ORIGINAL ARTICLE

Effects of Class II treatment with a banded Herbst appliance on root lengths in the posterior dentition
Gero S. M. Kinzinger,a Susanna Savvaidis,b Ulrich Gross,c Norbert Gulden,d Bjorn Ludwig,d and Jorg Lissone Homburg, Jena, and Wuppertal, Germany

Introduction: The aim of this study was a retrospective analysis of posterior teeth in 20 adolescents and young adults with Angle Class II Division 1 malocclusion treated with a banded Herbst appliance to check for inhibited root development and apical root resorption. Methods: Panoramic radiographs were taken of every patient at the beginning and after the completion of functional orthopedic treatment. The magnication of the area of the posterior teeth was determined individually for every radiograph. Then the vestibular lengths of the molars and premolars were assessed metrically. To assess root-length changes, the difference between the lengths of the teeth before and after treatment was calculated. Results: After treatment with a banded Herbst appliance, tooth length generally increased in the area of the anchorage. But there was a tendency toward root-length decrease in teeth immediately adjacent to the Herbst ttings in the vestibular roots of both the maxillary rst molars (distovestibular, 0.02 6 2.31 mm; mesiovestibular, 0.06 6 2.05 mm) and the mandibular rst premolars (0.46 6 3.53 mm). Conclusions: The banded Herbst appliance might deliver unphysiologic forces to immediate anchor teeth, thereby exposing these to a higher risk of root resorption than in other teeth incorporated into the anchorage either directly via bands or indirectly via occlusal or approximal contacts. Looking at uncompromised root morphology in the area of the anchorage, we believe that early treatment with xed functional appliances can be predicted to yield better outcomes than late treatment because of the higher biologic tolerance expressed by teeth with an apical latency. (Am J Orthod Dentofacial Orthop 2011;139:465-9)

ixed functional orthopedic appliances, such as the Herbst appliance (Dentaurum, Ispringen, Germany), allow achieving neutral or overcompensated neutral occlusion in the treatment of Class II malocclusion.1-10 The occlusal changes derive from a combination of skeletal and dental effects.2,4 The treatment stimulates mandibular growth2,4,6,11 and causes length increases in the mandible.2 Treatment with a Herbst appliance is indicated particularly when only a little residual growth can be expected or the

a Professor, Department of Orthodontics, University of Saarland, Homburg, Germany. b Assistant professor, Department of Orthodontics, Friedrich-Schiller-University, Jena, Germany. c Private practice, Wuppertal, Germany. d Assistant professor, Department of Orthodontics, University of Saarland, Homburg, Germany. e Professor and head, Department of Orthodontics, University of Saarland, Homburg, Germany. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Gero S. M. Kinzinger, Department of Orthodontics, University of Saarland, Kirrberger Strae 1, D-66421 Homburg/Saar, Germany; e-mail, kinzinger@kfo-homburg.de. Submitted, January 2009; revised and accepted, July 2009. 0889-5406/$36.00 Copyright 2011 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2009.07.020

pubertal growth peak is already over. The appliance is also used when the patients compliance is not sufcient to correct the distoclusion with a removable functional appliance. Both telescoping xtures of the Herbst appliance feature a guide tube and a sliding pin tted to the maxillary rst molar and the mandibular rst premolar with cast splints or prefabricated bands or crowns.7 In this study, the Herbst variant with prefabricated orthodontic bands on the rst premolars and the rst molars (banded Herbst appliance) was used. In terms of laboratory technique, it was constructed by soldering the Herbst xtures to the vestibular side of the bands placed on the anchorage teeth (maxillary rst molars and mandibular rst premolars). Palatal and lingual archwires were tted for connection to other anchorage teeth wearing bands and for transverse reinforcement. During treatment with xed functional orthopedic appliances, the occlusal changes stretch both the mastication musculature and the soft tissues. This exposes the patients teeth to a highly complex force system.12 The forces are intermittent, and their strength and duration vary according to the function (swallowing, opening, closing, or resting). If sustained forces are too strong
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or last too long, there is always the possibility that resorption in the apical area or, if root growth is incomplete, an inhibiting effect on root development will occur.13-18 It must be asked whether root-growth disorders or the development of apical root resorption in the anchorage teeth will result specically from treatment with a Herbst appliance tted to prefabricated bands. Therefore, the aim of this study was to compare the root lengths of the posterior dentition before and after functional orthopedic treatment. We assessed whether (1) apical root resorption in the area of the posterior teeth develops as an effect of functional orthopedic treatment with the banded Herbst appliance and (2) particular teeth or tooth groups of the posterior dentition are exposed more clearly to resorption than others.
MATERIAL AND METHODS

