Reference charts for controlled

extraoral force application to

maxillary molars
Ronald A. Greenspan, D.D.S.*
Boston, Has.

A lthough headgear appliances were originally designed by Norman

William Kingsley in 1892, half a century elapsed before orthodontists began to
employ extraoral force extensively. 1 Kloehn’$ results with the cervical neck-
strap actually provided the impetus to preserve extraoral traction from near
obliteration. Subsequently, a va-riety of methods have been developed to employ
extraoral force in conjunction with almost every type of orthodontic appliance.
Yet extraoral force is primarily used for two purposes: (1) to correct dental
arch relationships and (2) as anchorage to support teeth that would be dis-
placed while other movements are being carried out.
The most commonly used extraoral devices are the neckstrap for cervical
pull and headcaps for straight pull and for higher pull. Force delivery to the
teeth is usually accomplished by means of a face-bow attached to an intraoral
bow which is inserted into buccal tubes on the maxillary molar ba.nds or by direct
attachment of the headgear arms to hooks on the maxillary arch wire itself.
Extraoral traction has many advantages when used properly, but it may
produce unfavorable tooth movements and treatment results when basic bio-
mechanical principles governing the direction of the applied force are dis-
regarded. The most common adverse effects are extrusion and tipping of molar
teeth. Furthermore, Schudy3 stressed that molar elongation must be avoided in
persons with retrognathic facial profiles since extrusion of posterior teeth tends
to rotate the mandible dorsally, thereby aggravating their facial disfigurement.
Poulton* warned particularly against the indiscriminate use of the cervical
neckstrap because it harbors a considerable vertical force component. Kuhn5
considered the control of posterior tooth eruption a major factor in attempts to
modify or maintain lower face height.
Whatever the merits of these concepts and critiques may be, an understand-

*Postdoctoral Fellow in Orthodontics, Harvard School of Dental Medicine-Forsyth

Dental Center. Present address: University of the Pacific, San Francisco, Calif.
Volume 58 Colltrolled extraoral force applicatio9~ 407
Number 5

LINE OF
ACTION
PERPENDICULAR

APPLIED
FORCE

Fig. 1. Motion of a flywheel which revolves around a fixed axis (A). The direction of move-
ment (1) depends on the relation of the applied force (F) to the axis of rotation. a, Counter-
clockwise movement occurs when force is above the axis of rotation (P); b, no rotation
occurs when force is applied through the axis of rotation; c, clockwise movement occurs
when the force is below the axis of rotation. (From Gould: American Journal of Ortho-
dontics 43: 319-333, 1957.)

ing of the various force vectors and resultant tooth movements produced by each
type of extraoral traction is essential in orthodontic practice.
To clarify the mechanical principles involved, Gould6 utilized a theoretical
model by examining the motion of a flywheel which revolves around a fixed axis,
as shown diagrammatically in Fig. 1. The action line of an applied force is
projected beyond a point where a line (P) may be drawn perpendicular to it
from the axis or center of rotation. The flywheel will turn counterclockwise
when the force is above the axis of rotation (Fig. 1, a), and the rotation will be
clockwise when the force is applied below the axis of rotation (Fig. I., c). No
rotation occurs when the force intersects the axis (Fig. 1, 6).
According to these principles, the direction in which molars will tip is a
function of the position of the applied force in relation to the tooth’s axis of
rotation. The exact center of rotation or fulcrum of a tooth is unknown, but it is
generally assumed to be at the middle to apical third of the root.?-”
Only a minimal amount of Lipping occurs when the line of a&ion of the
applied force approximates the tooth’s cent,er of rotabion. Tipping increases
p~oportionntcl~- with the ~listatrr~ of this line to the center of rotation.
~Yroulcl~ has demonstratetl how ;~lt erat,ions in the length and in the inclina-
tion of t,he face-bow of the cervical or headgear appliances affect t.he direction
of the force and, consequently, the direction of tooth movement.
Yet, the type of extraoral traction dictates the main component of force,
cervical-pull headgears exerting extrusive force while high-pull headcaps
yield intrusive force on the permanent first molars.
Exceedingly long or short, arms of the fate-bow direct, the force farther away
from the tooth’s center of rotation and, therefore, produce excessive tipping.
 Amer. J. Orthodont.
488 Greenspatt November 1970

STRAIGHT

DOWN

Fig. 2. Key to interpretation of charts for tooth movement by means of extraoral force,
showing different lengths [short, medium, and long) and inclinations (up, straight, and
down] of the outer arms of the face-bow.

SHORT MEDIUM LONG

UP

STRAIGHT

DOWN

Fig. 3. Chart indicating the movement of maxillary molars when a cervical appliance or
neckstrap is used with variations in the length and inclination of the outer bow. The
resultant force vectors of the nine possible combinations of these two variables can be
found by matching the proper row (inclination) and column (length). The size and bold-
ness of the straight arrows are proportional to the direction of expected tooth movement.
The size and number of the curved arrows likewise indicate the relative amounts of tipping
produced.
%%%-“5” Co~holled extraoral force application 489

Bending face-bow arms upward or downward directs the force toward or away
from the axis of rotation, depending upon the direction of pull from the head-
gear.
The generally required bodily or translatory movement of molars requires
the design of an optimal force system which also involves careful adjustment of
the length and inclination of the outer bow. If desired, the direction of the force
can be approximated by taking a lateral head radiograph of the patient with
the extraoral appliance in place.

