Uses of head gears in growing skeletal class /certified fixed orthodontic courses by Indian dental academy

Uses of Head gears in Growing
Skeletal Class II patients.

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INDIAN DENTAL ACADEMY
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Introduction:
• Every orthodontic correction has to be fully integrated
into both the facial type and the growth pattern of the
patient being treated.

• By being aware of the patient's facial type, we can make
the best possible appraisal of his growth trend and
project our treatment into this scheme, choosing the
appliances suitable to the therapeutic objectives.


Characteristic features of Skeletal
class II patients.
Skeletal Class II malocclusion may be characterized
by both sagittal and vertical discrepancies:
Sagittal discrepancies:
a) Prognathic maxilla and orthognathic mandible.
( maxillary protrusion.)
b) Retrognathic mandible and orthognathic maxilla.
(mandibular retrusion.) or
c) a combination of both.

Maxillary protrusion.

Mandibular retrusion.


Combination of
both.

• Vertical discrepancies depend upon the rotation of the
mandible in respect to a site of rotation:
• A) Forward rotation: Three types.
• Type I: About centers in the joints resulting in deep
bite.
• Type II: About the centers at the incisal edges of
the lower anterior teeth due to the combination of
marked development of posterior face ht. and
normal increase in the anterior ht. resulting in
normal development.
• Type III: About the centers at the premolars
resulting in the decreased anterior facial ht. and
basal deep bites.

Class II malocclusion due to forward and upward rotation of the mandible.

• Backward rotation: Less common. Two types.
• Type I: About the centers in the joint resulting in open
bite and increased anterior facial height. Mandible is
normal.
• Type II: About the centers at the most distal occluding
molars resulting in open bites.


Class II malocclusion due to downward and backward rotation of the mandible.


• In Skeletal class II
malocclusion with prognathic
maxilla, the anteriorly placed
maxillary base can be tipped
upward or downward.
• If the palatal plane is tipped
upward anteriorly, it
accentuates the maxillary
prognathism.
• A palatal plane that is tipped
downward anteriorly reduces it.

Downward or upward tipping of the maxilla.


+

• In a cephalometric study (McNamara, 1981),
– Mandibular skeletal retrusion with deep bite was
the most common.
– A wide variation in vertical development, with onethird to one-half the sample having increased
vertical facial dimensions.
– The anteroposterior position of the maxilla was, on
average, neutral, with far more cases of maxillary
skeletal retrusion than maxillary skeletal protrusion
being observed.

Favourable and Unfavourable
Growth pattern.
• Skeletal class II base, deep bite, high mandibular plane
angle with vertical growth potential is unfavourable
• Skeletal class II base , deep bite, low mandibular plane
angle with horizontal growth is favourable for class II
sagittal correction but is most unfavourable for overbite
correction.
• Skeletal class II base, open bite, high mandibular plane
angle with vertical growth potential is unfavourable.


AJO, June 1969.

• According to Bjork, the more extreme the rotation of the
mandible during growth, the greater the problems.
• In case of pronounced forward rotation, there is a major
risk of deep bite developing.
• In case of backward rotation, opening the bite is difficult
to prevent.


Parts of Head gear.
•
•
•
•
•

Facebows
Head caps/Neck straps
Safety modules
Head gear tubes and
Fly tubes


Facebows


Standard Facebows:


1.14 mm

1.83 mm

• Various color codes.
• Standard and mini length outer bow.
TP orthodontics.

• With/without inner bow hooks.


Inner bows:

GAC international.


Inner bow bends:
• U loop bend:
• Allows adjustments in the inner bow for desired
arch lengths by closing the loops.

• Bayonet bend:
• Allows the inner bow to be seated without
impinging on the bicuspid teeth or retraction
springs.


Outer bows:

GAC international.


GAC international.


J-hooks:
• Two separate curved gauze
wires(.072”) that are formed on
their ends into small hooks
• Used only with the fixed
appliance. The midpoint between
most anterior and posterior teeth
is considered as center of
resistance.
• This is more commonly used for
retraction of canines or
incisors rather than orthopedic
purposes.

•Available as a pair.
•Available in small and large sizes.

Head caps/Neck straps


TP orthodontics.


