British Journal of Orthodontics

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Long-term Effects of the Herbst Appliance on the

Dental Arches and Arch Relationships: A Biometric
Study

Ken Hansen, Pannamas Iemamnueisuk & Hans Pancherz

To cite this article: Ken Hansen, Pannamas Iemamnueisuk & Hans Pancherz (1995) Long-term
Effects of the Herbst Appliance on the Dental Arches and Arch Relationships: A Biometric Study,
British Journal of Orthodontics, 22:2, 123-134, DOI: 10.1179/bjo.22.2.123

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 British Journal of Orthodontics/Val. 22119951123-134

Long-term Effects of the Herbst Appliance

on the Dental Arches and Arch
Relationships: A Biometric Study
KEN HANSEN, D.D.S., OooNT.DR.
PANNAMAS IEMAMNUEISUK, D.D.S., M.D.S.
Department of Orthodontics, Lund University. S-214 21 Malmo, Sweden

HANSPANCHERZ, D.D.S., OooNT. DR.

Department of Orthodontics, University of Giessen. Germany
Accepted for publication March 1994

Abstract. The purpose of this study was to evaluate biometrical/y the treatment and post-treatment effects of the
Herbst appliance on the dental arches and arch relationships. The sample consisted of 53 Class II, division 1
malocclusion patients (33 boys and 20 girls) treated with the Herbst appliance. The mean age of the patients before
treatment was 12·5 years (SD = 1·2 years). Dental casts were analysed before treatment, after treatment, 6 months
post-treatment and at the end of the growth period (5-1 0 years post-treatment). The following variables were assessed:
sagittal molar and canine relationships, overjet, overbite, maxillary and mandibular arch perimeters, and inter-molar
and inter-canine dental arch widths. During treatment, the overjet, overbite, and sagittal molar relationship were
overcorrected in most of the cases, while the sagittal canine relationship was normalized. The maxillary and
mandibular arch perimeters increased during treatment, as did dental arch widths (molar and canine).
In the long-term (mean = 6·7 years after treatment), Herbst appliance treatment resulted in a normal or over-
corrected sagittal molar relationship in 79 per cent and a normal canine relationship in 68 per cent of the cases.
Eighty-three per cent of the subjects had an overjet of 4·5 mm or less. In the long-term, the arch perimeters seemed
to follow a normal dental development pattern. The increase of the upper molar and canine dental arch widths during
treatment remained virtually stable whilst the lower intermolar arch widths seemed unaffected by treaJment.
Index words: Class II Malocclusion, Herbst Appliance, Stability, Study Cast Measurements.

Introduction Materials and Methods

The short- and long-term effects of Herbst appliance Materials
(Herbst, 1934; Pancherz, 1985) treatment in consecu-
tively treated Class II, division 1 patients have been In 1990 the total sample of Class II, division 1 malocclu-
investigated cephalometrically in numerous studies. A sion patients treated with the Herbst appliance at the
Class II malocclusion is generally corrected or over- Department of Orthodontics, Lund University, Malmo,
corrected within 6-8 months of treatment as a result of Sweden, consisted of 170 patients. Fifty-three patients
skeletal and dental changes (Pancherz, 1979, 1981, (33 males and 20 females) fulfilling the following criteria
1982, 1991; Pancherz and Hansen, 1986; Hansen and were selected for this study:
Pancherz, 1992). The settling of the occlusion in the
immediate post-treatment period is a result of adaptive (1) no permanent teeth extracted before or after the
tooth movements (Pancherz and Hansen, 1986). Long- Herbst treatment;
term stability seems to be dependent on a favourable (2) eruption of all permanent canine teeth before treat-
post-treatment growth pattern (Pancherz and Fackel, ment;
1990; Hansen eta/., 1991; Hansen and Pancherz, 1992) (3) an observation period of at least 5 years after treat-
and a stable cuspal interdigitation (Pancherz, 1991). All ment;
these studies concentrated on cephalometric changes, (4) growth completed at the end of the follow-up
however, and analysis of dental casts has received less period (Hansen eta/., 1991).
attention. The purpose of this investigation, therefore.
was to evaluate biometrically on dental casts, the treat- Twenty-nine patients received retainers (activators)
ment and post-treatment effects of the Herbst appliance. after removal of the Herbst appliance for 1-2 years
0301-228X/95/002000 Hl0$02 .CKl © 1995 British Orthodontic Society
 124 K. Hansen eta/. BJO Vu/. !2 1\'o. 2

TABLE I Distribwion of 53 Class II, dil·ision I malocclusion cases (20 females and 33 males) treated with the
Herbst appliance. T (before to after treatment), PI (after treatment to 6 months post-treatmelll), P2 (6 months post-
treatment to end of growth, follow-up, 0 (before treatment to end of growth, follow-up)

Age at
Age at start follow-up T PI P2 0
(years) (years) (years) (years) (years) (years)

Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

Male (n = 33) 12·7 1·2 19·6 1·1 0·6 0·1 0·5 0·0 5·8 1·0 6·9 0·9
Female (n = 20) 12·3 1·2 18·7 1·2 0·6 0·1 0·5 0·1 5·4 0·9 6·5 0·9
Total (n = 53) 12·5 1·2 19·3 1·2 0·6 0·1 0·5 0·0 5·7 J.() 6·7 0·9

(mean 1·66 years, SD 0·7), and 14 (nine males, five first premolar (or first deciduous molar) to the
females) received fixed appliance therapy after the distal contact point of the lateral incisor;
Herbst treatment for 6-12 months (mean 9.0 months (c) the distance from the distal contact point of the
SD 4.6 months). The mean age of the patients before lateral incisor to the midline point between the
treatment was 12.5 years (SD 1·2 years) and the distri- two central incisors.
bution of the patients' ages during the study period is Arch perimeter was calculated as the sum of a + b
shown in Table 1. +c.
5. Arch width: upper and lower arch widths.
(a) Intermolar arch width: the distance between the
Methods mesiobuccal cusp tips of the first molars.
(b) Intercanine arch width: the distance between
Measurements were made on dental casts in centric the cusp tips or estimated cusp tips in cases of
occlusion: before treatment, after treatment, 6 months wear facets.
post-treatment and at follow-up when growth was com-
The maxillary and mandibular arch perimeters and arch
pleted (at least 5 years post-treatment).
widths were digitized, and the distances calculated by
The changes during the following observation
a computer. Before being digitized, the dental casts
periods were analysed:
(with the measuring points marked with a sharp pen-
(I) treatment period (T)- from before to after treat- cil), were placed on an orientation platform beneath a
ment; crystal clear digitizing tablet and orientated with the
(2) 1st post-treatment period (Pl)- from after treat- occlusal plane parallel to the tablet surface. To avoid
ment to 6 months post-treatment; parallax, a plastic cylinder (3 X 4 em) with a hair-cross
(3) 2nd post-treatment period (P2)- from 6 months on the top end, was placed on the digitizing tracer. The
post-treatment to end of growth; hair-cross on the cylinder coincided with the hair-cross
(4) total observation period (0)-from before treat- on the tracer.
ment to end of growth
The variables measured were:
Statistical analysis
I. Sagittal dental arch relationship: molar and canine
relationships of left and right sides were recorded as
l. The percentage of cases exhibiting normal, distal, or
normal, mesial, or distal relationships. Deviation of
mesial molar and canine relationships was calcu-
more than half a cusp's width from normal was re-
lated, and a chi-square test was used to determine
corded as distal or mesial relationship.
the sex differences of these variables.
2. Overbite: the vertical overlap of the upper ( 11) and
2. The arithmetic mean and standard deviation (SD)
lower incisor (41) was measured with a steel ruler to
for each variable were calculated. Paired /-tests were
a level of precision of 0·5 mm.
performed to assess the changes occurring during
3. Overjet: the distance from the incisal edge of the
the different observation periods. Unpaired /-tests
most labial maxillary incisor to the opposing man-
were performed to assess the sex differences. The
dibular central incisor was recorded with a steel
levels of significance used were P<0-001(***),
ruler to a level of precision of 0-5 mm.
P<0-01 (**), P<0-05 (*). P~0.05 was considered
4. Arch perimeter: the maxillary and mandibular arch
not significant (NS).
perimeters were measured sectionally:
(a) the distance from the distal contact point of the All measurements were performed by one of the
second premolar (or second deciduous molar) to authors (P.I.) and repeated on 10 randomly selected
the mesial contact point of the first premolar (or dental casts after an interval of I month. The size of
first deciduous molar); the combined method error for variables 2-5 was calcu-
(b) the distance from the mesial contact point of the lated using the formula ME = ± Y(''I.cF/2n). where d
BJO May/995 Long-term Effects of the Herbst Appliance 125

TABLE 2 Error of measurement TABLE 3 Freqr1ency (number of cases) of sagittal

(ME) in millimetres molar relationship at the four examination periods

Variables ME Distal Normal Mesial

Overjet 0·4 Males Before 33

Overbite 0·3 (n= 33) After 2 10 21
Max. arch perimeter 0·3 6 months 6 18 9
Mand. arch perimeter 0·6 Follow-up 8 21 4
Max. molar width 0·2 Females Before 20
Max. canine width 0·1 (n = 20) After 4 16
Mand. molar width 0·2 6 months I 13 6
Mand. canine width 0·2 Follow-up 3 15 2
Total Before 53
(n = 53) After 2 14 37
6 months 7 31 15
is the difference between two registrations of a pair and Follow-up 11 36 6
n is the number of duplicate registrations. The results
are presented in Table 2.
TABLE 4 Frequency (number of cases) of sagittal
canine relationship at the four examination periods
Results
Distal Normal Mesial
Sagittal dental arch relationship
Males Before 33
The percentage of cases exhibiting normal, distal or (n= 33) After 3 26 4
mesial molar and canine relationships at each stage are 6 months 12 21
shown in Fig. 1. No sex differences were noted. Follow-up 12 21
In most of the cases, the molar (Table 3) and canine Females Before 19
(Table 4) relationships were corrected or overcorrected (n= 20) After 1 15 4
during Herbst treatment. At the end of the treatment 6 months 5 15
period, only two cases (4 per cent; males) displayed Follow-up 5 15

