American Journal of ORTHODONTICS

Founded in 19Y.5 Volume 81, Number 1 January, 1985

Copyright @ 1985 by The C. V. Mosby Company

ORIGINAL ARTICLES

The Herbst appliance-Its biologic effects

and cli@cal use
Hans Pancherz, D.D.S., Odont. Dr.
Dr. Pancherz
Malmti, Sweden

The purpose of this article is to survey the Herbst bite-jumping method. An outline of appliance design and
appliance construction is given. The effects of the treatment method on the dentofacial complex and on the
masticatory system have been analyzed with the aid of dental casts, cephalometric roentgenograms, and
electromyographic registrations from the masticatory muscles. The use and effectiveness of the Herbst appliance
in the treatment of Class II malocclusions are exemplified by clinical cases, some of which were followed for 5
years after treatment. The Herbst appliance is most effective in the treatment of Class II malocclusions, provided
it is used as indicated. Thus, the appliance must be limited to growing persons only. The treatment method
should not be looked upon as a last resort to be used only when other treatment approaches have failed.
Treatment prognosis is best in subjects with a brachyfacial growth pattern. Unfavorable growth, unstable occlusal
conditions, and persisting oral habits after treatment are potential risk factors for occlusal relapses. As treatment
with the Herbst appliance is performed during a relatively short period, the hard and soft tissues (teeth, bone, and
musculature) would need some time for adaptation to the new mandibular position after the appliance is
removed. Posttreatment retention as a routine with a removable functional appliance is therefore recommended.

Key words: Orthodontics, cephalometry, electromyography, treatment evaluation, treatment indications

T he Herbst appliance is a fixed bite-jump-

ing* device for treatment of Class II malocclusion.
The appliance has several advantages when compared
to removable bite-jumping appliances (functional ap-
pliances), such as the activator, bionator, and Frankel
appliance: (1) The Herbst appliance works :!4 hours a
day, (2) no cooperation from the patient is required,
and (3) treatment time is short (approximately 6 to 8
months).
The appliance was originally introduced by a Ger-
man professor, Emil Herbst, at the International Dental
Congress in Berlin in 1905. In 1934 Herbst presented a
series of articles in the Zuhniirztliche Rundschau on his
From the Departmentof Orthodontics, School of Dentistry, University of
Lund.
*Bite jumping = A changein sagittalintermaxillary dental arch relationships
by an anterior displacementof the mandible.
experiences with the appliance.’ After 1934, however,
very little was published on the subject, and the treat-
ment method was more or less forgotten. In the Octo-
ber, 1979, issue of the AMERICAN JOURNAL OF
ORTHODONTICS~ I called attention to the possibilities of
stimulating mandibular growth by means of the Herbst
appliance. In subsequent articles the effects of the
appliance on the dentofacial complex3-6 and on the
masticatoty system’, 8 were evaluated. Recently the
Herbst treatment method has gained increasing interest,
especially in the United States, and several articles on
appliance design have been published.s-‘3
The purpose of this article is to summarize the bio-
logic effects of the Herbst appliance and to discuss its
clinical applications. A true understanding of the pos-
sibilities and limitations of the treatment method will
help the clinician to avoid failures and disillusionment.

1

Fig. 1. The Herb9 appliance
Fig. 2. The Herb9 telescope mechanism disassembled.
When the appliances are used in the “right” cases, the
treatment results are most encouraging. My experi-
ences of the Herbst method presented in this article are
based on 75 treated cases, 15 of which have been fol-
lowed for 5 years after treatment. A thorough analysis
of the long-term effects of the Herbst appliance will be
considered in a future report.
DESCRIPTION OF THE HERBST APPLIANCE
The appliance can be compared to an artificial joint
working between the maxilla and the mandible. A
bilateral telescope mechanism* attached to orthodontic
bands keeps the mandible mechanically in a continuous
anterior jumped position (Fig. 1). Each telescope de-
vice consists of a tube, a plunger, two pivots, and two
screws (Fig. 2). The pivot for the tube is usually sol-
dered to the maxillary permanent first molar band, and
the pivot for the plunger to the mandibular first premo-
*The telescope mechanism is available in pairs, and of a standard length, from
Dentaurum, Inc., Three Neshaminy Interplex, Trevose, Pa 19047.
Fig. 3. Diagram demonstrating the anchorage system for the
Herb4 appliance. A, Partial anchorage. B, Total anchorage.
lar band. The screws prevent the telescoping parts from
slipping off the pivots. The length of the tube deter-
mines the amount of bite jumping. Usually the mandi-
ble is retained in an incisal end-to-end relationship. The
length of the plunger is kept at a maximum in order to
prevent it from slipping out of the tube when the mouth
is opened wide. If the plunger is too long, however, it
may protrude far behind the tube and injure the buccal
mucosa distal to the maxillary permanent first molar.
The mechanism permits vertical opening movements
and, when properly constructed, also lateral move-
ments of the mandible.
The anchorage system of the Herbst appliance con-
sists basically of the following: In the maxillary dental
arch the first premolars and the permanent first molars
are banded and are interconnected on each side with a
half-round (1.5 x 0.75 mm) lingual or buccal sectional
arch wire. In the mandibular dental arch the first premo-
lars are banded and connected with a half-round
(1.5 x 0.75 mm) lingual sectional arch wire touching
the lingual surfaces of the front teeth. This form of
anchorage is called partial anchorage (Fig. 3A). In
several instances this typ of anchorage is insufficient
and is therefore increased by the incorporation of addi-
tional dental units: In the maxillary dental arch a labial
arch wire is ligated to brackets on the first premolars,
canines, and incisors. In the mandibular dental arch the
lingual sectional arch wire is extended to the permanent
first molars which, therefore, also are banded. This
form of anchorage is called total anchorage (Fig. 3 B).
Modification in appliance design
In Class II cases with a narrow maxillary dental
arch, expansion can be performed in connection with
Herbst treatment by soldering a Quad-helix lingual arch
Volume 87 Herbst appliance 3
Number 1

