Efficiency of Class II Division 1 and Class II

Division 2 Treatment in Relation to Different

Treatment Approaches
Julia yon Bremen and Hans Pancherz

The aim of this study was to assess the efficiency of Class II Division 1 and
Class II Division 2 treatment comparing different treatment approaches
(conventional and Herbst). Treatment efficiency was defined as a better
result in a shorter treatment time. One hundred forty-two patients aged 10
to 15 years treated in the late mixed and permanent dentition were exam-
ined. The conventional treatment approach used at the University of Gies-
sen (removable and multibracket appliance) was used in 98 subjects (75
Class II Division 1 and 23 Class II Division 2). The Herbst approach (Herbst
appliance followed by a multibracket appliance) was used in 44 subjects (30
Class II Division 1 and 14 Class II Division 2). Pre- and posttreatment dental
casts were evaluated using the PAR Index. Active treatment duration was
recorded. Subjects treated with the Herbst approach had a shorter treat-
ment duration (Class II Division 1 = 21.0 months, Class 11:2 = 30.4 months)
than those treated with the Conventional approach (Class II Division 1 = 32.1
months, Class 11:2 = 38.3 months). The PAR Score reduction (= improve-
ment) was larger in subjects treated with the Herbst approach (Class II
Division 1 = 76%, Class 11:2 = 76%) than in subjects treated with the
Conventional approach (Class II Division 1 = 68%, Class II Division 2 = 65%).
It was concluded that both treatment of Class II Division 1 and Class II
Division 2 malocclusions was more efficient using the Herbst approach than
using the conventional approach. (Semin Orthod 2003;9:87-92.) Copyright
20032003, Elsevier Science (USA). All rights reserved.

ecause of constraints in the public health
B care system, the assessment of t r e a t m e n t
success is of increasing importance. In various
studies assessing orthodontic t r e a t m e n t out-
come, the influence of patient-related factors
(age, sex, cooperation), l ~6 the qualification of
the operator, l,:<~,v',~7 and the m e t h o d of ther-
apy3,7,S,ll,~U,15 m have been examined.
Many indices have b e e n developed to assess
orthodontic t r e a t m e n t outcome. ~,2° 2~ O f these,
From the Department of Orthodontics, (k*ivet:~ily q[ Giessen,
Giessen, Germany
Addre,~ co~responde~tce to Hans Par~che~z, I)DS; OdontDr; De-
partment of Orthodonti(~, University of (;iesse~, Schlangenzahl 14,
1)-35392 Giessen, German)~.
Copyright 2003, Elsevier Science (USA). All rights reserved.
1073-8746/03/0901-0001 $35.00/0
doi: 10.1053/sodo. 2003. 34028
the Peer Assessment Rating (PAR Index)2.~,,~ has
b e c o m e increasingly popular. It is an objective
method, and its reliability and validity have been
certified in m a n y studies.~.l:<17.9>:~4
At the o r t h o d o d o n t i c d e p a r t m e n t in Giessen,
the 2 most c o m m o n t r e a t m e n t a p p r o a c h e s for
Class II malocclusions are the conventional ap-
proach and the Herbst approach.
Conventional Approach
In Class II Division 1 subjects treated during
pubertal growth and in the late mixed dentition,
usually an activator is used for m a n d i b u l a r ad-
vancement, often p r e c e d e d by a removable plate
for expansion of the u p p e r jaw. Once the patient
is in the p e r m a n e n t dentition, m u h i b r a c k e t ap-
pliances in both jaws, often c o m b i n e d with Class
ii elastics, are used for final adjustments.