Twenty patients (9 male, 11 female) with Class II Division 1 malocclusion were treated with a functional orthopedic approach to achieve distal bite correction with a banded Herbst appliance. Treatment progress was documented by using dental plaster casts and 2 panoramic radiographs (start of treatment, T1; completion of functional orthopedic treatment, T2) for every patient. Pantomograms were the radiographic technique of choice, since they are routinely taken during orthodontic treatment. For reasons of radiation exposure management, no additional dental lms were taken. The patients mean age at the time of Herbst appliance placement was 13.5 years (range, 8.9-22.3 years), and the mean treatment duration was 12 months. The pantomograms were visually inspected to verify whether root development in the anchorage teeth was completed. Root formation was found to be incomplete in 61.25% of the premolars (60% of the maxillary rst premolars, 60% of the maxillary second premolars, 55% of the mandibular rst premolars, and 70% of the mandibular second premolars). Depending on the stage of root formation in the mandibular rst premolarsie, the teeth immediately exposed to the Herbst appliance anchoragethe patients were divided into 2 groups (PG 1, root growth not completed, n 511, mean age 11.7 years; PG 2, root growth completed, n 5 9, mean age 15.7 years). Radiographic images were digitized on a transmitted-light scanner (Epson Scan, Seico Epson, Tokyo, Japan) set to 800 dpi and then processed for analysis with Adobe Photoshop CS (version 8.0, Adobe Systems Software, Dublin, Republic of Ireland). The analysis of the panoramic tomograms was conducted by using the

computer program AutoCAD 2005 (Autodesk, Munich, Germany). A scale factor of 0.1 was inserted into the radiographic images. With this program, the mesiodistal diameter of each maxillary rst molar was traced rst. Then the tooth lengths of the rst and the second premolars and the rst molars in both jaws were determined by registering the distance from the vestibular cusp to the apex of the root. When the apical foramen was still open, the reference point chosen was the midpoint of the distance between both canal walls. The palatal roots of the maxillary teeth were not assessed because the imaging technique does not display them sharply, and tracings can be distorted as a result. In addition to the determination of the mesiodistal diameter of the maxillary rst molars based on the radiographic image, their widths were measured on the cast with a digital caliper. This enabled calculating the magnication of the pantomogram, which is not directly measurable, before proceeding to statistical analysis. This was achieved by dening the mesiodistal diameter of the rst molar (M1) in the rst and second quadrants from every cast in each patient as the reference for the calculation of magnication at T1 and T2. The factors of magnication at T1 and T2 were calculated as follows. 1. 2. Magnication factor MF T1 5 width (tooth M1) panto T1 : width (tooth M1) cast. Magnication factor MF T2 5 width (tooth M1) panto T2 : width (tooth M1) cast.

By using this magnication factor, the actual tooth lengths could then be computed individually (premolars and molars) as follows. 1. 2. Actual length (tooth) T1 5 length (tooth) T1 : MF T1. Actual length (tooth) T2 5 length (tooth) T1 : MF T2.