Fig. 4. Female patient, 8 years of age, treated with the Herbst appliance using bonded acrylic splints for
anchorage. A, Before treatment. B, At start of treatment. C, After 6 months of treatment, on the day the
appliance was removed. Note the absence of occlusal contacts in the posterior dental arch segments.
D, Occlusal stabilization treatment phase using an Andresen activator. E, After 4 months of activator
treatment.

important considerations in appliance construction

wire or a rapid-palatal-expansion device to the premo-
lar and molar bands.
If the first mandibular premolars have not yet
erupted, the permanent canines can be used ;asanchor-
age teeth. It must be pointed out, however, that the
buccal mucosa at the comer of the mouth is prone to
ulceration when the mandibular canine is used as an
abutment tooth for the plunger.
In the deciduous or early mixed dentition the
bonded type of Herbst appliance”, I2 may be used (Fig.
4). The splint anchorage system has some disadvan-
tages, however:
1. Tooth eruption and interocclusal adjustments
during treatment are prevented. This makes it necessary
to use an occlusal stabilization treatment phase after the
splints are removed (Fig. 40).
2. Unhygienic construction.
3. The bonding material is difficult to remove after
treatment, especially on the approximal tooth surfaces.
to avoid problems with loose or broken bands
1. All bands except those on the mandibular molars
should be formed individually (Figs. 5 and 6) of ortho-
dontic band material at least 0.15 mm in thickness.
Prefabricated bands are too weak. They will break
under the strains placed on them during treatment. The
use of orthodontic band material also has the advantage
that the bands can be extended in the occlusal-cervical
direction. This means that retention of the bands on the
teeth will be improved when compared to prefabricated
bands.
2. The upper and lower pivots on each side should
be placed parallel to each other (when seen in the same
plane). This will provide a correct and smooth function
of the telescope mechanism. The use of a jig (Fig. 7)
will facilitate orientation and soldering of the pivots to
the bands. When no jig is available, the procedure rec-
ommended by Langford may be useful.
4 Pancherz
Fig. 5. Plaster casts with teeth trimmed
Fig. 6. Bands made individually on plaster casts
tic band material (5.0 mm x 0.15 mm).
3. The upper pivois should be placed distally on
the molar bands and the lower pivots mesially on the
premolar bands (Fig. 3). A large interpivot distance on
each jaw side will prevent the plunger from slipping out
of the tube when the mouth is opened wide. If the
plunger should disengage from the tube on mouth open-
ing, it may get stuck in the tube opening (Fig. 8) on
subsequent mouth closure and damage the appliance
(especially the bands).
4. The pivot openings on the tube and plunger
should be widened (Fig. 9). This will provide an in-
creased lateral movement capacity of the mandible
(Fig. 10). Furthermore, the load on the anchorage teeth
(and bands) during mandibular lateral excursions will
be reduced.
TREATMENT EFFECTS ON THE DENTOFACIAL
COMPLEX
The effects of the Herbst appliance on the occlusion
and on dentofacial growth will be surveyed.** 4, 5 The
results presented here are based on analyses of dental
casts and profile roentgenograms from twenty-two con-
secutive Class II, Division 1 malocclusion cases treated
for banding. Fig. 7. Jig for the orientation of the telescoping pivots. (The
orientation jig is not offered on the market.)
with orthodon-
Fig. 8. Disengagement of the plunger from the tube on yawning.
with the Herbst appliance for an average time period of
6 months. None of the subjects had passed maximal
pubertal growth. Twenty untreated subjects with the
same type of malocclusion, skeletal morphology and
pubertal maturity served as a control group. In order to
assess possible changes in the condyle-fossa relation-
ships that occurred during Herbst treatment, tem-
poromandibular joint radiographs were taken before
and after therapy. For ethical reasons, radiographs were
taken of only the first ten of the twenty-two patients.
An oblique lateral transcranial projection with an indi-
vidualized technique was used.* The Herbst appliance
was constructed with partial maxillary and mandibular
anchorage (Fig. 3A) in eighteen cases. In four cases
partial maxillary and total mandibular anchorage (Fig.
3B) was used.
Volume 87
Number 1
Fig. 9. The telescoping tube and plunger before and after widening and beveling of the pivot openings.
Fig. 10. The lateral-movement capacity of the tube before (A)
and after (6) widening and beveling of the pivot opening.
Occlusal changes
Before treatment all patients had a bilateral Class II
molar relationship, a large overjet (mean, 8.2 mm), and
a large overbite (mean, 5.5 mm). Six months of treat-
ment with the Herbst appliance resulted in (Class I (or
overcorrected Class I) molar relationships, normal
overjet (mean, 3.0 mm) and normal overbite (mean,
2.5 mm) in all twenty-two subjects.
Sagittal cephalometric changes
The mandibular incisors proclined an ,average of
6.6” during 6 months of Herbst treatment. Tile position
Herbst appliance 5
degrees Herb9
appliance
tn=21>
+2.0
+ 1.0
-1.0
- 2.0
Fig. 11. Changes (mean, SD) in angles SNA, SNB, and ANB
during 6 months.
of the maxillary incisors was unaffected by treatment.
The effect of treatment on the sagittal position of
the jaw bases and on mandibular growth is seen in Figs.
11 and 12, respectively. The Herbst appliance had a
restraining effect on maxillary growth and a stimulating
effect on mandibular growth. Apparent mandibular
length increased about three times more in the Herbst
group than in the control group.
A quantitative evaluation of sagittal skeletal (Fig.
13) and dental (Fig. 14) changes4 brought about by the
Herbst appliance during 6 months of treatment dis-
closed that Class II molar correction (Fig. 15) and over-
jet correction (Fig. 16) were about equally a result of
skeletal and dental alterations.
Vertical cephalometric changes
In the twenty-two patients vertical overbite was re-
duced an average of 3 .O mm (55%) during 6 months of
treatment with the Herbst appliance. An analysis of
dental and skeletal changes brought about by the
appliance revealed the following:
-The mandibular incisors and maxillary molars
were intruded during treatment, while eruption of
the maxillary and mandibular second premolars
6 Pancherz