,Seminars in O~¢hodontics, l))l R No 1 (March), 2003: pp 87-92 87

88 yon Bremen and Pancherz
In Class II Division 2 subjects treated during
pubertal growth and in the late m i x e d dentition
the u p p e r incisors are first proclined using a
removable plate in the u p p e r jaw, thus convert-
ing the Class II Division 2 into a Class II Division
1. Thereafter, m a n d i b u l a r a d v a n c e m e n t is per-
f o r m e d by the use of an activator. Once the
patient is in the p e r m a n e n t dentition, multi-
bracket appliances in b o t h jaws, often c o m b i n e d
with Class II elastics, are used for final adjust-
ments.
Herbst Approach
In Class II Division 1 subjects treated after
pubertal growth and in the p e r m a n e n t denti-
tion, the m e t h o d of j u m p i n g the bite with the
H e r b s t appliance is the a p p r o a c h of choice.
O n c e the Class II occlusion has b e e n corrected,
the H e r b s t appliance is removed, and a multi-
bracket appliance in the u p p e r and lower jaw is
used for final adjustments.
In Class II Division 2 subjects treated after
pubertal growth and in the p e r m a n e n t denti-
tion, the Herbst appliance is also the c o m m o n
a p p r o a c h to correct the Class II malocclusion.
However, to be able to p e r f o r m m a n d i b u l a r ad-
vancement, the u p p e r incisors have to be pro-
clined first with a maxillary multibracket appli-
ance. O n c e the Class II occlusion has b e e n
corrected, the H e r b s t appliance is removed, and
a multibracket appliance in the u p p e r and lower
.jaw is used for final adjusunents.
T h e p u r p o s e of this study was to assess the
efficiency of Class II Division 1 and Class II
Division 2 t r e a t m e n t c o m p a r i n g the H e r b s t and
conventional approaches. T r e a t m e n t efficiency
was defined as a shorter t r e a t m e n t duration with
a better outcome. T h e t r e a t m e n t o u t c o m e was
assessed using the PAR I n d e x 2 5,2~
Subjects
All patients with a Class II Division 1 or Class II
Division 2 malocclusion aged 10 to 15 years
whose t r e a t m e n t was c o m p l e t e d between 1990
and 1997 at the orthodontic d e p a r t m e n t of the
University of Giessen were screened. Only those
subjects (n = 142) fulfilling the following re-
q u i r e m e n t s as d e t e r m i n e d f r o m p r e t r e a t m e n t
dental casts were selected for this study:
1. T r e a t m e n t in the late mixed or p e r m a n e n t
dentition.
2. Unilateral or bilateral distal m o l a r relation-
ship >1/~ cusp width when the deciduous
lower second molars still were present.
3. Unilateral or bilateral distal molar relation-
ship ->l/e cusp width when the second premo-
lars had erupted.
With respect to the t r e a t m e n t m e t h o d the
patients were divided into 2 groups: (1) Herbst
a p p r o a c h (n = 44) and (2) conventional ap-
proach (n - 98).
Within each of these groups the patients were
subdivided according to their malocclusion:
Herbst approach: Class II Division 1 (n = 30)
and Class II Division 2 (n = 14) and conven-
tional approach: Class II Division 1 (n = 75) and
Class II Division 2 (n = 23).
Methods
T h e duration of active t r e a t m e n t (before reten-
tion) was recorded. Pre- and p o s t t r e a t m e n t den-
tal casts were evaluated by using the PAR Index.
Posttreatment means after retention and full
eruption of all p e r m a n e n t teeth, with or without
third molars, were calculated.
In the PAR Index, 95,~6 the deviation f r o m a
normal occlusion and alignment is assessed by
using 5 dental c o m p o n e n t s which are weighted
differently. T h e weighted scores of the compo-
nents are s u m m e d to obtain a total score (PAR
Index), expressing the severity of the malocclu-
sion. T h e 5 c o m p o n e n t s are anterior alignment
(weighted × 1), buccal occlusion (weighted ×
1), overjet (weighted × 6), overbite (weighted ×
2), and midline discrepancy (weighted × 4). A
total score of 0 means a perfect occlusion and
alignment. The higher the score, the greater the
deviation f r o m normal. To assess t r e a t m e n t suc-
cess the p o s t t r e a t m e n t score is c o m p a r e d with
the p r e t r e a t m e n t score and the reduction in
PAR score (improvement) is expressed in per-
cent a n d / o r in points. All registrations are per-
f o r m e d with the PAR ruler, a plastic ruler de-
signed especially for this index. In this study, all
m e a s u r e m e n t s were m a d e twice, and the m e a n
value was used for the final evaluation. All reg-
istrations were p e r f o r m e d by one of the authors
(JB) calibrated for the use of this index.
 (;lass H Diwlsion 1 and 2
Statistical Methods
Because the variables showed an asymmetric
distribution, n o n p a r a m e t r i c Kruskal-Wallis H
tests and Hodges L e h m a n n estimates were ap-
plied for the statistical analysis. T h e significance
levels used were P < .001, P < .01, and P < .05.
P -> .05 was considered nonsignificant. The
results were expressed by box plot diagrams
(Fig 1).
Results
Treatment Duration
Class II Division 1 patients had a shorter treat-
m e n t duration than Class II Division 2 patients
(P < .001) F u r t h e r m o r e , patients treated with
the Herbst a p p r o a c h had a shorter (P < .001)
t r e a t m e n t duration (Class II Division 1, 21.0
months; Class II Division 2, 30.4 months) than
those treated with the conventional a p p r o a c h
(Class II Division 1, 32.1 months; Class II Divi-
sion 2, 38.3 months) (Fig 2).
PAR Index
T h e p r e t r e a t m e n t PAR score in subjects
treated with the Herbst a p p r o a c h (27.0) and
• maximum value ( • )
95 th percentile
T 75 th percentile
mean (e)
50 th percentile
25 th percentile
5 th percentile
• minimum value ( • )
Figure 1. Explanation of the box plot diagram.
89
months
80
60 ¸
40
20 ¸
Herbst Conventional Herbst Conventional
Class I1:1 Class Ih2
Figure 2. Treatment duration (months) in 105 Class
II DMsion 1 and 37 Class II Division 2 patients in
relation to the treatment approach. Herbst approach:
Class II Division 1 (n = 30), Class II Division 2 (11=
14); conventional approach: Class I1 Division 1 (11=
75), Class II Division 2 (n = 23).
snbjects treated with the conventional a p p r o a c h
(26.7) was nearly the same. After treatment, sub-
jects treated with the Herbst a p p r o a c h had a
lower (P < .01) PAR score (5.7) than those
treated with the conventional a p p r o a c h (8.2)
(Fig 3).
PAR Score Reduction in Points
Class II Division 1 patients had a higher PAR
score reduction (P < .001) in points than Class
II Division 2 patients. F u r t h e r m o r e , subjects
treated with the Herbst a p p r o a c h had a higher
PAR Score reduction (P < .01) in points (Class
II Division 1, 24.6; Class II Division 2, 13.7) than
subjects treated with the conventional a p p r o a c h
(Class II Division 1, 20.2; Class II Division 2,
13.5) (Fig 4).
PAR Score Reduction in Percent
Class II DMsion 1 patients had about the
same PAR score reduction as Class II Division 2
patients. Subjects treated with the Herbst ap-
proach had a higher PAR score reduction (P <
.001) in percentage (Class II Division 1, 75.9;
Class II Division 2, 76.4) than subjects treated
with the conventional a p p r o a c h (Class II Divi-
sion 1, 68.1; Class II Division 2, 65.3) (Fig 5).
90 yon Bremen and Panchevz

