CLINICAL

Impressions PUBLISHED BY ORMCO CORPORATION • VOL. 7, NO. 2, 1998

®

Dr. Wildman
on the
TwinLock
Appliance
Page 2

Dr. Smith on
Herbst Therapy
Page 6

Dr. Odom on
Indirect Bonding
Page 13 Dr. Wildman
The Wildman Twin
Revolutionary Self-Locking Design Provides
True Twin Versatility and Speedier Treatment
by A. J. Wildman, D.D.S., M.S.D. Introduction pleased with the new design. I called this
The Wildman TwinLock™* System is the bracket “MiniLine” because it was very
Eugene, Oregon
happy merging of three components: my small incisogingivally (Figure 5). I hoped
locking mechanism, Ormco’s twin-bracket that the MiniLine would be thin enough
design requirements and Dr. Charles and esthetic enough to be a good compro-
Burstone’s variable modulus concept. mise between clear brackets and a bulky
We have developed a true twin ligature- bracket like EdgeLok.
less bracket with no encumbering
“pseudotwin” features (Figures 1-2). The Ormco’s market research, however,
lock is strong and easy to open and close showed that I was probably on the wrong
with no special tools necessary (Figures track. Ormco challenged me to adapt my
3-4). We feel that the Wildman TwinLock, MiniLine locking mechanism to produce a
when used with the new space-age wires ligatureless Mini Diamond® bracket, so
in the variable modulus technique, has that the operator would not in any way
earned the right to be called a revolution- need to change techniques. This bracket
ary improvement. was to be an authentic Mini Diamond
bracket, with the additional feature of a
History strong, trouble-free lock that would not
Setting Our Goals – In May 1990, I require special opening or closing tools.
approached Ormco Corporation with a Design constraints called for a lock that
ligatureless bracket design that I felt would not encroach on the tie areas of the
would be a proper replacement for my Mini Diamond wings, so that Power O’s
EdgeLok® bracket. I had been developing and Chains could be used at the doctor’s
an improved bracket lock to replace discretion (Figure 6). We found that the
EdgeLok for a number of years and was compact MiniLine locking mechanism fit
Dr. A. J. (Jim) Wildman received his ortho-
dontic training at Northwestern University.
Throughout his professional life, Dr. Wildman
has pursued the goal of improving orthodon-
tic hardware. He developed the EdgeLok®
ligatureless bracket and holds a number of
patents concerning lingual orthodontics and
ligatureless bracket design. Dr. Wildman has
conducted his private practice of orthodon-
tics in Eugene, Oregon, since 1955.

Figure 1. Wildman TwinLock bracket – open Figure 2. Wildman TwinLock bracket –

2 position. closed position.

*The Wildman TwinLock™ design is patented under U.S. Patent Nos. 5,094,614; 5,474,446; 5,613,850 and foreign patents.
nLock Bracket
Figure 3. Open position. Figure 4. Closing with cleoid scaler – no
special tools required.

Figure 5. The MiniLine design focused on Figure 6. Wildman TwinLock is a Mini

esthetics. Diamond® twin bracket design, accommo-
dating Power Chain (as shown) and providing
all the working capabilities of a true twin
bracket.

perfectly inside the Mini Diamond wings, wires were placed to begin tooth move- Figure 7. Early 1900s heavy archwires were
making a ligatureless, uncompromised ment. A progression of heavier and bent to conform with the malocclusion and
twin bracket possible. heavier archwires was placed to complete then gradually straightened as the case
the case (Figure 8). We now begin with unraveled.
The Variable Modulus Concept – By a nearly-full- or full-sized, very flexible
1990, it was becoming apparent that the archwire and proceed to archwires of
use of the remarkable new titanium alloy increased stiffness. Since the new wires
archwires of constant cross section and can work out over long periods of time,
variable stiffness might replace the vari- the weak link turned out to be the ties.
able cross-section approach. Dr. Burstone Power O’s decayed too rapidly and could
called this the variable modulus concept. not seat the new wires fully in the slot.
You may recall that in the early 1900s, With the variable modulus technique,
orthodontic tooth movement was accom- steel ties bring their own set of problems.
plished with heavy, stiff, full-sized arch- As they are cinched tight, they bind and
wires bent to conform to the malocclusion produce a high degree of force. This
and then gradually straightened as the creates a double whammy: a slowing of Figure 8. The variable cross-section
case unraveled (Figure 7). treatment progress and a tendency to peel approach to archwire mechanics.
the bonds off the teeth. The use of steel
This was replaced by the variable cross- ties has played a larger role in bond failure
section concept. Very light, ideal arch- continued on following page
3
 Dr. Wildman
continued from preceding page

than most clinicians realize. To solve this typodont torture tests. The “oil can” I want to thank Ormco design team
problem, a strong, easy-to-use, ligatureless spring fatigued after a number of opening members and co-patent holders Jim Reher
bracket system seemed to be the logical and closing cycles. We discovered this and Larry Phaneuf for their major contri-
choice to complete the variable modulus problem during the typodont tests, so we butions to the project.
system. With this system, archwires did not clinic this design.
would not need to be changed for perhaps The Wildman TwinLock Today
six months. If this could be accomplished, In our next attempt, we went back to the A True Rigid-Walled Convertible Tube –
we felt we could call this new system a original design, but with a modification A distinct advantage is the in-front-of-
revolutionary step forward in efficiency. that allowed the lock to open and close the-archwire locking mechanism. To
In 1990, we could see that the superefficient smoothly and easily. Extensive clinical understand the design of ligatureless
archwires deserved a new, superefficient testing created no fatigue after repeated brackets, it helps to think of a bracket
bracket. opening and closing cycling, so we knew as a tube (Figure 13A), but with the labial
we had a winner. Our test doctors gave us wall removed as shown in Figure 13B.
Perfecting the Locking System – During rave reviews. The design breakthrough This wall must be replaced by a locking
the eight-year development period, was the replacement of the trip spring element, which must have some sort of
Wildman TwinLock went through several with a smooth shoulder spring that shear relation to contain the archwire.
design changes. The original locking moved into a pocket to prevent fatigue We placed a locking slider in a channel
mechanism was a trip spring (Figure 9).* during multiple cycling. After eight years in front of the archwire, creating an
It was adapted directly from the early of developing and testing, we feel that we incisal and gingival shear area there.
wingless MiniLine design. The lock was have met the rigorous goals set forth in The slider consists of a filler that provides
very strong and positive, and the results 1990 (Figure 11). strength and a spring with a locking
of extensive clinical tests were extremely shoulder that engages a labioincisal
encouraging. However, some clinicians Establishing the Design High Ground – shoulder during the locking cycle and
found the lock a bit difficult to unlock. It While we recognize that a number of tal- is compressed into a pocket in the filler
seemed that a special opening tool might ented teams are offering interesting and during the unlocking cycle (Figure 14).
be necessary. One of our goals was a lock innovative designs to the profession, we Since the archwire must be constrained
that was easy to open and close, with no feel that our team has distinct advantages. from moving labially, labial shear areas
special tools needed, so we began to I had been working on ligatureless bracket just make sense. We have patented this
modify our lock to make it easier to open. designs for 35 years and had used my design feature of the double shear in
patented laminated prototype manufac- front of the archwire (Figure 15). If the
The next design was a compression-spring turing technique to create many prototype locking element is in shear behind the
locking modification (Figure 10). The designs, testing them on typodonts and archwire, there is an inherent tendency
lock functioned beautifully – strong, in the mouth (Figure 12). This allowed for the device to rock, producing sloppy
positive and easy to open and close with a us to identify and patent early on what dimensional control. Brackets with shear
silky smooth action. However, it had one we considered to be the best designs – behind the archwire must be considered
fatal flaw that was detected during the to stake out the design high ground. “pseudoconvertible” tubes.

Figure 9. Trip spring locking mechanism Figure 10. The second design with an Figure 11. The third version replaced
of the first true twin bracket design was “oil can” compression spring locking the trip spring with a smooth shoulder
occasionally too positive and, consequently, mechanism fatigued after a number of spring that moved into a pocket to prevent
difficult to unlock. opening and closing cycles. fatigue – the Wildman TwinLock, a true twin
bracket with a superior locking device.

*This illustration and following illustrations (except Figure 13) are original engineering drawings of Dr. Wildman’s.
Figure 12. The laminated proto- Figure 13. (A) The ideal attachment is a tube. Figure 14. The Wildman TwinLock places a locking
type manufacturing technique (B) To remove the archwire, we must remove slider in a channel in front of the archwire, with the
allowed the testing of many the labial wall. The Wildman TwinLock incisal and gingival shear areas providing a rigid
design concepts. provides rigid metal-to-metal locking areas labial wall.
in front of the archwire (Points 1 and 2).

Figure 15. The locking design with a shear in front of the archwire Figure 16. The position of the locking element in front of the arch-
creates a rigid-walled tube. A locking element in shear behind the wire and between the wings frees all tie areas from locking element
archwire will be prone to rocking, reducing dimensional control. encumbrances.

