The effects of orthopedic forces on the

cranio facial complex utilizing cervical

and headgear appliances
Spiro J. Chaconas, D.D.S., M.S.,* Angelo A. Caputo, Ph.D.,** and
James C. Davis, D.M.D.***
Los A~geles, Calif., and Forest Park, Ga.

I t has long been the goal of orthodontics to correct anteroposterior tooth

diserepeneies. Considerable attention has been given to the horizontal relation-
ship of the individual arches, especially the maxillary and mandibular molars
within each denture. Many times the problem is only one of tooth relationships,
but often the malocclusion is due to basal bone dysplasia. Certainly, treatment
results are easier and more stable if the basic and deeper skeletal units can be
altered. It must be decided whether the developing facial structures should
be considered immutable and genetically controlled growth patterns or whether
they can be permanently changed by use of forces applied to bone.
The major objective in the treatment of skeletal Class II malocclusions is to
arrive at a correct maxillomandibular relationship. In most instances, the method
of treatment is to utilize orthopedic forces to the maxilla in order to redirect
growth of the midfaeial complex. The purpose of this investigation was to deter-
mine the nature of the forces transmitted to the craniofacial structures by
cervical and high-pull orthopedic traction.

Review of the literature

Although Angle 1 had earlier applied extraoral occipital anchorage in the
treatment of many cases, in 1907 he thought that its use had been largely super-
ceded by the development of other anchorage techniques.
Two rival ideas have served to frustrate the contemporary orthodontist. One
is the belief that only the teeth and apical bases may be affected by treatment. On
the other hand, there is the implication that orthopedic changes may be directed

~Professor and Chairman, UCLA Section of Orthodontics.

~~Professor and Chairman, UCLA Section of Biomaterials.
~ I n private practice, Forest Park, Ga.
527
5211 Chaco~tas, Caputo, a~d Davis A ..... i. o,.o~od.
Ma~.1 197~;

upon the maxilla and even translated to the pterygoid plates and other deeper
structures, thus t r u l y (tireeting growth of the craniofacial complex. This article
will only emphasize the orthopedic changes that m a y occur with the use of cer-
viral and headgear appliances.
Numerous authors have confirmed that extraoral traction to the maxillary
molars causes the palate to tip down anteriorly/-~' This must be some indication
that growth of the maxilla has been altered. Kloehn, '~ who had earlier stated that
there was no alteration in maxillary growth, stated in 1961 that f u r t h e r investi-
gations were necessary to determine the extent of the influence of eervical trac-
tion on a growing face.
I n his s t u d y of the clinical effects of orthopedic forces on the maxilla,
Ricketts; found that the palatal plane could be altered. B y the use of vigorous
extraoral forces, he was able to show a reduction of point A on the maxilla and
a similar retraction of the anterior nasal spine.
In another clinical study. Sandusky ~ evaluated twenty of his private patients
treated with cervical traction. He observed what he concluded to be a p a t t e r n of
change in direction of growth of the maxilla with a downward tipping of the
anterior portion as the palatal plane descended. In his younger patients, he
noticed a clockwise rotation of the sella-nasion line. l i e concluded that there was
a strong indication that rigorous continued pressure applied over a period of
time altered the position of the pterygoid plates amt the sphenoid bone. There
was no change in morphology, but rather a change in direction of growth.
Storey ~ demonstrated that direct distal movement of the maxilla is most com-
plicated. Because of the ]oeation of the sutures, direct force to the maxilla forces
the maxillary tuberosity against the spheno-occipital buttresses. In 1970, Damon:'
utilized high-pull orthopedic headgear and found that an u p w a r d and backward
foree to the maxilla can produce a change in the position of the maxilla in the
direction of the applied foree. Considering the sutural complex of the midfaee,
Merrifield and Cross TM concluded that cervical traction produces a shearing force
at the zygomatieomaxillary suture, tensile force at the frontomaxillary suture,
and a compressive foree at the pterygopalatine suture.
The questions which remain unanswered or only partially resolved are what
effects orthopedic forces have on sutures and whether or not these forces can be
demonstrated at distant craniofacial sites during orthodontic treatment. Hein-
ricksen and Storey H have proposed to answer the first question by their ex-
periments with the application of force to bones connected by sutures. Forces
applied across sutures induced rapid and remarkable changes. Under tensile
forces, the sutures ot)ened, while compressive forces caused changes directly re-
lated to the type of suture. I n sutures were bones abut, sutural growth was re-
tarded and in m a n y eases fusion occurred and growth stopped. The answers to
the latter question are still unresolved. Although some orthodontic t h e r a p y is
believed to exert forces on the craniofacial comI)lex, it has never been demon-
strated.
In introducing the techniques of photoelastie stress to dentistry. Zak r-' re-
viewed some of the effects of orthodontic mechanics within the alveolus. Some of
the more recent investigations were eondueted b y Caputo and Standlee, ~' ~'
v'oz~,~e 69
Number 5
Effects of orthopedic forces 529

