Case Report Effective and Efficient Herbst Appliance...

Case ReportEffective and Efficient Herbst Appliance Therapy forSkeletal Class II Malocclusion Patient with a Low Degree ofCollaboration with the Orthodontic Treatment

Bernardo Quiroga Souki1 Barbra Duque Costa Bastos1 Luana Fialho Ferro Araujo2

Wagner Fernando Moyses-Braga2 Mariele Garcia Pantuzo1 and Paula Loureiro Cheib1

1Graduate Program in Orthodontics School of Dentistry Pontifical Catholic University of Minas Gerais30535-610 Belo Horizonte MG Brazil2School of Dentistry Pontifical Catholic University of Minas Gerais 30535-610 Belo Horizonte MG Brazil

Correspondence should be addressed to Paula Loureiro Cheib paulalc27hotmailcom

Received 19 October 2014 Accepted 6 January 2015

Academic Editor Carla Evans

Copyright copy 2015 Bernardo Quiroga Souki et alThis is an open access article distributed under theCreative CommonsAttributionLicense which permits unrestricted use distribution and reproduction in anymedium provided the originalwork is properly cited

The current concept for effective and efficient treatment of skeletal Class II malocclusion prescribes that interceptive approachshould be delivered during the pubertal growth stage However psychosocial issues and a greater risk of dental trauma are alsofactors that should be addressed when considering early Class II therapy This paper reports a case of a patient that soughtorthodontic treatment due to aesthetic discomfort with the incisorsrsquo protrusion Two previous treatments failed because patientrsquoscollaboration with removable appliances was inadequate Given his history of no collaboration and because the patient was in theprepubertal stage it was decided to try a different approach in the third attempt of treatment Traumatic injury protective deviceswere used during the prepubertal stage and followed byHerbst appliance and fixedmultibrackets therapy during the pubertal stageresulting in an adequate outcome and long-term stability

1 Introduction

Class IImalocclusion is highly prevalent worldwide [1ndash4] andits treatment is one of the most frequent in the orthodonticoffices [5 6] When a severe skeletal disharmony is involvedin the etiology of the malocclusion and patientrsquos low collab-oration is expected a challenging situation is established toorthodontists

This paper describes the comprehensive orthodontictreatment of a child with a severe Class II malocclusionassociated with mandibular deficiency The patientrsquos parentsreported a lack of collaboration in previous orthodontic treat-ment The current concepts for efficiency and effectivenesson Class II treatment were followed and a discussion on theimportance of Class II treatment timing in the search ofexcellence is also offered

2 Case Report

The 10-year-old boy was referred to orthodontic treatmentby his pediatric dentist The chief complaint was ldquothe frontalteeth are toomuch advancedrdquoThe patient had amarked con-vex and unaesthetic facial profile due to the severe mandibu-lar deficiency He also had a great exposure of maxillaryincisors the absence of passive lip seal and an increasedlower anterior facial height (Figure 1)

During the first consultation interview it was reportedthat the patient was mouth breathing lip trapping andtongue thrusting Previously two treatments with interceptiveorthodontic appliances (Balters Bionator and Headgear) hadbeen performed unsuccessfully However the treatmentsrsquofailure in achieving an adequate outcome was associated withthe lack of patient collaboration in the use of the prescribeddevices

Hindawi Publishing CorporationCase Reports in DentistryVolume 2015 Article ID 986597 7 pageshttpdxdoiorg1011552015986597

2 Case Reports in Dentistry

Figure 1 Pretreatment extraoral and intraoral photographs

Initial102002

776∘

675

101∘

33∘

27∘

1014∘

401∘

1028∘

Figure 2 Pretreatment lateral cephalometric radiography cephalogram and hand-wrist radiography

Intraoral examination showed late mixed dentition acomplete Class II division 1 malocclusion 15mm of overjetdeep overbite (100) and no dental crowding The lowerincisors impinged on the palate mucosa during occlusion(Figure 1)

The lateral cephalometric radiograph showed a skeletalmandibular Class II relationship (SNA 776∘ SNB 675∘ANB 101∘) and vertical growth pattern (SNGoGn∘ 401∘)The incisors were proclined (1NA 27∘ 1NB 33∘ IMPA1014∘) Based on the cervical vertebrae maturation method(CVM) (stage CS1) and on the hand-wrist radiographicmethod (HWR) (absence of sesamoid bone) the patient wasprepubertal (Figure 2)

