The Herbst Appliance - The Workhorse of Dental Sleep Medicine

Back in the Day
The acrylic Herbst appliance was originally designed as a TMJ treatment device. In the 1980s, Dr. Eugene Williamson conducted courses demonstrating its effectiveness in managing TMJ disorders. He effectively demonstrated its ideal use by presenting detailed evidence from real cases that he had treated and meticulously documented.

Beneficial for both TMJ and Sleep Apnea
In 1991, Dr. Robert Ricketts, Dr. Edward Spiegel and I attended Dr. EuGene Williamson's seminar in Atlanta, Georgia. I had the opportunity to attend the course with Dr. Ricketts, who was also training Dr. Ed Spiegel, a dentist learning how to treat TMD.  Later on, I would come to feel like it was all divine intervention. During the lectures, Dr. Williamson shared an unusual observation with the audience, saying, "The strangest thing happened, my patient told me that while using the Herbst appliance for TMJ issues, their bed partner noticed that they also stopped snoring when the appliance was in their mouth. I then realized that several of my other patients, who were heavy snorers, also reported that they stopped snoring while wearing the Herbst appliance. I’m not sure why, but it seems to be a positive side effect of treating TMJ with the Herbst appliance.” Dr. Williamson then continued, “Remember, I originally prescribed it for TMJ treatment.” At that moment, Dr. Ricketts turned to Ed Spiegel and said, "there you go, Fast Eddie—there's your sleep apnea treatment appliance! That’s what must be happening, it's beneficial for both TMJ and sleep apnea."

“The Herbst appliance is keeping the airway open throughout the night." Then, Dr. Ricketts turned to me and said, "Dave, I’d start ramping up production on that Herbst appliance. I’d also modify it to function as a sleep apnea device and make sure it’s extra strong because I have a feeling you’re going to be making a lot of them!"

As a result, we went on to become the largest manufacturer of the Herbst appliance in the United States; we became synonymous with the Herbst name. Dr. Ed Spiegel traveled across the country, telling everyone, "Use Gergen's Orthodontic Lab for all your Herbst appliances." He consistently praised our work, saying, "they make the best Herbst appliance I’ve ever seen." This happened during all of his training sessions nationwide. As the knowledge and popularity of the Herbst appliance spread rapidly, Dr. Ed personally asked me to assist him with his dental sleep training program.

The intricacies of the Ricketts Phonetic Bite
Dr. Ricketts gave us his phonetic bite for sleep; it utilizes phonetically the numbering system starting with 55 and ending with 75, counting by ones while noticing the vertical openings on 5s/ 8s and 9s. For the AP adjustments, we were supposed to pay close attention to the number 66, which is the double “s” sound. As an additional test, he used the name “Shun” if he didn't like the mandible’s position while observing the double 66 sound. The reason Dr. Ricketts did that is that the “N” sound is a straight vertical drop in speech, and the tongue also goes to the incisive papilla. It’s so useful because wherever you're at, using the “N”, allows that straight vertical to drop. Then, if the numbering system doesn't give him the AP outcome that he wants, he would then check out the patient saying the word “Shun” multiple times (which is the “Sh” sound… again).

Dr. Ricketts had a knack for adding a bit of drama to his training sessions. He would tell us to think of it like dealing with kids who are misbehaving and that you want them to quiet down. You have to remember, this was back in the days of corded phones that plugged into the wall; thus, you couldn’t just walk away into the next room. Then he would continue, “put or hang the phone up while giving me a hard “Sh” sound and then see where that sound takes you during speech.” Many of the more seasoned and experienced sleep doctors often recall when I first visited their offices to train them with Dr. Rickett's phonetic bite method.

Work and Marriage
With all the sales work that Dr. Spiegel and I were doing, my ortho lab became extremely busy. I suggested hiring someone from one of the offices we had trained. We decided to bring on Courtney Meier, a dental assistant from Denver, to help out. She was exceptional at taking sleep bites, making impressions, and she also had incredible leadership skills. She was also an excellent instructor for our office protocols. In addition to her professional talents, she was a beautiful women and as I was single, I couldn't help but think that she would be the perfect wife for someone like me. (“After many years, David's family and friends are still waiting for him to make it permanent”). Courtney and I have known each other since 2011. It’s been 14 years and still waiting!

Courtney and David in 2011. 14 years and still waiting!

We also hired Jeremy Woods, an orthodontic technician from Gergens Orthodontic Lab. With him on board, Dr. Spiegel remarked that we could now double the number of offices we were training.

"Dave, you go one way, and I'll go the other." The system was working out exceptionally well. Dr. Spiegel would handle the didactic training, and then move on to the next office. Meanwhile, Courtney and I would come in to take bite records, manage the record-keeping, set up billing, and follow up on the appliances that had already been made.

With so many offices being trained in sleep apnea treatment, the success rates were skyrocketing, leading to incredible growth. Because there were so many successful cases and appliances made in the 90s, the federal government decided to do an impact study.

PDAC Study
PDAC initiated a study on all the appliances available on the market, but they didn't inform us about it until the study was completed. Furthermore, none of the labs were aware of what was happening;  but,  after six years, we all finally found out. They discovered that the Herbst appliance not only excelled in comfort and allowed for lateral movement with ease, but it also facilitated synovial joint fluid movement and proved to be effective in helping the recapturing of the disc (in cases of TMJ disc displacement). The downward and forward trajectory made it ideal for TMJ treatment, ensuring the disc remained properly positioned and could be effectively recaptured.

