Am J Orthod Dentofacial Orthop. 2015 Jan;147(1):19-28. doi: 10.1016/j.ajodo.2014.06.011.

Late adult skeletofacial growth after adolescent Herbst therapy:

A 32-year longitudinal follow-up study.
Pancherz H1, Bjerklin K2, Hashemi K3.

Introduction

The aim of this longitudinal 32-year follow-up investigation was to analyze the very long-term
effects of Herbst treatment on the dentoskeletal structures. We followed 14 patients from a
sample of 22 with Class II Division 1 malocclusions who were consecutively treated with the
banded Herbst appliance at ages 12 to 14 years. The subjects were reexamined after therapy
at the ages of 20 years (when the radius epiphysis/diaphysis plate was closed) and 46 years.

Methods

Lateral head films were analyzed from before (T1) and after (T2) treatment, and at 6 years (T3)
and 32 years (T4) after treatment.

Results

(1) In the standard analysis (angular measurements) during the T2 to T3 period of 6 years,
significant skeletal changes were the following: increase of the SNB (1.0°; P <0.01), decrease of
the ANB (0.9°; P <0.01), and decrease of the ML/NSL (2.5°; P <0.001). During the T3 to T4
period of 24 years, no further significant angular changes occurred. (2) In the analysis of the
sagittal changes in the occlusion (linear measurements) during the T2 to T3 period of 6 years,
the mandible (6.1 mm; P <0.001) and the maxilla (3.0 mm; P <0.01) grew forward. During the
T3 to T4 period of 24 years, the mandible (2.8 mm; P <0.01) and the maxilla (3.1 mm; P <0.01)
continued to grow forward. Thus, during the total posttreatment (T2-T4) period of 32 years,
there was continuous forward growth of the mandible (8.9 mm; P <0.001) and the maxilla
(6.1 mm; P <0.001). (3) The analysis of superimposed lateral head films showed in all 14
subjects large amounts of sagittal and vertical skeletofacial growth during T3 to T4.

Conclusions

In all 14 subjects, large amounts of sagittal and vertical skeletofacial growth occurred after the
age of 20 years. However, the question of when, during the period from 20 to 46 years, growth
had come to an end remains open. Closure of the radius epiphysis/diaphysis plate is not useful
as an indicator for completed skeletofacial growth. Our findings indicate the importance of
considering late adult skeletofacial growth in dentofacial orthopedics, orthognathic surgery,
and tooth implantology with respect to treatment timing, posttreatment retention, and
relapse.

In adolescent patients with Class II malocclusions treated with the Herbst appliance, to date
there are only 6 roentgenographic cephalometric studies dealing with follow-up data after
therapy exceeding 2 years.1x1Pancherz, H. The nature of Class II relapse after Herbst appliance
treatment: a cephalometric long-term investigation. Am J Orthod Dentofacial Orthop. 1991;
100: 220–233

Abstract | Full Text PDF | PubMedSee all References, 2x2Hansen, K. and Pancherz, H. Long-
term effects of Herbst treatment in relation to normal growth development: a cephalometric
study. Eur J Orthod. 1992; 14: 285–295

CrossRef | PubMed | Scopus (40)See all References, 3x3Pancherz, H. and Anehus-Panchez, M.

The head-gear effect of the Herbst appliance. A cephalometric long-term study. Am J Orthod
Dentofacial Orthop. 1993; 103: 510–520

Abstract | Full Text PDF | PubMedSee all References, 4x4Pancherz, H. Frühoder

spätbehandlung mit der Herbst-apparatur—stabiität oder rezidiv?. Inf Orthod Orthop. 1994;
26: 437–445

See all References, 5x5Ruf, S. and Pancherz, H. The effect of Herbst appliance treatment on the
mandibular plane angle: a cephalometric roentgenographic study. Am J Orthod Dentofacial
Orthop. 1996; 110: 225–229

Abstract | Full Text | Full Text PDF | PubMedSee all References, 6x6Phan, K.L.D., Bendeus, M.,
Hägg, U., Hansen, K., and Rabie, A.B.M. Comparison of headgear activator and Herbst
appliance—effects and posttreatment changes. Eur J Orthod. 2006; 28: 594–604

CrossRef | PubMed | Scopus (13)See all References Because in those studies the follow-up
periods ended in late adolescence or early adulthood (approximately age 20 years), any
persisting dentoskeletal growth7x7Lewis, A.B. and Roche, A.F. Late growth changes in the
craniofacial skeleton. Angle Orthod. 1988; 58: 127–135

PubMedSee all References, 8x8Behrents, R.G. Growth in the aging craniofacial skeleton.
Monograph 17. Craniofacial Growth Series. Center for Human Growth and Development;
University of Michigan, Ann Arbor; 1985

See all References, 9x9Israel, H. Age factor and the pattern of change in craniofacial structures.
Am J Phys Anthropol. 1973; 29: 111–128

CrossRefSee all References, 10x10West, K.S. and McNamara, J.A. Changes in the craniofacial
complex from adolescence to adulthood: a cephalometric study. Am J Orthod Dentofacial
Orthop. 1999; 115: 521–532

Abstract | Full Text | Full Text PDF | PubMedSee all References, 11x11Pecora, N.G., Baccetti,
T., and McNamara, J.A. The aging craniofacial complex: a longitudinal cephalometric study
from adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008; 134: 496–505
Abstract | Full Text | Full Text PDF | PubMed | Scopus (29)See all References could affect the
long-term outcome of treatment.

In a recent longitudinal biometric 32-year follow-up investigation using dental casts, the very
long-term effects after Herbst therapy on tooth position and occlusion were analyzed in 14
adolescents with Class II Division 1 malocclusions who were followed to middle life (average,
46 years).12x12Pancherz, H., Bjerklin, K., Lindskog-Stockland, B., and Hansen, K. Thirty-two-
year follow-up study of Herbst therapy: a biometric dental cast analysis. Am J Orthod
Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References12 After the total
follow-up period of 32 years, 64% of the patients had results that were overall successful. A
partial Class II relapse was noted in 29%, and a total relapse in 7% of the subjects. Thus, it
would be of utmost interest to verify any possible posttreatment adult skeletofacial growth
after age 20 and its possible impact on the long-term treatment outcome.

Therefore, the aim of this cephalometric roentgenographic follow-up investigation after Herbst
therapy was to analyze the long-term (32 years) dentoskeletal changes in the these subjects
investigated biometrically.12x12Pancherz, H., Bjerklin, K., Lindskog-Stockland, B., and Hansen,
K. Thirty-two-year follow-up study of Herbst therapy: a biometric dental cast analysis. Am J
Orthod Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References12 The specific
aims were to (1) assess the amounts of skeletal and dental components contributing to
changes in the occlusion, (2) evaluate and compare early posttreatment changes of 6 years
(ages,14-20 years) and late posttreatment changes of 26 years (ages, 20-46 years), and (3)
visualize the long-term skeletofacial growth changes with superimposed lateral head films.

Jump to Section

Material and methods

The subjects in this study were derived from a well-defined sample of 22 consecutive patients
with Class II Division 1 malocclusions (bilateral Class II molar and canine occlusion, large
overjet, and deep overbite) treated with the Herbst appliance at the University of Malmö in
Sweden in 1977 and 1978. The subjects were originally presented in 2 articles from
1982.13x13Pancherz, H. The mechanism of Class II correction in Herbst appliance treatment. A
cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References, 14x14Pancherz, H.
Vertical dentofacial changes during Herbst treatment. Swed Dent J Suppl. 1982; 15: 189–196

PubMedSee all References

In 2011 and 2012, 30 to 33 years after Herbst therapy, these 22 subjects were recalled to the
orthodontic department in Malmö, Sweden, for a follow-up investigation. At this time, they
were 42 to 48 years old. Two persons were deceased, and 6 did not appear for several reasons.
Thus, the final follow-up sample comprised 14 subjects (12 men, 2 women), shown in detail in
Table ITable I. The patients' ages were, on average, 12 years at the start of treatment and
14 years after treatment. The patients were reexamined 6 years (age 20) and 32 years (age 46)
after treatment.

Table ICharacteristics of the 14 patients with Class II Division 1 malocclusions treated with the
Herbst appliance and followed for 32 years after therapy

Follow-
up Class II Growth
Treatment Age (y) Retention
periods correction pattern
(y)
Patien
Sex
t T
2 T3 T2
Herbst/Extra Fixed/Remova Stable/Rel Horizontal/Ver
T1 T2 T3 T4 - - -
ction ble†† apse tical‡‡
T T4 T4
3

Herbst/extra 17
1X m 13 21 48 4 27 31 F/R (2 y) Stable V
ction ∗

14. 20. 27. 33.