To achieve sound statements about root-length development, the difference between the computed actual tooth lengths (T2-T1) was calculated. The clinical crown height was presupposed to remain constant. When a numeric result had a positive sign, length had increased; when the number was negative, length had decreased.
Statistal analysis

Statistical analysis was performed with a computer program (version 9.3.0.0, MedCalc Software, Mariakerke, Belgium); tests were performed with paired t tests for intragroup comparisons and with unpaired t tests for intergroup assessments. The level of signicance was dened as P #0.05.

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Table I. Mean tooth lengths (mm) of the rst and second premolars and the rst molars (overall, in both jaws, and

individually by patient groups, PG 1 and PG 2) at T1 and T2, difference between T2 and T1, and signicance
Overall PG 1 PG 2 Overall maxilla PG 1 maxilla PG 2 maxilla Overall mandible PG 1 mandible PG 2 mandible T1 mean and SD 23.23 6 5.82 22.24 6 4.30 24.18 6 6.11 22.95 6 5.60 22.20 6 4.57 23.61 6 5.74 23.51 6 6.02 22.27 6 4.07 24.74 6 6.45 T2 mean and SD 23.45 6 5.48 23.08 6 5.72 23.90 6 5.79 23.29 6 6.05 23.12 6 6.03 23.49 6 6.10 23.62 6 5.46 23.04 6 5.42 24.30 6 5.47 T2-T1 mean and SD 0.22 6 2.98 0.84 6 2.53 0.28 6 3.23 0.34 6 2.88 0.92 6 2.27 0.12 6 3.23 0.11 6 3.09 0.77 6 2.78 0.44 6 3.24 P value 0.2263 0.0004* 0.2920 0.1771 0.0030* 0.7446 0.6937 0.0366* 0.2484

Positive mean T2-T1, length increase; negative mean T2-T1, length decrease. *Statistically signicant.

RESULTS

Considering all teeth as 1 study group, tooth length increased by 0.22 6 2.98 mm (P 5 0.2263). In the subsamples, PG 1 showed a signicant increase (0.84 6 2.53 mm, P 5 0.0004), and PG 2 exhibited a trend for tooth-length decrease (0.28 6 3.23 mm, P 5 0.2920). When we assessed the jaws individually, tooth-length increase could be observed in both jaws (0.34 6 2.88 mm in the maxilla; 0.11 6 3.09 mm in the mandible). The changes were not signicant in either jaw. In the subsamples, the treatment outcomes were signicant length increases in both jaws in PG 1 (0.92 6 2.27 mm, P 5 0.0030 in the maxilla; 0.77 6 2.78 mm, P 5 0.0366 in the mandible) and slight toothlength reductions in PG 2 that were not signicant (Table I). For the assessments with the paired t test, the teeth of the respective jaws (ie, their roots) were dened as tooth groups. These groups were composed of the distovestibular (dv) and distal (d) roots of the maxillary and mandibular rst molars (UP 6 dv, LO 6 d), the mesiovestibular (mv) and mesial (m) roots of the maxillary and mandibular rst molars (UP 6 mv, LO 6 m), and the maxillary and mandibular rst and second premolars (UP and LO 5, UP and LO 4), respectively. Although, in the total patient sample no statistically signicant changes occurred, there was a tendency for rootlength decreases in both vestibular roots of the maxillary rst molars (UP 6 dv, 0.02 6 2.31 mm; UP 6 mv, 0.06 6 2.05 mm) and the mandibular rst premolars (0.46 6 3.53 mm). In all other tooth groups, however, rootlength increases were detected (maxillary rst premolars, 0.88 6 3.59 mm; maxillary second premolars, 1.04 6 3.87 mm; mandibular second premolars, 0.11 6 3.38 mm; distal roots of the mandibular rst molars, 0.53 6 2.82 mm; mesial roots of the mandibular rst molars, 0.06 6 2.87 mm). In the subsamples, PG 1 exhibited

