MODERN FIXED MECHANICALLY ACTING APPLIANCES FOR CORRECTION OF DISTAL BITE: COMPARATIVE ANALYSIS OF EFFECTIVENESS
DOI:
https://doi.org/10.35220/2523-420X/2025.3.28Keywords:
Class II malocclusion, fixed functional appliances, Herbst, Forsus FRD, Flex Developer, TMJAbstract
Objective: To analyze the effectiveness of fixed functional appliances (Herbst, Forsus FRD, Flex Developer) in correcting Class II malocclusion in adolescents, focusing on skeletal, dentoalveolar, and vertical changes, as well as temporomandibular joint (TMJ) effects, based on literature data, to develop clinical recommendations for appliance selection depending on patient characteristics.Materials and Methods: A systematic literature review was conducted for 2000–2025 using PubMed, Scopus, Web of Science, and Google Scholar. Keywords included: “Class II malocclusion,” “fixed functional appliances,” “Herbst appliance,” “Forsus FRD,” “Flex Developer,” “TMJ.” Randomized controlled trials, meta-analyses, and clinical case studies evaluating skeletal, dentoalveolar changes, and TMJ effects were included. Cephalometric parameters (ANB, overjet, Co-Gn), CBCT/MRI data, and statistical metrics (t-test, ANOVA, p<0.05) were analyzed.Results: Herbst provides the greatest skeletal effect (+2.9 mm mandibular lengthening, ANB reduction by 4–5°), Forsus FRD excels in dentoalveolar correction (lower incisor proclination +7.5°), and Flex Developer offers a balanced effect (+2.4 mm). TMJ adaptive changes (condylar displacement 2–3 mm, glenoid fossa remodeling 0.3–1.0 mm) are physiological in 95% of cases.Conclusions: Appliance choice depends on skeletal age, malocclusion type, and aesthetic demands. Herbst is optimal for severe skeletal discrepancies, Forsus FRD for dentoalveolar correction, and Flex Developer for balanced therapy. TMJ diagnostics are essential before treatment.
References
Zymperdikas, V.F., Koretsi, V., Papageorgiou, S.N., & Papadopoulos, M.A. (2016). Treatment effects of fixed functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis. Eur J Orthod. 38(2), 113-126. doi:10.1093/ejo/cjv034
Papadopoulos, M.A., Melkos, A.B., & Athanasiou, A.E. (2010). Noncompliance maxillary molar distalization with the first class appliance: a randomized controlled trial. Am J Orthod Dentofacial Orthop, 137(5):586.e1-586.e13; discussion 586-7. doi: 10.1016/j. ajodo.2009.10.033.
Guimarães, C.H. Jr., Oltramari-Navarro, P.V., Janson, G., & et al. (2020). Comparison of treatment effects of Class II fixed functional appliances vs intermaxillary elastics: A systematic review and meta-analysis. J Orofac Orthop, 81(6), 393-411. doi: 10.1016/j.ajodo.2019.05.013.
Aslan, B.I., Kucukkaraca, E., Turkoz, C., & Dincer, M. (2014). Treatment effects of the Forsus Fatigue Resistant Device used with miniscrew anchorage. Angle Orthod, 84(1), 76-87. doi: 10.2319/032613-240.1.
Marsico, E., Gatto, E., Burrascano, M., Matarese, G., & Cordasco, G. (2011). Effectiveness of orthodontic treatment with functional appliances on mandibular growth in the short term: A systematic review and meta-analysis. Am J Orthod Dentofacial Orthop, 139(1), 24-36. doi: 10.1016/j.ajodo.2010.04.028
Baysal, A., & Uysal, T. (2014). Dentoskeletal effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. Eur J Orthod, 36(2), 164-72. doi: 10.1093/ejo/cjt013
Nalbantgil, D., Arun, T., Sayinsu, K., & Işik, F. (2005). Skeletal, dental and soft-tissue changes induced by the Jasper Jumper appliance in late adolescence. Angle Orthod, 75(3), 426-436. doi: 10.1043/0003-3219(2005)75[426:SDASCI]2.0.CO;2
Pancherz, H. (1982). The mechanism of Class II correction in Herbst appliance treatment: A cephalometric investigation. Am J Orthod, 82(2), 104-113. doi:10.1016/0 002-9416(82)90489-4
Pancherz, H., Zieber, K., & Hoyer, B. (1997). Cephalometric characteristics of Class II division 1 and Class II division 2 malocclusions: A comparative study in children. Angle Orthod, 67(2), 111-120. doi: 10.1043/0003-3219(1997)067<0111:CCOCID>2.3.CO;2.