2 m Herbst 13 48 6 No retention Stable H
5 5 5 5

12. 6. 32.
3 m Herbst 11 19 45 26 No retention Stable H
5 5 5

14. 20. 47.

4 m Herbst 13 6 27 33 R (4 y) Stable H
5 5 5

13. 46. 27. 31.

5 m Herbst 15 19 4 R (3 y) Relapse H
5 5 5 5

14. 20. 47.

6 m Herbst 13 6 27 33 No retention Relapse H
5 5 5

14. 20. 27. 33.

7 f Herbst 13 48 6 R (2 y) Stable H
5 5 5 5

Herbst/extra
8X m 13 15 22 48 7 26 33 F/R (4 y) Stable H
ction

12.
9 m Herbst 14 20 45 6 25 31 R (2 y) Stable V
5
10 m Herbst 12 14 20 44 6 24 30 No retention Stable H

12. 18. 42.

11 f Herbst 11 6 24 30 R (2 y) Stable V
5 5 5

12. Relapse (1
12 m Herbst 14 21 46 7 25 32 F/R (3 y) H
5 side)

12.
13 m Herbst 14 21 45 7 24 31 R (2 y) Relapse H
5

12. Relapse (1
14 m Herbst 14 22 45 8 23 31 R (2 y) H
5 side)

Summ 12 12. 14. 20. 46. 6. 25. 31.

12 Herbst 4 no retention 9 stable 11 H
ary men 5 3 4 1 1 7 8

2 2
Mean wom Herbst/extra 10 retention 5 relapse 3 V
en ction

m, Male; f, female; T1, before treatment; T2, after treatment (12 months after the Herbst
appliance was removed and the occlusion had settled); T3, 6 years after treatment; T4,
32 years after treatment.

Patients 1X and 8X were treated by extractions after active Herbst therapy.

∗Includes a 2-year break in treatment during the period T1-T2.

†F implies fixed retention with a mandibular lingual canine-to-canine retainer; R implies

removable retention with an activator or a maxillary Hawley plate; F/R implies a fixed
mandibular canine retainer in combination with a removable maxillary Hawley plate.

‡H, Horizontal growth pattern that implies a reduction of the mandibular plane angle during
T1-T4; V, vertical growth pattern that implies an increase of the mandibular plane angle during
T1-T4.

All subjects were treated by an author (H.P.) using a banded type of Herbst appliance with a
simple anchorage system that did not include brackets on any teeth.13x13Pancherz, H. The
mechanism of Class II correction in Herbst appliance treatment. A cephalomteric investigation.
Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13 Since the treatment of
the original 22-subject sample was designed as a clinical experimental study, no further fixed
appliance treatment phase after the Herbst phase was planned. However, because of major
tooth irregularities after Herbst therapy, extractions of 4 premolars were performed in 2
subjects (patients 1X and 8X), and maxillary and mandibular fixed multibracket appliances
were placed for about 1 year. Furthermore, for tooth alignment in 1 nonextraction patient
(12), a maxillary multibracket appliance treatment phase was instituted for 6 months after the
Herbst phase. In these 3 patients, multibracket treatment after the Herbst phase aimed to
align the teeth after the Class I dental arch and overjet corrections were achieved by the
Herbst appliance.

Retention after Herbst treatment, performed in 10 of the 14 patients, was inconsistent and of
short duration (2-4 years). No retainers were used in 4 subjects (Table ITable I).

Lateral head films were analyzed at 4 times: T1, before Herbst treatment; T2, after treatment
(12 months after the Herbst appliance was removed and the occlusion had settled); for the 2
extraction patients (1X and 8X), T2 implied that analyses were done after removal of the
multibracket appliance; T3, 6 years after treatment at an average age of 20 years when the
radius epiphysis/diaphysis plate was closed (hand-wrist stage R-J, according to Hägg and
Taranger15x15Hägg, U. and Taranger, J. Skeletal stages of hand and wrist as indicators of the
pubertal growth spurt. Acta Odontol Scand. 1980; 38: 187–200

CrossRef | PubMed | Scopus (91)See all References15); and T4, 32 years after treatment at an
average age of 46 years.

The treatment and posttreatment changes of different variables were analyzed during the
following observation periods: T1-T2, treatment changes; T2-T3, early posttreatment changes;
T3-T4, late posttreatment changes; and T2-T4, total posttreatment changes.

All cephalometric roentgenograms were taken at the Department of Oral Radiology, Faculty of
Dentistry, Malmö University, Malmö, Sweden. The lateral head films at T1, T2, and T3 were
taken by the analog technique and the films at T4 by the digital technique. For each technique,
the radiographic records were obtained using a standardized procedure with a fixed-focus
midsagittal film distance. For accomplishing the same magnification of all head films, the
printouts of the T4 images were reduced in size by 14% to match the T1, T2, and T3 images
(7%). With the help of 1-mm metal indicators placed at intervals of 5 mm in the center of the
cephalostat's forehead rest, the final radiographic magnification could be checked.

The measurements from the roentgenograms were performed on matte acetate tracing film,
on which the reference points were marked with a sharp pencil. The angular measurements
were made to the nearest 0.5°, and the linear measurements to the nearest 0.5 mm. These
values were not corrected for linear enlargement (7%) in the median plane.

The reference points and lines used in the cephalometric analysis were those defined by
Björk16x16Björk, A. The face in profile. Swed Dent J. 1947; 40: 32–33

See all References16 and Pancherz.13x13Pancherz, H. The mechanism of Class II correction in

Herbst appliance treatment. A cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13

To minimize the tracing and landmark identification errors in the analysis of the serial head
films, the tracings of the 4 head films from each patient were done in a simultaneous parallel
way at the same occasion.17x17Richardson, A. An investigation into the reproducibility of
some points, planes, and lines used in cephalometric analysis. Am J Orthod. 1966; 52: 637–651

Abstract | Full Text PDF | PubMedSee all References, 18x18Carlsson, G.E. Error in x-ray
cephalometry. Scand Dent J. 1967; 75: 99–129

See all References, 19x19Baumrind, S. and Frantz, R.C. The reliability of head film
measurements. 1. Landmark identification. Am J Orthod. 1971; 60: 111–127

Abstract | Full Text PDF | PubMed | Scopus (313)See all References, 20x20Baumrind, S. and
Frantz, R.C. The reliability of head film measurements. 2. Conventional angular and linear
measures. Am J Orthod. 1971; 60: 505–517

Abstract | Full Text PDF | PubMed | Scopus (156)See all References, 21x21Björk, A. and
Skieller, V. Normal and abnormal growth of the mandible: a synthesis of longitudinal
cephalometric implant studies over a period of 25 years. Eur J Orthod. 1983; 5: 156–162

See all References

The head film evaluations comprised a standard analysis and an analysis of the sagittal changes
in the occlusion (SO).13x13Pancherz, H. The mechanism of Class II correction in Herbst
appliance treatment. A cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13

The head film analysis comprised 7 angular measurements (variables 1-7) and 2 linear
measurements, the latter of which were made on dental casts (variables 8 and 9).

1.

SNA, sagittal maxillary position to the cranial base.

2.

SNB, sagittal mandibular position to the cranial base.

3.

ANB, sagittal maxillomandibular relationship.

4.

ML/NSL, vertical mandibular position to the cranial base (mandibular plane angle).

5.

ILs/NSL, maxillary incisor inclination to the cranial base.

6.
ILi/ML, mandibular incisor inclination to the mandibular plane.

7.

ILs/ILi, interincisal inclination.

8.

Overjet, the horizontal distance between the incisal edge of the most prominent maxillary
central incisor and the labial surface of the corresponding mandibular incisor parallel to the
occlusal plane.

9.

Overbite, the vertical distance between the incisal edges of the maxillary central and
mandibular central incisors.

The SO analysis has been described extensively in a previous article.13x13Pancherz, H. The

mechanism of Class II correction in Herbst appliance treatment. A cephalomteric investigation.
Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13 The SO analysis allows a
quantitative assessment of skeletal and dental changes in the maxilla and mandible that
contribute to changes in the sagittal molar relationship and overjet.

