty Appliances for theindividual patient. The screws fit over the rods and tubes andlock them in place on the pivots. The pivots in turn, are solderedto the anchorage units, such as crowns or bands, or are attachedto a wire framework in the acrylic designs.

Herbst Appliance PartsHerbst Appliance Parts

The Acrylic Splint Herbst OverviewThe Acrylic Splint Herbst was originally introduced as areplacement for the banded Herbst. On the upper arch, thesplint was routinely bonded. On the lower arch, however,bonding was optional since the patient, for the most part, hadto wear the lower splint with the upper fixed in place. Thebonded design is not as popular today due to problems withleakage and appliance removal.

TMD and Sleep Disorders UsesThe acrylic splint Herbst has proven useful in treating patientswith TMD and sleep disorders. The acrylic incorporates theteeth on both arches, and the lower jaw is repositioned to theexact anteroposterior, vertical, and lateral positions required bythe treatment plan. In addition, adjusting the occlusal surfacesof the acrylic and/or changing the length of the Herbst rods andtubes can alter the orientation of the lower jaw quickly andeasily.

The Acrylic Splint Herbst DesignIn fabricating the acrylic splint Herbst, a wire framework isused that includes the bicuspids and first molars. Thisframework crosses the occlusion and follows the arch contoursof the bicuspids and molars at approximately the mid-point ofthe teeth. The Herbst pivots are soldered directly to this wireframework to ensure maximum strength. The framework isthen incorporated into an acrylic splint on each arch. Theocclusal surfaces of the splints are trimmed and balanced to thewaxed construction bite provided by the clinician.

The Acrylic Splint Herbst The Acrylic Splint Herbst

Original Banded Herbst DesignThe Banded Herbst, as introduced by Pancherz, utilized bandson the lower first permanent bicuspids and upper firstpermanent molars. When orthodontists and laboratories in theUnited States originally attempted this technique, many casesfailed due to the insufficient thickness of the bands andinadequate laboratory fabrication. Once a custom band materialwas adopted, greater success was achieved. However, this wasa time consuming process that was not very “user friendly” toorthodontists and laboratories.

Current Banded DesignsThere are several extremely durable and well-proven bandedHerbst designs in use today. As in the original design, a band isstill placed on the first permanent molars on the upper arch. Awire surrounds the occlusal portion of the band and is solderedin a continuous manner, which provides a dramatically strongerappliance. One of the keys to successful use of this design is anunderstanding of the laboratory process, a process thatSpecialty Appliances has been instrumental in developing.

Banded Herbst Design OptionsDepending on the clinician’s preference, a band may also beincluded on the first permanent bicuspid. In this design, acontinuous wire connects the bands on the first bicuspid andfirst molar on each side. In the lower arch, once the firstpermanent bicuspids are erupted, they may be banded andincluded with the lower first molars in the overall appliance. Onyounger patients whose permanent bicuspids are not yetpresent, a wire is extended forward to the first bicuspid region.In the lower first bicuspid area, the Herbst pivot is soldered tothe anchorage wire.

The Banded Herbst DesignThe Banded Herbst Design

Stainless Steel Crown HerbstThe Stainless Steel Crown Herbst is the most popular Herbstappliance in use today. Crowns offer excellent anchorage forthe appliance and provide a clean and hygienic design for thepatient. The crowns also facilitate the addition of auxiliariessuch as expansion screws, archwire tubes and otheraccessories. Much of the crown Herbst’s popularity can beattributed to its durability-it has proven to be the most durableof all of the Herbst anchoring systems.

Selecting and Fitting the Stainless Steel CrownsCrowns are extremely durable and are strong enough besoldered to. Ideally, the crowns are cut and contoured to coverthe complete tooth and will have a certain amount of “play” inthe overall fit. At Specialty Appliances, clinicians elect to haveour technicians fit crowns in more than 95 percent of the cases.Due to our experience and expertise in fitting crowns,orthodontic practices are able to save valuable clinical chairtime, as well as reduce their necessary inventory of crowns.The saved chair time alone gives great value to the indirecttechnique of fitting the crowns.

Crown Herbst Appliance Design OptionsWhen using crowns, it is easy to add a Rapid Palatal Expansion(RPE) screw to the upper arch, as well as an expansion screwto the lower arch. Archwire tubes are one of our more popularauxiliaries for either arch. They enable the clinician to utilizesectional wires to the anterior teeth during Herbst treatment.Depending on the clinician’s preference and the anchoragerequirements of the case, a combination of stainless steelcrowns and bands can be used.

The Stainless Steel Crown Herbst The Stainless Steel Crown Herbst

The Cantilever Herbst Appliance OverviewThe most popular of the crown Herbst Appliances is thecantilever design. This is a modification that was originallydesigned to better adapt the Herbst to younger patients. Itaccomplishes this by eliminating a crown or band on thedeciduous first molars. The cantilever name describes the metalbar that is soldered to the buccal of the crowns on the lower firstmolars. This bar extends forward to the bicuspid area where theHerbst pivots are located. The cantilever can also be used onpermanent dentition cases.

The Cantilever Herbst Appliance-Upper ArchStainless steel crowns are fit on the upper and lower firstpermanent molars. On the upper arch, the Herbst pivots andarchwire tubes are soldered on the buccal of the crowns. A bandmay be added to the first bicuspid with a wire extension fromthe buccal and lingual of the crown on the molar. An option toincrease anchorage is to bond a wire rest from the crowns to theocclusal of the deciduous molars. However, seating is mucheasier when the crowns are treated as individual units. This alsoallows the molars to rotate mesial-buccally, which helps in theClass II correction.

The Cantilever Herbst Appliance-Lower ArchOn the lower arch, a stainless steel bar extends forward from thebuccal of the crown on the molars. This bar has the Herbst pivotlocated on the mesial, adjacent to the first bicuspid. In order tofurther stabilize the lower cantilever, a continuous lingual archmay be incorporated. Another design alternative is to placebonded occlusal rests on the deciduous molars. Note: whensecond molars are present, an occlusal rest must beincorporated in the design to control the eruption of these teethand prevent any undesirable eruption.

The Cantilever Herbst ApplianceThe Cantilever Herbst Appliance

Using Anterior Brackets with the Cantilever HerbstThe anterior teeth can be bracketed with the archwire engagingtubes built into the Herbst pivots. By bracketing the loweranteriors, anchorage is dramatically improved, andsimultaneous alignment of the lower anteriors is also achieved.Generally, the lower brackets will have a negative torque tohelp level the arch. These brackets are also very important incontrolling the forces of the cantilever Herbst. Depending onthe age of the patient and the overall treatment timing andsequence, the transition from Herbst appliance therapy to fullfixed appliances can be made with minimal, if any, “holding”phases.

Expanding the Upper Arch with the Cantilever HerbstIn addition to repositioning the lower jaw, arch development isoften one of the treatment goals. With the stainless steel crowndesign, expansion can be built into the appliance for either theupper or lower arch. On the upper arch, a traditional rapidpalatal expansion screw is added to the molar crowns on theHerbst. In this design, there is no need to include the firstbicuspids in the appliance.

Lower Arch Expansion with the Cantilever HerbstOn the lower arch, an expansion screw can also be added to theHerbst. With crowns on the permanent molars, a continuouslingual wire is used with a modified expansion screw placedalong the midline. Bonded rests are also incorporated into theexpansion device to help prevent the expanders from rotating tothe occlusal or gingival. These rests also help keep the teethvertical while the expansion is taking place.

