Short- and Long-Term Effects of the Herbst

Appliance on Temporomandibular Joint

Function
Sabine Ruf
This article summari zes six papers on t he short- and l ong-term effects of t he
Herbst appliance on t emporomandi bul ar joint (TMJ) and masti catory mus-
cle function. The t r eat ment effects as wel l as t he clinical consequences are
discussed. The available knowl edge in the literature shows t hat bite j ump-
ing using t he Herbst appliance does not have a deleterious effect on the
masti catory system and does not induce t emporomandi bul ar disorder
(TMD) on a short- or long-term basis. On t he contrary, t he Herbst appliance
i mproves TMJ function in some Class II TMD subjects. (Semin Orthod 2003;
9:74-86.) Copyri ght 2003, Elsevier Science (USA). A l l ri ghts reserved.
O
ne of t he goal s of or t hodont i c t r e a t me nt is
to i mpr ove t he f unct i on of t he mast i cat or-/
syst em i ncl udi ng bot h t e mp o r o ma n d i b u l a r j o i n t
(TMJ) a nd mast i cat or y mus cl e f unct i on, Whe n
l ooki ng at t he l i t er at ur e, t her e is cont r over s y
wi t h r es pect to t he ef f ect of or t hodont i cs on TMJ
flmction.~,'~ The effect s of t he He r bs t appl i ance
on t he mast i cat oI T syst em bot h dur i ng and af t er
Class II cor r ect i on have be e n i nvest i gat ed in a
t ot al of 6 publ i s hed st udi es. 3 s Thi s art i cl e will
s umma r i z e t he sci ent i fi c f i ndi ngs of t hese arti-
cles and discuss t hei r clinical i mpl i cat i ons. The
mat er i al and me t hods of t he 6 He r bs t paper s ar e
gi ven in Tabl e 1.
Summari zed Resul t s
Art i cl e 1 (Pancherz and Pancherz, 19825)
Dur i ng He r bs t t r e a t me nt of 20 pat i ent s, t he
l at eral mo v e me n t capaci t y of t he ma ndi bl e was
r e duc e d by an aver age of 1.9 mm but i ncr eas ed
From the Department of Orthodontics, Unive~i('~ of Giessen,
Giessen, Ge~mam'.
Address ,respondence to Sabine Ruf DDS, Phi), Department
o] Orthodontics, School of Dentistry, Universi(, q[ Bern, e, Freibu~g-
strasse 7, CIt-3010 Berne, Switzerland.
Copyright 2003, Elsevier Scienc, (USA). All rights ~vseTved.
1073-8746/03/(t901-0001535.00/0
doi: 10.1053/sodo. 2003. 34027
to p r e t r e a t me n t val ues 1 year af t er t r eat ment .
The f r e que nc y of j o i n t t ender nes s i ncr eas ed
f r om 20% to 45 % dur i ng t he first 3 mont hs of
t r eat ment . However , af t er t r e a t me nt (15%) a nd
1 year af t er t r e a t me nt ( 10%) , r e duc e d preva-
l ence of . j oi nt t ender nes s c o mp a r e d wi t h pr e-
t r e a t me nt val ues wer e seen. Muscl e t ender nes s
s howed a c ompa r a bl e de ve l opme nt . Mast i cat or, /
p e r i b r ma n c e and t e mpor a l as well as mas s et er
mus cl e e l e c t r omyogr a phi c (EMG) activity wer e
mar kedl y r e duc e d dur i ng t he first 3 mont hs of
He r bs t t r e a t me nt but i ncr eas ed to p r e t r e a t me n t
val ues dur i ng t he fol l ow-up per i od.
Article 2 (Hansen et al, 19904)
Anamnes t i c, clinical, a nd r adi ogr aphi c fi nd-
i ngs in 19 mal e subj ect s t r eat ed with t he He r bs t
appl i ance an aver age of 7.5 years ear l i er wer e in
a c c or da nc e wi t h t hose of an or t hodont i cal l y un-
t r eat ed popul a t i on of young mal e adul t s. TM]
s ounds coul d be det ect ed in 26% and muscl e
t ender nes s in 32% of t he subj ect s. None of t he
i ndi vi dual s exhi bi t ed j oi nt t ender ness. St ruc-
t ural bony changes in t he TMJ wer e t ound on
bot h sides in 1 subj ect . Ei ght pe r c e nt of t he
condyl es wer e post er i or l y di spl aced. However ,
on aver age, t he condyl es wer e slightly ant er i or l y
pos i t i oned in t he fossa.
7 4 Seminm~ in Orthodontics, Vol 9, No 1 (March), 2003: pp 74-86
TMJ EJ]ects of the Herbst Appliance 75
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76 Sabine Ruf
Article 3 (Foucart et al, 1998 s)
Bef or e t r e a t me nt wi t h a r e mova bl e He r bs t
appl i ance, n o n e of t he 10 subj ect s e x a mi n e d
exhi bi t ed any disc di s pl a c e me nt or mus cl e or
j oi nt t ender nes s . Dur i ng t r e a t me nt mus cl e a nd
j o i n t t ender nes s was s een in 1 subj ect . Clinically,
t he onl y det ect abl e sign of t e mp o r o ma n d i b u l a r
di s or der s (TMDs) af t er t r e a t me nt was a r e duc e d
condyl ar t r ansl at i on in 1 subj ect . On t he mag-
net i c r e s ona nc e i mages (MRI) of t he TMJs, 3
subj ect exhi bi t ed var yi ng degr ees of disc dis-
p l a c e me n t af t er t r eat ment , t he disc be i ng dis-
pl aced ant er i or l y an aver age of 8.3 ( P = .023)
c o mp a r e d with p r e t r e a t me n t values.
Article 4 ( Ruf and Pancherz, 19987)
An aver age of 4 years af t er He r bs t t r e a t me nt
of 20 subj ect s, t he pr eval ence of a na mne s t i c and
clinical signs or s ympt oms of TMD was wi t hi n
t he r ange of " nor mal " r e p o r t e d in t he l i t er at ur e.
The f r e que nc y of disc di s pl a c e me nt was not
hi ghe r t han in as ympt omat i c popul at i ons . Mod-
er at e to severe signs of TMD r a ngi ng f r om par -
tial to t ot al disc di s pl a c e me nt or devi at i on in
f or m of t he condyl e wer e s een in 5 subj ect s
( 25%) . An o t h e r 3 subj ect s (15%) s howed mi l d
s ympt oms of TMD wi t h e i t he r smal l condyl ar
di s pl a c e me nt or subcl i ni cal soft-tissue l esi on.
Article 5 (Pancherz et al, 19996)
Bef or e He r bs t t r e a t me nt of 15 subj ect s, t he
ar t i cul ar disc was on aver age in a sl i ght pr ot r u-
sive posi t i on rel at i ve to t he condyl e. At t he st art
of t r eat ment , t he ma ndi bl e was a dva nc e d to an
incisal edge to edge posi t i on. Because of t he
physi ol ogi c rel at i ve mo v e me n t of disc a nd con-
dyle on ma ndi bul a r pr ot r us i on, t he disc at t ai ned
a p r o n o u n c e d r et r usi ve posi t i on. At t he e nd of
t r eat ment , t he disc had on aver age al mos t re-
t ur ne d to its or i gi nal p r e t r e a t me n t posi t i on.
However , a sl i ght r et r usi ve disc posi t i on pr e-
vai l ed, wher eas condyl ar posi t i on was on aver age
u n c h a n g e d dur i ng He r bs t t r eaUnent .