The reference points and lines used are shown in Figure 1Figure 1. The occlusal line (OL) is
defined by the incisal tip of the most prominent maxillary central incisor and the mesiobuccal
cusp tip of the first maxillary molar. The OLp is a line perpendicular to OL through the tangent
point of the anterior wall of sella turcica. The OL and the OLp from the first head film were
used as a reference grid. The grid was transferred from the T1 tracing to the following tracings
(T2, T3, and T4) by superimposition of the radiographs, using the stable skull structures in the
anterior cranial base for orientation.21x21Björk, A. and Skieller, V. Normal and abnormal
growth of the mandible: a synthesis of longitudinal cephalometric implant studies over a
period of 25 years. Eur J Orthod. 1983; 5: 156–162

See all References21 The objective was to obtain the closest coincidence for the maximum
number of the following structures: (1) the anterior wall of sella turcica, (2) the cribriform
plate, (3) the trabecular pattern of the superior portion of the ethmoid bone, (4) the medial
border of the orbital roof, (5) the anterior walls of the median cranial fossae, and (6) the
anterior contours of the pterygopalatine fossae.
Fig 1

Measuring points and lines used in the SO analysis. The reference grid (OL and OLp) is
shown.13x13Pancherz, H. The mechanism of Class II correction in Herbst appliance treatment.
A cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13

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Perpendicular to the OLp line, the following changes in linear measurements (Fig 1Fig 1) were
assessed (variables 1-8): (1) ms minus mi, molar relationship; (2) is minus ii, overjet; (3) ss,
maxillary base position; (4) pg, mandibular base position; (5) ms minus ss, maxillary molar
position; (6) mi minus pg, mandibular molar position; (7) is minus ss, maxillary incisor position;
and (8) ii minus pg, mandibular incisor position.

To visualize the dentoskeletal growth changes during the different observation periods, the
radiographs from T1, T2, T3, and T4 of each subject were superimposed using the stable
anterior cranial base structures for orientation.21x21Björk, A. and Skieller, V. Normal and
abnormal growth of the mandible: a synthesis of longitudinal cephalometric implant studies
over a period of 25 years. Eur J Orthod. 1983; 5: 156–162

See all References21

Jump to Section

Statistical analysis

The data generated from the head film measurements were imported to the SPSS software
package (version 20.0; IBM, Armonk, NY) for statistical analysis.

The arithmetic means and standard deviations were calculated. Because all variables were
normally distributed, as shown by the Kolmogorov-Smirnov test, paired t tests were used to
assess the statistical significance of changes during the different observation periods. The
levels of significance used were P <0.001, P <0.01, and P <0.05. P ≥0.05 was considered not
significant.

Because of the small sample size of 14 subjects, no correlation or multiple regression analysis
was performed.
The study was approved by the ethical committee of the University of Malmö in Sweden
(number 2012/44).

Jump to Section

Results

All head film registrations from the 14 subjects were performed twice. The precision of the
double registrations was tested with Dahlberg's formula22x22Dahlberg, G. Statistical methods
for medical and biological students. Allen and Unwin, London, United Kingdom; 1940

See all References22 with a 2-week interval. For the angular measurements, the method error
varied between 0.6° (SNA, SNB) and 1.1° (ILs/NSL). For the linear measurements, the error
ranged between 0.2 mm (pg-OLp) and 0.5 mm (mi-OLp).

The final results were based on the first series of head film measurements.

For the standard cephalometric evaluation for each variable, the arithmetic mean and
standard deviation at each examination as well as the statistical evaluation of changes during
the different examination periods are given in Table IITable II.

Table IIStandard analysis: lateral head film measurements of 14 subjects with Class II Division 1
malocclusions treated with the Herbst appliance and followed for 32 years after therapy

T1 T2 T3 T4 T1-T2 T2-T3 T3-T4 T2-T4

Variable
Mea Mea Mea Mea
SD SD SD SD t∗ P t∗ P t∗ P t∗ P
n n n n

SN-maxillary 4.1 4.5 4.5 5.2 −0.2 N

82.8 82.2 82.3 81.5 0.97 NS NS 1.15 0.90 NS
position (°) 5 6 8 5 9 S

SNB-
3.6 4.0 3.5 4.7 −3.6 <0.0 N −0.7
mandibular 77.0 76.9 77.9 77.4 0.08 NS 0.87 NS
1 2 2 2 1 1 S 9
position (°)

ANB-
maxillomandib 2.0 1.8 2.3 1.8 <0.0 <0.0 N
5.9 5.3 4.4 4.4 2.18 3.10 0.00 1.94 NS
ular 2 5 9 6 5 1 S
relationship (°)

ML/NSL-
5.7 6.7 6.5 7.2 −0.5 <0.0 N <0.0
mandibular 30.1 30.5 28.0 28.0 NS 6.15 0.06 3.93
2 1 3 3 3 01 S 1
plane angle (°)

ILs/NSL- 101. 4.7 7.9 6.8 6.7 <0.0 −1.2 N −0.8

maxillary 96.5 98.0 97.8 3.36 NS 0.22 NS
9 3 4 1 6 1 1 S 3
incisor
inclination (°)

ILi/ML-
mandibular 100. 6.2 104. 5.3 101. 4.5 101. 6.2 −4.5 <0.0 <0.0 −0.5 N
4.07 1.98 NS
incisor 1 5 2 3 1 9 7 9 9 01 01 4 S
inclination (°)

ILs/Ili-
128. 8.1 131. 7.1 133. 9.7 132. 9.4 −1.8 −1.0 N −0.7
interincisor NS NS 0.20 NS
0 3 1 5 3 2 9 0 8 6 S 9
inclination (°)

Overjet 1.6 0.8 1.1 1.6 <0.0 −0.3 −0.7 N −0.6

8.1 3.9 4.0 4.2 7.23 NS NS
(mm)†† 2 9 3 7 01 1 2 S 7

Overbite 1.2 1.0 0.7 0.8 <0.0 −0.7 −1.0 N −0.3

5.0 3.5 3.8 3.8 3.20 NS NS
(mm)†† 3 6 8 3 1 4 0 S 6

Registrations (mean, SD) at 4 stages of examination. Statistical evaluation of changes (t tests

and P values) during 4 examination periods: T1, before treatment; T2, after treatment
(12 months after the Herbst appliance was removed and the occlusion had settled); T3, 6 years
after treatment; T4, 32 years after treatment; NS, not significant.

∗Paired t tests.

†Measurements on dental casts (Pancherz et al12x12Pancherz, H., Bjerklin, K., Lindskog-

Stockland, B., and Hansen, K. Thirty-two-year follow-up study of Herbst therapy: a biometric
dental cast analysis. Am J Orthod Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References12).

During treatment (T1-T2), there were reduction of the ANB (mean, 0.6°; P <0.05),
retroclination of the maxillary incisors (ILs/NSL: mean, 5.4°; P <0.05), and proclination of the
mandibular incisors (Ili/ML: mean, 3.1°; P <0.01).

During the early posttreatment period of 6 years (T2-T3), the SNB was increased (mean, 1.0°;
P <0.01), the ANB was reduced (mean, 0.9°; P <0.01), and the mandibular plane angle was
reduced (ML/NSL: mean, 2.5°; P <0.001).

During the late posttreatment period of 26 years (T3-T4), no significant cephalometric angular
changes occurred.

During the total posttreatment period of 32 years (T2-T4), only the mandibular plane angle
changed: the ML/NSL was reduced (mean, 2.5°; P <0.01).

In the SO analysis, changes of the skeletal and dental components contributing to the changes
of molar relationship and overjet are presented in Figures 2Figures 2 and 33, respectively. The
arithmetic means and P values (t tests) for each examination period are given.
Fig 2

SO analysis: maxillary and mandibular skeletal and dental changes contributing to the sagittal
molar relationship changes in the 14 Class II Division 1 patients treated with the Herbst
appliance. Registrations during 4 examination periods: T1-T2 (treatment period of 6 months
plus occlusal settling period of 12 months), T2-T3 (early posttreatment period of 6 years), T3-
T4 (late posttreatment period of 26 years), and T2-T4 (total posttreatment period of 32 years).
Plus signs imply favorable changes and minus signs unfavorable changes for Class II molar
correction. The significance values are based on paired t tests; ns, not significant.

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Fig 3

SO analysis: maxillary and mandibular skeletal and dental changes contributing to overjet
changes in the 14 Class II Division 1 patients treated with the Herbst appliance. Registrations
during 4 examination periods: T1-T2 (active treatment period of 6 months plus occlusal settling
period of 12 months), T2-T3 (early posttreatment period of 6 years), T3-T4 (late posttreatment
period of 26 years), and T2-T4 (total posttreatment period of 32 years). Plus signs imply
favorable changes and minus signs unfavorable changes for Class II molar correction. The
significance values are based on paired t tests; ns, not significant.