Combination Herbst TreatmentCombination Herbst Treatment

“How to Do”Sequence -Introduction

“How to Do” Herbst Appliance Sequence“How to Do” Herbst Appliance Sequence

“How to Do” Sequence - Introduction Subsequent sections of this manual present a “how to” sequencefor clinical implementation of the crown Herbst appliance.Whenever possible, topics are presented as they wouldroutinely occur while using the Herbst. The material isorganized as follows:

In the Clinic Prior to Sending Your Case toSpecialty AppliancesThe first section discusses what a practice does initially toutilize the Herbst appliance. Included are steps discussingimpressions, models, and the construction bite. Also presentedare the key steps involved in completing the new SpecialtyAppliances Herbst Rx form.

In the Laboratory at Specialty AppliancesThe next section provides an overview of what SpecialtyAppliances does in the laboratory to fabricate the Herbst. Overthe years, we have found that practices that have anunderstanding of what goes on in the laboratory usually aremuch better off in terms of problem solving in the event thatthere are any difficulties in the clinic.

Clinical Delivery of the HerbstThe next section provides a comprehensive review of theclinical delivery and cementation of the Herbst. Following thecomprehensive review is additional information on patient andparent instructions, Herbst troubleshooting, and other relevantclinical topics that will help the practice integrate the Herbstappliance.

Dr. Terry Dischinger Herbst Educational VideotapeWe strongly encourage practices to obtain our videotapefeaturing Dr. Terry Dischinger and his “team”. It contains morethan two hours of step-by-step instructions on the Herbstappliance, including many of the topics discussed in thissection.

Steps in the Practice Prior to Sending a Herbst to SpecialtyThere are several key areas the practice should fully understand foroptimal use of the Herbst appliance. In addition, there are important stepsa clinic should take prior to sending a Herbst case to SpecialtyAppliances. The information below is an overview of those critical points.They are covered in further detail on the next several pages.

Consultation AppointmentThe Herbst is presented to the patient and parent during the initialconsultation. The benefits are explained and a decision is reached to usethe Herbst.

Note: Specialty can provide your practice with a sample Herbstappliance on plastic models to use as a demonstration aid duringconsultations with patients and parents. Call Specialty at (800) 522-4636to order a Herbst demonstration appliance.

Impressions and CrownsWhen impressions are taken for the Herbst, there are two optionsdepending on whether the practice or the laboratory is fitting the crowns.When requesting Specialty to fit crowns in the laboratory, it is notnecessary to create space (with spacers) prior to taking the impressions.Simply provide a model and we will fit the crowns in anticipation of theappropriate space being created mesial and distal to the molars. Thissaves an appointment!

If crowns are fit in the office, spacers are necessary (usually worn for 1week) to create adequate space to fit the crowns. Using this technique,the crowns are poured into the models using a traditional “pick-up”method, which should result in working models with the crowns seated inthe ideal position. Some offices also elect to fit crowns directly in themouth but send them loose to Specialty where we seat them on themodels. This reduces the chance of the crowns “floating” during themodel pour-up. These impressions should be taken with the crowns offthe teeth.

With either technique, spacers should be utilized while the appliance isbeing fabricated so there are no clinical problems at the time of Herbstdelivery.

Steps in the OfficePrior to Sendingthe Herbst to theLaboratory

In The Doctors OfficeIn The Doctors Office

Impressions and ModelsAs with any orthodontic appliance, accurate working modelsare critical for the laboratory to fabricate the appliance. In thecase of the Herbst, an accurate set of working models poured inorthodontic stone is required from the practice. For patientswhere the Herbst starts the initial treatment, one set ofimpressions may be taken and poured twice-the first forlaboratory use and the second for general records.

Fitting the CrownsWhen using the crown Herbst with Specialty providing thecrowns, there is no need to place spacers prior to taking theimpression. At Specialty Appliances, we will calculate theappropriate space mesial and distal to the teeth receivingcrowns. For offices that prefer to furnish and fit their owncrowns, the crowns are fit on the patient’s teeth and removedbefore the impressions are taken. This technique works bestbecause the crowns having little retention to hold them in placewhile the impression is being poured.

Construction BiteMany functional appliances utilize a wax construction bitetaken directly from the patient to show the desired mandibularrepositioning to be built into the appliance. With the Herbst, awax construction bite is not required. The clinician can simplyindicate on the models (using pencil lines) where they want themandible advanced in relationship to the maxilla.

Steps in the Office - Working Models and CrownsSteps in the Office - Working Models and Crowns

Specialty Appliance Prescription FormSpecialty Appliance Prescription Form

HERBST APPLIANCE / RxPHONE ME REGARDING THIS CASESPECIAL INSTRUCTIONS ON FILENEW ACCOUNT ADDRESS CHANGE

ACRYLIC HERBST DESIGNS

ACRYLIC SPLINT HERBST

SLEEP DISORDER HERBST

ACCESSORIES

Upper Lower

Upper Lower

Labial Bow

Ball Clasps

Arrow Clasps

Expansion Screw

Archwire Tubes .018 .022

Upper Lower

Acrylic Coverage - 2nd Molars

Acrylic Cap - Upper Anteriors

Add Palatal Acrylic

Bonded Acrylic Design

Add Debonding Screws

METAL HERBST DESIGNS

BANDED HERBST

CROWN HERBST

METAL UPPER/ACRYLIC LOWER

CROWNS and BANDS

Specialty Appliances Provide and FitCrowns/Bands - per diagram below

6 5/e 4/d

6 5/e 4/d

d/4 e/5 6

d/4 e/5 6

6 5/e 4/d

6 5/e 4/d

d/4 e/5 6

d/4 e/5 6

ACCESSORIESExpansion Screw

Ball Clasps

Lingual Arch

Upper Headgear Tubes

.045 .051

Upper Archwire Tubes

.018 .022

Lower Archwire Tubes

.018 .022

Occlusal Center Gingival

Send Shims mm

ORIGINAL CROWN HERBST

CANTILEVER HERBST

DISCHINGER OTHER (diagram)

SPECIALTY STANDARD DESIGNS

DISCHINGER DESIGNS

CANTILEVER HERBSTMAYES DESIGN

TYPE I TYPE II TYPE III SMITH DESIGNS

BAND / CROWN HERBSTHILGERS DESIGN

CIRCLE CROWNS TO BE SEATED

OCCLUSAL RESTS per diagram

R L

CIRCLE BANDS TO BE SEATED

R L6 5/e 4/d

6 5/e 4/d

d/4 e/5 6

d/4 e/5 6R L

Herbst is a registered trademark of Dentaurum

R L

2-98

Doctor

Address

City State Zip

Telephone Fax

Patient Name

Date Shipped

Date Needed

SPECIAL INSTRUCTIONS

1 800 LAB-INFO • In GA (770) 416-1822 • Fax (770) 446-6958 • www.specialtyappliances.com

P.O. Box 105224 Atlanta, GA 30348 (for use only with Specialty Appliances prepaid business reply labels) 1670 Oakbrook Drive Suite 390 Norcross, GA 30093 (for all cases shipped directly to street address)

RX SHEETSMAILING LABELS

SEND ADDITIONAL

Crowns/Bands Enclosed with Case Specialty Seat - per diagram below

* Debonding Screws Great Lakes Orthodontics

*

Specialty Appliance Prescription FormSpecialty Appliances provides practices with a detailed prescriptionsheet for the Herbst appliance. The key areas for this prescription sheetare illustrated in the graphic below. Please note that each of thesections of the prescription sheet includes an important piece ofinformation regarding the appliance design. Please fill out theprescription form completely. If you have any questions regarding theform, call (800) LAB-INFO (800-522-4636).