A True Mini Diamond Twin “doorstep.” He says that for these situa- special instrument. Incisal pressure on the
(Modified Roth Rx – .018 or .022 slot) – tions, he ties the wire in the doorstep at slider with a common cleoid scaler easily
The slider assembly nestled between the the first appointment, then invites the wire activates the unlocking action. Locking
wings does not encroach on the tie areas, inside at the second appointment. Power is equally easy. We found that most
making Wildman TwinLock a self-locking O’s and ties can be used with Wildman operators use a cleoid and an occasional
true twin Mini Diamond design. A locking TwinLock, just as with Mini Diamond. We fingernail to lock the archwire. This
element wrapped around the archwire try to get full engagement at the first ap- sounds unsophisticated, but our test
both labially and lingually produces a pointment, but this is not always possible. doctors found that it works. Even though
pseudotwin, since it must occupy the the lock was easy to open and close, our
same area as the tie wings (Figure 16). Clinical Advantages test doctors reported that patient tamper-
There is one more interesting feature of As a case begins, bonding Wildman ing was not a problem.
the design. The recess in front of the slider TwinLock is easy, because we retain the
is a perfect receptacle for the archwire to unique diamond shape that helps the The Wildman TwinLock works well when
be tied to during the first appointment in operator to visually reference the bracket full-sized, shape memory or superelastic
the case of an extreme rotation that can- to the incisal edge and the long axis of the wires are used for the first arch in the vari-
not be immediately engaged. My partner, tooth. Opening the diamond lock to able modulus technique. To obtain
Dr. Gary Chapman, has called this the receive the first archwire requires no continued on page 19
5
 Matching the
Herbst to the
Malocclusion
Three Types of Stainless Steel Crown Herbsts
by John R. (Bob) Smith, D.D.S., M.S.D. Bob Chastant. The stainless steel crown
Winter Springs, Florida design emerged as the most consistent
The development of noncompliant ortho- and durable form of Herbst appliance.
dontic appliances, like the Herbst* and Learning how to integrate this appliance
Pendex, has simplified the correction of into my practice was both challenging
our most challenging cases. Additionally, and exciting. I soon learned that the
the introduction of superelastic wires and Herbst appliance and appropriately-timed
sophisticated straight wire appliances treatment were the keys to consistent
has catapulted our profession to what practice improvement.
Dr. Jim Hilgers has termed the “era of
hyperefficient orthodontics1.” Since Let’s take a look at some of my office
integrating hyperefficient tools to our statistics from 1989 to 1997:
office in 1989, we have seen a profound • Patients Seen Per Year 8% decrease
improvement in the quality of care • Days Worked Per Year 15% decrease
delivered to our patients and a steady (157 days in 1997)
easing of stress. • Size of Staff 16% decrease
• Gross Collections 11% increase
• Profit 14% increase
Hyperefficiency and
the Herbst Appliance Using all the components of hyper-
Dr. John R. (Bob) Smith received his D.D.S. Sharing some of my personal experiences efficient and properly-timed treatment
from Emory University in 1975 and his will help me illustrate the profound allowed us to increase the intervals
M.S.D. from the University of Washington in
impact these hyperefficient modalities between appointments; as a result, our
1977. He received the Milo Hellman
Research Award for his graduate thesis. An have had on my practice. During the mid daily patient load was reduced. Because
original member of the “Lingual Task Force,” ‘80s, I began my quest to eliminate one of we were seeing fewer patients, as we
Dr. Smith has lectured and published exten- the biggest headaches in the practice of experienced the normal loss of staff
sively on lingual orthodontics as well as orthodontics – noncompliance. At that members over the years, we were able
practice management, diagnosis and treat-
time, the Herbst appliance was becoming to comfortably handle the patient care
ment planning, and early intervention. He
maintains a full-time practice in Winter more user-friendly, due to the work of with a smaller staff. Because staff expenses
Springs, Florida. such pioneers as Drs. Terry Dischinger, constitute the greatest portion of our
Joe Mayes, Dwight Damon, Bob Fry and overhead, practice profitability dramati-
* Herbst is a registered trademark of Dentaurum, Inc.
 numerous soft-tissue problems are
typically encountered when the patient
is young (ages 7-9). Because of the close
proximity of the molar axles to the
coronoid processes of the mandible,
irritations of the buccal cheek tissues
and parotid duct can occur. Additionally,
using the cantilever Herbst design on
patients this young can cause irritations
at the corners of the mouth. At this early
age, using the Herbst appliance for A-P
correction is often unsuccessful, long-
term. Ordinarily, the Herbst does an
excellent job of altering the dentoalveolar
and skeletal components throughout
early childhood and adolescence.
However, many patients experience
varying degrees of relapse due to the
continued expression of the original
genetic growth pattern. Through evaluat-
ing numerous completed cases, Dr. Hans
Figure 1. An open coil spring between the tubes on the cantilever arms increases arch length. Pancherz determined that it is best to
Note the occlusal rests on the primary molars. initiate Herbst therapy in the late mixed
dentition. His studies suggest that good
cally increased. Other benefits included invaluable tool for the correction of Class dental intercuspation at the end of Herbst
reduced supply costs, increased appoint- II malocclusions, I still use headgear and therapy enhances the stability of the
ment availability and reduced workdays. elastics. During the new patient exam, correction2. My clinical experience
Our capacity for growth was enhanced, it is usually possible to determine which supports these findings.
facilitating a 21 percent increase in new patients will more likely cooperate with
patient contracts over the last five years. headgear. Occasionally, a particular case
Best of all, I went from three offices to will need headgear traction to achieve an The Three
one highly sophisticated and comfortable optimal result, such as a Class II maloc- Herbst Designs
location. Focusing my energies on one clusion with procumbent lower incisors. I commonly use three types of Herbst
office has proven to be less stressful and Although a Herbst appliance will work in appliance designs, each with its inherent
much more rewarding. such cases, it places a mesial component strengths and weaknesses. Because I use
of force on the mandibular teeth that can stainless steel crowns to secure the Herbst
The Herbst appliance was the greatest further procline the incisors. The key to to the dentition, understanding how the
contributor to these hyperefficient treat- using any orthodontic appliance is to crowns influence the action of the Herbst
ment improvements. Herbst therapy has understand its strengths and weaknesses. appliance is essential in selecting which
evolved into a multifaceted discipline, The clinician can then select the approach type to use for optimal results. No one
the most efficient and consistent means that best suits the needs of the patient. design can be expected to effectively treat
for Class II skeletal and dental corrections. My goal has always been to select the every Class II malocclusion.
The purpose of this article is to explain course of treatment that requires the
my application of stainless steel crown- fewest appointments, has the lowest Type I Herbst
supported Herbst appliances. material costs, demands the least doctor I use the Type I or cantilever design for
time, allows maximum use of staff and, early Herbst therapy (ages 9-11) prior
All of us have experienced the time- most important, consistently produces to the eruption of the mandibular first
consuming and frustrating experience the best clinical results with the least bicuspids. There are four instances where
of trying to generate better compliance patient discomfort. I use the Type I Herbst: first, for the
with headgears, elastics or other remov- young patient who has an emotionally
able appliances. I learned very early Before I discuss the different types of debilitating Class II malocclusion that
that you don’t get anywhere with criticism. Herbst appliances, it is essential to cover demands correction to enhance the
It is always better to avoid confrontation the most common clinical decisions that patient's self-esteem; second, the Class II
with patients and parents when there are complicate and reduce their efficiency. openbite case; third, the Class II case
materials and methods available to reduce The most common is to initiate Herbst with a significant arch-length deficiency
the compliance issues. treatment in the early mixed dentition. and deviation of the dental midlines; and
Due to the bulk of the appliance and finally, the extraction case.
While the Herbst has proven to be an the diminutive size of the patient, continued on following page
7
Dr. Smith
continued from preceding page

Figure 2. The archwire tubes should be Figure 3. A tube on a short cantilever arm Figure 4. The RPE is soldered only to the
occlusal to the cantilever arms. mesial to the maxillary crowns simplifies first molar crowns.
archwire management.

Figure 6. The type II Herbst design. Figure 7. The crown and band are soldered Figure 8. A tube can be placed under the
to an .045 stainless steel wire. crown axle to facilitate archwire placement.