mm

0 Control
(fl=20)

2.8”
I

Fig. 12. Increase (mean, SD) in mandibular length during 6

months.

Fig. 14. The effects of the Herbst appliance on the sagittal

position of the maxillary and mandibular teeth. Mean changes
(mm) during 6 months. (xx indicates significance at 1% level;
xxx indicates significance at 0.1% level.)

/
Molar correction
6.7 mm

Fig. 13. The effects of the Herbst appliance on the sagittal

position of the maxillary and mandibular jaw bases. Mean Skeletal 2.9 (43%)
changes (mm) during 6 months. (xxx indicates significance at Denta I 3.8 (57%)
0.1% level.) Fig. 15. Skeletal and dental changes contributing to Class II
molar correction. Mean changes (mm) during 6 months of
treatment with the Herbst appliance.
and mandibular molars was enhanced (Fig. 17).
It must be pointed out, however, that part of the
registered change in the vertical position of the
Condykfossa relationships
mandibular incisors resulted from proclination of
these teeth. Temporomandibular joint radiographs taken before
-As a result of the dental changes, the overbite and after Herbst treatment revealed unchanged condy-
was reduced and lower facial height was in- lar relationships in all ten patients investigated. Fur-
creased (Fig. 17), as was the angulation of the thermore, no adverse structural changes in the condyle,
maxillary and mandibular occlusal planes (Fig. fossa, and/or articular tubercle were seen in any of the
18). subjects.
-The appliance had a limited effect on vertical
Stability and relapse posttreatment
maxillary and mandibular jaw position, as ex-
pressed by the angles NL/NSL and ML/NSL Dental casts and lateral roentgenograms were ana-
(Fig. 18). lyzed twelve months after removal of the Herbst
Volume 87 Herbst appliance 7
Number 1

n=22
-7:

NL

Overjet corection
ML
5.2 mm
+ 1.8””
Skeletal 29 (56%)
Denta I 2 3 (44%)

Fig. 16. Skeletal and dental changes contributing to overjet

correction. Mean changes (mm) during 6 months of treatment
with the Herbst appliance.
Fig. 17. The effects of the Herbst appliance on the vertical
position of the maxillary and mandibular teeth and on the lower
facial height. Mean changes (mm) during 6 months. (xxx indi-
cates significance at 0.1% level.)
appliance in the first ten3 of the twenty-two cases pre-
sented earlier. A matching group of ten untreated Class
r-r=22
II subjects was used for comparison.
Minor relapse of overjet and overbite was a com- )) NSL
mon finding. This could be explained mainly by a re-
lapse in lower incisor inclination after the Herbst
appliance was removed.
Posttreatment stability in sagittal dental arch rela-
tionships depended for the most part on a stable cuspal
interdigitation of the upper and lower teeth. Partial re- NL
lapse was seen in three of the ten cases because of 0.6 OLS
unstable occlusal conditions.
OLi
The inhibitory influence of the appliance on sagittal
maxillary growth was temporary. The stimulating ef- ML
fect of treatment on sagittal mandibular growth, on the
other hand, seemed to be permanent. The increase in
mandibular length (prognathion-condyle) seen during
the examination period of 18 months was significantly
larger (p > 0.01) in the Herbst group (mean 5.8 mm)
than in the control group (mean, 4.0 mm). The
follow-up period of 12 months was too short to permit Fig. 16. The effects of the Herbst appliance on the inclination of
any definite conclusions to be drawn about the long- the maxillary and mandibular jaw bases (NL/NSL and ML/NSL)
term effects of the Herbst appliance on mandibular and occlusal planes (OLslNSL and OLIINSL). Mean changes
growth. (degrees) during 6 months. (xx indicates significance at 1%
level, xxx indicates significance at 0.1% level.)
The increase in lower facial height seen during
treatment was temporary. At the time of re-examination
12 months posttreatment, lower facial height was the Overjet correction by increase in mandibular length
same in the Herbst group as in the control group. and mesial movement (proclination) of the mandibular
The action of the Herbst appliance in the treatment incisors.
of Class II, Division 1 malocclusion with a cleep over- Overbite correction by intrusion (partial proclina-
bite can be summarized as follows: tion) of the mandibular incisors and enhanced eruption
Class II molar correction by increase in mandibular of the mandibular molars.
length, distal movement of the maxillary molars, and Posttreatment stability secured by stable cuspal
mesial movement of the mandibular molars. interdigitation of the upper and lower dentition.
 8 Pancherz

