{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,27]],"date-time":"2026-05-27T14:56:01Z","timestamp":1779893761516,"version":"3.53.1"},"reference-count":50,"publisher":"MDPI AG","issue":"23","license":[{"start":{"date-parts":[[2022,11,26]],"date-time":"2022-11-26T00:00:00Z","timestamp":1669420800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Our study aimed to systematically summarize the dentoskeletal effects of Herbst appliance; Forsus fatigue resistance device; and Class II elastics in adolescent Class II malocclusion. Methods: Five databases; unpublished literature; and reference lists were last searched in August 2022. Randomized clinical trials and observational studies of at least 10 Class II growing patients that assessed dentoskeletal effects through cephalometric\/CBCT superimpositions were eligible. The included studies quality was assessed with the RoB 2 and ROBINS-I tools. A random-effects model meta-analysis was performed. Heterogeneity was explored with subgroup and sensitivity analyses. Results: Among nine studies (298 patients); two-to-three studies were included in each meta-analysis. Less post-treatment upper incisor retroclination (&lt;2) and no overbite; overjet; SNA; SNB; and lower incisor inclination differences were found between Herbst\/Forsus and Class II elastics. No differences in maxilla; condyle; glenoid fossa; and most mandibular changes were found between Herbst and Class II elastics; except for a greater 1.5 mm increase in mandibular length and right mandibular ramus height (1.6 mm) with Herbst. Conclusions: Herbst and Class II elastics corrected the molar relationship; but Herbst moved the lower molars more mesially. Apart from an additional mandibular length increase; no other dental and anteroposterior skeletal difference was found. Forsus was more effective in molar correction; overjet reduction; and upper incisor control than Class II elastics. Trial registration number OSF: 10.17605\/OSF.IO\/8TK3R.<\/jats:p>","DOI":"10.3390\/jcm11236995","type":"journal-article","created":{"date-parts":[[2022,11,28]],"date-time":"2022-11-28T06:04:36Z","timestamp":1669615476000},"page":"6995","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":20,"title":["Dental and Skeletal Effects of Herbst Appliance, Forsus Fatigue Resistance Device, and Class II Elastics\u2014A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7936-3706","authenticated-orcid":false,"given":"Stefanos","family":"Matthaios","sequence":"first","affiliation":[{"name":"Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, OH 44106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3019-5438","authenticated-orcid":false,"given":"Apostolos I.","family":"Tsolakis","sequence":"additional","affiliation":[{"name":"Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, OH 44106, USA"},{"name":"Department of Orthodontics, School of Dentistry, National and Kapodistrian University of Athens, 11527 Athens, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5100-8799","authenticated-orcid":false,"given":"Anna-Bettina","family":"Haidich","sequence":"additional","affiliation":[{"name":"Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ioannis","family":"Galanis","sequence":"additional","affiliation":[{"name":"2nd Propaedeutic Department of Surgery, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5435-4889","authenticated-orcid":false,"given":"Ioannis A.","family":"Tsolakis","sequence":"additional","affiliation":[{"name":"Department of Orthodontics, School of Dental Medicine, Case Western Reserve University, Cleveland, OH 44106, USA"},{"name":"Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,11,26]]},"reference":[{"key":"ref_1","first-page":"409","article-title":"A Philadelphia Fable: How Ideal Occlusion Became the Philosopher\u2019s Stone of Orthodontics","volume":"27","author":"Ackerman","year":"2007","journal-title":"Int. J. Periodontics Restor. Dent."},{"key":"ref_2","unstructured":"Graber, L., Vanarsdall, R., Vig, K., and Huang, G. (2017). Orthodontics Current Principles and Techniques, Elsevier. [6th ed.]."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1590\/2177-6709.23.6.40.e1-10.onl","article-title":"Global Distribution of Malocclusion Traits: A Systematic Review","volume":"23","author":"Alhammadi","year":"2018","journal-title":"Dent. Press J. Orthod."