Fig. 1. Partially assembled three-dimensional model indicating individual bones of the

midface.

who used photoelastic techniques in studying the effects of pin replacement on

tooth structures. Nikolai and Schwieker 15 used a wedge representing an anterior
tooth embedded in photoelastic material to study stresses at the root periodontal
interface. Chaeonas, Caputo, and Hayashi 'G, 17 visualized forces induced within
the supporting structures by various canine-retraction springs.
The use of photoelastic materials for analysis of stress and strain in bones has
been criticized by some. Evans TM is quick to point out that photoelastic methods
were developed for use in homogeneous materials and that these are different
from bone. However, the predictive validity of this modeling technique has been
amply demonstrated by Gliekman 19 and Standlee ~° and their colleagues and most
recently by Brodsky and associates7 ~ If one is aware that plastics are not
identical to bone but only models resembling the bone in outline, conclusions can
still be reached and something learned from their use.

Materials and methods

A three-dimensional model (Fig. 1) was reproduced from a human skull,
using different birefringent materials to simulate bone, teeth, and periodontal
ligament. First, molds were fabricated for each portion of the model from sill-
cone-based material.* Bones and portions of bones of the calvarium and cranial
~RTV-A, Hastings Plastic Co., Santa Monica, Calif.
530 Ch~tco'~tas, Caputo, ~t~d Dat,is .I.,. J.
Mayo,'tt.,d.
1976

Rg. 2. Assembled and mounted model with orthodontic bands attached.

base areas were molded as complete integral units. I n d i v i d a u l bones of the mid-
face (maxilla, palatine, zygoma, and w)mer) and the mandible were molded
separately. Teeth for the maxilla were carved in wax, and molds were made for
each individual tooth.
The teeth were then reproduced from a high-modulus epoxy-based plastic
(PL-1).* This material has been shown to have a modulus which falls in the low
range of reported dentinal modulus values. '-'2 To produce membranes, a thin layer
of wax was placed on the roots of the teeth and the silicone molding procedure
was repeated. A soft r u b b e r y urethane-based material was mixed and poured into
the membrane nmlds. The plastic teeth were inserted into their a p p r o p r i a t e
molds and the material was allowed to cure, resulting in plastic teeth covered
with a thin layer of SolithaneI to simulate the periodontal membrane.
These plastic teeth, with membranes attached, were placed in the original
mold of the maxilla and the mold was poured with PI~-2.* This resulted in a
maxilla containing separate teeth.
Other individual bones of the skull were produced with P1-2 and the same
molding procedure. They were then attached to the ealvarium and cranial base
unit. I t was necessary for all p a r t s to be attached at the same time to assure the
p r o p e r relationships. Assembly was accomplished by covering each anatomic
sutural area with an adhcsive$ and securing this relationship until the initial set
could assure its accuracy. A f t e r curing, all excess cement was removed and the
model was cleaned with pumice and water.
A hinged stand of round a l u m i n u m stock, 1 inch in diameter was made to
s u p p o r t the model (Fig'. 2). I t was secured through the foramen magnum. Ad-
ditional stability was obtained by attaching a :~ by 1/2 inch curved steel bar

*Photolastic, lnc., Malvern, Pa.

fSolithane 113, Thiokol Chemical Corporation, Trenton, N. J.
$PC-6 Adhesive, Photolastic, Inc., Malvern, Pa.
VoZ~,,~eso
Nu~nbe~" 5
Effects of orthopedic forces 531

Fig. 3. Model prepared for testing with high-pull traction. A, Face-bow; B, loading wire;
C, track for load cell positioning; D, load cell; E, load-control knob.

