An Evaluation of Two-Phase Treatment

With the Herbst Appliance and

Preadjusted Edgewise Therapy
Mesou Lai and James A. McNamara, Jr

The purpose of this study was to evaluate the skeletal and dentoalveolar
changes occurring during two-phase orthodontic treatment. A cephalomet-
ric study of Class II correction was carried out in 40 subjects (20 females, 20
males) w h o had been treated w i t h the acrylic-splint Herbst appliance
immediately followed by a second phase of preadjusted edgewise therapy.
The average age at the start of Herbst therapy was 12.5 _+ 0.8 years for
females and 13.6 ± 1.2 years for males. Descriptive cephalometric data were
compared w i t h the normative values derived from the University of Michi-
gan Elementary and Secondary School Growth Study. Control values were
generated for each of the 40 Herbst patients based on gender, initial age, and
duration of treatment. The results of this study indicate that the Class II
correction achieved during Phase I treatment w i t h Herbst appliance was due
mainly to an increase in mandibular length, as well as distal movement of the
maxillary molars and mesial movement of the mandibular molars and
incisors. The accelerated mandibular growth rate observed during Herbst
therapy was followed by a diminished growth rate during the edgewise
phase that was less than control values. The overall increase in mandibular
length was slight ( - 1 mm), but significantly greater than control data for the
whole group and the male subgroup; however, it was not significantly
different between the treatment group and control data in the female
subgroup. There were no significant treatment effects on lower anterior
facial height and the mandibular plane angle at the end of either phase of
treatment. The skeletal changes contributed to 55% of the molar correction
during the Herbst therapy, whereas at the end of the second phase of
treatment, skeletal change accounted for 80%. Significant anteroposterior
dentoalveolar rebound was seen during the edgewise phase. (Semin Orthod
1998;4:46-58.) Copyright © 1998 by W.B, Saunders Company

A contemporary strategy for the treatment of Class phase of fixed appliance treatment. Supposedly, the
II malocclusion features an initial phase of func- underlying skeletal discrepancy is corrected during
tional appliance therapy followed by a subsequent the first phase of treatment, and detailed tooth align-
ments are performed during the later fixed appliance
phase.
From the Graduate Orthodontic Program, The University of Among the various types of functional appliances
Michigan, Ann Arbor Michigan, and private practice of orthodon- available today, the Herbst appliance is thought to be
tics, Yorktown Heights, New York. an effective device to correct Class II malocclusions.
This research was funded in part by USPHS Grant DE-08716. The Herbst appliance, developed by Emil Herbst 1,2 in
Based on this research, Dr Lai was g~ven an Award of Special Merit 1905, is a bite-jumping device that features a bilateral
by the American Association of Orthodontists.
telescoping mechanism that keeps the mandible in a
Address correspondence to James A. McNamara, DDS, PhD,
Department of Orthodontics and Pediatric Dentistry, School of continuously protruded position. This appliance is
Dentistry, University of Michigan, Ann Arbor, MI48109-1078. designed to be worn 24 hours a day, and the treatment
Copyright© 1998 by W.B. Saunders Company effect can be achieved in a relatively short period of
1073-8746/98/0401-000658. 00/0 time (6 to 12 months).3

46 Seminars in Orthodontics, Vol 4, No 1 (March), 1998: pp 46-58

 Herbst and Edgewise Treatment 47

During the last 20 years, a n u m b e r of clinical force on the u p p e r posterior teeth and an anteriorly-
studies have evaluated the effects of the various types directed force on the lower anterior teeth, resulting in
of Herbst appliances on the craniofacial skeleton. distal tooth m o v e m e n t s in the maxillary buccal seg-
Both skeletal and dentoalveolar effects have b e e n ments and mesial tooth m o v e m e n t s in the mandible.
d o c u m e n t e d , regardless of the m e t h o d of a t t a c h m e n t T h e m a n d i b u l a r incisors have b e e n shown to procline
of the Herbst m e c h a n i s m to the dental arches (eg, during Herbst treatment. 3,4,u,15 A n analysis of vertical
banded, 3,4 cast splint, 5 acrylic splint, 6,7 and stainless dentoalveolar changes revealed that the u p p e r first
steel crownsS,9). molars and lower incisors are inhibited from e r u p t i n g
Most previous investigators have r e p o r t e d only d u r i n g treatment, 4,6,u whereas the e r u p t i o n o f lower
limited effects of the Herbst appliance on the maxil- first molars is n o t affected significantly. 6,7,u
lary complex. W h e n change in maxillary position T h e t r e a t m e n t effects p r o d u c e d by the Herbst
(SNA) was evaluated, the forward growth of maxilla appliance have b e e n well d o c u m e n t e d in the litera-
relative to nasion was slightly less in the t r e a t m e n t ture; however, the t r e a t m e n t changes o c c u r r i n g dur-
groups in comparison with controls. 3,4,7,1°,u In con- ing two-phase t r e a t m e n t have n o t b e e n described
trast, the measures of maxillary size (Co-ANS and previously. T h e purpose of this study was to evaluate
Co-Point A) indicated that the Herbst appliance did the skeletal and dental changes d u r i n g two-phase
not affect the growth of the maxilla significantly. 6'7'12 treatment: the acrylic-splint Herbst followed by a
Increases in the length of the mandible, ranging preadjusted edgewise appliance. In particular, this
from 1.3 m m to 3.5 ram, have b e e n d o c u m e n t e d in study emphasized the posttreatment impact of the
previous clinical studies of the Herbst appliance in acrylic Herbst appliance on subsequent m a n d i b u l a r
c o m p a r i s o n with u n t r e a t e d controls. P a n c h e r z S'13 growth, vertical control, and dentoalveolar move-
f o u n d that the average increase in m a n d i b u l a r length ment.
of 10 growing patients e x c e e d e d that of 10 u n t r e a t e d
subjects by 2.2 m m over a 6-month period. A subse-
q u e n t study by Pancherz 4 also showed an additional Subjects and Methods
2.0 m m of length increase. In an investigation of Sample Selection
headgear-Herbst treatment on a group of patients
with severe Class II malocclusions in the early m i x e d T h e c e p h a l o m e t r i c records of Class II, division 1
dentition, Wieslander 5 r e p o r t e d that within a 5-month subjects who u n d e r w e n t t r e a t m e n t with a Herbst
interval, m a n d i b u l a r length increased 2.0 m m m o r e in appliance immediately followed by a preadjusted edge-
a treated group than in an u n t r e a t e d control group. wise appliance were analyzed. T h e Herbst appliance
Additional m a n d i b u l a r growth of 1.3 m m was re- used was of the acrylic-splint type 16,17 that had occlusal
p o r t e d by Valant and Sinclair 11 in a 10-month treat- coverage from the canines to the first molars in the
m e n t period. McNamara et al 6 r e p o r t e d an average of maxillary arch and full occlusal and incisal coverage in
2.7 m m m o r e growth in patients wearing the acrylic- the m a n d i b u l a r arch. A b o u t 75% of the maxillary
splint Herbst than in an u n t r e a t e d group, whereas splints were removable, with the r e m a i n d e r bonded,
Windmiller 7 r e p o r t e d an additional 3.5 m m of man- whereas the m a n d i b u l a r splint always was removable.
dibular length increase. In about half of the appliances, a midpalatal expan-
Previous studies have shown that Herbst appliance sion screw was i n c o r p o r a t e d into the appliance and
t r e a t m e n t typically has a bite o p e n i n g effect. activated one quarter t u r n once per week until appro-
Pancherz 3,4 observed an increase in lower anterior priate expansion of the maxilla was achieved.
facial height p r o d u c e d by the b a n d e d Herbst appli- T h e samples were selected f r o m an original group
ance. In the investigation of t r e a t m e n t effects with the o f 135 consecutively-treated patients who u n d e r w e n t
acrylic-splint Herbst, both M c N a m a r a et al 6 and Wind- Herbst appliance therapy in one of two faculty practic-
miller 7 r e p o r t e d a significant increase in lower ante- es i o r in the Graduate O r t h o d o n t i c Program at the
rior facial height in the t r e a t m e n t groups. These University of Michigan. ii To be i n c l u d e d in this study,
studies did n o t show significant t r e a t m e n t effect on subjects had to m e e t the following criteria:
the mandibular plane, presumably because of an
1. a p r e t r e a t m e n t Angle Class II, division 1 malocclu-
increase in ramus height posteriorly. 6,7 In a study of
sion defined by at least an end-to-end molar relation-
vertical changes p r o d u c e d by different types of Herbst
ship;
appliances, Schiavoni et a114 f o u n d the b a n d e d type as
used by Pancherz did not modify the vertical growth
pattern significantly, whereas the acrylic-splint type
allowed an upward and forward rotation of the man- iDrs James A. McNamara, Jr. and Patrick J. Nolan
dible. (N = 120) and Dr RichardA.Johnson (N = 5).
In the dentoalveolar region, the Herbst bite- iiSubjects were treated under the supervision of Dr J.A.
j u m p i n g m e c h a n i s m produces a posteriorly-directed McNamara, Jr (N = 10).
48 Lai and McNamara

2. n o p e r m a n e n t t e e t h e x t r a c t e d b e f o r e o r d u r i n g Table 2. Average S t a r t i n g Age

treatment;
Group N 7"1 7"2 T3
3. two-phase t r e a t m e n t - - H e r b s t t h e r a p y i m m e d i a t e l y
followed by p r e a d j u s t e d edgewise a p p l i a n c e treat- Total 40 13y0m _+ 13m 14y0m -+ 13m 15y6m -+ 15m
ment; Female 20 12y6m -+ 10m 13y6m + l l m 14y9m -+ 12m
Male 20 13y7m-+14m 14y7m-+13m 16y2m-+ 13m
4. t h r e e consecutive c e p h a l o g r a m s , p r e - H e r b s t (T1),
i m m e d i a t e post-Herbst (T2) , a n d postedgewise (T3).

