Non-Cochrane · intervention · PM42222473
Herbst and Twin Block appliances in Class II malocclusion management for children: a systematic review and meta-analysis.
Coronel-Zubiate Franz Tito, Meza-Málaga Joan Manuel, Luján-Valencia Sara Antonieta, et al. · Frontiers in dental medicine · 2026 · PubMed · doi:10.3389/fdmed.2026.1717387
Findings
Population Growing patients (<=16 years) with Class II malocclusion
33 findings
| Herbst appliance | Twin Block appliance | si-B (supramentale inferius to point B) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.36 [-0.80, 1.53] Very low Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-prn Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.00 [-0.51, 0.52] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-pog Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) · Sensitivity analysis: fixed-effects model | SMD -0.54 [-1.07, -0.02] GRADE not reported 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Upper lip thickness Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.27 [-1.20, 0.66] Very low Downgraded: imprecision, inconsistency 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | E-line to labrale inferius (E-li) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.29 [-0.42, 0.99] Low Downgraded: imprecision, inconsistency 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Soft tissue convexity (na-prn-pog) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) · Sensitivity analysis: fixed-effects model | SMD -0.44 [-0.84, -0.03] GRADE not reported 3 studies · 99 participants |
| Herbst appliance | Twin Block appliance | VRL-si Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.48 [-1.16, 0.20] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Maxillary base (point A/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.01 [-0.23, 0.25] Moderate Downgraded: imprecision 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | VRL-ss Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.23 [-0.74, 0.28] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Mandibular base (pg/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.02 [-0.26, 0.22] Moderate Downgraded: imprecision 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | Skeletal discrepancy (A point to OLp, Pg to OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.04 [-0.20, 0.28] Moderate Downgraded: imprecision 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | Pog-pog (soft tissue to hard tissue pogonion) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.34 [-0.86, 0.17] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Composite mandibular length (pg/OLp + co/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.07 [-0.47, 0.33] Low Downgraded: imprecision, inconsistency 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | Condylar head position (co/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.01 [-0.54, 0.51] Very low Downgraded: imprecision, inconsistency 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | VRL-si Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) · Sensitivity analysis: fixed-effects model | SMD -0.52 [-1.04, 0.00] GRADE not reported 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-pog Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.50 [-1.19, 0.19] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | E-line to labrale superius (E-ls) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.34 [-0.17, 0.86] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-li Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.30 [-0.82, 0.22] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Soft tissue convexity (na-prn-pog) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.41 [-0.91, 0.09] Moderate Downgraded: imprecision 3 studies · 99 participants |
| Herbst appliance | Twin Block appliance | Lip strain (lip tension) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.18 [-0.33, 0.69] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Convexity without nose (na-sn-pog) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.53 [-1.20, 0.13] Low Downgraded: imprecision, inconsistency 3 studies · 99 participants |
| Herbst appliance | Twin Block appliance | Nasolabial angle (c-sn-ls) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.01 [-0.38, 0.41] Moderate Downgraded: imprecision 3 studies · 99 participants |
| Herbst appliance | Twin Block appliance | Interlabial gap Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.12 [-1.37, 1.60] Very low Downgraded: imprecision, inconsistency 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-sn Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.10 [-0.61, 0.41] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Basic upper lip thickness Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.11 [-0.41, 0.62] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Lower lip length (lls-me) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.13 [-0.64, 0.38] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Mentolabial angle (li-sl-pog) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.56 [0.15, 0.96] Moderate Downgraded: imprecision, indirectness 3 studies · 99 participants |
