Clinical complications during treatment with a modified Herbst appliance in combination with a lingual appliance

Evaluation of Facial Aesthetic Changes in Growing Class II Patients Treated with Herbst or Elastodontics: A Retrospective Study

Objective: The objective of this study was to evaluate the facial profile changes of patients treated for class II skeletal malocclusions with an elastodontic appliance compared to those treated with the Herbst appliance and a control group. Methods: Forty class II patients were treated using an elastodontic appliance (Group EA) and were compared to 40 patients treated with the Herbst appliance (Group H) and to 40 untreated class II children (Group C). Aesthetic profile variables were analysed using Arnett's analysis. Cephalograms were compared pre-treatment (T0) and post-treatment (T1). The Wilcoxon signed-rank test or paired-samples t-test was used for pairwise comparison of cephalometric measurements taken at T0 and T1. One-way ANOVA and Tukey's post hoc test were performed to assess differences between the groups. Results: In the elastodontic group, the inclination of the upper incisors increased by 4.05°. In addition, the Pog-TVL and B-TVL distances decreased by 2.84 mm and 1.79 mm, respectively. In patients treated with an elastodontic appliance, the inclination of the upper incisors increased by 4.05°. In addition, the Pog-TVL and B-TVL distances decreased by 2.84 mm and 1.79 mm, respectively. In patients treated with the Herbst appliance, the inclination of the lower incisors increased by 6.11°. Furthermore, the treatment resulted in reductions in the Pog-TVL distance (2.58 mm), the B-TVL distance (2.26 mm), and the LL-TVL distance (2.31 mm). Conclusions: The profile changes achieved by both devices are favourable for correcting class II skeletal malocclusion.

Evaluating the efficiency of mandibular molar protraction using Herbst appliances versus temporary anchorage devices: a retrospective case-controlled study

BACKGROUND

Mandibular second premolar agenesis is a common problem in orthodontics and is often treated in conjunction with maxillary counterbalancing extractions. However, in cases without maxillary crowding or dental protrusion, space closure may pose challenges leading to compromised occlusal results or patient profile. Multiple techniques have been described to treat these patients; nevertheless, there is a paucity of data comparing effectiveness of space closure utilizing various anchorage techniques. The goal of this study is to assess the effectiveness of the Herbst device during mandibular molar protraction and compare it to the use of temporary anchorage device (TADs) in patients with mandibular second premolar agenesis.

MATERIALS AND METHODS

This retrospective study included 33 patients with mandibular premolar agenesis treated without maxillary extractions. Of these patients, 21 were treated with protraction Herbst devices and 12 with TADs. Changes in molar and incisor positions, skeletal base positions and occlusal plane angulations were assessed on pretreatment (T0) and post-treatment (T1) lateral cephalograms. Scans/photographs at T0 and T1 were used to evaluate canine relationship changes representing anchorage control. Space closure and breakage/failure rates were also compared. Data was analyzed with paired and unpaired t-tests at the significance level of 0.05.

RESULTS

Within the Herbst group, changes in mandibular central incisor uprighting and mandibular molar crown angulations were statistically significant. However, no significant differences were noted between the Herbst and TAD groups. Protraction rates as well as overall treatment times were comparable (0.77 mm/month vs. 0.55 mm/month and 3.02 years vs. 2.67 years, respectively). Canine relationships were maintained or improved toward a class I in 82.85% of the Herbst sample, compared to in 66.7% of the TAD sample. Emergency visits occurred in 80.1% of the Herbst group, with cementation failures or appliance breakages as the most common reasons.

CONCLUSION

The Herbst device could be a viable modality in cases with missing mandibular premolars where maximum anterior anchorage is desired, or if patients/parents are resistant to TADs. Furthermore, they could be beneficial in skeletal class II patients with mandibular deficiency who also need molar protraction. However, the increased incidence of emergency visits must be considered when treatment is planned.