N o subject was e x c l u d e d f r o m t h e study o n t h e H e r b s t patients, b a s e d o n gender, age, a n d d u r a t i o n of

basis of c o o p e r a t i o n . Ninety-five o f the 135 subjects t r e a t m e n t . 19 T h e n o r m a t i v e values p r o v i d e d in t h e
were e l i m i n a t e d f r o m f u r t h e r c o n s i d e r a t i o n a c c o r d i n g U M G S d a t a are r e p o r t e d in yearly i n c r e m e n t s (11 to
to t h e e x c l u s i o n a r y criteria o u t l i n e d in Table 1, 12, 12 to 13, etc.). C o n t r o l data were calculated for
leaving a sample o f 40 p a t i e n t s for f u r t h e r analysis. e a c h individual, b a s e d o n the ages at w h i c h the
This sample consisted o f 20 females a n d 20 males. For c e p h a l o g r a m s were taken. To estimate a m e a n growth
females, t h e average age at t h e start of H e r b s t t h e r a p y i n c r e m e n t specific to e a c h subject's exact age, it was
was 12.5 -+ 0.8 years, with a r a n g e f r o m 11.2 years to necessary to i n t e r p o l a t e by p r o p o r t i o n a l parts.
13.8 years; for males, 13.6 _+ 1.2 years, with a r a n g e T h e U M G S c e p h a l o g r a m s have a s t a n d a r d i z e d
f r o m 11.8 years to 15.8 years. T h e average ages at T1, 12.92% e n l a r g e m e n t . F o r t h e c u r r e n t study, all l i n e a r
T2, a n d T3, as well as t h e m e a n t r e a t m e n t intervals for m e a s u r e m e n t s were c o n v e r t e d to 8%.
the whole s a m p l e a n d its two s u b g r o u p s are s u m m a - N o r m a t i v e data were n o t available for t h e m e a s u r e s
rized in Tables 2 a n d 3, respectively. t h a t u s e d t h e F r a n k f o r t H o r i z o n t a l because, as origi-
nally digitized in t h e U M G S sample, A n a t o m i c a l Po-
r i o n was n o t used. P o r i o n was d e f i n e d as " t h e mid-
Control Standards
p o i n t o f tl~e line c o n n e c t i n g t h e m o s t s u p e r i o r p o i n t
To c o m p a r e t h e t r e a t m e n t c h a n g e s with t h e g r o w t h o f t h e radiopacity g e n e r a t e d by e a c h of the two ear
c h a n g e s t h a t would have o c c u r r e d w i t h o u t t r e a t m e n t , rods of t h e cephalostat. ''18 N o r m a t i v e data were also
n o r m a t i v e values derived f r o m T h e University of n o t available for t h e m e a s u r e s of Class II c o r r e c t i o n . 2°
M i c h i g a n E l e m e n t a r y a n d S e c o n d a r y School G r o w t h
Study ( U M G S ) i s were used. T h e s e values are p o p u l a - Cephalometric Analysis
tion n o r m s in t h a t t h e u n t r e a t e d subjects were se-
lected solely o n t h e basis o f a t t e n d a n c e at the Univer- Serial lateral c e p h a l o g r a m s initially were h a n d - t r a c e d ,
sity School, a l a b o r a t o r y school o n the A n n A r b o r with t h e films of a given series analyzed at a single
campus. All m a l o c c l u s i o n types are r e p r e s e n t e d in this sitting by the same investigator (M.L.). T h e tracings
sample, a l t h o u g h t h e r e is a bias toward Class II were verified by a n o t h e r investigator (].A.M.), a n d any
m a l o c c l u s i o n a n d i n c r e a s e d lower a n t e r i o r facial disparities in l a n d m a r k l o c a t i o n were resolved by
height. T h e c u r r e n t digitized U M G S s a m p l e size n o w m u t u a l a g r e e m e n t . T h e l a n d m a r k s were digitized, a n d
is nearly d o u b l e t h e original n m n b e r of subjects 39 variables were g e n e r a t e d , 26 l i n e a r a n d 13 angular.
(N = 83) d e s c r i b e d in t h e atlas o f R i o l o et aP s t h a t was T h e H e r b s t g r o u p was divided i n t o two g r o u p s accord-
p u b l i s h e d in 1974. ing to g e n d e r to evaluate t h e a m o u n t o f m a n d i b u l a r
N o r m s for initial values a n d e x p e c t e d c h a n g e growth, r e p r e s e n t e d by t h e m e a s u r e C o n d y l i o n -
d u r i n g t r e a t m e n t were calculated for e a c h o f t h e 40 G n a t h i o n . T h e c h a n g e in t h e h o r i z o n t a l a n d vertical
positions o f t h e m o l a r s a n d incisors was d e t e r m i n e d
Table 1. S u m m a r y o f S a m p l e Selection a c c o r d i n g to t h e m e t h o d d e s c r i b e d previously by
M c N a m a r a et al. 6,21
Parent Sample 135 T h e m e t h o d for d e t e r m i n i n g skeletal a n d d e n t a l
Exclusionary Criteria c o n t r i b u t i o n s to Class II c o r r e c t i o n was a m o d i f i e d
In active treatment at the time records were version of J o h n s t o n ' s p i t c h f o r k analysis. 2° Regional
reviewed 17 s u p e r i m p o s i t i o n s were used to quantify the source of
No fixed appliance after Herbst therapy 13
c o r r e c t i o n at t h e level o f t h e f u n c t i o n a l occlusal plane:
Relocation during active treatment 6
Other treatment between Herbst therapy and d i s p l a c e m e n t o f maxillary a n d m a n d i b u l a r basal b o n e
fixed appliance treatment 14 relative to the cranial base, d i s p l a c e m e n t of t h e
Surgical cases 5
Molar relation less than 1/2 cusp Class II 5
Extraction of teeth 3 Table 3. Average T r e a t m e n t T i m e
Incomplete cephalograms 29 Group N TFFz T2-T3 Tz-T3
Poor film quality 2
Cephalogram with Herbst appliance in place 1 Total 40 12m -+ 4m 17m -+ 6m 29m + 8m
Female 20 12m -+ 4m 15m + 4m 27m + 6m
Sample Satisfying the Criteria 40 Male 20 12m + 4m 19m -+ 7m 31m -+ 9m
 Ho'bst and Edgewise Treatment 49