from the base of the stand to the calvarium. This metal piece also served as a
track for placement of a Statham Universal Load Cell* in different positions. By
moving the load cell on its track, both cervical and high-pull vectors of force
could be simulate(].
Preformed stainless steel bands, with 0.045 inch headgear tubes, were fitted
and cemented to the maxillary first molars. Two different nonangulated face-bows
were used. With cervical traction, a face-bow with long outer bow and 0.045
inch inner arch diameter was used. In the high-pull testing situation, the outer
arms of an identical face-bow were extended distally only to the level of the
maxillary first molars.
Forces were applied to the face-bow by means of bilateral 0.040 inch wires
which were attached to a cross member mounted directly on the load cell (Fig.
3). By the turning of a knob, the force to the face-bow could be increased or
decreased and measured directly by the load cell. This load cell was connected to
an X-Y recorder for accurate monitoring of the applied load levels.
The range of forces applied to the face-bow was that recommended by Arm-
strong 23 for use in combination headgear therapy. A distal force of 1,250 grams
was applied to each side of the face-bow for a net distal vector of 2,500 grams.
During activation of the extraoral appliances, photoelastic observation of
stresses developed within the model were made with a circular-transmission
polariscope arrangement (Fig. 4). The photoelastic data were recorded photo-
graphically.
In order to facilitate interpretation of the photeoelastie data, a clip type of
displacement transducer was fabricated, using semiconductor strain gauges. This

~Statham Instruments, Inc., Oxnard, Calif.

532 Chaco~as, Caputo, a~d Dal'is Am. J. Orthod.
M a y 1976

Quarter wave plate

\, /- Quarter wave
plate

Light Photoelastic Polarizing

source replica with lens
high pull face
bow
Fig. 4. Circular-transmission polariscope arrangement.

transducer was mounted across selected sutures to detect opening or closing of

these sutures.

Results

Initially, the skull was examined to show that all areas were in a stress-free
state after assembly. Stresses were recorded in certain areas of the skull upon ap-
plication of extraoral forces. Routinely, some anatomic areas were stressed by
both cervical and high-pull forces. These areas were the pterygoid plates of the
sphenoid bone, the zygomatic arches, the junction of the body of maxilla with
the lacrimal bone and the orbital plates of the ethmoid, and around the maxillary
molars.
There were other areas where stress was demonstrated by one headgear and
not the other. Cervical traction produced stre~es which could be recorded along
the frontal process of the maxilla, the zygomaticofrontal suture, and the junction
of the palatine bones, areas where high-pull traction produced no observable
effect. Only the high-pull headgear developed stress at the anterior junction of
the maxillae (anterior nasal spine).
Each anatomic area affected by either headgear, or both, will now be discussed
separately.
Pterygoid plates of the sphe~toid. Upon activation of either headgear, high
stresses were developed in the pterygoid plates of the sphenoid bone, as presented
in Fig. 5. In Fig. 5, A the pterygoid plate is shown prior to activation and demon-
strating a stress-free condition. Fig. 5, B shows this bone upon activation of
either headgear. These stresses began in the middle of the posterior curvature of
the plates and just superior to their anterior junction with the palatine bone and
maxilla. As the force was increased, the stresses were seen to progress superiorly
toward the body of the sphenoid bone.
Zygomatie orches. Stresses within the zygomatic arches were similar for both
types of headgear (Fig. 6). They tended to start at the inferior border of the
zygomatieotemporal suture and proceeded posteriorly along the zygomatic pro-
cess of the temporal bone. If any distinction could be made between the two dif-
volu,~eG9
N~ember 5
Effects of orthopedic forces 533

Fig. 5. Medial view of left pterygoid plate. A, Before loading; B, stresses produced by
either cervical or high-pull headgear; P, pterygoid plate; M, maxilla.

Fig. 6. Visualization of stresses caused by high-pull headgear along the zygomatic arch.
A similar distribution of higher intensity was induced by cervical headgear. Z, Zygomatic
bone; S, suture; T, temporal bone.

ferent vectors of force, it was that the cervical force produced more intensity at
a lower load level.
Junction of the maxilla with the lacrimal and ethmoid bones. Both high-pull
and cervical traction produced a stress concentration at the junction of the
maxilla with the lacrimal bones and with the orbital plates of the ethmoid. These
two areas (designated as A and B, respectively, in Fig. 7) demonstrated point
concentrations of stress and were almost identical for both types of headgear.
Maxillary teeth. High stresses were recorded around the maxillary molars
during application of cervical traction (Fig. 8). These forces were located around
the middle third of the mesiobuccal root of the maxillary first molar and around
the distobuceal root at a position more toward the apex. Some stress was demon-
strated at the apex of the second premolar. Fringe patterns were also recorded
534 Chaconas, Caputo, ( l ~ d i)~l['i,~ Am. J. Orthod.
M a y 1976

Fig. 7. Stresses produced by both headgear at the junction of the maxilla with (A) the
lacrimal bone and (B) the orbital plate of the ethmoid bone.