At this point the orthodontic treatment could be carriedout using a headgear or several types of functional appliances(Bionator Twin Block Bimler and Frankel eg) However

due to the reported lack of collaboration an alternativetreatment plan using a fixed orthopedic jumping device(Herbst appliance HA) was presented to patient and parents

In order to achieve greater efficiency and effectiveness thetreatment was postponed to the patientrsquos pubertal stage ofmaturation While waiting for the patientrsquos pubertal growthspurt traumatic injury protection devices were implementedas a 04010158401015840 plastic retainer during sports activities and a lip-bumper to avoid lower ldquolip traprdquoWhen the patient reached 11years and 4months (CS3 stage of skeletalmaturation) theHAwas installed (Figure 3) The HA design included articulatedbilateral telescoping arms positioned in both maxillary andmandibular arches The pivots were welded to a heavycantilever wire extending from the lower first permanentmolars bands (TP Orthodontics La Porte IN USA) tothe cuspid region of the mandibular arch In the maxillary

Case Reports in Dentistry 3

Figure 3 Herbst appliance immediately after insertion

Figure 4 Telescopic Herbst appliance design Hyrax expander and a heavy wire lingual arch add stability and increase the dental anchoragePlease note that this image is not from the reported case

arch the pivots were welded to the first permanent molarsrsquobands A Hyrax expander and a 10mm stainless steel lowerlingual holding arch (LLHA) were added to the HA structureto improve appliance stability and transversal relationshipExcessive mandibular incisors proclination was reduced withthe heavy wire LLHA Figure 4 shows images from anotherpatient with the same HA design used in the current case

The simultaneous occurrence of excessive overjet severeskeletal discrepancy and the ongoing pubertal growth matu-ration was the determining factor on the decision for choos-ing two phases of sagittal activation Each one comprised of8 months of HATheHAwas removed for 4 months betweenthe two active activations to allow the patient a treatmentbreak The cephalometric superimposition displayed signifi-cant mandibular growth during HA therapy By this time thepatient was finishing his pubertal stage (CS4) (Figure 5) Toachieve a better dental intercuspation a 17-month treatment

with edgewise multibrackets immediately following HA wasnecessary For every new alignment and leveling wire thepatient was requested to use 1 week of Class III elastics (38)thus reducing the lower incisorrsquos proclinationThe end of thetreatment occurred in the postpubertal stage (CS5) (Figures6 and 7) which might have contributed to the long-termocclusal stability

From aesthetical and myofunctional perspectives thetreatment achieved good results improving the initial profiledecreasing the incisors exposure during rest and reaching apassive lip seal (Figure 6) The maxillary incisors positioningin the basal bone also showed an improvement (1NA 17∘)while themandibular incisorsmaintained their original posi-tion (1NB 28∘ IMPA 104∘) providing an adequate overbite(30mm) and overjet (20mm) The treatment contributedto an increase in the mandibular prognathism (SNB 70∘)better maxillary positioning (SNA 77∘) and an improvement


End of Herbst102005

776∘

675

101∘

33∘

1014∘

390∘

1028∘

27∘

Figure 5 Lateral cephalometric radiography at the end of Herbst appliance phase and superimposition tracings between pretreatment andthe end of Herbst appliance phase

Figure 6 Posttreatment extraoral and intraoral photographs

End of treatment032007

770∘

700∘

70∘

901∘

18∘

28∘

990∘

398∘

Figure 7 Lateral cephalometric radiography at the end of treatment and superimposition tracings between the end of the Herbst appliancephase and fixed appliance phase


Figure 8 5-year postretention photographs

5 years after treatment

988∘

790∘

720∘

70∘

18∘

25∘

990∘

397∘

Figure 9 Lateral cephalometric radiography at 5 years after retention and superimposition tracings between the end of fixed appliance phaseand 5 years after retention

in sagittal relationship between maxilla and mandible (ANB70∘) The skeletal pattern of vertical growth showed noclinically significant changes (SNGoGn 39∘) (Figure 7)

