Maxillary molar distalization or mandibular enhancement: A cephalometric comparison of comprehensive orthodontic treatment including the pendulum and the Herbst appliances

doi:10.1067/mod.2003.7

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 123, Issue 2, February 2003, Pages 108-116

https://doi.org/10.1067/mod.2003.7 Get rights and content

Abstract

Several methods of Class II treatment that do not rely on significant patient compliance have become popular during the last decade, including several versions of the Herbst appliance and the pendulum or Pendex molar-distalization appliances. Yet, these 2 general approaches theoretically have opposite treatment effects, one presumably enhancing mandibular growth, and the other moving the maxillary teeth posteriorly. This study examined the treatment effects produced by 2 types of the Herbst appliance (acrylic splint and stainless-steel crown) followed by fixed appliances, and the pendulum appliance followed by fixed appliances. For each of the 3 treatment groups, lateral cephalograms were analyzed before the start of treatment (T1) and after the second phase of treatment (T2). Patients were matched according to age and sex. The comprehensive treatment time for the pendulum group was 31.6 months, and the acrylic and crowned Herbst groups were treated for 29.5 months and 28.0 months, respectively. Overall from T1 to T2, there were no statistically significant differences in mandibular growth among the 3 groups. Skeletal changes accounted for a larger portion of molar correction in the Herbst treatment groups than in the pendulum group. Patients in the pendulum group had an increase in the mandibular plane angle. Conversely, the mandibular plane angle in patients treated with either Herbst appliance closed slightly from T1 to T2. At T2, the chin points (pogonion) of patients in both Herbst groups, however, were located slightly more anteriorly than were the chin points of the pendulum patients. It is likely that the slight downward and backward rotation of the mandible occurring during treatment in the pendulum patients accounted for much of this difference. The treatment effects produced by the 2 types of Herbst appliance were similar at T2, in spite of their differences in design. It is important not to generalize the findings of this comparison beyond the appliance systems evaluated. The 2 general approaches we evaluated involved a substantial dentoalveolar component in the treatment of Class II malocclusion. A comparison of a molar-distalizing appliance such as the pendulum with other types of functional appliances might yield differing results. (Am J Orthod Dentofacial Orthop 2003;123:108-16)

Section snippets

Patients and methods

This is a retrospective study designed to evaluate cephalometrically the skeletal and dentoalveolar effects of Class II correction obtained by 3 two-phase treatment modalities. The first treatment group consisted of 30 patients treated with the stainless-steel crown Herbst appliance.²⁷ The outcome of these treatments was compared with that in 30 patients treated with the acrylic-splint Herbst appliance³⁷ and in 30 patients treated with rapid molar distalization with the pendulum appliance.⁵

Results

The crown Herbst group, the acrylic-splint Herbst group, and the pendulum group did not show any significant differences with the Hotelling T² test (F = 1.42; P = .103). The 3 groups generally were similar at T1, and there were no significant differences as to molar relationship, mandibular length, mandibular position, maxillary position, and vertical skeletal relationships (Table III).The crown Herbst group had a greater overbite of 1 mm and a smaller maxillomandibular differential⁴¹ of 2 mm

Discussion

This study compared the treatment effects achieved in 3 two-phase Class II treatment modalities. One method incorporated the pendulum appliance⁵ intended to distalize the maxillary molars. The other 2 methods integrated the bite-jumping mechanism of Herbst³ into 2 types of Herbst appliances. On the surface, both general approaches seemingly had differing effects on the skeletal and dentoalveolar structures of the craniofacial complex. The results of this study, however, showed that the

Conclusions

This study examined the treatment effects of the stainless-steel Herbst appliance followed by fixed appliances, the acrylic-splint Herbst appliance followed by fixed appliances, and the pendulum appliance followed by fixed appliances.

There were no statistically significant differences in mandibular growth among the 3 treatment groups. The Herbst patients, however, had slightly greater mandibular projection than did the pendulum patients, who had an increase in the mandibular plane angle during

Acknowledgements

The authors thank Dr Richard Walker, president of Dentofacial Software, for customizing the Dentofacial Planner software for this study; Drs James Hilgers, John Damas, Brad Porter, Larry Spillane, Mart McClellan, Robert Smith, and David Snodgrass for contributing patient records for this project; and Dr Lysle E. Johnston, Jr, for his help and advice in preparing this manuscript.