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"83","DOI":"10.3109\/00016357409002537","article-title":"Prevalence of Dental and Occlusal Anomalies in Swedish Conscripts","volume":"32","author":"Ingervall","year":"1974","journal-title":"Acta Odontol. Scand."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"706","DOI":"10.1177\/002203459607502S10","article-title":"Prevalence and Distribution of Selected Occlusal Characteristics in the US Population, 1988\u20131991","volume":"75","author":"Brunelle","year":"1996","journal-title":"J. Dent. Res."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1093\/ejo\/cjv009","article-title":"Stability of Class II Fixed Functional Appliance Therapy--a Systematic Review and Meta-Analysis","volume":"38","author":"Bock","year":"2016","journal-title":"Eur. J. Orthod."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1007\/s00056-003-0236-4","article-title":"Interdisciplinary Study of Orthopedic and Orthodontic Findings in Pre-School Infants","volume":"64","author":"Lippold","year":"2003","journal-title":"J. Orofac. Orthop."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/S0889-5406(97)70267-1","article-title":"The Functional Matrix Hypothesis Revisited. 1. The Role of Mechanotransduction","volume":"112","author":"Moss","year":"1997","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1016\/S0889-5406(97)70249-X","article-title":"The Functional Matrix Hypothesis Revisited. 2. The Role of an Osseous Connected Cellular Network","volume":"112","author":"Moss","year":"1997","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Tsolakis, I.A., Verikokos, C., Perrea, D., Alexiou, K., Gizani, S., and Tsolakis, A.I. (2022). Effect of Diet Consistency on Rat Mandibular Growth: A Geometric Morphometric and Linear Cephalometric Study. Biology, 11.","DOI":"10.3390\/biology11060901"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Karamani, I.I., Tsolakis, I.A., Makrygiannakis, M.A., Georgaki, M., and Tsolakis, A.I. (2022). Impact of Diet Consistency on the Mandibular Morphology: A Systematic Review of Studies on Rat Models. Int. J. Environ. Res. Public Health, 19.","DOI":"10.3390\/ijerph19052706"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1603","DOI":"10.12681\/jhvms.21782","article-title":"Effects of Diet Consistency on Mandibular Growth. A Review","volume":"70","author":"Tsolakis","year":"2019","journal-title":"J. Hell. Vet. Med. Soc."},{"key":"ref_13","unstructured":"Proffit, W.R., Fields, H.W., and Sarver, D.M. (2019). Contemporary Orthodontics, Elsevier. [6th ed.]."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1093\/ejo\/12.2.209","article-title":"The Skeletofacial Growth Pattern Pre-and Post-Dentofacial Orthopaedics. A Long-Term Study of Class II Malocclusions Treated with the Herbst Appliance","volume":"12","author":"Pancherz","year":"1990","journal-title":"Eur. J. Orthod."},{"key":"ref_15","unstructured":"Papadopoulos, M.A. (2006). Orthodontic Treatment of the Class II Noncompliant Patient, Mosby Ltd."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1016\/0002-9416(79)90227-6","article-title":"Treatment of Class II Malocclusions by Jumping the Bite with the Herbst Appliance. A Cephalometric Investigation","volume":"76","author":"Pancherz","year":"1979","journal-title":"Am. J. Orthod."},{"key":"ref_17","unstructured":"Herbst, E. (1910). Atlas und Grundriss der Zahn\u00e4rztliche Orthop\u00e4die, J. F. Lehmann."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/0002-9416(82)90489-4","article-title":"The Mechanism of Class II Correction in Herbst Appliance Treatment. A Cephalometric Investigation","volume":"82","author":"Pancherz","year":"1982","journal-title":"Am. J. Orthod."},{"key":"ref_19","first-page":"31","article-title":"Dentoskeletal Effects of the ForsusTM Fatigue Resistance Device in the Treatment of Class II Malocclusion: A Systematic Review and Meta-Analysis","volume":"7","author":"Linjawi","year":"2018","journal-title":"J. Orthod. Sci."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"383","DOI":"10.1016\/j.ajodo.2012.10.015","article-title":"Correction of Class II Malocclusion with Class II Elastics: A Systematic Review","volume":"143","author":"Janson","year":"2013","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_21","first-page":"344","article-title":"Dentoskeletal and Soft-Tissue Changes in Growing Class II Malocclusion Patients during Nonextraction Orthodontic Treatment","volume":"61","author":"Combrink","year":"2006","journal-title":"SADJ J. S. Afr. Dent. Assoc."