mandible relative to the maxilla (apical base change Analysis of Treatment Effects
or ABCH), and dental m o v e m e n t relative to maxillary
and m a n d i b u l a r basal bone. T h e functional occlusal Descriptive and inferential statistics for changes dur-
plane was used because it is less affected by t r e a t m e n t ing each interval (T1-T2, T~-T3, and TrT~) are summa-
changes in incisor position. ~°,22 rized in Tables 5, 6, and 7. T h e differences between
T h e skeletal and dental c o m p o n e n t s of Class II the m e a n changes in the two groups constitute the
molar and overjet correction were m e a s u r e d along a t r e a t m e n t effects.
m e a n functional occlusal plane (MFOP), 2° the aver- Maxillomandibular relationship. In the t r e a t m e n t
age of the pre-Herbst (T1) and post-edgewise (T~) group, significant i m p r o v e m e n t s in the sagittal skel-
functional occlusal planes, when the tracings were etal relationship were evident at the end of Herbst
superimposed in the maxilla. 22 T h e MFOP then was therapy, as indicated by a significant decrease in the
transferred to each tracing based o n superimposition ANB angle and a significant increase in the maxillo-
on maxillary structures. T h e tracings were digitized, m a n d i b u l a r differential (P < .001; Table 5). A l t h o u g h
and all m e a s u r e m e n t s were calculated parallel to the the t r e a t m e n t g r o u p had a lesser increase ( P < .05;
MFOP based on the protocols of Johnston. 2°,~2 Table 6) in the latter measure d u r i n g the second
phase, the t r e a t m e n t effects still were significant at the
Statistical Analysis e n d of total t r e a t m e n t (P < .001; Table 7).
Maxillary effects. A significant decrease in the SNA
Means and standard deviations were calculated for
angle was observed d u r i n g both phases w h e n com-
age, duration of treatment, and all c e p h a l o m e t r i c
p a r e d with the controls (P < .01 and P < .001, respec-
variables for the Herbst group and the control data, as
tively). With respect to the change in the size of the
well as for the m e a s u r e m e n t s of t r e a t m e n t changes
midface, r e p r e s e n t e d by the measures Condylion-
taken along the MFOP for the t r e a t m e n t group.
Point A and Condylion-Anterior Nasal Spine, no
To evaluate the between-group differences in pre-
significant between-group difference was found, ex-
treatment m o r p h o l o g y and change d u r i n g each inter-
val, paired t-tests were used to test the null hypothesis cept for the distance Co-Pt A, which increased less in
(Ho): la~ = P2. T r e a t m e n t changes executed along the t r e a t m e n t g r o u p than could be inferred f r o m the
MFOP were analyzed by completely r a n d o m i z e d t- control data for T2 to T3 (P < .01).
tests, Ho: 81 = 82, for each phase (Herbst phase, Mandibular ~ects. A significant increase in the
edgewise phase, and overall change). SNB angle was evident d u r i n g Herbst t r e a t m e n t
(P < .001). T h e reverse was n o t e d in the fixed appli-
ance phase ( P < .001), resulting in no significant
difference between the two groups for the overall
Results change in the SNB angle. A greater increase in
Comparison of Starting Forms m a n d i b u l a r length, as r e p r e s e n t e d by Co-Gn, was
n o t e d during Herbst t r e a t m e n t (4.7 m m v 2.5 mm,
Means and standard deviations for selected cephalo- P < .001). The reverse again was seen in the incre-
metric variables before t r e a t m e n t (T1) are p r e s e n t e d ments of m a n d i b u l a r length during the fixed appli-
in Table 4. Significant between-group differences were ance phase, with greater growth increments observed
n o t e d for some measures. T h e Herbst group was m o r e in the controls (3.1 m m ) than in the treated group
Class II than the controls at the onset of treatment, as (1.9 ram; P < .001). A significant difference between
i n d i c a t e d by a significantly g r e a t e r ANB a n g l e
the two groups, however, still was n o t e d for the overall
(P < .001) and a significantly smaller maxillomandibu-
change in the m a n d i b u l a r length (6.6 m m v 5.6 mm,
lar differential ~'~ (P < .001) in comparison with the
P < .01). The same trend was n o t e d for the Articulare-
population norms. T h e size of the maxilla was larger
Anatomical G n a t h i o n measure.
than the normative values (Co-ANS and Co-Pt A;
T h e whole g r o u p was divided into two groups
P < .001). In the vertical dimension, the t r e a t m e n t
according to gender. The a m o u n t of m a n d i b u l a r
subjects had a greater posterior facial h e i g h t and
ramal height, as m e a s u r e d by S-Go and Co-Go (P < .05 growth, as m e a s u r e d by Co-Gn, in each of the resulting
and P < .01, respectively), and a flatter m a n d i b u l a r groups was c o m p a r e d with the control standards. An
plane angle (SN-MP, P < .05). increased growth rate d u r i n g Herbst therapy followed
Dentoalveolar measures showed the lower denti- by a slower growth rate in comparison with control
tion to be in a m o r e anterior position relative to the n o r m s was obvious for b o t h subgroups. The overall
mandibular basal bone, as indicated by the shorter L1 change was n o t significant in the female group,
horizontal and L6 horizontal (P < .05). In addition, whereas this overall increase was significant in the
the lower incisor was m o r e p r o c l i n e d in the t r e a t m e n t male group (P < .05).
sample (98.7 °) than in the controls (95.5°; P < .01). Verticaleffects. Significant treatment-related changes
50 L a i and McNamara

T a b l e 4. C o m p a r i s o n o f S t a r t i n g F o r m s t
Herbst Group (N = 40) Control Data (iV = 40)
Measure Mean S.D. Mean S.D. Sign~anee
Sa#ttalSkeletalMeasures
~N 73.4 3.3 74.1 2.1 ns
M/Mdifferential 23.0 3.6 25.6 1.7
ANB(°) 4.9 1.5 3.6 0.2

Maxillary Skeletal Measures

Co-ANS 97.2 5.4 92.8 3.0 ***
Co-Pt A 93.9 5.4 89.7 2.8 ***
Pt A-Nasion Perp 0.2 2.5 - - -
SNA (°) 81.7 3.3 80.6 0.2 ns

Mandibular Skeletal Measures

Co-Gn 116.8 6.7 115.0 4.3 ns
Ar-Gn 108.3 6.7 108.8 3.8 ns
Pog-Nasion Perp - 6.8 4.9 - - -
SNB (°) 76.7 3.4 77.1 0.3 ns

Vertical Skeletal Measures

N-Me 118.2 7.5 118.7 4.5 ns
N-ANS 53.6 3.2 53.6 1.5 ns
ANS-Me 67.0 5.8 67.1 3.0 ns
S-Go 76.6 5.8 74.5 3.6 *
Co-Go 56.9 4.7 54.9 2.8 **
SN-Occlusal plane (°) 17.4 4.6 16.2 0.7 ns
SN-Mand plane (°) 31.8 5.4 33.9 0.4 *
FMA (°) 23.2 5.2 - - -
Facial axis (°) -0.6 3.8 -2.0 0.2 *

Maxillary Dentition
U6 horizontal 28.4 2.7 - - -
U1 horizontal 59.2 3.5 - - -
U1-Pt A Perp 5.8 2.1 - - -
U1-SN (°) 106.1 7.2 103.4 0.7 *
U6-PP 22.7 2.5 22.1 1.5 ns
U1-PP 28.6 2.4 28.6 1.3 ns

Mandibular Dentition
IMPA (°) 98.7 6.3 95.5 0.9 **
L6 horizontal 31.5 2.7 32.4 0.3 *
L1 horizontal 8.3 3.0 9.4 0.6 *
L1 to A-Pog 0.7 1.9 1.7 0.2 **
L6 vertical 32.2 2.7 31.7 1.7 ns
L1 vertical 41.8 3.2 41.2 1.9 ns

NOTE. t = in m m unless otherwise noted; - = n o t available; ns = n o t significant.

*P < .05.
* * P < .01.
***P < .001.

in v e r t i c a l m e a s u r e s also w e r e n o t e d . T o t a l a n t e r i o r The palatal plane angle increased when compared

facial h e i g h t ( N - M e ) , u p p e r a n t e r i o r facial h e i g h t w i t h c o n t r o l v a l u e s ( P < .01) d u r i n g t h e first treat-
( N - A N S ) , total p o s t e r i o r facial h e i g h t (S-Go), a n d ment phase. During the second phase, however, the
l o w e r p o s t e r i o r facial h e i g h t ( C o - G o ) i n c r e a s e d signifi- p a l a t a l p l a n e a n g l e d e c r e a s e d ( P < .05), r e s u l t i n g in
c a n t l y m o r e d u r i n g t h e H e r b s t t r e a t m e n t ( P < .001). no overall between-group differences. The same ten-
T h e s e m e a s u r e s w e r e l a r g e r still i n t h e H e r b s t g r o u p at d e n c y also was t r u e f o r t h e o c c l u s a l p l a n e . T h e
the end of fixed appliance treatment. In contrast, o c c l u s a l p l a n e i n t h e t r e a t m e n t g r o u p , h o w e v e r , was
neither the Herbst appliance nor fixed-appliance s t e e p e r a f t e r f i x e d a p p l i a n c e t h e r a p y ( P < .05) i n
therapy had any significant effect on lower anterior comparison with the controls. The overall effect on
facial h e i g h t ( A N S - M e ) . facial axis a n g l e was n o t s i g n i f i c a n t , a l t h o u g h t h e r e
 Herbst and Edgewise Treatment 51

T a b l e 5. C o m p a r i s o n o f C h a n g e D u r i n g t h e H e r b s t P h a s e (T1 - T2)

He@st Group (N = 40) Control Data (N = 40)

Measure Mean S.D. Mean S.D. Significance
Sagittal Skeletal Measures
M / M difference 3.6 1.4 1.4 0.7 ***
ANB (°) -1.5 0.9 -0.2 0.2 ***

Maxillary Skeletal Measures

Co-Pt A 1.1 1.5 1.1 0.5 ns
Co-ANS 1.1 1.6 1.2 0.5 ns
Pt A-Nasion Perp -0.5 0.8 - - -
SNA (°) -0.3 0.8 0.1 0.3 **

Mandibular Skeletal Measures

Co-Gn 4.7 1.7 2.5 1.0 ***
Ar-Gn 4.6 1.7 2.3 1.0 ***
Pog-Nasion Perp 1.8 1.6 - - -
SNB (°) 1.2 0.8 0.3 0.3 ***