Ruf, S., & Pancherz, H. (1999). Temporomandibular joint remodeling in adolescents and young adults during Herbst treatment: A prospective longitudinal magnetic resonance imaging and cephalometric radiographic investigation. Am J Orthod Dentofacial Orthop, 115(6), 607-18. doi: 10.1016/s0889-5406(99)70285-4.
Hägg, U., Rabie, A.B., Bendeus, M., Wong, R.W., Wey, M.C., Du, X., & Peng, J. (2008). Condylar growth and mandibular positioning with stepwise vs maximum advancement. Am J Orthod Dentofacial Orthop, 134(4), 525-36. doi: 10.1016/j.ajodo.2006.09.064
Siara-Olds, N.J., Pangrazio-Kulbersh, V., Berger, J., & Bayirli, B. (2010). Long-term dentoskeletal changes with the Bionator, Herbst, Twin Block, and MARA functional appliances. Angle Orthod, 80(1), 18-29. doi: 10.2319/020109-11.1
Jones, G., Buschang, P.H., Kim, K.B., & Oliver, D.R. (2008). Class II non-extraction patients treated with the Forsus Fatigue Resistant Device versus intermaxillary elastics. Angle Orthod, 78(2), 332-8. doi: 10.2319/030607-115.1.
Baccetti, T., Franchi, L., & McNamara, J.A.Jr. (2005). The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod, 11(3), 119-129. doi:10.1053/j.sodo.2005.04.005
Heinig, N., & Göz, G. (2001). Clinical application and effects of the Forsus spring: A study of a new Herbst hybrid. J Orofac Orthop, 62(6), 436-450. doi: 10.1007/s00056-001-0053-6.
Perinetti, G., Primožič, J., Furlani, G., Franchi, L., & Contardo, L. (2015). Treatment effects of fixed functional appliances on vertical dimensions: A systematic review. Orthod Craniofac Res, 18(2), 75-88. doi: 10.2319/102813-790.1.
Cozza, P., Baccetti, T., Franchi, L., De Toffol, L., & McNamara, J.A. Jr. (2006). Mandibular changes produced by functional appliances in Class II malocclusion: A systematic review. Am J Orthod Dentofacial Orthop, 129(5), 599.e1-599.e12. doi:10.1016/j.ajodo.2005.11.010
Li, H., Ren, X., Hu, Y., & Tan, L. (2020). Effects of the Forsus Fatigue-resistant Device on Skeletal Class II Malocclusion Correction. J Contemp Dent Pract, 21(1), 105-112.
Gunay, E.A., Arun, T., & Nalbantgil, D. (2011). Evaluation of the Immediate Dentofacial Changes in Late Adolescent Patients Treated with the Forsus(™) FRD. Eur J Dent, 5(4), 423-32.
Karacay, S., Akin, E., Olmez, H., Gurton, A.U., & Sagdic, D. (2006). Forsus Nitinol Flat Spring and Jasper Jumper corrections of Class II division 1 malocclusions. Angle Orthod, 76(4), 666-72. doi: 10.1043/0003-3219(2006)076[0666:FNFSAJ]2.0.CO;2.
Aidar, L.A., Dominguez, G.C., Abrahão, M., Yamashita, H.K., & Vigorito, J.W. (2009). Effects of Herbst appliance treatment on temporomandibular joint disc position and morphology: a prospective magnetic resonance imaging study. Am J Orthod Dentofacial Orthop, 136(3), 412-24. doi: 10.1016/j.ajodo.2007.12.027.
Elkordy, S.A., Fayed, M.S., Abouelezz, A.M., & Attia, K.H. (2023). Flex Developer appliance: A novel approach for Class II correction. J Clin Orthod, 57(2):89-97.
Wadhawan, N., Kumar, S., Kharbanda, O.P., Duggal, R., & Sharma, R. (2008). Temporomandibular joint adaptations following two-phase therapy: an MRI study. Orthod Craniofac Res, 11(4), 235-50. doi: 10.1111/j.1601-6343.2008.00436.x.
Flores-Mir, C., Ayeh, A., Goswani, A., & Charkhandeh, S. (2007). Skeletal and dental changes in Class II division 1 malocclusions treated with splint-type Herbst appliances. A systematic review. Angle Orthod, 77(2), 376-81. doi: 10.2319/0003-3219(2007)077[0376:SAD- CIC]2.0.CO;2.
