The Herbst Appliance: Resear ch-

Based Updat ed Clinical P ossibilities

Hans Pancherz, DDS, Odont Dr1/Sabine Ruf, DDS, Dr med dent2

Aim: To focus on the efficacy of the Herbst appliance in the treatment of Class II malocclu-
sions that otherwise would have been difficult without tooth extractions or orthognathic
surgery measures. Methods: Evidence-based study and review of our recent clinical,
cephalometric roentgenographic, and magnetic resonance imaging research. This research
reveals that growth modification with the Herbst appliance is successful in older Class II
patients, who are generally considered unresponsive to therapy with removable functional
appliances. Conclusions: We suggest a change in the current concept of Class II treatment,
with growth adaptation through use of the Herbst appliance in children, adolescents, post-
adolescents, and young adults. World J Orthod 2000;1:17–31.

ased on the “bite jumping” idea introduced by
B Kingsley in 1877, Emil Herbst developed his
appliance in the early 1900s and presented it for the
first time at the International Dental Congress in
Berlin in 1909. Twenty-five years later, in 1934,
Herbst wrote about his experiences with the appli-
ance in 3 articles. After that time, very little was pub-
lished about the subject until Pancherz reintroduced
the treatment method in 1979.
Inititally, Pancherz used the Herbst bite jumping
mechanism as a scientific tool in clinical-experimen-
tal orthodontic-orthopedic research. Through the
years, however, it became obvious that the appli-
ance is most useful in the therapy of severe Class II
malocclusions. In comparison to conventional func-
tional appliances (eg, activator, bionator, Fränkel),
the Herbst appliance has several clinical advan-
tages: The appliance is (1) fixed to the teeth, (2)
works continuously 24 hours a day, (3) does not
interfere with speech, and (4) requires no patient
compliance to attain the desired treatment effects.
1
Professor, Department of Orthodontics, University of Giessen,
Giessen, Germany
2 Associate Professor, Department of Orthodontics, University of
Giessen, Giessen, Germany
REPRINT REQUESTS/CORRESPONDENCE
Prof Dr Hans Pancherz, Department of Orthodontics, University
of Giessen, Schlangenzahl 14, D-35392 Giessen, Germany.
Tel: +49 641 9946120. Fax: +49 641 9946119.
E-mail: hans.pancherz@dentist.med.uni-giessen.de
In 1979, Pancherz used a banded design of the
Herbst appliance with a simple anchorage system. In
the maxillary dental arch, the anchorage units on
each side comprised the first premolar and the first
permanent molar connected to each other by a lin-
gual sectional arch wire. In the mandibular dental
arch, the first premolars were interconnected by a
lingual arch wire touching the lingual surfaces of the
anterior teeth. The telescoping tube was attached to
the maxillary molar band and the plunger to the
mandibular premolar band (Figs 1a and 1b).
In 1982, the anchorage system of the banded
Herbst appliance was changed. In the maxilla, the
canines and the incisors were incorporated into the
anchorage unit by placing brackets on the teeth and
connecting them to the premolar bands with a labial
sectional arch wire. In the mandible, the lingual arch
wire was extended to the first permanent molars,
which also were banded (Figs 1c and 1d).
In the modern Herbst appliance, which has been
used on a regular basis since 1995, most teeth in
the maxilla and mandible are incorporated into the
appliance for maximum anchorage. The bands have
been replaced by cast splints of cobalt-chromium
alloy covering the teeth in the lateral segments. Addi-
tionally, the maxillary and mandibular anterior teeth
are incorporated into the anchorage unit by connect-
ing them to the splints with labial sectional arch
wires. The axes for the telescoping tube and plunger
are soldered to the splints in the region of the maxil-
lary first permanent molars and the mandibular first
premolars, respectively (Figs 1e and 1f). The splints
are fixed to the teeth with a glass-ionomer cement.

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a b

c d

e f
Fig 1 The banded Herbst appliance with simple (a) maxillary and (b) mandibular anchorage. The
banded Herbst appliance with extended (c) maxillary and (d) mandibular anchorage. The cast splint
Herbst appliance with all (e) maxillary and (f) mandibular teeth incorporated into anchorage.