Vertical Skeletal Measures

N-Me 4.0 1.90 2.5 1.3 ***
N-ANS 1.6 1.0 0.8 0.4 ***
ANS-Me 2.0 1.5 1.6 0.9 ns
S-Go 4.0 1.3 2.0 0.9 ***
Co-Go 3.5 1.4 1.7 0.6 ***
SN-Palatal plane (°) 0.4 0.8 -0.1 0.2 **
SN-Occlusal plane (°) 2.1 2.5 -0.5 0.5 ***
SN-Mand plane (°) -0.6 1.2 -0.3 0.5 ns
VMA (°) -0.5 1.0 - - -
Facial axis (°) 0.6 1.0 0.0 0.4 **

Maxillary Dentition
U6 horizontal - 0.9 1.4 - - -
U1 horizontal -0.2 2.1 - - -
U1-Pt A Perp -0.6 1.7 - - -
U6-PP -0.2 0.9 1.0 0.6 ***
U1-PP 0.8 1.2 0.5 0.3 ns

Mandibular Dentition
IMPA (°) 5.1 4.0 -0.5 1.1 ***
L6 horizontal 1.5 1.0 0.1 0.2 ***
L1 horizontal 1.6 1.4 -0.5 0.4 ***
L1 to A-Pog 2.8 1.3 0.0 0.2 ***
L6 vertical 1.5 0.8 0.9 0.3 ***
L1 vertical 0.2 1.2 0.8 0.5 ***

NOTE. = not available; ns = not significant.

-

*P < .05.
* * P < .01.
* * * P < .001.

was a s i g n i f i c a n t m e a n c h a n g e in this a n g l e d u r i n g t h e p o s i t i o n at t h e e n d o f t r e a t m e n t (L6 h o r i z o n t a l ,

first p h a s e . T h e r e was n o s i g n i f i c a n t t r e a t m e n t effect P < .01; L1 h o r i z o n t a l a n d IMPA, P < .001).
on the mandibular plane. I n t h e vertical d i m e n s i o n , t h e H e r b s t a p p l i a n c e
Dentoalveolar effects. W h e n t h e d e n t o a l v e o l a r p r e v e n t e d the u p p e r molars a n d the lower incisors
c h a n g e s in t h e H e r b s t g r o u p w e r e c o m p a r e d w i t h f r o m e r u p t i n g ( P < .001), b u t a l l o w e d t h e l o w e r
those inferred from the Michigan controls, the man- m o l a r s to e r u p t m o r e ( P < .001). T h e u p p e r i n c i s o r s
d i b u l a r t e e t h o f t h e H e r b s t g r o u p m o v e d f o r w a r d (L6 w e r e n o t a f f e c t e d by t h e H e r b s t a p p l i a n c e . D u r i n g t h e
h o r i z o n t a l a n d L1 h o r i z o n t a l , P < .001; T a b l e 5) a n d f i x e d a p p l i a n c e p h a s e , u p p e r p o s t e r i o r vertical alveo-
t h e m a n d i b u l a r i n c i s o r s f l a r e d a n a v e r a g e 5.5 ° m o r e lar c h a n g e was n o t significantly d i f f e r e n t b e t w e e n t h e
d u r i n g t h e first p h a s e ( P < .001). A l t h o u g h t h e r e was two g r o u p s . T h e r e f o r e , t h e overall c h a n g e s f e a t u r e d
o p p o s i t e t o o t h m o v e m e n t t h e r e a f t e r ( T a b l e 6), t h e less o f a n i n c r e a s e in u p p e r p o s t e r i o r a l v e o l a r h e i g h t
l o w e r d e n t i t i o n still was l o c a t e d in a m o r e a n t e r i o r (U6-PR P < .001) a n d a g r e a t e r i n c r e a s e in l o w e r
52 Lai and McNamara

T a b l e 6. C o m p a r i s o n o f C h a n g e D u r i n g t h e F i x e d A p p l i a n c e P h a s e (T 2 - T:0

Herbst Group (N = 40) Control Data (N : 40)

Measure Mean S.D. Mean S.D. Significance

Sagittal Skeletal Measures

M / M difference 1.1 1.5 1.8 1.1 *
ANB (°) -0.2 0.9 -0.2 0.3 ns

Maxillary Skeletal Measures

Co-Pt A 0.7 1.4 1.3 0.7 **
Co-ANS 1.1 1.6 1.5 0.8 ns
Pt A-Nasion Perp -0.5 0.8 - - -
SNA (°) -0.3 0.7 0.4 0.2 ***

Mandibular Skeletal Measures

Co-Gn 1.9 1.8 3.1 1.8 ***
Ar-Gn 1.7 1.8 3.0 1.8 ***
Pog-Nasion Perp 0.5 2.0 - - -
SNB (°) -0.1 0.9 0.5 0.3 ***

Vertical Skeletal Measures

N-Me 2.5 2.5 2.7 2.1 ns
N-ANS 0.7 1.0 0.8 0.6 ns
ANS-Me 1.7 1.9 2.0 1.7 ns
S-Go 1.9 1.8 2.5 1.6 **
Co-Go 1.2 1.3 2.3 1.2 ***
SN-Palatal plane (o) -0.3 0.7 0.0 0.2 *
SN-Occlusal plane (°) -1.7 2.6 -0.1 0.5 ***
SN-Mand plane (°) -0.3 1.5 -0.6 0.7 ns
FMA (°) -0.1 1.4 - - -
Facial axis (°) -0.4 1.2 0.4 0.6 **

Maxillary Dentition
U6 horizontal 1.9 1.5 - - -
U1 horizontal -0.3 1.5 - - -
U1-Pt A Perp - 0.6 1.3 - - -
U6-PP 1.6 1.1 1.3 0.8 ns
U1-PP 0.2 1.1 0.6 0.4 *

Mandibular Dentition
IMPA (°) -2.8 5.5 -0.3 0.9 **
L6 horizontal 0.7 1.1 0.0 0.4 ***
L1 horizontal - 1.2 1.5 -0.5 0.5 *
L1 to A-Pog -0.7 1.4 0.1 0.4 **
L6 vertical 1.6 1.2 1.2 0.8 **
L1 vertical 1.4 1.4 1.1 1.1 ns

NOTE. = not available; ns = not significant.

-

*P < .05.
* * P < .01.
* * * P < .001.

p o s t e r i o r alveolar h e i g h t (L6 Vertical, P < .001) w h e n m a n d i b u l a r m o l a r s (Fig 1A). O v e r j e t c o r r e c t i o n also

c o m p a r e d with the controls. was largely a r e s u l t o f apical b a s e c h a n g e in c o m b i n a -
Class I I correction. L i n e a r c h a n g e s m e a s u r e d a l o n g t i o n w i t h 1.1 m m m e s i a l m o v e m e n t o f t h e l o w e r
t h e M F O P d u r i n g e a c h p h a s e f o r t h e t r e a t m e n t are incisors. D u r i n g t h e s e c o n d p h a s e o f t r e a t m e n t , t h e
d e p i c t e d d i a g r a m m a t i c a l l y in F i g u r e 1. At t h e s t a r t o f sagittal m o l a r r e l a t i o n s h i p r e b o u n d e d by a n a v e r a g e
H e r b s t t r e a t m e n t , t h e Class II m o l a r a n d o v e l j e t w e r e o f 1.9 m m (Fig 1B), l e a d i n g to a r e d u c e d Class I I
1.2 m m a n d 7.2 m m , respectively, as m e a s u r e d a l o n g c o r r e c t i o n by t h e e n d o f total t r e a t m e n t (3.8 r a m ; Fig
the MFOE 1 C). T h e r e s u l t s w e r e d u e to s i g n i f i c a n t o p p o s i t e t o o t h
A n i m p r o v e m e n t in sagittal o c c l u s a l r e l a t i o n s h i p m o v e m e n t s f o r t h e u p p e r a n d l o w e r m o l a r s (1.4 m m
was o b s e r v e d at t h e e n d o f H e r b s t t h e r a p y . T h e 5.7 a n d 0.4 r a m , respectively). T h e u p p e r a n d l o w e r
m m m o l a r c o r r e c t i o n was a c c o m p l i s h e d by 3.1 m m i n c i s o r s w e r e r e t r a c t e d 0.9 r a m . At t h e e n d o f two-
apical b a s e c h a n g e , 1.3 m m distal m o v e m e n t o f t h e p h a s e t r e a t m e n t , t h e r e f o r e , t h e Class II m o l a r c o r r e c -
m a x i l l a r y m o l a r s , a n d 1.3 m m m e s i a l m o v e m e n t o f t h e t i o n was a r e s u l t o f t h e apical b a s e c h a n g e a n d m e s i a l
 Herbst a n d Edgewise Treatment 53

T a b l e 7. C o m p a r i s o n o f O v e r a l l C h a n g e , I n c l u d i n g P h a s e I a n d P h a s e II T r e a t m e n t (T1 - T3)

Herbst Group (N = 40) Control Data (N = 40)