After braces removal the patient was instructed to anight use of removable plastics retainers Five years afterdebonding great stability and no relapses were observedThe patient reported no use of the removable retainers sincebrackets were removed (Figures 8 and 9)

3 Discussion

Current evidence-based guideline on the treatment timingof Class II malocclusion defines that skeletal maturationpsychosocial aspects and the risk of traumatic injuries mustbe considered [7] Randomized clinical trials in the pastdecade concluded that in the search for an effective and effi-cient outcome severe Class II patterns should be approached

in one-phase treatment including the pubertal stage ofmaturation [8 9] Treatments starting too early will extendthroughout a long period and will present greater chance ofrelapse besides exhausting the patientrsquos collaboration [9 10]However postponing the interceptive approach may exposethe patient to bullying and to an increased risk of incisorrsquostraumatic injury [7]

The treatments of malocclusions that rely on the patientrsquoscollaboration are less likely to achieve good results Severalaspects are associated with the patientrsquos compliance as theage and gender of the patient [11] the childrsquos self-esteem [12]the patientorthodontist relationship [13] and the duration oftreatment [14] But the type of appliance plays an importantrole in the final treatment outcome Removable appliances arecontraindicated when patientrsquos compliance is a problem Inthe last 30 years the HA has been widely used in orthodonticsto correct Class II malocclusion associated with mandibular


deficiency [14ndash16] A major advantage of this fixed applianceis the independence from the patientrsquos collaboration [15]

We believe that the successful outcome of the pre-sented case report might be associated with three aspects(1) an orthopedic therapy performed during the pubertalperiod (2) the end of the treatment that occurred afterthe completion of the pubertal maturation and (3) the useof fixed appliances excluding the patient collaboration

Several evaluative methods have been proposed to assessthe biological age [10 17 18] but certainly the HWM and inthe last decade the CVM are the most used in orthodonticsWe used both HWM and CVM to the establishment ofthe optimum window for the orthopedic approach of thissevere Class II malocclusion Including the pubertal stageof development certainly contributed to the effective andefficient outcome and favored a greater mandibular growth[8] However we must call attention to the fact that excessiveoverjet is a risk factor to traumatic injuries in Class II division1 young subjects Therefore the decision to postpone theskeletal discrepancy therapy should be synchronized withsome protective devices to avoid traumatic injuries on themaxillary incisors During the 1 year 5monthswaiting periodthe patient was recommended to use a 04010158401015840 plastic retainerduring his sports practice He also received a full time lipbumper to eliminate ldquolip traprdquo providing a psychosocialcomfort and the reduction of the risk of trauma in themaxillary incisors

The literature has showed that Class II malocclusionsubjects present the mandibular growth pattern similar toClass I peers during the prepubertal and the postpubertalperiods However during the pubertal growth stage ClassII adolescents have a significant smaller mandibular length(Co-Gn) gain than Class I subjects [19 20] Therefore inorder to avoid skeletal relapse it is mandatory to wait forthe end of the pubertal growth spurt to finish the orthopedicgrowth controlWe ended the active orthodontic treatment ata postpubertal stage (CS5) The facial growth that the patientpresented after braces removal was more balanced and didnot contribute to a Class II relapse

Patientrsquos complaint from the tremendous discomfortimmediately after HA installation is very common Buta natural adjustment will follow and an increase in thetreatment adherence after the first week is expected In thepresent case as the patientrsquos self-esteem greatly improvedafter the appliance installation it may have contributed to thecollaboration to therapyThere was no breakage of the deviceor emergency visits during treatment which are one of thecomplicating factors in this type of treatment [21]

4 Conclusion

A comprehensive treatment plan not only including theconcepts of effectiveness and efficiency but also consider-ing the psychosocial and traumatic injury risks should beaddressed when a skeletal Class II malocclusion is diagnosedHA therapy is an alternative way when the expected patientcollaboration is low

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

Acknowledgments

The authors deeply appreciate the collaborative efforts of MrGabriel S Richardson in the language editing of the paperThe authors also like to thank the stipends provided by thePontifical Catholic University of Minas Gerais (Grant no20148545-S1) supporting the scientific development of theundergraduate students involved in the present project

