December, 1998
The Pendulum Appliance: Maintaining the Gain
James J. Hilgers, D.D.S., M.S.
Movement of any tooth in any direction with the proper application of pressure has long been a tenet or principle of Bioprogressive Therapy. Some clinicians have steadfastly maintained that it is impossible to move upper molars distally more than 1 or 2mm. Contrary to this opinion, newer, more predictable methods of force application to the upper molars have proven that in many cases the ability to move the upper molars distally is virtually unlimited. Whether that is always desirable is another question, but the mechanical applications to do so are no longer in doubt. It is the purpose of this article to further explore one of these distalizing techniques and to discuss the sequelae of its use.
The Pendulum or Pendex Appliance that was described in the first part of this article was designed by Dr. James Hilgers to use the inherent anchorage provided by the palate and, to some extent, the upper buccal segment teeth, to distalize, expand and rotate the upper molars without unduly disturbing the lower arch.
It became very clear at the outset that moving the upper molars back was not the difficult part of this form of appliance therapy it was, in fact, very dynamic and predictable. Holding them back during retraction of the rest of the maxillary teeth has been a more challenging task, however. It makes absolutely no sense to simply round-trip the molars with little or no Class II correction. The techniques described herein define the authors’ experience with molar stabilization to date.
There are basically 13 techniques that can be used singly or in concert to position the upper molar in its proper location. Each will be discussed and demonstrated separately. They are:
Index
- Overcorrection
- Quick-Nance (Hilgers)
- Short term headgear
- Stops on archwires
- Upper utility arch
- Push coil spring at cuspids
- Early bonding in the upper arch
- Class II elastics
- Upper lip bumper
- Hawley or clear-type retainers
- Bionator
- Short-haul Herbst appliance
- Long-haul Herbst appliance
Overcorrection
Figure 1. Buccal view of a full-step Class II malocclusion prior to Pendex treatment.
Figure 2. Overcorrected Class III molar position following 14 weeks of therapy. Note distal drifting of upper buccal segments upon eruption.
Indications for Use
Commonly indicated as the sole method of correction where the Class II malocclusion is very mild. If the upper molar can be moved distally and tipped back early in the eruption sequence of the upper teeth, the erupting bicuspids will have a tendency to drift distally, also. Although much of this overcorrection comes by virtue of upper molar tipping, in the strong growth patterns the inclined-plane effect uprights these teeth with little or no mechanical intervention. In more severe Class II malocclusions, the molars are greatly overcorrected and used in conjunction with other anchorage techniques mentioned herein. It is axiomatic that the farther you need to go, the more you need to overcorrect. Simply put, just moving the upper molar back into a Class I occlusion is most often not enough. Moving it back into a Class III relationship is more desirable.
Technique
The more the upper molar moves distally in a Class II malocclusion, the more it must be expanded to prevent crossbite. The midpalatal jackscrew is activated one turn every third day to create this expansion in the molar region. As the molar is tipped distally, it has atendency to rotate mesially – a phenomenon quite commonly seen when using reverse curve Ni-Ti archwires. This is thought to be due to the nature of the cortical bone surrounding these teeth, but other mechanical factors no doubt come into play. This can be compensated for somewhat by placing approximately 30 degrees of distal rotation in the terminal legs of the Pendulum springs.
Considerations
Since the distal movement of the upper molars occurs so rapidly (10-12 weeks), there is a transient bite opening due to driving these teeth back into the wedge of occlusion. This is commonly not a problem with brachyfacial types, as muscular rebound and growth more than compensate for this initial bite opening. In fact, in extremely strong muscular patterns, this response can be very beneficial in the bite opening process. But in vertical growth patterns with weak muscular rebound, bite opening can be a harbinger of further negative side effects. Once the bite opens, the tongue goes into the interspace, sometimes initiating a reverse swallow/tongue thrust (if it doesn’t already exist). Severely tipping the upper molar only aggravates this problem because the bite can be propped open on the inclines of these teeth, allowing the buccal segments to supererupt. The answer: choose this type of appliance only in mesofacial and brachyfacial types where the muscular pattern, growth and subsequent mechanics can compensate for this response. Fortunately, approximately 65% of all Class II malocclusions fall into this category. In the others, a more conservative approach should be utilized.