Measure Mean S.D. Mean S.D. Significance
Sagittal Skeletal Measures
M / M difference 4,8 1.8 3.2 1.5 ***
ANB (°) -1.7 1.1 -0.3 0.2 ***

Maxillary Skeletal Measures

Co-Pt A 1.8 2.1 2.4 1.0 *
Co-ANS 2.2 2.3 2.7 1.0 ns
Pt A-Nasion Perp - 1.0 1.0 - - -
SNA (°) -0.6 1.0 0.5 0.3 ***

Mandibular Skeletal Measures

Co-Gn 6.6 3.0 5.6 2.3 **
Ar-Gn 6.3 2.9 5.3 2.3 **
Pog-Nasion Perp 1.3 2.5 - - -
SNB (°) 1.1 1.0 0.8 0.4 ns

Vertical Skeletal Measures

N-Me 6.5 3.5 5.2 2.9 **
N-ANS 2.3 1.5 1.6 0.9 ***
ANS-Me 3.7 2.4 3.6 2.2 ns
S-Go 5.9 2.4 4.6 1.9 ***
Co-Go 4.7 1.9 4.0 1.4 **
SN-Palatal plane (°) 0.1 0.8 - 0.1 0.2 ns
SN-Occlusal plane (°) 0.4 2.7 -0.6 0.8 *
SN-Mand plane (°) -0.8 1.7 -0.8 0.9 ns
FMA (°) -0.6 1.7 - - -
Facial axis (o) 0.2 1.5 0.4 0.7 ns

Maxillary Dentition
U6 horizontal 1.0 1.5 - - -
U1 horizontal -0.4 2.4 - - -
U1-Pt A Perp - 1.2 1.9 - - -
U6-PP 1.4 1.3 2.2 1.0 ***
U1-PP 1.0 1.8 1.1 0.5 ns

Mandibular Dentition
IMPA (o) 2.3 3.9 -0.7 0.8 ***
L6 horizontal 0.7 1.3 0.1 0.4 **
L1 horizontal 0.4 1.8 - 1.0 0.6 ***
L1 to A-Pog 2.1 1.2 0.1 0.5 ***
L6 vertical 3.1 1.4 2.1 1,0 ***
L1 vertical 1.6 1.5 1.9 1.4 ns

NOTE. - = not available; ns = not significant.

* P < .05.
* * P < .01.
***P < .001.

tooth m o v e m e n t s of the lower molars, whereas overjet p r o c e s s t h a t c o n t r i b u t e s to t h e c o r r e c t i o n m u s t be

c o r r e c t i o n was d u e to t h e apical b a s e c h a n g e a n d f a c t o r e d o u t to e v a l u a t e t h e effects o f a p p l i a n c e s . I n
r e t r a c t i o n o f t h e u p p e r i n c i s o r s (Fig 1C). general, the p a t t e r n of growth that a c c o m p a n i e s the
d e v e l o p m e n t o f Class II m a l o c c l u s i o n o f t e n m a y b e
relatively short-livedfl ° S u b s e q u e n t l y , t h e r e a p p e a r s to
Discussion b e little o b v i o u s d i f f e r e n c e b e t w e e n Class II individu-
T h i s r e t r o s p e c t i v e clinical s t u d y c o m p a r e d a s a m p l e o f als a n d t h e g e n e r a l p o p u l a t i o n in t e r m s o f t h e g r o w t h
40 p a t i e n t s , d e r i v e d f r o m a n o r i g i n a l s a m p l e o f 135 that can be expected d u r i n g a p e r i o d of observation
consecutively-treated patients undergoing Herbst o r t r e a t m e n t . 24-~7 D e s p i t e t h e fact t h a t t h e t r e a t m e n t
t h e r a p y , to p o p u l a t i o n n o r m s d e r i v e d f r o m u n t r e a t e d g r o u p o f this s t u d y h a d l a r g e r m a x i l l a e a n d m o r e
i n d i v i d u a l s o f m i x e d m a l o c c l u s i o n type. B e c a u s e p r o t r u s i v e l o w e r d e n t i t i o n s at t h e t i m e o f initial
changes during treatment contain both normal growth r e c o r d s , t h e r e is little r e a s o n to e x p e c t t h a t s u b s e -
a n d c h a n g e s d u e to t r e a t m e n t , t h e n o r m a l g r o w t h q u e n t g r o w t h will differ f r o m t h e c h a n g e s given by t h e
54 Lai and McNamara

A. Herbst Phase B. Edgewise Phase preted as a stimulation of growth in the condyle. This
-1.01"** -0.69***
finding is in agreement with those of several authors, B-
7,10,11,19,21,22,28,29all of whom have suggested that func-
(0'25) I 1.25"*" ~ 0 . 2 8 (-0'33) 1-1.43"** ~ 0.85"* tional appliances are capable of inducing additional
.00]*** I .101"**I
mandibular growth. The greater increase in mandibu-
3.13"** 5,66*** 4.48*** -0.10 -1.88"** -0.14"** lar length, however, contradicts the findings of other
investigators who have failed to document significant
T0 .37)* I
4.14"**
.18)*** I
0.59
differences between functional appliance treatment
and controls, s{~~2
The increase in mandibular length during func-
Tx time = 12.2 months Tx time = 17.3 months
tional appliance treatment can be interpreted in two
C. Total Both Phases
ways. The first possibility is that the increase may
indicate a true stimulation of the growth of the
~l- -1.70"** \
condyle. An increase in both the rate and amount of
(-o.o0) -0.19 \ 1.13"* condylar growth might take place during functional
0.10 U__ \ [ ] : Tipping
( ) : Bodily
appliance treatment, followed by a normal growth rate
3.03*** 3.78*** 4.34*** thereafter, leading to a mandible that is larger than it
* p<O.05

.55)*** ]
4.72***
/ 0.18
** p<O.01
*** p<0.001
would have been without treatment. ~3 Secondly, the
increase could be a transient phenomenon. The
increased growth rate during functional appliance
treatment would be followed by a subnormal growth
Tx time = 29.5 months
rate, resulting in no p e r m a n e n t increase in the final
Figure 1. Skeletal and dentoalveolar treatment length of the mandible (Fig 2).
changes along the mean functional occlusal plane In the present study, the mandible increased 4.7
(MFOP) by phases: (A) Herbst Phase, (B) Edgewise mm during an average 12-month interval during the
phase, (C) Total treatment. first phase. This rate, however, was not maintained
during the second phase. Instead, it dropped to an
average of 1.9 m m over a 17-month period. This
UMGS Standards. is Therefore, normative values de- finding may be interpreted as a deceleration in the
rived from the Michigan Growth Study were used to rate of increase in mandibular length during the
provide a baseline against which the effects of the
appliances could be assessed.
L growthcurvefor
true stimu[ation " , ~ ~.
Maxillomandibular Relationship
n- 100 , ~ _ ......
A t the end of Herbst therapy, the significant decrease ,~
in the ANB angle was accomplished both by a signifi- D
cant reduction in the SNA angle and a significant temporaryacceleration
increase in the SNB angle. In contrast, the significant <
increase in the maxillomandibular differential was ~, 90
accomplished primarily by a significant increase in without treatment
mandibular length. The changes observed in the ,,< functional
treatment group were in agreement with the Herbst 0 appliance
treatment
results published by Pancherz, B,4,13 Valant and Sin-
801 I I I I
clair,11 McNamara et al, 6 and Windmiller.7
10 20 30 40 50 60
During the fixed appliance treatment, the basal jaw AGE
relationship continued to improve in both groups.
The improvement, however, was larger in the control Figure 2. An illustration of true stimulation and
group. Mandibular growth exceeded maxillary growth temporary stimulation of mandibular growth. True
by 1.8 mm in control group and by 1.1 m m in the stimulation indicates that growth occurs at a faster-than-
Herbst group. expected rate during functional appliance therapy,
then continues at the expected rate thereafter, so that
the ultimate size of the mandible is larger. Temporary
Mandibular Effects acceleration means that faster growth occurs during
functional therapy, but slower growth thereafter ulti-
During the Herbst phase, mandibular length, repre-
mately brings the mandible back to the size that would
sented by Co-Gn, increased significantly more than be expected without treatment. (Modified and re-
that inferred from the Michigan Standards. Relative to printed with permission from Proffit WR, Fields HW
control data, a 2.2 mm increase over a 12-month Jr. Contemporary Orthodontics (2nd ed). St Louis,
period was observed. This observation could be inter- MO, Mosby-Year Book, Inc, 1993. 33)
 Herbst and Edgewise Treatment 55

