The role of the headgear in growth modification

Nanda,Semin Orthod 2006;12:25-33

Upper

headgear versus lower headgear, yokes, and Cl II elastics M. Osvaldik-Tapl and H.Droschl Angle orthod 1978;48:57-61

HG
the extraoral applaince that applied forces through

the maxillary molars can be absorbed by the

different sutural articulations of the maxilla, temporal,

zygomatic, and sphenoid bones.

Nanda,Semin Orthod 2006;12:25-33

A reduction in SNA angle during use of the HG as a result of

Maxillary restraint Resorption at a-point due to distal movement of the

maxillary anterior teeth

Lengthening of the cranial base

Nanda,Semin Orthod 2006;12:25-33

The palatal plane is a reliable reference plane since its inclination to the cranial base changes very little during growth.
the palatal plane tips down to a more horizontal

position during use of the headgear.

This is due to its clockwise rotation

Nanda,Semin Orthod 2006;12:25-33

Dependent on the direction of pull of force:

High pull (occipital)

Straight pull,
Low pull (cervical)

Center of resistance of maxillary first molar

Nanda,Semin Orthod 2006;12:25-33

The cervical or low-pull HG is the most commonly used of all three types of HG

Referred to as the Kloehn type HG The unwanted side effect, however, of molar extrusion and distal tipping of the crown

Nanda,Semin Orthod 2006;12:25-33

Unwanted side effect can be controlled by alternate adjustment of the outer bow at each subsequent visit

bending the outer bow upward of the occlusal plane an

average of 10 to 20 can minimize distal tipping of the

maxillary molars

Nanda,Semin Orthod 2006;12:25-33

The low-pull facebow headgear is more effective in achieving maxillary restraint and distal molar movement

The high-pull headgear is effective in controlling the

vertical dimension

Nanda,Semin Orthod 2006;12:25-33

Unwanted side effect from the use of the high-pull facebow headgear is
The compensatory eruption of the mandibular molars

Can be controlled through concomitant use of the

fixed lingual arch

Nanda,Semin Orthod 2006;12:25-33

Class II malocclusion may be accompanied by a narrow maxilla

Nanda,Semin Orthod 2006;12:25-33

Orthodontists routinely expand the maxillary arch

To improve arch form To loosen the sutures before engagement of the HG To augment class II correction
Increase arch width and arch length

Reduce overjet

To derotate Molar
Nanda,Semin Orthod 2006;12:25-33

1. It is effective in distal movement of the molars.

2. The observed correction of Class II is not due to distal movement of the molars alone but that of the maxilla as a whole. 3. To achieve effective and long-term results, the

headgear needs to be used consistently and over

a long period of time. A 6-month period can be considered to be the minimum
Nanda,Semin Orthod 2006;12:25-33

4. If used in the early transitional dentition, it is

advisable to use the headgear to retain the achieved result till the rest of the permanent teeth

erupt.
5. Alternatively, treatment can be initiated during the late transitional dentition and during the maximum skeletal growth spurt. The maximum skeletal growth spurt can be verified
Nanda,Semin Orthod 2006;12:25-33

Angle orthod 1978;48:57-61

To compare the 2 methods of distalization

of upper molars : upper headgear versus

HGY-II (lower headgear,yokes and class II

elastics)

Creekmore 1967
Compare headplates of patient with HG

and without HG
ANB reduce -1.85o in treated patient * in conclusion : maxillary HG >> inhibits

growth of upper jaw

Wieslander 1963
Observed 30 children with cervical HG and 30

untreated patient
Inhibition of forward growth of maxilla 1.91 mm. Force of HG >> palatal plane

Blueher 1959
Cervical HG Reduction of SNA 2 degree Increase palatal plane angle 2 degree