Let’s look at the unique components of found no clinical advantages in placing of the tissue over the coronoid processes
this Herbst design. Cantilever arms extend the tube gingivally. during excursive movements of the
mesially to the contact points of the first mandible. Placing the axle in the middle
molars and primary canines. Care must be Maxillary components include crowns of the buccal surface of the crown or to
taken not to extend the arm too far for- on first molars. These crowns can have the area over the mesiobuccal cusp can
ward in order to avoid irritation of the mesially extended archwire tubes that make screw insertion and tightening
cheek tissues and bulges at the corner enable the placement of utility archwires easier. Many Herbst designs position the
of the mouth when the patient smiles. to manage the alignment and torque of axle on the distal aspect of the crown or
An .045” stainless steel lingual wire the incisors (Figure 3). Most Class II cases even on a short cantilever extending the
connected to both lower molars, with need maxillary expansion to properly axle more distally. Although these designs
occlusal rests on the primary second align the mandible to the maxilla; I usually work on older patients, the young
molars, gives rigidity to the lower portion usually incorporate it with most Class II patient needs careful evaluation prior to
(Figure 1). These rests are usually placed therapy, irrespective of the orthopedic Herbst fabrication to determine where to
through the lingual grooves of the appliance used to correct the antero- place the maxillary axles. As the axle is
mandibular primary second molars posterior discrepancy. A rapid palatal moved mesially on the crown, the overall
and rest on the occlusal surfaces. Their expander (RPE) is attached to the first rod length is shortened, which may cause
purpose is to stabilize the entire lower molars with .045” stainless steel wires frequent rod disengagement on opening.
Herbst unit by minimizing the rotational extending mesially to the primary first Axle position and rod length need to be
moment generated by the action and molars (Figure 4). The stainless steel carefully balanced to ensure comfort and
direction of the rods. To facilitate place- crowns, due to their occlusogingival success with the Herbst appliance.
ment of lower archwires for lower incisor height and infringement on the freeway
alignment, an .022” x .028” tube can be space, help prevent extrusion of the All crowns should have a 3 mm hole over
placed occlusal to the cantilever arm. maxillary first molars during expansion. the mesiobuccal cusp to facilitate crown
This tube should always be placed In young patients, it may be necessary to removal with the AEZ Chastant Crown
occlusally to simplify distal archwire move the axle to the mesial aspect of the Removing Plier (Ormco #803-0610).
8 management (Figure 2). I have maxillary crowns to prevent impingement Removal of the upper and lower units
 Herbst unit. After splitting the crowns months of Herbst therapy, the bicuspids
with a bur or plier, place the plunger of and canines are in their final eruptive
the plier on the occlusal surface of the phase. I feel that once these teeth have
erupting first bicuspids, with the carbide erupted into a solid Class I occlusion, the
tip under the cantilever arm. Apply a overall A-P correction will be more stable.
gentle fulcrum force to this area to remove
the crown with little patient discomfort. Type III Herbst
The Type III Herbst design is the same
Type II Herbst as Type II except for not including rigid
I use the Type II Herbst most often in connections between the mandibular
Figure 5. The vertical cut should be placed my practice. This design is extremely bicuspid crowns and molar bands. It is
where it is easily accessible with a plier or esthetic and comfortable. The major used in cases where mandibular first
bur. design difference between Type I and molar or second bicuspid spaces are to
Type II is in the mandibular portion. be closed, especially in maintaining lower
With the Type II design, crowns are anterior anchorage as the posterior teeth
placed on the first bicuspids rather than are moved mesially. Use closing-loop
first molars. Bands are placed on the archwires or sliding mechanics for space
mandibular first molars (Figure 6). Solder closure (Figure 9). I have found this
the crowns and bands to an .045” stain- particular design to be very helpful in the
less steel lingual wire to consolidate the treatment of Class I or Class II patients
lower portion into an anchorage unit with congenitally missing mandibular
(Figure 7). To allow archwire placement second bicuspids. It is possible to move
for aligning the lower anteriors, place an the molars mesially and still maintain a
.022” x .028” tube under the axle screw Class I cuspid relationship. The resultant
Figure 9. Type II Herbst design using power on the bicuspid crowns (Figure 8). This occlusion in either case is a Class III
chains to close bicuspid spaces. is also helpful if the .045” stainless steel molar and Class I canine relationship,
lingual wire breaks between the bicuspids. assuming no maxillary bicuspids are
during the fitting and trying process is If this occurs, brackets can be placed on extracted. Again, the maxillary portion
difficult without the aid of the occlusal the incisors and cuspids to gain stability of this type of Herbst is the same as the
holes and plier. Microetch the interiors of and anchorage in the lower arch. Also, previous designs.
all crowns to enhance cement adhesion. if the lingual wire breaks between the
Failure to microetch their interior can bicuspids and molars, a buccal .022” x Type I Herbst
present difficulties with cement removal, .025” stainless steel segmental wire can be
particularly with the dual-cured glass placed to accomplish the same objectives.
Therapy for
ionomer cements. Most of the cement Nonextraction Cases
will remain on the teeth rather than the I have found Type II to be the most Now that we have a general understand-
crowns, creating a cleanup nightmare. durable and hygienic design. Since it is ing of the various Herbst types, let’s
A 2 mm vertical cut at the buccal or attached to the lower first bicuspids, it look at the specific details of the Type I
mesiobuccal line angle at the gingival forces the clinician to wait for the patient design for nonextraction cases:
margin of the crown facilitates removal to develop further before starting treat- • Case Selection
following Herbst therapy (Figure 5). ment. The Herbst has been found to be • Fabrication
When removing the crowns, use a #556 more successful in patients between 10 • Placement
high-speed bur to connect the vertical and 14, when they are approaching maxi- • Typical Treatment Protocol
gingival cut with the occlusal hole; then mum pubertal growth. I have also found • Case Examples
extend the cuts to the distal marginal the A-P corrections to be more attainable • Retention
ridge of the crowns. Use the crown and stable when treatment is initiated in
removal plier to pop the crowns loose. that age range. The intraoral environment Case Selection
Another effective plier is the AEZ Crown is more conducive to Herbst therapy in Prior to fabricating any Herbst appliance,
Slitting Plier (#803-0430); use the sharp- larger patients. The maxillary portion of a careful intraoral evaluation should be
ened point to split the crown from the Type II is the same as Type I. made to recognize any potential problems
gingival vertical cut to the occlusal surface that might modify either the timing of
of the crown. Use the Chastant Crown The key to successful Type II treatment is treatment or the design of the appli-
Removing Plier to remove the lower to time treatment so that after the 12 continued on following page
9
Dr. Smith
continued from preceding page

ance. Because the Type I Herbst is at- screw placement. The cheek should be re- oral environment can usually accommo-
tached to the permanent first molars, they tracted as far as possible to ensure there is date the Herbst appliance. Occasionally,
must be fully erupted and accessible prior adequate access for the screw and wrench. the permanent mandibular canines will
to attempting placement. A common error At what stage of dental development is precede the eruption of the bicuspids.
using the Type I design is to attempt it appropriate to use the Type I Herbst? Treatment should be initiated before
placement when there is still tissue over The answer to this question can have a severe canine displacement occurs. An
the distal marginal ridge of these teeth. tremendous impact on the outcome of advantage of using the Type I Herbst at
This produces significant patient discom- Herbst therapy and the level of discom- this stage of dental development is that it
fort and is a common emergency associat- fort. Type I Herbst therapy should be provides the ability to gain arch length.
ed with Herbst therapy. At this visit, a initiated when the patient’s mandibular We often encounter cases where the
determination is made as to where to primary first molars are in the final stage dental midlines are incongruent with the
position the maxillary axles for ease of of exfoliation. At this time, the patient’s facial midline due to an arch-length

Case Illustration – Type I Herbst Therapy

This 9-year-old patient exhibits a dolicofacial pattern with hypermentalis muscle behavior.

Note pretreatment Class II anterior openbite malocclusion.

10 Occlusion immediately after Type I Herbst removal. Note openbite between first molars.
deficiency in one or both dental arches. desired position (Figure 1). In cases with resolving arch-length deficiencies and
The Type I Herbst is excellent for modify- mandibular skeletal asymmetry, the Class II malocclusions, it is tempting to
ing the transverse and A-P relationships mandible can be incrementally moved start Herbst therapy at that time. But a
of teeth in both arches. Expanding the using different shim lengths. It is possible decision to start Herbst therapy at such a
lower lingual wire prior to cementation to make mandibular positional adjust- young age will predispose both the patient
increases mandibular arch length. Using ments to align the skeletal structures with and orthodontist to many problems.
an RPE increases the maxillary transverse the facial midline. Tissues around the first molar and cheek
dimension. Additionally, because upper areas are affected by the bulk of the appli-
and lower archwires can be placed Many orthodontists begin expansion ance. It is best to remove primary canines
between the tubes on the upper molars therapy when lower incisors erupt into to allow autonomous alignment of the
and cantilever arms, open-coil springs can inadequate space for proper alignment. incisors. Patients can be seen every 6 to
be used to move the incisors to the Because the Type I Herbst is so effective at continued on following page

Occlusion after primary second molar occlusal reduction. Maintaining the maxillary incisors
in their original position or placing them slightly forward and intruded would have allowed
additional autorotation of the mandible (see Figures 11-13).