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During treatment (T1-T2), the Class II molar relationship was improved in the direction of Class
I by an average of 5.9 mm (P <0.001) (Fig 2Fig 2). This was accomplished by a small amount of
skeletal change (mean, 1.0 mm; not significant) and a large amount of dental change (mean,
4.9 mm; P <0.001). Concerning the skeletal changes contributing to Class II molar correction,
the anterior growth of the maxillary base was unfavorable (mean, 1.4 mm; P <0.05), whereas
the anterior growth of the mandibular base was favorable (mean, 2.4 mm; P <0.01). With
respect to the dental changes, the maxillary molars moved posteriorly (mean, 1.3 mm;
P <0.05), and the mandibular molars moved anteriorly (mean, 3.6 mm; P <0.001). The
movements of both molars were favorable for Class II molar correction.

During the early posttreatment period of 6 years (T2-T3), the molar relationship relapsed by
0.9 mm (P <0.01) (Fig 2Fig 2). For the relapse, the dental changes were responsible. Although
the skeletal changes were favorable (mean, 3.1 mm; P <0.001), they could not counteract the
dental changes (mean, 4.0 mm; P <0.001). Looking closer at the skeletal changes, we noted
that both the maxillary and mandibular bases grew anteriorly. Maxillary growth (mean,
3.0 mm; P <0.01) was unfavorable, and mandible growth (mean, 6.1 mm; P <0.001) was
favorable. With the dental changes, the maxillary molars relapsed anteriorly (mean, 2.2 mm;
P <0.01), and the mandibular molars relapsed posteriorly (mean, 1.8 mm; P <0.05).

During the late posttreatment period of 26 years (T3-T4), the molar relationship remained on
average unchanged (Fig 2Fig 2). Insignificant skeletal (mean, 0.3 mm) and dental (0.6 mm)
changes occurred. There was a large amount of unfavorable maxillary base growth anteriorly
(mean, 3.1 mm; P <0.01) partly compensated by favorable mandibular base growth anteriorly
(2.8 mm; P <0.01). Concerning the insignificant dental changes, both the maxillary molars
(mean, 1.0 mm) and the mandibular molars (mean, 0.4 mm) moved posteriorly.

During the total posttreatment period of 32 years (T2-T4), the molar relationship relapsed by
0.6 mm (P <0.05) (Fig 2Fig 2). With respect to the relapse, the dental changes were
responsible. Although the skeletal changes were favorable (mean, 2.8 mm; P <0.01), they could
not counteract the dental changes (mean, 3.4 mm; P <0.001). With respect to the skeletal
changes, both the maxillary and mandibular bases grew anteriorly. Maxillary growth (mean,
6.1 mm; P <0.001) was unfavorable, but mandible growth (mean, 8.9 mm; P <0.001) was
favorable. Concerning the dental changes, the maxillary molars relapsed anteriorly (mean,
1.2 mm; not significant), and the mandibular molars relapsed posteriorly (mean, 2.2 mm;
P <0.01).

The skeletal changes responsible for overjet reduction were the same as for the molar
relationship changes (Fig 3Fig 3).

During treatment (T1-T2), overjet was reduced by an average of 3.7 mm (P <0.001) (Fig 3Fig 3).
This was accomplished by a small amount of skeletal change (mean, 1.0 mm; not significant)
and a large amount of dental change (mean, 2.7 mm; P <0.01). Of the dental changes, the
maxillary incisors moved palatally (mean, 2.1 mm; P <0.05), and the mandibular incisors
moved labially (mean, 0.6 mm; not significant). The movements of both incisors were
favorable for overjet reduction.

During the early posttreatment period of 6 years (T2-T3), overjet relapsed insignificantly by
0.4 mm (Fig 3Fig 3). Responsible for the relapse were the dental changes. Although the skeletal
changes were favorable (mean, 3.1 mm; P <0.001), they could not counteract the dental
changes (mean, 3.5 mm; P <0.01). With the dental changes, the maxillary incisors relapsed
labially (mean, 1.0 mm; not significant), and the mandibular incisors relapsed lingually (mean,
2.5 mm; P <0.001).
During the late posttreatment period of 26 years (T3-T4), overjet relapsed insignificantly by
0.4 mm (Fig 3Fig 3). For this relapse, small skeletal (mean, 0.3 mm; not significant) and dental
(0.1 mm; not significant) changes were responsible. With respect to the dental changes, the
maxillary incisors proclined (mean, 0.1 mm; not significant), and the mandibular incisor
position was unchanged (mean, 0.0 mm; not significant).

During the total posttreatment period (T2-T4) of 32 years, overjet relapsed by 0.8 mm
(P <0.05) (Fig 3Fig 3). For this relapse, the dental changes were responsible. Although the
skeletal changes were favorable (mean, 2.8 mm; P <0.01), they could not counteract the dental
changes (mean, 3.6 mm; P <0.01). Regarding the dental changes, the maxillary incisors
relapsed labially (mean, 1.1 mm; not significant), and the mandibular incisors relapsed lingually
(mean, 2.5 mm; P <0.01).

To visualize the dentoskeletal changes during the different examination periods, superimposed
cephalometric tracings from the 14 subjects are presented in Figure 4Figure 4.

View Large Image | View Hi-Res Image | Download PowerPoint Slide

View Large Image | View Hi-Res Image | Download PowerPoint Slide

Fig 4

A and B, Superimposed cephalometric tracings from the 14 patients with Class II Division 1
malocclusions treated with the Herbst appliance. The 4 times of examination were before
treatment (black); after treatment, 12 months after the appliance was removed and the
occlusion had settled (red); 6 years after treatment (blue) and 32 years after treatment
(green). Note the pronounced posttreatment skeletofacial growth, especially after age 20 (6-
32 years after treatment) when the radius epiphysis/diaphysis plate was closed (stage R-
J15x15Hägg, U. and Taranger, J. Skeletal stages of hand and wrist as indicators of the pubertal
growth spurt. Acta Odontol Scand. 1980; 38: 187–200
CrossRef | PubMed | Scopus (91)See all References15).

Posttreatment (T2-T4), in all 14 subjects, large amounts of maxillary and mandibular growth
occurred in both the sagittal and vertical directions. Also, pronounced growth changes took
place during the late posttreatment period (T3-T4), after the age of 20 years, when the radius
epiphysis/diaphysis plate was closed.

For the sagittal growth changes in relation to the original occlusal plane (Figs 2Figs 2 and 33),
the following were observed. During the treatment period (T1-T2), sagittal mandibular growth
exceeded sagittal maxillary growth in 12 patients (2-11, 13, and 14), whereas the opposite was
true in 2 patients (1 and 12). During the total posttreatment period (T2-T4), sagittal
mandibular growth exceeded sagittal maxillary growth in 11 patients (1-4, 7-10, and 12-14),
and the opposite was true in 3 patients (5, 6, and 11).

Jump to Section

Discussion

These 14 subjects belonged to an original sample of 22 Herbst patients, who were the first 22
with Class II Division 1 malocclusions treated with that appliance in modern
times.13x13Pancherz, H. The mechanism of Class II correction in Herbst appliance treatment. A
cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References, 14x14Pancherz, H.
Vertical dentofacial changes during Herbst treatment. Swed Dent J Suppl. 1982; 15: 189–196

PubMedSee all References In 5 of the 14 subjects, a partial or total Class II relapse was noted
32 years after treatment12x12Pancherz, H., Bjerklin, K., Lindskog-Stockland, B., and Hansen, K.
Thirty-two-year follow-up study of Herbst therapy: a biometric dental cast analysis. Am J
Orthod Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References12 (Table ITable I).
This figure seems rather high, but when the original treatment was performed (1977-1978), no
one had practical clinical experience about how to manage the Herbst appliance. It could be
expected that if a sample of Herbst patients started treatment later, say 10 years later,
stability would be improved.

A loss of subjects at follow-up is a potential source of bias.23x23Zelle, B.A., Bhandari, M.,

Sanches, A.I., Probst, C., and Pape, H.C. Loss of follow-up in orthodontic trauma: is 80% follow-
up still acceptable?. J Orthop Trauma. 2013; 27: 177–181

CrossRef | PubMed | Scopus (3)See all References23 At the recall of the 22 patients, 30 to
33 years after therapy, the attendance rate was 70% (when excluding the 2 persons who were
deceased); this must be considered acceptable, especially for the long follow-up period of 30
to 33 years. Furthermore, when looking closer at the 6 who did not attend compared with the
14 attending ones, they did not differ with respect to patient characteristics, length of
treatment, and immediate treatment results.13x13Pancherz, H. The mechanism of Class II
correction in Herbst appliance treatment. A cephalomteric investigation. Am J Orthod. 1982;
82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13 Thus, the 14 subjects
must be considered as an unbiased group for a reliable long-term follow-up study.