Quick-Nance
Indications for Use
The Quick- or Insta-Nance appliance is utilized com-monly to stabilize the molars in their overcorrected locations. The advantages are numerous. Compliance is not needed as the palatal vault is still utilized for anchorage; it can be placed immediately after removal of the Pendulum Appliance and it prevents virtually any rebound. Common sense would tell us that the palatal vault would be too inflamed for immediate placement of the Nance. This has proven not to be the case. Since there is some supraeruption of the buccal segments during Pendulum usage, the acrylic tends not to impinge heavily on the palatal tissues. Quite often, the tissues are pink and healthy and allow for immediate placement. The Quick-Nance can also be used in conjunction with multiple other anchorage techniques, such as overcorrection, utility arches, stops at molars, Class II elastics, and early bonding of the upper arch.
Technique
A series of preformed Nance cribs (available soon from Ormco) fabricated from .032 stainless steel is used to make the Quick-Nance. The authors take an impression of the upper arch at the appointment prior to Pendulum removal. This allows for preselection of the proper Nance crib (there are 5 sizes). The .032 wire size is utilized because it is easily placed recurved to fit into the .036 lin-gual sheath. Although the wire fits quite loosely into the sheath, it is stable enough once the acrylic button has been formed. After the pendulum appliance has been removed, the patient is instructed to brush the roof of the mouth. The crib is then fitted into the lingual sheaths. Since the upper molars have been tipped back a bit, the anterior portion of the crib should be somewhat away from the palatal rugae. This is desirable at this point as you need to bend the crib down into the soft acrylic so that there is no void under the button after fabrication. The roof of the mouth is thoroughly dried with an air syringe so that the soft acrylic button doesn’t flow prematurely. A ball of Triad light-set acrylic approximately 1 cm in diameter is formed and placed up against the rugae at the greatest depth of palatal vault, and the Nance crib is bent into the acrylic ball, using a three-pronged pliers (just mesial to the molar lingual sheaths).
The button is then smoothed and contoured around the retention loop of the Nance crib, making sure that there are no voids and that all the edges have been rounded for comfort. This is best accomplished with the Teflon blade that accompanies the Triad acrylic and can be further smoothed with a moistened finger. A Kulzer light is then used to set the acrylic button. The patient is informed that the acrylic might become slightly warm and to raise their hand if it becomes uncomfortable. The acrylic is set in four 20-sec. bursts of light (1 min., 20 sec. overall), giving a few seconds between each burst to allow for cooling of the acrylic as necessary. The patient is then instructed on the cleansing and care of the newly placed Quick-Nance appliance.
Considerations
Although the Quick-Nance is the appliance of choice in many Pendulum cases, there are certainly contraindications and precautions. The Nance button cannot be placed over already inflamed or compressed tissue. When the palatal tissue is inflamed, the use of a clear immediate (Tru-Tain type) retainer for approximately one week will allow for adequate recovery of the tissue. This retainer must be placed immediately to prevent the almost instantaneous rebound. It is also not judicious to place immediate and heavy retracting forces against the Nance button, as you will surely bury the button in the tissue. Normally, the buccal segments are allowed to drift distally for six to ten weeks before any retractive force is placed upon them. If the buccal segments can be “floated” distally (not sliding along an arch wire), this will further reduce the pressure on the Nance button. It is quite common to use an upper utility arch and an elastomeric chain to free-float the buccal teeth back into Class I positions. Patience is the key here. Quite often, when the Pendulum Appliance has been used in Phase I and the permanent buccal teeth have yet to erupt, the Quick-Nance will serve as the only anchorage unit. The upper buccal teeth will drift distally as they erupt, further simplifying the overall mechanics.
Figure 3. Preformed .032 Nance Crib is placed in .036 lingual sheaths of the upper molar bands. Due to the molar tipping, the wire is away from the palatal rugae.
Figure 4. The area where the Nance button will be placed is thoroughly dried. Ideally, the acrylic button is placed at the most vertical portion of the palatal vault.
Figure 5. A small ball of light-set acrylic (approximatetly one cm in diameter) is placed under the retentive bends in the Nance crib.
Figure 6. A three pronged plier is used to bend the crib down into the soft acrylic. The bends are made on the right and left sides as close as possible to the lingual molar sheaths. Bending the crib into the acrylic prevents creating a void underneath the button.
Figure 7. The acrylic button is first flattended, shaped and rounded with moist finger pressure. It can be further contoured for comfort using a Teflon spatula (product of Dentsply Corp.).