References

[1] R E Emrich A G Brodie and J R Blayney ldquoPrevalence ofClass 1 Class 2 and Class 3 malocclusions (Angle) in an urbanpopulation An epidemiological studyrdquo Journal of DentalResearch vol 44 no 5 pp 947ndash953 1965

[2] R R dos Santos J G Nayme A J Garbin N Saliba C AGarbin and S A Moimaz ldquoPrevalence of malocclusion andrelated oral habits in 5- to 6-year-old childrenrdquo Oral Health ampPreventive Dentistry vol 10 no 4 pp 311ndash318 2012

[3] M R de Almeida A L P Pereira R R de Almeida R R deAlmeida-Pedrin and O G D S Filho ldquoPrevalence of maloc-clusion in children aged 7 to 12 yearsrdquo Dental Press Journal ofOrthodontics vol 16 no 4 pp 123ndash131 2011

[4] M Massler and J M Frankel ldquoPrevalence of malocclusion inchildren aged 14 to 18 yearsrdquoTheAmerican Journal of Orthodon-tics vol 37 no 10 pp 751ndash768 1951

[5] W R Proffit H W Fields Jr and L J Moray ldquoPrevalence ofmalocclusion and orthodontic treatment need in the UnitedStates estimates from the NHANES III surveyrdquo The Interna-tional Journal of Adult Orthodontics and Orthognathic Surgeryvol 13 no 2 pp 97ndash106 1998

[6] G Lagana C Masucci F Fabi P Bollero and P Cozza ldquoPreva-lence of malocclusions oral habits and orthodontic treatmentneed in a 7-to 15-year-old schoolchildren population in TiranardquoProgress in Orthodontics vol 14 no 1 pp 1ndash7 2013

[7] J F C Tulloch W R Proffit and C Phillips ldquoOutcomes in a2-phase randomized clinical trial of early class II treatmentrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 125 no 6 pp 657ndash667 2004

[8] P Cozza T Baccetti L Franchi L de Toffol and J A McNa-mara Jr ldquoMandibular changes produced by functional appli-ances in Class II malocclusion a systematic reviewrdquoThe Amer-ican Journal of Orthodontics and Dentofacial Orthopedics vol129 no 5 pp 599e1ndash599e12 2006

[9] W R Proffit and J F C Tulloch ldquoPreadolescent class II prob-lems treat now or waitrdquoThe American Journal of Orthodonticsand Dentofacial Orthopedics vol 121 no 6 pp 560ndash562 2002

[10] L Franchi C Pavoni K Faltin Jr J A McNamara Jr and PCozza ldquoLong-term skeletal and dental effects and treatmenttiming for functional appliances in Class II malocclusionrdquo TheAngle Orthodontist vol 83 no 2 pp 334ndash340 2013

[11] G J King S D Keeling R A Hocevar and T T Wheeler ldquoThetiming of treatment for Class II malocclusions in children aliterature reviewrdquo Angle Orthodontist vol 60 no 2 pp 87ndash971990


[12] G Trakyali F Isik-Ozdemir T Tunaboylu-Ikiz B Pirim andA E Yavuz ldquoAnxiety among adolescents and its affect onorthodontic compliancerdquo Journal of Indian Society of Pedodon-tics and Preventive Dentistry vol 27 no 4 pp 205ndash210 2009

[13] R Stephens F S Ryan and S J Cunningham ldquoInformation-seeking behavior of adolescent orthodontic patientsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 143no 3 pp 303ndash309 2013

[14] S J Bowman ldquoOne-stage versus two-stage treatment are tworeally necessaryrdquoAmerican Journal of Orthodontics and Dento-facial Orthopedics vol 113 no 1 pp 111ndash116 1998

[15] H Pancherz ldquolsquoby jumpingrsquo the bite with the Her amp t applianceA cephalometric investigationrdquo 1979

[16] H Pancherz ldquoThe effects limitations and long-term dento-facial adaptations to treatment with the Herbst appliancerdquoSeminars in Orthodontics vol 3 no 4 pp 232ndash243 1997

[17] H Pancherz K Bjerklin B Lindskog-Stokland and K HansenldquoThirty-two-year follow-up study of Herbst therapy a biomet-ric dental cast analysisrdquo American Journal of Orthodontics andDentofacial Orthopedics vol 145 no 1 pp 15ndash27 2014