Fig. 8. Stresses generated around maxillary teeth under cervical traction.

Fig. 9. Visualization of the effect of cervical traction only along the frontal process
(orbital ridge) of the maxilla.
vN ou m
~ b. ~ G9
er 5
Effects of orthopedic forces 535

Fig. 10. Anterior view of the zygomaticofrontal suture. Only cervical traction produced
stress palcern. F, Frontal bone; Z, zygomatic bone.

Fig. 11. Oral view of hard palate. Stresses produced at the midpalatine suture, which
corresponded to posterior palatal separation, were produced only by cervical traction.
ms, Midpalatine suture; MP, maxillary palatine suture; M, maxilla; Pa, palatine bone.

distal to the apex of the second molar and spreading into the tuberosity. The
high-pull headgear stressed the same areas, but to a much lesser degree.
Fronttll process of ~taxilla. With cervical traction, but not with high-pull,
stress was concentrated along the frontal process of the maxilla anterior to the
nasolacrimal foramen, as illustrated in Fig. 9. With high load levels, the inten-
sity was increased and the pattern moved somewhat more cranially.
Zygomatieofrontal suture. ,Just before the maximum cervical load limit was
reached, stress patterns began to develop at the zygomaticofrontal suture (Fig.
10). The concentration, as viewed from the anterior, was in the middle of the
suture and tended to creep laterally. High-pull forces did not produce any
stresses here.
Palate. Viewing the palate from the oral side, we see that cervical traction
began to produce stress patterns in its posterior region (Fig. 11). The patterns
536 Chaco~ms, Caputo, ,ntd Dal,i.s A,,..I.May
ortl,,cL
1976

Fig. 12. Frontal view of the anterior junction of the left and right maxilla; stresses pro-
duced by high-pull traction.

developed in the horizontal portion of the palatine bones at their junction. As

the load was increased, the stress pattern developed parallel to the suture and
then spread laterally toward the two alveolar processes. Using a displacement
transducer, it was demonstrated that cervical traction tended to separate the two
palatine bones at the suture. High-pull traction produced no observable effect
here.
A~terior ju~ction of left (n~d right maxillae. The anterior junction of the
left and right maxillae showed stress only when high-pull traction was applied.
The forces were concentrated directly below the anterior nasal spine and just
lateral to the suture between the two maxillae. Fig. 12 demonstrates stresses pro-
duced by the high-pull traction.
A displacement transducer showed that the stresses produced with high-
pull traction indicated compression at the suture between the left and right
maxillae. Cervical traction produced no measurahle effect here.

Discussion
Activation of the high-pull and cervical headgear demonstrated that both
appliances can produce forces which may be visualized around the teeth and
transmitted to distant craniofaeial structures. Fig'. 8 shows that these stresses
were most severe at the maxillary teeth and their alveolar support. These findings
were correlated with those of Kloehn, s~-2~' Epstein, ~°~ Graber, 2s King, ~' and
numerous other early authors ~, :~o,:~ who contended that extraoral anchorage
affected the position of the maxillary molar and its resulting alveolar develop-
ment. Of particular clinical interest was the difference in magnitude of stress
patterns when the high-pull headgear was compared with ee~wieal headgear.
It was easily deduced that cervical headgear had a much greater tipping effect
on the maxillary first molar. This is an important clinical consideration during
rol~,,~e 69
N~tmber 5
Ef]'ects of orthopedic forces 537