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/S0889-5406(99)70311-2","article-title":"Overjet Reduction and Molar Correction in Fixed Appliance Treatment of Class II, Division 1, Malocclusions: Sagittal and Vertical Components","volume":"115","author":"Nelson","year":"1999","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1016\/0003-9969(72)90039-8","article-title":"Dentofacial Remodelling Produced by Intermaxillary Forces in Macaca Mulatta","volume":"17","author":"Adams","year":"1972","journal-title":"Arch. Oral Biol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"g7647","DOI":"10.1136\/bmj.g7647","article-title":"Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015: Elaboration and Explanation","volume":"349","author":"Shamseer","year":"2015","journal-title":"BMJ"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"195","DOI":"10.5195\/jmla.2020.834","article-title":"Improving the Translation of Search Strategies Using the Polyglot Search Translator: A Randomized Controlled Trial","volume":"108","author":"Clark","year":"2020","journal-title":"J. Med. Libr. Assoc."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1016\/j.jclinepi.2020.01.008","article-title":"A Full Systematic Review Was Completed in 2 Weeks Using Automation Tools: A Case Study","volume":"121","author":"Clark","year":"2020","journal-title":"J. Clin. Epidemiol."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Mcgowan, J., Sampson, M., Salzwedel, D.M., Cogo, E., Foerster, V., and Lefebvre, C. (2016). CADTH Methods and Guidelines PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Explanation and Elaboration (PRESS E&E), CADTH.","DOI":"10.1016\/j.jclinepi.2016.01.021"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"l4898","DOI":"10.1136\/bmj.l4898","article-title":"RoB 2: A Revised Tool for Assessing Risk of Bias in Randomised Trials","volume":"366","author":"Sterne","year":"2019","journal-title":"BMJ"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"i4919","DOI":"10.1136\/bmj.i4919","article-title":"ROBINS-I: A Tool for Assessing Risk of Bias in Non-Randomised Studies of Interventions","volume":"355","author":"Sterne","year":"2016","journal-title":"BMJ"},{"key":"ref_30","unstructured":"(Review Manager (RevMan) [Computer Program], 2020). Review Manager (RevMan) [Computer Program], Version 5.4."},{"key":"ref_31","unstructured":"Higgins, J.P.T., Thomas, J., Chandler, J., Cumpston, M., Li, T., Page, M.J., and Welch, V.A. (2022). Cochrane Handbook for Systematic Reviews of Interventions, Cochrane. Available online: https:\/\/training.cochrane.org\/handbook#how-to-cite."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1016\/j.jclinepi.2010.07.015","article-title":"GRADE Guidelines: 3. Rating the Quality of Evidence","volume":"64","author":"Balshem","year":"2011","journal-title":"J. Clin. Epidemiol."},{"key":"ref_33","first-page":"89","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_34","first-page":"96","article-title":"Evaluation of the Posterior Maxillary Teeth Movements during Class II Correction: 3-Dimensional Superimposition of Casts","volume":"20","author":"Griblasky","year":"2018","journal-title":"Stomatol. Balt. Dent. Maxillofac. J."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1186\/s40510-019-0280-2","article-title":"Evaluating the Treatment Effectiveness and Efficiency of Carriere Distalizer: A Cephalometric and Study Model Comparison of Class II Appliances","volume":"20","author":"Yin","year":"2019","journal-title":"Prog. Orthod."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"\u00c7oban, G., G\u00fcl Amuk, N., Ya\u011fc\u0131, A., Akg\u00fcn, G., and Abbood Abbood, I.H. (2021). Evaluation of External Apical Root Resorption Caused by Fixed Functional Treatment of Class II Malocclusion: Cast Splint Herbst Appliance vs. Forsus Fatigue Resistant Device. J. Orofac. Orthop., 1\u201310.","DOI":"10.1007\/s00056-021-00334-x"},{"key":"ref_37","unstructured":"Ambr\u00edz, G.M., and la Cruz P\u00e9rez, D.J. (2018, January 11\u201313). Changes of angulation of the lower incisor in class ii correction: Comparison forsus vs elastic vs herbst. a retrospective study. Proceedings of the 49th International Congress 2018, Florence, Italy."