edgewise phase. This finding agrees with Pancherz, 1~ Effects on the Vertical D i m e n s i o n
Wieslander 5 and Pancherz and Faekel, 34 who showed a
T h e acrylic-splint Herbst has occlusal coverage and
reduction in the m a n d i b u l a r growth rate after Herbst
appliances were removed. thus is t h o u g h t to be better than the b a n d e d type in
Furthermore, Pancherz 13 and Wieslander 5 have terms of vertical control. The occlusal coverage pre-
r e p o r t e d that an acceleration of m a n d i b u l a r growth sumably inhibits dental eruption, helps control the
during Herbst therapy is followed by a return to a vertical d i m e n s i o n and thereby allows the growth of
n o r m a l growth rate during the p e r i o d after treatment. the m a n d i b l e to express itself m o r e horizontally than
By the end of the 10 to 12 m o n t h follow-up period, vertically. In the present study, total anterior facial
mandibular length was significantly l o n g e r in compari- h e i g h t (N-Me) increased significantly (1.2 m m ) m o r e
son with the controls. In the present study, m e a n than control values, as did posterior facial height
mandibular length (Co-Gn) in the control group (S-Go; 1.3 ram). These findings explain the observa-
increased an average of 3.1 m m during the second tion that the m a n d i b u l a r plane angle did not deviate
treatment period, whereas in the Herbst patients the significantly f r o m the control value. It s e e m e d that the
measure increased by 1.9 mm. Significantly less growth Herbst appliances, either the b a n d e d type or the
was n o t e d ( P < .001) in the t r e a t m e n t group. T h e acrylic-splint type, has little effect on the mandibular
plane.3,5-7Al,J5
same trend was n o t e d for both female and male
subgroups. Accordingly, the present results do not Interestingly, the present study did not d e m o n -
support the findings of Pancherz 1~ and Wieslander 5 strate an increase in lower anterior facial height
that m a n d i b u l a r growth continues to the same extent (ANS-Me) after either phase of treatment. This find-
in the treated group as in the control g r o u p d u r i n g ing contradicts o t h e r Herbst studies in which the
the p e r i o d after Herbst treatment. authors f o u n d a significant increase in this dimen-
W h e n the changes during the second p e r i o d were sion. "~,4,6,7In addition, the finding that u p p e r anterior
added to the changes during the first period, there facial h e i g h t i n c r e a s e d significantly contradicts
was great individual variation. The overall increase in P a n c h e r z 3 and Wieslander, 5 who f o u n d no difference
mandibular length was significantly different between between treatment and control groups. The present
the t r e a t m e n t group and control data for the whole findings could be ascribed to the location of attach-
group and the male subgroup; however, it was n o t m e n t of the piston and sleeve assemblies on the
significantly different between the t r e a t m e n t group appliance. This telescope system exerted a posterosu-
and control data in the female subgroup. T h e possible perior force on the maxillary posterior region, result-
reason for this difference between these two sub- ing in a clockwise rotation of the palatal plane. The
groups could be due to the fact that females already telescope m e c h a n i s m also m i g h t cause the increase in
had c o m p l e t e d most of their m a n d i b u l a r growth by occlusal plane angulation. T h e maxillary molars and
the conclusion of Phase II. Given that tile T3 films m a n d i b u l a r incisors were p r e v e n t e d f r o m e r u p t i n g
were taken at age 14.8 years for females, one m i g h t because of the proximity of the piston and sleeve
assume that at the e n d of the edgewise t r e a t m e n t the assembly. In contrast, m o r e vertical e r u p t i o n was
female individuals in the Herbst sample were close to observed in the lower m o l a r region, p r o d u c i n g an
or at the e n d of their growth. 35,36 It also should be increase in m a n d i b u l a r alveolar h e i g h t that was signifi-
r e m e m b e r e d that the UMGS cephalograms were gath- cantly m o r e than expected. As a result of dental
e r e d in the 1950s and 1960s, a time during which the changes, the angulation of the occlusal plane in-
onset of m e n a r c h e may have b e e n delayed in compari- creased. This observation is consistent with the find-
son with adolescents today. ~7 ings of Harvold 41 who showed that the transformation
The present data support the studies of Pancherz f r o m a Class II occlusion to a n o r m a l m o l a r occlusion
and Littmann 3s and Wieslander, ~5 who f o u n d no was intimately related to an increase in lower facial
significant increase in the m a n d i b u l a r length after height that resulted from an increased vertical develop-
growth was completed. These results do n o t corrobo- m e n t of alveolar h e i g h t in the region of the lower
rate the findings of Petrovic et aP 9 on y o u n g male rats molars. H a r v o l d and Vargervik 3~ c o n c l u d e d that man-
or the long-term study of M c N a m a r a and Bryan 4° on dibular teeth are e n c o u r a g e d to e r u p t vertically and
Macaca mulatta, who c o n c l u d e d that, when e x p e r i m e n - mesially, while the maxillary molars are prevented
tal mandibular protrusion was p e r f o r m e d t h r o u g h o u t f r o m vertical e r u p t i o n and are even m o v e d posteri-
the growth period, the final length of the m a n d i b l e orly, transforming the Class II m o l a r relationship into
could be increased. Therefore, the present study a Class I molar relationship.
shows that, in a clinical situation, an acceleration of
mandibular growth during functional appliance treat- Anteroposterior Effects
merit was followed by a growth rate lesser than normal, in the Dentoalveolar Region
resulting in a limited increase in m a n d i b u l a r length in
males and no p e r m a n e n t increase in the final length Force exerted from the telescope m e c h a n i s m induced
of the m a n d i b l e for the female. distal tooth m o v e m e n t s in the maxillary buccal seg-
56 Lai and McNamara

m e n t s a n d mesial t o o t h m o v e m e n t in t h e m a n d i b l e . In e n ' s study c o u l d b e d u e to the fact t h a t the u p p e r

c o n t r a s t to activator therapy, w h i c h has b e e n s h o w n to incisors were i n c o r p o r a t e d within t h e a p p l i a n c e i n
p r o d u c e a significant a m o u n t o f maxillary retrac- m o s t o f the t r e a t e d subjects, whereas in the p r e s e n t
tion,4245 this study s h o w e d essentially" n o t r e a t m e n t study t h e acrylic splint d i d n o t cover these teeth.
effect o n maxillary incisor position d u r i n g P h a s e I It a p p e a r e d t h a t Class II c o r r e c t i o n c a m e f r o m a
t r e a t m e n t . This o b s e r v a t i o n p e r h a p s derives f r o m t h e c o m b i n a t i o n of factors, i n c l u d i n g skeletal changes,
fact t h a t t h e acrylic s p l i n t d i d n o t cover t h e maxillary distal m o v e m e n t of t h e maxillary t e e t h a n d mesial
incisors. C o n s i d e r a b l e flaring o f m a n d i b u l a r incisors m o v e m e n t o f t h e m a n d i b u l a r teeth. I n particular,
with f u n c t i o n a l t h e r a p y a n d with t h e H e r b s t a p p l i a n c e m a n d i b u l a r skeletal c h a n g e s d o m i n a t e d . In t h e pre-
was n o t e d in m o s t of t h e studies. This study s h o w e d s e n t study, 55% of t h e total m o l a r c o r r e c t i o n was d u e
5.1 ° o f incisor flaring d u r i n g a n average 1 2 - m o n t h to apical base c h a n g e . This f i n d i n g was l a r g e r t h a n
t r e a t m e n t period. P a n c h e r z ' s d e t e r m i n a t i o n o f 35% in b a n d e d H e r b s t
After t h e H e r b s t a p p l i a n c e was r e m o v e d , t h e d e n t a l t r e a t m e n t . Similar skeletal c h a n g e with t h e acrylic
c h a n g e s r e b o u n d e d to a c o n s i d e r a b l e extent. T h e H e r b s t a p p l i a n c e was r e p o r t e d by Windmiller. 7 Apical
u p p e r molars m o v e d anteriorly a n d t h e lower t e e t h base c h a n g e is, by d e f i n i t i o n , t h e c h a n g e in the
m o v e d posteriorly. Even t h o u g h r e b o u n d was ob-
m a x i l l o m a n d i b u l a r r e l a t i o n s h i p o b s e r v e d at t h e level
s e r v e d d u r i n g t h e P h a s e II, t h e d e n t o a l v e o l a r effects o f
of t h e f u n c t i o n a l occlusal plane. This c h a n g e may b e a
the H e r b s t a p p l i a n c e s e e m to b e m a i n t a i n e d at t h e
r e f l e c t i o n of growth o r t r e a t m e n t effects or b o t h .
e n d o f two-phase t r e a t m e n t , b u t to a lesser extent, ie,
F u r t h e r m o r e , apical base c h a n g e would b e e x p e c t e d
m o r e anteriorly p o s i t i o n e d m a n d i b u l a r t e e t h ( - 1 . 5
to b e a f u n c t i o n of differential j a w growth a n d treat-
m m ) , a n d m o r e p r o c l i n e d lower incisors (3.0°).
m e n t t i m e u n t i l growth is c o m p l e t e d . 1°,2°,47 It m u s t b e
e m p h a s i z e d t h a t t h e skeletal c h a n g e is n o t l i n e a r over
Class II Correction time. T h e average t r e a t m e n t d u r a t i o n in P a n c h e r z
A n average m o l a r c o r r e c t i o n o f 5.7 m m a n d overjet a n d H a n s e n ' s studya6 was 6 m o n t h s , whereas it was 12
c o r r e c t i o n o f 4.5 n u n were a c h i e v e d d u r i n g H e r b s t m o n t h s in b o t h W i n d m i l l e r ' s 7 a n d the p r e s e n t study.
t h e r a p y (Table 8 a n d Fig 1A). Similar Class II m o l a r T h e d i f f e r e n c e in t r e a t m e n t time may a c c o u n t for t h e
a n d overjet c o r r e c t i o n s have b e e n r e p o r t e d for o t h e r o b s e r v a t i o n t h a t skeletal c h a n g e s c o n t r i b u t e d m o r e to
H e r b s t samples. P a n c h e r z a n d H a n s e n 46 r e p o r t e d , o n t h e Class II c o r r e c t i o n i n acrylic H e r b s t studies.
average, a m o l a r c o r r e c t i o n o f 6.3 m m a n d a n overjet M a n d i b u l a r l e n g t h , as m e a s u r e d by Co-Gn, in-
c o r r e c t i o n o f 6.9 m m . W i n d m i l l e r 7 r e p o r t e d 5.4 m m creased 2.2 m m m o r e t h a n c o n t r o l s d u r i n g the H e r b s t
m o l a r c o r r e c t i o n a n d 5.3 m m overjet c o r r e c t i o n . T h e p h a s e (Table 5). To estimate h o w m u c h o f this e x t r a
g r e a t e r overjet c o r r e c t i o n seen in P a n c h e r z a n d Hans- growth c o n t r i b u t e s to Class II c o r r e c t i o n , this c h a n g e