Posttreatment result with associated superimpositions. Patient has an improved smile with normal mentalis muscle function.
She will need a free gingival graft facial to the lower incisors.
11
 Dr. Smith
continued from preceding page

12 months until they are more mature

and the mandibular primary first molars
“My goal has always been to select the
are exfoliating. Overall treatment efficien- course of treatment that requires the fewest
cy will be enhanced when combined with
a prudent approach to patient manage- appointments, has the lowest material costs,
ment3,4
.
demands the least doctor time, allows
Fabrication
The Type I Herbst can be fabricated maximum use of staff and, most important,
directly in the mouth or indirectly on
the models. I prefer the indirect approach consistently produces the best clinical results
because the appliance can be fabricated
in its entirety on models. This reduces
with the least patient discomfort.”
chairtime dramatically compared to the
direct approach where crowns are fitted cal tissues can occur. Prior to sending any in the appliance and crimp the gingival
and the appliance is fabricated while the cases to the laboratory, it is best to request margins of the crowns with the AEZ
patient waits. Also, it reduces the time their forms and ask what materials and Crown Forming Plier (not yet available
and discomfort the patient endures during information are needed for proper fabrica- for purchase). To enhance retention, I use
the fitting of the crowns. tion of the appliance. The quality of the glass ionomer cement on all portions of
Herbst appliance is a by-product of the the Herbst. The maxillary arch must be
Specific laboratory instructions are neces- understanding and communication expanded prior to cementing the lower
sary to ensure the proper advancement between the laboratory technician and unit due to the buccolingual dimension
of the mandible. Simply take upper and orthodontist. of the cantilever arms. This is necessary
lower impressions. I typically do not send to prevent the axle arms of the female
a bite registration to the laboratory. I ask In the indirect technique, the laboratory portion, which are attached to the maxil-
them to advance the mandible to an will trim the molars on the plaster models lary first molar crowns, from hitting the
end-to-end incisor relationship, but no to facilitate sizing of the crowns. Once the cantilever arms extending from the lower
more than 8 mm. During the course of crowns are trimmed and sized, they will first molars. This premature contact could
Herbst treatment, our office will make solder occlusal rests and the RPE to the place the maxillary first molars in hyper-
any additional advancements. Every lingual wire. If you would like to use occlusion and prevent the patient from
doctor should have a shim kit that .032” hinge cap attachments on the first completely closing. I will typically expand
allows incremental advancement of the molar crowns, it is a simple process the RPE 28 to 34 turns, depending on the
mandible. In cases with overjets of 12 mm for the laboratory to weld them in place pretreatment maxillary width. I usually
or greater, it is necessary to change the after sizing. The hinge cap brackets see the patient in three weeks to allow
entire rod mechanism to enable adequate require laboratory fabrication of the time for expansion and appliance accom-
mandibular projection without constant RPE with .032” x .032” stainless steel modation. A semirigid light-cure material,
disengagement of the rods. Learning the lingual wires. The beauty of using the Barricaid™ (visible light-cure periodontal
range of activation and timing of rod hinge cap brackets is in simplifying surgical dressing – Calk/Dentsply), is
replacement comes through experience removal of the lingual wire and RPE. applied over the axles to smooth the
and careful questioning of the patient. Their major weakness is the nonrigid contours of the appliance. I give written
I typically advance the mandible in 1 or connection of the RPE to the stainless instructions explaining the expansion
2 mm increments. The maximum forward steel crowns. Since the .032” x .032” process to the parent and patient. With
projection of the mandible should not wire does not fully engage the bracket careful and complete education, we have
exceed an end-to-end incisor relationship. slot, there is a tendency to lose molar experienced very few problems during
It is not necessary or desirable to place the torque as the appliance screw is activated. the early stages of Herbst therapy.
patient in an anterior crossbite; not only Because the RPE and crowns are cemented
is it uncomfortable, but it invariably as one unit, third-order bends can be I schedule the patient for cementation of
requires explanation to the parents and placed in the wire prior to cementation the lower unit three weeks after the initial
patients. One of the common errors in to enhance buccal root torque to the placement of the Herbst. If bonding of
rod length adjustment is to make the male maxillary first molars. brackets is necessary to align the incisors,
portion of the rod mechanism too long. If do it at this appointment. After the lower
the male portion extends more than 2 mm Placement unit is tried in, crimp and contour the
beyond the distal aspect of the fe- Once the Herbst appliance returns from crowns and bands to ensure proper
12 male tube, impingement of the buc- the laboratory, it is a simple process to try continued on page 20
 Cookbook
Bonding,
Indirectly
by William M. Odom, D.D.S. face, natural or artificial, and we can do it
San Mateo, California indirectly with a minimum of doctor time
or patient discomfort.
Composite technology has had a dramatic
impact on orthodontics. The ability to Why, we might ask, if indirect bonding
bond directly or indirectly to natural and is so great, do only 7-10 percent of the
artificial tooth surfaces has changed the orthodontists routinely bond indirectly?
diagnosis and treatment planning of or-
thodontic cases as well as the day-to-day A great many more have tried it, with little
delivery of care. Bonding indirectly to the success.
tooth surface has been an enticing proto-
col from the days of the Sugar Daddy and What went wrong?
Elmer’s glue to the breakthrough in heat-
cured resin technology that we have today. Well, actually some or most of the
brackets fell off.
The promise of bonding indirectly is that
it will result in more accurate bracket And why is that?
placement. It offers the ability to:
• view the tooth from all perspectives. It is really the challenge of technique and
• take into consideration any special training. All bonding has some technique
circumstances, such as incisal and cuspal sensitivity, even with the new hydrophilic
wear and the need for additional rotation, resins. Bonding indirectly is a bit more
tip or torque. sensitive because there are some addition-
• see unusual tooth form, etc. al steps. The preparation of the tooth
Bonding indirectly allows the clinician to surface is the same. How the field is
use his or her experience and skill to place isolated may be different and the prepara-
Dr. Bill Odom received his D.D.S. from the University the bracket in the most advantageous tory work in the lab is different.
of the Pacific in 1964 and a certificate in orthodon- position in a clear, unobstructed field,
tics from the University of Oregon in 1969. He has without concern for patient comfort, After diagnosis and treatment planning,
published some and lectured a bit on the paperless arguably, the most important single doctor
field isolation or fiddling with the bracket
office, imaging in orthodontics and bonding. Dr.
Odom is a member of the orthodontic faculty at UOP
during the gel stage. procedure is getting the brackets on the
and maintains private practices in San Mateo and teeth in the most ideal position. The most
Half Moon Bay, California. Today we can bond from second molar to valuable time in the office is the
second molar on virtually any tooth sur- continued on following page
13
 Dr. Odom
continued from preceding page