PAR Score %

120 -
60
100 £
50
80-
40
60-
30-
4o~
20.
20-
10- ol
¢
0 -20 ~
, , , ]'
before after before after
Herbst Conventional Herbst Conventional
Herbst Conventional
Class Iht Class 11:2
Figure 3. PAR score before and after treatment in
105 Class II Division 1 and 37 Class II Division 2 Figure 5. PAR Score reduction (%) in 105 Class II
patients in relation to the treatment approach. Herbst Division 1 and 37 Class II Division 2 patients in rela-
approach: Class II Division I (n = 30), Class II Divi- tion to the treatment approach. Herbst approach:
sion 2 (n = 14); conventional approach: Class II Class II Division 1 (n = 30), Class II Division 2 (n =
Division 1 (n = 75), Class II Division 2 (n = 23). 14); conventional approach: Class II Division 1 (n =
75), Class II Division 2 (n = 23).

Discussion t h e s a m e t e a m o f i n s t r u c t o r s , thus e n s u r i n g uni-

I n i n t e r p r e t i n g t h e p r e s e n t findings, it m u s t b e f o r m i t y in t h e r a p e u t i c a l a p p r o a c h e s .
k e p t in m i n d t h a t all p a t i e n t s w e r e t r e a t e d by
orthodontic postgraduate students. However, Treatment Duration
t h e t r e a t m e n t o f t h e p a t i e n t s was s u p e r v i s e d by T h e d u r a t i o n o f active t r e a t m e n t f o r all 142
p a t i e n t s r a n g e d b e t w e e n 8 a n d 71 m o n t h s , with
points a m e d i a n o f 30.6 m o n t h s . U s i n g exclusively f i x e d
a p p l i a n c e s , a s i m i l a r t r e a t m e n t d u r a t i o n (4-91
50- m o n t h s ) was r e p o r t e d by Vig et al TM with a m e a n
o f 31 m o n t h s . A s h o r t e r m e a n d u r a t i o n was de-
40- s c r i b e d by A l g e r Is with 22 m o n t h s a n d F i n k a n d
S m i t h y with 23 m o n t h s . T h e p r e s e n t study, how-
30- ever, s h o w e d t h a t t r e a t m e n t t i m e was s h o r t e r
w h e n u s i n g t h e H e r b s t a p p r o a c h (Class II Divi-
20- sion 1, 21 m o n t h s ; Class II Division 2, 30

