Three-dimensional skeletal and dentoalveolar sagittal and vertical changes associated with cantilever Herbst appliance in prepubertal patients with Class II malocclusion

Published:January 08, 2022DOI:


      • Changes were assessed using a 3D landmark-based superimposition model.
      • Largest dental movement was the mesial movement of mandibular molars (3.70 mm).
      • Largest skeletal changes were an increased mandibular length (1.2 mm).
      • Herbst appliance corrected Class II malocclusion through more dental than skeletal changes.
      • The changes were more significant in the sagittal than in the vertical dimension.


      This study aimed to assess sagittal and vertical skeletal and dentoalveolar changes through the use of 3-dimensional imaging in prepubertal Class II malocclusion patients treated with a cantilever Herbst appliance (HA). Condyle-glenoid fossa positional changes were also quantified.


      This retrospective cohort study assessed 22 children (11.2 years ± 1.2) consecutively treated with a cantilever HA for 12 months and 11 untreated children (aged 9.3 ± 0.30 years) that served as controls. Cone-beam computed tomography was performed at baseline (T1) and at the end of the observation period (T2). Movements in the regions of interest were measured as linear displacements from cone-beam computed tomography images through algebraic calculations. A Student t test for independent samples was used for group equivalence testing at T1, and the treatment differences between T2 and T1 were evaluated by 2 analyses of covariance, one considering the expected growth unit as a covariate and the other with an annualized factor.


      The largest dental movement was a mesial movement of mandibular molars (3.70 mm), whereas the largest skeletal changes consisted of a larger relative length of the mandible (difference of 1.2 mm) in the HA group than in the control group.


      Within the study limitations (retrospective cohort, historical control group, and sample size), 3-dimensional imaging suggests that HA corrected Class II malocclusion in a predominantly prepubertal sample through more dental than skeletal changes. The changes were more significant in the sagittal than in the vertical direction. In addition, relative stability in the condyle-fossa relationship was noted.
      To read this article in full you will need to make a payment