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2023, American Journal of Orthodontics and Dentofacial Orthopedics
This study aimed to quantify the outcomes of adolescent patients with Class II malocclusion treated with the Carriere Motion 3D Appliance (CMA) combined with full fixed appliances.
Cone-beam computed tomography scans of 22 patients were available before orthodontic treatment (T1), at removal of the CMA (T2), and posttreatment (T3). The average age of the patients was 13.5 ± 1.6 years at T1, 14.1 ± 0.2 years at T2, and 15.6 ± 0.5 years at T3. The 3-dimensional image analysis procedures were performed using ITK-SNAP (version 3.6.0; www.itksnap.org, Hatfield, Pa) and SlicerCMF (version 4.11.0; http://www.slicer.org, Cambridge, Mass); skeletal and dentoalveolar changes relative to cranial base, maxillary, and mandibular regional superimpositions were evaluated.
Changes were analyzed with 1 sample t tests using the mean differences during the CMA phase (T1 to T2) and total treatment time (T1 to T3). Significant skeletal changes included a slight reduction of ANB from T1 to T3, mandibular growth (Co-Gn increment of 1.2 mm and 3.3 mm from T1 to T2 and T1 to T3, respectively), inferior displacement of point A, and anterior and inferior displacement of point B. The mandibular plane did not change significantly during treatment. During the CMA treatment, posterior tipping and distal rotation of the maxillary molars, tip back and inferior displacement of the maxillary canines, significant mesial rotation, and superior displacement of the mandibular molars were observed. These movements rebounded during the full fixed appliance phase except for the molar and canine vertical displacements. Clinically significant dental changes during treatment included a reduction in overjet and overbite, Class II correction of the molar and canine relationship, and proclination of the mandibular incisors.
The CMA is an effective treatment modality for Class II correction in growing patients because of a combination of mesial movement of the mandibular molar, distal rotation of the maxillary molar, and anterior displacement of the mandible.
Cephalometric analysis of dental and skeletal effects of Carriere Motion 3D appliance for Class II malocclusion
2022, American Journal of Orthodontics and Dentofacial Orthopedics
The objective was to describe the dental and skeletal changes obtained using the Carriere Motion Appliance (CMA), lateral cephalogram, and the corresponding cephalometric tracings.
A sample of 29 patients with Class II malocclusion (mean age, 12.6 ± 1.7 years) was retrospectively selected. All patients were treated at a single center using a CMA as the primary sagittal correction device. Cephalometric tracings at the beginning and end of treatment were compared. Each cephalometric tracing was performed 3 times by the same operator.
Using the CMA, the 29 patients studied reached dental Class I in 4.4 ± 0.98 months. All measurements were subjected to statistical analysis, paired t test, and all displayed differences between T0 and T1 (P <0.05) except for the SNA. At the end of treatment, the Wits and ANB values were reduced by 1.38 mm and 0.8°, respectively. Overbite and overjet were also reduced by 1.4 mm and 2 mm, respectively. The SNB, FMA, LAFH, and IMPA increased to a lesser extent (ie, 0.7°, 0.4°, 1.5 mm, and 1.5°, respectively).
The CMA is a rapid and efficient means of correcting Class II malocclusion. Its effects are predominantly dentoalveolar, with minimal skeletal alteration of little clinical significance.
Changes in the craniofacial structures and esthetic perceptions of soft-tissue profile alterations after distalization and Herbst appliance treatment
2021, American Journal of Orthodontics and Dentofacial Orthopedics
Citation Excerpt :
Thirty patients were included in this study, based on the study by Burkhardt et al.16 Findings from the multivariate analysis of variance indicated that at least 80% statistical power necessitated a minimum sample size of 15 in each group to detect a significant difference between the groups.
The purpose of this prospective clinical trial is to evaluate the changes of soft tissues and designate the esthetic perceptions of children with Class II malocclusion after Herbst appliance therapy and maxillary molar distalization using stereophotogrammetry.
Thirty patients were allocated either to Herbst (6 boys and 9 girls; mean age = 11.60 ± 0.82 years) or distalization (4 boys and 11 girls; mean age = 11.46 ± 1.30 years) groups. Dentoskeletal and soft-tissue treatment changes were examined objectively by cephalometric analysis and stereophotogrammetry, respectively. Pre- and posttreatment profile views were evaluated subjectively by orthodontists and laypeople using the 7-point Likert scale. Intra- and intergroup comparisons for the repeated measurements were performed with 2-way variance analysis. Bonferroni test was used for multiple comparisons (P ≤0.05).
Greater skeletal changes were observed in the Herbst group than in the distalization group. Maxillary incisor retrusion and mandibular incisor protrusion were observed in the distalization and Herbst groups, respectively. Stereophotogrammetric measurements showed that mandibular body length and lower and anterior facial height increased in both treatment groups. Convexity angle (P = 0.020) and labiomental angle (P = 0.033) were greater in the Herbst group than the distalization group.
The skeletal contribution to correction of maxillomandibular discrepancy was greater in the Herbst group than the distalization group. Significant profile improvements were recorded for both groups with treatment. After both treatments, orthodontists were found to have higher rates of detection in the profiles than laypeople. The esthetic contribution of treatments to the facial profile was found similar in both groups.
Three-dimensional condylar changes from Herbst appliance and multibracket treatment: A comparison with matched Class II elastics