10-
q m o n t h s ) t h a n w h e n u s i n g t h e c o n v e n t i o n a l ap-
p r o a c h (Class II Division 1, 32 m o n t h s ; Class II,
Division 2, 38 m o n t h s . ) In b o t h t r e a t m e n t ap-
0- p r o a c h g r o u p s , Class II Division 2 p a t i e n t s g e n -
I I 1 1 erally h a d a l o n g e r t r e a t m e n t d u r a t i o n t h a n
Herbst Conventional Herbst Conventional
Class II Division 1 p a t i e n t s , p r o b a b l y b e c a u s e a
Class II Division 2 h a d to b e c o n v e r t e d into a
Class Ihl Class Ih2 Class II Division 1, b e f o r e m a n d i b u l a r a d v a n c e -
Figure 4. PAR score reduction (points) in 105 Class II ment could be performed.
Division 1 and 37 Class II Division 2 patients in rela-
tion to the treatment approach. Herbst approach: PAR Index
Class II Division 1 (n = 30), Class lI Division 2 (n =
14); conventional approach: Class II Division 1 (n = T h e a v e r a g e ( m e d i a n ) p r e t r e a t m e n t PAR
75), Class II Division 2 (n - 23). s c o r e o f all 142 p a t i e n t s was 26.8 points. S i m i l a r
 Class II DivMon 1 and 2
scores (27-31 points) were f o u n d by Turbill et
al -~2,34 w h e n assessing the o r t h o d o n t i c s t a n d a r d
o f the G e n e r a l Dental Services in E n g l a n d a n d
O ' B r i e n et al v' a n d H a m d a n a n d Rock :~' w h e n
e x a m i n i n g patients treated in dental schools.
Lower scores (16-25 points) were f o u n d by Pan-
grazio-Kulbersh et al p-~a n d Firestone et al. s Pan-
grazio-Kulbersh et al 1:~ e x a m i n e d 103 consecu-
tively treated cases (average p r e t r e a t m e n t age,
9.8 years), a n d Firestone et al s patients treated at
a dental school. T h e majority were treated with
fixed appliances. T h e low p r e t r e a t m e n t PAR
Score o f Pangrazio-Kulbersh et al ~ m i g h t be
explained by the y o u n g patient material a n d the
fact that d e c i d u o u s teeth are n o t evaluated in
the PAR Index.
After treatment, the average ( m e d i a n ) PAR
score o f all 142 patients was 7.3 points. This
score is in a c c o r d a n c e with that (5-12 points) o f
o t h e r studies. ~,2~'.2~;,-~2,:~4 R i c h m o n d et al 2:~,~ re-
m a r k e d that a final PAR score below 10 is an
acceptable result a n d scores u n d e r 5 are close to
a perfect occlusion a n d alignment. T h a t m e a n s
that, o n average, an acceptable result was
r e a c h e d in the p r e s e n t patient material.
F u r t h e r m o r e , R i c h m o n d et al ~',2~i p o i n t e d o u t
that a high t r e a t m e n t s t a n d a r d is characterized
by a PAR score r e d u c t i o n o f at least 70%. A high
PAR score r e d u c t i o n is, o f course, r e a c h e d easier
in subjects with a high p r e t r e a t m e n t PAR I n d e x
than in subjects with a low p r e t r e a t m e n t index.
This means, the worse the p r e t r e a t m e n t maloc-
clusion, the greater the possible i m p r o v e m e n t
t h r o u g h treatment. This is in a g r e e m e n t with
Taylor et al, 1~' w h o also f o u n d that a high pre-
t r e a t m e n t PAR Score h a d a positive effect w h e n
assessing the quality o f o r t h o d o n t i c therapy.
Similar results were f o u n d by Kerr et al I~ a n d AI
Yami et al. 2
PAR Score Reduction in Relation to the
Treatment Approach
Patients treated with the H e r b s t a p p r o a c h
had a g r e a t e r PAR score r e d u c t i o n in points a n d
in p e r c e n t than patients treated with the conven-
tional a p p r o a c h . O t h e r a u t h o r s ~',~'.~7 also re-
p o r t e d a b o u t a correlation b e t w e e n t r e a t m e n t
m e t h o d a n d o u t c o m e . T h e y f o u n d that fixed
appliances in b o t h arches h a d the greatest effect
in i m p r o v i n g a malocclusion. However, n e i t h e r
Pangrazio-Kulbersh et al 1:~ n o r A h l g r e n ~ f o u n d
91
any association between the appliances used a n d
the t r e a t m e n t success.
In the p r e s e n t study Class II Division 1 sub-
jects achieved a greater PAR score r e d u c t i o n in
points than Class II Division 2 subjects. This can
be explained by a h i g h e r p r e t r e a t m e n t PAR
score in Class II Division 1 subjects because o f
the great overjet (weighted × 6). However, the
PAR score r e d u c t i o n in % was a b o u t the same in
Class II Division 1 a n d Class Ii Division 2 sub-
jects. T h a t means, that in relation to the severity
o f the p r e t r e a t m e n t malocclusion, the a m o u n t
o f i m p r o v e m e n t was a b o u t the same in b o t h
malocclusion groups.
Conclusion
Both with respect to t r e a t m e n t d u r a t i o n a n d to
t r e a t m e n t o u t c o m e , Class II Division 1 a n d Class
II Division 2 t r e a t m e n t was m o r e efficient with
the H e r b s t a p p r o a c h than with the conventional
approach.
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