half a cusp's distal molar relationship. A distal canine Total Before 52 I

relationship remained in four cases (8 per cent; one (n = 53) After 4 41 8
6 months 17 36
female, three males). Follow-up 17 36
Normal molar relationship was noted in 31 cases (58
per cent; 13 females, 18 males) at the end of the first
post-treatment period and in 36 cases (68 per cent; 15
females, 21 males) at follow-up. Seven cases (13 per
cent) showed distal molar relationship at the end of the sagittal canine relationship was noted in 36 cases (68
first post-treatment period (one female, six males) and per cent; 15 females, 21 males) during the first and
in 11 cases (21 per cent; three females, eight males) at second post-treatment periods. At the end of the first
the follow-up examination. post-treatment period, 17 cases (32 per cent; 12 females,
During the first post-treatment period, all of the five males) showed a distal canine relationship which
overcorrected canine relationships settled. A normal remained unchanged until the follow-up examination.

Distal relationship Normal relationship Mesial relationship

Percentage of cases Percentage of cases Percentage of cases
100 1oo.------.---.-----.-----, 100.----.----~--~----~

80 80 80
60 60
40
20
o~-="-'-
Before Before After Six.. Follow- Before After Six.. Follow-
months up months up
- molar relationship [LZ] canine relationship
Fro. I. Sagittal molar and canine relationships (n = 53). Registrations from before treatment (before). after treatment (after). fl months post-treatment (6 months)
and follow-up (follow-up) when growth was completed.
 l~n K. H~nscn et ul. BJO Vol. 22 No.2

Overbite Overjet
The mean values of the overbite observed at each The mean values of the overjet observed at each exam-
examination are shown in Fig. 2. Changes that occurred ination are shown in Fig. 2. Changes that occurred
during the four observation periods are presented in during the four observation periods are presented in
Table 5. Table 5. The overjet was significantly larger in the male
During treatment, the overbite of the total patient than in the female sample (Table 6) both before treat-
sample was reduced by 3.4 mm {P<0·001; Table 5). ment (male > female = 1· 3 mm, P<0·05) and 6 months
In the first and second post-treatment periods, the after treatment (male > female = 1 mm, P<0·05).
overbite increased by 1·7 mm (?<0·001) and 0·6 mm During treatment, the mean overjet of the total
(P<O.OOI), respectively. The net reduction in overbite sample decreased by 6·8 mm (?<0·001; Table 5). In
during the total observation period was l mm the first post-treatment period the overjet recovered by
( P<O·OO l). Sex differences (Table 5) were noted during l· 7 mm ( P = 0·0 1) and remained unchanged in the
the first post-treatment period {P<0·05): in the female second post-treatment period. The overjet observed at
sample the increase in overbite was 0.9 mm greater the follow-up examination was 3·7 mm on average. No
than in the male sample (male = 1·4 mm, female = 2·3 significant sex differences were noted for the changes
mm). occurring during the different observation periods.

Overbite (mm)
0
1
2 0 2 4 6 8 10
3 Overjet (mm)
4
5

• Before UZJ After [ ] Six months ~ Follow-up

F~t .. ~- (hcrhite and o'erjet (11 = 53). Rcgistr~tions from oefore tre~tment (heforc). after treatment (after), n months post-treatment (6 months) and follow-up
(follov.-up) \\hen grov.th was completed.

TAlll.l· 5 Changes (mm) of m·ajet and ol'ahite during the four obsen•ation periods: T
(before to after treatment), PI (after treatment to 6 months post-treatment), P2 (6 months
post-treatment to end of growth) and 0 !before treatmem to end of growth)

T PI P2 0

Mean SD Mean SD Mean SD Mean SD

Overjet
Males (33) -7·1*** 3·1 1·9*** 1·9 0·1 1·7 - 5·1 ••• 2·8
Females (20) -ti·.t··· 2·3 1·5*** 1·2 0·4 1·1 -.t·4*** 1·6
Total (.'i3) -n·X*** 2·9 1·7*** l·ti 0·2 1·5 -4·9*** 2·4
Overbite
Mab (33) - J.J*** 1·5 1·4*** 1·7 0·7*** 1·0 -1·3*** 1·1
Females (20) ~J..t*** 2·0 2·3*** 1·2 0·5* 0·9 -0·6 1·4
Total (53) -3.-t*** 1·7 1·7*** l·ti O·ti*** 0·9 -1·0*** 1·3

• Significant changes occurring during each ohservation period at 5 per cent level.
** Significant changes occurring during each ohservation period at I per cent level.
••• Significant changes occurring during each ohservation period at 0·1 per cent level.
Rold- indicate' si!!nificant sex difference.
BJOMay /995 Long-term Effects of the Herbst Appliance 127

TABLE 6 Overjet and overbite (mm) at the four examination periods

Before After 6 months Follow-up

Mean SD Mean SD Mean SD Mean SD

Overjet
Males (33) 9·0 2·4 1·9 1·9 3·8 1-6 3·9 1·3
• •
Females (20) 7·7 2·3 1·3 1·5 2·8 0·9 3·3 1-1
Overbite
Males (33) 4·7 1·1 1·4 1-4 2·8 1·2 H 1-1
Females (20) 4·5 1·5 1·1 1·1 H 1·0 3·9 0·8

• Significant sex differences noted at 0·05 per cent level.

