Step 2. Slide an advancement shim (whichever size is applicable) over the rod, crimp the shim to the rod using pliers, place rod into upper tube and replace screw using Ceka Bond to secure.

Step 3. At each activation check to make sure that the midlines are still correct, and that the tubes and rods are functioning correctly. After several activation’s, the patient’s may need to have the tubes and or rods lengthened to keep them from disengaging. If any of the later need to be corrected refer to sections 4, 5 and 6 of the Pre-Insertion Check List for directions.

Pearl: It is helpful before activating the appliance to ask the patient if they have been falling apart frequently. This is a good indication that the tubes and rods may have to be replaced with longer ones.

Note:

Efficiency, profitability and consistently predictable results are what the Crown Bite Jumping Appliance affords today’s orthodontic practices. Below is an example of a typical Herbst (CBJ) treatment sequence provided by Dr. Joe Mayas.

Final Activation & Determining When to Remove Crown Bite Jumping (Herbst):

Final activation has been taken as far as a Class III skeletal and dental position with the maxillary cuspids in an end-to-end relationship with the lower first bicuspid and held for an additional 10 weeks. While other clinicians activate to, or keep the patient at an edge to edge Class I in Herbst therapy for about a year.

Tomograms or Transcranial are taken if available, to determine if the condyles are reasonably centered in the fossa. When the condyles are centered, the patient is then scheduled for removal of the Herbst appliance.

Not Centered	Centered

Note:

If Tomograms or Transcranial x-rays are not available clinician’s may choose to leave the appliance on additional ten to twelve weeks; then disengage the patient, removing only the upper tubes and lower rods waiting a few more weeks to determine if the patient will relapse too much.

Pictorial Review of Changes Resulting from Herbst Treatment:

Before Herbst Treatment

Completion of Herbst Treatment: Ready for Removal of Appliance

Removal of the Crown Bite Jumping Appliance (Herbst)

As the Crown Bite Jumping Appliance has increased in popularity, finding solutions to the more time consuming aspects of managing the appliance has been addressed with rapid enthusiasm.

Removing the crowns was at first a very tedious procedure at best. Even though we are not yet there, great strides are constantly being made to perfect this procedure. Listed in this chapter are several of the current techniques being used today.

Cutting Crowns with a Bur:

Step 1: Using a 557 or 1171 bur cut the crowns occlusally and down the buccal margin.

Maxillary Crown Mandibular Crown

Step 2. The crowns are then removed using a rocking and peeling motion utilizing the attached upper tube and the lower cantilever for leverage. Simultaneously, Pliers may be used to grab the loosen crown helping to complete the removal. Sometimes a screw driver may also be used to get up under the crown to help pry it off.

Maxillary Crown Mandibular Crown

Crown Removing Pliers:

Step 1. Place a crown removal hole in the occlusal surface of the crowns. On the upper a lingual window may be placed on the lingual to act as a perch point for the pliers. (Many crowns are slightly sub-gingival and accessing the edge of it could be uncomfortable for the patient). The upper tubes can remain attached to the crown, but the lower rods need to be removed.

Maxillary Crown Mandibular Crown

Step 2. The maxillary crown is moved with the pliers utilizing the perch window, and the lower crown is removed using the cantilever arm for leverage.

Maxillary Crown Mandibular Crown

Crown Removing Pliers

Pearl #1: Because many of the crowns are slightly sub-gingival and accessing the end of the crown is sometimes difficult, a slit can be incorporated into the crowns during fabrication to ease the removal procedure.

Pearl #2: Document large restorations before cementation. Crown removal on such teeth during active treatment could produce a fracture, and it may be wise to remove crowns with the cutting technique.

Pearl #3: A tinted glass ionomer such as ProTech Gold by Ormco helps to identify the cement from the tooth enamel when cutting into the crowns.

Pearl #4: Removal vents on occlusal surfaces can also be placed in the crowns during fabrication, saving time later. Having them placed by the laboratory is easier because you will have to re-micro etch the crown before delivery.

The Orthodontic CYBERjournal wishes to thank both Paula Allen for her article and Allesee Orthodontic Appliances (AOA) for permission to publish this information.

About the Author:

Paula is the clincal liason for Allesee Orthodontic Appliances (AOA). Many of you know Paula from her 30 years in the industry. She worked in an orthodontic practice for fourteen years and has attended and lectured at continuing education seminars, presented staff and doctor's clinics at the Great Lakes, Midwest, Southern, and Mid-Atlantic constituent meetings, as well as, for the American Association of Orthodontists. Paula has visited and interacted with hundreds of orthodontic offices. Her experience in orthodontics covers a wide range of areas.

Clinical management of the bite jumping appliances, especially the crown versions is one of the areas in which she has been extremely active over the last ten years. Her involvement in "hands on" clinical systems and techniques has given her valuable insights into what must be done in the orthodontic practice from a clinical perspective to facilitate predictable, profitable and excellent treatment results.

She can be reached at: p-allen-noble@mindspring.com

or

Paula S. Allen Clincal Liason Allesee Orthodontic Appliances (AOA) 13931 Spring Street Sturtevant, WI 53177 USA

or more directly:

Paula S. Allen Clincal Liason (AOA) 463 Club View Drive Lawrenceville, GA 30043 USA

1-800-990-3485