In the SO analysis and the presentation of superimposed head films, the stable skull structures
of the anterior cranial base were used for the orientation of the films (skull-structure
method).21x21Björk, A. and Skieller, V. Normal and abnormal growth of the mandible: a
synthesis of longitudinal cephalometric implant studies over a period of 25 years. Eur J Orthod.
1983; 5: 156–162

See all References21 This method has been found to be more accurate in longitudinal studies,
covering many years of the growth period, than when using the anatomic landmarks sella and
nasion in constructing a cranial base reference line (landmark-based method).24x24Pancherz,
H. and Hansen, K. The nasion-sella reference line in cephalometry: a methodologic study. Am J
Orthod. 1984; 86: 427–434

Abstract | Full Text PDF | PubMed | Scopus (17)See all References24 For serial head film
orientation, growth displacement changes of nasion and sella over a long time result in a
registration error of the cranial base that is larger than when using the stable cranial base
structures.24x24Pancherz, H. and Hansen, K. The nasion-sella reference line in cephalometry: a
methodologic study. Am J Orthod. 1984; 86: 427–434

Abstract | Full Text PDF | PubMed | Scopus (17)See all References24

In comparing angular cephalometric measurements (Table IITable II) with linear measurements
(Figs 2Figs 2 and 33), no significant angular changes could be recorded during the late
posttreatment period (T3-T4) for any variable. The opposite was true for the linear variables
(Figs 2Figs 2 and 33). This was most likely because, in the angular measurements, the actual
anatomic nasion points at T1, T2, T3, and T4 were displaced forward during growth (Fig 4Fig 4),
thus affecting the SNA and SNB angles.

To date, this is the only published cephalometric roentgenographic long-term follow-up (30-
33 years) investigation after fixed functional appliance treatment in which the follow-up period
after therapy ended in the patients' middle life. In previous semi-long-term follow-up studies,
the follow-up periods were relatively short and ended at about 20 years of age, when the
radius epiphysis/diaphysis plate was closed.1x1Pancherz, H. The nature of Class II relapse after
Herbst appliance treatment: a cephalometric long-term investigation. Am J Orthod Dentofacial
Orthop. 1991; 100: 220–233

Abstract | Full Text PDF | PubMedSee all References, 2x2Hansen, K. and Pancherz, H. Long-
term effects of Herbst treatment in relation to normal growth development: a cephalometric
study. Eur J Orthod. 1992; 14: 285–295
CrossRef | PubMed | Scopus (40)See all References, 3x3Pancherz, H. and Anehus-Panchez, M.
The head-gear effect of the Herbst appliance. A cephalometric long-term study. Am J Orthod
Dentofacial Orthop. 1993; 103: 510–520

Abstract | Full Text PDF | PubMedSee all References, 4x4Pancherz, H. Frühoder

spätbehandlung mit der Herbst-apparatur—stabiität oder rezidiv?. Inf Orthod Orthop. 1994;
26: 437–445

See all References, 5x5Ruf, S. and Pancherz, H. The effect of Herbst appliance treatment on the
mandibular plane angle: a cephalometric roentgenographic study. Am J Orthod Dentofacial
Orthop. 1996; 110: 225–229

Abstract | Full Text | Full Text PDF | PubMedSee all References, 6x6Phan, K.L.D., Bendeus, M.,
Hägg, U., Hansen, K., and Rabie, A.B.M. Comparison of headgear activator and Herbst
appliance—effects and posttreatment changes. Eur J Orthod. 2006; 28: 594–604

CrossRef | PubMed | Scopus (13)See all References Many clinicians consider this age as an
indicator of completed skeletofacial growth. In our subjects, however, much skeletofacial
growth occurred from 20 (after the closure of the radius epiphysis/diaphysis
plate25x25Deicke, M. and Pancherz, H. Is radius-union an indicator for completed facial
growth?. Angle Orthod. 2005; 75: 295–299

PubMedSee all References25) to 46 years of age (Table IITable II, Fig 2, Fig 3, Fig 4). However, it
could not be verified when that growth had taken place. Was growth distributed over the
whole period, or was it only at the beginning of the period? Thus, the question remains open:
When during T3 to T4 had growth come to an end?

In untreated subjects, Behrents8x8Behrents, R.G. Growth in the aging craniofacial skeleton.

Monograph 17. Craniofacial Growth Series. Center for Human Growth and Development;
University of Michigan, Ann Arbor; 1985

See all References8 demonstrated skeletofacial growth after the age of 25 years in 50%, after
30 years in 24%, after 35 years in 9%, and after 40 years in 4% of the subjects he screened.
Thus, in our patients, it could be expected that many grew for several years after T3 (20-
30 years of age), but at age 46 (T4), only minimal or no growth would be expected in any
subject. However, there were differences with respect to the subjects in the Behrents' study
and ours. Behrents investigated untreated (mostly Class I) subjects, whereas our subjects were
treated Class II patients who from the beginning had a different skeletofacial morphology and
also were thought to have a different growth pattern.2x2Hansen, K. and Pancherz, H. Long-
term effects of Herbst treatment in relation to normal growth development: a cephalometric
study. Eur J Orthod. 1992; 14: 285–295

CrossRef | PubMed | Scopus (40)See all References, 26x26Pancherz, H. and Fackel, U. The
skeletofacial growth pattern pre- and post-dentofacial orthopaedics. A long-term study of
Class II malocclusions treated with the Herbst appliance. Eur J Orthod. 1990; 12: 209–218
CrossRef | PubMedSee all References, 27x27Pancherz, H., Zieber, K., and Hoyer, B.
Cephalometric characteristics of Class II division 1 and Class II division 2 malocclusions: a
comparative study in children. Angle Orthod. 1997; 67: 111–120

PubMedSee all References, 28x28Bishara, S.E., Jakobsen, J.R., Vorhies, B., and Bayati, P.
Changes in dentofacial structures in untreated Class II division 1 and normal subjects: a
longitudinal study. Angle Orthod. 1997; 67: 55–66

PubMedSee all References, 29x29Sidlauskas, A., Svalkauskiene, V., and Sidlauskas, M.

Assessment of skeletal and dental pattern of Class II division 1 malocclusion with relevance to
clinical practice. Stomatologija. 2006; 8: 3–8

PubMedSee all References

Our 14 subjects exhibited various growth patterns ranging from marked horizontal growth to
marked vertical growth. Furthermore, the pattern in some subjects changed during the
examination periods (Fig 4Fig 4).

When comparing the changes from T1 to T2 with those from earlier Herbst studies, the
reductions in overjet and overbite and the normalization of Class II molar relationship were
less pronounced.1x1Pancherz, H. The nature of Class II relapse after Herbst appliance
treatment: a cephalometric long-term investigation. Am J Orthod Dentofacial Orthop. 1991;
100: 220–233

Abstract | Full Text PDF | PubMedSee all References, 30x30Pancherz, H. and Hansen, K.
Occlusal changes during and after Herbst treatment. Eur J Orthod. 1986; 8: 215–228

CrossRef | PubMed | Scopus (79)See all References This was due to the difference in defining
the T1 to T2 period. In the earlier studies, the period ranged from before treatment to
immediately after active treatment; for our subjects, T2 was 1 year after active therapy when
settling of the occlusion (overjet, overbite, and sagittal occlusion) had occurred. Our definition
of T2 might also explain the less marked treatment changes of the mandible (SNB and pg
point) compared with the T1 to T2 changes in the 1982 study.13x13Pancherz, H. The
mechanism of Class II correction in Herbst appliance treatment. A cephalomteric investigation.
Am J Orthod. 1982; 82: 104–113

Abstract | Full Text PDF | PubMed | Scopus (205)See all References13

During the total posttreatment period (T2-T4), on average, minimal relapses in molar
relationship and overjet occurred (Figs 2Figs 2 and 33). This was the result of unfavorable
maxillary and mandibular dental changes, partly compensated by the net effect of favorable
mandibular growth exceeding unfavorable maxillary growth (Figs 2Figs 2 and 33).