Safety modules

•Available in various colours.
•Available in various force magnitudes:
350 gf – light.
500 gf – medium.
750 gf – heavy.


Headgear tubes

Advantages: (Worms ct. al. -1973).
• Ease of control
• Better access and
• Better hygiene.

Disadvantages:
• Away from the center of resistance as a result more
moment is created.


Advantages:
• Close to the center of resistance therefore line of force
close to it.
Disadvantages:
• Poor oral hygiene and
• Poor accessibility


Fly tubes:

“Flying tubes” are
incorporated
independently in the
base plate.


Biomechanics of Head gears.


Center of resistance of various units.

• The center of resistance of a single-rooted tooth is
generally assumed to be .4h, where h is the amount
of root covered with bone.

• Force passing through the center of resistance can
cause pure translation and any other force will
produce translation and rotation with the movement.


Center of resistance of an individual molar tooth.


Center of resistance of a segment.


The center of resistance of a fully bonded arch lies
between the premolar roots.


Centers of resistance in mid facial complex

1. Alveolar process.
2. 2. Maxilla.

The center of resistance of the nasomaxillary complex is
somewhere in the area of the posterosuperior aspect of
the zygomaticomaxillary suture.

• Lowering the outer facebow
enhances the tipping effect,
thus increasing anterior
overbite and reducing
posterior facial height.
• Vertical control is crucial
because it dictates the final
position of the chin in the
profile.
• This effect should be
avoided in brachyfacial
cases, but can be used to
advantage in mesofacial or
dolichofacial types with
tendencies to anterior
open bite.

• When the outer facebow is
bent upward, both the occlusal
and palatal planes are rotated
counterclockwise.
• anterior intrusion and normal
molar eruption result in an
improvement of anterior deep
bite and an increase in
posterior facial height.
• Forward movement of the
mandible is inhibited, despite
the effect of the activator. Such
an effect is indicated in
brachyfacial patients with
anterior deep bite and short
lower facial height . www.indiandentalacademy.com

• When the direction of
force passes between the
two centers of resistance,
there is a slight clockwise
rotation of the palatal
plane and a
counterclockwise rotation
of the occlusal plane,.
• The facial axis remains
unchanged or closes
slightly, allowing
complete freedom of
mandibular growth.
• Indicated in moderate
deep bite and
mesofacial or slightly
dolichofacial patterns

Direction of the force.


Cureton1992 JCO Nov

• The direction of force of a headgear at the center of
resistance of a tooth or group of teeth can be accurately
assessed by projecting a profile slide of the patient over
a cephalometric tracing. This allows the clinician to
adjust the headgear as necessary until the desired force
system is obtained.


Lateral cephalogram taken
with headgear in place;
stainless steel wires taped to
headgear straps show lines
of force.

Profile photograph of same
patient.


Profile slide of patient
wearing headgear projected
over cephalometric tracing.

Duration of the force.

• Atleast 12 to 14 hrs per day (Klein 1957, Rickets 1960).
• Recommended in the evenings- growth hormone release
is higher. Growth hormone enhances the new bone
formation at the epiphyseal plates of the long bones in
growing children.


Force:
• Heavy
• Light
• Intermittent
• Continuous

Heavy - Intermittent forces.
• Less damage to the teeth and periodontium, minimal
tooth movement.
• Helps in growth modification at sutural areas by
preventing the amount of separation that would have
occurred during growth.
• Stimulus for the resorption is diluted.


Magnitude of the force.
• For dental movements -15 to 400gms per side depending
on the size and tooth movement.
• A minimum force of 250 gm per side (total 500gm) is
enough for to modify skeletal change.
• To maximize the potential for skeletal change, orthopedic
force – 400 to 900 gm per side [ 1 to 2 pounds ] (Graber
1965).


• Analysing the force system.
Magnitude of
moment of force

=

Magnitude of force
x
perpendicular distance from the
center of resistance to the
line of force.

• Thus for a given force the greater the distance from the
CR that the force is applied, the greater will be the
moment.

Timing of force application
•

Orthopedic effect – in growing children

•

Most active period of growth –
- Just before the eruption of permanent teeth or in
mixed dentition.
- During the pubertal growth spurt


Cervical pull headgear.
• Point of attachment lies below the occlusal plane ,the
external force is directed inferiorly as well as posteriorly.
• With the face bow the cervical attachment permits the
creation of force vector that permits the extrusive and
distal movement of molars.
• Force vector is altered when the angle of the face-bow in
relation to the dental bow and the length of the face-bow
are changed.