Article 6 ( Ruf and Pancherz, 20008)
Dur i ng He r bs t t r e a t me nt of 62 subj ect s, t he
condyl e was pos i t i oned si gni fi cant l y f or war d but
r e t ur ne d t o its or i gi nal pos i t i on af t er r emoval of
t he appl i ance. A t e mpor a r y capsul i t i s of t he in-
f er i or s t r at um of t he pos t er i or a t t a c h me n t was
i nduc e d dur i ng t r eat ment . Over t he ent i r e ob-
ser vat i on pe r i od f r om be f or e t r e a t me nt to 1 year
af t er t r eat ment , bi t e j u mp i n g with t he He r bs t
appl i ance (1) di d not r esul t in any mus cul ar
TMD, (2) r e duc e d t he pr eval ence of capsulitis,
(3) r e duc e d t he pr eval ence st r uct ur al condyl ar
bony changes, (4) di d not i nduce any disc dis-
p l a c e me n t in subj ect s wi t h a physi ol ogi c pr e-
t r e a t me nt disc posi t i on, (5) r esul t ed in a st abl e
r epos i t i oni ng of t he disc in subj ect s wi t h a pr e-
t r e a t me nt par t i al disc di s pl a c e me nt wi t h r educ-
t i on, a nd (6) coul d not r e c a pt ur e t he disc in
subj ect s wi t h a p r e t r e a t me n t t ot al disc di spl ace-
me n t wi t h or wi t hout r educt i on. The overal l
pr eval ence of TMD was r e duc e d f r om 48% be-
f or e t r e a t me nt to 24% 1 year af t er t r eat ment .
D i s c u s s i o n
I n cl i ni cal t er ms, t he i mp o r t a n t quest i ons wi t h
r es pect to t he short - a nd l ong- t er m effect s of t he
He r bs t appl i ance on TMJ f unct i on ar e as follows.
1. Does t he He r bs t appl i ance da ma ge t he TMJ?
2. Does t he He r bs t appl i ance i mpr ove TMJ
f unct i on?
3. Wha t ki nd of Class I I pat i ent s benef i t f r om
He r bs t t r e a t me nt in t er ms of i mpr ove d TMJ
f unct i on?
I n t he fol l owi ng, t hese quest i ons will be ad-
dr essed in t he l i ght of t he knowl edge avai l abl e in
l i t er at ur e.
Do e s t he Herbst Appl i ance Damage the
TMJ?
The f i ndi ngs to be e xpe c t e d i f t he He r bs t
appl i ance gener al l y ha d an adver se ef f ect on t he
TMJ or t he mast i cat or y mus cul at ur e woul d be an
i ncr ease in t he signs or s ympt oms of TMD ei t her
on a short - or l ong- t er m basis c o mp a r e d wi t h
bot h p r e t r e a t me n t val ues a nd unt r e a t e d con-
trols.
Wh e n s umma r i z i ng t he anamnes t i c, clinical,
a nd MRI signs and s ympt oms of TMD seen in
Class I I pat i ent s be f or e He r bs t t r e a t me nt (arti-
cles 1, 3, a nd 6), 0% t o 48 % of t he pat i ent s
exhi bi t ed ei t her cl i ni cal or subcl i ni cal TMD.
However , signs a nd s ympt oms of TMD ar e no
rari t y in chi l dr en a nd adol escent s. The i r fre-
75~J Effects of the Herbst Appliance 77
quency vari es bet ween 2. 4% a nd 67. 6% de pe nd-
i ng on t he age of t he subj ect s, t he subj ect selec-
t i on, t he def i ni t i on of t he di agnost i c cri t eri a,
and t he e xa mi na t i on me t hods (Fig 1).'-)-~4
Af t er He r bs t t r eat ment , Pancher z a nd Ane-
hus - Pancher z 5 (art i cl e 1) des cr i bed a decr eas e in
j oi nt s ounds of 100%, in j oi nt t ender nes s of
25%, and in muscl e t ender nes s of 40%. Foucar t
et aP (art i cl e 3) r e por t e d an i ncr ease in disc
di s pl acement s of 30%. Ruf and Pancher z 7 (arti-
cle 6), on t he ot he r hand, f ound a decr eas e in
disc di s pl a c e me nt of 45%, a decr eas e in st ruc-
t ural bony changes of 41%, a nd an i ncr ease in
subcl i ni cal capsul i t i s of 64%. A possi bl e expl ana-
t i on f or t he cont r adi ct or y resul t s in t er ms of disc
di s pl a c e me nt mi ght be t hat Foucar t et al :~ (arti-
cle 3) us ed a r emovabl e i nst ead of a fi xed He r bs t
appl i ance and t ook sagittal i nst ead of angul at ed
sagittal MRIs. On st r ai ght sagi t t al MRIs of t he
TMJ t he pos t er i or ba nd of t he ar t i cul ar disc is
not i ma ge d reliably, especi al l y in t he l at eral and
medi al j oi nt sect i ons( '5 r esul t i ng in an overest i -
ma t i on of disc di s pl acement s . The l at t er expl a-
nat i on seems qui t e likely as Foucar t et aP (art i cl e
3) r e por t e d t hat 2 out of 3 disc di s pl a c e me nt
pat i ent s wer e clinically s ympt om f r ee over t he
ent i r e obs er vat i on per i od.
One year af t er t r eat ment , t he pr eval ence of
TMD in He r bs t subj ect s was 94% c o mp a r e d wi t h
48% p r e t r e a t me n t (art i cl e 6). s Cor r es pondi ngl y
a 20% r educt i on in muscl e t ender nes s , 50% re-
duct i on in j oi nt t ender nes s , and 100% r educt i on
in TM] s ounds was des cr i bed by Pancher z and
Anehus - Pancher z (art i cl e 1)7' Such a r educt i on
in TMD pr eval ence has not be e n r e por t e d to
dat e t br any or t hodont i c appl i ance.
An aver age of 4 years af t er He r bs t t r e a t me nt
(art i cl e 4), t he anamnes t i c, clinical, and MRI
dat a usi ng t he s ame cr i t er i a as in art i cl e 6 re-
veal ed t hat 35% of t he f o r me r He r bs t pat i ent s
s howed cl i ni cal or subcl i ni cal TMD. Because
bot h pat i ent mat er i al s of art i cl es 4 and 6 had t he
s ame p r e t r e a t me n t mal occl us i on char act er i st i cs
and wer e t r eat ed wi t h t he s ame a p p r o a c h
( Her bs t appl i ance t bl l owed by mul t i br acket ap-
pl i ance) , it seems val i d to c o mp a r e t hem. Thus,
on one hand, t he TMD pr eval ence 4 years af t er
He r bs t t r e a t me nt was less t han in a gr oup of
Class II pat i ent s be f or e He r bs t t r e a t me nt (art i cl e
6), despi t e t he f act t hat an i ncr ease of signs and
s ympt oms of TMD wi t h age s houl d have be e n
expect ed. 1a9~2'-~ On t he ot he r hand, t he TMD
pr eval ence 4 years af t er t r e a t me nt i ncr eas ed
c o mp a r e d with 1 year af t er He r bs t t r e a t me nt
(art i cl e 6). Thi s i ncr ease mi ght be expl ai ned by
t he i ncr ease in age of t he subj ect s 1s,%-2-~ and by
t he mul t i f act or i al et i ol ogy of TMD. 9'-<~t I n gen-
eral , t he pr eval ence of TMD in subj ect s 4 years
af t er t r e a t me nt was c ompa r a bl e to t hat seen in
nor ma l unt r e a t e d popul a t i ons ? >:~s
Fur t her mor e, it was f bund (article 2) t hat pa-
tients an average of 7 years aft er Her bs t t r eat ment
exhi bi t nor mal structural condi t i ons of t he con-
dyle and tbssa and t hei r anamnest i c and clinical
TMD fi ndi ngs are in accor dance with t hose of an
ort hodont i cal l y unt r eat ed popul at i on of young
adults. Thus, it can be concl uded t hat t he Her bs t
appl i ance does not seem m have an adverse effect
on TMJ funct i on on a short- or l ong- t er m basis.