length increases in all tooth groups. In PG 2, trends for tooth-length decreases were observed in particular in the maxillary rst molars and the mandibular rst premolars, which were the anchorage teeth immediately exposed to tting the Herbst appliance (UP 6 dv, 0.60 6 2.09 mm, P 5 0.2407; UP 6 mv, 1.01 6 2.19 mm, P 5 0.0424; mandibular rst premolars, 1.22 6 3.58 mm, P 5 0.1663). Comparison of tooth groups between both patient subsamples showed a signicant difference in tooth-length changes only in the mesiovestibular roots of the maxillary rst molars (PG 1, 0.72 6 1.57 mm; PG 2, 1.01 6 2.19 mm; intergroup signicance, P 5 0.0059) (Table II).
DISCUSSION

Fixed functional orthopedic appliances affect anchorage teeth immediately, causing force to be applied and transferred directly to the tooth roots and the periodontium. The Herbst appliance used in this study has paired telescoping xtures that are tted to the vestibular side of the bands on the maxillary rst molars and the mandibular rst premolars. To broaden the anchorage setup, bands were also placed on the mandibular rst premolars and the maxillary rst premolars, and laboratory techniques were used to connect all bands of the maxilla with a transpalatal bar, and all bands of the mandible with a lingual archwire. It can be expected that the amount of force applied is greatest and might favor the development of root resorption in teeth that are immediately exposed to the Herbst appliance. In a clinical study with a Herbst appliance tted to prefabricated bands, Nasiopoulos et al19 demonstrated a statistically signicant decrease in the root surfaces of the mandibular rst premolars, which were used as the anchorage teeth. The results of this study also indicate unfeasible results for teeth directly exposed to the anchorage. In

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Table II. Mean tooth lengths (mm) individually by tooth groups and patient groups (overall, PG 1, and PG 2) (means and standard deviations) at T1 and T2, difference between T2 and T1, and signicance
T1 mean and SD UP 6 dv Overall PG 1 PG 2 UP 6 mv Overall PG 1 PG 2 UP 5 Overall PG 1 PG 2 UP 4 Overall PG 1 PG 2 LO 6 d Overall PG 1 PG 2 LO 6 m Overall PG 1 PG 2 LO 5 Overall PG 1 PG 2 LO 4 Overall PG 1 PG 2 18.08 6 2.12 17.46 6 1.57 18.85 6 2.48 18.14 6 2.52 17.19 6 1.54 19.30 6 3.01 28.14 6 4.79 26.14 6 4.76 28.84 6 4.68 27.42 6 3.12 27.29 6 2.61 27.49 6 3.42 18.59 6 3.48 17.90 6 2.57 19.43 6 4.27 18.95 6 3.68 17.96 6 2.68 20.17 6 4.39 28.56 6 4.44 26.55 6 4.72 29.36 6 3.42 28.37 6 4.45 26.61 6 1.57 30.01 6 4.54 T2 mean and SD 18.06 6 2.03 17.91 6 2.05 18.25 6 2.05 18.08 6 1.87 17.91 6 1.76 18.29 6 2.01 29.18 6 4.15 28.39 6 3.74 29.54 6 4.48 28.30 6 3.23 28.47 6 3.34 27.90 6 3.13 19.12 6 1.77 18.35 6 1.37 20.06 6 1.77 19.01 6 1.84 18.49 6 1.31 19.66 6 2.21 28.67 6 3.73 28.67 6 3.39 28.68 6 4.13 27.91 6 3.69 27.68 6 2.92 28.79 6 4.08 T2-T1 mean and SD 0.02 6 2.31 0.45 6 2.43 0.60 6 2.09 0.06 6 2.05 0.72 6 1.57 1.01 6 2.19 1.04 6 3.87 2.25 6 3.13 0.70 6 4.07 0.88 6 3.59 1.18 6 2.68 0.41 6 3.96 0.53 6 2.82 0.45 6 2.42 0.63 6 3.32 0.06 6 2.87 0.53 6 2.46 0.51 6 3.29 0.11 6 3.38 2.12 6 4.29 0.68 6 2.69 0.46 6 3.53 1.07 6 3.07 1.22 6 3.58 P value 0.9586 0.3883 0.2407 0.8591 0.0661 0.0424* 0.2108 0.1836 0.4724 0.2165 0.0771 0.6662 0.2414 0.3958 0.4298 0.8953 0.3270 0.5198 0.8774 0.2390 0.2989 0.5093 0.3256 0.1663 Signicance PG 1 vs PG 2

