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 Table of Contents  
Year : 2018  |  Volume : 10  |  Issue : 3  |  Page : 152-155

Class II deep bite correction with herbst appliance assisted with mini screws

Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Hosam Ali Baeshen
Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, P. O. Box: 80209, Jeddah 21589, Kingdom of Saudi Arabia, Vice Dean, Al-Farabi Privet Dental and Nursing Schools, Jeddah
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_275_17

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This case report describes the orthodontic treatment of a 36-year-old female with Class II Division 1 malocclusion associated with deep overbite. The treatment was based on nonextraction therapy using MBT: McLaughlin, Bennett and Trevesi. Orthodontic bracket system slot 0.022 straight-wire appliance. Deep bite correction was assisted with labial mini screws. A Herbst appliance with Class II elastics was used for canine and molar Class II correction and overjet reduction. Treatment goals were achieved in 22 months, and the results included a normal overjet, Class I occlusion, competent lips, and an acceptable facial profile.

Keywords: Class II malocclusion, Herbst appliance, mini screws, retrognathic mandible

How to cite this article:
Baeshen HA. Class II deep bite correction with herbst appliance assisted with mini screws. J Int Oral Health 2018;10:152-5

How to cite this URL:
Baeshen HA. Class II deep bite correction with herbst appliance assisted with mini screws. J Int Oral Health [serial online] 2018 [cited 2023 Oct 5];10:152-5. Available from:

  Introduction Top

Correction of Class II malocclusion is the most common treatment modality in day-to-day orthodontic clinical practice.[1] In children and adult patients with mandibular retrusion in skeletal Class II malocclusion, functional fixed type appliances can be used for Class II correction nowadays among orthodontists to treat such cases.[2],[3],[4],[5],[6],[7] In addition, nonextraction therapy is often used with the adoption of Class II mechanics aiming to reduce the overjet and attain a suitable occlusal relationship. Early intervention is crucial to the success of treatment of dental and skeletal Class II cases. The use of fixed functional appliances in the treatment of Class II mandibular retrusion in several studies [1],[8],[9],[10],[11],[12],[13] has shown that mandibular residual growth may continue beyond puberty. Moreover, there are a lot of different types of appliances such as fixed functional appliance which can help to achieve a Class I occlusion in such cases. Patil et al.[14] treated an adult female with Class II Division 1 malocclusion with mandibular retrusion and deep bite using a fixed functional appliance and miniplate. They propose this treatment as an alternative to orthognathic surgical intervention for growing and postpubertal patients. To maintain the treatment output and allow for successful correction of Class II skeletal and dental malocclusions, Class II elastics are essential. On the other hand, protrusion of the lower incisors may be problematic and limit the use of functional appliances;[8],[9] therefore, mini screws may present a reasonable solution.[10] Mini screws are considered a breakthrough in orthodontic anchorage, especially in deep bite cases.[10]

  Case Report Top

This 36-year-old female patient presented to the Orthodontic Clinic complaining about the appearance of her upper teeth. She was healthy and had previous routine dental check-ups.

As apparent in [Figure 1], extraoral examination showed an asymmetric normal face with a gummy smile. The lateral facial profile showed a retrusive chin (convex profile), thin upper lip, incompetent lips, and obtuse nasolabial angle. Intraoral examination revealed an Angle Class II Division 1 malocclusion, a complete traumatic deep bite with 11 mm overjet. There were mild upper and lower anterior crowdings (1.5 mm and 2 mm, respectively), a moderate curve of Spee in both arches, upper right second premolar in crossbite, and impacted lower right third molar. The soft tissue was fare and within normal limits. The patient was consented to have her photographs and radiographs published.
Figure 1: Pretreatment extraoral and intraoral photographs

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  Radiographic Examination Top

As seen in [Table 1] and [Figure 2], panoramic radiograph evaluation showed the presence of a full permanent dentition with an impacted lower right third molar. The periodontal condition was within normal limits. Condyles appeared normal, confirming normal joints, and normal mouth opening with no deviation [Figure 3]. Cephalometric analysis showed normal maxillary growth (SNA 79.5°), retrognathic mandible (SNB 72°), and skeletal Class II relationship (ANB 7°) with a horizontal facial growth pattern and Y-axis of 54°. Both the upper and lower central incisors were retroclined (upper incisor to NA angle 1.5° and lower incisor to NB angle 8°), and the chin was prominent.
Table 1: Pre- and post-treatment values of cephalometric analysis

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Figure 2: Pretreatment cephalometric X-ray

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Figure 3: Pretreatment orthopantomogram X-ray

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  Treatment Objectives Top

The treatment objectives were as follows: (1) correction of the deep bite, (2) mandibular enhancement into a more forward position using a Herbst appliance with an anterior bite plane to accelerate the mandible anteriorly and correct deep bite as well, (3) relieve of the upper and lower anterior crowdings, (4) midline correction to attain a Class I molar and canine relationship, (5) obtaining an acceptable overjet and overbite, (6) establish proper occlusion, and (7) improve the patient's facial profile.