As verified by an earlier study analyzing dental casts, there was a Class II relapse after
treatment in 5 of the 14 patients (5, 6, and 12-14) (Table ITable I).12x12Pancherz, H., Bjerklin,
K., Lindskog-Stockland, B., and Hansen, K. Thirty-two-year follow-up study of Herbst therapy: a
biometric dental cast analysis. Am J Orthod Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References12 When looking at
the patients who relapsed (Fig 4Fig 4) and comparing them with the stable subjects, we noted
that sagittal maxillary growth exceeded sagittal mandibular growth during the late
posttreatment period (T3-T4). In patients 5, 12, 13, and 14, mandibular growth was also
oriented more vertically during that period. Thus, the Class II molar and overjet relapses can be
explained by an unfavorable posttreatment maxillomandibular growth pattern, especially
when combined with unstable interdigitation of the teeth.1x1Pancherz, H. The nature of Class
II relapse after Herbst appliance treatment: a cephalometric long-term investigation. Am J
Orthod Dentofacial Orthop. 1991; 100: 220–233

Abstract | Full Text PDF | PubMedSee all References, 4x4Pancherz, H. Frühoder

spätbehandlung mit der Herbst-apparatur—stabiität oder rezidiv?. Inf Orthod Orthop. 1994;
26: 437–445

See all References, 12x12Pancherz, H., Bjerklin, K., Lindskog-Stockland, B., and Hansen, K.
Thirty-two-year follow-up study of Herbst therapy: a biometric dental cast analysis. Am J
Orthod Dentofacial Orthop. 2014; 145: 15–27

Abstract | Full Text | Full Text PDF | PubMed | Scopus (3)See all References A stable occlusion
will preserve a Class I occlusion after treatment by the dentoalveolar compensatory
mechanism.31x31Solow, B. The dentoalveolar compensatory mechanism: background and
clinical implications. Br J Orthod. 1980; 7: 145–161

CrossRef | PubMedSee all References31

Finally, the posttreatment findings depicting a significant amount of skeletofacial growth after
age 20 (after the closure of the radius epiphysis/diaphysis plate) suggest that we should revise
our current strategy in treating elderly Class II and Class III patients. For minimizing the risk of
posttreatment relapses, orthognathic surgical and tooth implantologic measures should be
postponed for several years after age 20.

Jump to Section

Conclusions

Fourteen adolescent Class II Division 1 Herbst patients were reexamined 6 years (at age 20,
after the closure of the radius epiphysis/diaphysis plate) and 32 years (at age 46) after
treatment.

1.

In all subjects, there were large amounts of sagittal and vertical skeletofacial growth after age
20. However, the question of when, during the period from 20 to 46 years of age, growth had
come to an end remains open.
2.

Closure of the radius epiphysis/diaphysis plate is not a useful indicator of completed

skeletofacial growth.

3.

Posttreatment Class II relapse seemed to be due to an unfavorable maxillomandibular growth

pattern, with insufficient dentoalveolar compensation.

4.

These findings indicate the importance of considering late adult skeletofacial growth in
dentofacial orthopedics, orthognathic surgery, and tooth implantology with respect to
treatment timing, posttreatment retention, and relapse.

Jump to Section

References

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long-term investigation. Am J Orthod Dentofacial Orthop. 1991; 100: 220–233

View in Article

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2Hansen, K. and Pancherz, H. Long-term effects of Herbst treatment in relation to normal

growth development: a cephalometric study. Eur J Orthod. 1992; 14: 285–295

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View in Article

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angle: a cephalometric roentgenographic study. Am J Orthod Dentofacial Orthop. 1996; 110:
225–229

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6Phan, K.L.D., Bendeus, M., Hägg, U., Hansen, K., and Rabie, A.B.M. Comparison of headgear
activator and Herbst appliance—effects and posttreatment changes. Eur J Orthod. 2006; 28:
594–604

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7Lewis, A.B. and Roche, A.F. Late growth changes in the craniofacial skeleton. Angle Orthod.
1988; 58: 127–135

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9Israel, H. Age factor and the pattern of change in craniofacial structures. Am J Phys Anthropol.
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12Pancherz, H., Bjerklin, K., Lindskog-Stockland, B., and Hansen, K. Thirty-two-year follow-up
study of Herbst therapy: a biometric dental cast analysis. Am J Orthod Dentofacial Orthop.
2014; 145: 15–27

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13Pancherz, H. The mechanism of Class II correction in Herbst appliance treatment. A

cephalomteric investigation. Am J Orthod. 1982; 82: 104–113

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14Pancherz, H. Vertical dentofacial changes during Herbst treatment. Swed Dent J Suppl. 1982;
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15Hägg, U. and Taranger, J. Skeletal stages of hand and wrist as indicators of the pubertal
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156–162

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22Dahlberg, G. Statistical methods for medical and biological students. Allen and Unwin,
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23Zelle, B.A., Bhandari, M., Sanches, A.I., Probst, C., and Pape, H.C. Loss of follow-up in
orthodontic trauma: is 80% follow-up still acceptable?. J Orthop Trauma. 2013; 27: 177–181

View in Article

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24Pancherz, H. and Hansen, K. The nasion-sella reference line in cephalometry: a

methodologic study. Am J Orthod. 1984; 86: 427–434

View in Article

| Abstract

| Full Text PDF

| PubMed

| Scopus (17)

25Deicke, M. and Pancherz, H. Is radius-union an indicator for completed facial growth?. Angle
Orthod. 2005; 75: 295–299

View in Article
| PubMed

26Pancherz, H. and Fackel, U. The skeletofacial growth pattern pre- and post-dentofacial
orthopaedics. A long-term study of Class II malocclusions treated with the Herbst appliance.
Eur J Orthod. 1990; 12: 209–218

View in Article

| CrossRef

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27Pancherz, H., Zieber, K., and Hoyer, B. Cephalometric characteristics of Class II division 1 and
Class II division 2 malocclusions: a comparative study in children. Angle Orthod. 1997; 67: 111–
120

View in Article

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28Bishara, S.E., Jakobsen, J.R., Vorhies, B., and Bayati, P. Changes in dentofacial structures in
untreated Class II division 1 and normal subjects: a longitudinal study. Angle Orthod. 1997; 67:
55–66

View in Article

| PubMed

29Sidlauskas, A., Svalkauskiene, V., and Sidlauskas, M. Assessment of skeletal and dental
pattern of Class II division 1 malocclusion with relevance to clinical practice. Stomatologija.
2006; 8: 3–8

View in Article

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30Pancherz, H. and Hansen, K. Occlusal changes during and after Herbst treatment. Eur J
Orthod. 1986; 8: 215–228

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31Solow, B. The dentoalveolar compensatory mechanism: background and clinical

implications. Br J Orthod. 1980; 7: 145–161

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Am J Orthod Dentofacial Orthop. 2014 Sep;146(3):310-8. doi: 10.1016/j.ajodo.2014.02.009.

Mandibular incisor inclination, tooth irregularity, and gingival

recessions after Herbst therapy: a 32-year follow-up study.
Pancherz H1, Bjerklin K2.

Introduction
The aim of this study was to analyze the very long-term results after Herbst treatment with respect to
changes in the mandibular incisor segment: incisor inclination, incisor alignment, and gingival status.

Methods
Fourteen patients were derived from a sample of 22 consecutive patients with Class II Division 1
malocclusions treated with the banded Herbst appliance. Intraoral photographs, mandibular dental casts,
and lateral head films were analyzed from before (T1, age 12.5 years) and after (T2, age 14 years)
treatment, and at 6 years (T3, age 20 years) and 32 years (T4, age 46 years) after treatment.

Results
At T1, incisor inclination in the 14 subjects was, on average, 100.1°. From T1 to T2, the incisors were
proclined in 11 (79%) of the 14 patients, with an average value of 5.2°. Maximum proclinations of 10° were
found in 2 subjects. From T2 to T4, tooth inclination recovered completely in 7 (63%) of the 11 patients.
Incisor irregularity values were, on average, 3.4 mm at T1 and 3.0 mm at T2. These increased from T2 to
T4 by 40% and had an average value of 5.0 mm at T4. Clinically insignificant labial gingival recessions on
single front teeth were registered in 1 subject at T2 and in 8 subjects at T4. Gingival recessions were seen
especially on bodily displaced incisors.

