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Telescoping Herbst Appliance
Telescoping Herbst Appliance
A mini telescoping herbst is used typically in younger patients with mixed dentition (still have baby teeth). It is a fixed appliance used to bring the lower jaw forward (mandibular advancement). The telescoping herbst helps enhance facial features and stimulates growth while holding the lower jaw forward. It is made up of metal crowns/bands over the first molars with rods and tubes, also known as arms, attaching the upper and lower, which help position your teeth forward as it is adjusted each appointment.
Keys to a Telescoping Herbst Appliance:
The patient has mixed dentition - remaining baby teeth
Upper braces only! (In some cases no braces)
The appliance typically advances and holds the lower jaw for a minimum of 12 months, then lower braces are added for another 12 months. (24 month total treatment time)
How to cement a Telescoping Herbst
At the consultation, it will have been decided that the patient is getting a telescoping herbst and the patient would have been scanned for the appliance. The telescoping herbst's are not made in house, and take about 2 weeks to arrive. When the patient comes in they will be getting their upper brackets on and the appliance cemented.
Depending on doctor time, you can start the appointment by cementing the bands, but typically you would start by bonding the upper brackets first.
When the appliance arrives from the lab, it comes already connected on the model. So, start by unscrew the bottom screws only, it is hard to screw the arms to the upper crowns once they are cemented, so leave the upper crowns and arms connected while cementing. The lower crowns are connected and one segment so have a small suction at hand and place a cotton the lower lip. It is hard to keep the lower molars completely isolated so try your best, but it does not have to be 100% isolated because it is a whole crown, not just a band.
Take two scoops of the powder and the glass ionomer and mix enough cement for all four bands. Fill the lower bands first, making sure the whole crown is covered. You can always wipe the excess glue out, so it is better to have too much than not enough because the crown has a better chance of falling off with not enough cement. Make sure to cover the cement that is left for the upper two bands while you are placing the lower segment because the glue can cure from sitting in the light too long.
Get the lower 6's as isolated as possible and have the patient open as wide as possible. Have the patient bite on the bite stick, securing the crowns and making sure they are fully seated. As the patient is biting, you can use the small suction to help catch any of the extra saliva. Once is is fully seated, cure each crown for 60 seconds.
When placing the upper bands, use a little cotton tucked on each side to help keep the upper lip away. Just like the lower, you are going to place cement around either band, but just one at a time. Remember, the arm should already be attached to the crown. Cement the upper 6 crowns, making sure that arm is in the right direction and that it is not uncomfortable to the patient. Cure each side one at a time for 60 seconds. once all the crowns are cemented, you are going to attach the upper arms and screw them into the lower, connecting the two. With your fingers or a weingart, you are going to hold the arm in place, dry the area to make sure there is not any saliva where the screw will go, add a light about of secabond to the screw and place it. After screwing both sides into place, you are going to metal wire tie the upper left 6 of the herbst, connecting all of the teeth to the upper right 6 of the herbst. One wire tie is not long enough, so typically you will wire tie from the upper left 6 to the upper right 3, and then start a new one from the upper right 6 and connect back over the upper right 3 ensuring the whole upper arch is connected.
**THE WIRE TIE CONNECTING THE HERBST FROM SIDE TO SIDE IS KEY!! IF IT IS NOT PLACED, THE MOLARS CAN DISTALIZE FROM THE FORCE OF THE HERBST AND CAN CAUSE ISSUES WITH PATIENT COMFORT, WORKING WITH THE HERBST, AND EVENTUALLY REMOVING IT!**
Once the wire tie is in place, you can now place the wire upper 6-6. It is difficult to trim the wire with the arms of the herbst, so make sure it is cut the correct length. It has to be long enough to go all the way through the molar tube without causing discomfort but not too short that it will not connect to the molars.
Before the patient leaves, make sure to get a check out from the doctor or your clinical lead. Typically when the appliance is placed, it is not adjusted the first time due to the light wire and allowing the patient to get comfortable with the appliance, but in some cases it has to be adjusted so make sure to always check.