In comparison to the banded Herbst appliance, the
cast splint appliance has many advantages: It has a
precise fit on the teeth, is strong and hygienic, and
saves chair time because it is easy to insert and
causes few clinical problems (no broken bands).
Due to the higher laboratory costs of the cobalt-
chromium splints, acrylic splints have been advo-
cated by some clinicians. However, acrylic splints
break more easily and are less hygienic. To over-
come the hygiene problem, many orthodontists use
the acrylic splint Herbst appliance as a removable
bite jumping device. However, the major advantage
of the Herbst method, as a fixed functional appli-
ance, working 24 hours a day, independent of
patient cooperation, is lost with this adaptation.

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VOLUME 1, NUMBER 1, 2000 Pancherz/Ruf

a b c

Fig 2 Female Class II, Division 1

subject, 16 years of age, treated
with the cast splint Herbst appli-
ance. Parasagittal MRIs of the right
TMJ exhibiting a physiologic disc-
to-condyle relationship during dif-
ferent phases of therapy. (a)
Before treatment. (b) Start of treat-
ment when the Herbst appliance
was placed. (c) After 12 weeks of
treatment. (d) After 7 months of
treatment when the appliance was
removed. (e) One year posttreat-
ment. Tracings of the articular
structures (condyle, disc, fossa) are
given for better orientation.

d e

TREATMENT POSSIBILITIES incisal edge-to-edge position and the condyles are

In current dentofacial orthopedics, Herbst appliance
therapy, followed by a conventional multibracket
appliance treatment phase, is a most efficient 2-
step approach in the management of severe Class II
malocclusions. In the first step, Class II correction is
accomplished with the Herbst appliance (6 to 8
months of therapy). Final tooth alignment, in the sec-
ond step, is performed with conventional multi-
bracket appliances (8 to 12 months of treatment).
When the appliance is placed at the start of Herbst
treatment, the mandible is usually advanced to an
positioned on the top of the articular eminence. Dur-
ing the course of therapy, however, the condyles return
to their original fossa position. This is accomplished by
adaptive dental and skeletal changes: posterior move-
ment of the maxillary dentition and anterior movement
of the mandibular dentition,1 stimulation of sagittal
condylar growth in a more favorable direction,2,3 and
remodeling of the glenoid fossa.3 Throughout treat-
ment, a normal disc-to-condyle relationship is main-
tained (Fig 2). At the end of treatment, the disc has
either returned to its original pretreatment position or
has attained a slightly retrusive position.4

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Fig 3 Female Class II, Division 1 subject, 13 years of age, treated with a cast splint Herbst/multibracket appliance system
in combination with a rapid maxillary expander. (a) Before treatment. (b) Start of treatment when the cast splints (without
the telescope mechanism) were placed. (c) After 2 weeks of rapid maxillary expansion (when the telescope mechanism
was placed). Note the diastema and the open bite. (d) After 6 months of Herbst treatment, before the appliance was
removed. (e) During the second phase of treatment with a multibracket appliance. (f) After 18 months of Herbst/multi-
bracket appliance treatment. (g) Retention with a maxillary Hawley plate and a mandibular canine-to-canine retainer. (h)
Lateral head films from before treatment (left), after the Herbst treatment phase (middle), and after the multibracket treat-
ment phase (right).