(A)Long arm, resultant line of
force passes distal and apical
to centre of resistance - distal
root tipping.

CERVICAL PULL

(B) Short arm, resultant line of
force passes mesial and
occlusal to centre of
resistance - mesial root
tipping.


High pull headgear.
• Point of attachment is above the occlusal plane
• The extra oral force is directed superiorly and posteriorly
• High attachment permits the force vector to correct
anteroposterior maxillary excess and vertical maxillary
excess.
• Force vector is altered when vertical position of the
outer bow is changed.

(C) Long arm, resultant line of force passes
distal and occlusal to centre of resistance –
mesial root tipping.

OCCIPITAL PULL

(D) Short arm, resultant line of force passes
mesial and apical to centre of resistance distal root tipping.


Straight pull headgear
• External force is directed to more surface area – more
comfort.
• Direction of the force vector can be modified.
• If the forces are equal for each attachment the resulting
force vector is usually above the occlusal plane but
inferior to the vector created with the occipital
attachment alone.
• Requires more patient co operation

Clinical applications of Head gears
in Skeletal Class II patients.


The sagittal correction of Class II cases
may be brought in several ways:
• Relocating the maxilla backward or inhibiting its growth,
• Moving the upper teeth distally,
• Releasing forward growth of the mandible,
• Moving the lower teeth mesially,
• Inhibiting the vertical growth of the maxilla,and
• Inhibiting eruption of upper posterior teeth while
permitting eruption of lower posterior teeth.

Low angle cases.
The treatment objectives in cases of this nature
are to:
• reposition the maxilla posteriorly,
• permit forward growth of the mandible,
• promote eruption of lower posterior teeth,
• promote extrusion of the upper molars and distal
eruption of the remaining upper posterior teeth,
• restrain the anterior vertical growth and eruption of teeth,
and
• prevent mesial drift of lower posterior teeth and buccal
tipping of lower incisors.

• Extra oral force is mandatory for 2 reasons:
• There is an extensive skeletal discrepancy due
essentially to a protracted maxilla and,
• The lower incisors would not be tipped further
labially, which happens often when activator are
used alone.
• Extraoral appliance of choice - Cervical headgear, since it
has both a distal and an inferior force component.


Cervical Pull Headgear.


• The long outer bows - 15 degrees above the inner bow
to facilitate extrusion and prevent any distal tipping of the
anchor molars.
• The sagittal correction will be achieved mostly by a
posterior repositioning of the upper arch and teeth and,
to some extent, by the natural forward growth of the
mandible.
• The ramal growth compensates for eruption of molars
and horizontal growth contributes to move the mandible
forward


• Outer bow is adjusted
such that the headgear
force line of action
passes through the units
center of resistance.
• Effects:
Extrusive component,
distal
component, and
no
moment.

• In treating short-face Class
II maxillary protrusive cases
with low mandibular plane
angles and deep bites,
where it is desirable to
extrude the upper posterior
teeth.
• Long outer bow
• Outer bow is adjusted high
such that the headgear
force line of action passes
distal to the units center of
resistance
• Effects:
distal force
component, and moment
that tends to flatten the
occlusal plane

• Outer bow is low and short.
• Effects:
distal
component,
Large moment steepens
the occlusal plane.
• The clockwise moment
produced with this
headgear is very effective
in helping conserve
anchorage in extraction
cases.

Average angle cases.
• Class II children with normal face height (many of whom
have anterior deep bite because of excessive eruption of
lower incisors) can be treated with either headgear or a
functional appliance,
• If molars are moved distally and extruded, the mandibular
plane angle tends to increase.
• Straight-pull or Interlandi headgear is preferred over
cervical headgear, to reduce elongation of maxillary
molars and better control

Straight pull headgear


• It is a combination of the high-pull and cervical headgear.
• Main advantage is pure posterior translatory force as
required in Class II malocclusion with no vertical problems.
• This is accomplished by placing the force vector through
the center of resistance, parallel to the occlusal plane.
• This means bending the outer bow to the same level as
CR, and hooking the elastic to a notch at the same vertical
level. This prevents anterior migration of maxillary teeth, or
possibly even translate them posteriorly.