Laboratory OverviewThis section presents a brief overview of the key technical stepsinvolved in the laboratory when fabricating the crown Herbstappliance. Many of our Herbst customers have indicated thattheir practices are able to better utilize the Herbst byunderstanding what happens in the laboratory. This is especiallytrue when it comes to troubleshooting and problem solving withthe Herbst.

Quality Control - Incoming StageThe first step in the laboratory is to verify the accuracy of themodel received from the practice. This is done on a routinebasis with all cases received at Specialty Appliances, but isespecially important with the Herbst because of the precise fitof the stainless steel crowns. We recommend that you use stonefor your models since plaster may fracture too easily whenseating the stainless steel crowns.

Fitting the CrownsThe next step is to prepare the model and fit the stainless steelcrowns. In this step, crowns are fit on the upper and lower firstpermanent molars. The model is prepared by trimming themargins around each tooth. The goal is to simulate the dentalanatomy with the surrounding tissue removed. Theappropriately sized crown is selected, trimmed, contoured, andfit on the model.

Overview of Laboratory ProceduresOverview of Laboratory Procedures

Locating and Soldering the Pivots andAttachmentsOn the upper crown, the Herbst pivot and archwire tube arelocated on the buccal of the crown. On the lower arch, theHerbst cantilever bar is positioned along the buccal of thecrown. On the mesial of the cantilever arm, the Herbst pivotand the archwire tube are located. Once the parts have beensoldered, they are removed from the models and finished.

Fitting the Herbst MechanismsThe final step in the laboratory is to cut the Herbstmechanisms. The upper and lower jaws are held in the desiredocclusion and the Herbst mechanisms are cut to this dimension.The upper and lower members of the Herbst are placed over theeyelets on the pivot, where it is easy for the technician to markthe correct length of the tubes and rods.

Final Quality Control ProcessAll cases are checked to make sure the cantilever arms andother parts fit accurately. The edges of the crowns are checkedfor sharp spots. Another important point to check at this stageis the end of the rods where they come out of the back of thetubes in the upper first molar region. They should be two tothree millimeters long-any additional rod length in this areacould cause ulcerations.

Overview of Laboratory ProceduresOverview of Laboratory Procedures

Delivery Appointment and Staff Involvement

Clinical Delivery-OverviewOnce the office receives the appliance, there are several keysteps involved in the initial appliance delivery. The next sectionprovides a detailed explanation of the clinical steps involved indelivering the Herbst appliance. In the experienced practice, the initial appliance delivery takesapproximately sixty minutes. Depending on the specific statelaws, many of the clinical delivery steps may be performed bythe staff. Quality of care is enhanced when the staff has acomplete understanding of the necessary procedures and of thetheoretical basis behind the appliance.

Dr. Terry Dischinger Herbst EducationalVideotapeThe above statement is the basis for the educational videotapeSpecialty Appliances produced with Dr. Terry Dischinger andhis staff. All key aspects of the Herbst appliance are covered inthis tape, along with detailed, close-up photography.Throughout the tape, Dr. Dischinger explains and narrates thetheory and basis for using the Herbst, as well as how each phaseof the Herbst and related topics fit into the overall treatment.

Contact Specialty Appliances for Herbst Videotapeand Demonstration ApplianceThis valuable educational videotape is available from SpecialtyAppliances and can be ordered by calling (800) 522-4636. Inaddition to this videotape, we recommend ordering a Herbstdemonstration appliance on pink and white acrylic models.This patient and parent educational tool is invaluable inexplaining the treatment and clinical steps involved with theHerbst, especially relating to the appliance delivery and initialhome instructions.

Clinical Delivery of the Herbst ApplianceClinical Delivery of the Herbst Appliance

Initial Step-Identify and Organize the Herbst PartsThe first step in delivering the Herbst is to assemble andorganize the Herbst parts. It is important for the staff membersto keep the upper and lower, and right and left portions of theappliance identified and separated. Even though the right andleft lower rods are interchangeable parts, in the laboratory atSpecialty, they are cut to fit the right and left sides of eachpatient’s case.

Herbst Screws Attached to the CrownsTypically, for clinical delivery, the lower rods are removedfrom the crowns, while the upper tubes are left connected to theupper crowns. The standard protocol at Specialty Appliances isto return the mechanisms attached to the crowns with thescrews “finger tightened.” This assists in the clinical steps forthe delivery of the Herbst, since the parts will be removed andsecured with Ceka Bond before the final delivery of theappliance.

Upper Crowns and Herbst Tube AssemblyMany offices bond the upper crowns with the Herbst tubesattached due to the difficulties in placing the screws on theupper crowns once they are cemented. For offices that do bondthe crowns with the Herbst attached, the screws need to beremoved, dipped in Ceka Bond, and then re-inserted into thepivots on each upper crown. This may be done prior to theinitial try-in. However, once all the crowns are cemented andthe mechanism assembled, any discrepancies in the mandibularposition or working of the Herbst mechanism may result inhaving to remove and adjust the upper tubes.

Clinical Delivery - Step by Step SequenceClinical Delivery - Step by Step Sequence

Spacers and the Fit of the CrownsAn important point worth mentioning again is the use of spacersto create adequate room for the crowns. The thicknesses of thecrowns are approximately twice that of orthodontic bands, soadequate space will be required in order to seat the crowns. Inaddition, the crowns come in only seven graduated sizes, so theoverall fit will not be as precise as an orthodontic band. Thisdoes not present a problem, however, since excess space insidethe crown is filled with the bonding material. All crowns areetched to help aid in retention before they leave SpecialtyAppliances.

Trial Fitting the Crowns and CantileversWe recommend that on a routine basis, all Herbst appliances betrial fit in the mouth prior to cementation. The crowns havebeen contoured at Specialty; however, additional contouringmay be necessary to get a “snap fit” of the crown. This is doneusing the crown contouring pliers. These pliers will produce aslight undercut in the border of the crown, which in turn snapsin place on the tooth. In checking the fit of each crown, manypractitioners and assistants report that they actually hear thecrown snapping into place when it fits properly.

Verify the Fit of the CrownsCrowns used for the Herbst will have a “positive” fit on thetooth as described above. They may not seat completely froman occlusal standpoint however as the cusps of the teeth maycontact the inside of the crown. A slightly elevated (1-mm)crown position on a molar does not present a problem as longas it does not interfere with the opposing teeth.

Important Note: After each crown is fit and verified, it shouldbe immediately removed from the mouth to prevent any chanceof the patient swallowing an uncemented crown.

Herbst Initial Delivery - Trial Fitting the CrownsHerbst Initial Delivery - Trial Fitting the Crowns

Checking the Cantilever Arms and Occlusal RestsOnce the crowns are fully seated, the position of the cantileverarms and any occlusal rests should be evaluated. The cantileverarms are formed in the laboratory to lay approximately 1mmfrom the adjacent teeth. If these bars are too close to or too farfrom the tissue, they can cause irritation. Any adjustmentsrequired can be made using a pair of headgear pliers.

Checking the Occlusal RestsThe occlusal rests should also be evaluated to make sure theylay flush against the dental surfaces. Of critical importance isthe position of the rests on the second permanent molars (ifpresent). The second molar rests should engage the buccalocclusal groove completely to prevent unwanted verticaleruption of these teeth. This also prevents tongue irritation.

Cleaning the CrownsAfter the crowns have been satisfactorily trial fitted, they areremoved and the insides cleaned using alcohol. As a routineprocedure, all Herbst crowns and bondable rests are micro-etched at Specialty Appliances before they are sent to theorthodontist. Micro-etching the metal increases the adhesion ofthe bonding material to the metal. This is extremely helpful inremoval and clean up when the desired result is for as much ofthe adhesive as possible to remain on the inside of the crown,with as little as possible on the tooth.