Treatment of Class II malocclusion with a customized lingual appliance combined with a Class II corrector

Correcting a complete Class II malocclusion in an adult patient can be quite difficult. If the patient has a large skeletal discrepancy, orthognathic surgery is the treatment of choice. However, if the discrepancy is small or if the situation is borderline and the mandibular incisors are retroclined, Class II correctors can be used. This clinical report presents the orthodontic treatment of a 24-year-old woman with Class II malocclusion. Clinically, her maxilla was slightly protruded, and the mandible was well-positioned. She had uprighted maxillary and mandibular anterior teeth and a deepbite, and she opted for a more esthetically appealing orthodontic appliance. The treatment plan included leveling and alignment of the teeth in both arches, Class II correction, establishing Class I molar and canine relationships, correction of overbite and overjet, adjustment of midlines, and improvement of facial and dental esthetics. Orthodontic treatment consisted of customized lingual appliances combined with a Class II fixed corrector.

Clinical complications during early treatment of anterior open bite

The object of this study was to compare the clinical complications of 4 different appliances used in the early treatment of anterior open bite (AOB), and to test the null hypothesis that there is no difference in the number of complications among the appliances. Records from 99 Class I malocclusion patients with AOB treated using bonded spurs, BS, n = 25; chin cup, CC, n = 25; fixed palatal crib, FPC, n = 25; and removable palatal crib, RPC, n = 24) were examined. The total number and frequency of clinical complications that occurred over 12 months were described and compared by using chi-square and Kruskal-Wallis tests (Dunn's post-test) (α = 5%, CI = 95%). The incidence of clinical complications was 66.7%, comprising: breakage, bond failure, maladjustment, allergy, soft-tissue lesion, loss of removable appliance and abandonment. Eighteen patients gave up treatment; this occurred more frequently in the groups with removable appliances. Regarding the total number of complications per patient, Group BS exhibited a significantly higher number than the other groups (p < 0.0001). A low frequency of complications (1 to 3) was found in the groups, except for Group BS, in which 8% of the patients presented moderate frequency (4 to 6). In terms of appliance types (fixed or removable), there was no difference in the incidence of complications (p > 0.094). The null hypothesis was rejected, since the BS group exhibited the highest total number and frequency of complications. There was no difference between fixed and removable appliances in terms of incidence of clinical complications, although more patients using removable appliances abandoned their treatment.

The Herbst appliance and its modifications - prevalence and individuality

OBJECTIVE

The aim of this study was to analyze the use of modified, cast splint Herbst appliances for the treatment of skeletal class II as an alternative to surgical bite correction over a period of five years.

MATERIALS AND METHODS

The patient cases all originate from the patients of the Department of Orthodontics at the University Medical Center of the Johannes Gutenberg University Mainz, Germany and the orthodontic practice Dres. Zöller, Kaiserslautern, Germany. Inclusion criteria were orthodontic treatment with the Herbst appliance and its modifications. The type of modification, number and frequency of the different modifications were determined on the basis of patient files, X-ray documents, photos and models.

RESULTS

Of a total of 2881 new admissions over a period of five years, 1751 patients came from the Department of Orthodontics at the University Medical Center of the Johannes Gutenberg University Mainz and 1130 from the orthodontic practice in Kaiserslautern. A total of 336 patients were treated with a Herbst appliance during the period mentioned. 14 (13%) of the cases from the Herbst patient collective of the University Medical Center and 45 (19%) of the cases from the orthodontic practice were classified as modifications. The following modifications could be determined in descending order: University Medical Center Mainz: Herbst for anchorage during space closure (65%) > distalization (14%) ≥ bar construction as a space maintainer (14%) > Herbst applicance for anchoring for the adjustment of impacted teeth (7%); orthodontic practice Kaiserslautern: Herbst appliance with quadhelix in the maxilla (42%) > distalization (27%) > space closure (15%) > bar construction as a space maintainer (9%) > adjustment of impacted teeth (7%), multiple modifications occurred at 11%. The combination of quadhelix and Herbst appliance as well as multiple modifications have not yet been used in the University Medical Center Mainz. As an alternative to dysgnathia surgery, 23 adult patients (> 18 years) from the University Medical Center and 22 from the orthodontic practice were treated with a Herbst appliance.

CONCLUSION

Nearly 12% of Herbst appliances are used in everyday orthodontic practice and almost 18% of these are used with modification(s). The high anchoring quality and force-effect geometry of the Herbst appliance is suitable for combining and treating various other treatment tasks in addition to the classical treatment task of class II therapy.