doctor’s chairtime. Bonding indirectly

saves the most valuable time in the office
“Bonding indirectly saves the most
and allows the single most important valuable time in the office and allows
procedure to be done more accurately.
the single most important procedure
The following protocol works! Do we
have bond failures? Yes! Do we ever need to be done more accurately.”
to reposition brackets? Yes! Do we have
more problems when a new staff member with the original preadjusted designs, impression material instead of alginate to
is being trained? Yes! However, the ease, gets us one big step closer to meeting the get an accurate model. You do need to use
accuracy and savings in doctor time biggest challenge: making the teeth fit a quality alginate, to mix properly and to
outweighs the additional time spent by together well at the end of treatment. pour immediately. We use Basis™ (Ormco)
the laboratory team. alginate and wrap in a wet paper towel
The great news about Therma-Cure is until poured. A good working model is
The procedure to be described uses a that brackets can be placed by the assis- the first critical step.
single silicone tray. For those of you who tants and repositioned by the doctor • The model really does need to be dry.
previously heard me speak about bonding without concern for the material setting If not, the brackets will not bond well to
indirectly, you may remember that we until heated. All flash can be seen and the model when it is cured and will come
utilized a two-tray, piggyback system removed. The custom base closely loose when you make your tray.
when simultaneously bonding upper and approximates the tooth surface, making • Yes, put three thin coats of liquid foil on
lower arches from second molar to second the bracket-resin, resin-tooth interface the model, allowing it to dry between
molar. That is the neatest procedure as thin as possible. (If days elapse coats. We put a hash mark on the base of
imaginable. It is, unfortunately, a very between placing and repositioning the the model each time a coat is placed to
laboratory intensive procedure. For my brackets, the material will dry out and keep track of the number of coats. If not,
practice, I did not feel that the savings in you will need to place fresh resin on the plaster may adhere to the custom
doctor time warranted the additional lab those brackets that need to be moved.) base, making it harder to microetch. Only
time and costs. However, it is really slick. The end result will be brackets on the the liquid foil residue should remain on
If you are interested in the protocol, call model with no flash and a thin tooth- the base when the tray is removed from
my office at (650) 342-4171 and we will bracket interface. the model. No plaster.
send you an outline. • The human eye finds the center of an
The great news about Custom I.Q. two- object most accurately. That’s why sella is
The recipe that follows has evolved over part, liquid unfilled resin is that it adds the reference point with the least potential
the last couple of decades while I was virtually no thickness to the tooth-bracket for error. It is easier for the assistants to
trying to find an easier and better way to interface. The clinical effect of the pread- place the bracket in the center of the
put brackets on teeth. It is the most user- justed appliance will be expressed more clinical crown than to train them to
friendly recipe to date. It works! It is accurately, the strength of the bond is consider the anomalies of tooth position
simple, accurate, predictable and cost enhanced and posttreatment cleanup is and form to draw reference lines. Yes, the
effective. It requires the least additional simplified. The biggest challenge to doctor can draw the lines and assistants
investment in materials and equipment. mastering bonding is the “Yeah, but...” can learn to draw them, but why?
reflex. If you are inclined to give this • If the position of the tooth does not
The composite breakthroughs are recipe a try, I have a strong recommenda- allow the bracket to be properly placed,
Therma-Cure™, the heat-cured resin that tion: suspend disbelief! This really is first position the bracket to level the
forms the custom base between the model “cookbook.” Before you start changing tooth. Once the tooth is level, the bracket
and the bracket, and Custom I.Q.™, the the recipe, master this way first. Then can be repositioned to align it.
two-part, unfilled resin that forms the you can change the ingredients, one • The thermostat on the toaster oven is
interface between the custom base and thing at a time. not accurate. Use a thermometer. What do
the tooth surface. The appliance break- you expect for $40?
through is Orthos™, * Ormco’s recent Tips, Secrets and FAQ’s • No, you do not need to use both light-
improvement in the field of preadjusted • Start by bonding indirectly from second bodied and heavy-bodied silicone impres-
orthodontic appliances. The improved bicuspid to second bicuspid. Wait until sion materials. The heavy body alone is
accuracy of bonding indirectly, combined that is mastered before you try second fine, but the tray needs to be trimmed as
with an appliance that has solved molar to second molar. described.
14 most of the problems associated • No, you don’t need to use a silicone • Honestly, the assistants will make a
*Products identified as “Orthos” are distributed in Europe as “Ortho-CIS.”
better tray if they are trained to place brackets to be removed when the tray is the bracket base. The conditioned but
small pinches of the silicone over the removed. unsealed enamel will begin remineralizing
brackets instead of making a long roll • If trimmed as suggested, the tray does as soon as it is exposed to the saliva.
and laying it over the brackets. It will not need to be cut or sectioned with a • When bonding to gold, amalgam or
have fewer voids and an adequate bulk blade to remove it. stainless steel, microetch for two to four
of material over the brackets to resist • If the field is isolated properly, the entire seconds with 50-micron aluminum oxide
deformation when you place and hold it arch can be bonded from second molar to from Danville Engineering and apply an
in the mouth. second molar at one time without section- intermediate resin. We use Enhance™ by
• Adding a handle to the tray will keep ing the tray and doing one side at a time. Reliance.
your fat little fingers away from the teeth • No, you don’t have to pumice the teeth; • When bonding to porcelain, microetch
and allow an unobstructed view of the a rubber cup is sufficient. If the teeth are two to four seconds with 50-micron
arch when placing the tray. Always mark really dirty, put the patient on a hygiene aluminum oxide. Condition for one
the midline on both the tray and the program before bonding. minute with 37 percent phosphoric
handle. • I recommend etching from 15-30 acid; do not rinse. Apply two coats of
• Making the tray the day that it is to be seconds. Ormco’s Porcelain Primer (silane), rinse
delivered assures that the silicone will not • Failure to rinse and dry thoroughly thoroughly, dry thoroughly and continue
dry out and will remain supple, making reduces bond strength. with indirect technique.
removal easier. • We dry with warm air and don’t use
• If you don’t soak the tray long enough air/water spray because of the high proba- If you would like to have a separate copy
for the tray to separate easily, plaster may bility of having moisture (or oil) in the air of the step-by-step pages with illustrations
adhere to the custom bracket base. supply. Yes, we do have a top-of-the-line to use for training or to put up in the lab,
• Look carefully at the picture of the dental compressor with an air dryer. call Ormco at (800) 854-1741, Ext. 7573,
trimmed tray. Exposing the wings of the • Thin coats of Custom I.Q. are applied to or (714) 516-7573 and they will send an
brackets and making small cuts between the tooth surface and to the bracket base extra copy of Clinical Impressions.
each wing and facially make removing only. Do not coat the entire inside of the
the tray a less threatening event. A bulky, tray with the resin – only the bracket Remember, the hardest part of the cook-
under-trimmed, rigid tray may cause the itself. Polymerization will occur under book is following the recipe.

Dr. Odom’s Indirect Bonding Recipe

The Ingredients
Lab Procedure Clinical Procedure
• Accurate Stone Models • Basis™ Alginate (Ormco)
• Liquid Foil and Brush • Glasses and Bib
• Disinfectant • Cheek Retractors (Nola™)
• Mixing Pad and Scaler • Rubber Cup (Denticator™)
• Flat Toothpicks • Water Syringe and Saliva Ejector
• Bracket Holder • Dappen Dish, Cotton Pliers, Pledgets
• Brackets (Ormco) Mixing Pad and Brushes
• Therma-Cure™ (Reliance) • 37% Phosphoric Acid
• Toaster Oven w/Thermometer • Custom I.Q.™ (Reliance)
• Timer • Enhance™ (Reliance) The Impression
• Silicone Impression Material: • Porcelain Conditioner (Ormco) • Polish teeth w/Denticator. Rinse with
Citricon® – Heavy Body Base • Dri-Angles® (Dental Health Products) mouthwash.
and Accelerator (Kerr) • Warm-Air Dryer • Mechanically spatulate a good quality alginate.
• Bowl and Hot Water • Plastic Conditioner (Reliance) • Take an accurate impression that shows
• Bard-Parker Blade • Silicone Tray w/Brackets alveolar anatomy.
• Microetcher • Timer • Spray with disinfectant and pour
w/50 Micron Aluminum immediately.
Oxide (Danville Engineering) continued on following page
Dr. Odom
continued from preceding page

The Model • Apply Therma-Cure to base.

• Pour w/stone – not plaster. • Be certain to thoroughly fill
• Mix under vacuum to mesh with resin.
avoid bubbles and voids.
• Trim back of model parallel Bracket Placement
to occlusal plane to make • Assistant places bracket on
bracket placement easier tooth as doctor prescribes.
to visualize. • The human eye is very
Therma-Cure adept at finding the center
• Heat-cured resin allows
of things.
assistant to place brackets
and leave until convenient
for doctor to adjust position.
• Brackets remain adjustable
until heat cured. Eventually,
the resin will dry out. oven, turn off the heat and
• If working model sits for allow to cool.
several days, add new
Therma-Cure if major
repositioning of any brack-
• Assistant places bracket in Custom Silicone
the center of the tooth. Tray
ets is needed.
• Press firmly and remove all • Use Citricon.
the flash. • Heavy Body Citricon is the
Model Preparation • Set model aside for doctor to
• Already coated with three only material needed if the
• Thoroughly dry model! reposition as needed. tray is made and trimmed
coats of liquid foil.
Bench drying overnight is properly.
best, or you can place under Doctor Repositions
lamp or in oven for a short
NO Brackets as Needed
time. Do not completely • The bracket is in the center
desiccate the plaster. REFERENCE of the tooth, all cleaned up,
• Remove any air bubbles at without any flash.
gingival margin that might LINES
interfere with bracket
placement. • Do not draw reference lines.
• Coat three times w/liquid It is easier to train staff to
foil; dry between coats. Put place bracket in the middle
hash marks on back of mod- of the tooth than it is to • Mix putty with accelerator
el to track number of coats. draw appropriate reference using fingers (will stick to
lines. gloves).
Materials for Lab • The doctor can use a gauge, • You can now reposition the • If the mix is setting too
Procedure if desired, when deciding bracket with all those special quickly, stop, make another
• Therma-Cure by Reliance. precisely where this bracket considerations that each mix and add on (next time
• Brackets – Orthos™* by should be on this patient. patient brings. use less accelerator).
Ormco.
• Bracket holder. Bracket Preparation The Cure Fabricating
• Flat toothpicks. • Microetch bracket base • Preheat toaster oven to the Tray
• Pad and scaler. where appropriate. 325°-350°. • Place small pinches of
• If curing a number of Citricon around each
models at the same time, bracket to prevent voids.
increase the temperature. • Build a wedge-shaped bulk
• Cure for 20 minutes at 325°; over the brackets.
this causes the resin to cure. • Cover the occlusals and
• Open the door of the toaster linguals of the teeth.
 • Do not remove the Therma- Preconditioning
Cure base! Preparation
• Mark the centerline of the • Prophy teeth with
tray to help orientation Denticator or rubber cup
when seating. and water only.
Clinical Setup
minutes or until tray comes for IDB
off model easily. • IDB tray
• Separate tray from the • I.Q. Sealant A & B by
model. Reliance (very short gel time
and specifically for indirect
Trimming the Tray bonding).
• Use Bard-Parker blade to • Glasses, cotton pliers,
trim material from base. pledgets, Dri-Angles,
• Extend tray one tooth distal bonding brushes, plastic
• Carefully expose each • Rinse thoroughly, 10-15
to the last tooth to be primer and Denticator.
bracket wing and hook. seconds/tooth. You do
bonded unless bonding 7-7;
• Trim lingual of tray material not need to use pumice or
this stop assists in seating
above the tissue margin. polyacrylic acid unless the
the tray accurately.
teeth are covered with
plaque.
Add a Handle
• After covering the teeth,
use a sectioned tongue blade
Conditioning
to fabricate a handle. the Teeth
• Condition each tooth for
• Tooth conditioner, 37% 15 seconds, no more than
phosphoric acid. 30 seconds.
• Warm-air dryer, cheek
retractors and water syringe.