Figure 8. The acrylic is set using a light source in four 20-second increments. To prevent heat buildup, wait five seconds between each burst of light.
Figure 9. The Quick-Nance in place immediately following removal of the Pendex Appliance.
Figure 10. Quick-Nance in place with the upper arch bonded. The upper molars have been overcorrected, stops are bent mesial to the buccal tubes and a short-term, high-pull headgear is being worn to further bolster anchorage while the upper buccal segments are retracted.
Short-term Headgear
A short-term (3-5 months) high-pull headgear worn while retracting the buccal segments. Outer bow is high to help distally upright molar roots. You must be sure of patient compliance.
Indications for Use
Sometimes we for-get that there are some cooperative patients out there. In those cases where the patient acquiesces to wear the headgear, they are told that it will be for a few months only. It is the best of both worlds. The molars are already in an overcorrected Class I relationship, so the headgear is used for anchorage while the upper buccal segments are being retracted. This is usually no more than a three-to four-month period.
Technique
Most often, a high-pull head-gear is selected because its direction of force allows for molar uprighting on the already distally tipped molars. The outer bow is kept high, above the center of resistance of the tooth, and moderate-force loads applied (500-750 grams). The headgear can be used in conjunction with other anchorage methods so that if compliance wanes, the molars will not be allowed to rebound.
Considerations
As with any headgear, if you are unsure about the ability of the patient to comply, it can be a somewhat questionable technique. We try to choose only those patients whose background and responsibility levels appear to be good. A cervical headgear should be used only in the strong muscular patterns, as it contributes to the bite-opening process and aggravates tipping of the molars.
Stops on Archwires
Indications for Use
Whenever the first leveling or continuous archwire is placed in the upper arch, bent-in or pinch-on stops should be placed mesial to the upper molar buccal tubes. This will prevent the upper molars from sliding forward along the archwire and the subsequent loss of anchorage. These first archwires start the uprighting process in the molar region that will take place over many months.
Technique
If a stainless steel archwire is used, small vertical steps or omega loops at the buccal tubes will suffice. Where a more resilient (Ni-Ti, Copper Ni-Ti) archwire is needed for leveling and bracket engagement, the archwire is placed without any stops. Pinch-on stops are then placed at the buccal tube.
Considerations
By placing a stop at the molar, any rebound will be expressed as flaring or forward movement of the upper arch. Therefore, other anchorage techniques must always be used in conjunction with stops on the archwire.
Figure 12. An omega loop placed against the molar buccal tube to prevent mesial slippage of the distally-driven upper molars. The leveling arch is .014 round wire.
Figure 13. When a resilient archwire (nickel titanium) is needed to level the upper arch, a pinch-on stop is placed following archwire placement. When placed against the molar tube, the stop will help prevent forward molar movement.
Figure 14. Molars are overtreated in this mild Class II malocclusion. The upper buccal segments are retracted using stops at the uppe molars.
Figure 15. The upper buccal segments are fully retracted, moving the space from the molar region mesial to the upper cuspids. The upper incisors are commonly retracted and intruded using the Reverse Curve TMA (TM) “T” looped archwire.
Upper Utility Arch
Indications for Use
An upper utility arch is, in effect, using the upper incisor teeth as the anchorage unit in maintaining the distalized molar position. It is the archwire of choice for several reasons. (1) The utility arch can be placed without full eruption of the buccal segment teeth, a quite common situation due to treatment timing. (2) The vertical step on the utility arch places an automatic stop at the molar. (3) There is no loss of anchorage caused by archwire friction when retracting the buccal segments. These teeth can be free-floated back into a Class I relationship when using a utility arch. (4) In Cl II, D 2 cases, the reciprocal force of incisor advancement is utilized to hold the upper molars back. (5) There is immediate torque control in the upper incisors using a square or rectangular archwire that is not achieved with a round leveling archwire. (6) If Cl II elastics are going to be one of the anchorage sources , the utility arch acts as the forward purchase point for the elastics.
Figure 16. Upper utility arch in place following overcorrection of upper molars (note position of upper cuspid). The buccal segments are being “floated” back into a Class I relationship. A Quick-Nance appliance is also being used for concert anchorage.
Technique
The upper utility arch is fabricated from either .016 x .016 Azurloy (TM) or .017 x .017 TMA ® . The molar tipback should generally just accommodate the molar’s tipping, as attempting to intrude the upper incisors at this time only serves to further tip the molars.