Conclusions
In Herbst patients followed for 32 years after therapy, proclined mandibular incisors generally rebounded.
The increase in posttreatment incisor tooth irregularity was not thought to be related to incisor tooth
inclination changes but more likely resulted from physiologic processes occurring throughout life. Minor
gingival recessions (especially on bodily displaced and crowded canines and incisors) seen in a few
patients, 32 years after treatment, seemed not to be related to the posttreatment tooth inclination changes.
POWER

 2. INTRODUCCION
o El Herbst es un aparato funcional fijo, que está diseñado para corregir la
clase II debida a un retrognatismo mandibular.
 3.
o Sus brazos telescópicos bilaterales trabajan como una articulación
artificial para forzar la mandíbula a una protrusión continua provocando
un patrón de mordida diferente, que debe estimular el crecimiento
mandibular.
 4. HISTORIA
o Este aparato fue diseñado y concebido por Emil Herbst y presentado en
el Congreso Internacional Dental de Berlín en 1905, como un aparato
que buscaba crear un “salto de mordida”.
 5.
o En Suecia (1979) Hans Pancherz, lo reintrodujo con una modificación,
que pretendía producir un “crecimiento condilar efectivo”
 6.
o En 1988 Mc Namara, le adiciona una férula acrílica con el propósito de
evitar la excesiva vestíbuloversión de los incisivos inferiores .
 7. MECANISMO DE ACCION
o Pertenece al grupo de los aparatos funcionales fijos y rigidos
o Después de fijados y activados ellos no permiten que el paciente cierre
en relación céntrica. Esto significa que la mandíbula está en una posición
adelantada 24 horas al día, creando un mayor el estímulo para el
crecimiento mandibular
 8.
o Mediante el empleo del aparato de HERBST® se crea en el maxilar una
fuerza hacia atrás parecida a un ”High Pull Headgear” logrando una
retrusión del frente del maxilar y una protrusión del frente de la
mandíbula.
 9.
o El principio de RFFAs se basa en un mecanismo telescópico que alienta
el reposicionamiento anterior de la mandíbula cuando los pacientes
entran en oclusión.
 10. ANCLAJE
o El primer artículo publicado describe un diseño de Herbst que implica el
apropiado bandeado de las muelas superiores y primero premolares con
las bandas conectadas por un arco lingual.
 11.
o Más tarde, la versión del aparato se modificó para incorporar las
unidades adicionales de anclaje:
o Las bandas se colocaron en premolares y primeros molares y tanto en
bucal como lingual conectados los premolares y molares.
o (Pancherz 1979)
 12.
 o A finales de los 80, se sugiere el uso de ferulas acrilicas cementadas a las
caras oclusales como retencion, asi como para prevenir la proclinacion
dental. (Mc Namara,1988)
 13. DESCRIPCION
o El aparato de Herbst se compone de dos tubos, dos embolos, los ejes y
los tornillos. El aparato de Herbst ha experimentado algunos cambios en
su diseño original pero desde el setenta ha mantenido su forma general
con sólo unos pocas modificaciones con respecto a métodos de su
fijacion (Tipo I, II y IV).
 14. CLASIFICACION SEGUN SU FIJACION
 15. TIPO 1
o Es caracterizado por un sistema que se fija a las coronas o bandas por el
uso de tornillos. Esto es la forma más común. Es necesaria la fijación de
los ejes a las bandas o coronas y luego se fijan los tubos y embolos con
los tornillos.
 16. TIPO 2
o se fija directamente al arco por el uso de tornillos. Tiene la desventaja de
causar fracturas constantes en el arco. La falta de la flexibilidad junto
con la dificultad de movimientos laterales y el stress sobre el arco
causado por la activación, causa fracturas
 17. TIPO 4
o El tipo IV tiene un sistema de fijación con una fijación en bola, que
permite la flexibilidad y la libertad más grande del movimiento
mandibular. Una desventaja con relación a otros aparatos semejantes es
el hecho que necesita brackets para estabilizar la articulación. Cuándo un
fractura ocurre o un bracket se despega, el aparato se afloja.
 18. APARATO MALU
o ( Saga Dental A/S, postboks 216, Kongsviner, Noruega)
o El MALU (Unidad de Adelantamiento Mandibular) es un artefacto
recientemente desarrollado para la fijación del Herbst
o Se compone de dos tubos, dos embolos, dos bisagras superiores de
&quot;Mobee&quot; con postes en bola y dos bisagras más bajas de
llave con postes de latón. Las ventajas mayores son el costo más bajo, no
necesita laboratorio, la flexibilidad y la posibilidad de usarlo combinado
con la terapia de edgewise
 19.
o Cada bisagra superior de Mobee se mete en el hoyo a fines del tubo de
MALU y se asegura al primer tubo del headgear de la muela con el poste
en bola.
o Cada bisagra clave se mete en el hoyo a fines del embolo y cierra al arco
a distal del canino, con el poste de latón.
 20. APARATOS HERBST
o Prefabricados
o Fabricados en laboratorio
 21. HERBST FIJACION EN BOLA
o Ventajas:
o Es una modificacion de la fijacion tipo 1
o mejorar el confort y la aceptación de los pacientes
o causar menos problemas clínicos para enroscar o fijar los aditamentos
o permitir los movimientos mandibulares laterales
 o permitir la aplicación fácil en guardas para la corrección en dentición
mixta
o Desventajas: no es posible tener brackets inferiores ni aparato fijo al
mismo tiempo
 22.
 23. HERBST FLIP-LOCK
o Prefabricado (TP ortho)
o Fijacion tipo I
o Ventajas:Se activa mediante la colocacion de espaciadores
o Desventajas: se requiere de un kit completo
 24. CANTILEVERED BITE JUMPER
o Prefabricado (Ormco 1717 West Collins Ave., Orange, CA 92867)
o Fijacion tipo 1
o Desventaja: el espesor del mecanismo del tornillo puede incrustarse en la
mejilla de paciente. Se requiere de un kit completo de diferentes tamanos
 25. TELESCOPIC 41 MAGNETICO
o Fabricado en laboratorio
o Fijacion tipo 1
o Ventajas: ofrecer un campo magnético al aparato funcional.
o Desventajas: principales son su espesor, el trabajo necesario de
prepararlo en el laboratorio y el cubrir los imanes
 26. UNIVERSAL BITE JUMPER 5 (UBJ)
o Prefabricado (Calvez X., 1998).
o Fijacion tipo 1
o Ventajas:se prueba en la boca de paciente y se corta a la longitud
apropiada para el adelantamiento mandibular deseado.
 27. APARATO RITTO
o Prefabricado
o Fijacion tipo 2
o Ventajas: No desembraga después de lograr la extensión máxima. no
afecta la apariencia estética ni el habla. Entra un solo formato que
permite ser usado en ambos lados y está disponible en un sólo tamaño.
o Desventajas: relacionadas a su fijacion
 28. APARATO DE PROTRACCION 7-9
o Fabricacion en laboratorio
o Descrito por Filho C., 1995, 1997, 1998
o Ventajas: comodidad de fabricación, el costo bajo, la rotura poco
frecuente, se puede componer en cualquier momento. Esto es útil cuando
ha habido un fracaso en el suministro de otros aparatos comercialmente
disponibles o si el ortodoncista practica en un área dónde es difícil de
obtener rápidamente otras alternativas.
 29. MPA I
o Fijacion tipo 2
o cada lado del aparato es hecho doblando un lazo pequeño en un ángulo
derecho de un. 032&quot; alambre de SS. La longitud del aparato
entonces es determinada protruyendo la mandíbula y otro loop pequeño
se dobla en una dirección opuesta. El aparato desliza distalmente por el
arco mandibular y mesialmente por el arco maxilar.
o Desventaja: Abrir limitadamente la boca
 30. MPA II
 o Fijacion tipo 2
o esta hecho haciendo los loops en dos pedazos de. 032&quot; alambre de
SS. Un pedazo pequeño de resorte se desliza sobre uno de los alambres.
Un fin de cada alambre entonces se mete por el lazo en el otro alambre.
Esta versión permite que la boca abra más que la primera versión.
 31. MPA III
o Fijacion tipo 1
o Esta versión elimina el stress sobre el arco que ocurre con el MPA I y II.
Permite una distancia más grande del movimiento de mandíbula al
mantenerla en una posición protruida
o Desventajas: Requiere más tiempo para ser construido y un soldador
electrónico bueno que no oscurezca ni debilite el alambre
 32. VENTRAL TELESCOPE
o Prefabricado (Positioners, S.a..)
o Fijacion tipo 1
o Este fue el primer telescopic RFFA que apareció como una sola unidad;
al alcanzar el máximo de apertura no se desembraga.
o Está disponible en dos tamaño y se fija por fijaciones de pelota. Es fácil
de activar y se lleva a cabo destornillando el tubo así permite una
activación de alrededor de 3 Mm.
o Desventajas: es bastante grueso y sufre de fracturas al freno que
estabiliza la articulación.
 33. INDICACIONES
o El aparato de HERBST® se utiliza en casos de oclusión distal (Clase II,
div.1, de Angle), por retrognatismo mandibular.
o La edad más adecuada para iniciar el tratamiento es a la mitad del
crecimiento originado por la pubertad. (9-11 aňos)
o Se alcanza una relación neutra al cabo de unos 6-8 meses,
aproximadamente de ser utilizado
o El tiempo de retención con un aparato móvil llevado durante la noche (p.
ej. El Bionator) hasta el final del crecimiento esencial, es corto, cuando
se comienza el tratamiento relativamente tarde. No obstante, en los casos
distales graves en niños pequeños, pueden existir indicaciones de tipo
psicológico o profiláctico traumático para realizar un tratamiento precoz.
 34. VENTAJAS
o La acción se ejerce de forma ininterrumpida las 24 horas del día.
o La duración del tratamiento activo es corta (6 -8 meses).
o No requiere ninguna colaboración por parte del paciente.
o Se puede llevar siempre puesto.
o Se puede configurar de manera que sea aceptable desde el punto de vista
estético e higiénico.
o El aparato es fijo.
 35. DESVENTAJAS
o Al aparato de Herbst se le han atribuido efectos adversos en la
articulación temporo-mandibular (ATM) y en los tejidos periodontales
(recesión gingival), por ser un aparato fijo que mantiene la mandíbula en
una posición adelantada forzada, y por la pro-inclinación generada en los
incisivos
 36. RESULTADOS
 o Los promedios de restricción del crecimiento maxilar obtenidos con el
aparato de Herbtz, varían desde
o – 0.3mm hasta –1.2 mm.
 37.
o Con el aparato de Herbtz se reportaron aumentos en la longitud de la
rama desde 1 mm hasta 3.6mm. Sin embargo teniendo en cuenta la
dificultad que representa la ubicación del punto Co , no es posible
determinar si existe realmente un crecimiento de la rama, o si esta
diferencia es originada por errores de medición en los diferentes estudios
analizados.