| Herbst appliance | Twin Block appliance | Molar relationship (ms/OLp-mi/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.19 [-0.55, 0.18] Low Downgraded: imprecision, inconsistency 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | Molar relationship (is/OLp-li/OLp) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.31 [-0.56, -0.05] Moderate Downgraded: imprecision, indirectness 2 studies · 263 participants |
| Herbst appliance | Twin Block appliance | Lower lip thickness Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.05 [-0.56, 0.46] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | VRL-ls Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD -0.23 [-0.74, 0.28] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | Upper lip length (sn-uls) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.21 [-0.44, 0.86] Moderate Downgraded: imprecision 2 studies · 59 participants |
| Herbst appliance | Twin Block appliance | H angle (Holdaway) Post-treatment (final values, T1) · Orthodontic clinics (Turkey, Brazil, UK) | SMD 0.15 [-0.25, 0.55] Moderate Downgraded: imprecision 3 studies · 99 participants |
Included primary studies 14
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Baysal 2013 Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy DOI:10.1093/ejo/cjq187 | 2011 | this review only | not stated | not extracted yet |
| Baysal 2013 Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. PMID:21357655 | 2013 | this review only | not stated | not extracted yet |
| Baysal 2014 Dentoskeletal effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy DOI:10.1093/ejo/cjt013 | 2013 | this review only | not stated | not extracted yet |
| Baysal 2014 Dentoskeletal effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. PMID:24663007 | 2014 | this review only | not stated | not extracted yet |
| Brandao 2024 Facial soft tissue changes in adolescent patients treated with three different functional appliances: a randomized clinical trial DOI:10.1590/2177-6709.29.5.e242440.oar | 2024 | this review only | not stated | not extracted yet |
| Brandao 2024 Facial soft tissue changes in adolescent patients treated with three different functional appliances: a randomized clinical trial. PMID:39383371 | 2024 | this review only | not stated | not extracted yet |
| Guler 2020 Comparison of facial soft tissue changes after treatment with 3 different functional appliances DOI:10.1016/j.ajodo.2019.06.020 | 2020 | this review only | not stated | not extracted yet |
| Guler 2020 Comparison of facial soft tissue changes after treatment with 3 different functional appliances. PMID:32988567 | 2020 | this review only | not stated | not extracted yet |
| O'Brien 2003 Effectiveness of treatment for Class II malocclusion with the Herbst or twin-block appliances: a randomized, controlled trial. PMID:12923506 | 2003 | this review only | not stated | not extracted yet |
| OBrien 2003 Effectiveness of treatment for class II malocclusion with the herbst or twin-block appliances: a randomized, controlled trial DOI:10.1016/s0889-5406(03)00345-7 | 2003 | this review only | not stated | not extracted yet |
| Pacha 2023 The use of the Hanks Herbst vs Twin-block in Class II malocclusion: A randomized controlled trial DOI:10.1016/j.ajodo.2023.06.002 | 2023 | this review only | not stated | not extracted yet |
| Pacha 2023 The use of the Hanks Herbst vs Twin-block in Class II malocclusion: A randomized controlled trial. PMID:37409988 | 2023 | this review only | not stated | not extracted yet |
| Pacha 2024 The skeletal and dental effects of Hanks Herbst versus twin block appliances for class II correction in growing patients: a randomized… DOI:10.1093/ejo/cjad065 | 2023 | this review only | not stated | not extracted yet |
| Pacha 2024 The skeletal and dental effects of Hanks Herbst versus twin block appliances for class II correction in growing patients: a randomized… PMID:37930325 | 2024 | this review only | not stated | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Growing patients (16 years or younger) with Class II malocclusion treated with functional appliances | Growing patients with Class II malocclusion, mean age about 11.8 to 13.1 years (n=548 in 7 RCTs; n=99 to 263 per meta-analysis) |
| Intervention | Herbst appliance | Herbst appliance (including Hanks Herbst, dental and skeletal anchorage) |
| Comparison | Twin Block appliance | Twin Block appliance |
| Outcomes | Skeletal (SNA, SNB, ANB, Co-Gn, base positions), dental (molar relationship, overjet, overbite) and soft tissue profile changes; primary: molar relationship and mandibular advancement | 30 skeletal, dental and soft tissue cephalometric outcomes pooled as SMDs |
| Study designs | RCTs | RCTs (7 included; 5 in meta-analysis) |
| Timing | Baseline and post-treatment | End of treatment, 3 to 16.2 months |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | Yes | No | no |
| 4Comprehensive literature searchcritical | Partial Yes | Partial Yes | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | Yes | Yes | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: N/A | NRSI: N/A · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: Yes · NRSI: N/A | NRSI: N/A · RCT: Yes | no |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Low | Low | yes |