0.1541

0.0059*

0.4420

0.3506

0.8403

0.2617

0.0606

0.1135

Positive mean T2-T1, length increase; negative mean T2-T1, length decrease; m, mesial; mv, mesiovestibular; d, distal; dv, distovestibular. *Statistically signicant.

the mandibular rst premolars, a tendency toward a root-length decrease could be observed. Hence, it is important to realize that the length of these teeth increased in patients whose root formation was not completed at the start of the Herbst treatment; in patients with already developed roots, a tendency for length decreases could be observed. The mesiovestibular roots of the maxillary rst molars showed increases of length in the patients in PG 1 and signicant length decreases in PG 2. The difference between the subsamples was signicant. These results might lead to the following conclusions. With the Herbst appliance type used in this study, with bands placed only on the rst molars and the rst premolars, the load sustained by the anchorage teeth that are immediately exposed to the xtures appears to be particularly great. This might favor the development of root resportion. The tendencies observed in this study,

particularly in the mandibular rst premolars, conrm the results of Nasiopoulos et al.19 The prefabricated elements of the Herbst appliance can be tted, as an alternative, to cast splints. If the t is proper, it can be hypothesized that the splints ensure even distribution of the applied forces and moments onto the anchorage setup. Fixed functional orthopedic appliances, such as the Herbst appliance, are increasingly often the choice for noncompliance treatment of younger patients. In the patients of this study also, the formation of the roots, particularly in the area of the premolars, was not fully completed in many of them. A specic issue to be addressed here is whether the forces to which the anchorage setup is exposed adversely affect the development of the root and whether treatment this early favors root resorption. A fact arguing against the thesis of root development being adversely affected is that immature,

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uncalcied tissues, such as predentin and cementoid, show better resistance to root resorption than their calcied forms.20-22 Teeth with apical latencies also show higher biologic tolerance with respect to resorption conditions. In this situation, a wide open apical foramen ensures that the pulp is exposed to fewer circulatory disorders even with application of strong forces, resulting in less risk of compression of the vessels that otherwise might be involved in resorptive developments.21 This is matched by the outcome found in this study for PG 1: signicant root-length increases in both the maxilla and the mandible. The assessment by tooth group individually did not yield any hints at treatment-induced growth-inhibiting effects. Rather, these outcomes entail the conclusion that there is a tendency, especially in immediate anchorage teeth, for a higher risk of developing apical root resorption when root formation is already largely completed.
CONCLUSIONS