Bold- indicates significant sex difference.

TABLE 7 Arch perimeter (mm) from second premolar to second premolar for the total sam-
ple of 53 subjects

Before After 6 months Follow-up

Mean SD Mean SD Mean SD Mean SD

Maxilla 78·6 4·6 81·3 4·6 79·1 3·8 76·6 3·5

Mandible 67·7 J.9 68·7 3·7 66·4 3·2 64·4 3·0

Arch perimeter existed (Table 10). The net increase in intermolar arch
width during the total observation period for the female
For the total patient sample the a~ch perimeter in- sample was 1·1 mm (P<O·Ol) and for the male sample
creased during the treatment penod by 2· 7 m~ 2·2 mm (P<O·OOl).
(P<0·001) in the maxilla and by 0·9 mm (?<0·001) m Significant sex differences were noted also at 6
the mandible (Table 7). During the first and second months post-treatment (P<0·05, male>female = 1·8
observation periods the perimeter decre~sed by _more mm) and at follow-up (?<0·0.1, male>female = 2·2
than 2 mm in each period in both the maxilla and m the mm) examination (Table 8).
mandible (?<0·001; Table 7). At the time of foll~w-up The intercanine arch width of the total sample
the perimeter had decreased 2·1 m_m (P<O·OOl)_ m the (Table 11) increased by 1·4 mm (P<O·OOl) during
maxilla and 3·3 mm (?<0·001) m the mandible as treatment. The arch width decreased during the first
compared with the pretreatment values. post-treatment period (0·1 mm, NS) and second post-
The changes for the male and the ~emale sa~~les treatment period (0·4 mm, P<0·05). The net increase
are shown in Fig. 3. The two sam~les displayed s~m~lar in intercanine arch width during the total observation
changes during the observation penod~ and no statistical period was 0·9 mm (?<0·001). No significant sex dif-
differences were found. The arch penmeter, however, ferences of changes were noted for any of the obser-
was significantly larger in the male sample a~ all stag~s vation periods (Table 11).
of examinations (Fig. 3) except for th~ maxillary pen-
meter at the end of the treatment penod. Mandibular dental arch width. The intermolar arch
width for the total sample (Table 10) increased by 0.8
mm ( P<O·OOl) during treatment The arch width was
reduced gradually during the first (0·2 mm, NS) and the
Dental arch widths (Figs 4 and 5) second post-treatment (0·7 mm, P<O·OOl) periods. The
intermolar arch width at the follow-up examination was
The mean values of dental arch widths observed at each
unchanged when compared to the pre-treatment
examination and the changes that occurred during the
values. At the 6-month post-treatment and at the
four observation periods are presented in Tables 8-11.
follow-up examinations, significant sex differences
Maxillary dental arch width. The intermolar arch wete noted (?<0·05). For the changes occurring during
width of the total sample increased by 3·0 mm the four observation periods, however, no significant
(P<O·OOl) during the treatment period, but decreased sex differences were noted (Table 10).
by 0·4 mm (NS) and by 0·8 mm (?<0·001) during the The intercanine arch width for the total sample
1st and the second post-treatment periods (Table 10). (Table 11) increased by 0·3 mm (?<0·05) during the
During the total observation period the inter~·10~ar treatment period, but decreased gradually during the
arch width increased by 1·8 mm (?<0·001). A sigmfi- first (0·5 mm P<0·01) and the second post-treatment
cant sex difference (P<0·05, male>female 1·1 mm) (0·9 mm, P<O·OOl) periods. The net decrease during
 128 K. Hansen eta/. 810 Vol. 22 No. 2

mm Maxillary arch perimeter the total observation period was 1·0 mm (P<0.001). No
significant sex differences were noted.

