Too Mild for Surgery, Too Skeletal for Elastics

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Too Mild for Surgery, Too Skeletal for Elastics
Straight Talk draws its cases and discussions from the Orthotown message boards. Written by the editorial team with the assistance of AI, each article showcases how orthodontists tackle unusual and challenging scenarios.
A finished Class II deep bite case sparked a familiar debate when the records surfaced in a message board discussion. The patient, an adolescent male at the start of treatment, had been treated with a Herbst appliance. The records were posted as an example of what functional appliance therapy can accomplish in patients who fall into the gray zone—too skeletal for elastics alone, too mild for surgery. Initial extraoral, intraoral, and cephalometric records were paired with final records taken at debond (Figs. 1–4).
Too Mild for Surgery, Too Skeletal for Elastics
Fig. 1
Too Mild for Surgery, Too Skeletal for Elastics
Fig. 2
Too Mild for Surgery, Too Skeletal for Elastics
Fig. 3
Too Mild for Surgery, Too Skeletal for Elastics
Fig. 4

The skeletal discrepancy at the start was estimated at 3 to 4 millimeters. That detail framed the entire conversation. Insurance wouldn’t approve surgery at that magnitude, and most contributors agreed they wouldn’t refer a patient like this for orthognathic consultation in the first place. Surgical candidates, several noted, typically present with discrepancies of 6 millimeters or more. So the real question wasn’t surgery versus appliances. It was which non-surgical mechanics handle this kind of case best.

Herbst advocates made the case for the appliance on two fronts. The first was bite opening. Clinicians who favor the Herbst pointed out that the appliance opens deep bites in a way fixed Class II correctors simply don’t replicate. When the Herbst is designed with crowns on the upper first molars and lower first premolars, the lower posterior segments are free to erupt, which contributes meaningfully to the bite-opening effect. The second argument centered on lower incisor control. By keeping brackets off the lower arch until the Herbst has finished its work, proclination of the lower incisors can be reduced compared to protocols that bond the full lower arch from the start.

The counterpoint came from clinicians who use Forsus springs or similar fixed functional appliances. One contributor argued that a case with a 3 to 4 millimeter discrepancy could be finished with comparable results using a Forsus or analogous spring appliance, and questioned whether the Herbst offered any meaningful advantage. The suspicion was that the final outcome involved a mix of upper incisor retraction, some lower incisor proclination, and possibly a small amount of skeletal growth—effects achievable through multiple Class II correction strategies.

Herbst proponents pushed back on the equivalency claim. Forsus breakage was cited as a practical concern, though others noted that newer Forsus designs have reduced that problem considerably. The more substantive objection was that Forsus requires the case to be essentially finished before placement, which limits flexibility and timing. A Herbst, by contrast, can be deployed early in treatment as the primary skeletal corrector, with finishing mechanics layered on afterward.

A separate clinician offered a middle path for Forsus protocols: Place the springs earlier in treatment than the traditional six-month mark, after a brief sequence of leveling wires and Class II elastics, to identify patients who respond readily to lighter mechanics. Those who don’t respond move to the spring at the next visit. The approach acknowledges that timing matters as much as appliance selection in these in-between cases.

Patient selection drew its own commentary. Several contributors flagged that the Herbst is not universally appropriate. Patients with already-proclined lower incisors or thin mandibular anterior gingiva are poor candidates. Severely retrognathic patients without a defined chin button tend to finish with compromised aesthetics regardless of dental correction, and surgery remains the better option there. Girls were noted as more challenging Herbst candidates because of reduced growth potential and the need to start earlier, often before enough teeth have erupted to support the appliance reliably.

One clinician added that the Herbst remains a useful tool for mild-to-moderate mandibular asymmetry and associated subdivision malocclusions, where reliable non-surgical options are limited.

The case at the center of the discussion drew broad agreement on the result itself. Most contributors called the finish a strong outcome and an appropriate use of functional appliance therapy. The disagreement was narrower: whether the Herbst earned credit for the result, or whether the same patient would have finished comparably with a different Class II corrector.

For a Class II deep bite patient in peak growth with a 3 to 4 millimeter skeletal discrepancy, does the Herbst’s bite-opening capacity and lower incisor control justify its place as the first-choice functional appliance, or do modern fixed spring appliances offer enough equivalence, with less chair time and fewer design considerations, to make the choice clinician preference rather than clinical necessity? 

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June 2026
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