Xi

 38.
o Aunque diversos estudios realizados con resonancia magnética nuclear
reportan “Crecimiento Condilar Efectivo”, actualmente no existen
trabajos que cuantifiquen el crecimiento que aparentemente se observa
en esta zona
o La corrección en la relación molar obtenida con el uso del aparato de
Herbtz varia de 3.1mm a 6.1 mm que obedece a cambios dentales en su
mayoría (37% esquelético y 63% dental).
 39.
o
Los resultados varían significativamente de un individuo a otro
dependiendo de su patrón facial de crecimiento. Un patrón de
crecimiento horizontal que coincida con una forma facial braquicéfala, al
parecer responde mejor al tratamiento.
 40. ELABORACION DE HERBST
 41. MORDIDA DE CONTRUCCION
o Se elaboran rodillos de cera de 4 mm de espesor aproximadamente
 42.
o Se colocan en boca y se pide al px que muerda en protrusiva, si se
requiere de mas de 5-6 mm, se toma en la posicion mas adelantada
posible y en un segundo tiempo en relacion borde a borde
 43. BONDEADO FIJACION TIPO I
o Uso en Px sin aparatologia fija
o PASOS:
o Ajuste de los modelos en el Fixator con mordida de construcción.
o MAXILAR:
o Se confecciona ATP a 2mm del paladar
o Contornear con acero 0.028 molares y premolares (caninos en caso de
exodoncias)
o Se soldan los aditamentos de fijacion a la cara vestibular del contorneado
en primeros molares, cuidando de no alterar la rosca de los mismos
 44.
o MANDIBULA:
o Se realiza en contorneado 0.028 ss de primer premolar (canino en caso
de extracciones) hasta el primer molar
o Se unen y soldan ambos contorneados por medio de un arco lingual
o Se soldan los aditamentos de fijacion a la zona de primer premolar.
o ACRILADO
 o Hidratar los modelos y eventualmente aislarlos.
o Mezclar el acrílico y modelarlo primeramente sobre la mandíbula.,
dejarlo que polimerize
o Acrilar maxilar y dejar que el acrílico cubra el contorneado de alambre y
de 3 a 3 hasta el ecuador del diente como apoyo. Esto incrementa la
estabilidad del riel.
 45.
oUna vez pulido el acrilico, se adaptan los tubos de guía y las barras
deslizantes
o se acortan los tubos guia de acuerdo con la mordida de construcción
o se adaptan las barras deslizantes, que deben ser 2 mm más largas, ya que
si son demasiado cortas pueden permitir que se salgan de los tubos de
guía, y si son demasiado largas pueden producir irritaciones de la
mucosa
 46. TIPO I
o Se corren los modelos con las bandas en premolares inferiores y molares
superiores
o Se colocan en el fixator con la mordida de construccion
o Se elabora arco lingual de 4-4
o Se elabora ATP
 47. TIPO I
o Se puntean y soldan los aditamentos de fijacion
 48. TIPO I
o se adaptan los tubos de guía y las barras deslizantes:
o Primero se acortan los los tubos guia de acuerdo con la mordida de
construcción, seguidamente
o se adaptan las barras deslizantes, que deben ser 2 mm más largas.Si son
demasiado cortas se pueden salir de los tubos y si son demasiado largas
pueden producir irritaciones de la mucosa
 49. TIPO II Y TIPO IV
o Requieren de la presencia de arcos de acero y de bandas con tubos para
arco extraoral.
o La pieza de unión (tuerca) está provista de una ranura, la cual se
introduce en el arco existente en el aparato fijo y después se fija con el
tornillo que se adjunta al arco entre el 3 y el 4 de la mandíbula. Y en el
caso de fijacion tipo II en mesial de 6 maxilar
 50.
o Después de colocar las tuercas en el arco de acero se mide la distancia
entre la tuerca superior y la inferior y se acortan correspondientemente
los tubos guia.
o se fijan el dispositivo a las tuercas con los tornillos de montaje.
o Si se tiene que cambiar el arco del aparato fijo, primero se tendrán que
desenroscar las tuercas.
o En caso necesario el aparato se puede activar 1, 2 ó 3 mm con
o anillos distanciadores
 51. Secuencia tx
o En el tratamiento funcional con un aparato (RFFA) funcional, fijo y
rígido, es necesario preparar al paciente para 1 a 2 meses para estimular
la musculatura y evitar que el paciente ejerza también mucha fuerza en
los sistemas de apoyo, la rotura de aparato, o cause movimiento dental
 no deseado. Por esta razón, el uso de un de estimulador mini para el
adelantamiento mandibular es recomendado. Esto es una guarda
termomoldeada de 0.7 Mm en el espesor, para los incisivos superiores
sólo e incorporar un bloque de mordida de acrílico para los incisivos
inferiores. El bloque de mordida se construye con la mandíbula en
protrusión
 52.
o
Para los primeros 15 días o 1 mes, el paciente debe llevar la guarda y
mantener los incisivos inferiores en el bloque de mordida. En las
semanas siguientes, el paciente debe practicar los ejercicios para tragar
con los labios en contacto y con incisivos inferiores contra el bloque de
la mordida.
o Sólo después de esta etapa debe ser comenzada la terapia con el Aparato
de Ritto, ahora que la musculatura se ha estimulado y el paciente ha
memorizado la posición delantera mandibular. Se logra también el
destrabe de la oclusión.
 53. SECUENCIA DE TX EN PX CON BKT
o Fase 1: Conformación de los arcos dentales con aparato fijo
o Dilatación transversal del maxilar para prepararlo para la futura relación
neutra.
o Corrección de la curva de Spee.
o Retención del frente del maxilar mediante la utilizacion de arcos de acero
rectangulares para prevenir proclinacion
o Fase 2: Desplazamiento de la mordida con el aparato de HERBST®
o En los controles mensuales se comprueba la colaboración y el
desplazamiento de la mordida. En caso necesario se alargan los tubos
telescópicos mediante anillos distanciadores, para reforzar el movimiento
protrusivo.
o Pueden utilizarse planos de mordida para eliminar interferencias al inicio
de la utilizacion del aparato
 54.
o Fase 3: Ajuste de precisión del engranaje y la retención
o Después de 6–8 meses se sustituye el aparato de Herbst® por un
Bionator en posición de mordida. El acrílico se elimina por oclusal de los
posteriores mediante abrasión para permitir una erupción en un buen
engranaje.
o El Bionator se lleva puesto durante 1–2 años.
o Una alternativa al Bionator sería un posicionador que permita todavía un
ajuste de precisión de los dientes.
 55. COLOCACION EN BOCA
o Colocación en boca:
o Las bandas se colocan en boca con el cemento de bandas habitual. Se
recomienda cubrir con cera los zócalos de las articulaciones, para
proteger las roscas contra la penetración del cemento.
o Después de haber fraguado el cemento, se fijan los tubos de
o guía y las barras deslizantes (ya acortadas) a las bandas
 56.
o En el caso de los aparatos con fijacion tipo II y Iv, primero se fija el tubo
(porcion maxilar) en el tipo II con un tornilloal baston para tubo de head
gear
o Se coloca el tornillo en el arco sin apretarlo
o Se inserta la barra deslizante en el tubo guia
o Se ajusta el tornillo