Does the Herbst Appliance Improve TMJ
Function?
A possi bl e i mp r o v e me n t of TMJ f unct i on is
mu c h mo r e di ffi cul t to det ect t hen a det er i or a-
t i on because of t he fact t hat t he et i ol ogy of TMD
is mul t i f act or i al . ~<~ I f t he He r bs t appl i ance
woul d i mpr ove TMJ f unct i on, t he pr e s e nc e of a
TMD p r o mo t i n g f act or such as par af unct i on
mi ght di sgui se t he posi t i ve ef f ect of or t hodont i c
t r eat ment . Thus, becaus e of t he mul t i f act or i al
et i ol ogy of TMD, it woul d be unreal i st i c to ex-
pect a c ompl e t e di s a ppe a r a nc e of all signs and
s ympt oms of TMD in or t hodont i c pat i ent s. Fur-
t he r mor e , cer t ai n ki nds of TMD such as disc
di s pl acemenl s wi t hout r educt i on, whi ch mi ght
be pr e s e nt pr e t r e a t me nt , c a nnot be t r eat ed or t h-
odont i cal l y. Thus, a cer t ai n pr eval ence of TMD
will i nevi t abl y prevai l af t er or t hodont i c t reat -
ment , despi t e a possi bl e posi t i ve ef f ect of t he
or t hodont i c appl i ance on TM] f unct i on.
As des cr i bed earl i er, t he pr eval ence of TMD
in Class II subj ect s decr eas ed by 50% f r om be-
f or e to af t er He r bs t t r e a t me nt and by 27% t i o m
bef or e to 4 years af t er He r bs t t r e a t me nt (art i cl es
4 and 6). Thus, t he f r equency c ha nge was oppo-
site to t hat in t he nor ma l popul a t i on in whi ch
t he TMD pr eval ence i ncr eases with age. ~a2~2~-~
The r e f or e , it can be sai d t hat TMJ f unct i on was
in t act i mpr ove d by He r bs t appl i ance t r eaunent ,
possi bl y becaus e of t he nor mal i zat i on of t he oc-
cl usi on. However , t he signs and s ympt oms of
78 Sabine Ruf
DD clinical (n = 11) DD in MRI (n = 22)
TDDnoR ODD PDD
,,4 7
2
TDDnoR
9
TDDwR TDDwR
5 6
Figure 1. Prevalence of disc displacements (DD) in 62 consecutive Herbst patients before treatment analyzed
clinically and by means of MRI. The total number of joints with disc displacements (n), the number of partial
(PDD), and total disc displacments with reduction (TDDwR) as well as the number of total disc displacements
without reduction (TDDnoR) is given.
TMD could not be completely resolved by
Herbst treatment, which, as ment i oned earlier,
mi ght be because of the fact that the etiology of
TMD is multifactorial.
What Kind of Class II Patients Benefit
From Herbst Treatment in Terms of
Improved TMJ Function?
To be able to i nform a patient specifically on the
benefits of Herbst t reat ment in terms of im-
proved TMJ function, it must be differentiated
between the appliance effects on (1) disc posi-
tion, (2) condyl ar position, (3) TMJ soft tissues,
(4) TMJ bony structures, and (5) the masticatory
musculature.
Di s c Pos i t i on
A slight retrusion of the disc compar ed with
pret reat ment values is seen at the end of Herbst
t reat ment (article 5). This seems at least partly
to be the result of a slight ant eri or position of
the condyle after t reat ment (Fig 2). Duri ng the
post t reat ment peri od (after to 1 year after
Herbst t reat ment ), the amount of disc retrusion
decreased (article 6). However, a slight retrusive
disc position prevailed even 1 year after Herhst
treatment. This seems even more remarkable
because this retrusion was not associated with an
ant eri or position of the condyle (Fig 2). The
reason for this disc retrusion is unknown. I t
could, however, be the result of a change in
Index
47,9
34,5
21,1 T
7,7
-5,7
-19,1
-32,5
-45,9
-59,3
De, rees
40,9
29,8
18,7
7,6
-3,5
-14,6
-25,7
-36,8
-47,9
Anterior di spl acement
0, . . , , . .
. . . . " ' " ' " ' " " O. . " . . . . . . . . . . , , , , . , , . . . O
Posterior di spl acement
Before After 1 Year
mm
3,1
2,4
1,7
1
0,3
-0,4
-1,1
-1,8
-2,5
- - Disc (PB)
- . Disc (IZ)
Condyle
Figure 2. Average changes
in articular disc and condy-
lar position from before to
one year after treatment in
62 consecutive Herbst pa-
tients. Disc position was
measured using the poste-
rior band (PB) or interme-
diate zone (IZ) criterion
(article 6). The gray shaded
area represents the physio-
logic range.
TM[ Effects o[ the Herbst Appliance 79
f or m becaus e of t he r e mo d e l i n g pr ocesses of t he
condyl e and fossa. Fur t he r mor e , a r e mode l i ng
of t he disc :'-~*.4 in t he cour se of bi t e j u mp i n g
mi ght also have c ont r i but e d to t he disc r et r u-
sion, a l t hough becaus e of its avascul ari t y t he
r e mode l i ng capaci t y of t he disc is l i mi t ed.
The ef l ect of t he He r bs t appl i ance on t he
posi t i on of t he ar t i cul ar disc was f o u n d to de-
p e n d on t he p r e t r e a t me n t disc posi t i on. I n pa-
t i ent s with a physi ol ogi c p r e t r e a t me n t disc posi-
t i on or a di s pl a c e me nt t endency, t he posi t i on of
t he disc r e ma i n e d u n c h a n g e d or i mpr oved, re-
spectively, dur i ng He r bs t t r e a t me nt (art i cl es 5
a nd 6). Thi s is in cont r as t to t he f i ndi ngs of
Foucar t et a1:4 (art i cl e 3), who r e por t e d t hat 3 out
of 10 heal t hy He r bs t pat i ent s de ve l ope d a disc
di s pl a c e me nt dur i ng t r eat ment . Thi s, as al r eady
des cr i bed earl i er, is pr oba bl y becaus e of t he fact
t hat Foucar t et aP (art i cl e 3) us ed a r emovabl e
i nst ead of a fi xed He r bs t appl i ance a nd t ook
sagittal i nst ead of angul at ed sagittal MRIs.
I n c onc or da nc e with pr evi ous investiga-
tions, 4~ it was t bund t hat t he pr ognos i s t ot disc
r epos i t i oni ng d e p e n d e d on t he de gr e e of disc
di s pl a c e me nt exi st ent pr e t r e a t me nt . Part i al disc
di s pl acement s (Fig 3) coul d be r epos i t i oned suc-
cessfully and r e ma i n e d st abl e unt i l t he e nd of
t he obsen~at i on pe r i od (art i cl e 6). I n cont r as t to
nor ma l disc r epos i t i oni ng t her apy, 41-44 r ecapt ur -
i ng of t he disc dur i ng He r bs t t r e a t me nt was
achi eved by a r et r us i on of t he disc and not by a
pr ot r us i on of t he condyl e. A possi bl e mi si nt er -
pr et at i on of disc r epos i t i oni ng in t he MRI be-
cause of a fibrosis of t he pos t er i or a t t a c hme nt 4~
seems unl i kel y as disc r epos i t i oni ng was associ-
at ed with a di s a ppe a r a nc e of t he clinical symp-
t oms.