Make sure and go over all instructions for oral hygiene and the appliance which include:
Brushing really good behind the arms and where the bands are
No aggressive movements side to side or opening super wide- the pressure fighting against the appliance can break the crowns or the arms
The patient will get small cotton rolls to tuck underneath the arm on the lower for the first two weeks of sleeping for comfort
No sticky, chewy food such as caramel, taffy, bubble gum, starburst, etc.
The patient will come back after 8-10 weeks for a new upper archwire and adjustment of the herbst appliance. Make sure that the patient and the guardian(s) are aware that the appliance is on for 12 months, but it is important that they come to all of there appointments so it can be properly adjusted.
Advanced Sync Herbst Appliance
Advanced Sync Herbst Appliance
An advanced sync appliance is used when all of the primary teeth are in (no baby teeth left), but it is used for the same reasons as a mini telescoping herbst.
The differences between an advanced sync is:
No baby teeth- All primary teeth
Upper and lower braces
Typically built at the chair the day of the initial bonding
To build the advanced sync herbst: In the clinic there are containers that have bands for all molars with a variety of sizes (as shown above). You will individually fit a band for each 6, letting them sit without any glue while the others are being fitted. After you have found an ideal fit for each tooth, individually take one off at a time and re-cementing it with glass ionomer. Use a cotton roll and small suction to help with isolation if needed. When cementing the upper crowns, you want to attach the arm first. This is not crucial, but it is difficult and uncomfortable for the patient to screw the arms on the upper once the band is already cemented.
**The arms are separate, the RIGHT and LEFT arms!! The thick part of the arm is the upper section that connected to the upper crown and the skinny section is where the shims are added during treatment which is towards the bottom and attached to the lower crown**
**The upper screw is placed in the distal hole and the lower in the mesial hole!**
Once the arms are in place, just like the telescoping herbst, wire tie upper 6-6 connecting every tooth!
After screwing both sides into place, you are going to metal wire tie the upper left 6 of the herbst, connecting all of the teeth to the upper right 6 of the herbst. One wire tie is not long enough, so typically you will wire tie from the upper left 6 to the upper right 3, and then start a new one from the upper right 6 and connect back over the upper right 3 ensuring the whole upper arch is connected.
**THE WIRE TIE CONNECTING THE HERBST FROM SIDE TO SIDE IS KEY!! IF IT IS NOT PLACED, THE MOLARS CAN DISTALIZE FROM THE FORCE OF THE HERBST AND CAN CAUSE ISSUES WITH PATIENT COMFORT, WORKING WITH THE HERBST, AND EVENTUALLY REMOVING IT!**
After the herbst is built, you can place wires. Typically in an IB appointment, the .014 is only placed 5-5, but in this case, it will connect 6-6 upper and lower. If the lower is not connected to the 6's, just having the appliance in will start to add pressure to the lower teeth and can rotate the teeth, making it difficult at there next appointment in 10 weeks to place a wire 6-6.
Make sure and go over all instructions for oral hygiene and the appliance which include:
Brushing really good behind the arms and where the bands are
No aggressive movements side to side or opening super wide- the pressure fighting against the appliance can break the crowns or the arms
The patient will get small cotton rolls to tuck underneath the arm on the lower for the first two weeks of sleeping for comfort
No sticky, chewy food such as caramel, taffy, bubble gum, starburst, etc.
Warm salt water rinses morning and night: 8 oz of warm water and 1tsp salt swished around. This helps with sores and discomfort
The patient will come back in 2 weeks for a quick appliance check just to make sure the patient does not have any major sores caused from the herbst. Then in 8-10 weeks for a new archwires upper and lower and adjustment/advancement of the herbst appliance. Make sure that the patient and the guardian(s) are aware that the appliance is on for 12 months, but it is important that they come to all of there appointments so it can be properly adjusted.
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