Herbst Initial Delivery - Checking the Cantilever ArmsHerbst Initial Delivery - Checking the Cantilever Arms

Herbst Appliance Delivery ProtocolBonding the Herbst is a procedure that typically requires thedoctor and staff member to work in a “four handed” fashion. Atthis point, the orthodontist has checked and verified the fit ofthe appliance and the Herbst has been removed and cleanedback to the condition in which it was delivered from SpecialtyAppliances. All supplies and materials required for cementingthe Herbst are assembled and ready for the procedure.

Tooth PreparationWhen using Fuji I glass ionomer cement (from GC America),there is no need to etch the teeth. Experience has shown thatadequate bond strength for crowns is achieved by bonding theentire periphery of the tooth, without the occlusal surfaceincluded. This is accomplished by placing a small amount ofVaseline on the occlusal surface of each molar using a Q-tip.The Vaseline prevents the adhesive from adhering to theocclusal surface of the molar, which makes appliance removaland clean up easier.

Herbst Appliance Preparation - Holding the TubesIn this illustration, the upper tubes are attached to the crowns onboth sides. The fit of the appliance was verified directly in themouth, so the Herbst screws are secured with Ceka Bond.When the upper crowns are cemented with the Herbst tubesalready assembled, an elastic is used to hold the mechanismagainst the crown during the bonding process. This prevents thetube from “hanging down” into the working field whilecementing the crown.

Cementing the Herbst ApplianceCementing the Herbst Appliance


Appliance PreparationScrew pivots, RPE key holes, and archwire tubes on any Herbstparts must be covered prior to bonding so the adhesive will notaccidentally flow into these areas. This is done by placingtoothpaste in these holes. Once the Herbst is cemented, thetoothpaste is easily rinsed out of these holes.

Bonding Adhesive There are several adhesive products on the market that may beused to bond the crown Herbst. One of the more popularadhesives is Fuji I glass ionomer cement from GC AmericaCorporation. This material is extremely strong, durable, andeasy to handle. Cements are also available in colors, whichhelps in identifying the residual material on the teeth during theclean-up process. The adhesive is mixed on a cold slab andloaded generously into each of the crowns.

Delivering the ApplianceFrom the beginning of mixing the adhesive, there isapproximately 8 minutes of total working time. At this point,the clinician is at the chair and can begin seating each crown.The crown is seated with finger pressure first, and then thepatient should be asked to bite down on a band-seatinginstrument to fully seat the crown. On cases with the right andleft sides connected (a RPE Herbst) the patient should bitealternatively on each side to seat the appliance completely.

Note: Lingual cleats can be added to the crowns to aid inseating the appliance.

Cement Clean UpThe excess adhesive is expressed from the edges of the crownwhere it can be easily cleaned up using an air-water syringe andQ-tips. Since the crowns were trial fitted, the delivery can bedone in minutes, leaving ample time for clean up before thecement starts to set. After removing the excess adhesive, ascaling instrument is used around the entire border of eachcrown. Care must always be taken to make sure that all of theadhesive is removed from the gingival margins, as excessadhesive could cause tissue irritation.

Adhesive for Bonding the Occlusal RestsSeveral popular Herbst designs utilize bonded occlusal rests toprovide additional stability and anchorage. These wire rests arebonded using a light-cure adhesive. The Fuji Ortho LC bondingadhesive is recommended for this procedure, as moisturecontrol is not an issue and etching the surfaces of the teeth is notrequired. A standard light cured adhesive with etching can beused if desired.

Bonding the Occlusal Rests Using an explorer or scaler, the light-cure adhesive is adaptedto the occlusal surface where it covers the bonded rest. Once theadhesive is properly contoured, the material is cured with thehand-held light gun. The outer surface of the bonding adhesiveshould be smooth and require no further finishing. Thisprocedure is repeated until all of the bonded occlusal rests havebeen placed.


Appliance CheckAt this point, all four crowns have been cemented and theocclusal rests bonded. Prior to assembling the Herbstmechanisms, the following items are once again checked:

Cement Clean upAll cement must be removed from the margins below thecrowns. This is checked visually as well as by using anexplorer. Excess cement that is not removed can cause tissueinflammation and discomfort for the patient. This may benoticeable due to blanching of the tissue.

Cantilever PositionWith the crowns cemented, the position of the cantilever armsis again checked. The bars should lay adjacent to the teeth witha 1-2mm clearance. Once the crowns are cemented, it is verydifficult to adjust the cantilever arms, so they need to bechecked carefully during the try-in procedures.

Occlusal and RestsBonded occlusal rests should be secure and smooth. Occlusalrests on the second permanent molars should be adjusted to fitcompletely into the buccal/occlusal groove. Note: The wirerests on the second molars are not bonded to the teeth, in fact,these rests may be left a little occlusal in cases where the teethare still erupting.

Herbst Appliance Initial Delivery Checklist Herbst Appliance Initial Delivery Checklist

Trial Fit the Herbst MechanismOnce the crowns have been cemented and the adhesive cleanedup, the next step is to attach the Herbst mechanism. Dependingon the experience level of the practice, a suggestion that may behelpful is to “trial fit” the Herbst mechanism prior to setting thescrews with Ceka Bond. There are several important areasregarding the mechanism that need to be checked and adjustedif necessary.

Assembling the MechanismIf the upper tubes were not included in the initial delivery, theyare attached at this point using the offset on the allen wrench.The lower rods are then inserted into the tubes on theirrespective sides and the patient is instructed to protrude themandible. With the lower jaw advanced, the holes on the endsof the lower rods will fit over the Herbst pivots in the lower firstbicuspid area. Another suggestion here is to lightly tighten thelower screws to hold the appliance in place while checking theoverall fit of the mechanism.

Setting the ScrewsIf the screws are set with Ceka Bond immediately after placingthe mechanism, any necessary follow-up adjustments willrequire removal of the bonded screws. This is accomplished bygrasping the outside head of the screw with a pair of “Howe”or “Weingart” pliers to break the bond. The screws can then beremoved with an Allen wrench. Once the final fit of theappliance has been verified, the screws are set using the Allenwrench with the ends of the screws first dipped in Ceka Bond.

Assembling the Herbst MechanismAssembling the Herbst Mechanism

Laboratory and Clinical Coordination in Fitting the Herbst Mechanism

In the Specialty Appliances laboratory, the Herbst mechanism is cut and fitfor each individual patient. The amount of mandibular advancement isdetermined by either the clinicians wax construction bite, or by referencelines on the sides of the models. We also check the working range of theappliance, and test to make sure there is no binding of the mechanism.Even though these items are checked in the laboratory, they must bechecked again once the appliance is assembled in the mouth. Somepatients adapt better than others to the appliance, and minor problems withthe fit can occur clinically that cannot be determined in the laboratory.

Checklist for Fitting the Herbst Mechanism

There are several important items to check regarding the fit and functionof the mechanism:* Amount of mandibular advancement * Alignment of the dental midlines* Smooth working of the mechanism (no binding)* Rod length out of the distal of the tubes (not too much)* Sufficient rod length to keep the mechanism from

disengaging on opening

Checking the Fit of the MechanismChecking the Fit of the Mechanism

Amount of Mandibular AdvancementThe first point to check is the amount of mandibularadvancement. This is determined by the length of the uppertubes. If needed, this can be altered several ways. The firstoption is to reduce the length of the tubes if the mandible isadvanced too far. This is done by cutting the tube with adiamond wheel and finishing the ends smooth with a stone orcarbide burr. If the lower jaw is not advanced far enough, shims(small rings made from tube sections) can be added to bothsides of the mechanism.