Fig. 19A. Case 1. Extraoral and intraoral photographs. A, Before treatment. B, At start of treatment with
the Herbst appliance. The appliance was constructed with partial anchorage in the maxilla and total
anchorage in the mandible. C, After 3 months of treatment. Maxillary anchorage was extended by
incorporation of the front teeth (total anchorage). D, After 8 months of treatment, on the day the
appliance was removed. Note the overcorrected sagittal dental arch relationships. E, Twelve months
posttreatment.

Fig. 19A (Cont’d).

Case presentation
The cases of one girl and four boys with Class II,
Division 1 malocclusion treated with the Herbst
appliance are presented. In Cases 1 and 2 the design of
the appliance and the treatment procedure are demon-
strated. In Cases 3 to 5 the long-term results are shown.
Sagittal skeletal and dental changes occurring during
treatment and posttreatment were analyzed on profile
roentgenograms according to the method proposed by
Pancherz.4
CASE 1
This female patient (Fig. 19) was I I years 10 months of
age and underwent treatment with the Herbst appliance for 8
months. Retention after treatment was with an Andresen ac-
tivator. The Class II dental arch relationship was overcor-
Volume 87 Herbst appliance 9
Number 1

Fig. 19B. Case 1. Plaster casts. A, Before treatment. B, After 8 months of treatment with the Herbst
appliance, on the day the appliance was removed. C, Twelve months posttreatment.

-~----~ ELefore 11’O ’

P.fter 126
- Follow-up 136

Fig. 19C. Case 1. Cephalometric tracings superimposed on the nasion-sella line with sella as registra-
tion point. Diagrammatic representation of sagittal skeletal and dental changes (mm) occurring during
the treatment period (T), posttreatment period (P), and total observation period. (0).
10 Puncher-z Am. .I. Orrhou
.Innuarv 1985

Fig. 20A. Case 2. Extraoral and intraoral photographs. A, Before treatment. B, At start of treatment with
the Herbst appliance. The appliance was constructed with partial anchorage in the maxilla and total
anchorage in the mandible. C, After 3 months of treatment. Maxillary anchorage was extended by
incorporation of the front teeth (total anchorage). Note the repeated reactivation of the appliance. The
mandible was advanced farther forward by placing small pieces of tube material over the plunger
shafts, thereby lengthening the telescope mechanism. D, After 7 months of treatment, on the day the
appliance was removed. Note the overcorrected sagittal dental arch relationships. E, Twelve months
posttreatment.

Fig. 20A (Cont’d).

rected during treatment. An analysis of skeletal and dental
changes occurring revealed the following (Fig. 19C): Molar
correction of 8.5 mm was a result of forward growth of the
mandible by 3.5 mm, distal movement of the maxillary mo-
lars by 2.5 mm, and mesial movement of the mandibular
molars by 2.5 mm. Overjet correction of 5.5 mm was a result
of forward growth of the mandible by 3.5 mm, distal move-
ment of the maxillary incisors by 1 .O mm, and mesial move-
ment of the mandibular incisors by 1 .O mm. During the post-
treatment period of 12 months the occlusion was stabilized.
Skeletal and dental changes occurring posttreatment are seen
in Fig. 19C.
CASE 2
This male patient (Fig. 20) was 13 years 3 months of age
and had aplasia of one permanent mandibular incisor. A
chronic nasal airway obstruction made the use of a removable
functional appliance impossible. He was treated with the
Herbst appliance for 7 months. Retention after treatment was
with a modified Hawley plate in the maxilla and a lingual arch
wire in the mandible. The Class II dental arch relationship
was overcorrected during treatment. An analysis of skeletal
and dental changes occurring revealed the following (Fig.
2OC):
Molar correction of 8.0 mm was a result of a forward
Volume 87 Herbst appliance 11
Number 1

Fig. 208. Case 2. Plaster casts. A! Before treatment. B, After 7 months of treatment with the Herbst
appliance, on the day the appliance was removed. C, Twelve months posttreatment.

Before 133
After 13’O
-- Follow-up 14”

Fig. 2OC. Case 2. Cephalometric tracings superimposed on the nasion-sella line with sella as registra-
tion point. Diagrammatic representation of sagittal skeletal and dental changes (mm) occurring during
the treatment period (T), posttreatment period (P), and total observation period (0).
12 Puncher2

Fig. 21A. Case 3. Plaster casts. A, Before treatment. B, After 6 months of treatment with the Herbst
appliance, on the day the appliance was removed. Partial maxillary and mandibular anchorage was
used in constructing the appliance. C, Five years posttreatment.

v.-,-.- - - 1.“
------ Before 115
After 11"
--- Follow-uo 16"

Fig. 218. Case 3. Cephalometric tracings superimposed on the nasion-sella line with sella as registra-
tion point. Diagrammatic representation of sagittal skeletal and dental changes (mm) occurring during
the treatment period (T), posttreatment period (P), and total observation period (0).
Volume 87 Herbst appliance 13
Number I

Fig. 22A. Case 4. Plaster casts. A, Before treatment. B, After 6 months of treatment with the Herbst
appliance, on the day the appliance was removed. Partial maxillary and mandibular anchorage was
used in constructing the appliance. C, Five years posttreatment.