2020, American Journal of Orthodontics and Dentofacial Orthopedics
The purpose of this study was to quantify and qualify the 3-dimensional (3D) condylar changes using mandibular 3D regional superimposition techniques in adolescent patients with Class II Division 1 malocclusions treated with either a 2-phase or single-phase approach.
Twenty patients with Herbst appliances who met the inclusion criteria and had cone-beam computed tomography (CBCT) images taken before, 8 weeks after Herbst removal, and after the completion of multibracket appliance treatment constituted the Herbst group. They were compared with 11 subjects with Class II malocclusion who were treated with elastics and multibracket appliances and who had CBCT images taken before and after treatment. Three-dimensional models generated from the CBCT images were registered on the mandible using 3D voxel-based superimposition techniques and analyzed using semitransparent overlays and point-to-point measurements.
The magnitude of lateral condylar growth during the orthodontic phase (T2-T3) was greater than that during the orthopedic phase (T1-T2) for all condylar fiducials with the exception of the superior condyle (P <0.05). Conversely, posterior condylar growth was greater during the orthopedic phase than the subsequent orthodontic phase for all condylar fiducials (P <0.05). The magnitude of vertical condylar development was similar during both the orthopedic (T1-T2) and orthodontic phases (T2-T3) across all condylar fiducials (P <0.05). Posterior condylar growth during the orthodontic phase (T2-T3) of the 2-phase approach decreased for all condylar fiducials with the exception of the posterior condylar fiducial (P <0.05) when compared with the single-phase approach.
Two-phase treatment using a Herbst appliance accelerates condylar growth when compared with a single-phase regime with Class II elastics. Whereas the posterior condylar growth manifested primarily during the orthopedic phase, the vertical condylar gains occurred in equal magnitude throughout both phases of the 2-phase treatment regime.
Treatment stability after total maxillary arch distalization with modified C-palatal plates in adults
2019, American Journal of Orthodontics and Dentofacial Orthopedics
The purpose of this study was to evaluate skeletal, dentoalveolar, and soft tissue changes at 3 years posttreatment in patients with Class II Division 1 malocclusion treated with modified C-palatal plates (MCPPs).
The sample consisted of 69 lateral cephalograms of 23 patients Class II Division 1 malocclusion (9 men, 14 women; average age, 20.1 years) who underwent bilateral distalization of their maxillary dentition. The lateral cephalograms were taken immediately before the placement of the MCPPs (T1); at the end of orthodontic fixed appliance therapy (T2); and at the posttreatment observation period (3 years posttreatment; T3). Twenty-three variables were measured. Repeated measures ANOVA followed by post hoc analysis using Bonferroni test was used to identify significant differences between time points.
Maxillary first molars showed a distal movement of 3.44 ± 1.08 mm (P <0.001) distal crown tipping of 2.35° ± 6.74°, and intrusion of 1.42 ± 1.12 mm from T1 to T2. However, from T2 to T3, there was an average of 0.41 ± 0.25 mm of mesial movement, 0.50 ± 0.46 mm of extrusion, and insignificant mesial crown tipping (0.92° ± 2.46°; P = 0.06). The nasolabial angle increased 9.36° ± 6.04° from T1 to T2 (P <0.001) but then decreased 1.55° ± 1.54° from T2 to T3.
MCPPs are a viable treatment option for maxillary total arch distalization with minimal changes in treatment effects 3 years posttreatment.
Rotational effects of Class II Division 1 treatment with the Herbst appliance and fixed appliances in growing subjects with different vertical patterns
2019, Journal of the World Federation of Orthodontists
Citation Excerpt :
In two recent studies, however, it was shown that during Herbst treatment, short faces generally remain short and long faces generally remain long [10,11]. Only a few previous studies have addressed Herbst treatment combined with a follow-up fixed appliance phase [12–14] and none have directly addressed rotational effects in subjects with different underlying vertical facial patterns. With this in mind, the present study was undertaken to confirm the generally accepted anteroposterior dental and skeletal changes occurring during overall Class II Division 1 treatment with the Herbst appliance and contemporary fixed appliances, and then to focus on the range of vertical and rotational effects.
This retrospective study was undertaken to assess the rotational effects of the Herbst appliance and fixed appliances in the treatment of Class II Division 1 subjects with different vertical facial patterns.
Pretreatment, post-Herbst, and post-fixed appliance lateral cephalograms from 115 growing Class II Division 1 subjects were divided into three groups based on differences in the mandibular plane angle. Changes in dental and skeletal measurements were assessed within these vertical groups and in relation to pretreatment overbite, overjet, and stage of cervical maturity.
During the overall treatment period, there were changes as expected in upper and lower incisor angulations, reductions in the incisal overjet, and increases in total mandibular length in all groups. A real increase in horizontal chin projection was, however, seen only in mesofacial and brachyfacial subjects. In general, rotational facial changes during treatment were minimal, so that dolichofacial patterns remained long and brachyfacial patterns remained short.
The results support previous reports that combined Herbst and fixed appliance treatment is likely to be associated with considerable Class II dental correction in many cases. Although there is likely to be a wide range of individual response to the use of the Herbst appliance, it is unlikely that such overall treatment will be associated with clinically significant forward mandibular rotation in dolichofacial subjects.