Complications, impacts, and success rates of different approaches to treatment of Class II malocclusion in adolescents: A systematic review and meta-analysis

INTRODUCTION

We aimed to explore the prevalence and nature of complications associated with Class II correctors in adolescents and their impact on the quality of life (QOL), completion of treatment, and success rate.

METHODS

The review was registered in PROSPERO, and a comprehensive electronic search was performed without language or date restrictions. Randomized and nonrandomized trials, prospective cohort and cross-sectional studies, case series, and qualitative research were included. The Cochrane Collaboration's risk of bias tool and the Newcastle-Ottawa scale were used to assess the quality of included studies. Data were grouped according to appliances design: removable functional, fixed functional, hybrid functional, headgear, and fixed maxillary molar distalization appliances.

RESULTS

Data from 27 studies were included, of which 11 were deemed eligible for meta-analysis. Overall, 1676 adolescents were included related to fixed functional (n = 682), removable functional (n = 682), hybrid functional (n = 84), headgear (n = 186), and Carriere (n = 42) appliances. The mean number of emergencies was 0.8 (95% confidence interval [CI], 1.1-2.1) and 2 (95% CI, 0.9-3.0) for removable and fixed designs, respectively. However, the rate of discontinuation was 35% (95% CI, 0.28-0.42) and just 1% (95% CI, 0.01-0.1) for removable and fixed designs, respectively. Other QOL dimensions such as eating, sleep, speech, and emotional domains were significantly impaired during treatment with removable functional appliances.

CONCLUSIONS

Removable Class II correctors were associated with a high rate of treatment discontinuation, most likely because of the negative impact on QOL and lack of compliance. More complications were observed with fixed designs, although this did not impact the overall success rates. Further prospective studies are needed to explore patient perceptions and cost-effectiveness to inform treatment decisions better.

Additional appointments and discomfort associated with compliance-free fixed Class II corrector treatment: a systematic review

OBJECTIVE

A critical analysis of the literature to determine the prevalence and type of emergency/additional appointments, and discomfort levels associated with fixed Class II correctors.

METHODS

Studies examining patient's sources of discomfort or emergency appointments associated with compliance-free Class II correctors were included. Comprehensive searches up to July 2018 were conducted using the following databases: MEDLINE (OvidSP), PubMed, Web of Science, and Embase. A partial grey literature search was taken using Google Scholar and OpenGrey. Two reviewers independently performed the selection process and risk of bias assessment. The Newcastle-Ottawa Scale for cross-sectional studies were used. A summary of the overall strength of evidence was presented using 'Grading of Recommendations, Assessment, Development and Evaluation' (GRADE) tool. Included studies were evaluated according to their design, study quality, consistency, and directness.

RESULTS

The selected studies were published between 2001 and 2018, and the number of patients per studied group ranged from 8 to 182. One thousand five hundred forty-two patients were evaluated in total. The patients' mean age at start of treatment ranged from 10 to 16.9 years and the fixed Class II corrector treatment duration ranged from 4 to 12 months. The included studies in this systematic review were too clinically heterogeneous (different appliances, different data recollection processes) to justify a meta-analysis.

LIMITATIONS

This review was not previously registered. A low level of evidence was observed among the two randomized trials, the 10 cohorts and three cross-sectional studies identified.

CONCLUSIONS

The main source of discomfort from Forsus-type appliances appears to be soreness in the cheeks (low level of evidence with a weak recommendation strength). Most evaluated patients treated with a Herbst appliance, regardless of design, will experience complications (fractures and/or dislodging) requiring emergency appointments (low level of evidence with a weak recommendation strength).

REGISTRATION

The review protocol was not registered.

Quality of occlusal outcome following space closure in cases of lower second premolar aplasia using lingual orthodontic molar mesialization without maxillary counterbalancing extraction

Background

Controlled space closure in cases of isolated lower second premolar aplasia (ILSPA) without maxillary counterbalancing extraction is challenging. Anterior anchorage loss may occur during space closure resulting in compromised occlusal results in terms of an absence of proper canine guidance during laterotrusive mandible movements.

In order to evaluate the effectiveness of Herbst telescope anchorage in combination with double-cable, pull mechanics and a completely customized lingual appliance for orthodontic space management in cases of ILSPA, we tested the null hypothesis that there is a significant deterioration in the sagittal canine relationship towards an Angle-Class-II occlusion expressed as a loss of anterior anchorage following space closure with molar mesialization.