Alignment of the Dental MidlinesOccasionally, the dental midlines may not be aligned properlywhen the mechanism is in place. This is corrected by eitherreplacing the tubes (one or both), by reducing the length of thetube on one side, or by adding a shim to advance one side.When shims are added, they should be crimped onto the rodwith a heavy wire-cutter to prevent tissue irritation. Any timeshims are added, the patient is checked to make sure they do notdisengage on wide opening.

Smooth Working of the MechanismAnother important point to check is the overall smooth workingof the Herbst mechanism. There should be no binding when thepatient opens or moves laterally or side to side. In thelaboratory, the eyelets of the tubes and rods are enlargedroutinely, which increases the “play” in the system and helpsprevent binding. Patients with narrow upper arches may need anexpansion system added before the appliance will functionproperly.

Checking the Fit of the Herbst Mechanism Checking the Fit of the Herbst Mechanism

Rod Length Out of the Distal of the TubesOne of the most important points to check is the length that therods extend out of the back of the tubes in the upper first molararea. Most patients (especially younger ones) will tolerate onlya couple millimeters of the rod extending out of the tube.Adjustments to the rod must be made prior to final assembly ofthe mechanism. The rods can be cut with a heavy-duty wirecutter and the cut ends blunted off with a rubber wheel.

Sufficient Rod Length to Keep the Mechanismfrom Disengaging on OpeningWhile it is critical the rods do not extend too far out of thetubes, at the same time they must have sufficient length so thepatient does not disengage on wide opening. This is addressedby first making sure the rods are cut to their full length. Forpatients who still disengage on wide opening, additionalinstructions are provided at the time of the patient/parentconsultation to demonstrate how to reassemble the mechanism.

Final Assembly of the MechanismOnce the final fit and function of the mechanisms has beenverified, the screws are set in place using Ceka Bond adhesive.If necessary (for example, to readvance the mandible), thescrews can be loosened once they are placed with Ceka Bondby turning them. This will break the seal. In some instances, itmay be necessary to replace a screw that has previously beenset in place with Ceka Bond.

Checking the Fit of the Herbst Mechanism Checking the Fit of the Herbst Mechanism

Patient and Parent InstructionsOnce the appliance has been delivered, the next step is toprovide instructions and home care information to the patientsand parents.

Muscle TendernessThe first point to explain is that the patient will require an initialperiod of adjustment to the Herbst. The most common concernsare overall muscle tenderness and soreness of the teeththemselves. The patient is instructed that they may have tochange their diet to softer foods for the first week or so.

Tissue IrritationThe second point to explain is that the patient will have to getused to the Herbst mechanisms, especially the screws on thelower arch. It will take the mouth time to adapt and build“calluses” with regards to the metal parts. In the transitionperiod, the patient may want to use cotton rolls secured to theHerbst with a small rubber band in the lower first bicuspidregion. These should be worn at night for the first 1-2 weeksand daily only if tenderness persists.

Facial AppearanceSome patients may be concerned with their appearanceregarding the “fullness” of their face, especially in the lowerbicuspid area. Explain to them that this will become lessnoticeable over a short period of time. On the other hand, it canbe extremely positive to emphasize the improvements that havebeen made in their profile view now that the lower jaw isadvanced.

Patient and Parent InstructionsPatient and Parent Instructions

Herbst Becomes DisengagedPatients who have the capacity to open wide, may disengagethe Herbst mechanism on one or both sides. This informationmust be explained to the patient during the initial deliveryappointment to reduce the need for unnecessary follow-upappointments. Using a typodont with a sample Herbstappliance, it is easy to show the patient and parents how toreassemble the mechanisms if it comes apart.

Rapid Palatal Expansion ActivationPatients who have an RPE screw incorporated into their Herbstare given instructions on how and when to activate the screw.Many offices will activate the RPE screw at the initial deliveryappointment by turning it 1/4 turn with the parent present, andthen instruct them do activate it another 1/4 turn, assisting asneeded. Check the screw activation by measuring the gap witha millimeter gauge.

Appliance BreakageIf there are any parts of the appliance that become loose orbreak, the patient is instructed to contact the office and explainthe problem. In many instances, such as a loose screw, thepatient can be seen the next day. Other situations, including abroken or damaged appliance, may necessitate an emergencyappointment.

Note: Many offices provide parents with a screwdriver or hexwrench and extra screws. With proper explanation, parentscan, in many cases, replace or tighten a Herbst screw,eliminating the need for an “emergency” visit.

Patient and Parent InstructionsPatient and Parent Instructions

Appointment SequencesDepending on the clinician’s preference, the use of Herbst auxiliaries, andthe overall treatment plan, there may be several related adjustmentappointments required. The following section of this manual illustratesseveral of the follow-up Herbst-related appointments and the clinical stepsrelated to those procedures including:* Fixed appliances used with the Herbst* Expansion screws used with the Herbst (upper and lower)* Molar distalization with the Herbst* Mandibular reactivation

Length of Treatment TimeThe Herbst can be used in the basic design for anteroposterior changesonly, or can be enhanced by the addition of auxiliaries. On average, theHerbst is used for 8 to 12 months to correct Class II problems. The exacttime will vary based on the clinicians’ attitudes toward the time requiredfor skeletal, dental, and muscular adaptation. The severity of correctionneeded, as well as the age of the patient, factors into treatment time. Forthe basic Herbst appliance, many practices have extended the timebetween appointments to 6, 8, or even 10 weeks, as long as there are noproblems reported.

Herbst RemovalThe last part of this section covers clinical techniques for removing theHerbst. Practices often have questions and concerns when removingcrowns. This section addresses these issues. The most common way toremove the crowns is to cut them in sections and separate the crown withband removing pliers. This technique is covered in detail in the Dr.Dischinger Herbst Video.

Clinical Adjustments of the Herbst - IntroductionClinical Adjustments of the Herbst - Introduction

Placing Anterior Brackets Many clinicians use fixed appliances on the anterior teeth inconjunction with the Herbst to provide anchorage and to alignthe teeth. When indicated, anterior brackets are typicallyadded at the appointment after the initial Herbst delivery. Thisreduces the overall length of the initial delivery appointment,which already takes approximately sixty minutes. Patientstreated at an age when more of the permanent teeth are presentmay also have brackets placed on the cuspids and bicuspids.

Bracket and Archwire LocationThe sectional archwire is engaged in the brackets with theterminal ends extending into tubes fitted into the Herbst pivots.At Specialty, the clinician can specify the location of thearchwire tubes depending on the case requirements. For deepbite cases where an intrusion force is desired, the archwiretubes are located gingival to the Herbst pivots. Conversely, inan open bite situation, the tubes are located occlusal to thepivots. In cases that have been leveled before the Herbsttreatment, the tubes are placed in the center of the pivots.

Brackets and ArchwiresMany clinicians use a relatively full-sized, flexible rectangularwire to gain anchorage with some initial torque control of theanterior teeth. In addition, minus 10 degree lower anteriorbrackets may be used to counteract any “dumping forward”forces on the anteriors. On the upper arch, .022 degreecentrals and .014 degree lateral brackets are recommended toestablish and maintain proper torque control for Class 1correction. The terminal ends of the archwire insert into thetubes, where they are bent back to avoid tissue irritation.