Considerations
Rebound at the molar region will result in upper incisor flaring and possibly an open bite. The upper utility arch is best used in deep bite patterns where the reciprocal response of incisor advancement is desirable. The upper buccal segment teeth can be free-floated distally using a light elastomeric chain attached to the molar hook. If the space between the second bicuspid and molar is large, skip one of the elastomeric links.
Push Coil Rings at Cuspid Region
Indications for Use
The most effective way to retract the upper buccal segments without forward movement of the molars is with a push coil between the lateral incisors and first bicuspids. It is ideally utilized when: (1) The upper cuspids lack enough space for eruption. (2) The upper incisors can afford to be flared to clear the lower arch for bonding.
Figure 17. Push coils in the cuspid region designed to advance the upper incisors, clear the lower arch for bonding and move the upper bicuspids distally. Note that the upper cuspids are blocked. A bent-in omega stop is also utilized at the molars.
Figure 18. Push coil springs at the cuspid region when the Pendex Appliance is still in place – commonly used to prevent excessive forward movement of the bicuspids into the erupting cuspids. It is important to bond the upper arch early whenever the upper cuspids are not in place.
Technique
An upper continuous (usually reverse curve Ni-Ti) archwire is placed with Ni-Ti push coil in the cuspid regions. A pinch-on stop at the molars prevents their forward movement along the archwire. The archwire is not cinched or tied back.
Considerations
If the upper incisors are already flared (Cl II, D I), this technique will increase the overjet. It is ideally utilized in the Cl II, D II malocclusion where it is beneficial to advance the incisors, round out the anterior arch form and create room for blocked-out cuspids.
Early Bonding of the Upper Arch
Indications for Use
Increasing anchorage in the upper arch by adding tooth units is a very effective way to maintain the gain. Typically, the upper bicuspids have a tendency to come forward slightly (about 1/3 of the movement) while the upper molars move distally. This is particularly true when the upper deciduous cuspids have been lost and the permanent cupids are either unerupted or blocked out of the arch. This is very common due to the timing of Pendulum therapy and the tendency for blocked cuspids in Class II malocclusions. The bicuspids can very easily come forward, further impacting the unerupted cuspids. It is very important that the cuspid eruption site either be maintained or increased during the Pendulum phase of therapy.
Figure 19. Anterior view of early bonding of the upper arch while the Pendex Appliance is still active. The archwire is sectioned at the midline to allow for expansion. The sections terminate in the bicuspid areas. No attempt is made to align the upper incisors until expansion is completed; then a continuous archwire can be placed.
Figure 20. Occlusal view of sectional leveling arches with Pendex in place. Note push coil in upper left cuspid region. This technique pits the entire upper arch against the upper molars to bolster anchorage and prevent undue forward movement of the buccal teeth.
Technique
The upper arch is bonded at the same time that the Pendulum Appliance is placed. A push coil is added between the lateral incisors and first bicuspids and a sectional leveling wire (.016 Ni-Ti) is placed to the midline. These left and right sectional wires are stopped at the midline so that the mid-palatal jackscrew can be activated and upper arch expansion can occur. Using a continuous arch prevents the maxillae from separating at the midline.
Considerations
In severe Cl II, D 1 malocclusions with a large overjet where the upper incisors are already flared, early bonding can further exacerbate the incisor proclination. Early bonding is ideal in the Cl II, D 2 malocclusion, however, as the reciprocal forward movement of the incisors clears the lower arch for future bonding, improves incisor torque, opens space for erupting cuspids, frees the mandible from distal displacement and greatly enhances upper molar movement. All of these are quite desirable responses in the Cl II, D 2 brachyfacial malocclusion, where midfacial orthopedics can create maxillary deficiency with negative esthetic consequences.
Class II Elastics
Indications for Use
Class II elastics are quite effective as an anchorage source when it is desirable to advance or develop the lower arch forward. The retruded lower arch is quite common in strong facial patterns and can be utilized quite effectively to help achieve overall facial balance. Early use of Class II elastics means early bonding of the lower arch, which can be difficult with the locked-in overbite. A utility arch or reverse curve Ni-Ti is often used at the very outset of Pendulum therapy to clear the lower arch for bonding.
