Biomechanical Guidelines For Headgear

Application
GISELA I. CONTASTI , DDS, HARRY L. LEGAN, DDS
The efficient use of the headgear requires a sound knowledge of basic biomechanics.
Understanding how to control the direction and magnitude of the forces produced by various
headgear designs is paramount in achieving desirable clinical results. Decreasing the patient's length
of treatment and improving the treatment results would be only two of the benefits derived from
applying well-planned force systems. To aid the clinician, a method of analyzing force systems
produced in the anterior-posterior and vertical planes will be presented.

In 1971 Armstrong1 demonstrated the importance of the precise control of magnitude, direction,
and duration of extraoral force to increase its efficiency and effectiveness in treating malocclusions
in the late mixed dentition. Gould 5 has shown how changes in the inclination of the facebow affect
the direction of the force and ultimately the direction of tooth movement. Greenspan 8 presented
reference charts elaborating the different moments and forces produced with the various headgear
designs.

Mechanical Model

The orthodontist should not need to memorize or refer to charts when selecting and fitting
headgears. An understanding of simple biomechanics will enable the practitioner to optimally plan
the appliance. To clarify the forces and moments produced by the headgear, the principle of force
application relative to a center of resistance will be used.

For diagrammatic purposes, the headgear is applied to the maxillary first molar. The center of
resistance (CR) is that point of a constrained body through which a single force will cause
translation of that body2. The CR is located about four-tenths of the distance apically from the
height of the alveolar bone, or approximately at the trifurcation of the first molar roots. When the
line of force (LF) is applied through the CR no tipping will occur. For practical purposes, the CR
does not change for a given object such as a tooth. However, varying the application of the LF will
change the way the tooth moves and, therefore, the center of rotation (CRot) 4.

The inner bow of the headgear is placed into the molar buccal tubes parallel to the occlusal plane
so that it lies comfortably between the lips. The outer bow is infinitely adjustable short, medium,
long, up, down, etc. The assembly may be regarded as rigid, although we know that elastic
deformation takes place when the headgear is activated.

Only posterior-pull headgear applied to the upper first molar will be considered here. The
principles, however, apply to protraction headgears, headgears to the mandibular arch, etc. In Figure
1, the relation of the application of force relative to the body to be displaced is shown. When the LF
is applied through the CR, the object translates (all points of the object move the same distance

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 along parallel lines). If the LF is moved superiorly, the CRot moves coronally, and one gets a
counterclockwise moment. Conversely, a more inferiorly positioned line of force will displace the
CRot apically, creating a clockwise moment. Changing the direction of the line of force also
determines the vertical forces that are often overlooked, but so extremely important in orthodontic
treatment.

The magnitude of the moment produced by the headgear is calculated by multiplying the
perpendicular distance (P) from the LF to the CR by the magnitude of the force. Thus, for a given
force, the greater the distance from the CR that the force is applied, the greater will be the moment.
A comprehensive understanding of the potential, limitations, and undesirable side-effects can be
gained by understanding the mechanical principles involved in its application. We can now apply
our basic principles to assess force systems applied by various headgear designs.

Cervical Headgear

The cervical (Kloehn) headgear is a device that many orthodontists have used routinely in the
great majority of their headgear cases. It is composed of three basic parts: (1) molar bands and
tubes, (2) inner bow and outer bow soldered together near the middle of the two bows, and (3) a
neckstrap that is placed around the back of the neck to provide traction to the denture. This extraoral
pull is generally applied bilaterally, for three main purposes: (1) as a restraining force, (2) as a
retracting force, or (3) as a supplementary force.

The cervical headgear is applied in early treatment of Class II malocclusion to inhibit forward
displacement of the maxilla or maxillary teeth, while the rest of the dentofacial structures continue
their normal growth. As demonstrated by Oppenheim, this can cause a change in the intermaxillary
relationship from Class II to Class I. Perhaps the change in molar relationship is due not so much to
the distal force, but to the clockwise moment that very effectively tips the molar crown distally.

The main disadvantage to the use of the cervical headgear is that it normally will cause extrusion
of the upper molars. This movement is seldom desirable except in treatment of patients with short
lower facial heights. These patients, it should be remembered, are few and far between.