T a b l e 8. T r e a t m e n t C h a n g e M o n g t h e M e a n F u n c t i o n a l Occlusal P l a n e by Phases: Skeletal

a n d D e n t a l C o m p o n e n t s of M o l a r a n d Overjet C o r r e c t i o n
Herbst Phase (N = 40) Fixed Phase (N = 40) Two Phases (N : 40)
Measure Mean S.D. Mean S.D. Mean S.D.

Time (months) 12.2 4.0 17.3 5.8 29.5 7.9

Skeletal Measures
Maxilla - 1.0 0.9 -0.7 1.1 -1.7 1.5
Mandible 4.1 2.0 0.6 2.1 4.7 2.69
ABCH 3.1 1.6 -0.1 1.7 3.0 2.02

Dentoalveolar Measures
Upper molar to maxilla
Tipping 1.0 1.2 -1.1 1.4 -0.1 1.3
Bodily 0.3 1.0 -0.3 1.3 -0.1 1.4
Total 1.3 1.1 -1.4 1.2 -0.2 1.2
Lower molar to mandible
Tipping 0.9 1.1 -1.5 1.1 -0.6 1.1
Bodily 0.4 1.1 1.2 1.0 1.6 1.1
Total 1.3 0.9 -0.4 0.8 1.0 1.1
Upper incisor to maxilla 0.3 1.8 0.9 1.5 1.1 2.0
Lower incisor to mandible 1.1 1.3 -0.9 1.5 0.2 2.0

Total Correction
Molar (6/6) 5.7 2.2 -1.9 1.8 3.8 1.4
Incisor (1/1) 4.5 2.0 -0.1 1.3 4.3 1.9
 Herbst and Edgewise Treatment 57

was p r o j e c t e d o n the m e a n f u n c t i o n a l occlusal plane. 4. Significant r e b o u n d was s e e n d u r i n g the edgewise

A n average angle o f 37.4 ° was f o u n d b e t w e e n Co-Gn phase. At t h e e n d o f two-phase t r e a t m e n t , t h e Class
line a n d t h e m e a n f u n c t i o n a l occlusal plane. T h e 2.2 II m o l a r c o r r e c t i o n h a d b e e n a c c o m p l i s h e d by
m m of e x t r a growth was m u l t i p l i e d by t h e cosine o f m a n d i b u l a r skeletal c h a n g e , as well as mesial move-
37.4 °. Based o n this calculation, 1.9 m m o f extra m e n t o f t h e m a n d i b u l a r molars, whereas t h e over-
m a n d i b u l a r growth (reflected as a d d i t i o n a l apical j e t c o r r e c t i o n was d u e to m a n d i b u l a r growth a n d
base c h a n g e ) was s e e n at t h e m e a n f u n c t i o n a l occlusal r e t r a c t i o n o f t h e maxillary incisors.
p l a n e d u r i n g the H e r b s t p h a s e of t r e a t m e n t . 5. Skeletal c h a n g e s c o n t r i b u t e d to 55% o f t h e m o l a r
At the e n d of edgewise t r e a t m e n t , t h e m o l a r c o r r e c t i o n d u r i n g t h e H e r b s t therapy, whereas at
c o r r e c t i o n a v e r a g e d 3.8 m m . T h e relapse o f correc- t h e e n d of two-phase t r e a t m e n t it a c c o u n t e d for
tion was d u e primarily to t h e m o v e m e n t o f maxillary 80%.
molars a n d m a n d i b u l a r d e n t i t i o n d u r i n g fixed appli-
T h e p r e s e n t results suggest t h a t t h e acrylic H e r b s t
a n c e t h e r a p y (Fig 1B, Table 8). T h e s e findings are in
a p p l i a n c e may have a m o d e s t s t i n m l a t o r y effect o n
a g r e e m e n t with those of P a n c h e r z a n d H a n s e n , 46 w h o
m a n d i b u l a r growth t h a t d i m i n i s h e s with t i m e a n d
f o u n d t h a t relapse of t h e sagittal m o l a r r e l a t i o n s h i p
does n o t significantly affect t h e vertical growth of t h e
was almost exclusively a result o f t o o t h m o v e m e n t
face. A n t e r o p o s t e r i o r d e n t o a l v e o l a r r e b o u n d d u r i n g
d u r i n g t h e follow-up p e r i o d of 12 m o n t h s . After 29
t h e edgewise p h a s e is significant.
m o n t h s of t r e a t m e n t , skeletal c h a n g e s a n d mesial
t o o t h m o v e m e n t of m a n d i b u l a r m o l a r s c o n t r i b u t e d to
m o l a r c o r r e c t i o n . T h e overjet c o r r e c t i o n was t h e Acknowledgment
result of skeletal c h a n g e s a n d distal t o o t h m o v e m e n t
T h e a u t h o r s t h a n k D r Lysle E. J o h n s t o n , J r for his
of u p p e r incisors. It was f o u n d t h a t apical basal c h a n g e
assistance in t h e p r e p a r a t i o n o f this m a n u s c r i p t .
c o n t r i b u t e d to 80% o f m o l a r c o r r e c t i o n a n d 70% o f
overjet c o r r e c t i o n , with t h e m a n d i b u l a r c o m p o n e n t
dominating. References
1. Herbst E. Atlas und Grundriss der Zahn/irztlichen Or-
thop~idie. Munich, Germany, J.E Lehmann Verlag, 1910.
Summary and Conclusions 2. Herbst E. Dreissigjfihrige Erfahrungen mit dem Reten-
tions-Scharnier. Zahn/irztl Rundschau. 1934;42:151-
T h e p u r p o s e of this study was to evaluate t h e skeletal
1524, 1563-1568, 1611-1616, 1934.
a n d d e n t a l c h a n g e s t h a t o c c u r d u r i n g two-phase 3. Pancherz H. Treatment of Class II malocclusions by
t r e a t m e n t : a n acrylic-splint H e r b s t followed by a pread- jumping the bite with the Herbst appliance. A cephalo-
j u s t e d edgewise appliance. T h e a u t h o r s e x a m i n e d 40 metric investigation. AmJ Orthod 1979;76:423-442.
subjects (20 females, 20 males) w h o b e g a n H e r b s t 4. Pancherz H. The Herbst appliance-Its biologic effects
t h e r a p y at a n average age of 12.5 + 0.8 years for and clinical use. AmJ Orthod 1985;87:1-20.
females, a n d 13.6 _+ 1.2 years for males. Descriptive 5. Wieslander L. Intensive treatment of severe Class II
c e p h a l o m e t r i c data were c o m p a r e d with n o r m a t i v e malocclusions with a headgear-Herbst appliance in the
values derived f r o m the University of M i c h i g a n Elemen- early mixed dentition. AmJ Orthod 1984;86:1-13.
6. MeNamaraJA, Jr, Howe RP, Dischinger TG. A compari-
ta W a n d S e c o n d a r y School G r o w t h Study. N o r m a t i v e
son of the Herbst and Fdinkel appliances in the treat-
values were g e n e r a t e d for e a c h o f the 40 individuals ment of Class II malocclusion. A m J Orthod Dentofacial
b a s e d o n gender, initial age, a n d d u r a t i o n o f treat- Orthop 1990;98:134-144.
m e n t . T h e following c o n c l u s i o n s c a n b e r e a c h e d : 7. Windmiller EC. The acrylic-splint Herbst appliance: A
cephalometric evaluation. Am J Orthod Dentofacial
1. A n a c c e l e r a t i o n o f m a n d i b u l a r g r o w t h d u r i n g
Orthop 1993;104:73-84.
H e r b s t t h e r a p y was followed by a r e d u c e d rate of 8. Goodman R McKenna E Modified Herbst appliance for
m a n d i b u l a r growth d u r i n g t h e edgewise phase. the mixed dentition.J Clin Orthod 1985;19:811-814.
T h e overall increase in m a n d i b u l a r l e n g t h was 9. Dischinger TG. Edgewise bioprogressive Herbst appli-
significantly g r e a t e r t h a n c o n t r o l data for b o t h t h e ance.J Clin Orthod 1989;23:608-617.
whole g r o u p a n d for t h e male s u b g r o u p ; however, 10. Pancherz H, Hftgg U. Dentofacial orthopedics in relation
it was n o t significantly g r e a t e r in t h e f e m a l e sub- to somatic inaturation. An analysis of 70 consecutive
group. cases treated with the Herbst appliance. Am J Orthod
2. T h e r e was n o significant t r e a t m e n t effect o n lower 1985;88:273-287.
11. Valant JR, Sinclair PM. Treatment effects of the Herbst
a n t e r i o r facial h e i g h t a n d o n t h e m a n d i b u l a r p l a n e
appliance. AmJ Orthod Dentofacial Orthop 1989;95:138-
angle, e i t h e r at t h e e n d of H e r b s t t h e r a p y or at t h e
147.
e n d of two-phase t r e a t m e n t . 12. Pancherz H. The mechanism of Class II correction in
3. Class II c o r r e c t i o n a c h i e v e d by t h e H e r b s t appli- Herbst appliance treatment. A cephalometric investiga-
a n c e was mainly d u e to m a n d i b u l a r growth, distal tion. AmJ Orthod 1982;82:104-113.
m o v e m e n t of t h e maxillary molars, a n d mesial 13. Pancherz H. The effect of continuous bite jumping on
m o v e m e n t of t h e m a n d i b u l a r m o l a r s a n d incisors. the dentofacial complex: A follow-up study after Herbst
58 Lai and McNamara