Herbst Treatment Sequence - Anterior Brackets AddedHerbst Treatment Sequence - Anterior Brackets Added

The Herbst Combined with Arch ExpansionMany clinicians elect to expand the jaws in conjunction withHerbst therapy by incorporating expansion screws into thestainless steel crown design. In the original Class II posteriorrelationship, the upper jaw may accommodate the lower jaw inthe molar width. With the mandible advanced, however, oftenthe upper arch is not wide enough. This discrepancy, if notaddressed, can cause the Herbst rods to “bind up” when thepatient moves laterally. Expanding the upper arch can usuallysolve this problem.

Herbst Expansion and Treatment SequencingScrews may be placed in the upper appliance in the traditionalmanner, as with the banded RPE. Once the expansion has beenachieved and stabilized, the screw can be removed using adiamond burr in a high-speed handpiece, all while continuingHerbst therapy. The Herbst will naturally hold the upperexpansion due to the buccal forces it inhibits.

Lower Arch Expansion with the HerbstAn expansion screw also can be added to the lower appliance byincorporating a heavy lingual support wire, which the screw issoldered to. When using either expansion design, the treatmentsequence is explained to the patient and parents and the parentinstructed to activate the expansion screw(s) on the scheduleprovided by the clinician. The lower arch expander will need tobe left in for at least 10 weeks after expansion is completed.

Herbst Treatment with ExpansionHerbst Treatment with Expansion

Molar Distalization with the HerbstThe Herbst has a natural tendency to distalize the upper molarsdue to the forces transmitted from the lower jaw, through theHerbst mechanism, to the upper molars. Depending on thedesirability of this treatment effect, the molars may or may notbe “tied in” to the rest of the upper teeth when using fixedappliances with the Herbst.

Controlling the Upper Molar MovementBy using fixed appliances on the upper teeth and “tying back”a continuous archwire to the molar crowns, the amount ofdistal molar movement can be minimized. If, on the otherhand, maximum molar distalization is desired, the crowns arenot connected to the rest of the upper arch. A longer archwiretube may be added to keep the molar upright while it isdistalizing.

Herbst Combined with the PendulumAnother option is the addition of a Pendulum type appliance tothe Herbst. In this design, palatal expansion with molardistalization is achieved while wearing the Herbst. Wires canbe added from the pendulum acrylic and soldered to the molarbands/crowns, where they hold these teeth until the initialexpansion is achieved. Once the upper arch is expanded, thestabilization wires are cut, and the Pendulum springs candistalize the molars.

Molar Control with the HerbstMolar Control with the Herbst

Mandibular AdvancementThe next clinical adjustment the practice may need to consideris the reactivation of the lower jaw. This will depend on theamount of mandibular advancement built into the initialappliance at the laboratory. Many clinicians also believe thatonce the Class I cuspid relationship has been achieved, theappliance should be activated to an overcorrected anteriorposition to account for the rebound once the appliance isremoved.

Clinical Sequence for Mandibular AdvancementWhether the Herbst is being activated for further mandibularadvancement or overcorrected positioning, the clinicalsequence is identical in adjusting the mechanism. The first stepis to remove the lower screws that hold the rods to theanchorage units. The rods are then removed from the tubes oneach side to allow placement of the shims. The shims arecrimped onto the rods using a heavy-duty wire cutter. Thisprevents the shim from moving up and down on the rod whenthe patient opens and closes.

Placing the Shim and Reseating the MechanismWith the shims crimped and placed, the rods are inserted backinto the tubes and the screws replaced in the pivots with CekaBond. Some patients who are “reactivated” forward may reportinitial contact with the anterior teeth with little posteriorocclusion. This is usually due to the anteriors not being leveland the patient having too deep of a bite. Use of anteriorbrackets to level and align will help prevent this problem.

Subsequent Mandibular Advancement with the HerbstSubsequent Mandibular Advancement with the Herbst

Herbst Re-activation with Shims and RodsIn some instances when reactivating the mandible for furtheradvancement, it may also become necessary to replace theupper tubes. As the shims are added to the rods, the rods fitfurther forward inside the tubes. On some patients, this willeventually cause a problem in that opening the mouth willcause the mechanisms to disassemble. In some instances (forexample, in the second advancement), this can be overcome bysubstituting a new, longer rod on the lower in addition toadding the advancement shims.

Replacing the Upper TubesWhen it becomes necessary to replace the upper tubes with alonger overall length, they are removed from the crowns and alonger, pre-cut tube (3-5mm longer) is selected for each side.Practices that have experience with the Herbst will have extraparts on hand for these types of adjustments. When new rodsor tubes are used (directly from the manufacturer) make sureto enlarge the holes where the parts fit over the pivots tofacilitate lateral movement.

Reassembling the Upper Tubes to the HerbstOnce the longer tubes have been screwed onto the uppercrowns, the new set of rods can also be fit. The decision onexactly which technique to use to advance the lower jaw isdependent on the case requirements and the overall experienceof the practice. Some practices find there is no difficultywhatsoever in simply adding shims to reactivate themandibular advancement, while other practices report it iseasier to replace the Herbst mechanisms with a longer set, asneeded.

Mandibular Advancement Adjustments Mandibular Advancement Adjustments

Herbst Appliance-Stainless Steel Crowns RemovalRemoval of the stainless steel crown Herbst is accomplished ina two-step procedure. First, the crowns are cut using a high-speed handpiece and cross-cut burr. Next, the crowns are liftedfrom each tooth using a crown removing tool. As with mosttechniques in orthodontics, this procedure has a learning curveand becomes easier with experience.

Remove the Herbst MechanismThe first step in Herbst removal is to take off the mechanisms.This is accomplished by unscrewing the four screws that holdthe tubes and rods in place. During this process, while theHerbst is disassembled and the lower rods are removed, makesure the patient does not “bite down,” since the upper tubes thatare still attached could impinge into the tissue. The alasticsused to hold the upper tubes during cementation also work wellfor this step.

Cutting the CrownsNext, a high-speed handpiece with a 1171 cross-cut burr is usedto cut each crown. The crown is cut along the buccal wall, thenextended over the occlusal surface all the way forward to theopposite side of the crown. It is important to cut the crown allthe way to the gingival. Once the cut has been completed, acrown removing tool is used to gently pry the crown from thetooth. The patient should be informed that they might feel“pressure” during this procedure, and that it will be very brief.

Removing the Stainless Steel CrownsRemoving the Stainless Steel Crowns

Occlusal RemovalAn alternative technique for crown removal is to cut a hole or“window” in the occlusal surface of the crown. Once thiswindow has been cut, the “anchorage foot” of the removingtool is placed against the occlusal surface and the lever force isactivated against the bottom of the crown in a lifting fashion.The advantage of this technique is that more of the adhesivetends to remains on the inside if the crown.

Add Vertical Cut in CrownsSome clinicians advocate using a small vertical slit in thegingival-most edge of the crown. This cut is made in thelaboratory, and provides the clinician with a routine andpredictable place to access the pliers for crown removal. Withthis technique, the removal pliers are also used with a “liftingand prying” motion to unseat the crown, making the procedureas comfortable as possible for the patient.

Herbst Removal-Cement Clean upThe time required to clean up the adhesive is proportional tothe amount of time spent in properly preparing the case duringthe initial delivery. If the Vaseline was applied to the occlusalsurface during initial bonding, the removal will be much easierat this point. Cement removal is best accomplished usingcrown removing pliers to remove the large bulk adhesive,followed by a series of acrylic burrs in a low speed handpiece.