Clinical Procedure
• Place glasses.

• If the material is set, the

handle can still be added.
• Remove interproximal
• The handle keeps your
interferences that might • Dab the surface with
fingers away from the tray
interfere with seating of tray, conditioner; don’t wipe it.
and the teeth while seating
e.g., severely rotated or • You need to move very
the tray, thus avoiding
displaced teeth. quickly to get from 7-7 and
possible contamination;
• Make a small cut between start rinsing within the
it also makes it easier to see
the wings and to the facial of 30-second limit.
the arch.
each bracket. • Conditioning longer does
Removing the not increase bond strength.
Finishing the Tray
Tray From the • Microetch the custom base Rinsing the Teeth
Working Model to remove the liquid foil • Rinse the surfaces of all
• Soak in hot water for 10-15 only. teeth very quickly from side
• Place cheek retractors to side.
(preferably from Nola – they • Then go back and rinse each
are easier to remove after the tooth for another 10-15
doctor places the tray). seconds.
• Place Dri-Angles.
continued on following page
17
 Dr. Odom
continued from preceding page

• If the interproximal and

facial cuts have been made
properly, the tray will come
off easily and the brackets
won’t.

Ready to Place
• Thoroughly! Thoroughly! allowed to air dry for at least together as the doctor holds the Archwire
Thoroughly! Rinse each 60 seconds. the tray in place. (We start with a 35° Copper
tooth! • The doctor paints a thin coat • Pressure is applied to the Ni-Ti™.)
• Leaving conditioner on the of I.Q. Sealant B onto the tray from the facial and
tooth surface will decrease custom base while the occlusal as far back as there
bond strength. assistant is painting the are bonds being placed.
surfaces of the teeth. • The doctor holds the tray
• Do not cover the silicone for one minute and the
tray with sealant or allow assistant waits another
the sealant to pool in the three minutes before
tray. removing the tray.

Tray Placement Tray Removal

• As the doctor paints the • Remove the Dri-Angles.
Warm-Air Dry sealant, the assistant gives • Starting at the second molar,
• Thoroughly! Thoroughly! the patient instructions the tray is teased down with
Thoroughly! Dry each tooth about what is to happen so a scaler around the arch
with a warm-air dryer! they don’t open their mouth perimeter.
• Moisture contamination is before the doctor is ready to
the primary culprit in bond place the tray.
failures, both direct and
indirect.
• Compressed air from your
air syringe may have water
vapor or oil vapor as a
contaminant.

Tooth Preparation
• Paint a thin coat of I.Q. • The assistant controls the
Sealant A on the face of each lips by pushing up when
tooth. seating an upper tray and
pulling down for a lower
tray.
• The saliva ejector is
removed. To avoid contami-
nation, remove over the
upper teeth when placing
a lower tray and over the
lower teeth when placing
Tray Preparation an upper tray.
• When you hear the warm- • The doctor places the tray.
air dryer, it’s time to move
toward the chair. After Tray
• Each custom base has been Placement
previously primed with • The cheek retractors are
plastic conditioner and removed by squeezing them
18
Dr. Wildman
continued from page 5

maximum performance from the new

wires, it is important to get full engage-
ment as soon as possible. Steel ties are to The Wildman TwinLock Bracket-
be used with discretion. As they are
cinched, they bind the system, creating a Revolutionary Design Speeds Treatment
force that tends to pull the bracket off the
tooth. We call this “cinch and shock.” The While Reducing Chairtime & Bond Failure
Wildman TwinLock allows the operator to
seat the wire in the slot without binding
and, at the same time, to lock the slider in Quicker Treatment: Wildman
place. The seating force can then be gently TwinLock’s superior, patented mecha-
released. We call this “seat and lock,” nism locks in the archwire, reducing
as opposed to “cinch and shock.” The friction 40 to 50 percent by eliminating
archwires are then free to work out to their steel ligature ties. An additional advan-
full potential (Figures 17-18). Early, full tage is that, unlike elastomeric ties,
engagement requires a strong locking it doesn’t deform, allow the archwire
mechanism. During the design phase, to protrude outside the slot and
we tested for strength by locking in a full- produce even higher friction. Wildman
sized superelastic wire that would logically TwinLock’s labial slider creates a solid
be used as a starting wire, and then we wall that does not intrude into the slot,
bent it at a right angle (Figure 19). We permitting archwires to work out to advanced bonding base in orthodontics.
continued on following page their full potential. Ideally suited for OptimeshXRT™ is an improved version
the application of variable modulus of Optimesh, a proven performer since
mechanics, the Wildman TwinLock™ 1992 in reducing bond failures and
provides a solid channel free of tie emergency office visits by providing an
wire and elastomeric binding. Easy additional 35 percent bond strength to
engagement of shape memory and mesh bases.
superelastic wires permits the early use
of larger rectangular wires and allows The Mini Diamond® Twin
for extended intervals between visits. Advantage: Unlike other self-locking
brackets, the Wildman TwinLock
Reduced Chairtime: As well as requires no sacrifices. You get the
Figure 17. Patient K.B.: Initial bonding on
eliminating unnecessary office visits, patented Mini Diamond rhomboidal
June 19, 1997. Wildman TwinLock design the Wildman TwinLock greatly shape that facilitates bracket placement.
allows full engagement of a 40° .019 x .025 reduces the time required for each It’s a true twin design that provides twin
Copper Ni-Ti archwire (.022 slot). visit. Independent university studies bracket rotational control and accom-
Reproximation of lower anteriors was done confirm that archwire changes are modates power chain. And when the
at this visit. three to four times faster than conven- occasion arises, you have the ability to
tional ligation. The slide mechanism use elastomeric or steel ties.
is easy to open and close, requiring
no special instrumentation. Additional benefits include improved
hygiene and patient comfort – a
Fewer Emergencies: “Seat and lock” smooth, clean labial surface and no
archwire placement avoids the “cinch requirements for plaque-accumulating
and shock” effect of steel ligature ties elastomeric ties or gingiva-irritating
and the resulting tendency to pull the steel ligatures. Wildman TwinLock is
bracket off the tooth. The slider locks available in the Level Arch Modern
securely in place, unlike previous Prescription (Modified Roth) in .018
Figure 18. Patient K.B.: Second appointment self-locking brackets subject to frequent and .022. See this major advancement
on July 31, 1997. Reduced friction of the accidental archwire disengagement. in orthodontic treatment in Dallas!
ligature-free Wildman TwinLock provides The Wildman TwinLock bracket also Order information is provided on page
more efficient tooth movement compared to provides the latest, most technically H of the Center Section.
traditional twin brackets.
Dr. Wildman Dr. Smith
continued from preceding page continued from page 12