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1067\/mod.2000.104489","article-title":"Class II Correction in Patients Treated with Class II Elastics and with Fixed Functional Appliances: A Comparative Study","volume":"118","author":"Nelson","year":"2000","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"499","DOI":"10.1016\/j.ajodo.2005.10.027","article-title":"A Long-Term Follow-up Study of Class II Malocclusion Correction after Treatment with Class II Elastics or Fixed Functional Appliances","volume":"132","author":"Nelson","year":"2007","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"813","DOI":"10.2319\/082707-391.1","article-title":"\u201cEffective\u201d TMJ and Chin Position Changes in Class II Treatment: Orthodontics versus Orthopedics","volume":"78","author":"Pancherz","year":"2008","journal-title":"Angle Orthod."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"332","DOI":"10.2319\/030607-115.1","article-title":"Class II Non-Extraction Patients Treated with the Forsus Fatigue Resistant Device versus Intermaxillary Elastics","volume":"78","author":"Jones","year":"2008","journal-title":"Angle Orthod."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1016\/j.ajodo.2019.09.011","article-title":"Three-Dimensional Condylar Changes from Herbst Appliance and Multibracket Treatment: A Comparison with Matched Class II Elastics","volume":"158","author":"Wei","year":"2020","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1016\/j.ajodo.2013.07.014","article-title":"Three-Dimensional Treatment Outcomes in Class II Patients Treated with the Herbst Appliance: A Pilot Study","volume":"144","author":"Lecornu","year":"2013","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1016\/j.ajodo.2017.11.037","article-title":"Three-Dimensional Treatment Outcomes in Class II Patients with Different Vertical Facial Patterns Treated with the Herbst Appliance","volume":"154","author":"Atresh","year":"2018","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Nindra, J., Sidhu, M.S., Kochhar, A.S., Dabas, A., Valletta, R., Rongo, R., and Spagnuolo, G. (2021). Three-Dimensional Evaluation of Condyle-Glenoid Fossa Complex Following Treatment with Herbst Appliance. J. Clin. Med., 10.","DOI":"10.3390\/jcm10204730"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"371","DOI":"10.2319\/070216-518.1","article-title":"Class II Subdivision Treatment with the Forsus Fatigue Resistant Device vs Intermaxillary Elastics","volume":"87","author":"Aras","year":"2017","journal-title":"Angle Orthod."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"604","DOI":"10.1016\/S0889-5406(03)00149-5","article-title":"Condyle-Fossa Modifications and Muscle Interactions during Herbst Treatment, Part 1. New Technological Methods","volume":"123","author":"Voudouris","year":"2003","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/S0889-5406(03)00150-1","article-title":"Condyle-Fossa Modifications and Muscle Interactions during Herbst Treatment, Part 2. Results and Conclusions","volume":"124","author":"Voudouris","year":"2003","journal-title":"Am. J. Orthod. Dentofac. Orthop."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1053\/j.sodo.2010.08.012","article-title":"Clinical Application of 3D Imaging for Assessment of Treatment Outcomes","volume":"17","author":"Cevidanes","year":"2011","journal-title":"Semin. Orthod."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1016\/j.ajodo.2009.01.018","article-title":"Superimposition of 3-Dimensional Cone-Beam Computed Tomography Models of Growing Patients","volume":"136","author":"Cevidanes","year":"2009","journal-title":"Am. J. Orthod. Dentofac. Orthop."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/23\/6995\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T01:27:37Z","timestamp":1760146057000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/23\/6995"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,11,26]]},"references-count":50,"journal-issue":{"issue":"23","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["jcm11236995"],"URL":"https:\/\/doi.org\/10.3390\/jcm11236995","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,11,26]]}}}