Multifactorial Benefits
The Herbst appliance provided multifactorial benefits, including improved airway function by keeping the mandible in a downward and forward position for a more open airway, as well as offering significant TMJ advantages. This downward and forward trajectory was also ideal for avoiding any pinching of the retro-discal tissue, known as the “Bilaminar zone.” This is the zone where the auriculo-temporal nerve (branch of Cranial Trigeminal V run) runs and is so helpful to patients suffering from TMD to have the condyle be downward and forward from this zone.

PDAC reviewed over 70 appliances and dismissed them all. Ultimately, they narrowed down their selection by reviewing all of the existing evidence and appliances at the time. The Herbst appliance emerged as the clear winner for all the reasons mentioned. Furthermore, because the Herbst allows for freedom and forgiveness in slop and minor inaccuracies, it makes sense why they selected the way they did. Also, that is very important due to border movements that are actively going on during the night. This adaptability of the Herbst design is especially important during REM sleep.

During REM sleep, when the body is paralyzed and patients are dreaming, it becomes challenging to determine the exact force vectors and sleep bruxism loads. They can occur in any direction, from AP, lateral, vertical, pitch, roll and yaw. Add gravity to the equation, and those muscles that are atonic will be more likely to collapse affecting the airway in REM even more. It can be catastrophic to TMJ patient now dealing with bruxism and load / forces due to airway problems.  The patient shifts from parasympathetic to sympathetic with “fight or flight” on top of dealing with orofacial pain, trigger points, and migraines.

It's noteworthy that all the pioneers and leaders in the TMJ field exclusively use Herbst-type appliances when treating sleep apnea. The PDAC study was extensive and conducted over a significant period. That convinced me of the substantial merit behind their decision to establish guidelines that shaped Medicare dental sleep medicine treatment and eventually,  approving Herbst-style appliances. Reflecting on it now, I think to myself, "it’s very interesting and powerful on just how the government operates."

A Tale of Two Labs
Next, they excluded all other labs except for two: my lab, Gergen’s Orthodontic Lab, and Space Maintainers Lab (SML) in California. The reason was that we had the lowest breakage rate in the nation, under 2%. At that time, all other labs in the country were no longer permitted to produce Medicare appliances. Only Gergen's Orthodontic Lab and Space Maintainers SML were allowed, as the Herbst was the only appliance qualified for Medicare due to its high success rate.

Gergen’s Orthodontic Lab experienced record years from 2012 to 2016. We remain a top manufacturer in the country for the Acrylic Herbst appliance for Sleep Apnea. Our appliances consistently fit and we have a breakage rate of less than 1%! Being able to employ over 100 people without ever having sales reps speaks volumes about the success and quality of our work.

For the Record
Allow me to explain why the Herbst was ranked as the number one appliance and deemed most successful by the federal government’s assessment. The key reason is that the appliance has built-in slop, allowing for flexibility and adaptability. With the Herbst device, you’ve got two major factors that give it success and the first factor that allows the success is, you can miss the bite a little to the left or a little to the right and appliance is still forgiving with that issue. The nature with the freedom built in for slop in the Herbst system allows for corrections in the appliance itself. The durability of the arms and freedom in lateral dimension permits forgiveness in slop or inaccuracies made when bites and impressions were taken.

A leading expert in sleep medicine, Dr. Jerry Hu from Soldotna, Alaska reminds us that “many dental offices rush through taking impressions and scans,” even though Dr. Hu advises against it in his lectures. However, when they do rush, appliances that allow a little flexibility in slop or inaccuracies can help patients experience more freedom in excursions and border movements, resulting in greater comfort, better compliance, and improved long-term success rates. Nearly all pain management Sleep/TMJ experts agree that a well-made Herbst appliance is the “workhorse” of customized oral sleep appliances. The Herbst design allows for border movements, like two glass slabs sliding over each other, and offers forgiveness in slop—qualities that other appliances, such as dorsal fin devices, lack.”

I should also mention that many years ago, while I was in Australia, several well-known oral appliance companies in the industry approached me to manufacture their dorsal fin-type appliances. However, when I reviewed the evidence-based data and saw the alarming breakage rates, I was completely turned off by dorsal fins. Their breakage rates were appalling. In fact, Dr. Wayne Halstrom once showed me a radiograph of a broken dorsal fin that had been aspirated by a patient. I was shocked. Over the years, the only way I felt comfortable making a dorsal fin appliance for my doctors was by redesigning it to be stronger and more reinforced, which led to my version—Dave's Double D. The fins in this type of appliance need extra reinforcement and durability, and I’m glad I put in the effort to address that issue. However, even the best dorsal fin can’t replicate everything a Herbst appliance can do, particularly when it comes to promoting the flow of synovial fluid in the joint.

Another reason the Herbst appliance is superior is that it avoids the issues associated with immobilizing a joint. When a joint is immobilized, such as with certain appliances, the flow of synovial fluid is restricted, leading to limitations and potential problems. This is similar to putting a brace on a knee that restricts lateral movement, which can result in decreased synovial fluid flow. Over time, this can lead to TMJ issues. If a patient already has TMJ problems, immobilization can exacerbate them, as the body’s first response is to defend itself and attempt to open the airway. Muscles of mastication will fire for 11 to 13 seconds and fire extremely hard, and we will see in that with linear pattern grinding, grinding away at the teeth, and that causes nocturnal bruxism. All this as you know, is just the body going through the motions to fight and struggle to have a patent airway. This is why the Herbst is superior to other appliances; it’s because it addresses that grinding in that lateral movement and with the freedom it provides, it makes it second to none for sleep apnea appliances.

David Gergen
CEO, Pro Player Health Alliance
602-478-9713
gxployer@aol.com