Removing the Stainless Steel CrownsRemoving the Stainless Steel Crowns

Herbst TroubleshootingFor the most part, the Herbst appliance, especially the stainless steel crownand banded designs, is quite durable, and the majority of appliancebreakage has been eliminated. There are, however, certain situations wherethere may be problems with the Herbst. This section is designed to informthe practice of what type of problems can occur with the Herbst, and toprovide troubleshooting tips in solving the problems. Below is a list of themore common problems that can be encountered with the Herbst.

* The Herbst cannot be delivered (the crowns do not fit).

* The Herbst mechanism is binding on opening or lateral movement.

* The midline is off with the Herbst mechanisms in place.

* A stainless steel crown has become loose.

* A bonded occlusal rest has come loose.

* A Herbst screw has come loose or come out.

“Emergency” AppointmentsMany of these clinical problems can represent a potential emergency forboth the patient and the practice. In many instances, however, these are nottrue emergencies and they can be dealt with accordingly. The key is tocommunicate to the patient and parent that the practice is aware of thesesituations and is prepared to resolve them quickly.

Herbst Troubleshooting - IntroductionHerbst Troubleshooting - Introduction

Fitting the Crowns There is a definite “learning curve” in working with thestainless steel crowns, whether in the clinic or lab in sizing andfitting, or in the clinic when the appliance is delivered. Eachpractice will determine their comfort level regarding the initialfitting of the crowns, either by doing this important step in theoffice or requesting that Specialty provide and fit the crowns inthe laboratory.

Importance of Trial Fitting the HerbstIn sizing and fitting crowns, there are only 3-5 sizes to selectfrom once the overall shape and anatomy of the tooth isdetermined. Regardless of which technique is used to size andfit the crowns, there may be cases where the delivery of theappliance is difficult or not possible due to the fit of the crowns.This is determined during the “try in” step just prior tocementing the Herbst.

What to do When the Herbst Cannot be DeliveredDepending on the appliance design, there may be differentsolutions to the problem when the Herbst does not fit. On thelower arch when the bicuspids and molars are included in onesection and the unit does not fit, the entire appliance must beremade in the laboratory. A new impression model is taken andthe model sent to Specialty along with the appliance. If a singlecrown does not fit (for example, one side on the upper molars),a model and that crown are sent to Specialty for resizing.

Herbst Troubleshooting - Crowns Do Not FitHerbst Troubleshooting - Crowns Do Not Fit

Alignment of the Herbst PartsIn the laboratory at Specialty Appliances, one of the criticalfactors in making the appliance is lining up the Herbst pivots toensure the smooth functioning of the mechanisms. Once thisangle is set, the pivots are soldered to the crowns and cannot bechanged clinically. In situations where the patient has possiblybent the mechanism, the deformed sections of the appliancewill need to be replaced.

Fit of the Rods and Tubes over the PivotsAnother important factor is the fit of the eyelets on the rods andtubes over the Herbst pivots. At Specialty, a small burr is usedto enlarge the eyelet openings on all four components of themechanism. This ensures the mechanisms will functionproperly when attached to the pivots. Of primary concern is thelateral movement, which is greatly enhanced when these holesare enlarged.

Other Binding ProblemsAnother potential problem that may affect the functioning ofthe mechanisms is the width of the upper jaw. If the maxilla istoo narrow in the first molar area once the lower jaw hasadvanced, the engaged mechanisms can cause binding of theappliance. In this situation, the upper jaw usually needs to bewidened to accommodate the mandible and ensure themechanisms will function freely.

Herbst Troubleshooting - Mechanism is BindingHerbst Troubleshooting - Mechanism is Binding

Midline Alignment with the HerbstThe alignment of the dental midlines is determined by thelength of the rods and tubes on each side. In the lab atSpecialty, we carefully adjust the Herbst mechanism to advancethe lower jaw and align the midlines (unless an alternativemidline relationship is requested by the clinician).

Checking the Midline in the ClinicWhen delivering the Herbst, the midline can be checked withthe appliance fully engaged, just prior to securing the screwswith Ceka Bond. The rods and tubes are placed over the pivotsand held in place while the midline is observed (for practicesthat deliver the upper with the tubes attached, only the lowerrods need to be held). If there is a midline problem that needsto be corrected, either the rod and/or tube on one side can bemodified or replaced.

Correcting the MidlineIf the midline is shifted undesirably to one side, the situationcan be corrected by further advancement of the opposite side,or shortening the longer side, which will correct the midlines.This is accomplished by trimming the tube on the long side, orby adding either shims or a longer tube to the shorter side. Ingeneral, adding shims is the easier alternative to correct themidline.

Herbst Troubleshooting - Midline OffHerbst Troubleshooting - Midline Off

Fuji Glass Ionomer Cement When using Fuji I glass ionomer cement (GC AmericaCorporation), loose bands or crowns are extremely rare. Theremay, however, be occasions where the patient is constantlybiting against or working the Herbst side to side, and a crownbecomes loose. In this situation the crown can be rebondedfollowing the manufacturers instructions.

Removing a Crown for ReplacementIf a loose crown can be removed without sectioning, it can bereused by removing all of the original adhesive, followed bymicroetching the inside of the crown. All of the originaladhesive must also be cleaned off the tooth. Once the crownand tooth have been thoroughly cleaned, the crown is rebondedusing the same procedure as described earlier.

Note: An easy way to remove cement from a crown is to gentlyheat it over a Bunsen burner and quench it in water. This willfacilitate removing the cement with a scaler.

Damaged Crown Sent Back to Specialty forReplacementIn cases where a loose crown needs to be sectioned for removal,or when a supporting wire (such as a lower lingual wire) breaks,the appliance is typically removed and sent back to Specialtyfor repairs. Often, we can repair the original Herbst using acurrent model. If the appliance cannot be repaired, we fabricatea new one using the current model.

Herbst Troubleshooting - Loose CrownHerbst Troubleshooting - Loose Crown

Occlusal Rest DesignsMany Herbst designs utilize occlusal rests for additionalappliance anchorage and stability. Several types of wire restsare typically bonded to the teeth using light-cure orthodonticadhesive. There are considerable overall forces on the Herbstappliance, especially in the vertical dimension. This can onoccasion, cause an occlusal rest to fracture, which is a relativelyeasy clinical repair.

Occlusal Rest Repair The first step in repairing a fractured occlusal rest is to removethe old bonding adhesive from the wire rest and the dentalsurfaces. Once the adhesive has been removed, new light-cureadhesive is applied over the occlusal rest and smoothed outusing the explorer tip, followed by rebonding with the light-cure gun.

Occlusal Molar Rests The wire rests on the second molars are very important as theyprevent the undesirable eruption of the teeth. These rests aremade from .032 stainless steel wire, and are soldered to thecrowns in the laboratory. On rare occasion, these wire rests canfracture from the crown. In this event, the rest must be replacedor the second molar could erupt and cause undesirable loss ofvertical control.

Herbst Troubleshooting - Loose Occlusal RestHerbst Troubleshooting - Loose Occlusal Rest

Loose Screws with the HerbstEarly in the design and evolution of the Herbst, the screwspresented a significant problem in terms of coming loose. Withthe application and use of Ceka Bond, this problem has beengreatly reduced and in many practices virtually eliminated.Ceka Bond is designed to secure dental implants and is anextremely strong adhesive that easily holds the Herbst screwsin place.

Stripped Screw or PivotThere are rare situations where a screw may come loose, evenwith the application of Ceka Bond. The first recommendationis to try a new screw using Ceka Bond. If that does not work,the screw or pivot is probably stripped. When this happens, thescrew will continue to turn as it is tightened, but it will not staysecure in the pivot. In this situation, the appliance will need tobe removed and returned to Specialty Appliances where wewill replace the pivot and add a new screw.