Discussion
As most of the cases had a retention appliance (acti-
vator) after the Herbst treatment or a multibracket
76 appliance (14 cases) it must be acknowledged that this
would have influenced some of the results, especially
74 those of the first post-treatment period. However, since
72 most of the sagittal post-treatment changes occurred
70~~~~~~~~~~~~~~ during the first post-treatment period (Figs 1-3), it
0 1 2 3 4 5 6 7 appears that the retaining appliances were not able to
years maintain the sagittal treatment results. The effect of
T P1 P2 activator retention on sagittal changes after Herbst
treatment has been investigated earlier (Pancherz and
Hansen, 1986). It was concluded that the effect of the
retention appliance was small and the only significant
mm Mandibular arch perimeter change found between the retention and non-retention
.-------------------~----------, groups was for the mesial movement of the maxillary
74 molars (Pancherz and Hansen, 1986).
However, arch widths (Figs 4 and 5) continued to
relapse very slightly during both the first and the second
post-treatment periods. Whilst the benefit of the reten-
tion appliances might be greater in the transverse
dimension, the treatment result was still not fully main-
tained.
64 *
Female sample
62
6o~~~~~~~~~~~~~~ Sagittal dental arch relationships
0 1 2 3 4 5 6 7
years In untreated Class II malocclusions, the sagittal dental
T P1 P2 arch relationships (molar and canine relationships) do
Fl<i. 3. Maxillary and mandihular arch perimeters (n = 53). Treatment not improve with age (Frohlich, 1961). In the present
period (T): from hefore 10 after treatment, first post-treatment period (PI): study, the Herbst appliance corrected or overcorrected
from after treatment to 6 months post-treatment and second post-treatment
period (P2): from 6 months after treatment to end of growth. *Indicates
both molar and canine sagittal relationships to a normal
significance at 5 per cent level. **Indicates significance at I per cent level. sagittal relation in most of the cases. However, the

Maxillary dental arch Mandibular dental arch

Expansion Constriction Constriction Expansion

0 1 2 mm 2 0 2 3 4 mm
4 3 2

[i2ZJ PI §P2 ~0
fl<;. -'· Maxillarv and mandihular intermolar width changes (n = 53). Treatment period (T): from he fore to after treatment. first )XJSt-treatmcnt period (PI):
from after treatm~nt to fJ months post-treatment. second post-treatment period (P2): from fJ months after treatment to end of growth and total oh,ervatinn
period (0): from hefore treatment to end of growth.
BJOMay/995 Long-term Effects ofthe Herbst Appliance 129

Maxillary dental arch Mandibular dental arch

Expansion Constriction Constriction Expansion

4 3 2 0 2 mm 2 0 1 2 3 4 mm

[ZZLJ Pl ~0
FrG. 5. Maxillary and mandibular intercanine width changes (n = 53). Treatment period (T): from before to after treatment. first post-treatment period (PI):
from after treatment to 6 months post-treatment. second post-treatment period (P2): from 6 months after treatment to end of growth and total observation period
(0): from before treatment to end of growth.

TABLE 8 /ntermo/ar arch width (in mm) at four examination periods

Before After 6 months Follow-up

Mean SD Mean SD Mean SD Mean SD

Maxilla
Males (33) 50·8 2·2 53-8 2·9 53·7 2·7 53·0 2·5

52·7 2·3
••
Females (20) 49·7 2-3 51·9 2·0 50·8 2-1
Total (53) 50·4 2·3 53-4 2·7 53·0 2·6 52·2 2·6
Mandible
Males (33) 45·1 2·2 45·9 2·7 45·9 2·8 45·3 2·7
• •
Females (20) 43·9 2·5 44·8 2·5 44·1 1·8 43·4 2-2
Total (53) 44·6 2-4 45·5 2·6 45·2 2·6 44·6 2·7

• Significant sex difference noted at 0·05 per cent level.

•• Significant sex difference noted at 0·01 per cent level.
Bold- indicates significant sex difference.

treatment was more effective in the molar than in the Overjet and overbite
canine region (Fig. 1). This was probably due to the
maxillary anchorage system: the molar, connected to The overbite and overjet were reduced in all patients
the first premolar, was pushed distally by the telescope during treatment. Although both overbite and overjet
mechanism (Pancherz and Hansen, 1986). The canine, increased during the first and second post-treatment
on the other hand, was not directly engaged in the period (Table 12), in the majority of the cases this was
anchorage system. of minor clinical significance. The relapses might well
Some relapse was noted during the first post- be explained by 'rebound' in incisor tooth position after
treatment period both in sagittal molar and canine rela- Herbst treatment (Pancherz and Hansen, 1986).
tionships. During the second post-treatment period the The overbite of the patients before treatment was on
sagittal canine relationship seemed to remain stable average slightly greater than that of 'normal' occlusion
(Table 4). The sagittal molar relationship, on the other patients (Moyers et a/., 1976). Overbite normally
hand, continued to change in a few cases during the decreases somewhat with age (Seipel, 1946; Moorrees,
second post-treatment period (Table 3), but the number 1959; Moyers eta/., 1976) or remains unchanged after
of cases which displayed normal sagittal molar and the age of 12. Thus, the decrease in overbite seen
canine relationships was the same at follow-up ( 15 during the Herbst treatment is thought to be due to the
females, 21 males) as at 6 months post-treatment. Some appliance. The increase in overbite during the first and
cases with overcorrected sagittal molar relationships, second post-treatment periods was probably due to
however, were still noted (Fig. 1) at the time of follow- some recovery of the overcorrected sagittal dental arch
up. relationship.
 130 K. Hansen eta/. BJO Vol. 22 No.2

TABLE 9 lntercanine arch width (in mm) at the four examination periods

Before After 6 months Follow-up

Mean SD Mean SD Mean SD Mean SD

Maxilla
Males (33) 34·4 H 35-8 1·8 35·7 H 35·5 2-1
• • • ••
Females (20) 33-1 1·8 34·6 1·7 34·6 2-3 33·8 2·3
Total (53) 33·9 2·1 35·3 1·9 35·2 2·3 34·8 2·3
Mandible
Males (33) 26·5 1·9 26·9 1·8 26·4 1·5 25·7 1·7
Females (20) 26·0 1·9 26·1 1·6 25·7 1·5 24·7 2·3
Total (53) 26·4 1·9 26·7 1·8 26·2 1·5 25·3 1·9

• Significant sex difference at 0·05 per cent level.