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VOLUME 1, NUMBER 1, 2000
The Herbst/multibracket appliance approach
makes it possible to treat severe Class II malocclu-
sions, which otherwise would have been very diffi-
cult, if not impossible, to handle without extraction
or orthognathic surgery. Our clinical-experimental
research throughout the years has shown that the
Herbst appliance is most useful in the Class II sub-
jects and situations described below.
Class II, Division 1 malocclusions
This malocclusion is the main indication for Herbst
therapy. In cases with a narrow maxilla, it is advanta-
geous to combine the maxillary splints with a rapid
maxillary expander (Fig 3) or a quad-helix.
In analyzing the treatment effects in consecu-
tively treated subjects, it has been demonstrated
that Class II correction is the result of both skeletal
and dental changes.5 Skeletal changes are more
pronounced in early adolescent subjects, and dental
changes are more pronounced in late adolescent or
young adult patients6–9 (Fig 4).
In most Class II, Division 1 cases, an undesirable
side effect of the Herbst appliance is the proclina-
tion of the mandibular incisors. This effect is the
result of anchorage loss, due to the forces exerted
by the telescope mechanism on the anterior teeth.
The incisor proclination is difficult to control10 inde-
pendently of the anchorage system used. However,
no increased incidence of mandibular anterior
crowding could be found several years posttreat-
ment10,11 despite a spontaneous uprighting of the
teeth after Herbst therapy.
Class II, Division 2 malocclusions
The Herbst appliance is also very effective in Class
II, Division 2 cases12 (Fig 5). In this type of malocclu-
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Pancherz/Ruf
sion, the mandibular incisors (as well as the maxil-
lary incisors) have a retroclined position. Therefore,
the mandibular anchorage loss (proclination of the
mandibular anterior teeth) during Herbst treatment
can be used advantageously to reduce the interin-
cisal angle and to create a stable anterior occlusion.
This would be a prerequisite for the prevention of a
deep bite relapse (Fig 5).
Furthermore, the changes in incisor tooth angula-
tions during Herbst therapy will improve the vertical
lower lip to maxillary incisor relationship (Fig 5). A high
lip line (the lower lip covering the maxillary incisors) is a
common finding in Class II, Division 2 malocclusions
and is considered to be both an etiologic and a relapse
factor for a deep bite. Therefore, the improvement in lip
position will favor the stability of the corrected overbite
High-angle malocclusions
Class II malocclusions with a hyperdivergent jaw base
relationship are generally considered to have an unfa-
vorable growth pattern, making their treatment diffi-
cult. As the Herbst appliance has been shown to
increase condylar growth in the therapeutically
desired sagittal direction13 (Fig 6) without resulting in
a posterior (backward) rotation of the mandible,14
high-angle Class II subjects are good candidates for
successful Herbst therapy (Figs 7 and 8).
Maxillary anterior crowding
Besides the orthopedic effect on the mandible, the
Herbst appliance has a pronounced high-pull head-
gear effect on the maxillary molars.15 During therapy,
the molars are distalized and significantly intruded.
The headgear effect is most useful in gaining ante-
rior space and relieving crowding in the maxillary
canine and incisor areas (see web appendix Fig A-1).
21
Pancherz/Ruf WORLD JOURNAL OF ORTHODONTICS

Early adolescent treatment Early adolescent treatment

(n = 25) (n = 25)

Overjet correction Molar correction

9.8 mm 9.3 mm
100% 100%

Skeletal Dental Skeletal Dental

3.8 mm 6.0 mm 3.8 mm 5.5 mm
39% 61% 41% 59%

Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible

-0.5 mm 4.3 mm 3.3 mm 2.7 mm -0.5 mm 4.3 mm 3.0 mm 2.5 mm
-5% 44% 34% 27% -5% 46% 32% 27%

Late adolescent treatment Late adolescent treatment

(n = 21) (n = 21)

Overjet correction Molar correction

8.4 mm 6.1 mm
100% 100%

Skeletal Dental Skeletal Dental

2.3 mm 6.1 mm 2.3 mm 3.8 mm
27% 73% 38% 62%

Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible

-0.1 mm 2.4 mm 2.6 mm 3.5 mm -0.1 mm 2.4 mm 2.0 mm 1.8 mm
-1% 28% 31% 42% -1% 39% 33% 29%

Young adult treatment Young adult treatment

(n = 14) (n = 14)

Overjet correction Molar correction

9.5 mm 8.6 mm
100% 100%

Skeletal Dental Skeletal Dental

2.1 mm 7.4 mm 2.1 mm 6.5 mm
22% 78% 24% 76%

Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible

-0.2 mm 2.3 mm 3.6 mm 3.8 mm -0.2 mm 2.3 mm 2.7 mm 3.8 mm
-2% 24% 38% 40% -2% 26% 32% 44%

c
Fig 4 Maxillary and mandibular skeletal and dental changes contributing to overjet (left) and sagittal molar (right) correc-
tion in (a) 25 early adolescent, (b) 21 late adolescent, and (c) 14 young adult subjects treated with the banded and the cast
splint Herbst appliances for a period of 6 to 9 months.6,8 Negative (–) values indicate changes counteracting overjet and
molar correction.