retention. The cantilever arms may • Deliver upper portion of Herbst with
need minor adjustment, using a large RPE
three-prong headgear plier (AEZ/Ormco • Give instructions on RPE and number
#803-0450). A common emergency is of turns
impingement of gingival tissues under • Place separators mesial to the
the forward cantilever axle area. Placing mandibular first molars
occlusal rests on the primary second • Oral hygiene instructions, toothbrush
molars and properly adjusting the kit, fluoride Rx and office T-shirt
cantilever arm will help prevent this.
Appointment #3 (after 3 weeks) –
Figure 19. Strength testing included locking After the lower portion is cemented, 90 minutes
in full-sized superelastic wires and subject- place and secure the rods with screws. To • Deliver lower portion of Herbst
ing lock to stress of 90° bends. ensure screw retention, apply Ceka Bond® • Add Herbst rods
(Preat Company 800-232-7732) to the • Bond brackets to maxillary and
insisted, as a design constraint, that the screw threads prior to insertion and tight- mandibular central and lateral incisors
lock meet the archwire in this severe test. ening. Again, Barricaid is applied over the • Place either .016 Ni-Ti ™ or .016 x .022
After years of designing, testing, redesign- cantilever axle for patient comfort. 35°C Copper Ni-Ti™ archwires
ing and retesting, our lock meets the • Review oral hygiene
strength goal which we laid down at the Treatment Protocol
beginning of the project. Other than the extraction case, the treat- Appointment #4 (after 12 weeks) –
ment protocol for the Type I Herbst is the 15 to 30 minutes
As treatment progresses, when full-sized same for most cases. The usual duration • Check Herbst and resecure archwires
archwires are locked down completely in of Herbst therapy is 12 to 16 months.
the variable modulus technique, they are I rarely remove the Herbst prior to 12 Appointment #5 (after 12 weeks) –
free to work out over long periods of time; months. I feel the appliance must exert 45 minutes
but they are also not encumbered by ties. its influence for a sufficient duration to • Add 2 mm shims as needed to advance
Wildman TwinLock becomes a tube, so sustain the A-P correction. Additional mandible and align midlines
they can work out without the inherent prospective randomized studies evaluating • Remove RPE
friction produced by ties. A study by treatment outcomes and efficiency are • Place .019 x .025 35°C Copper Ni-Ti or
Dr. John Voudouris at the University of needed to answer the questions of timing TMA® archwires
Toronto showed that treatment time is and duration of Herbst treatment.
significantly reduced in this situation. Appointment #6 (after 10 weeks) –
The following is a typical treatment 30 minutes
The Wildman TwinLock – protocol with the Type I Herbst. The time • Add shims as needed
Variable Modulus Revolution allocated for each appointment includes: • Resecure archwires
When we compare the efficiency of the old, • Seating of the patient
standard variable cross-section approach • Performing the procedures Appointment #7 (after 12 weeks) –
with the new Wildman TwinLock-variable • Scheduling 45 minutes
modulus technique, we have to conclude • Treatment progress review with • Place .021 x .025 TMA archwires
that we are experiencing a true efficiency responsible party • Add shims as needed
revolution. In the new technique, we often • Cleanup and sterilization
place a full-size, shape memory wire, such Appointment # 8 (after 8 weeks) –
as 35°C Copper Ni-Ti™. Dr. Chapman Appointment #1 – 90 minutes 60 minutes
reports he is routinely into full-sized steel • Records • Remove Type I Herbst
or TMA® archwires after six months. The • Consultation contract signed • Fit bands for lingual holding arches
frequent archwire changes in the old • Take upper and lower full arch if necessary
leveling process are a thing of the past. impressions for indirect fabrication of • Take full arch impressions for indirect
Archwire changes are reduced dramatically. the Type I Herbst fabrication of lingual arches
Treatment time is reduced dramatically. • Place separators mesial to maxillary
This is certainly the profile of a revolution first molars Appointment #9 (after 1 week) –
in productivity, and I’m proud to partici- 45 minutes
pate by offering the Wildman Appointment #2 (after 3 weeks) – • Cement lingual holding arches
20 TwinLock System to the specialty. 60 minutes • Consult with patient and parents to
 intrusion is due to stalling of the normal
vertical eruption of the first molars rela-
tive to the continued development of the
adjacent teeth and bone. I have noticed
few instances where the mandibular plane
angle (relative to S-N) was increased.
Therefore, if the Type I Herbst is used in
the late mixed dentition and is removed
near or at the time the primary second
molars are lost, the openbite can be closed
substantially. If lower primary second
molars are still present or loose at the
end of Herbst therapy, they should be
removed or vertically reduced to allow
closure of the bite. With vertical closure,
the mandible autorotates, reducing the
A-P discrepancy (see openbite case on
pages 10-11).

Figure 10. Typical openbite between first molars following Type I Herbst therapy. To take full advantage of the autorotation
of the mandible, it is essential to under-
review treatment objectives and explain frustrating and time consuming to treat. stand how the Herbst appliance influences
the rest period and need for final phase Initiating the Type I Herbst therapy at the position of upper incisors if they are
of corrective treatment the appropriate time has been the most connected by an archwire to the crowns
• See the patient on a six-month recall positive addition to my armamentarium on the first molars. Due to the posterior
basis after lingual holding arches are for treating these cases. vertical directional force exerted by the
placed – typical duration of the rest Herbst rods, the maxillary first molars are
period is 6 to 18 months, depending on Why is the Type I Herbst such an effective moved distally. A clockwise rotational
the developmental stage of the patient openbite corrector? Because of their moment is directed to the first molars that
occlusal height, the stainless steel crowns exerts a lingual and extrusive force to the
Case Example infringe on the freeway space, altering the maxillary incisors. This change in the
One the most difficult malocclusions to vertical dental and skeletal development. maxillary incisor positions reduces the
treat is the Class II openbite case. Over the Additionally, the posterior-superior forces autorotation of the mandible after Herbst
years, I have used numerous appliances, generated by the appliance are of consid- removal. To ensure maximum autorota-
including headgear, elastics, bite blocks erable assistance in closing the bite. When tion of the mandible, specific mechanics
and removable functional appliances, the Herbst appliance is removed, invari- should be directed to the maxillary
to treat openbites. The success of each ably there is an openbite between the incisors to counteract the lingual extrusive
appliance was invariably linked to patient permanent first molars (Figure 10). After movement. It is usually necessary to
cooperation and compliance. Therefore, tracing many lateral head radiographs intrude and move the incisors labially
I found openbite cases to be the most following Type I therapy, I have found the continued on following page

Figures 11-13. Maximizing the effectiveness of the Type I Herbst in openbite cases.
 Dr. Smith
continued from previous page

lingual arch. I typically do not use the

Nance appliance due to the tissue irrita-
tion commonly found with this form of
retainer. A lingual arch made from .045”
stainless steel soldered to the first molar
bands provides the most dependable and
durable retention. I do not use removable
retainers because of the potential for
relapse in case of noncompliance. In the
maxillary arch, the lingual wire is bowed
inward toward the palatal midline to
allow space for the erupting bicuspids
Figures 14-15. Brackets and continuous archwires impede
and canines. Maintaining arch length
the distal drift of the bicuspids and canines during Herbst
treatment.
during the eruptive phase is essential to
allow the distal drift of the bicuspids
(Figures 11-13). In many Class II open- used on the maxillary incisors to establish and canines3. During the rest period, the
bite cases, due to excessive gingival proper torque and A-P position. Once patient is seen every six months. Usually,
exposure, the maxillary incisors need the incisors are in the desired position, I will wait for the eruption of all perma-
intrusion to improve the patient’s smile. remove the brackets and continue the nent second molars prior to initiating the
Herbst therapy. Fewer bonded attach- final phase of treatment. If I have accom-
There has been a great deal of confusion ments mean less potential for emergencies plished my treatment goals with the
concerning the placement of vertical stops and decalcification, and the therapeutic Herbst therapy, the second phase of
on second molars and bicuspids. Due to affect of the Herbst is optimized. The treatment should take 8 to 12 months.
the ability of the Type I Herbst to alter first simplicity of the designs I am presenting
molar eruption, all openbite cases should is why Herbst therapy is efficient and not Have you ever seen a second molar erupt
have occlusal rests on the second molars labor intensive. into a poor position after you have done
to impede eruption. If it is desirable to a beautiful job aligning the other teeth?
stall the eruption of either the first or Retention To align the second molars requires
second bicuspids, stops can be placed If Herbst therapy is timed properly, the additional appointments and materials.
on one or both teeth. I have found rest period from the time the appliance is The greatest cost is the disappointment
the Type I Herbst to be best suited for removed until full-banded and bonded experienced by the patient due to the
dolicofacial openbite malocclusions therapy begins should be 6 to 12 months. extended treatment time. Not a practice-
and that Types II and III work best on Occasionally, the bicuspids and canines building experience! Efficiency is based
mesiofacial and brachyfacial patterns. erupt during Herbst therapy and create on properly-timed treatment3,4.
If there is a normal or excessive overbite, the desired Class I occlusion. In these
occlusal rests should not be used on cases retention is not necessary. However, Placing full braces immediately after
second molars or bicuspids. Some propo- if the bicuspids and canines are in the Herbst therapy prior to the full eruption
nents of Herbst therapy bond wires on eruptive phase, some form of retention is of the bicuspids and canines can result
the occlusal surfaces of bicuspids and necessary to maintain the molar relation- in significant loss of A-P correction.
molars. In my opinion, these wires are ship and arch length. The most common The maxillary molars tend to drift
unnecessary, time consuming to place form of retention in my office is the fixed mesially if there is insufficient dental
and remove, and complicate the Herbst
design. One of the most desirable
sequelae of the distal movement of the “…Dr. Hans Pancherz determined that it is
molars is the autonomous distal drift of
the bicuspids and canines. Placing brack- best to initiate Herbst therapy in the late mixed
ets, bonded occlusal wires or acrylic
impedes the distal drift of these teeth
dentition. His studies suggest that good dental
(Figures 14-15). intercuspation at the end of Herbst therapy
The objective is to use the fewest bonded enhances the stability of the correction. My
attachments during Herbst therapy.
22 Bonded attachments are primarily clinical experience supports these findings.”
intercuspation in the buccal segments. Also, I will cover the utilization of the bite jumping on the dentofacial complex:
This is particularly true if retraction of Type II and III Herbsts. Hopefully, the A follow-up study after Herbst appliance
the bicuspids and cuspids is initiated. information provided in this article will treatment of Class II malocclusions,
If retraction is necessary, it should be increase the usefulness of Herbst therapy Eur. J. Orthod. 3: 49-60, 1981.
done while the Herbst is in place to in your practice. 3. Smith, J.: How to improve practice
provide molar anchorage. The only time efficiency and profitability, Clinical
I use Herbst-supported retraction References Impressions, Vol. 4, No. 4: 6-21, 1995.
mechanics is in extraction cases and adult 1. Hilgers, J.: Hyperefficient orthodontic 4. Smith, J.: A treatment philosophy…that
treatment. treatment using tandem mechanics, really works, Clinical Impressions, Vol. 5,
Seminars in Orthodontics, Vol. 4, No. 1: No. 1: 2-25, 1996.
In future articles I will discuss the use of 17-25, 1998.
the Type I Herbst in extraction cases. 2. Pancherz, H.: The effect of continuous