Methods

Twenty-five consecutively de-bonded subjects (female / male 17 / 8; aged at T0 (start of MB Tx) 12.3 to 20.6 years; mean age 15.0 / SD 1.7 years) were included in this retrospective analysis using the inclusion criteria of least of one lower second premolar aplasia; completed treatment with a totally customized lingual appliance (CCLA) in combination with Herbst telescopes. Exclusion criteria were the absence of counterbalancing maxillary extractions, as well as additional tooth aplasia other than lower second premolars. A total of 33 single, lower premolar aplasia space closures (right / left sided 17 / 16) were assessed using plaster casts and intra-oral photographs scaled to the plaster casts, at bonding (T0), Herbst insertion (T1), following gap closure (T2) and de-bonding (T3). Parallelism of roots was controlled by panoramic x-rays at T3.

Results

The mean aplasia space at T0 was 7.5 mm (SD 2.6). Complete space closure was achieved in all 33 situations. The null hypothesis was rejected. There was a significant improvement in the initial canine relationships (mean 3.5 mm distal occlusion at T0) to a mean 0.1 mm at T3. When evaluated against the individual treatment plan, the following amounts of planned improvements were achieved: space closure 100%, canine relationship 97.5%, overjet 93.9%, overbite 96.4%, parallel roots in space closure site 93.9%.

Conclusion

Herbst telescope anchorage in combination with double-cable pull mechanics and a CCLA for orthodontic space closure can deliver predictable, high-quality treatment results.

[Completely-customized lingual orthodontics to correct class II malocclusion in adolescents]

INTRODUCTION

Completely-customized lingual orthodontics is an efficient, predictable and esthetic solution for our patients. Adolescents showing a class II malocclusion represent the majority of patients in orthodontic practices. Several modes of treatment are available to correct this sagittal discrepancy such as inter-maxillary elastics, flexible or rigid protrusion devices, maxillary distalization using mini-screws or symmetric and asymmetric extractions. The choice depends on several decision criteria such as the severity of the malocclusion, the symmetry of the class II discrepancy as well as the age and the motivation of the patient.

MATERIALS AND METHODS

In this article, the authors will describe the current therapeutical strategies to correct a class II malocclusion in adolescents with a completely-customized lingual appliance.

CONCLUSION

It is as easy to correct a significant class II malocclusion with a lingual technique as it is with vestibular techniques, completely-customized lingual orthodontics providing the advantage of facilitating treatments.

Herbst plus Lingual versus Herbst plus Labial: a comparison of occlusal outcome and gingival health

OBJECTIVES

To analyse and compare the effects during Herbst treatment combined with a lingual (completely customized) or labial (straight-wire) multibracket appliance (MBA), with special regard to lower incisor gingival recessions.

SUBJECTS AND METHODS

Eighteen Class II:1 patients [overjet ≥ 5mm, Class II molar relationship ≥ 0.5 cusp widths (CW) bilaterally or 1.0 CW unilaterally, median age 16.0 years] treated with a Herbst appliance in combination with a lingual MBA (group LINGUAL) were retrospectively matched (molar relationship and skeletal maturity) to 18 Class II:1 patients treated with a Herbst appliance combined with a labial MBA (group LABIAL). Study models and intraoral photographs from before and after treatment were evaluated regarding occlusal variables and gingival recessions. Lateral cephalograms from before, during (before and after Herbst), and after treatment were analysed to assess lower incisor changes.

RESULTS

Both groups showed similar reductions of overjet (5.4/5.6mm), overbite, (2.9/2.7mm) and sagittal molar relationship (0.9/0.8 CW). During the Herbst phase, the changes in lower incisor inclination and incisal edge position were significantly smaller in the LINGUAL than in the LABIAL group (iiL/ML: +7.0/+12.7degrees, P = 0.002; ii-MLppg: +2.5/+3.9mm, P = 0.004). For the total treatment period, no significant differences were found (iiL/ML: +5.3/+8.6degrees; ii-MLppg: +2.1/+2.4mm). No clinically relevant gingival recessions were seen.

CONCLUSION

Both treatment approaches successfully corrected the malocclusion. The group LINGUAL exhibited significantly less proclination during the Herbst phase only. Neither treatment approach induced deleterious gingival recessions.