In t he case of t ot al disc di s pl acement s with
r educt i on, onl y a t e mp o r a W r epos i t i oni ng of t he
disc coul d be achi eved dur i ng He r bs t t r e a t me nt
(art i cl e 6). Thus, with an i ncr easi ng de gr e e of
di s pl acement , t he r et r usi ve ef f ect of t he He r bs t
appl i ance on disc posi t i on seems to be insuffi-
ci ent to stabilize t he disc. Cons equent l y and in
c onc or da nc e wi t h pr evi ous f i n d i n g s , 41-44 t he disc
r el aps ed to a di spl aced posi t i on when t he con-
dyle move d backwar ds in t he fossa dur i ng t he
pos t t r e a t me nt per i od.
I n j oi nt s wi t h a t ot al disc di s pl a c e me nt with-
out r educt i on, t he di s pl a c e me nt of t he disc pr e-
vai l ed dur i ng t he ent i r e obser vat i on pe r i od (at -
ticle 6). The d e v e l o p me n t of a ps eudodi s c
becaus e of ext ensi ve fi brot i c adapt at i on of t he
pos t er i or a t t a c hme nt 4~i-4s was, however, s een in
s ome j oi nt s (Fig 4). TMJ f unct i on in gener al
i mpr oved, however, in all subj ect s wi t h a t ot al
disc di s pl a c e me nt wi t hout r educt i on. Clinically,
t hese subj ect s wer e i ndi st i ngui shabl e f r om
heal t hy i ndi vi dual s al t er t r eat ment . Thus, with-
out any MRI, t he disc di s pl a c e me nt woul d never
have be e n di agnosed.
To dat e, t he di sc- r ecapt ur i ng capaci t y of
ot he r f l mct i onal appl i ance t han t he He r bs t ap-
pl i ance has not be e n i nvest i gat ed, except f or t he
act i vat or. 4'-~ Thi s appl i ance was f ound to be tin-
abl e to r ecapt ur e any di spl aced disc i nde pe n-
de nt of t he de gr e e of di s pl acement . Thus, unt i l
f ur t he r knowl edge is available, t he He r bs t appl i -
ance mus t be cons i der ed t he onl y f unct i onal
appl i ance abl e to i mpr ove t he posi t i on of tile
ar t i cul ar disc in t he cour s e of t r eat ment .
Clinical consequences. I t mus t be poi nt e d out
t hat a disc di s pl a c e me nt t hat pr es ent s no ot he r
s ympt oms t han cl i cki ng does not war r ant t reat -
ment . :~ However , if t her e is an i ndi cat i on t or
or t hodont i c t r e a t me nt becaus e of an exi st i ng
Class I I mal occl usi on, t he disc posi t i on mus t be
cons i der ed in t r e a t me nt pl a nni ng to achi eve
ma x i mu m benef i t s f or t he pat i ent .
Treatment considerations f or Class I I pati ents
with different degrees of disc displacement. Wi t h
part i al disc di s pl acement , t her e is a good pr og-
nosis t br disc r eposi t i oni ng. The He r bs t appl i -
ance s houl d be t he appl i ance of choi ce to
achi eve i na xi mum f unct i onal i mp r o v e me n t du>
i ng or t hodont i cs even i f t he de gr e e of mal occl u-
si on s ever i ~ i t sel f mi ght not j ust i fy t he use of t he
He r bs t appl i ance.
Wi t h t ot al disc di s pl a c e me nt with r educt i on,
t her e is a bad pr ognosi s f or disc r eposi t i oni ng.
Appl i ance sel ect i on f or Class II t r e a t me nt
s houl d be based on mal occl us i on severi t y only.
Wi t h t ot al disc di s pl acement wi t hout r educ-
t i on, t her e is no chance f or disc r eposi t i oni ng.
Th e r e is a good pr ognos i s f or tissue adapt at i on
a nd f l mct i onal i mp r o v e me n t when usi ng t he
He r bs t appl i ance.
Condylar Position. A ma r ke d i nt er i ndi vi dual
w: ri at i on in condyl ar posi t i on was f ound bef or e,
aft er, 1 year aft er, 4 years aft er, and even 7 years
al t er He r bs t t r e a t me nt (art i cl es 2, 4, and 6).
Compa r a bl e var i at i ons in condyl ar posi t i on have
80 Sabine Ruf
Figure 3. Parasagittal MRIs
of the TM] of a 12-year-old
male Class II:l subject
treated with the Herbst ap-
pliance. Before treatment
note the partial disc dis-
placement with reduction
(A). The disc was recap-
tured at start of Herbst
treatment (B). Both alter
(C) as well as 1 year after
Herbst treatment (D) the
recaptured disc is in a phys-
iologic disc-condyle rela-
tionship.
also been r epor t ed for asympt omat i c popul a-
t i ons 23,5-5z and f or di f f er ent mal occl usi ons. 53
However, it seems r emar kabl e t hat a t endency
t owar d an average ant er i or condyl ar posi t i on
was pr esent at all exami nat i on t i mes (articles 2,
4, and 6). Thi s mi ght be an expr essi on of t he
Class II mor phol ogy. 54
Dur i ng Her bst t r eat ment , t he a mount of an-
t eri or posi t i on of t he condyl e was t empor ar i l y
i ncr eased (Fig 2). Thi s was t he resul t of an over-
cor r ect i on of t he Class II dent al arch rel at i on-
shi p in t he pat i ent mat eri al anal yzed (article 5).
Nevert hel ess, when t he occl usi on set t l ed aft er
t r eat ment , 55 t he condyl e r et ur nd to its ori gi nal
fossa posi t i on. Thus, on a gener al basis condyl ar
posi t i on will not be al t ered per manent l y by
Her bst t r eat ment .
Ther e was an inverse rel at i onshi p bet ween
t he posi t i on of t he disc and t he condyl e, whi ch
was especially pr onounc e d bef or e t r eat ment (ar-
ticle 6). I n c onc or da nc e with t he l i t erat ure, ~6,57
this i nt er r el at i on was mor e obvi ous in subjects
with a disc di spl acement ; a mor e post er i or con-
dyl ar posi t i on was associ at ed with a mor e an-
TMJ Jfects of the Herbst Appliance 81
Figure 4. Parasagittal MRIs
of the TMJ of a 15-year-old
male Class II:l subject
treated with the Herbst ap-
pliance. Before treatment,
a total disc displacement
without reduction was pres-
ent (A). After treatment,
a pseudodisc (dotted area)
has developed. Note also
the improvement in condy-
lar bony shape (B).
t eri or disc position. Duri ng Her bst t reat ment ,
condyl ar posi t i on in these pat i ent s coul d be im-
proved al t hough an opt i mal -cent ered condyl ar
posi t i on coul d not be achieved.
Clinical consequences. In subjects with disc dis-
pl acement s, an i mpr ovement of the condyl ar
position f r om a post eri or toward a mor e cen-
t ered posi t i on within the fossa can be expect ed.
