4/20/16

Does Class II malocclusion deserve “Early treatment” ??

Herbst  appliance  treatment:  

what  we  have  learned

Bernardo  Souki  DDS,  MsD,  PhD  

Class II vs. Early treatment Special indications for Class II Early treatment
Dentoskeletal effects Psychosocial effects

“Early treatment should not

be thought of as an effective
and efficient way to treat most
Class II children.”    

“The decision for Class II early

treatment should be based on Pre-treatment Post-treatment
with Headgear
special indications for each child.”
   

Special indications for Class II Early treatment Special indications for Class II Early treatment
Psychosocial effects Risk of traumatic injury

“Early orthodontic treatment for Class II/1

malocclusion results in higher self-concept
scores and fewer negative social
experiences.”    
O`Brien et al., 2003

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Class II vs. Early treatment Class II vs. Early treatment

Risk of traumatic injury Risk of traumatic injury

•  Overjet ≥5mm

“Providing early orthodontic treatment PEDIR  FOTO  MARIA  ILMA  

for children with prominent upper front
teeth is more effective in reducing the
incidence of incisal trauma than
providing one course of orthodontic
treatment when the child is in the early
adolescence.”    
Thiruvenkatachari et al., 2014

Class II vs. Early treatment

Risk of traumatic injury

ld be the
•  Overjet ≥5mm
But, when wou
in g to treat
ideal tim
al C lass II ????

skelet
•  Lip incompetence

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Class II dentofacial orthopedics Class II vs. Early treatment

Ideal timing Summary
Peak in Mandibular Growth

Primary Early mixed Intertransitory

CS 1 CS 2 CS 3 CS 4 CS 5 CS 6

Class II vs. Early treatment

Summary

Late mixed dentition

One-phase Class II treatment associated One-phase Class II treatment associated

with fixed appliance with fixed appliance

Advantages  
1.  Effectiveness: >2 mm mandibular growth

2. Efficiency: Shorter total duration

3. Stability: Ideal intercuspation

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How to treat
al
effectively skelet
oc cl usion???

Class II mal

Skeletal Class II malocclusion

How to treat?

ü  Facial convexity is not bad ü  Risk of trauma is not too big

ü  No psychosocial problems ü  Extensive growth potential forecast

ial convexity is
What if the fac O
O big , the co mpliance is TO
TO
all , or the re sidual growth
sm
o long???

phase is NOT to

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Class II malocclusion
Herbst appliance

The  Herbst  appliance  is  the  most  frequently  used  

mandibular  advancement  device  in  the  USA.  
von Bremen, Pancherz, Ruf, 2007
Emil Herbst’s original appliance (1910)
Pancherz,  1979  
Silva et al., 2015
 

Skeletal Class II malocclusion

Mandibular deficiency

Retrusion of the mandible is the most commonly occurring

factor contributing to skeletal Class II malocclusion

Renfroe, 1948
McNamara Jr., 1981
Buschang & Martins, 1998
Pancherz & Ruf, 2008

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Herbst appliance
Immediate benefits Benefits of Herbst appliance

•  Expedite improvement of the self-esteem

•  Reduce the risk of incisor trauma

•  Less reliance on patient compliance

•  Shorter treatment duration

Patients & Methods

Skeletal Class II patients (n=50)

Pubertal stage (CS3 – CS4)

Ethics approval from IRB

Herbst appliance treatment effects

3D assessment study

Patients & Methods Patients & Methods

Sampling design Herbst group

50 skeletal Class II growing patients

One-step full activation
Herbst  Group   Comparison  Group  

n  =  25   n  =  25  

Age:     Age:    
12y  –  16y   12y  –  16y  

CS3  –  CS4   CS3  –  CS4  

Permanent   Permanent  
den??on   den??on  

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Patients & Methods Patients & Methods

Comparison group Comparison group

Marsupialization of cysts
Previous alignment and leveling

Patients & Methods Patients & Methods

Herbst appliance design
Comparison group

Maxillary impacted canines

Image analysis
3D virtual models

What  we  have  learned

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What we have learned about

Mandibular displacement
a) Mandibular displacement
b) Condylar growth
c) Condylar displacement
d) Glenoid fossa remodeling
e) Dentoalveolar changes
f) Maxillary adaptations

Mandibular displacement Pre-treatment

Herbst insertion

2 months

6 months

Herbst removal
8 months of tx.