• Combination of occipital
and cervical pull
• Short outer bow
angulated at high.
• Net force’s line of action
passes through the
center of resistance
• No moment
• Pure distal force
• Used typically for
redirecting maxillary
horizontal growth
,distal translation of
maxillary molar

High angle cases.
A) High angle with open bite -Treatment
objectives are to :
•
•
•
•
•
•

inhibit vertical and sagittal growth of the maxilla,
prevent further eruption of the upper molars or, even
better, intrude the upper molars,
promote sagittal growth of the mandible through
reorientation of physiologic muscle forces,
prevent eruption of the lower molars,
move the lower teeth mesially, and
promote vertical growth of the anterior alveolar bone
and eruption of incisors by removing any possible
muscle interferences.

•The extraoral appliance of choice is the occipital high-pull
headgear since we want
(1) to inhibit sagittal and vertical growth of the
maxilla and
(2) intrude the upper molars.
•The outer bows are short so as to direct the elastic force
over the center of resistance of the molars, thus avoiding
any tipping of these teeth.
•Eruption of lower molars is controlled with interocclusal
bite blocks, which are essentially incorporated into a
functional appliance that also postures the mandible
forward.

High pull Headgear.


• In a long-face Class II
patient with a high
mandibular plane angle
where intrusion of maxillary
molars would decrease
facial height.
• Headgear line of action of
force passing through the
center of resistance. Outer
bow must be placed
somewhere along the LFO.
• Effects:
No moment - no change in
the cant of occlusal plane.
Only intrusive, distal,
component of force.

• Indicated for class II
openbite cases
• Long outer bow placed
posterior to this line, the
moment produced will be
in a clockwise direction.
• Effects:
steepen the occlusal
plane, intrusive and
distal force


B) High angle with deep bite- Treatment objectives
are to:
• inhibit growth of the maxilla and reposition it somewhat
distally,
• correct all habits and allow free growth of the mandible,
• promote slight mesial displacement of lower teeth,
• intrude upper and lower incisors,
• inhibit eruption of upper posterior teeth, and
• restrain anterior alveolar growth and eruption of teeth.


• Extra oral forces: The extra oral appliance used will be a
low- or medium-pull occipital headgear. The direction
of pull has to be precisely evaluated, clinically or
radiographically, to orient the forces along, or even slightly
above, the occlusal plane.
• During treatment with the fixed appliances, the headgear
will be used either in conjunction with an incisor spur or
hooked directly on the upper arch between the canines
and lateral incisors.


• In intrusion of anterior
segment with base arch.
Short outer bow
• Angulated at higher level
• Line of action of force
passes anterior to center
of resistance of the unit,
the moment produced
will be counterclockwise
direction.
• Effects:
Distal, intrusive,
flattening of occlusal
plane

Asymmetric headgear
• Asymmetrical molar relations can be corrected by
transpalatal arch or lingual arch.
• Same mechanism can be used with headgear.
• Molar relation with class I on one side and class II on
other side without any asymmetries in molar axial
inclinations and rotations is the ideal indication for
asymmetrical headgear


• Distal forces are 3 times greater on the long outer bow
side than the short outer bow side.
• Short outer bow side – more amount of lateral forces
can result in cross bite.

High pull headgear to a functional
appliance with bite blocks
• In Class II cases associated with severe denture-base
discrepancy in the growth period, it is logical to restrict
the forward growth of the maxilla or maxillary dentition
and, simultaneously, to stimulate all possible forward
growth of the mandible.
• Most effective approach to growth modification involving
vertical maxillary excess and a class II relationship.
• Here the force is directed entirely on to the
maxilla,controls eruption of posteriors.

• Headgear force increases the retention of the
functional appliance.
• High pull headgear produces a force direction near
the estimated center of resistance of the maxilla.
• The functional appliance enhances the mandibular
growth simultaneously controlling the eruption of
anterior and posterior teeth.