The decision to treat with cervical headgear needs to be based on a complete understanding of the
desired tooth movement and the force system that is produced with this headgear style. These
principles of understanding resultant force systems are diagrammed in Figure 2, taking as a starting
reference the "O moment line of force" (LFO), which is a line from the strap-force application point
through the maxillary center of resistance. The different moments and forces produced by the
cervical headgear depend on the situation of the outer bow in relation to the LFO. By definition,
when the outer bow lies along the LFO, no moment occurs, and the force system will be reduced to
a bodily movement in a posterior and extrusive direction. If the outer bow is placed above this line,
the moment produced by the force will be in a counterclockwise direction. On the other hand, if the
outer bow is adjusted below this line the moment created will be clockwise. However, the direction
of the forces are the same - extrusive and posterior. It should be noted though that there is an

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 exception to this rule. If the outer bow is located below the neckstrap, the resultant force will be a
small intrusive one, instead of extrusive. Of course, a distal force and large clockwise moment will
also be produced.

The direction of pull provided by the cervical headgear is especially advantageous 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. Also, the clockwise moment that is so
readily produced with this headgear is very effective in helping conserve anchorage in extraction
cases.

High-Pull Headgear

The high-pull headgear, like the cervical-pull, is analyzed using the same principles of force and
moment production described before. This style headgear always produces an intrusive and posterior
direction of pull, due to the position of the headcap.

The direction of the moment that is produced is dependent on the position of the outer bow (Fig.
3). If the outer bow is placed anterior to the LFO, either above or below the occlusal plane level, the
moment produced will be counterclockwise. On the other hand, if the outer bow is placed posterior
to this line, the moment produced will be in a clockwise direction. The magnitude of this moment
will be proportional to the distance of the outer bow to the CR. If a distal and intrusive movement
with no moment is desired, the outer bow must be placed somewhere along the LFO. This force
system would be beneficial in a long-face Class II patient with a high mandibular plane angle, where
intrusion of maxillary molars would decrease facial height and improve the facial profile.

Straight-Pull Headgear

This style headgear is a combination of the high-pull and cervical headgear, with the advantage
of increased versatility. Depending on the force system desired, the orthodontist has the opportunity
to change the location of the LFO.

The prime advantage of this headgear is its ability to produce an essentially pure posterior
translatory force. This is accomplished by placing the LFO through the center of resistance, parallel
to the occlusal plane. Clinically, this means bending the outer bow to the same level as CR, and
hooking the elastic to a notch at the same vertical level.

The relation of the outer bow to the LFO dictates the direction and magnitude of forces and
moments. As shown in Figure 4, placing the outer bow above the LFO will produce a posterior
force, counterclockwise rotation, and most often an intrusive force. However, if the LFO cants up
anteriorly (attachment site of elastic is lower on headcap than at outer bow), an extrusive force will
be produced. If the outer bow is below the LFO, the force produced will be posterior and superior,
and the moment will be in a clockwise direction.

The straight-pull is the headgear of choice in a Class II malocclusion with no vertical problems. It

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 is also the headgear of preference when the main thrust of headgear wear is to prevent anterior
migration of maxillary teeth, or possibly even translate them posteriorly.

Vertical-Pull Headgear

The main purpose of this headgear is to produce an intrusive direction of force to maxillary teeth,
with posteriorly directed forces. If the outer bow is hooked to the headcap so that the line of force is
perpendicular to the occlusal plane and through the CR, pure intrusion may take place. Due to the
multiple notches in the headcap, this headgear is also very versatile, as the LFO orientation may be
changed. However, upon establishing the LFO, our principles of determining force systems
produced remains unchanged. In Figure 5, the head is divided into two components: the anterior
component from the LFO forward and the posterior component located behind the LFO. If the outer
bow is placed anywhere in the anterior compartment, the moment created will be counterclockwise,
and the forces produced will be intrusive and posterior. If the outer bow is placed anywhere in the
posterior section, the moment will be clockwise and the vertical force will be intrusive, but the
horizontal force will be forward. If this latter force system is desired, it will require inserting the
inner bow into the buccal headgear tube from the distal.

The vertical-pull headgear is not as commonly used as are the others. However, it is very useful
when pure intrusion of buccal segments is required, as in the Class I open-bite patient.

Conclusion

The main steps in designing a headgear to deliver the desired force system are as follows:
1. Locate the center of resistance of the object (i.e., entire maxillary arch, first molar only, etc.) to
which the force is to be applied.
2. Construct the "O moment line of force" (LFO) based on force direction requirements. The choice
of headcap or neckstrap is thereby
determined.
3. Based on the desired direction and magnitude of the moment, position the outer bow relative to
the LFO.