~--- Before 115

After 11"
--- Follow-uo 16"

Fig. 228. Case 4. Cephalometric tracings superimposed on the nasion-seila line with sella as registra-
tion point. Diagrammatic representation of sagittal skeletal and dental changes (mm) occurring during
the treatment period (T), posttreatment period (P), and total observation period (0).
14 Pancherz

Fig. 2314. Case 5. Plaster casts. A, Before treatment. B, After 6 months of treatment with the Herbst
appliance, on the day the appliance was removed. Partial maxillary and mandibular anchorage was
used in constructing the appliance. C, Five years posttreatment.

~~----~ Before 135

~ After 13”
- Follow-up 19’

Fig. 338. Case 5. Cephalometric tracings superimposed on the nasion-sella line with sella as registra-
tion point. Diagrammatic representation of sagittal skeletal and dental changes (mm) occurring during
the treatment period (7J, posttreatment period (P), and total observation period (0).
Volume 87 Herbst appliance 15
Number 1

growth of the mandible by 1.5 mm, distal movement of the

maxillary molars by 3.0 mm, and mesial movement of the
mandibular molars by 3.5 mm. Overjet correction of 8.5 mm
was a result of forward growth of the mandible by 1.5 mm,
distal movement of the maxillary incisors by 4.5 mm, and
mesial movement of the mandibular incisors by 2.5 mm.
During-the posttreatment period of 12 months the occlusion
was stabilized. Skeletal and dental changes occurring post-
treatment are seen in Fig. 20C.
T--b- m.:

CASE 3
This male patient (Fig. 21) was 11 years 5 months of age
and underwent treatment with the Herbst appliance for 6
months. No retention was used after treatment. The Class II
dental arch relationship was overcorrected during treatment.
An analysis of skeletal and dental changes revealed the fol-
lowing (Fig. 21 B): Molar correction of 7.5 mm was a result
of mandibular forward growth exceeding maxillary forward
growth by 1.5 mm, distal movement of the maxillary molars
by 3.5 mm, and mesial movement of the mandibular molars
by 2.5 mm. Overjet correction of 3.5 mm was a result of
forward mandibular growth exceeding maxillary forward
growth by 1.5 mm, distal movement of the maxillary incisors
by 0.5 mm, and mesial movement of the mandibular incisors
by 1.5 mm. Five years posttreatment, normal sagittal dental
arch relationships persisted. Skeletal and dental changes that
occurred during the posttreatment period are seen in Fig.
21B.

CASE 4
This male patient (Fig. 22), 11 years 5 months of age, had
treatment with the Herbst appliance for 6 months. Retention
after treatment was with an Andresen activator for 2 years.
The Class II dental arch relationship was overcorrected during
treatment. An analysis of skeletal and dental changes revealed
the following (Fig. 22B): Molar correction of 9.0 mm was a
result of mandibular forward growth exceeding maxillary
forward growth by 3.0 mm, distal movement of the maxillary Fig. 24. Intraoral photographs and electromyograms (direct and
molars by 5.5 mm, and mesial movement of the mandibular integrated recordings during chewing of peanuts) from a 12-
molars by 0.5 mm. Overjet correction of 7.0 mm was a result year-old male patient treated with the Herbst appliance. A, Be-
of mandibular forward growth exceeding maxillary forward fore treatment. 6, At start of treatment. C, After 3 months of
growth by 3.0 mm, distal movement of the maxillary incisors treatment. D, After 6 months of treatment, when the appliance
by 1 .O mm, and mesial movement of the mandibular incisors was removed. E, Twelve months posttreatment. T, Temporal
by 3.0 mm. Five years posttreatment normal sagittal dental muscle (right side). M, Masseter muscle (right side).
arch relationships persisted. Skeletal and dental c:langes that
occurred during the posttreatment period are seen in Fig.
22B. Overjet correction of 4.5 mm was a result of forward growth
of the mandible by 4.0 mm and mesial movement of the
CASE 5 mandibular incisors exceeding mesial movement of the maxil-
lary incisors by 0.5 mm. Five years posttreatment, normal
This male patient (Fig. 23), 13 years 5 months of age, had
sagittal dental arch relationships persisted. Skeletal and dental
treatment with the Herbst appliance for 6 months. Retention
changes that occurred during the posttreatment period are
after treatment was also with an Andresen activator for 2
seen in Fig. 23B.
years. The Class II dental arch relationship was overcorrected
during treatment. An analysis of skeletal and dental changes TREATMENT EFFECTS ON THE MASTICATORY
revealed the following (Fig. 238): Molar correction of 7.0 SYSTEM
mm was a result of forward growth of the mandible by 4.0
mm, distal movement of the maxillary molars by 1.5 mm, The Herbst appliance keeps the mandible continu-
and mesial movement of the mandibular molars by 1.5 mm. ously in a protruded position, both during jaw closure
16 Pamher:

temporal muscle activity is relatively unaffected

by age.
60
El
MllS&S
The influence of the Herbst appliance on the EMG
pattern of the temporal and masseter muscles during

q:.:.’
50

40
.:.,.,
:.:
maximal biting and chewing was investigated in the
first ten of the twenty-two cases presented above.7 The
TMJ following results were found (Fig. 24):
30;
-At the start of treatment, when the appliance was
inserted, the EMG activity from both the tem-
20 1 poral and masseter muscles was reduced.
-After 3 months of treatment the EMG activity
1oi
from the two muscles had increased to almost
pretreatment values.
A 6 C D -After 6 months of treatment, when the appliance
was removed, the EMG activity from the tempo-
Fig. 25. Frequency of patients with tenderness to palpation of
the masticatory muscles and TMJ. Registrations in twenty sub- ral and masseter muscles exceeded pretreatment
jects treated with the Herb9 appliance. A, Before treatment. B, values.
After 3 months of treatment. C, After 6 months of treatment, -Twelve months posttreatment, when the occlu-
when the appliance was removed. D, Twelve months post- sion was stabilized, the contraction pattern in the
treatment.
two muscles was most like that seen in subjects
with normal occlusion.

and when the teeth are not in occlusion, thus challeng-
ing the harmonious interaction between the occluding
teeth, masticatory muscles, and jaw joints. The follow-
ing questions would be of interest:
1. Does treatment affect the function of the mas-
ticatory muscles?
2. Does treatment result in dysfunction symptoms
from the temporomandibular joints (TMJ) and associate
musculature?
3. Does treatment affect masticatory ability?
Muscle function
Electromyography (EMG) is widely used in study-
ing normal and abnormal muscle contraction patterns.
In the field of orthodontics, EMG studies of the mas-
ticatory muscles are concerned mostly with the activity
of the temporal and masseter muscles, as these muscles
are of easy access for EMG registrations.
EMG recordings from cases of normal occlusion’4
and from cases of Class II malocclusion’j have revealed
the following:
-Children with Class II malocclusion exhibit an
impaired muscle activity in comparison to chil-
dren with normal occlusion. This is especially
apparent with respect to the masseter muscle.
-Temporal and masseter muscle activity is similar
in children with normal occlusion.
-Mass&er muscle activity is reduced in compari-
son to temporal muscle activity in children with
Class II malocclusion.
-Masseter muscle activity increases with age;
Functional disorders
The occurrence of possible functional disturbances
in the masticatory system during or after treatment with
the Herbst appliance was investigated in twenty of the
twenty-two cases presented earlier.”
Relution hct\veen RP and IP. After treatment the
anteroposterior distance between retruded contact posi-
tion (RP) and intercuspal position (IP) of the mandible
did not exceed 1.5 mm in any of the patients. Twelve
months posttreatment, however, the RP-IP distance
was 2.5 mm in one subject, indicating the formation of
a dual bite.‘6. li The dual bite was probably due to an
inadequate treatment period for this particular patient.
Six months of treatment was too short for a complete
skeletal and neuromuscular adaptation to the new
mandibular position created by therapy. On re-
treatment of this subject with the Herbst appliance, the
dual bite was eliminated.
TM./ WWUIS. Clicking was noticed in two subjects
before treatment. The symptoms disappeared during
treatment, and no sounds were noticed in any of the
subjects 12 months posttreatment. As clicking may be
related to an anterior dislocation of the articular disc,18
it is possible that the jumped position of the condyle
during treatment promoted reposition of a displaced
disc.
TMJ and muscle tenderness. The number of pa-
tients exhibiting tenderness to palpation of the TMJ and
of one or more masticatory muscles was doubled during
the first 3 months of treatment with the Herbst
appliance (Fig. 25). After removal of the appliance,
most of the joint and muscle symptoms noted during
Volume 87
Number 1
Fig. 26. Male patient, 13 years of age, with a Class II, Division 1 malocclusion. A, Before treatment. 8,
Treatment with the Herbst appliance for 6 months (orthopedic treatment phase). C, Treatment with the
Begg appliance (nonextraction) for 8 months (orthodontic treatment phase).
treatment had disappeared. Twelve months posttreat-
ment the number of subjects with symptoms was the
same as before treatment. This was probably due to the
fact that normal occlusal contact conditions were es-
tablished and the condyles had returned to their normal
fossa position,2 thus creating an occlusion ie. harmony
with the neuromuscular system and jaw joints.
The most frequently noted area of muscle tender-
ness was the posterior belly of the digastric muscle,
followed by the lateral pterygoid muscle, the masseter
muscle, the medial pterygoid muscle, and the temporal
muscle. Hyperactivation and increased tonic tension of
these muscles when the mandible was jumped an-
teriorly could explain the findings.
Masticatory ability
Chewing difficulties were experienced &uing the
first 7 to 10 days of treatment. Thereafter, no such
problems were usually reported although masticatory
efficiency measurements disclosed* that the test mate-
rial was poorly cornminuted during the first 3 months of
treatment before antagonist contacts in the lateral seg-
ments had been established. Obviously, the patients
adapt to the appliance very quickly and accept it read-
ily, despite the fact that they could chew with contact
only between the front teeth.
Herbst appliance 17
The effects of the Herbst appliance on the mas-
ticatory system can be summarized as follows:
-Class II malocclusion cases exhibit a diverging
EMG pattern from the temporal and masseter
muscles when compared to normal occlusion
cases. Treatment with the Herbst appliance nor-
malizes the EMG pattern from the two muscles.
-The Herbst appliance causes minor functional
disturbances in the masticatory system. These
disturbances are of a temporary nature, appearing
mainly at the beginning of the treatment period.
-The patients experience chewing difficulties dur-
ing the first 7 to 10 days of treatment, although
chewing ability is reduced during a much longer
period.
INDICATIONS FOR TREATMENT
The Herbst appliance is aimed at stimulating man-
dibular condylar growth and is thus especially useful in
the treatment of the Class II malocclusion with a ret-
rognathic mandible. The treatment method should be
used only in growing persons. An early treatment ap-
proach is recommended. In normalizing the skeletal
morphology and muscle contraction patterns at a young
age, a normal, continuing development of the facial
skeleton and masticatory muscles will be favored. The
18 Pancherz