Mandibular growth Advancer. MGA
• It is a modified activator.
• Functional appliance (MGA, mandibular growth
advancer) with headgear have obtained jaw and occlusal
relationships, that are well-balanced, both anatomically
and functionally, producing a harmonious profile.
• The MGA is a modified activator for gradually
accommodating the muscle function by progressively
advancing the mandible

Head gear with Functional appliance.
MGA


Method of maxillary growth
restriction:
• Bands are placed on both upper first molars and
maxillary growth is restricted with an extraoral
appliance.
• The traction force is 500 gm .
• A cervical-type traction is used, but a high-pull or a
straight-pull vector is used in cases where excessive
molar extrusion is contraindicated.

Method of mandibular forward
induction:
• The MGA is a functional appliance for mandibular
protraction.
• It is composed of two separate splints fused together
by self cure acrylic.
• With this appliance, the mandible is advanced
progressively with a mandibular splint.
• The objective is to remodel the condyle and the
glenoid fossa in the temporomandibular joint with
concomitant adaptation of orofacial muscles.

Activator Headgear therapy.
• An activator alone creates a force system passing behind
the centers of resistance of both the maxilla and alveolar
process resulting in clockwise rotation of both the
palatal and occlusal planes.
• Pfeiffer and Grobety described combination of
activator — cervical headgear therapy:
• to extrude maxillary molars,
• to apply orthopedic traction to the maxilla,
• to induce orthopedic mandibular changes,
• restrain maxillary growth, and
• cause selective eruption of teeth.

Activator with Headgear.


• Hypothetically, a simultaneous application of both
appliances may result in desirable treatment effects
greater than those induced by each appliance
separately.
• Indicated in class II div 1 cases where the dental arches
are coordinated but class II correction encounters.
Difficulties.
• Cervical headgear with long outer bow; outer bow 5
degrees below the inner bow to produce distal force
through the centre of resistance of the molar teeth and a
lesser extrusive force component.

Comparative evaluation of a New Removable Jasper
Jumper Functional applaince vs an Activator- Headgear
combination. (zafer Sari, Yasar Goyenc; AO 2003).
• Results suggest that ANB angle was decreased significantly
with both treatment modalities.
• Increase in total facial height was greater with activator-HG
than with JJ-HG.
• Vertical growth inhibition of lower incisors was greater with
the JJ-HG.
• The activator- HG was more effective on the mandible,
whereas the JJ appliance was mainly active on the maxilla.
• Thus ideal cases for JJ- splinted appliance should be high
angle cases, particularly with maxillary excess and some
mandibular deficiency.

Maxillary Intrusion Splint
• M.I.S. is a full coverage, acrylic palatal plate with both
anterior and posterior capping carried round and onto labial
surfaces of the incisor teeth and extra-oral traction tubes
incorporated in the base plate mesially to the cusp tip of
the first premolar.
• M.I.S reduces the visibility and vulnerability of the maxillary
incisors by the intrusion of maxillary teeth, restraining
maxillary growth, and encouraging an element of
subsequent forward mandibular rotation.
• Indicated in “gummy smile” patients.

Maxillary Intrusion Splint (M.I.S.).

A)Cribs and occlusal capping
combine to produce a well
retained appliance.
B)“Fly tubes”are incorporated
independently in the base plate
and are aligned mesially along
the cusp tip of 4 and 5.


(C) Acrylic capping for the
incisors and canines should
cover the incisal third of the
crown.

(D) Occlusal coverage in
the .buccal segments does
not extend onto the buccal
surface of the premolars and
molars.


• vertical pull to the Kloehn bow at about 60 degrees to the
occlusal plane.
• The outer arm was shortened so that traction could be
applied through the centre of resistance of the maxillary
dentition.– dental and skeletal effects can be achieved
with good vertical control.
• A force of 500 g and upwards was applied bilaterally
depending
upon the patient tolerance.
• worn for up to 14 hours per day .

Head gear with Herbst appliance.
• The appliance consisted of cast Vitallium splints bonded
to the upper and lower arches with Herbst telescopic
arms inducing constant anterior mandibular jumping.
• A combination of high-pull and low-pull forces was used
at night to increase the force against the maxilla.A plate
was constructed in the upper jaw as anchorage for a
headgear to be worn 12 to 14 hours per day.
• A 1000 gm force was applied against the headgear
tubes intially. As the distal force from the Herbst
appliance alone against the upper teeth appeared
sufficient, the heavy headgear forces were reduced to
300 to 400 gm.
• Headgear-Herbst treatment followed by activator
retention.