This implies an unl oadi ng of the TMJ soft tissues
in the retrodiscal area, thus pr omot i ng tissue
adapt at i on and i mpr oved TMJ funct i on. Because
compar abl e positive effects of ot her funct i onal
appl i ances on the condyl ar position have not
been r epor t ed in literature, t he Her bst appli-
ance shoul d be consi der ed as the appl i ance of
choi ce in Class II pat i ent s with post eri or condy-
lar di spl acement s.
TMJ Soft Tissues
In general , i nf l ammat or y condi t i ons of t he
t empor omandi bul ar j oi nt are subdi vi ded into
synovitis and capsulitis. ~ In the following, cap-
sulitis refers to an i nt racapsul ar i nf l ammat i on
pri mari l y affecting the post eri or at t achment .
The t er m post eri or at t achment is used as de-
scri bed by Scapi no 5~,-~,~ and refers to the vascular
and i nnervat ed tissue lying behi nd the articular
disc.
No effects of Her bst t r eat ment on t he supe-
rior st rat um of the post eri or at t achment or the
st ruct ures of t he j oi nt capsule coul d be obselwed
iii
(article 6). The only affected st ruct nre was the
i nferi or st rat um of the post eri or at t achment .
The lateral part of the i nferi or st rat um react i ng
mor e t han the cent ral part. In the following,
only the preval ences for t he lateral part of the
i nferi or st rat um will be given.
Duri ng Her bst t reat ment , the preval ence of a
capsulitis of the inferior st rat um of the post eri or
at t achment changed from 24% pr et r eat ment to
100% al t er 6 weeks Herbst t r eat ment and 88%
i mmedi at el y after removal of the Her bst appli-
ance (Fig 5). It must, however, be stressed that
the existing capsulitis pr et r eat ment was bot h
clinical and subclinical, whereas, duri ng and af-
ter Her bst t reat ment , all findings where solely
subclinical, meani ng that none of the patients
was compl ai ni ng of TMJ pai n (article 6). Duri ng
the post t r eat ment settling of the occl usi on): '
the capsulitis preval ence decreased to 32% 6
mont hs al t er removal of the Her bst appl i ance
and to 7% 1 year after. Thus, over the ent i re
observat i on peri od, the preval ence of a capsulitis
of the i nferi or st rat um of the post eri or attach-
ment was r educed from 24% to 7% (Fig 5). This
is most likely the result of a normal i zat i on of the
occlusion (article 6).
The devel opment of a capsulitis in the course
of Her bst t r eat ment was not an effect restricted
to a mechani cal bite j umpi ng with the Her bst
appl i ance. Compar abl e react i ons of the i nferi or
st rat um of the post eri or at t achment have been
82 Sabine Ruf
%
100
80
60
40
20
98% 100% 97%
Before I week 6 weeks 3 months After 6 months 1 year
(n=62) (n=60) (n=53) (n=57) (n=59) (n=57) (n=57)
Severe
Moderate
Mild
None
Figure 5. Prevalence of a
capsulitis of the lateral part
of the inferior stratum of
the posterior attachment in
62 consecutive Herbst pa-
tients. The percentage (%)
of affected joints is given
separately for the left and
right TMJ. The level of dis-
comfort and the number
(n) of analyzed patients is
s hown.
f ound in activator pat i ent s 49 and thus also for
funct i onal bi t e-j umpi ng procedures.
The i nduct i on of a t empor ar y subclinical cap-
sulitis of t he i nferi or st rat um of the post eri or
at t achment is probabl y caused by the advance-
ment of the condyl e pr ovoked by the Her bst
appl i ance, which results in an expansi on of the
post eri or at t achment . 5s-64 In cont rast to nor mal
mout h openi ng or prot rusi ve j aw movement ,
dur i ng which this expansi on (Fig 6) prevails
only for seconds, in Her bst t r eat ment it remai ns
24 hours a day. Al t hough the soft-tissue expan-
sion does not seem to have a long-lasting effect
on the synovial pressure, 65 no doubt it will result
in a mechani cal irritation of t he tissue l eadi ng to
an i nf l ammat or y reactiona,6<67: the observed
capsulitis of the i nferi or st rat um of t he post er i or
at t achment .
Clinical consequences. Becauase patients ex-
hibiting a capsulitis of the post eri or at t achment
pr et r eat ment have a 70% chance to adapt dur-
ing a peri od f r om before to 1 year after treat-
ment , the Her bst appl i ance shoul d be consid-
er ed for t r eat ment in Class II cases with clinically
mani fest capsulitis of the i nferi or st rat um of the
post eri or at t achment .
TMJ Bony Structures
Normal l y t he preval ence of structural bony
changes increases with age. ~s However, a spon-
t aneous heal i ng of osseous condyl ar changes
dur i ng adol escence has also been report ed. 6s,~'-~
Duri ng Her bst t reat ment , the preval ence of"
structural bony changes of the condyl e (flat-
tening, subchondr al sclerosis, erosions, osteo-
Figure 6. Anatomic section
of the temporomandibular
joint region 83 in closed (A)
and open-mouth position
(B). Note the expansion of
the posterior attachment
upon mouth opening,
which is maintained 24
hours daily during Herbst
t r eat ment .
1 Posterior attachment 2 Posterior band of the disc
3 Condyle Retrodiscal venous plexus
1 Vascular genu 2 Superior stratum
3 Inferior stratum # Retrodiscal venous pJexus
TMJ Effects of the Herbst Appliance 83
p h y t e s ) d e c r e a s e d ( a r t i c l e 6) . Mt h o u g h b e f o r e
t r e a t me n t n e a r l y 14% o f t h e j o i n t s e x h i b i t e d
c o n d y l a r b o n y c h a n g e s , t hi s was t h e cas e f o r o n l y
3% 1 y e a r a f t e r He r b s t t r e a t me n t . P r o b a b l y t he
r e mo d e l i n g p r o c e s s e s o f t h e c o n d y l e i n d u c e d by
t h e He r b s t a p p l i a n c e 7-7:~ p r o mo t e d t h e n o r ma l -
i z a t i o n o f t h e c o n d y l a r b o n y s t r u c t u r e s . F o r ex-
a mp l e , t h e d i s a p p e a r a n c e o f o s t e o p h y t e s mi g h t
b e e x p l a i n e d by t h e a n t e r i o r r e s o r p t i v e p r o -
t e s s 74-76 t a k i n g p l a c e i n t h e c o u r s e o f c o n d y l a r
r e mo d e l i n g d u r i n g He r b s t t r e a t me n t .
I n al l j o i n t s wi t h a p h y s i o l o g i c d i s c - c o n d y l e
r e l a t i o n s h i p , t h e s i gns o f s t r u c t u r a l b o n y
c h a n g e s d i s a p p e a r e d d u r i n g t h e o b s e r v a t i o n pe -
r i o d f r o m b e f o r e t o 1 y e a r a f t e r He r b s t t r e a t -
me n t . I n j o i n t s wi t h a p r e t r e a t me n t di s c d i s p l a c e -
me n t wi t h o u t r e d u c t i o n , a c o n d i t i o n wh i c h i n
b o t h c l i ni c a l a n d a n i ma l s t u d i e s ha s b e e n s h o wn
t o b e mo r e s u s c e p t i b l e t o t he d e v e l o p me n t o f
b o n y c h a n g e s , 46,4~,77 t h e c o n d y l a r b o n y c h a n g e s
i mp r o v e d d u r i n g He r b s t t r e a t me n t ( Fi g 4) .