Ehsani, S., Nebbe, B., Normando, D., Lagravere, M.O., & Flores-Mir, C. (2015). Short-term treatment effects produced by the Twin-block appliance: a systematic review and meta-analysis. Eur J Orthod, 37(2), 170-6. doi: 10.1093/ejo/cju030.
Bates, W.R., Cevidanes, L.S., Larson, B.E., Adams, D., & De Oliveira, Ruellas, A.C. (2022). Three-dimensional cone-beam computed technology evaluation of skeletal and dental changes in growing patients with Class II malocclusion treated with the cervical pull face-bow headgear appliance. Am J Orthod Dentofacial Orthop, 162(4), 491-501. doi: 10.1016/j.ajodo.2021.05.011
McNamara, J.A. Jr, Howe, R.P., & Dischinger, T.G. A comparison of the Herbst and Fränkel appliances in the treatment of Class II malocclusion. Am J Orthod Dentofacial Orthop, 98(2)134-144. doi:10.1016/0889-5406(90)70 007-Y
O’Brien, K., Wright, J., Conboy, F., & et al. (2003). Effectiveness of early orthodontic treatment with the Twinblock appliance: A multicenter, randomized, controlled trial. Am J Orthod Dentofacial Orthop, 124(3), 234-243. doi: 10.1016/S0889540603003524
DeVincenzo, J.P. Treatment options for sagittal corrections in noncompliant patients. In: Grabber TM, Vanarsdall RL, Vig KWL (eds). Orthodontics: Current Principles and Techniques. 4 th ed. Missouri: Elsevier
Bock, N., & Ruf, S. (2008). Post-treatment occlusal changes in Class II division 2 subjects treated with the Herbst appliance. Eur J Orthod, 30(6), 606-13. doi: 10.1093/ejo/cjn062
Chhibber, A., Upadhyay, M., Uribe, F., & Nanda, R. (2018). Long-term stability of Class II correction with fixed functional appliances: A systematic review. J Orthod, 45(3), 185-194.
Rongo, R., Antoun, J.S., & Farella, M. (2020). Gingival recession in patients treated with fixed functional appliances: A systematic review. Orthod Craniofac Res. 23(2), 139-147.
Arici, S., Akan, H., Yakubov, K., & Arici, N. (2008). Effects of fixed functional appliance treatment on the temporomandibular joint. Am J Orthod Dentofacial Orthop, 133(6), 809-14. doi: 10.1016/j.ajodo.2006.07.035.
Baysal, A., & Uysal, T. (2013). Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. Eur J Orthod, Feb;35(1):71-81. doi: 10.1093/ejo/cjq187.
Chung, C.H., & Font, B. (2004). Skeletal and dental changes in the sagittal, vertical, and transverse dimensions after rapid palatal expansion. Am J Orthod Dentofacial Orthop, 126(5), 569-75. doi: 10.1016/j.ajodo.2003.10.035.
Alhammadi, M.S., Fayed, M.S., & Labib, A. (2017). Three-dimensional assessment of condylar position and joint spaces after maxillary first premolar extraction in skeletal Class II malocclusion. Orthod Craniofac Res, 20(2), 71-78. doi: 10.1111/ocr.12141
Franchi, L., Pavoni, C., Faltin, K. Jr., McNamara, J.A. Jr., & Cozza, P. (2013). Long-term skeletal and dental effects and treatment timing for functional appliances in Class II malocclusion. Angle Orthod, 83(2), 334-40. doi: 10.2319/052912-450.1.
Voudouris, J.C., Woodside, D.G., Altuna, G., Angelopoulos, G., Bourque, P.J., Lacouture, C.Y., & Kuftinec, M.M. (2003). Condyle-fossa modifications and muscle interactions during Herbst treatment, Part 2. Results and conclusions. Am J Orthod Dentofacial Orthop, 124(1), 13-29. doi: 10.1016/s0889-5406(03)00150-1.
Cevidanes, L.H., Franco, A.A., Gerig, G., Proffit, W.R., & Slice, D.E. (2005). Assessment of mandibular growth and response to orthopedic treatment with 3-dimensional magnetic resonance images. Am J Orthod Dentofacial Orthop, Jul;128(1):16-26. doi: 10.1016/j.ajodo.2004.03.032.
Serbesis-Tsarudis, C., & Pancherz, H. (2008). «Effective» TMJ and chin position changes in Class II treatment. Angle Orthod, 78(5), 813-8. doi: 10.2319/082707-391.1.doi:10.1093/ejo/cjn005