•• Significant sex difference at 0·01 per cent level.
Bold- indicates significant sex difference.

TABLE 10 lntermolar arch width changes (in mm) during the four observation periods: T
(before to after treatment), PI (after trl'atment 10 6 months post-treatment), P2 (6 months post-
trl'atment to l'nd of growth) and 0 (bt'fore treatment to end of growth)

T PI P2 0

Mean SD Mean SD Mean SD Mean SD

Maxilla
Males (33) 3·0*** 1·7 -0·1 1·5 -0·7* 1·4 2·2* .. 2·2
•
Females (20) 3·0*"* 1·5 -0·8* 1·4 -I· I** 1·3 1·1** 1·6
Total (53) 3·0*** 1·6 -0·4 1·5 -0·8*** 1·4 1.8*** 2·0
Mandible
Males (33) 0·8** 1·4 01 1·2 -0·6* 1·6 0.2 1·7
Females (20) 0·9*** 1·0 -0·7 1·7 -0·8* 1·2 -1.5 1·9
Total (53) 0·8*** 1·2 -0·2 1·4 -0·7*** 1·4 -0.1 1·8

* Significant changes occurring during each observation period at 0·05 per cent level.
** Significant changes occuring during each observation period at 0·01 per cent level.
••• Significant changes occurring during each observation period at 0·001 per cent level.
Bold- indicates significant sex difference.

TABLE II lntercanine arch width changes (in mm) during the four observation periods: T
(before 10 after treatment), PI (after treatment to 6 months post-treatment), P2 (6 months post-
treatment to end of growth) and 0 (before treatment to end of growth)

T PI P2 0

Mean SD Mean SD Mean SD Mean SD

Maxilla
Males (33) 1·4*** 1·3 -0·1 1·8 -0·2 1·1 1·1*** 1·2
Females (20) 1·5*** 1·3 -0·2 1·2 -0·6* 0·9 0·7* 1·4
Total (53) 1·4*** 1·3 -0·1 1·6 -0·4* 1·1 0·9*** 1·3
Mandible
Males (33) 0·4** 0·8 -0·5* 1·4 -0·8*** 0·9 -0·9*** 1·3
Females (20) 0·1 0·9 -0·4 1·0 -0·9** 1·2 -1·3** 1·6
Total (53) 0·3* 0·8 -0·5** 1·2 -0·9*** 1·1 -1·1*** 1·4

• Significant changes occurring during each observation period at 0·05 per cent level.
•• Significant changes occuring during each observation period at 0·01 per cent level.
••• Significant changes occurring during each observation period at 0·001 per cent level.

The overjet before treatment was, on average, lower values. Thirty-seven cases (70 per cent) exhibited
approximately 4·5 mm larger than that in a 'normal' stable results during the second post-treatment period,
population (Moyers eta/., 1976). At the end of the first while 16 cases (30 per cent) showed an increase in
post-treatment period, 14 cases (26 per cent) had an overjet (l-2·5 mm). Only one case had a marked
overjet of more than 3·5 mm, while the rest showed increase in overjet of 6·5 mm. The mean overjet at the
810 May 1995 Long-term Effects of the Herbst Appliance 131

TABLE 12 Changes in overbite and overjet (number of cases and range of changes) that occurred dur-
ing the four observation periods: T (before to after treatment), PI (after treatment to 6 months post-
treatment), P2 (6 months post-treatment to end of growth) and 0 (before treatment 10 end of growth)

T PI P2 0

Overbite
Increase 0 46 (0·5-4·4 mm) 3 (0·5 mm) 5 (0·5-3·5 mm)
Decrease 51 (0·5-7·0 mm) 5 (0·5-3·0 mm) 50 (0·5-5·0 mm) 41 (0·5-3·0 mm)
Unchanged 2 2 0 7
Overjet
Increase 0 45 (0·5-6·5 mm) 43 (0·5-7·0 mm) I (1·5 mm)
Decrease 53 (2·5-13·0 mm) 4 (0·5-3·5 mm) 5 (0·5-1·0 mm) 52 (0·5-10·0 mm)
Unchanged 0 4 5 0