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^*: ^bThomas M. and Doris Graber Endowed Professor of Dentistry, Department of Orthodontics and Pediatric Dentistry, School of Dentistry; Professor of Cell and Developmental Biology, School of Medicine; Research Scientist, Center for Human Growth and Development, University of Michigan, Ann Arbor. Private practice, Ann Arbor, Michigan.

^**: ^cAssistant professor, Department of Orthodontics, University of Florence, Florence, Italy; Thomas M. Graber Visiting Scholar, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor.

^*: Reprint requests to: Dr James A. McNamara, Department of Orthodontics and Pediatric Dentistry, School of Dentistry, University of Michigan, Ann Arbor, MI 48109-1078; e-mail, [email protected].

^**: 0889-5406/2003/$30.00 + 0

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Original ArticleMaxillary molar distalization or mandibular enhancement: A cephalometric comparison of comprehensive orthodontic treatment including the pendulum and the Herbst appliances*,**,*,**

Abstract

Section snippets

Patients and methods

Results

Discussion

Conclusions

Acknowledgements

Am J Orthod

Am J Orthod

Am J Orthod

Am J Orthod

Am J Orthod Dentofacial Orthop

Am J Orthod

Am J Orthod

Am J Orthod

Am J Orthod Dentofacial Orthop

Semin Orthod

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Semin Orthod

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod Dentofacial Orthop

Am J Orthod

Am J Orthod

Am J Orthod

Semin Orthod

Am J Orthod Dentofacial Orthop

Components of Class II malocclusion in children 8-10 years of age

Angle Orthod

Atlas und Grundriss der Zahnärztlichen Orthopädie

The pendulum appliance for Class II non-compliance therapy

J Clin Orthod

Original Article
Maxillary molar distalization or mandibular enhancement: A cephalometric comparison of comprehensive orthodontic treatment including the pendulum and the Herbst appliances*,**,*,**