King 1957
Class II div 1 treated with cervical HG

Posterior movement of point A

Barton 1972
20 cases tx. with high pull , 20 cases tx. with

cervical pull
Extrusion of molar with cervical pull HG

Droschl and Jarabak 1975

Effect of yoke mechanism Reduction of ANB -1 to -2 degree >> reduction

of SNA

HGY-II
Sectional method Lower HG Yoke Class II elastics

HGY-II

Class II elastics HG

Elastics 250 g per side Worn full time Replace twice a day

HG : stabilize molar 300 g Worn 14-16 hrs a day

40 cases of class II
20 treated with HGY-II (average age 11.2 yr)

wear elastic 24 hr
20 treated with upper HG (average age 10.4 yr)

wear HG 18 hr a day
13 : cervical pull 7 : high pull

Yokes

Upper HG

Yokes

Upper HG

Time saved by HGY-II method ~ 35 percent

Cephalometric results

Both group showed the same decrease in ANB differenced due to 1o reduction of SNA

No change of mandible in sagittal plane

Cephalometric results

Dental changes

Lower molar distance

Center of the occ. Plane of the first molar to

the point of its projection on the Go-Me line

No change in HG group

In HGY-II >> extrusive effect 2 mm. (class II

elastic effect + uprighting effect by HG)

Dental changes

Inclination of upper molar to SN-plane

Dental changes

Incisal tooth position

Lower incisors

Dental changes

Incisal tooth position

Upper incisors

Dental changes

Incisal tooth position

Upper & lower incisal relationship

HGY-II works faster than maxillary headgear

Distal tipping of molars greater in HGY-II
Result from quicker tooth movement Speed of distalization >> from constant force of class II

elastics

Orthopedic change
Reduction of SNA Slightly clockwise rotation of palatal plane

HG therapy
Non-erupted permanent teeth Complete therapy is not possible

HGY-II
Most permanent teeth are available Complete in one treatment period

Important factors >> determining time of treatment

Severity of malocclusion Facial morphology Age Patient compliance

Some investigators have followed their patients over 10-year periods and found the headgear results to be stable
Wieslander L, Buck DL: Am J Orthod 66:295-301, 1974

Other investigators have described a catch-up period in which the observed growth direction changes to the original but at a much faster rate than in untreated individuals
Melsen B. Am J Orthod 73:526-540,1978.

Melsen and Dalstra reported a downward and

backward rotation of the maxilla during cervical traction, which returned to downward and forward direction after removal of the headgear

Melsen B, Dalstra M: Distal molar movement with Kloehn headgear: is it stable? Am J Orthod Dentofacial Orthop 123:374-378, 2003

A clinical study on 8-year-old children that involved

headgear use and the Herbst appliance showed relapse in the mandible but stable results in the maxilla
Wieslander L: Long-term effect of treatment with the headgearHerbst appliance in the early mixed dentition. Stability or relapse? Am J Orthod Dentofacial Orthop 1993

For patients treated with headgear, the headgear itself

may be the best form of retention until such time that fixed appliances can be used.
Kim YE, Nanda RS, Sinha PK: Transition of molar relationships in different skeletal growth patterns. Am J Orthod Dentofacial Orthop 121:280-290, 2002

Extraoral appliances : A twenty-first century update

Stanley Braun, DDS, MME, PE
Am J Orthod Dentofacial Orthop 2004;125:624-9

3 primary purposes :
to achieve forecastable changes in the growth

pattern of the dentomaxillary complex

to negate or enhance clinician- induced

intratraoral force systems

to provide a protractive force system to the

surgically separated dentomaxillary complex

The normal growth pattern

of the dentomaxillar complex

C-axis

Braun S, Rudman RT, Murdock HJ, Hicken S, Kittleson R,Ferguson DJ. C-axis: a growth vector for the maxilla. Angle Orthod 1999;69:539-42.

M-Point
The center of the largest circle that is tangent to the superior ,anterior , and palatal surfaces of maxilla

Braun S, Rudman RT, Murdock HJ, Hicken S, Kittleson R,Ferguson DJ. C-axis: a growth vector for the maxilla. Angle Orthod 1999;69:539-42.