follow-up examination was comparable to that found in ment (Table 10) in 51 (95 per cent) out of 53 cases
a 'normal' population (Moyers et al., 1976). Thirty- (Table 13). The force directed from the telescope
eight cases (72 per cent) had an overjet :s 4·0 mm and mechanism to the upper molars is both distal and
44 cases (83 per cent) :s 4·5 mm. buccal. Despite the reduction in intermolar width
Males had a significantly larger overjet, both before during the first and second post-treatment period, a net
treatment and 6 months after treatment than females increase was found in 46 cases (87 per cent; 18 females
(Table 6). In the normal population sample studied by and 28 males) during the total observation period
Moyers et al. (1976), a similar sex difference was (Table 13). This net increase was more pronounced in
found; however, this difference was not significant. As the male than in the female sample. Other functional
no significant sex difference could be noticed after appliances such as the Activator and Frankel appliance
treatment, it seems that the Herbst treatment influences also produced expansion of 1.7-4.5 mm during treat-
males and females equally. The relapse in overjet noted ment (Pancherz, 1976; Gibbs and Hunt, 1992; Hime
during the first and second post-treatment periods was and Owen III, 1990). In normal dental development
not significantly different when the sexes were com- samples studied by Moorrees (1959) and Van der
pared. Linden (1983), intermolar width remained unchanged
or slightly decreased with age. However, in the work
by Moyers et a/. ( 1976) intermolar width continued to
Arch perimeter increase in the male sample but were almost constant
in the female sample. The sexual dimorphism found in
The arch perimeter increased during treatment both in
the Herbst treated sample were in accordance with
the maxilla and in the mandible. The increase in the
normal recordings (Van der Linden, 1983; Moyers et
maxilla was probably due to the distal movements of al., 1976).
the maxillary molars as shown in previous investigations
During Herbst treatment the intercanine width in-
(Pancherz, 1982; Pancherz and Hansen, 1986; Pancherz
creased in 4fi cases (87 per cent; 18 females and 28
and Anehus-Pancherz, 1993). In the mandible the
males) (Table 13). Some relapse occurred during the
increase in arch perimeter could be explained by procli-
first and second observation period. At the end of the
nation of the lower incisors (Pancherz, 1982; Pancherz
follow-up period, 12 cases showed a reduced intercanine
and Hansen, 1988). In the first post-treatment period,
width and five of those displayed a reduction of more
the shortening of the arch perimeters is probably
than 1 mm. The net increase in intercanine width for
caused by some relapse of both maxillary and man-
the total sample during the total observation period was
dibular teeth (Pancherz and Hansen, 1986; 1988). For
0·9 mm, on average. The increase in intercanine width
the long-term results, however, it is interesting to com- ( 1·4 mm) during treatment was smaller than that in
pare the changes in arch perimeter to what may be intermolar width (3·0 mm) and is in accordance with
considered to be normal changes, due to growth alone.
findings in other studies of functional appliances (Gibbs
In Fig. 6 the changes in maxillary and mandibular arch and Hunt; 1992, McDougall eta/., 1982). An increase
perimeter for the male and female samples are com- in intercanine width in the maxilla normally does not
pared with corresponding values taken from work by exceed 0· 7 mm during the period from 12 to 14 years
Moyers et a/. (1976). Although the measurements
of age (van der Linden. 1983). Similar findings were
were not recorded in exactly the same way (Moyers et reported by Moorrees (1959) and Moyers et a/.
a/. used the Bonwili-Hawley method), the reduction in (1976). The results of the present study thus show that
arch perimeter over the years follows the same pattern. some of the expansion in the maxillary canine region
occurring during treatment is as a result of the Herbst
Maxillary dental arch width
appliance. This might be explained by the mode of
action of the appliance as the premolars are connected
The Herbst appliance resulted in expansion. by an to the molars by a lingual sectional arch and the canines
average of 3 mm, of the intermolar width during treat- to the premolars by a labial sectional arch. The pre-
132 K. Hansen el a/. 810 Vol. 22 No. 2

Maxillary arch perimeter

mm Female sample mm Male sample
.-------------------~-------------- 84r-------------~-----------,
84
82 82

78
Herbst sample 76
74 74
I
72 721
70 70 I 11
0 1 2 3 4 5 6 7 0 2 3 4 5 6 7
T P1 P2 years T P1 P2 years

Mandibular arch perimeter

mm Female sample mm Male sample

74~
74
72
~2 •..
Occlusal standards "\' . Occlusal standards
- . - - 68 .
66
64 64
62 62
60 60
0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7
T P1 P2 years T P1 P2 years
F1r.. 6. Maxillary and mandibular arch perimeters (n = 53. 20:female. 33:male) and corresponding values from Moyers el a/. ( 1976). Treatment period (T):
from before to after treatment. first post-treatment period (PI): from after treatment to 6 months post-treatment and second post-treatment period: (P2) from
6 months after treatment to end of growth.