appliance treatment of Class II malocclusions. Eur J 32. Wieslander L, Lagerstr6m L. The effect of activator
Orthod 1981;3:49-60. treatment on class II malocclusions. Am J Orthod 1979;
14. Schiavoni R, Grenga V, Macri V. TreaUnent of Class II 75:20-26.
high angle malocclusions with the Herbst appliance: a 33. Proffit WR, Fields HW, Jr. Contemporary Orthodontics.
cephalometric investigation. Am J Orthod Dentofacial (2nd ed) St. Louis, MO, Mosby-Year Book, Inc, 1993.
Orthop 1992;102:393-409. 34. Pancherz H, Fackel U. The skeletofacial growth pattern
15. Wieslander L. Long-term effect of treatment with the pre- and post-dentofacial orthopaedics. A long-term
headgear-Herbst appliance in the early mixed dentition. study of Class II malocclusions treated with the Herbst
Stability or relapse? Am J Orthod Dentofacial Orthop appliance. EurJ Orthod 1990;12:209-218.
1993;104:319-329. 35. TannerJM, Whitehouse RH, Takaishi M. Standards from
16. McNamaraJA, Jr. Fabrication of the acrylic splint Herbst birth to maturity for height, weight, height velocity and
appliance. Am J Orthod Dentofacial Orthop 1988;94: weight velocity: British children. Arch Dis Child 1966;41:
10-18. 454, 613.
17. McNamaraJA, Jr, Howe RP. Clinical management of the 36. H/igg U, Pancherz H, Taranger J. Pubertal growth and
acrylic splint Herbst appliance. AmJ Orthod Dentofacial orthodontic treatment, in Carlson DS, Ribbens KA,
Orthop 1988;94:142-149. (eds): Craniofacial Growth during Adolescence. Ann
18. Riolo ML, Moyers RE, McNamaraJA, Jr, Hunter WS. An Aa'bm, MI, Center for Human Growth and Development,
Atlas of Craniofacial Growth: Cephalometric Standards The University of Michigan, 1987: Craniofacial Growth
from The University School Growth Study, The Univer- Monograph Series, vol 20.
sity of Michigan. Ann Arbor, MI, The Center for Human 37. Jay MS. Compliance: The adolescent/provider partnei~
Growth and Development, The University of Michigan, ship, in McNamaraJA, Jr, Trotman C-A (eds.): Creating
1974. Craniofacial Growth Monograph Series, vol 2. the compliant patient. Ann Arbm; MI, Center for Hu-
19. Mahon WT. A cephalometric appraisal of Class II func- man Growth and Development, The University of Michi-
tional appliance therapy (master's thesis). St. Louis, MO, gan, 1997:47-58. Craniofacial Growth Monograph Series,
Saint Louis University, 1982. vol 33.
20. Johnston LE, Jr. A comparative analysis of Class II
38. Pancherz H, Littmann C. Morphologie und Lage des
treatments, in Vig PS, Ribbens KA (eds): Science and
Unterkiefers bei der Herbst-Behandlung. Eine kephalom-
Clinical Judgment in Orthodontics. Ann Arbor, MI,
etrische Analyse der Ver/inderungen bis zum Wachstums-
Center for Human Growth and Development, The Uni-
abschluss. Inf Orthod Kieferorthop 1989;21:493-513.
versity of Michigan, 1986: Craniofacial Growth Series, vol
39. Petrovic A, Stutzmann J0, Gasson N. The final length of
19.
the mandible: Is it genetically determined?, in Carlson
21. McNamaraJA, Jr, Bookstein FL, Shaughnessy TG. Skel-
DS (ed) : Craniofacial Biology. Ann Arbor, MI, Center for
etal and dental changes following functional regulator
Human Growth and Development, The University of
therapy on Class II patients. A m J Orthod 1985;88:91-
Michigan, 1981, Craniofacial Growth Monograph Series,
110.
vol 10.
22. Livieratos FA,Johnston LE,Jr. A comparison of one-stage
40. McNamara JA, Jr., Bryan FA. Long-term mandibular
and two-stage nonextraction alternatives in matched
adaptations to protrusive function: An experimental
Class II samples. Am J Orthod Dentofacial Orthop
study in Macaca mulatta. Am J Orthod Dentofacial
1995;108:118-131.
Orthop 1987;92:98-108.
23. McNamaraJA,Jr. A method ofcephalometric evaluation.
3anJ Orthod 1984;86:449-469. 41. Harvold EP. The role of fimction in the etiology and
24. Lande MJ. Growth behavior of the human bony facial treatment of malocclusion. Am J Orthod 1968;54:883-
profile as revealed by serial cephalometric roentgenol- 898.
ogy. Angle Orthod 1952;22:78-90. 42. MossJE Cephalometric changes during functional appli-
25. Johnston LE, Jr. A statistical evaluation of cephalometric ance therapy. Europ Orthod Soc Trans 1962:327-341.
prediction. Angle Orthod 1968;38:284-304. 43. Evald BH, Harvold EP. The effect of activators on
26. Hixon E, Klein P. Simplified mechanics: A means of maxillary-mandibular growth and relationships. Am J
treatment based on available scientific information. AnaJ Orthod 1966:252-257.
Orthod 1972;62:113-141. 44. Hotz RP. Application and appliance manipulation of
27. Greenberg LZ, Johnston LE, Jr. Computerized predic- functional forces. AmJ Orthod 1970;58:459-478.
tion: The accuracy of a contemporary long-range fore- 45. Pfeiffer JE Grobety D. Simultaneous use of cervical
cast. AnlJ Orthod 1975;67:243-252. appliance and activator: An orthopedic approach to
28. Baumrind S, Korn EL. Patterns of change in mandibular fixed appliance therapy. AmJ Orthod 1972;61:353-373.
and facial shape associated with the use of torces to 46. Pancherz H, Hansen I~L Occlusal changes during and
retract the maxilla. AmJ Orthod 1981;80:31-47. after Herbst treatment: A cephalometric investigation.
29. Kerr WJ, TenHave TR, McNamaraJA,Jr. A comparison of EurJ Orthod 1986;8:215-228.
skeletal and dental changes produced by function regula- 47. Janson I. Skeletal and dentoalveolar changes in patients
tors (FR-2 and FR-3). EurJ Orthod 1989;11:235-242. treated with a bionator during prepubertal and pubertal
30. Jakobsson SO. Cephalometric evaluation of treatment growth, in McNamara JA, Jr, Ribbens KA, Howe RP,
effect on Class II, Division I malocclusions. AnlJ Orthod (eds): Clinical Alteration of the Growing Face. Ann
1967;53:446-457. Arbor, MI, Center for Human Growth and Development,
31. Harvold EP, Vargervik K. Morphogenetic response to The University of Michigan, 1983. Craniofacial Growth
activator treatment. AmJ Orthod 1971;60:478-490. Monograph Series, vol 14.