  Treatment Alternatives Top

This patient refused surgical correction of her case and requested camouflage treatment. The suggested treatment was nonextraction based with Class II mechanics using fixed functional appliance (Herbst) and mini screws along with a straight-wire appliance system (MBT slot 0.022). The treatment included banding on the first molars and bonding of the premolars, canines, and incisors. Heat-activated nitinol archwire size 0.014 was loaded as the initial wire followed by archwire progression for the first phase as prescribed by the MBT system. At the end of the first phase of treatment, mini screws were placed between the upper laterals and canines to intrude the upper incisors. A Herbst appliance for Class II correction was overloaded and inserted for mandibular advancement and overjet correction, aiming to attain Class I canine and molar relationship. Class I molar and canine relationships were accomplished with excellent patient cooperation. Class II elastics were used at the end of active treatment (22 months). After debonding, clear and lingual fixed retainers for both the maxillary and mandibular arches were used as retention activators. Instructions given to the patient included (1) wearing the upper retainer for 24 h for two consecutive years, and at night afterward for one more year and (2) coming back for a follow-up visit in 3 months for treatment evaluation. The posttreatment facial photographs are shown in [Figure 4]. A Class I molar and canine relationship were achieved. The overbite and overjet were corrected, and the maxillary and mandibular crowdings were solved. [Figure 5] showed the final cephalometric radiograph. The posterior intercuspation was normal with occlusal settlement, and the panoramic radiograph showed near parallel root position as shown in [Figure 6]. The maxilla showed a slight forward movement, most likely because of the residual growth. The mandible moved in a favorable forward and downward direction. The interarch relationship of the upper and lower incisors showed normal relationship. Slight extrusion and protraction of the lower molars were observed [Figure 7]. This can be explained as the effect of the Class II mechanics that opened the bite. The following esthetic changes were accomplished: a slight decrease in facial convexity, slight increase in anterior facial height, and a flatter labiomental sulcus. The profile was well balanced. The superimposition of cephalometrics before and after treatment is shown in [Figure 7]. Posttreatment radiographic examination showed no root resorption in both upper and lower anterior teeth.
Figure 4: Posttreatment extraoral and intraoral photographs

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Figure 5: Posttreatment cephalometric X-ray

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Figure 6: Posttreatment orthopantomogram X-ray

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Figure 7: Superimposition, before and after treatment: (a) maxillary, (b) mandibular, and (c) cephalometric

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  Discussion Top

The ideal treatment for adults with skeletal Class II malocclusion and mandibular retrusion is always carried out surgically. However, camouflage is a possible alternative, especially if the maxillary-mandibular disproportion is not severe. In the current case, the patient chose camouflage treatment using Herbst interarch mechanics for mandibular advancement and a fixed orthodontic appliance. In the literature, various mechanics have been used to control the anterior proclination of the lower incisors including the use of negative torque and mini screws.[10] In this report, relative intrusion was employed to the curve of Spee through an anterior bite plate allowing posterior teeth to extrude while the distalizing forces turn on the upper arch to move back and the mandible move forward. Consequently, a retrusion of the upper lip was observed, the maxillary incisors were proclined by 2°, and the lower incisors were proclined. Upadhyay et al.[15] reported that dental changes are encountered at the postpubertal period. According to Mihalik et al.,[16] nonsurgical approaches to treat postpubertal Class II with retrusive mandible can be utilized. They found more relapse in the surgical intervention versus treatment using a fixed functional appliance. Bock et al.[17] reported that in adult Class II Division 1 Herbst treatment showed good occlusal stability even 2.5 years posttreatment. Ruf and Pancherz [12] found fewer relapse in adults treated with Herbst appliance. In addition, both Ruf and Pancherz[18] as well as Cassidy et al.[19] recommended the use of Herbst appliance in surgical borderline cases. Such findings were also confirmed by Atik and Kocadereli [2] in a long-term follow-up period using Forsus Fatigue Resistant Device appliance. In their report, a retentive activator was given to the patient to wear for 2 years to maintain the stability of the occlusion.