Fig 5 (Facing page) Male Class II, Division 2 subject, 14.5 years of age, treated with a cast splint Herbst/multibracket
appliance system. (a) Before treatment. Note the high lip line (the lower lip covering the maxillary incisors). (b) Proclination
of the maxillary incisors. (c) During Herbst treatment. Note 2 mandibular advancement shims added to the plunger for
reactivation of the telescope mechanism. (d) After 7 months of Herbst treatment, when the appliance was removed. Note
the Class I dental arch overcorrection, the lateral open bite, and the improvement of the lower lip to maxillary incisor rela-
tionship. (e) During the multibracket phase of treatment. (f) After 2.4 years of Herbst/multibracket appliance treatment.
Note the stability of the lower lip to maxillary incisor relationship.

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"High angle" treatment "High angle" treatment

(n = 16) (n = 16)

Overjet correction Molar correction

7.6 mm 6.4 mm
100% 100%

Skeletal Dental Skeletal Dental

2.8 mm 4.8 mm 2.8 mm 3.6 mm
37% 63% 44% 56%

Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible

-0.2 mm 3.0 mm 1.8 mm 3.0 mm -0.2 mm 3.0 mm 1.5 mm 2.1 mm
-2% 39% 24% 39% -3% 47% 23% 33%

"Low angle" treatment "Low angle" treatment

(n = 15) (n = 15)

Overjet correction Molar correction

5.5 mm 5.7 mm
100% 100%

Skeletal Dental Skeletal Dental

1.4 mm 4.1 mm 1.4 mm 4.3 mm
25% 75% 25% 75%

Maxilla Mandible Maxilla Mandible Maxilla Mandible Maxilla Mandible

-0.5 mm 1.9 mm 1.9 mm 2.2 mm -0.5 mm 1.9 mm 2.4 mm 1.9 mm
-9% 34% 35% 40% -9% 34% 42% 33%

b
Fig 6 Maxillary and mandibular skeletal and dental changes contributing to overjet (left) and sagittal molar (right) correc-
tion in (a) 16 high-angle and (b) 15 low-angle Class II, Division 1 malocclusions treated with the banded Herbst appliance
for a period of 6 to 8 months.12 Negative (–) values indicate changes counteracting overjet and molar correction.

Fig 7 (Facing page) Male high-angle Class II, Division 1 subject, 15 years of age, treated with a banded Herbst appliance
in combination with a quad helix for maxillary expansion (not shown). (a) Before treatment. (b) During Herbst treatment.
Note mandibular advancement shims added to the plunger. (c) After 6 months of Herbst treatment when the appliance
was removed. Note the Class I overcorrection and the open bite. (d) At 6 months posttreatment. Note the spontaneous
closure of the open bite. No multibracket or retention appliances were used after Herbst treatment.

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e
Fig 8 Male high-angle Class II, Division 1 subject, 14 years of age, treated with a banded Herbst/multibracket appliance
system in combination with extraction of the 4 first premolars. (a) Before treatment. (b) Start of Herbst treatment when
the appliance was placed. (c) After 6.5 months of Herbst treatment when the appliance was removed. (d) After 12 months
of multibracket appliance treatment and extraction of the 4 first premolars. (e) At 12 months posttreatment.

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VOLUME 1, NUMBER 1, 2000 Pancherz/Ruf

Fig 9 Male Class II, Division 1 sub-

ject, 13 years of age, treated with
the Herbst appliance for 6 months.
The boy has the prerequisites for
favorable profile treatment changes:
retrognathic chin, retrusive lower and
protrusive upper lips. (Left) Before
treatment. (Right) After treatment.

a b c

Fig 10 Female Class II, Division 1 subject, 19 years of age, treated with the cast splint Herbst/multibracket appliance sys-
tem. Parasagittal MRIs of the right TMJ are shown. (a) Before treatment. (b) After 9 weeks of treatment. Note the
remodeling of the condyle and ramus. (c) After 8 months of Herbst treatment, when the appliance was removed. Note
that the signs of remodeling have subsided.