Clinical consequences. I n Cl ass I I p a t i e n t s wi t h
p r e t r e a t me n t s t r u c t u r a l b o n y c h a n g e s , t h e r e is
n o c o n t r a i n d i c a t i o n f or t h e He r b s t a p p l i a n c e .
Masticatory Musculature
T h e r e a c t i o n o f t h e ma s t i c a t o r y mu s c u l a t u r e
t o He r b s t t r e a t me n t was a n a l y z e d u s i n g 9 di f f e r -
e n t me t h o d s : (1) mu s c l e p a l p a t i o n ( a r t i c l e s 1, 2,
a n d 3) a n d (2) i s o me t r i c mu s c l e c o n t r a c t i o n
e x e r c i s e s ( a r t i c l e s 3, 4, a n d 5) . T h e r e s ul t s o f
t h e s e 2 d i f f e r e n t a p p r o a c h e s a r e di f f i c ul t t o c o m-
p a r e .
I n t h e a s s e s s me n t o f myof a s c i a l p a i n , i s o me t -
r i c mu s c l e c o n t r a c t i o n s ha ve b e e n s hown t o ex-
h i b i t l ess i nt r a - a n d i n t e r e x a mi n e r va r i a bi l i t y 7s-s~
t h a n mu s c l e p a l p a t i o n . F u r t h e r mo r e , i n c o n t r a s t
t o mu s c l e p a l p a t i o n , myof a s c i a l p a i n p r o v o k e d
by me a n s o f i s o me t r i c c o n t r a c t i o n s is a s s o c i a t e d
wi t h mo r p h o l o g i c c h a n g e s o f t h e mu s c l e , i n
f o r m o f a mu s c l e e d e ma d e t e c t a b l e by me a n s o f
MRI . s2
I n u s i n g p a l p a t i o n t o assess myof a s c i a l p a i n , i t
c o u l d b e s h o wn t h a t d u r i n g He r b s t t r e a t me n t
( a r t i c l e 1) t h e p e r c e n t a g e o f p a t i e n t s e x h i b i t i n g
mu s c l e t e n d e r n e s s i n c r e a s e d f r o m 25% b e f o r e
t o 55% a f t e r 3 mo n t h s He r b s t t r e a t me n t . Fort -
c a r t e t a P ( a r t i c l e 3) d e s c r i b e d a n i n c r e a s e f r o m
0% t o 10% d u r i n g t r e a t me n t . Al t e r t r e a t me n t ,
mt t s c l e t e n d e r n e s s was e i t h e r a b s e n t ( a r t i c l e 3)
o r p r e s e n t i n 15% o f t h e s ubj e c t s ( a r t i c l e 1).
On e y e a r a f t e r He r b s t t r e a t me n t , a t ot a l o f 20%
( a r t i c l e 1), a n d 7 ye a r s a f t e r 32% ( a r t i c l e 2) o f
t he s ubj e c t s s h o we d t e n d e r mu s c l e si t es. Thi s
i n c r e a s e mi g h t b e e x p l a i n e d by t h e a ge i n c r e a s e
o f t h e s ubj e c t s Is.2~-2'-~ a n d by t h e mu h i f a c t o r i a l
e t i o l o g T o f TMD. 2'-~-:~1
By u s i n g i s o me t r i c c o n t r a c t i o n s t o assess myo-
f as ci al p a i n , n o p a t h o l o g i c f i n d i n g s we r e d e t e c t -
a b l e e i t h e r b e f o r e , d u r i n g , a f t e r , 1 y e a r af t er ,
o r 4 ye a r s a f t e r He r b s t t r e a t me n t ( a r t i c l e s 3, 4,
a n d 6) .
Clinical consequences. T r e a t me n t wi t h t h e
He r b s t a p p l i a n c e d o e s n o t s e e m t o ha ve a s i g n i f
l e a n t e f f e c t o n t h e f u n c t i o n a l s t at ns o f t h e mas -
ticatoD~ mt t s c ul a t t t r e .
Conclusion
Bi t e j u mp i n g u s i n g t h e He r b s t a p p l i a n c e d o e s
n o t s e e m t o have a d e l e t e r i o u s e f f e c t o n TM]
a n d ma s t i c a t o r y f i mc t i o n a n d d o e s n o t s e e m t o
i n d u c e TMD o n a s hor t - o r l o n g - t e r m basi s. On
t he c o n t r a r y , t h e He r b s t a p p l i a n c e i mp r o v e s
TM]" f u n c t i o n i n s o me Cl ass I I TMD s ubj ect s .
References
I. Luther E. Orthodontics and the temporomandibular
joint: Where are we now? Part 1. Orthodontic treatment
and temporomandibular disorders. Angle Orthod 1998;
68:295-304.
2. McNamara.lA. Orthodontic treatment and temproman-
dibular disorders. Oral Surg Oral Med Oral Pathol Oral
Radiot Endod 1997;83:107-117.
3. FoucartJM, Pa:joni D, Carpentier P, et al. Etude I.R.M.
du comportement discal de I'A.T.M. des enfants por-
leurs d' hyperproputseur. Orthod Fr 1998;69:79-91.
4. Hansen K, Pancherz H, Petersson A. Long-term eltiects
of the Herbst appliance on the craniomandibular system
with special reference to the TMJ. Eur J Orthod 1990:
12:244-253.
5. Pancherz H, Anehns-Pancherz M. The effect of contin-
uous bite jumping with the Herbst appliance on the
inasticator T system: A fimctional analysis of treated Class
11 malocclusions. EurJ Orthod 1982;4:37-44.
6. Pancherz H, Ruf S, Thomalske-Faubert C. Mandibular
articular disk position changes during Herbst treatment:
a prospective longitudinal MRI study. Am J Orthod
Dentof~acial Orthop 1999;116:207-214.
7. Ruf S, Pancherz H. I,ong-term effects of Herbst treat-
merit: a clinical and MR1 study. Am,] Orthod Dentofhcial
Orthop 1998; 114:475-483.
8. Ruf S, Pancherz H. Does bite-jumping damage the TMI?
84 Sabine Ruf
A prospective longitudinal clinical and MRI study of
Herbst patients. Angle Orthod 2000;70:183-199.
9. Dibbets JMH. Juvenile temporomandibular joint dys-
function and craniofacial growth [doctoral thesis[. Rij-
kuniversiteit te Groningen, 1977.
I0. Egermark-Eriksson I, Carlsson GE, Ingervall B. Preva-
lence of mandibular dysfunction and orolacial parafunc-
tion in 7-, 11- and 15-year-old Swedish children. Eur
J Orthod 1981;3:163-172.
11. Geering-Gaerny M, Rakosi T. Initialsymptome von Kiel:
ergelenksst6rungen bei Kindern im Alter von 8-14
Jahren. Schweiz Monatsschr Zahnheilkd 1971;81:691-
712.
12. Grosfeld O, Czarnecka B. Musculo-articular disorders of
the stomatognathic system in school children examined
according to clinical criteria. J Oral Rehabil 1977;4:193-
200.
13. Hans MG, LiebermanJ, GoldbergJS, et al. A comparison
of clinical examination, history, and magnetic resonance
imaging tbr identifying orthodontic patients with tem-
poromandibular joint disorders. Am J Orthod Dentofa-
cial Orthop 1992;101:54-59.
14. Katzberg RW, Tallents RH, Hayakawa K, et al. Internal
derangements of the temporomandibular joint: Find-
ings in the pediatric age group. Radiology 1985;154:125-
127.
15. List T, Wahlund K, Wenneberg B, et al. TMD in children
and adolescents: Prevalence of pain, gender differences,
and perceived treatment need. J Orofac Pain 1999;13:9-
20.