Figure 21. Class II elastics worn to an upper utility arch while the upper buccal segments are being retracted. The lower arch is bonded as soon as possible and a rigid TMA ® archwire placed to carry the elastics. This is the anchorage source when it is desirable to develop the lower arch forward.
Technique
Class II elastics are worn to an upper continuous archwire or, more ideally, to an upper utility arch. The utility arch has the added benefit of delivering the Class II elastic forces directly to the upper molar through the buccal arm, freeing the buccal teeth for segmental movement.
Considerations
Since one of the major advantages of Pendulum therapy is that the lower arch is not strained during Class II correction, proper visualization of the final location of the lower arch is important before using Class II elastics for anchorage very early in treatment. In general, Class II elastics are beneficial in strong muscular patterns (brachyfacial) and detrimental in the weaker ones (mesofacial).
Upper Lip Bumper
Indications for Use
The upper lip bumper is a seldom used yet viable source of stabilization in the upper arch. Although it cannot be relied upon as the sole anchorage unit, it is a good adjunct.
Figure 22. Upper lip bumper in the vestibule superior to the upper incisor brackets. A 5mm step-up at the upper molars allows for a more ideal positioning of the lip bumper.
Technique
An .040 lip bumper with a soft covering in the labial vestibule is adapted above the upper incisor brackets. Normally, a vertical step of 5-8mm is bent mesial to the upper molar headgear tubes. The bumper is tipped back passive to the upper molar position to locate the anterior portion properly in the vestibule and can be tied in.
Considerations
The upper lip bumper is an ideal anchorage unit when one is not actively trying to retract the upper buccal segments. When the buccal teeth can be “floated” distally or in late mixed dentition, the upper lip bumper can be utilized. It is also used in conjunction with other anchorage sources.
Clear (slipcover) or Hawley-type retainers
Indications for Use
After Pendulum Appliance removal, it is often beneficial to place a retainer as an interim device for other mechanics. If the tissues are unduly inflamed or irritated, it’s beneficial to allow a week or two of tissue rebound to occur prior to placing a more secure anchorage appliance, such as a Quick-Nance. A clear-type retainer (slip-cover) is ideal because it can be made immediately on a Biostar machine and is easily and cheaply fabricated. It also has the benefit of not touching the palatal tissue, permitting it to heal easily. The clear retainer is also an excellent interim retention device while a Bionator or Herbst appliance is being fabricated. A Hawley retainer is also used as a retention device in Phase 1 therapy.
Figure 23. A clear retainer placed immediately after removal of Pendex appliance. Utilized when tissues are too inflamed for Quick-Nance placement or as a feeder to Bionator or Herbst ®
therapy.
Technique
A slipcover retainer is fabricated while the patient waits in the office after appliance removal. The impression must go all the way over the first molar and touch the tissue in the interspace to prevent relapse. The patient is instructed to wear the slipcover retainer full-time until scheduled for the subsequent form of anchorage.
Considerations
Again, compliance can be a problem. If the patient fails to wear the retainer for even a few days, the rebound of the upper first molars can be enough to keep it from fitting over the teeth. This is particularly true with the clear retainer because the adaptation to the teeth is so critical.
Bionator
Indications for Use
The Bionator or removable functional appliance is used for Pendulum anchorage in those brachyfacial types with short mandibular corpus length. It serves to maintain the distalized molar position while developing the lower arch forward.
Figure 24. Bionator in place following expansion and distalization with a Pendex Appliance. A clear retainer used for interim stabilization. The molars are now in a super Cl III molar relationship.
Figure 25. Occlusal view of the upper arch while the Bionator is being utilized. An acrylic block fills in the space between the upper deciduous and permanent molars (although a small clip-spring can also be used). This is adjusted as the upper buccal segments erupt distally.
Figure 26. Facial and occlusal changes following Pendex and Bionator wear. Total treatment time to date: 13 months. Upper buccal segments are being retracted to severely overcorrected molar position. A very dramatic response in this severe Class II, D I malocclusion.
Technique
After the Pendulum Appliance is removed, impressions and construction bite for the Bionator are made. A second impression of the upper arch is taken and a clear retainer made and placed. The Bionator is fabricated with a clip spring mesial to the molar or the bicuspid-molar space is filled with acrylic. With the Bionator in place, the molar will be in a full step (almost a full tooth) Class III relationship. This allows the upper buccal segments to erupt in more distal positions. The space is maintained until full eruption of the dentition and then released for space closure.