Reference charts for headgear design

To provide a guide for the clinician, three charts have been developed which
illustrate the effect of modifications in the length and inclination of the outer
bow of the extraoral appliance on molar movement for each of three different
types of extraoral anchorage. All theoretically possible combinations of changes
in length and inclination of the face-bow arms have been included, although it
was recognized that they do not all have practical application.
The direction of expected tooth movement is represented by straight arrows,
and the most predominant movement has been shown with a bold arrow. The
amount and direction of tipping are indicated by curved arrows, their number
and size being proportional to the extent of tipping movement transmitted to
the permanent first molars.
A key is provided for reference purposes (Fig. 2). It illustrates the length
of the outer arms of the face-bow considered when evaluating the force systems
represented in these chart,s (the long arms extending distal to the maxillary
first molars, the short arms anterior to the molars, and the medium arms reach-
ing the level of the molar tubes). -41~0 shown are upward and downward bends
of the outer arms of t,he face-bow at approximately 30 degrees.
The expected molar movement achieved with a cervical device, straight-pull,
and high-pull tract’ion with headgears is shown in Figs. 3 to 5, respectively, on
the assumption that the biologic response to the difflerent force systems conforms
to the inferences from Gould’s model.
For these charts to be used in clinical practice, the required tooth movement
must be defined first, and subsequent reference to the charts facilitates the de-
sign of the proper appliance. Conversely, they also serve to check the effective-
ness of extraoral appliances that are already worn by patients in a,ctive treat-
ment.
Ccrvic!al devices cause t~~trusion of teeth, a movement that may be desirablr
fw the rnwec+ion of R i*lose- or deep-bite, particularly in patirnts with low
FBIA angIt%~ t3ut undesirable in those with high E’MA angles and c011vex profile
outlines. Long outer arms bent downward (insofar as tolerated by the patientsj
direct the force through the axis of rotation, thus causing both extrusion and
distalization (Fig. 3, Row 3, Column 3), as would medium-length arms bent
upward (Fig. 3, Row I, Column 2).
The amount of tipping can also be controlled when the cervical pull is used,
by varving the length and direction of the outer arms, as shown in Fig. 3.
The straight-pull occipital appliance primarily delivers a distal force, but
 Amer. J. Orthodont.
November 1970

SHORT MEDIUM LONG

UP

STRAIGHT

DOWN

Fig. 4. Chart indicating the movement of maxillary molars when an occipital headgear is
used for straight pull. (See legend below Fig. 3 for additional explanation.)

SHORT MEDIUM LONG

UP

STRAIGHT

DOWN

Fig. 5. Chart indicating the movement of maxillary molars when a high-pull headgear is
used. (See legend below Fig. 3 for additional explanation.)
Volume 58 Controlled extrnornl force application 491
Number 5

it can also produce intrusive and extrusive forces. If the outer arms are bent
upward, extrusion will result (Fig. 4, Row l! Columns 1, 2, and 3)) and intru-
sion of permanent molars should occur when the outer bow arms are bent down-
ward (Fig. 4, Row 3, Columns 1, 2, and 3).
Pure distal movement is difficult to obtain, even with the straight-pull
headgear, because some degree of tipping is unavoidable (Fig. 4, Row 2, Col-
umns 1, 2, and 3).
As mentioned previously, a high-pull headgear is the appara.tus of choice
for inducing an intrusive force component to maxillary molars, while it is also
capable of delivering as much distal force t,o the molars as the cervical appli-
ance.
If an upward and backward force is desired, the high-pull headgear with
straight a.nd medium-length outer bow arms is most suitable (Fig. 5, Row 2,
Column 2). Changes in the length of the outer arms with a high-pull headgear
result in tipping of molars in addition to their distalization and the delivery
of an intrusive force. Slight distal root tipping will occur when straight outer
arms are cut short (Fig. 5, Row 2, Column 1)) and the amount of tipping can be
increased by bending the arms upward (Fig. 5, Row 1, Columns 1,2 and 3).

Conclusion

Monitoring of force systems according to biomechanical principles is a pre-

requisite to obtain controlled tooth movement. The guidelines presented here in
chart form for quick reference purposes should likewise prove advantageous in
the design of extraoral appliances. Yet it must be emphasized that the actual
changes in the position of the teeth are dependent on tissue response not only to
forces from orthodontic appliances but rather to the addition of such forces in
the equation of a multifactorial system in which all factors interrelate.
The author is indebted to Coenraad F. A. Moorrees, professor of orthodontics, for counsel
and guidance during the preparation of this manuscript.

REFERENCES
1. Weinberger, B. WY.: Orthodontics-An historical review of its origin and evolution,
St. Louis, 1926, The C. V. Mosby Company, Vol. II.
2. Kloehn, 5. J.: Orthodontics-Force or persuasion, Angle Orthodont. 23: 56-65, 1953.
3. Schudy, F. F.: Vertical growth versus anteroposterior growth as related to function and
treatment, Angle Orthodont. 34: 75-93, 1964.
.s. Poulton, D. R.: Changes in Class II malocclusions with and without occipital headgear
therapy, Angle Orthodont. 29: 234-249, 1959.
.i. Kuhn, R. J.: Control of anterior vertical dimrbnsion and p~op,‘r sclcction of extra-oral
anchorage, .\rrglo Orilwlunt. 38: 240.340, lQ68.
ii. Gould, 1. E. : Mwhanical prin~iplw in orthwlonti~+, .\ ~IRI:. .I. ~I:TIlOFK~Sl~. 43: 319.33.7,
1957.
7. Oppenheim, ,4.: Biologic orthodontic therapy and reality, Angle Orthodont. 6: 77-81, 1936.
R. Thurow, C. : Periodontal membrane in function, Bngle Orthodont. 15: 20-25, 1945,
9. Dijkman, J. E’. P. : Krachtenverdelingen bij orthodontische behandelingen, Doctoral thesis,
University of Nijmegen, The Netherlands, 1969.