        • Moro A.
        • Borges S.W.
        • Spada P.P.
        • Morais N.D.
        • Correr G.M.
        • Chaves Jr., C.M.
        • et al.
        Twenty-year clinical experience with fixed functional appliances.
        Dental Press J Orthod. 2018; 23: 87-109
        • Pancherz H.
        The Herbst appliance--its biologic effects and clinical use.
        Am J Orthod. 1985; 87: 1-20
        • Tomblyn T.
        • Rogers M.
        • Andrews 2nd, L.
        • Martin C.
        • Tremont T.
        • Gunel E.
        • et al.
        Cephalometric study of Class II Division 1 patients treated with an extended-duration, reinforced, banded Herbst appliance followed by fixed appliances.
        Am J Orthod Dentofacial Orto. 2016; 150: 818-830
        • Puncherz H.
        Treatment of class II malocclusions by jumping the bite with the Herbst appliance. A cephalometric investigation.
        Am J Orthro. 1979; 76: 423-442
        • Durão A.R.
        • Pittayapat P.
        • Rockenbach M.I.
        • Olszewski R.
        • Ng S.
        • Ferreira A.P.
        • et al.
        Validity of 2D lateral cephalometry in orthodontics: a systematic review.
        Prog Orthod. 2013; 14: 31
        • Yang X.
        • Zhu Y.
        • Long H.
        • Zhou Y.
        • Jian F.
        • Ye N.
        • et al.
        The effectiveness of the Herbst appliance for patients with Class II malocclusion: a meta-analysis.
        Eur J Orthod. 2016; 38: 324-333
        • Cevidanes L.H.S.
        • Styner M.A.
        • Proffit W.R.
        Image analysis and superimposition of 3-dimensional cone-beam computed tomography models.
        Am J Orthod Dentofacial Orthop. 2006; 129: 611-618
        • DeCesare A.
        • Secanell M.
        • Lagravère M.O.
        • Carey J.
        Multiobjective optimization framework for landmark measurement error correction in three-dimensional cephalometric tomography.
        Dentomaxillofac Radiol. 2013; 4220130035
        • Lagravère M.O.
        • Hansen L.
        • Harzer W.
        • Major P.W.
        Plane orientation for standardization in 3-dimensional cephalometric analysis with computerized tomography imaging.
        Am J Orthod Dentofacial Orthop. 2006; 129: 601-604
        • Cevidanes L.H.C.
        • Heymann G.
        • Cornelis M.A.
        • DeClerck H.J.
        • Tulloch J.F.C.
        Superimposition of 3-dimensional cone-beam computed tomography models of growing patients.
        Am J Orthod Dentofacial Orthop. 2009; 136: 94-99
        • Borges S.W.
        • Moro A.
        • Spada P.C.
        • Cevidanes L.H.
        Effects of Herbst appliance: a 3D analysis.
        Ortodontia. 2014; 47: 553-559
        • LeCornu M.
        • Cevidanes L.H.
        • Zhu H.
        • Wu C.D.
        • Larson B.
        • Nguyen T.
        Three-dimensional treatment outcomes in Class II patients treated with the Herbst appliance: a pilot study.
        Am J Orthod Dentofacial Orthop. 2013; 144: 818-830
        • Atresh A.
        • Cevidanes L.H.S.
        • Yatabe M.
        • Muniz L.
        • Nguyen T.
        • Larson B.
        • et al.
        Three-dimensional treatment outcomes in Class II patients with different vertical facial patterns treated with the Herbst appliance.
        Am J Orthod Dentofacial Orthop. 2018; 154: 238-248.e1
        • Souki B.Q.
        • Vilefort P.L.C.
        • Oliveira D.D.
        • Andrade Jr., I.
        • Ruellas A.C.
        • Yatabe M.S.
        • et al.
        Three-dimensional skeletal mandibular changes associated with Herbst appliance treatment.
        Orthod Craniofac Res. 2017; 20: 111-118
        • Lagravère M.O.
        • Secanell M.
        • Major P.W.
        • Carey J.P.
        Optimization analysis for plane orientation in 3-dimensional cephalometric analysis of serial cone-beam computerized tomography images.
        Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011; 111: 771-777
        • McNamara Jr., J.A.
        • Franchi L.
        The cervical vertebral maturation method: A user’s guide.
        Angle Orthod. 2018; 88: 133-143
        • Lagravère M.O.
        • Major P.W.
        Proposed reference point for 3-dimensional cephalometric analysis with cone-beam computerized tomography.
        Am J Orthod Dentofacial Orthop. 2005; 128: 657-660
        • Johnston Jr., L.E.
        Growth and the Class II patient: rendering unto Caesar.
        Semin Orthod. 1998; 4: 59-62
        • Stepanko L.S.
        • Lagravère M.O.
        Sphenoid bone changes in rapid maxillary expansion assessed with cone-beam computed tomography.
        Korean J Orthod. 2016; 46: 269-279
        • Jakobsone G.
        • Latkauskiene D.
        • McNamara Jr., J.A.