[18] S M Danaei A Karamifar A Sardarian et al ldquoMeasuringagreement between cervical vertebrae and hand-wrist matu-ration in determining skeletal age reassessing the theory inpatients with short staturerdquo American Journal of Orthodonticsand Dentofacial Orthopedics vol 146 no 3 pp 294ndash298 2014

[19] L S Fishman ldquoMaturational patterns and prediction duringadolescencerdquoThe Angle Orthodontist vol 57 no 3 pp 178ndash1931987

[20] F Stahl T Baccetti L Franchi and J A McNamara Jr ldquoLon-gitudinal growth changes in untreated subjects with Class IIDivision 1 malocclusionrdquo American Journal of Orthodontics ampDentofacial Orthopedics vol 134 no 1 pp 125ndash137 2008

[21] J F E Silva C Gerszewski R C Moresca G M Correr CFlores-Mir and A Moro ldquoRetrospective study of clinical com-plications during orthodontic treatment with either a remov-able mandibular acrylic splint Herbst or with a cantileverHerbstrdquoThe Angle Orthodontist vol 85 no 1 pp 64ndash71 2015

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Figure 1 Pretreatment extraoral and intraoral photographs

Initial102002

776∘

675

101∘

33∘

27∘

1014∘

401∘

1028∘

Figure 2 Pretreatment lateral cephalometric radiography cephalogram and hand-wrist radiography

Intraoral examination showed late mixed dentition acomplete Class II division 1 malocclusion 15mm of overjetdeep overbite (100) and no dental crowding The lowerincisors impinged on the palate mucosa during occlusion(Figure 1)

The lateral cephalometric radiograph showed a skeletalmandibular Class II relationship (SNA 776∘ SNB 675∘ANB 101∘) and vertical growth pattern (SNGoGn∘ 401∘)The incisors were proclined (1NA 27∘ 1NB 33∘ IMPA1014∘) Based on the cervical vertebrae maturation method(CVM) (stage CS1) and on the hand-wrist radiographicmethod (HWR) (absence of sesamoid bone) the patient wasprepubertal (Figure 2)

At this point the orthodontic treatment could be carriedout using a headgear or several types of functional appliances(Bionator Twin Block Bimler and Frankel eg) However

due to the reported lack of collaboration an alternativetreatment plan using a fixed orthopedic jumping device(Herbst appliance HA) was presented to patient and parents

In order to achieve greater efficiency and effectiveness thetreatment was postponed to the patientrsquos pubertal stage ofmaturation While waiting for the patientrsquos pubertal growthspurt traumatic injury protection devices were implementedas a 04010158401015840 plastic retainer during sports activities and a lip-bumper to avoid lower ldquolip traprdquoWhen the patient reached 11years and 4months (CS3 stage of skeletalmaturation) theHAwas installed (Figure 3) The HA design included articulatedbilateral telescoping arms positioned in both maxillary andmandibular arches The pivots were welded to a heavycantilever wire extending from the lower first permanentmolars bands (TP Orthodontics La Porte IN USA) tothe cuspid region of the mandibular arch In the maxillary









End of Herbst102005

776∘

675

101∘

33∘

1014∘

390∘

1028∘

27∘




770∘

700∘

70∘

901∘

18∘

28∘

990∘

398∘





988∘

790∘

720∘

70∘

18∘

25∘

990∘

397∘




3 Discussion










4 Conclusion




Acknowledgments


References






























Biomaterials












Journal of



























End of Herbst102005

776∘

675

101∘

33∘

1014∘

390∘

1028∘

27∘




770∘

700∘

70∘

901∘

18∘

28∘

990∘

398∘





988∘

790∘

720∘

70∘

18∘

25∘

990∘

397∘




3 Discussion










4 Conclusion




Acknowledgments


References






























Biomaterials












Journal of






















988∘

790∘

720∘

70∘

18∘

25∘

990∘

397∘




3 Discussion










4 Conclusion




Acknowledgments


References






























Biomaterials












Journal of

























4 Conclusion




Acknowledgments


References






























Biomaterials












Journal of





































Biomaterials












Journal of



















Case Report Effective and Efficient Herbst Appliance...

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