The alterations in C-axis

changes in C-axis length (sella-M point, in millimeters)

The alterations in C-axis

alterations in the C-axis vector related to sella-nasion ( in degrees )

The alterations in C-axis

the palatal plane (ANS-PNS) related to the C-axis ( in degrees)

Extraoral appliances to affect the growth of the dentomaxillary complex

the frontomaxillary sutures

the nasomaxillary sutures the zygomaticomaxillary sutures

the transverse palatine suture

The centers of resistance of the dentomaxillary complex

Distal contact of maxillary first molar

The centers of resistance of the dentomaxillary complex

Headgear >> Clinical use

I. Negating (balancing) intraoral force systems

II. Enhancing intraoral force systems

Negating (balancing) intraoral force systems

extraoral energy applied = intraoral energy applied

energy = impulse (force or moment) (time)

[E/O force or moment] (time) = [I/O force or moment] (time)

applied to a clinical case

Worn 8 hrs a day

Occipital HG

Intrusive cantilevers, emanating from the posterior reactive teeth on each side of the arch, exert a 50-g intrusive force on each side of the 4tooth incisor segment

To establish the magnitude of the occipital headgear force required per side: reactive force

FY (8 hours) = F sine 60 (8 hours) = 50 (24) F = 173 grams

To establish the line of action (D) of the occipital headgear force relative to the center of resistance of the reactive posterior teeth:

[headgear moment] (hours) = [intraoral moment] (hours)

173 (D) [8] = [50(30)] 24

D = 26 mm

An occipital headgear worn 8 hours per day exerting a force of 173 g per side acting 60 to the buccal occlusal plane

line of action offset 26 mm perpendicular from

the buccal segment center of resistance stability of the reactive teeth

extraoral energy applied = intraoral energy applied

energy = impulse (force or moment) (time)

[E/O force or moment] (time) = [I/O force or moment] (time)

Additional research is necessary to quantify the physiologic limits of this energy calculation. However, the clinician can confidently use this energy calculation if the part-time extraoral force range is 6 to 10 hours in 24 hours.

TMA T-loop

A part-time headgear can be used to maintain the stasis of the

posterior reactive teeth during en masse bilateral translatory space closure

of the anterior 6 teeth into the first premolar extraction sites, bilaterally.

??

TMA T-loop activated to produce 10:1 moment/force ratios at brackets

E/O appliance impulse energy = I/O appliance impulse energy FH (10 hours) = 200 (24 hours) FH = 480 g
assumed the patient will wear the E/O appliance 10 hours in 24 hours

Straight distal pull headgear : intraoral protractive force would be 480 g/side High-pull headgear

: an angle approximating 40 to the occlusal plane, the highpull force would be 627 g (480g/cos 40) Cervical headgear

: an angle of 45 to the buccal occlusal plane, then the neck

strap force required would be 679 g (480g/cos 45).

Enhancing intraoral force systems

Force systems resulting from extrusive cantilevers and cervical headgear to enhance eruption of posterior teeth while maintaining occlusal plane.

The activation of the extrusive cantilevers bilaterally, each buccal segment will experience an extrusive force of 125 g and a moment relative to each center of resistance of 4375 g mm

A sleeping-time cervical headgear force system is used to ensure that the buccal segments occlusal planes will not tip, but will erupt, maintaining the existing occlusal

plane bilaterally

extraoral energy applied = intraoral energy applied energy = impulse (force or moment) (time)

[headgear moment] (8 hours) = [intraoral cantilever moment] (24 hours) [F(D)] (8) = 4375(24) M = 13,125 g mm If headgear traction is 300 g per side, then D = 13,125/300 = 43.8 mm

Each segment will experience

: a maximal total eruptive force of 385 g (125 g + 300 sine 60)

The headgear might thus need to be adjusted

relative to the centers of resistance of the dentomaxillary

complex for growth control and be periodically adjusted relative to the centers of resistance of the appropriate teeth to balance or enhance intraoral force systems