Allesee Orthodontic Appliances (AOA)

Go to the Experts for Dr. Smith’s Three Herbst Designs

Type I Type II Type III

AOA has established itself in the forefront of the steadily • Instructions for delivering and removing the appliance.
increasing trend to Herbst therapy. AOA provides Dr. Smith’s • Treatment sequence with suggested activations.
Type I, II, and III Herbst appliances, as well as the various
designs recommended by other leading authorities. To To discuss the Smith Herbst designs with the experts or to
minimize problems and to maximize the benefits of Herbst request your copy of the book, call AOA at (800) 262-5221
noncompliance therapy in your practice, take advantage of or fax to (414) 886-6879. To discuss or order bite-jumping
AOA’s design expertise in construction of bite-jumping components for your laboratory, for CBJ or traditional
appliances. As a service to the specialty, AOA also provides appliances, call Ormco at (800) 854-1741 or (714) 516-7400,
Clinical Management of Crown Bite Jumping Herbst Appliances, or call your Ormco distributor. Ormco is also the source for
which is available upon request. The book includes: the AEZ Chastant Crown Removing Plier, the AEZ Crown
• Various designs used by the leading authorities. Slitting Plier and the AEZ Large Three-Jaw Headgear Plier
• Prefabrication and preparation for the Herbst. (see order information on page H of the Center Section).

23
 Lecture/Course Schedule at a Glance – Through October 1998
Date Lecturer Location Sponsor, Contact and Subject
6/1-2 Joe Mayes Paris, France AOSM; Josiane 331 4859 1617; STM & CBJ Typodont Course*
6/3 Jim Hilgers San Francisco, CA PCSO; Lecture— “The Era of Hyperefficient Orthodontics”
6/5-6 Joe Mayes Lisbon, Portugal AOSM; Josiane 331 4859 1617; STM & CBJ Typodont Course*
6/6-7 Kyoto Takemoto Tokyo, Japan Dr. Takemoto; R. Kishi 81 3 3945 0065; In-Office Lingual Typodont Course*
6/12-13 Barbara Brunner Orange, CA Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“Executive Presentations”
6/18-20 ESLO Rome, Italy Eur. Soc. of Ling. Ortho.; Dr. Scuzzo 39 6 5685852; Third Eur. Ling. Ortho. Conf.
6/19 Jerry Clark Montreal, Canada Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“Marketing: Strategies & Tactics”
6/26-27 Terry Dischinger Lake Oswego, OR Dr. Dischinger; Kelly (503) 557-3509; “In-Office Comprehensive Hands-On Herbst Training”*
6/28-30 Wick Alexander Tokyo, Japan Ormco Japan; R. Kishi 81 3 3945 0065; Alexander Discipline Comprehensive*
6/29-7/1 Didier Fillion Paris, France Dr. Fillion (Fax) 33 1 47551833; In-Office Lingual Ortho.: Typodonts, Lab & Clinic*
7/1-2 Wick Alexander Kamakura, Japan Ormco Japan; R. Kishi 81 3 3945 0065; Alexander Discipline Advanced
7/1-5 Luis Batres Panama City, Panama Dr. Batres (507) 264-3920; Alexander Discipline Comprehensive*
7/2-3 Wick Alexander Kamakura, Japan Ormco Japan; R. Kishi 81 3 3945 0065; ADSCJ Annual Meeting
7/6-8 Didier Fillion Paris, France Dr. Fillion (Fax) 33 1 47551833; In-Office Lingual Ortho.: Typodonts, Lab & Clinic*
7/17-18 Duane Grummons Spokane, WA Dr. Grummons; Kaci (310) 822-8711; “Nonextraction Orthodontic Innovations”
7/23-25 Stanley Braun Milwaukee, WI Marquette Univ.; Dr. Ferguson (414) 288-7473; Comprehensive Biomechanics
7/24 J. Piankoff/B. Brunner Seattle, WA Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“Round Peg...Round Hole”
8/27 Michael Swartz Wellington, NZ NZAO Annual Conf.; Dr. Taylor 64 4 385 7213; Ortho. Bonding—Achieving a 97% Success Rate
8/28 Michael Swartz Wellington, NZ NZAO Annual Conf.; Dr. Taylor 64 4 385 7213; Optimal Use of Titanium Archwires
8/28 K. Black/B. Brunner White Plains, NY Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“Just Say It!”
8/29 Michael Swartz Wellington, NZ NZAO Annual Conf.; Dr. Taylor 64 4 385 7213; “Fact or Friction,” “Taking Quality Photographs”
8/31 Michael Swartz Sydney, Australia Ormco Pty; J. Doon 612-9870-7344; Use of Titanium Archwires
9/2 Michael Swartz Brisbane, Australia Ormco Pty; J. Doon 612-9870-7344; Use of Titanium Archwires
9/4-5 Joe Mayes Gainsville, FL U. of FL Orthodontic Alumni Mtg.; Barbara Jones (352) 392-4355; Lecture—STM & CBJ
9/13-15 Wick Alexander F. Dei Marmi, Italy Ormco Biaggini; Roberta 0039 187 509575; Alexander Discipline Comprehensive*
9/16-17 Wick Alexander F. Dei Marmi, Italy Ormco Biaggini; Roberta 0039 187 509575; Alexander Discipline Advanced
9/18 Wick Alexander F. Dei Marmi, Italy Ormco Biaggini; Roberta 0039 187 509575; Alexander Study Club
9/18 Rebecca Poling Orange, CA Ormco; Katie (800) 854-1741, Ext. 7573; Staff Seminar—Quality Records*
9/19 Rebecca Poling Orange, CA Ormco; Katie (800) 854-1741, Ext. 7573; Staff Seminar—Quality Bonding & Banding Procedures*
9/23 Joan Garbo Indianapolis, IN Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“More Than Hired Hands”
9/24-26 Wick Alexander Arlington, TX Dr. Alexander; Brenda (817) 275-3233; Alexander Discipline Comprehensive*
9/25 Jim Hilgers San Francisco, CA Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“The Era of Hyperefficient Orthodontics”
10/2 Joan Garbo New Orleans, LA Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“More Than Hired Hands”
10/3 Terry Dischinger Washington, DC MD Ortho Society; Duane (301) 236-0600; “Edgewise Herbst Appliance”
10/8-10 Mario Paz Beverly Hills, CA Dr. Paz; Shelly (310) 278-1681; Hands-On Lingual Ortho. with Typodonts & Patients*
10/9 David Sarver Washington, DC Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—Maximizing Appliance Systems for Efficiency
10/9 Jim Hilgers Sao Paulo, Brazil Paulista Society of Ortho.; “The Essence of Practical Orthodontics”
10/16 J. Piankoff/B. Brunner Houston, TX Ormco; Katie (800) 854-1741, Ext. 7573; Seminar—“Round Peg...Round Hole”
10/16-17 Terry Dischinger Lake Oswego, OR Dr. Dischinger; Kelly (503) 557-3509; “In-Office Comprehensive Hands-On Herbst Training”*
10/19 Wick Alexander Asheville, NC South. Ortho. Society; Sharon Hunt (800) 261-5528; Lecture—Alexander Discipline Advanced
10/24-25 K. Takemoto/G. Scuzzo Munich, Germany Ormco Europe; 41 1 3065111 (Fax 41 1 3065151); Lingual Orthodontics
10/27-28 K. Takemoto/G. Scuzzo Vigevano, Italy Biaggini Ormco Italia; 39 187 509575 (Fax 39 187 599076); Lingual Orthodontics
10/30-31 K. Takemoto/G. Scuzzo Madrid, Spain Kalma SA; 34 1 3802383 (Fax 34 1 7784864); Lingual Orthodontics
*Typodonts and/or Participation
For additional information on any course, please call the contact number shown or (international doctors) Ormco distributor.

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