16. Liu.]K, Tsai MY. The prevalence of TMD in orthodontic
patients prior to treatment at NCKUH in sonthern Tai-
wan. Funct Orthod 1996;13:9-12.
17. Morrant DG, Taylor GS. The prevalence of temporo-
mandibular disorder in patients reterred for orthodon-
tic assessment. BrJ Orthod 1996;23:261-265.
18. Motegi E, Miyazaki H, Ogura I, et al. An orthodontic
study of temporomandibularjoint disorders. Part l : Ep-
idemiological research in Japanese 6-18 year olds. Angle
Orthod 1992;62:249-256.
19. Petrikowski CG, Grace M. Age and gender differences in
temporomandibular joint radiographic findings before
orthodontic treatment in adolescents. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 1999;87:380-385.
20. Sanchez-Woodworth RE, Katzberg RW, Tallents RH, et
al. Radiographic assessment of temporomandibular
joint pain and dysfunction in the pediatric age-group..]
Dent Child 1988;55:278-281.
21. Schellhas KP, Pollei SR, Wilkes CH. Pediatric internal
derangements of the temporomandibular joint: effect
on facial development. AmJ Orthod Dentofacial Orthop
1993;104:51-59.
22. Sonnesen L, Bakke M, Solow B. Malocclusion traits and
symptoms and signs of temporomandibular disorders in
children with severe malocclusion. Eur J Orthod 1998;
20:543-559.
23. Tallents RH, Catania J, Sommers E. Temporomandibu-
lar joint findings in pediatric populations and young
adults: A critical review. Angle Orthod 1991;61:7-16.
24. Widmalm SE, Christiansen RL, Gunn SM. Crepitation
and clicking as signs of TMD in preschool children. J
Craniomand Pract 1999;17:58-63.
25. Steenks MH, Bleys RL, Witkamp TD. Temporomandib-
ular joint structures: A comparison between anatomic
and magnetic resonance findings in a sagittal and an
angulated plane. J Orofac Pain 1994;8:120-135.
26. Egermark-Eriksson I, Carlsson GE, Magnusson T. A
long-term epidemiologic study of the relationship be-
tween occlusal fiactors and mandibular dysfunction in
children and adolescents. J Dent Res 1987;66:67-71.
27. Keeling SD, McGorray S, Wheeler TT, et al. Risk factors
associated with temporomandibularjoint sounds in chil-
dren 6 to 12 years of age. Am J Orthod Dentofacial
Orthop 1994;105:279-287.
28. Magnusson T. Five-year longitudinal study of signs and
symptoms of mandibular dysfunction in adolescents. J
Craniomand Pract 1986;4:338-344.
29. Nilner M, Kopp S. Distribution by age and sex of fimc-
tional disturbances and diseases of the stomatognathic
system in 7-18 year olds. Swed Dent J 1983;7:191-198.
30. Okeson JP. Orofacial pain: Guidelines for assessment,
diagnosis, and management. Chicago: Quintessence,
1996:32-34, 11(')-127.
31. Rugh JD, Harlan J. Nocturnal brnxism and temporo-
mandibular disorders. Adv Neurol 1988;49:329-341.
32. Dahl BL, I~'ogstad BS, Ogaard B, Eckersberg T. Signs
and symptoms of craniomandibular disorders in two
groups of 19-year-old individuals, one treated orthodon-
tically and the other not. Acta Odontol Scand 1988;46:
89-93.
33. DibbetsJMH, van der Weele LT. Orthodontic treatment
in relation to symptoms attribnted to dysfunction of the
temporomandibular joint. A 10-year report of the Uni-
versity" of Groningen study. Am J Orthod Dentofacial
Orthop 1987;91:193-199.
34. Egermark-Eriksson I, Carlsson GE, Magnusson T, Thi-
lander B. A longitudinal study on malocclnsion in rela-
tion to signs and symptoms of cranio-mandibular disor-
ders in children and adolescents. EurJ Orthod 1990;12:
399-407.
35. Janson M, Hasund A. Functional problems in orthodon-
tic patients out of retention. Eur J Orthod 1981;3:173-
179.
36. Nielsen I~, Melsen B, Terp S. TMJ function and the
effects on the masticatol T system on 14-16-year-old Dan-
ish children in relation to orthodontic treatment. Eur
J Orthod 1990;12:254-262.
37. Sadowsky C, BeGole EA. Long-term status of temporo-
mandibular joint function and fimctional occlusion af-
ter orthodontic treatment. Am J Orthod 1980;78:201-
212.
38. Sadowsky C, Poison AM. Temporomandibular disorders
and fimctional occlusion alter orthodontic treatment:
Results of two long-term studies. Am J Orthod 1984;86:
386-39(I.
39. Nagy NB, Daniel J. Development of the rabbit cranio-
mandibular joint in association with tooth eruption.
Arch Oral Biol 1992;37:271-280.
40. C)berg T, Carlsson GE. Makroskopische und mikrosko-
pische Anatomic des Kiefergelenks. In: Zarb GA, Carls-
TMJ Effl'cts of the Hevbst Appliance 85
son GE editors. Physiologie und Pathologie des Kielierge-
lenks. Berlin: Quintessenz, 1985:115-133.
41. Summer JD, Westesson PL. Mandibular repositioning
can be effective in treatment of reducing TMJ disk dis-
placement. A long-term clinical and MR imaging tollow-
tip. J Craniomand Pract 1997;15:107-120.
42. Lnndh H, Westesson PL, Kopp S, et al. Anterior reposi-
tioning splint in the treatment of teinporomandibnlar
joints with reciprocal clicking: Comparison with a fiat
occlusal splint and an untreated control group. Oral
Surg Oral Med Oral Pathol 1985;60:131-136.
43. Lundh H, Westesson PL. Long-term follow-up afl.er oc-
clusal treatment to correct abnormal temporomandibn-
lar joint disk position. Oral Surg Oral Med Oral Pathol
1989;67:2-11).
44. Tallents RH, Katzberg RW, Macher D.], et al. Use of
protrusive splint therapy in anterior disk displacement
of the temporomandibularjoint: A 1- to 3-year follow-up.
J Prosthet Dent 1990;63:336-3~II.
45. Westesson PL, Paesani D. MR imaging of the TM]. De-
creased signal flom thc rctrodiskal tissue. Oral Surg Oral
Mcd Oral Pathol 1993;76:631-635.
46. lsacsson G, lsberg AM, Johansson AS, et al. Internal
derangement of the temporomandibular joint: radio-
graphic and histologic changes associated with severe
pain. J Oral Maxillofac Surg 1986;44:771-778.
47. Luder HU. Articular degeneration and remodeling in
human temporomandibular.joints with normal and ah-
normal disc position. J Orofac Pain 1993;7:391-402.
48. Scapino PP. Histopatholog)' associated with malposition
of the human temporomandibular joint disc. Oral Surg
Oral Med Oral Pathol 1983;55:382-397.
49. Ruf S, W/isten B, Pancherz H. TM] effects of activator
treatment. A prospective kmgitudinal magnetic reso-
nance imaging and clinical study. Angle Orthod 2002;
72:527-540.
50. Alexander SR, Moore RN, DuBois LM. Mandibular con-
dyle position: comparison of articulator motmtings and
magnetic resonance imaging. Ant J Orthod l)entofacial
Orthop 1993;104:230-239.