  Conclusion Top

The use of Herbst appliance in postpubertal stage with skeletal Class II Divsion1 malocclusion (surgical borderline) may enhance the mandible to move forward by harnessing and distalizing the maxillary teeth along with permanent retention and provide an alternative to surgical intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pancherz H, Bjerklin K, Hashemi K. Late adult skeletofacial growth after adolescent Herbst therapy: A 32-year longitudinal follow-up study. Am J Orthod Dentofacial Orthop 2015;147:19-28.  Back to cited text no. 1
Atik E, Kocadereli I. Treatment of class II division 2 malocclusion using the forsus fatique resistance device and 5 year follow-up. Case Rep Dent 2016:3168312.  Back to cited text no. 2
Kinzinger GS, Lisson JA, Frye L, Gross U, Hourfar J. A retrospective cephalometric investigation of two fixed functional orthodontic appliances in class II treatment: Functional mandibular advancer vs. herbst appliance. Clin Oral Investig 2018;22:293-304.  Back to cited text no. 3
Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr. Mandibular changes produced by functional appliances in Class II malocclusion: A systematic review. Am J Orthod Dentofacial Orthop 2006;129:599.e1-12.  Back to cited text no. 4
Aras I, Pasaoglu A. Class II subdivision treatment with the forsus fatigue resistant device vs. intermaxillary elastics. Angle Orthod 2017;87:371-6.  Back to cited text no. 5
Zymperdikas VF, Koretsi V, Papageorgiou SN, Papadopoulos MA. Treatment effects of fixed functional appliances in patients with class II malocclusion: A systematic review and meta-analysis. Eur J Orthod 2016;38:113-26.  Back to cited text no. 6
Dalci O, Altug AT, Memikoglu UT. Treatment effects of a twin-force bite corrector versus an activator in comparison with an untreated Class II sample: A preliminary report. Aust Orthod J 2014;30:45-53.  Back to cited text no. 7
Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Baccetti T, et al. Effectiveness of comprehensive fixed appliance treatment used with the forsus fatigue resistant device in class II Patients. Angle Orthod 2011;81:678-83.  Back to cited text no. 8
Jones G, Buschang PH, Kim KB, Oliver DR. Class II non-extraction patients treated with the forsus fatigue resistant device versus intermaxillary elastics. Angle Orthod 2008;78:332-8.  Back to cited text no. 9
Aslan BI, Kucukkaraca E, Turkoz C, Dincer M. Treatment effects of the forsus fatigue resistant device used with miniscrew anchorage. Angle Orthod 2014;84:76-87.  Back to cited text no. 10
Bock NC, Ruf S, Wiechmann D, Jilek T. Dentoskeletal effects during Herbst-Multibracket appliance treatment: A comparison of lingual and labial approaches. Eur J Orthod 2016;38:470-7.  Back to cited text no. 11
Ruf S, Pancherz H. Herbst/multibracket appliance treatment of Class II division 1 malocclusions in early and late adulthood. A prospective cephalometric study of consecutively treated subjects. Eur J Orthod 2006;28:352-60.  Back to cited text no. 12
Konik M, Pancherz H, Hansen K. The mechanism of class II correction in late Herbst treatment. Am J Orthod Dentofacial Orthop 1997;112:87-91.  Back to cited text no. 13
Patil HA, Kerudi VV, Rudagi BM, Sharan JS, Tekale PD. Severe skeletal Class II Division 1 malocclusion in postpubertal girl treated using forsus with miniplate anchorage. J Orthod Sci 2017;6:147-51.  Back to cited text no. 14
Upadhyay M, Yadav S, Nagaraj K, Uribe F, Nanda R. Mini-implants vs. fixed functional appliances for treatment of young adult Class II female patients: A prospective clinical trial. Angle Orthod 2012;82:294-303.  Back to cited text no. 15
Mihalik CA, Proffit WR, Phillips C. Long-term follow-up of Class II adults treated with orthodontic camouflage: A comparison with orthognathic surgery outcomes. Am J Orthod Dentofacial Orthop 2003;123:266-78.  Back to cited text no. 16
Bock NC, von Bremen J, Ruf S. Occlusal stability of adult Class II Division 1 treatment with the Herbst appliance. Am J Orthod Dentofacial Orthop 2010;138:146-51.  Back to cited text no. 17
Ruf S, Pancherz H. Orthognathic surgery and dentofacial orthopedics in adult class II division 1 treatment: Mandibular sagittal split osteotomy versus Herbst appliance. Am J Orthod Dentofacial Orthop 2004;126:140-52.  Back to cited text no. 18
Cassidy DW Jr., Herbosa EG, Rotskoff KS, Johnston LE Jr. A comparison of surgery and orthodontics in “borderline” adults with Class II, division 1 malocclusions. Am J Orthod Dentofacial Orthop 1993;104:455-70.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1]


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