Retrognathic facial profile Postpubertal/Young adult patients

The excessive facial profile convexity characteristic of
Class II malocclusions is generally reduced by Herbst
therapy.16 This effect is obvious both in subjects
treated during growth and those treated at the end of
growth (“late” treatment, described below). The most
favorable soft tissue profile changes are seen in
Class II malocclusions with a retrognathic chin,
retruded lower lip, and protruded upper lip (Fig 9).
Herbst therapy has been shown to be very succcess-
ful not only in adolescent patients, but also in posta-
dolescent and young adult patients. 7–9 Although
mandibular growth is almost completed in these
older patients, our recent magnetic resonance imag-
ing (MRI) studies have shown8 that some condylar
growth can be reactivated in subjects at the end of
growth (Fig 10).

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Pancherz/Ruf
100
80
Relapse
60
% jects were treated “late” (late adolescence/permanent
Stable
40
20
0
Overjet Molar Overjet Molar
relation relation
Early n = 31 Late n = 24
Furthermore, in comparison to an “early” treat-
ment approach (early adolescence/mixed dentition),
“late” treatment (late adolescence/permanent den-
tition) can more easily accomplish a stable post-
treatment cuspal interdigitation, preventing a
relapse.17,18 Additionally, the retention time can be
reduced since the residual growth period (with a
possible unfavorable growth pattern) is relatively
short (Fig 11).
In our opinion, after extensive clinical experi-
ences, early Class II treatment should be per-
formed with removable functional appliances (not
the Herbst appliance) because these appliances
are more effective and easier to handle in young
children. Herbst treatment, on the other hand,
should be confined to patients who are in the
pubertal-postpubertal growth period and have their
permanent dentition; at these late somatic and
dental developmental stages, removable appli-
ances are less efficient and patient compliance is
more difficult.
Alternative to orthognathic surgery
As mentioned above, our recent clinical, cephalo-
metric roentgenographic, and MRI research has
shown that the Herbst appliance is very efficient in
Class II subjects at the end of their growth (radius
union).8,9 Thus, we consider the method to be an
alternative to orthognathic surgery in many adult
Class II subjects (Figs 12 and 13). Our conviction is
substantiated by the findings from an ongoing study
that compares young Class II adults treated with
either the Herbst appliance or with mandibular
sagittal split osteotomy. Comparable changes in
sagittal maxillary/mandibular jaw base relationship
and skeletal profile convexity were seen in the 2
28
WORLD JOURNAL OF ORTHODONTICS
Fig 11 Diagram exhibiting the long-term results of Herbst
treatment with respect to stability and relapse in overjet
and sagittal molar relationship. Evaluation of patients 5 to
10 years posttreatment. Thirty-one subjects were treated
“early” (early adolescence/ mixed dentition) and 24 sub-
dentition).17
groups at the end of treatment (after final tooth
alignment with multibracket appliances) (Fig 14).
Furthermore, in comparison to surgery, Herbst treat-
ment implies lower costs and lower risks for the
patient without increasing total treatment time.
TMJ patients
Our short- and long-term TMJ research using tomog-
raphy19 and MRI4,20 has shown no adverse effects
of Herbst treatment on the different hard and soft
tissue joint structures. However, many cases have
demonstrated that Herbst therapy results in a retru-
sion of the articular disc.4 This effect can be used in
the therapy of Class II malocclusions with milder
forms of anterior disc displacement to attain a
reduction of the disc malposition (Fig 15).
NEW CONCEPT OF
CLASS II THERAPY
With respect to age and growth development, the
dominant current concept of Class II treatment is:
• Growth adaptation in children and adolescents
• Camouflage orthodontics in postadolescents
• Surgical correction in adults
However, when considering the fact that skeleto-
facial growth continues many years after cessation
of body height growth and that the adult TMJ is
capable of remodeling,8,9,21,22 it seems logical to
revise the above treatment concept. Thus, with
respect to age and growth development, the follow-
ing modified new concept for Class II therapy is
proposed:
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c
Fig 12 Adult female Class II, Division 1 subject, 18 years of age, treated with the cast splint Herbst/multibracket appli-
ance system. (a) Before treatment. (b) Start of Herbst treatment when the appliance was placed. (c) After completion of
Herbst/multibracket appliance treatment. Note the improvement in the hard and soft tissue profile. Total treatment time
was 24 months.

c
Fig 13 Adult female Class II, Division 1 subject, 34 years of age, treated with the cast Herbst/multibracket appliance sys-
tem. (a) Before treatment. (b) During the Herbst phase of treatment. (c) After completion of Herbst/multibracket appliance
treatment. Note the improvement in the hard and soft tissue profile seen in the cephalogram. Total treatment time was 15
months.