51. Braun S, Marcotte MR, Frendenthaler JW, et al. An
evaluation of condyle position in cenu'ic relation ob-
tained by ntanipulation of the mandihle with and with-
out leaf gauge deprogramming. Am J Orthod Demofa-
cial Orthop 1997;111:34-37.
52. Pullinger AG, Hollender L, 8olherg WK, et al. A tomo-
graphic study of mandibular condyle position in an
asymptomatic population. J Prosthet Dent 1985;53:706-
713.
53. Cohhnia JT, Ghnsh J, Sinha PK, et al. Tomographic
assessment of temporomandibularjoints in patients with
malocclusion. Angle Orthod 1996;66:27-35.
54. Pullinger AG, Solberg \~qK, Hollender L, et al. Relation-
ship of mandibular condylar position to dental occlusion
factors in an asymptomatic population. Ant .] Orthod
Dentofhcial Orthop 1987;91:200-206.
55. Pancherz H, Hansen K. Occlusal changes during and
after Herbst treatment: A cephalometric investigation.
EurJ Orthod 1986;8:215-228.
56. Fernandez-Sanromfin J, G6me>Gonzfilez JM, del Hoyo
JA. Relationship between condylar pnsitkm, dentofacial
detbrmity and temporomandibnlar .joint dysthnction:
An MRI and CT prospective study..] Craniomaxillofac
Surg 1998;26:35-42.
57. Ozawa S, Boering G, Kawata T, et al. Reconsideration of
the TMJ condylar position during internal derange-
ment: comparison helween condylar position on tomo-
grant and degree of disk displacement. J Craifiomand
t'ract 1999;17:93-100.
58. Scapino RP. The posterior attachment: Its structure,
function, and appearance in TMJ imaging studies. Part
2. J Craniomandib Disord 1991;5:155-166.
59. Scapino RP. The posterior attachment: hs structure,
[hnction, and appearance in TMJ imaging studies. Parl
1. J Craniomandih Disord 1991;5:83-95.
60. Finlay IA. Mandibular joint pressures. J Dent Res 1964;
43:140-148.
61. Kino K, Ohmura Y, Amagasa T. Reconsideration of the
bilaminar zone in the retrodiskal area of the temporo-
mandihularjoint. Oral Surg Oral Med Oral Pathol t 993;
75:410-421.
62. Rccs I~\. The structure and function of thc mandihular
joint. Br Dcnt,] 1054;96:125-133.
63. Wilkinson TM, Crowley CM. A histologic study of retro-
discal tissues of the }roman temporomandibular joim in
the open and closed position..] OroIac Pain 1994:8:7-17.
64. Wish-Baratz 8, Ring GD, Hiss J, et al. The microscopic
structure and function of the vascular retrodiscal pad ot
the human temporoinandibular joint. Arch Oral Biol
1993;38:265-268.
65. Ward DM, Behrents R(;, GoldbergJS. Temporomandih-
ular synovial fluid pressure response to altered mandib-
ular positions. Am J Orthod Dentofi~cial Orthop 1990;
98:22-28.
66. Carvalho RS, Scott .]E, Bulnann A, el al. Commctive
tissue responsc to mechanical stimulation. In: McNcill
(;, ed. Science and Practice of Occlusion. Chicago, IL:
Qnintessence, 1997:205-219.
67. Pinals RS. Tramnatic m-thritis and allied conditions. In:
McCarth? D.I, cd. Arthritis and Allied Conditions. Phila-
delphia, PA: l*:a 8,: Febiger, 1995:1205-1222.
68. DihbetsJMH, van der Weele LT. Prevalence of structural
bony changc in the mandibular condyle..l Cranioman-
dih l)isord 1992;6:254-259.
69. PeholaJ8, Kgn6nen M, Nystr6m M. A follow-up study of
radiographic tindings in the mandibular condyles of
orthodontically lreated patients and associations with
TMI).J /)cnt Res 1995;74:1571-1576.
70. Paulsen ]tU. Morphological changes of the TM] con-
dyqes of 100 patients treated with the Herbst appliance in
the perind of puberty to adulthood: A long-term radio-
graphic study. EurJ Orthod 1997;19:657-668.
71. Ruf S, Panchcrz 1t. Tcn~poromandihular joint growth
adaptation in Herbst treatnlent: a prospective magnetic
resonance imaging mad cephalometric roentgeno-
graphic study. Enr.] Orthod 1998;20:375-388.
72. Ruf S, Pancherz H. Kietcwgelenkwachsmmsadat)tation
bei jungen Erwachsenen wahrend Behandhmg mit der
Herhst-Apparamr. l"+inc prospektive magnetresonanzto-
mographische und kephalometrische Studie. Inf
Orthod KieR:rorthop 1998;30:735-75l).
73. Ruf S, Panchcrz H. Temporomandibularjoint rcmodel-
86 Sabine RuJ
i ng i n adol escent s and young adults dur i ng Her bst treat-
ment : A prospective l ongi t udi nal magnet i c r esonance
i magi ng and cephal omet r i c radi ographi c investigation.
Am J Or t hod Dentofacial Or t hop 1999;115:607-618.
74. McNamar aJA, Connel l y TG, McBride MC. Histological
studies of t e mpor oma ndi bul a r j oi nt adaptability. In: Mc-
Namar a JA (Hrsg.). Det er mi nant s of mandi bul ar t or m
and growth. Craniofacial Growt h Series, Monogr aph 4.
Ann Arbor: Cent er for huma n growth and devel opment .
The University of Michigan, 1975:209-227.
75. McNamaraJA, Carlson DS. Quant i t at i ve analysis of tem-
por omandi bul ar j oi nt adapt at i ons to prot rusi ve timc-
tion. Am J Or t hod 1979;76:593-611.
76. McNamara JA, Bryan FA. Long-t erm mandi bul ar adap-
t at i ons to prot rusi ve funct i on: An exper i ment al study i n
Macaca mulatta. AmJ Or t hod Deutofacial Or t hop 1987;
92:98-108.
77. Westesson PL, Rohl i n M. I nt er nal der angement rel at ed
to ost eoart hrosi s in t empor omandi bul ar j oi nt autopsy
specimens. Oral Surg Oral Med Oral Pat hol 1984;57:17-
22.
78. Lagerst r6m C, Nor dgr en B. On t he reliability and use-
fidness of met hods for gri p st rengt h measuremenks.
Scand J Rehabi l Med 1998;30:113-119.
79. Leggin BG, Neuman RM, I annot t i JP, Williams GR,
Thomps on EC. I nt r ar at er and i nt er r at er reliability of
t hr ee isometric dynamomet er s i n assessing shoul der
st rengt h. J Shoul der Elbow Surg 1996;5:18-24.
80. Mal er baJL, Adam ML, Harris BA, Krebs DE. Reliability
of dynami c and isometric testing of shoul der ext ernal
and\ i nt er nal rotators. J Or t hop Sports Phys Ther 1993;
18:543-552.
81. Thomas CA, Okes onJ P. Evaluation of lateral ptel"ygoid
muscle symptoms usi ng a common pal pat i on t echni que
and a met hod of funct i onal mani pul at i on. J Crani-
omand Pract 1987;5:125-129.
82. Evans GF, Hal l er RG, Wyrick PS, Parkey RW, Flecken-
stein JL. Submaxl mal delayed-onset muscle soreness:
Correl at i ons bet ween MR i magi ng fi ndi ngs and clinical
measures. Radiology 1998;208:815-820.
83. Bumann A, Lot zmann U. Funkt i onsdi agnost i k und
Ther api epr i nzi pi en. Stuttgart: Thi eme, 2000.