Pre-treatment Facial balance improvement

Herbst insertion

Herbst removal T0   T1   T2  
(Pre-treatment) (Herbst insertion) (Herbst removal)

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Mandibular forward displacement vs. Facial improvement Diego – 16 y

8  mos.  Herbst  appliance  

T0   T2  

Diego’s CBCT scans superimposition

Relative to the cranial base

T0 T0
T1 T2 T2
T1

10mm initial Mandible moved 4mm effective

advancement after back 6mm during mandibular
Herbst insertion Herbst treatment advancement

T0 – Pre-treatment
T1 – Immediately after Herbst insertion
T2 – After 8 mos. Herbst treatment

Mandibular displacement
(Superimposition at the cranial base) Mandibular displacement
Herbst group Take home message

ü  Mean 65% of rebound during Herbst treatment

(range 47% - 75%).

ü  1.7 mm of effective mandibular forward displacement

(5 mm of Herbst advancement ).

ü  Herbst appliance treatment improved the patient’s profile

(short-term evaluation).
Comparison group

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3D superimposition at the body of the mandible

Condylar growth

Condylar growth Condylar growth

(Regional Mandibular Superimposition)
(Regional Mandibular Superimposition)
Herbst group
Herbst group Comparison group

1.9 mm - backward 0.7 mm - backward

2.5 mm - upward 1.6 mm - upward

Comparison group Herbst vs. Comparison

+ 1.2mm (2x more) - backward

+ 0.9 mm (0.5x more) - upward

-4.0 -2.0 0.0 2.0 3.0 4.0

Condylar growth
Take home message
Condylar displacement
ü  Effective backward condilar growth (1.2 mm).

ü  Change in the direction of condilar growth.

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Condylar displacement
? ? Condyle-Glenoid fossa relationship after Herbst removal
? ?
?
yle positioned
Where is cond 3D superimposition at the glenoid fossa

bst tre atment ???

after Her Difference
Herbst vs. Comparison groups

X (RL) = 0.01 mm

Y (AP) = 0.06 mm

Z (IS) = 0.11 mm

3D = 0.07 mm

Condylar displacement
Take home message
Glenoid fossa remodeling
ü  Regardless how much the condyle is moved
forward and downward, it returned to its
original relationship with the glenoid fossa.

Herbst group Comparison group

Superimposition at the anterior cranial fossa
Superimposition at the anterior cranial fossa

Pre-treatment Immediately after Herbst insertion 8 months after Herbst insertion

Baseline 10 months after

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Glenoid fossa remodeling

Take home message
Dentoalveolar changes
ü  Bone remodeling developed at the
articulating surface of the glenoid fossa of
Herbst patients.

ü  At this point it is not possible to determine Molars Incisors

that 8 months of Herbst treatment is
sufficient to produce a stable new bone in
the glenoid fossa.

Dentoalveolar changes
Take home message
ü  Significant lower incisor proclination
Mean 7.3 degrees (up to 21 degrees)

ü  Variable, but mostly small, upper incisor uprighting

ü  Maxillary molar

1.4 mm backward
0.4 mm upward (but maxilla moved 0.9 downward)

ü  Mandibular molar

1.1 mm forward
0.6 mm upward

Maxillary changes
Take home message
Maxillary changes

ü  No significant skeletal SAGITAL and VERTICAL

changes were observed.

ü  Essentially dentoalveolar movements

(Headgear effect).

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