Screw Head DamagedAnother problem that can occur is damaging the screw head. Iftoo much force is applied when tightening the screw, not onlycan the threads inside the pivot be stripped, but the inside headof the screw can become stripped or even break off. If theinside hex is stripped, a new screw can be used. If the headbreaks off, the part should be returned to Specialty Appliancesfor repair.

Herbst Troubleshooting - Problems with the ScrewsHerbst Troubleshooting - Problems with the Screws

Herbst Appliance DesignsSeveral leading clinicians have developed Herbst designs based on specifictreatment objectives. Through lectures and publications, these designshave been advanced throughout the profession and are often referred to bythe clinicians’ name. At Specialty, we have worked with the leaders inHerbst designs and are able to offer the appliance designs as referred to bythose doctors’ names. The following section presents many of the mostpopular Herbst designs advocated by Specialty and leading practitioners.

Dr. Terry Dischinger Herbst Designs

Dr. Bob Smith Herbst Designs

Dr. Jim Hilgers Herbst Designs

Dr. Joe Mayes Herbst Designs

Herbst Appliance DesignsHerbst Appliance Designs

Specialty Appliances Crown HerbstSpecialty Appliances Crown Herbst

1. Crowns placed on upper molars and lower bicuspids

2. Bands on lower molars

3. .045 lingual arch connects lower components

4. Archwire tubes added to upper and lower crowns

Notes

Upper

Lower

Specialty Appliances Banded HerbstSpecialty Appliances Banded Herbst

1. Bands are placed on upper and lower first molars

2. TPA wire connects upper bands

3. Heavy reinforced wire on lower

4. Archwire tubes can be added to upper and lower

Notes

Lower

Upper

Specialty Appliances Acrylic HerbstSpecialty Appliances Acrylic Herbst

1. Upper and lower individual splints

2 Incisal acrylic shouldbe at least 1.5mm thick if used

3. Upper is connected with TPA

4. Clasp can be addedfor additional

support

Notes

Upper

Lower

Specialty Appliances Cantilever HerbstSpecialty Appliances Cantilever Herbst

1. Crowns on first permanent molars

2. Archwire tubes on lower cantilever and upper molars

3. Bondable rests to lower bicuspids

4. Occlusal rest on permanent molars if erupting

Notes

Lower

Upper

Specialty Appliances Metal and Acrylic HerbstSpecialty Appliances Metal and Acrylic Herbst

1. Crowns are placed on upper front molars

2. TPA archwires on upper crowns

3. Lower acrylic splint gives full stability

4. Second molar rest are added to prevent undesirable eruption

Notes

Upper

Lower

Specialty Appliances Sleep Apnea HerbstSpecialty Appliances Sleep Apnea Herbst

1. Upper and lower arecompletly tooth bornsplints

2. Hooks are placed at upper cuspids for elastics

3. Appliance has acrylicon second molars for added support

4. Appliance is fully adjustable for proper airway opening

Notes

Lower

Upper

Specialty Appliances Band and Acrylic HerbstSpecialty Appliances Band and Acrylic Herbst

1. Upper appliance is secured by using bandson the first permanent molars

2. TPA connects upper bands

3. Lower removable splint offers complete support

4. Second molar rests are added to prevent super eruption

Notes

Upper

Lower

Dr. Terry Dischinger Permanent HerbstDr. Terry Dischinger Permanent Herbst

1. Archwire tubes are placed on upper molars and lower cantilever

2. Crowns are placed on upper and lower first permanet molars

3. Ball stops are used to prevent tipping and prevent eruption

4. Bioprogressive technique helps balance treatment effects

Notes

Lower

Upper

Dr. Terry Dischinger Expansion HerbstDr. Terry Dischinger Expansion Herbst

1. Upper and lower first molars are crowned

2. Archwire tubes are added to upper molars and lower cantilever

3. Ball stops help prevent tipping and eruption

4. RPE screw is trimmed to allow better access and reduce bulk

Notes

Upper

Lower

Dr. Terry Dischinger U/L Expansion HerbstDr. Terry Dischinger U/L Expansion Herbst

1. Crowns are placed on first permanet molars

2. Archwire tubes are placed on upper crowns and lower cantilever

3. Bondable rests are placed on lower bicuspids

4. Expansion screws are trimmed to reduce bulk

Notes

Lower

Upper

Dr. Terry Dischinger Mixed Dentition HerbstDr. Terry Dischinger Mixed Dentition Herbst

1. Crowns placed on Decidious second molars

2. Archwire tubes added to cantilevers and molars

3. Cantilever upper expands opening

4. Bondable ball rests are added for stability

Notes

Upper

Lower

Dr. Terry Dischinger Mixed Dentition Expansion HerbstDr. Terry Dischinger Mixed Dentition Expansion Herbst

1. Crowns placed on Decidious second molars

2. Archwire tubes added to cantilevers

3. Reduced expansion screwfor reduced bulk

4. Bondable ball rests are added for stability

Notes

Lower

Upper

Dr. Terry Dischinger Space Closing HerbstDr. Terry Dischinger Space Closing Herbst

1. Crowns on upper molarsand lower bicuspids

2. Molar kept upright with tube on band for sliding mechanisum

3. Archwire closing loop and springs close space

4. Archwire tubes on uppermolars, lower molars and bicuspids

Notes

Upper

Lower

Dr. Bob Smith Herbst Type IDr. Bob Smith Herbst Type I

Notes

Lower

Upper

1. Crowns on upper and lower first molars

2. .045 lingual added to lower for support

3. Rests on lower decidious molars for support

4. Archwire tubes added to upper molars andlower cantilever

Dr. Bob Smith Herbst Type IIDr. Bob Smith Herbst Type II

Notes

Upper

Lower

1. Crowns on upper molars and lower bicuspids

2. Bands on lower molars

3. Archwire tube andrests added on request

4. Low profile for comfort

Dr. Bob Smith Herbst Type I ExpansionDr. Bob Smith Herbst Type I Expansion

1. Crowns on upper and lower first molars

2. .045 lingual added to lower for support

3. Rests on lower decidious molars for support

4. Expansion screw added to upper arch

5. Archwire tubes added to upper molars and lower cantilever

Notes

Lower

Upper

Dr. Jim Hilgers Banded HrebstDr. Jim Hilgers Banded Herbst

1. Bands placed on upper molars and lower bicuspids

2. .045 lingual arch added to lower molars

3. Rests on lower molars bonded

4. Archwire tubes added on request

Notes

Upper

Lower

Dr. Jim Hilgers Crown HerbstDr. Jim Hilgers Crown Herbst

1. Crowns placed on upper molars and lower bicuspids


3. Rests on lower molars bonded


Notes

Lower

Upper

Dr. Joe Mayes HerbstDr. Joe Mayes Herbst

Notes

Upper

Lower

1. Crowns placed on upper and lower first molars


3. Molar rest added on request


Dr. Joe Mayes Expansion HerbstDr. Joe Mayes Expansion Herbst

Notes

Lower

Upper

1. Crowns placed on upper and lower first molars


3. Cantilever arm parallel to occlusal plane


5. .060 wire for lingual support on RPE

© 1998 Specialty Appliances Inc. all rights reservedThis book, or parts thereof, may not be reproduced in any form

without permission of Specialty Appliances Inc.

Also, please keep in mind your Herbst experts at Specialty are only a telephone call awayand are ready to assist your practice with valuable information. We can be reached at:

1 800 522-4636 Toll Free or: (770) 416-1822 Fax (770) 446-6958

www.specialtyappliances.com on the Internet

E Mail - [email protected]

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