Fig. 27. Male patient, 12 years of age, with a Class II, Division 1 malocclusion. A, Before treatment. B,
Treatment with the Herbst appliance for 6 months (orthopedic treatment phase). C, Treatment with the
Begg appliance (extractions of four first premolar@ for 12 months (orfbocfontic treatment phase).

Herbst appliance should not be used in nongrowing
subjects. Skeletal alterations will be minimal and the
treatment effects will be confined to the dentoalveolar
area, according to unpublished material by J. Ahlgren.
Furthermore, there will be an increasing risk for the
development of a dual bitelg with dysfunction symp-
toms from the TMJ as a possible consequence.l’
Basically, the same prerequisite conditions for
successful treatment apply for the Herbst appliance as
for removable bite-jumping (functional) appliances,
namely, the maxillary and mandibular teeth should be
well aligned and the dental arches should fit each other
in normal sagittal position. Unlike removable bite-
jumping appliances, the Herbst appliance can be used
successfully in the following instances:
Postadolescent patients. Neglected patients who
have passed maximal pubertal growth may be too old
for functional appliances, as treatment with these
appliances is extended over a long time period (2 to 3
years). Treatment with the Herbst appliance, on the
other hand, can be finished within 6 to 8 months, thus
making it possible to use the residual growth left in
these older patients.
Mouth breathers. Nasal airway obstructions can
make the proper use of removable appliances impossi-
ble, while this does not interfere with the correct func-
tion of the Herbst appliance.
Uncooperative patienrs. The Herbst appliance is
fixed to the teeth and works continuously 24 hours a
day without any assistance from the patient.
As a rule, Class II cases cannot be treated to a
perfect end result with the Herbst appliance exclu-
sively. Many cases will require a subsequent dental-
alignment treatment phase with a multibracket appli-
ance. Thus, treatment of a Class II, Division 1 mal-
occlusion will usually occur in two steps (Figs. 26
and 27):
STEP 1. ORTHOPEDIC PHASE. The sagittal jaw base
relationship is normalized and the Class II
malocclusion is transferred to a Class I maloc-
clusion by means of the Herbst appliance.
STEPS. ORTHODONTIC PHASE. Tooth irregularities
and arch discrepancy problems are treated with a
multibracket appliance (with or without ex-
tractions of teeth).
A Class II, Division 2 malocclusion may require a
three-step treatment approach (Fig. 28):
STEP 1. ORTHODONTIC PHASE. Alignmentofthean-
terior maxillary teeth by means of a multibracket
orthodontic appliance.
Volume 87 Herbst appliance 19
Number 1

STEP 2. ORTHOPEDIC PHASE. Normalization ofsag-

&al jaw base relationships and transfomlation of
the Class II malocclusion into a Class 1 maloc-
clusion by means of the Herbst appliance.
STEP 3. ORTHODONTIC PHASE. Tooth irregularities
and arch-discrepancy problems are treated with a
multibracket appliance (with or without ex-
tractions of teeth).
In summary, the ideal patient for treatment with the
Herbst appliance has the following characteristics:
Skeletal morphology
-Retrognathic mandible.
-Small mandibular plane angle indicatirlg an an-
terior growth direction of the mandible. (A
favorable growth pattern both facilitates treat-
ment and counteracts posttreatment relapse.)
-Normal or reduced lower facial height.
Dental morphology
-Class II dental arch relationships with increased
overjet and normal or increased overbite. (Open-
bite cases are not quite suitable for the Herbst
appliance. Some kind of incisal support and/or
guidance during treatment seems to be -necessary
for the patient to feel comfortable with the
appliance .)
-The maxillary and mandibular teeth well aligned
and the two dental arches fitting each other in
normal sagittal position. Minor crowdi.ng in the
maxillary anterior segment (especial1.y in the
canine
region) is usually no problem. In using partial
anchorage, the buccal tooth segments are moved
backward and space is created (Fig. l!)A).
Maturation
-Treatment during pubertal growth.