Considerations
The functional appliance requires cooperation, so it is intended for those with high responsibility levels.
Short-haul Herbst appliance
Indications for Use
The short haul Herbst (Herbst is a registered trademark of Dentarum, Inc.) appliance is intended mainly as a short-term anchorage appliance following Pendulum therapy (although many clinicians consider it the Herbst appliance of choice for its simplicity and its functional and growth benefits). It is utilized where headgear cooperation is questionable and the permanent dentition is either in place or almost erupted. The appliance is simplified greatly for comfort by attaching to the lower first bicuspids and upper molars only. This version of the classical Herbst appliance is easy to use, allows for adjunctive bonding and space closure of the upper arch and supplies some of the classical functional responses commonly attributed to this fixed functional appliance. In effect, it is like having a headgear on full time while the upper buccal segments are being retracted to the molars. Although there is some strain on the lower arch, we have found it to be minimal, as the Herbst appliance ultimately puts very little strain on the appliance itself once muscle memory has been altered.
Figure 27. Lower unit of the short-haul Herbst in place. An .050 lingual arch is soldered and Herbst hubs placed on the mesiogingival of lower first bicuspid crowns.
Figure 28. Components of the short-haul Herbst. This simplistic Herbst appliance is easy to fabri-cate and comfortable for the patient. Note small Peerless® tubes on the upper molar crowns that can be used to retract the upper buccal teeth.
Figure 29. Frontal view of short-haul Herbst appliance in place following Pendex treatment and prior to full bonding in the upper arch. Patient in treatment for five months.
Technique
To fit crowns on these teeth, the upper molars cannot be severely tipped distally. We commonly move the upper molar back into an ideal Class I relationship (don’t overcorrect it excessively), and although some distal tipping is allowable, it should be minimized. The Pendulum Appliance is removed and the slipcover is fabricated. Upper first molars and lower first bicuspids are fitted with stainless steel crowns. The upper hubs are welded to the distal of the upper molar crowns and impressions taken to fabricate the short-haul Herbst appliance. Small Mini-Peerless tubes are welded to the mesial of the upper molar stainless steel crowns in order to retract the upper buccal segments. A short lingual arch (.050 stainless steel) is soldered to the lower first bicuspids for stability. The upper arch is bonded and retracted to the upper molar, using the short-haul Herbst for anchorage. The Herbst appliance can be left in longer if needed for other functional and growth responses, but its main purpose is to work as an anchorage unit while retracting the upper arch.
Considerations
Once the upper buccal segments have been retracted, there will be a large space between the upper lateral incisors and upper cuspids. The upper incisors will be in an ideal overbite and overjet relationship because the mandible is advanced to hold molar position. The upper incisors cannot be retracted until the Herbst appliance is removed and overjet recurs. The short-haul Herbst is often left in during the alignment and leveling phase in the lower arch. Then the upper incisors are retracted with a Reverse Curve TMA with “T” Loops closing arch to open the bite and consolidate upper spaces.
Long-Haul Herbst Appliance
Indications for Use
The long-haul Herbst appliance is used to accomplish long-term functional responses common to Herbst appliance therapy and also to serve as the anchorage unit to hold the upper molars back following Pendulum therapy. This appliance is most commonly used in conjunction with the Pendex Appliance in Phase 1 therapy, long before the permanent upper buccal segments have erupted. The most typical case would be the brachyfacial Class II that has a short corpus length and retruded lower face. In these cases, it is not ideal to retract or orthopedically reduce the maxillary complex (à la headgear) and yet dental movements are acceptable and desirable.
Technique
The cantilever Herbst appliance is most commonly used for this function. Following use of the Pendex appliance, where maxillary expansion is accentuated and distal tipping of the molars minimized, crowns are fitted and the cantilever Herbst appliance fabricated. A slipcover retainer is placed the day of Pendex removal to assure maintenance of the dental and expansive changes.
Considerations
The long-haul Herbst appliance must be in place long term (over 12 months) to garner some of the orthopedic and orthodontic results attributed to this appliance. This combination of Pendex and long-term Herbst appliance is a very dynamic Phase 1 therapy that holds great potential in early treatment. The results to date have been very encouraging and improvements in technique come on almost a daily basis.
Previous articles on the Pendulum/Pendex™ appliance:
Contributed by:
James J. Hilgers, D.D.S., M.S.