orthodontic therapy where the extrusion of the molar teeth would be a de-
trimental factor in the treatment of malocclusions representing vertical dys-
plasias.
Although effects at the teeth are important, the purpose of this project was
to demonstrate that stresses could also be produced at deeper craniofaeial struc-
tures. The photoelastic data presented demonstrate that cxtraoral traction may
produce forces which can be transferred to several deeper craniofacial sutures.
Activation of either headgear produced high stresses at the pterygoid plates.
This finding is in agreement with both Ricketts ~ and Weislander, 3" who believed
that orthopedic forces affect not only the maxilla but also the pterygoid plates of
the sphenoid and cause a change or alteration in their position.
Clinically, this observation demonstrated that the buttressing effect of the
pterygoid plates of the sphenoid bone with the tuberosity of the maxilla is an im-
portant factor when one is considering orthopedic changes to the maxillary com-
plex. If movement of midfacial structures is possible with orthopedic forces
generated t)y headgear appliances, the pterygoid platcs of the sphenoid bone
may very well represent the posterior limit to which the maxilla can be re-
positioned.
The generation of stresses at the zygomaticotemporal suture, the zygomatico-
frontal suture, and the pterygoid plates and along the frontal process of the
maxilla indicates a downward and backward tipping of the maxilla under cervical
traction. These findings reiterate those of Sandusky, ~ Poulton, :~ and others ~, '~who
radiographically showed a tipping of the palatal plane.
The combination of the downward and backward tipping of the palate and
high fringe orders seen in the pterygoid plates indicates that the entire naso-
maxillary complex has a tendency to rotate. This supports the findings of San-
dusky ~ an(] Drosckl, '~:~ who demonstrated clinically and with animal studies a
tendency for the pterygoid plates and sphenoid bone to change position and
cause a bending or retardation of the entire midfacial complex.
Also of importance is the fact that the intensity of stresses produced at com-
mon structures by cervical headgear was greater than that produced with high-
pull headgear. Not only was the intensity greater, but also cervical traction
stressed three areas where high-pull conditions produced no observable effects.
These findings support the contention of many that cervical traction can produce
a much greater orthopedic change than high-pull traction.
Certainly of clinical importance was the effect of cervical traction on the
posterior portion of the palate. The separation of the palatine bones can enable
the clinician to maintain lateral development of the alveolar processes and help
to prevent iatrogenic cross-bites as the malocclusion is progressing from Class II
to Class I.
The only area stressed solely by the high-pull traction was just inferior to the
anterior nasal spine at cephalometric point A. This effect of high-pull traction on
this anterior region of the palate combined with the effect of cervical traction at
the posterior region could help justify the clinical use of these two types of head-
gear in combination.
538 Chaco~as, Caputo, o~d Davis A,,, J. Orthoa.
May 1976

Summary and conclusions

1. A t h r e e - d i n m n s i o n a l a n a t o m i c model of a h u m a n skull was p r o d u c e d with
b i r e f r i n g e n t m a t e r i a l s for photoelastie analysis. B y m e a n s of photoelastic tech-
n i q u e s d u r i n g a p p l i c a t i o n of high-pull a n d cervical e x t r a o r a l t r a c t i o n , stresses
were v i s u a l i z e d w i t h i n the model.
2. E x t r a o r a l a n c h o r a g e affected the p o s i t i o n of the m a x i l l a r y m o l a r a n d its
r e s u l t i n g alveolar d e v e l o p m e n t . Cervical h e a d g e a r h a d a m u c h g r e a t e r t i p p i n g
effect on the m a x i l l a r y m o l a r t h a n d i d the h i g h - p u l l headgear.
3. B o t h a p p l i a n c e s e x a m i n e d could p r o d u c e stresses which m a y be t r a n s -
m i t t e d to d i s t a n t c r a n i o f a c i a l sutures. As opposed to h i g h - p u l l t r a c t i o n , cervical
p u l l i n g e n e r a l stressed more areas a n d to a m u c h g r e a t e r degree.
4. The p t e r y g o i d p l a t e s of the s p h e n o i d bone, the zygomatic arches, the
j u n c t i o n of the m a x i l l a with the l a c r i m a l bone a n d the ethmoid, a n d the m a x i l l a r y
teeth were affected b y both t y p e s of headgear.
5. O n l y cervical t r a c t i o n p r o d u c e d stresses at the f r o n t a l process of the
m a x i l l a a n d the Z y g o m a t i c o f r o n t a l s u t u r e .
6. T h e r e were two f i n d i n g s which had not been p r e v i o u s l y r e p o r t e d : F i r s t ,
cervical t r a c t i o n t e n d e d to open the p a l a t e in the posterior region. Second, high-
p u l l t r a c t i o n p r o d u c e d compressive stresses at the j u n c t i o n of the r i g h t a n d left
m a x i l l a e i n f e r i o r to the a n t e r i o r nasal spine.

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Number 5 E f f e c t s of orthopedic forces 539

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