During treatment with xed functional appliances, the anchorage teeth are exposed to a highly complex force system. Potential side effects on the tooth roots during treatment over several months include growth inhibition and apical root resorption. A trend for root reduction was found with a Herbst appliance tted to prefabricated bands, particularly in the maxillary rst molars and the mandibular rst premolars. Potentially, the specic design of the banded Herbst appliance applies unphysiologically strong forces to teeth that serve as immediate anchors, thereby exposing them to a higher risk of root resorption compared with other teeth incorporated into the anchorage, either directly via bands or indirectly via occlusal or approximal contacts. On the other hand, in patients whose root formation in the area of the premolars was not fully completed at the start of the treatment, root-length increases were found in all areas when assessing the outcomes individually by jaws and tooth groups. For uncompromised root morphology in the area of the anchorage, it seems that early treatment with xed functional appliances can be predicted to yield better outcomes than late treatment because of the higher biologic tolerance expressed by teeth with an apical latency.
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3. Pancherz H. The effect of continuous bite jumping on the dentofacial complex: a follow-up study after Herbst appliance treatment of Class II malocclusions. Eur J Orthod 1981;3:49-60. 4. Pancherz H. The mechanism of Class II correction in Herbst appliance treatment. Am J Orthod 1982;82:104-13. 5. Pancherz H. The Herbst applianceits biologic effects and clinical use. Am J Orthod 1985;87:1-20. 6. Pancherz H, Hgg U. Dentofacial orthopedics in relation to somatic a maturation. An analysis of 70 consecutive cases treated with the Herbst appliance. Am J Orthod 1985;88:273-87. 7. Pancherz H, Hansen K. Mandibular anchorage in Herbst treatment. Eur J Orthod 1988;10:149-64. 8. Pancherz H. The nature of Class II relapse after Herbst appliance treatment: a cephalometric long-term investigation. Am J Orthod Dentofacial Orthop 1991;100:220-33. 9. Pancherz H, Anehus-Pancherz M. The headgear effect of the Herbst appliance. Am J Orthod Dentofacial Orthop 1993;103: 510-20. 10. Pancherz H, Anehus-Pancherz M. Facial prole changes during and after Herbst appliance treatment. Eur J Orthod 1994;16: 275-86. 11. Hansen K, Pancherz H. Long-term effects of Herbst treatment in relation to normal growth development: a cephalometric study. Eur J Orthod 1992;14:285-95. 12. Nasiopoulos A. Biomechanics of the Herbst scharnier orthopedic method and head posture: a synchronized electromyographic and dynamographic study [thesis]. Malm, Sweden: Lund Univero sity; 1992. 13. Casa MA, Faltin RM, Faltin K, Sander FG, Arana-Chavez VE. Root resorption in upper rst premolars after application of continuous torque moment. Intraindividual study. J Orofac Orthop 2001;62: 285-95. 14. Faltin RM, Arana-Chavez VE, Faltin K, Sander FG, Wichelhaus A. Root resorptions in upper rst premolars after application of continuous intrusive forces. Intra-individual study. J Orofac Orthop 1998;59:208-19. 15. Faltin RM, Faltin K, Sander FG, Arana-Chavez VE. Ultrastructure of cementum and periodontal ligament after continuous intrusion in humans: a transmission electron microscopy study. Eur J Orthod 2001;23:35-49. 16. Hendrix I, Carels C, Kuijpers-Jagtman AM, VanT Hof M. A radiographic study of posterior root resorption in orthodontic patients. Am J Orthod Dentofacial Orthop 1994;105:345-9. 17. Reitan K. Initial tissue behavior during apical root resorption. Angle Orthod 1974;44:68-82. 18. Vardimon AD, Graber TM, Voss LR, Lenke J. Determinants controlling iatrogenic external root resorptions and repair during and after palatal expansion. Angle Orthod 1991;61:113-22. 19. Nasiopoulos AT, Athanasiou AE, Papadopoulos MA, Kolokithas G, Ioannidou I. Premolar root changes following treatment with the banded Herbst Appliance. J Orofac Orthop 2006;67:261-71. 20. Chutimanutskul W, Darendeliler M, Shen G, Petocz P, Swain MV. Changes in the physical properties of human premolar cementum after application of 4 weeks of controlled orthodontic forces. Eur J Orthod 2006;28:313-8. 21. Mavragani M, Boe OE, Wisth PJ, Selvig KA. Changes in root length during orthodontic treatment: advantages for immature teeth. Eur J Orthod 2002;24:91-7. 22. Sameshima GT, Sinclair PM. Predicting and preventing root resorption: part I, diagnostic factors. Am J Orthod Dentofacial Orthop 2001;119:505-10.

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