        Mechanisms of Class II correction induced by the crown Herbst appliance as a single-phase Class II therapy: 1 year follow-up.
        Prog Orthod. 2013; 14: 27
        • Valant J.R.
        • Sinclair P.M.
        Treatment effects of the Herbst appliance.
        Am J Orthod Dentofacial Orthop. 1989; 95: 138-147
        • Moro A.
        • Janson G.
        • de Freitas M.R.
        • Henriques J.F.
        • Petrelli N.E.
        • Lauris J.P.
        Class II correction with the Cantilever Bite Jumper.
        Angle Orthod. 2009; 79: 221-229
        • Barnett G.A.
        • Higgins D.W.
        • Major P.W.
        • Flores-Mir C.
        Immediate skeletal and dentoalveolar effects of the crown- or banded type herbst appliance on class II division 1 malocclusion.
        Angle Orthod. 2008; 78: 361-369
        • Flores-Mir C.
        • Ayeh A.
        • Goswani A.
        • Charkhandeh S.
        Skeletal and dental changes in Class II division 1 malocclusions treated with splint-type Herbst appliances. A systematic review.
        Angle Orthod. 2007; 77: 376-381
        • de Almeida M.R.
        • Henriques J.F.
        • de Almeida R.R.
        • Weber U.
        • McNamara Jr., J.A.
        Short-term treatment effects produced by the Herbst appliance in the mixed dentition.
        Angle Orthod. 2005; 75: 540-547
        • Pancherz H.
        • 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
        • McNamara Jr., J.A.
        • Howe R.P.
        Clinical management of the acrylic splint Herbst appliance.
        Am J Orthod Dentofacial Orthop. 1988; 94: 142-149
        • Wieslander L.
        Long-term effect of treatment with the headgear-Herbst appliance in the early mixed dentition. Stability or relapse?.
        Am J Orthod Dentofacial Orthop. 1993; 104: 319-329
        • Cozza P.
        • Baccetti T.
        • Franchi L.
        • De Toffol L.
        • McNamara Jr., J.A.
        Mandibular changes produced by functional appliances in Class II malocclusion: a systematic review.
        Am J Orthod Dentofacial Orthop. 2006; 129 (discussion e1): 599.e1-599.e12
        • Perinetti G.
        • Braga C.
        • Contardo L.
        • Primozic J.
        Cervical vertebral maturation: are postpubertal stages attained in all subjects?.
        Am J Orthod Dentofacial Orthop. 2020; 157: 305-312
        • Hägg U.
        • Pancherz H.
        Dentofacial orthopaedics in relation to chronological age, growth period and skeletal development. An analysis of 72 male patients with Class II division 1 malocclusion treated with the Herbst appliance.
        Eur J Orthod. 1988; 10: 169-176
        • Zymperdikas V.F.
        • Koretsi V.
        • Papageorgiou S.N.
        • Papadopoulos M.A.
        Treatment effects of fixed functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis.
        Eur J Orthod. 2016; 38: 113-126
        • Baccetti T.
        • Franchi L.
        • Stahl F.
        Comparison of 2 comprehensive Class II treatment protocols including the bonded Herbst and headgear appliances: a double-blind study of consecutively treated patients at puberty.
        Am J Orthod Dentofacial Orthop. 2009; 135 (discussion 698): 698.e1-698.e10
        • Purkayastha S.K.
        • Rabie A.B.
        • Wong R.
        Treatment of skeletal Class II malocclusion in adults: stepwise vs single-step advancement with the Herbst appliance.
        World J Orthod. 2008; 9: 233-243
        • Amuk N.G.
        • Baysal A.
        • Coskun R.
        • Kurt G.
        Effectiveness of incremental vs maximum bite advancement during Herbst appliance therapy in late adolescent and young adult patients.
        Am J Orthod Dentofacial Orthop. 2019; 155: 48-56
        • Ruf S.
        • Pancherz H.
        Long-term TMJ effects of Herbst treatment: a clinical and MRI study.
        Am J Orthod Dentofacial Orthop. 1998; 114: 475-483
        • Voudouris J.C.
        • Kuftinec M.M.
        Improved clinical use of Twin-block and Herbst as a result of radiating viscoelastic tissue forces on the condyle and fossa in treatment and long-term retention: growth relativity.
        Am J Orthod Dentofacial Orthop. 2000; 117: 247-266
        • Ruf S.
        • Pancherz H.
        Does bite-jumping damage the TMJ? A prospective longitudinal clinical and MRI Study of Herbst patients.
        Angle Orthod. 2000; 70: 183-199
        • Cheib Vilefort P.L.
        • Farah L.O.
        • Gontijo H.P.
        • Moro A.
        • Ruellas A.C.O.
        • Cevidanes L.H.S.
        • et al.
        Condyle-glenoid fossa relationship after Herbst appliance treatment during two stages of craniofacial skeletal maturation: a retrospective study.
        Orthod Craniofac Res. 2019; 22: 345-353