RETENTION AFTER TREATMENT

The improvement in sagittal molar and incisor rela-
tionships seen during Herbst appliance treatment is
mainly a result of an increase in mandibular growth,
distal tooth movements in the maxilla, and mesial tooth
movements in the mandible.
A possible relapse in dental arch relationships after
treatment will result from dental changes in the maxilla
and mandible and/or from an unfavorable growth de-
velopment. A stable cuspal interdigitation ,nill coun-
teract an occlusal relapse. As treatment usually is per-
formed in the mixed dentition, retention will thus be
necessary until permanent teeth have erupted and the
occlusion is stabilized.
The Andresen activator is a most suitable retention
device after Herbst treatment (Fig. 4). The appliance
holds the teeth in the desired position. Selective grind-
Fig. 28. Female patient, 13 years of age, with a Class II, Divi-
sion 2 malocclusion. A, Before treatment. B, Treatment with a
maxillary Begg appliance (alignment of the front teeth) for 5
months (orthodontic treatment phase). C, Treatment with the
Herbst appliance for 6 months (orthopedic treatment phase). D,
After treatment. No finishing orthodontic treatment phase was
needed.
ing of the acrylic makes interocclusal adjustments pos-
sible by guiding tooth eruption. The appliance trains
and accommodates the musculature to the new man-
dibular position. A musculature in harmony with the
dentofacial structures is certainly of utmost importance
for a stable treatment result. As was demonstrated from
20 Pancherz

the EMG analysis, the Class II muscle-contraction pat- 6. Sam% K-V. Pancherz H, Rune B, Selvik C: Hemifaciai m-
tern seen in the patients was normalized during Herbst crosomia treated with the Herbst appliance: report of a cast
analyzed by means of roentgen stereometry and metallic in-
treatment. The treatment time of 6 to 8 months is rather
plants. AM J ORTHOD 82: 68-74, 1982.
short, however, and the musculature would most likely 7. Pancherz H, Anehus-Pancherz M: Muscle activity in Class II,
need a longer time for permanent adaptation. Division 1 malocclusions treated by bite jumping with the Herbst
appliance: an electromyographic study. AM J ORTHOD 78: 32 I
CONCLUDING REMARKS 329, 1980.
8. Pancherz H, Anehus-Pancherz M: The effect of continuous bite
The Herbst appliance is most effective in the treat- jumping with the Herbst appliance on the masticatory system: a
ment of Class II malocclusions, provided it is used as functional analysis of treated Class 11 malocclusions. Eur J
indicated in this article. Thus, the appliance must be Orthod 4: 37-44, 1982.
limited to growing persons only. The treatment method 9. Langford NM: The Herbst appliance. J Clin Orthod 15: 558-561.
1981.
should not be looked upon as a last resort to be used
10. Langford NM: Updating fabrications of the Herbst appliance. J
only when other treatment approaches have failed. Clin Orthod 16: 173-174, 1982.
Treatment prognosis is best in subjects with a brachy- 11. Howe RP: The bonded Herbst appliance. J Clin Orthod 16:
facial growth pattern. Unfavorable growth, unstable 663-667, 1982.
occlusal conditions, and oral habits that persist after 12. Howe RP: Updating the bonded Herbst appliance. J Clin Orthod
treatment are potential risk factors for occlusal relapse. 17: 122-124, 1983.
13. Clements RM, Jacobson A: The MARS appliance: report of a
As treatment with the Herbst appliance is per- case. AM J ORTHOD 82: 445-455, 1982.
formed during a relatively short period, the hard and 14. Pancherz H: Temporal and masseter muscle activity in children
soft tissues (teeth, bone, and musculature) will need and adults with normal occlusion: an electromyographic investi-
some time for adaptation to the new mandibular posi- gation. Acta Odontol Stand 38: 343-348, 1980.
tion after the appliance is removed. Routine posttreat- 15. Pancherz H: Activity of the temporal and masseter muscles in
Class II, Division 1 malocclusions: an electromyographic inves-
ment retention with a removable functional appliance is tigation. AM J ORTHOD 77: 679-688, 1980.
therefore recommended. 16 Posselt U: Physiology of occlusion and rehabilitation, Oxford,
1968, Blackwell Scientific Publications.
REFERENCES 17. Egermark-Erikson I, Carlsson GE, Ingervall B: Function and
1. Herbst E: Dreissigjtige Erfahrungen mit dem Retentions- dysfunction of the masticatory system in individuals with dual
Schamier. Zahn&ztl Rundschau 43: 1515-1524, 1563-1568, bite. Eur J Orthod 1: 107-l 17. 1979.
1611-1616, 1934. 18. Farrar WB: Diagnosis and treatment of anterior dislocation of the
2. Pancherz H: Treatment of Class II malocclusions by bite jump- articular disc. NY J Dent 41: 348-351, 1971.
ing with the Herbst appliance: a cephalometric investigation. AM 19. Held AJ, Spirgi M, Cimasoni G: An orthopedically treated adult
J ORTHOD 76: 423-441, 1979. case of Class II malocclusion. AM J OR~HOD 49: 761-765, 1963.
3. Pancherz H: The effect of continuous bite jumping on the dento- Rqrinr requests IO:
facial complex: a follow-up study after Herbst appliance treat- Dr. Hans Pancherz
ment of Class II malocclusions. Eur J Orthod 3: 49-60, 1981. Department of Orthodontics
4. Pancherz H: The mechanism of Class II correction in Herbst School of Dentistry
appliance treatment: a cephalometric investigation. AM J University of Lund
ORTHOD 82: 104-113, 1982. S-214 21 MalmG, Sweden
5. Pancherz H: Vertical dentofacial changes during Herbst appli-
ance treatment: a cephalometric investigation. Swed Dent J Supp
15: 189-196, 1982.