molars and the canines will be moved in a distal-buccal 1959). The present study, however, showed some
direction into a broader part of the maxillary arch when larger expansion as compared to normal dental de-
the telescope mechanism moves the maxillary molars velopment.
distally. During the first post-treatment period, the inter-
molar width remained unchanged in the male sample,
although in the female sample some decrease (NS) in
Mandibular dental arch width arch width was noted. During the second post-
treatment period 70 per cent of the entire sample (37
An expanded intermolar width during treatment was cases) showed a reduced intermolar width ranging from
found in 44 cases (83 per cent; range = 0-2-4·5 mm; 0·1 to 5·3 mm. However, a net increase in intermolar
Table 14). while eight cases (15 per cent) showed a width was found during the total observation period in
reduced intermolar width (two females, six males). The 29 cases (55 per cent; eight females, 21 males) ranging
mandibular molar expansion is probably not a result of from 0·1 to 4· 7 mm. Reduction in intermolar width
forces from the Herbst appliance but rather a compen- during the total observation was noted in 24 cases (45
satory expansion. secondary to the maxillary expan- per cent; 12 females. 12 males) ranging from 0·2 to 4·3
sion. As the mandible is positioned anteriorly during mm.
treatment the degree of compensatory expansion is According to Moorrees ( 1959). Moyers et a/. ( 1976)
relatively small. Frohlich (1961) found no difference in and Van der Linden (1983). the normal development
mandibular intermolar width between an 'untreated of mandibular intercanine width tends to decrease after
class II malocclusion group.' and normative data the age of 12. Thus, the expansion of the lower inter-
(Moorrees, 1959). From the normative data, inter- canine width seen during Herbst treatment may be
molar width increases slightly with age (Moorrees, considered to be an effect of treatment. The expansion
BJ0Mayl995 Long-term Effects of the Herbst Appliance 133

TABLE 13 Changes in maxillary molar and canine width (number of cases and range of changes) that
occurred during the four observation periods: T (before to after treatment), PI (after treatment to 6
months post-treatment), P2 (6 months post-treatment to end of growth) and 0 (before treatment to end of
growth)

T PI P2 0

Molar width
Increase 51 (0·4-5·6 mm) 23 (0·1-H mm) 12 (0·2-2·6 mm) 46 (0·2-4·9 mm)
Decrease 2 (0·9-3·0 mm) 30 (0·1-4·7 mm) 40 (0·1-5·5 mm) 7 (0·15-5·2 mm)
Unchanged I
Canine width
Increase 46 (0·2-6·1 mm) 26 (0·1-3·7 mm) 20 (0·1-3·7 mm) 40 (0·2-3·6 mm)
Decrease 6 (0·1-1·1 mm) 26 (0·1-5·8 mm) 26 (0·1-5·8 mm) 12 (0·1-1·9 mm)
Unchanged I I I I

TABLE 14 Changes in mandibular molar and canine width (number of cases and range of changes) that
occurred during the four observation periods: T (before to after treatment), PI (after treatment to 6
months post-treatment), P2 (6 months post-treatment to end of growth) and 0 (before treatment to end of
growth)

T PI P2 0

Molar width
Increase 44 (0·2-4·5 mm) 26 (0·3-3·3 mm) 14 (0·1-1·9 mm) 29 (0·1-4·7 mm)
Decrease 8 (0·1-2·1 mm) 24 (0·2-5·7 mm) 37 (0·1-4·1 mm) 24 (0·2-4·3 mm)
Unchanged I 3 2
Canine width
Increase 30 (0·1-1·6 mm) 15 (0·1-1·9 mm) 7 (0·2-Hl mm) 10 (0·2-1·3 mm)
Decrease 17 (!J.l-5·7 mm) 34 (0·1-5·7 mm) 41 (0·1-3·9 mm) 43 (0·1-5·1 mm)
Unchanged 6

was, however, small (0·29 mm) and of no clinical Hansen, K., Pancherz, H. and Hiigg, U. (1991)
significance. Long term effects of the Herbst appliance in relation to the treatment
Some relapse in intercanine width was noted during growth period: a cephalometric study.
the first and second observation periods. At the end of European Journal of Orthodontics, 13, 471-481.
the follow-up period, 43 cases (81 per cent) displayed Hansen, K. and Pancherz, H. (1992)
a constricted intercanine width ranging from 0·1 to 5·1 Long term effects of Herbst treatment in relation to normal growth
mm (Table 14). development: a cephalometric study,
European Journal of Orthodontics, 14, 285-295.
Conclusions Herbst, E. (1934)
Dreissighjahrige Erfahrungen mit dem Retentions-Schamier.
1. In the long-term, Herbst appliance treatment gener- Zahnaerztliche Rundschau, 43, 1515-1524. 1563-1568, 1611-1616.
ally results in normal sagittal molar and canine rela-
Hime, D. L. and Owen III, A. H. (1990)
tionships, and in reduction of overjet and overbite.
The stability of the arch expansion effects of Frankel appliance
2. Although maxillary and mandibular arch perimeters therapy.
increase during treatment, in the long-term the arch American Journal of Orthodontics and Dentofacial Orthopedics. 98,
perimeters follow a normal dental development pat- 437-445.
tern.
3. The increase in upper intermolar and canine arch McDougall, P. D., McNamara, J, A. and Dierkes, J, M. (1982)
widths during treatment remained fairly stable after Arch width development in Class II patients treated with the Frankel
appliance,
treatment. The lower intermolar width, however,
American Journal of Orthodontics, 82, 10-22.
seemed to be unaffected by treatment.
Moorrees, C. F. A. (1959)
The Dentition of the Growing Child.
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