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Fig 14 Sagittal inter-jaw base relationship (Wits

+5 appraisal) and skeletal profile convexity (N-A-Pg). Changes
+4 in young adults treated with either the cast splint Herbst
+3 appliance (n = 12) or with mandibular sagittal split osteo-
+2 tomy (n = 16).
+1
Degrees

0
-1
Herbst n = 12
-3
-2 Surgery n = 16
-4
-5
mm Wits Skeletal profile angle
Young adults / Class II:1

a b c

Fig 15 Male Class II, Division 1 subject, 12 years of age, with an anterior disc
displacement with reduction. Treatment with the cast splint Herbst appliance.
Analyses of parasagittal TMJ-MRIs. (a) Before treatment. Note the anterior disc
displacement. (b) Start of treatment when the Herbst appliance was placed.
Note the disc reduction accomplished when the condyle was placed on the
articular eminence. (c) After 12 weeks of treatment. Note the return of the
condyle to its original fossa position and the physiologic disc-to-condyle relation-
ship. (d) After 7 months of Herbst treatment when the appliance was removed.
Note the stability of the normal disc-to-condyle relationship.18

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VOLUME 1, NUMBER 1, 2000
• Growth adaptation in children, adolescents,
postadolescents, and young adults
• Camouflage orthodontics in older adults
• Surgical correction in older adults
Growth adaptation
Growth adaptation should be performed with remov-
able functional appliances in children and adoles-
cents with mixed dentition. However, in adolescents
who have their permanent dentition, in postadoles-
cents, and in young adults, the Herbst appliance is
usually indicated. The approximate age for young
adulthood would be 18 to 24 years in females and
20 to 25 years in males. An upper age limit for suc-
cessful Herbst treatment is, however, difficult to
define (Fig 15).
Camouflage orthodontics
Camouflage orthodontics mainly comprises tooth
sacrifice in the maxillary dental arch to create space
for retraction of the anterior teeth. By this approach,
however, the skeletal Class II problem (mandibular
retrusion) remains.
Surgical correction
Surgical correction implies that the mandible is
advanced to a Class I skeletal jaw relationship using
either sagittal split osteotomy or mandibular distrac-
tion osteogenesis. Occasionally, mandibular
advancement is combined with maxillary setback
surgery (Le Fort I). The philosphical question is
based on potential iatrogenic sequelae for a primar-
ily cosmetic problem: “What price surgery?”
REFERENCES
1. Pancherz H, Hansen K. Occlusal changes during and after
Herbst treatment: A cephalometric investigation. Eur J
Orthod 1986;8:215–228.
2. Pancherz H, Littmann C. Morphologie und lage des unter-
kiefers bei der Herbst-behandlung. Eine kephalometrische
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Pancherz/Ruf WORLD JOURNAL OF ORTHODONTICS

WEB APPENDIX

f
Fig A-1 Female Class II, Division 1 subject, 15 years of age, with almost complete space closure, after traumatic loss of
the left permanent maxillary central incisor at the age of 10 years. Treatment with the cast splint Herbst/multibracket appli-
ance system in combination with a rapid maxillary expander. (a) Before treatment. (b) Start of treatment with the Herbst
appliance and the maxillary expander were placed. (c) During Herbst treatment. Note the transverse maxillary expansion
and the spaces that developed distally to the maxillary canines as a result of the headgear effect of the Herbst appliance
moving the lateral teeth posteriorly. (d) After 12 months of Herbst treatment, when the appliance was removed. Note the
overcorrected Class I dental arch relationships and the space opening for the left central incisor. (e) During the multi-
bracket phase of therapy. Note the maxillary plate replacing the missing central incisor. (f) After 6 months of multibracket
appliance treatment. Note the complete space opening for the central incisor, and the correction of the midline and the
Class I dental arch relationships. After completion of growth, an incisor implant in planned.

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THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH-
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