Appliance construction: A, Splints bonded to the teeth. At far right, note Herbst telescopic arms
for correction of the intermaxillary relationship with pieces of tubes for progressive jumping. B
(left to right), Appliance in situ; mandible jumped to a Class I molar relationship; progressive
jumping after 2 months. C (left to right), Headgear in situ; further jumping after 4 months to
final stage of treatment; activator for stabilization.

Effects of headgear and mandibular step-by-step
advancement versus conventional Herbst appliance
and maximal jumping of the mandible. (Xi Du, Urban
Hagg and A. Bakr M. Rabie; EJO 2002)
• The herbst appliance, with high-pull headgear and stepby-step mandibular advancement, seemed to have a
greater influence on maxillary jaw base position, jaw
relationship and improved control over the rotation of the
mandibular plane than herbst appliance without headgear
and maximal jumping of the mandible.
•

The step-by-step advancement did not reduce the
mandibular anchorage loss.

The effects of headgear treatment on dental
arches and craniofacial morphology:a report of a 2
year randomized study. (Tuomo kantomaa, pertii
pirttiniemi and aila pykalainen; EJO 2004).
• The use of headgear in early mixed dentition is effective
in the treatment of moderate crowding .
• Space was gained in both dental arches by widening the
arches and labial inclination of the incisors. With the
distal force on the upper first molars, a restraint of
maxillary growth distally was observed.


Vertical tube headgear
1989 May JCO-Jan Reurink

• Buccal expansion – bend the inner bow outwards
• Inner bow has to be adjusted for severe mesiopalatal
rotation of the first molar
•

palatal bar is required

• The moment of force resulting from the intrusive forces
of high or vertical pull traction – can flare the molars
• Horizontal extension of inner bow- can have chance of
eye injuries

Vertical Tube Headgear Construction:
• The prototype appliance used an .045" vertical tube
soldered to a Dentaurum triple tube . A convertible
combination bracket can also be used.
• The facebow is modified simply by cutting off the
horizontal extensions of the inner bow.
• The vertical tube allows insertion of the facebow either
from the gingival for cervical traction or from the
occlusal for high pull traction

Vertical molar tube


Upward

Downward


Safety measures and systems
(JCO 2002 oct)

• Check the fit of the locking facebow in a mirror, and
confirm the lock by lightly pulling forward on the
facebow. Then attach the safety head or neck strap at
the prescribed tension (mark the appropriate holes) while
holding on to the facebow.
• Never wear the headgear while playing.
• If someone else grabs the headgear, take hold of it until
the other person lets go. Then take the headgear and
facebow apart to make sure nothing has been dislodged
or broken

• If the headgear or facebow ever comes off at night, or
if there are any other problems, stop wearing it and
schedule an appointment as soon as possible.
• Always remove the head or neck strap before
removing the facebow.
• An eye injury, however minor, see an
ophthalmologist immediately. Penetrating injuries
may appear relatively asymptomatic, but immediate
antibiotic therapy is required to reduce the likelihood
of infection


Safety Catch Mechanism (JCO

1993 Mar)

"Tom Catch“
• Hold a Kloehn facebow in the molar tubes The catch
is bent from a length of .032" austenitic stainless steel
wire, soldered to the end of a facebow, and attached
to a buccal tube assembly.
• The facebow is inserted by placing the end of the
safety catch in the channel between the molar band
and the buccal tube assembly. The inner bow is then
compressed gingivally against the spring until the end
of the bow lines up with the molar tube . While still
compressed, the bow is guided posteriorly into the
tube until the safety catch locks behind the tube
assembly

Kloehm face bow with safety catch mechanism.


Nitom locking Face bow


Plastic Neck-strap


Face bow soldered to functional appliance.


Conclusion.
There are a number of ways to attempt the correction
of class II malocclusions. The method chosen depends
on a series of factors that must be carefully evaluated
before each therapy. The right indication is the formula
for success. Only a careful and complete diagnosis and
a continued diagnostic monitoring during treatment
enables the choice of the right appliance for the
individual case to assure optimal treatment.


Thank you
Leader in continuing dental education


Uses of head gears in growing skeletal class /certified fixed orthodontic courses by Indian dental academy

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