GISELA I. CONTASTI

Orthodontic Resident, Department of

Surgery, Division of Oral Surgery, The University of Texas
Health Science Center at Dallas, 5323 Harry Hines

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Footnotes 4
 Boulevard, Dallas, Texas 75235.

HARRY L. LEGAN

Assistant Professor and Director of

Orthodontics, Department of Surgery, Division of Oral
Surgery, The University of Texas Health Science Center at
Dallas, 5323 Harry Hines Boulevard, Dallas, Texas 75235.

FIGURES

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Footnotes 5
Fig. 1

Fig. 1 Moments (M) and forces produced by force vectors applied at varying positions relative to the center of
resistance (CR) of a constrained body in this case the maxillary 1st molar. The vertical (V} and horizontal (H) forces are
proportional in magnitude to the legs of the triangle that is constructed. In (a) the vertical and horizontal components of
the force are approximately equal. The moment's direction is counterclockwise since the line of force is above CR. The
magnitude of M is the product of LF times the perpendicular distance (identified as P)from LF to CR. LF goes through
CR in (b) thus there is no M produced. The tooth will translate parallel to the line of force. The posterior force
component is larger than the superior. The LF in (c) will produce a posterior and interior movement. The moment (P x
LF) is below CR and is therefore clockwise.

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Figures 6
Fig. 2

Fig. 2 Force systems with cervical headgear. OB (Outer bow)-A lies along the LFO and therefore only vertical and
horizontal forces v ill be produced no M. The position of OB-B will produce an extrusive F posterior F and
counterclockwise M since it is above CR. Outer bows located below the LFO will produce posterior forces and smaller
extrusive forces since they are closer vertically to the neckstrap and clockwise moments.

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Figures 7
Fig. 3

Fig. 3 High-pull headgears produce intrusive and posterior forces. Locating the outer bow in front of the LFO (A and D)
will produce a counterclockwise M while an OB behind (B and C) will create a clockwise M. An OB located on the LFO
would of course produce no M.

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Figures 8
Fig. 4

Fig. 4 The straight-pull headgear is versatile in that the clinician has many optional LFO's . In this case an OB located
on the LFO would cause translation in a posterior and slightly superior direction. OB's above the LFO will produce
posterior and extrusive forces and clockwise moments. Placing the outer bow along an LFO that Is parallel to the
maxillary occlusal plane will produce a pure posterior translation.

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Figures 9
Fig. 5

Fig. 5 The vertical-pull headgear is used primarily when a large magnitude of pure intrusion is needed. The outer bow
must be located on the LFO to obtain pure intrusion (A). An OB located anterior to the LFO will produce an intrusive
force and a smaller posterior force and a counterclockwise moment (B and C). Locating the OB posterior to LFO will
cause intrusion a small anterior force and a clockwise moment (D and E).

References

1. Armstrong, M.M.: Controlling the magnitude, direction and duration of the extraoral force, Am. J. Orthod.
59:217-243, 1971.

2. Burstone, C.J.: The biomechanics of tooth movement. Vistas in Orthodontics, Kraus, B.S. and Riedel, R.A. ed., Lea
and Febiger, 197-213, 1962.

3. Case, Calvin S.: Dental Orthopedia, 2nd Ed. C.S. Case Co., Chicago, III., 1921.

4. Christiansen, R.A. and Burstone C.J.: Centers of rotation within the periodontal space, Am. J. Orthod., 55:353-369,
1969.

5. Gould, I.E.: Mechanical principles in extraoral anchorage, Am. J. Orthod., 43:319-333, 1957.

6. Graber, T.M.: A cephalometric appraisal of the result of cervical gear therapy, Am. J. Orthod., 40:60, 1954.

7. Graber, T.M.: Extraoral force-facts and fallacies, Am. J. Orthod., 41:490-505, 1955.

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References 10
8. Greenspan, R.A.: Reference charts for controlled extraoral force application to maxillary molar, Am. J. Orthod.,
58:486-491, 1970.

9. Kloehn, S.J.: An appraisal of the results of treatment in Class II malocclusion with extraoral forces. Vistas in
Orthodontics Kraus B.S. and Riedel, R.A. ed., Lea and Febiger 227-258, 1962.

10. Oppenheim, A.: A possibility for physiologic orthodontic movement, Am. J. Orthod. and Oral Surg., 30:354-356,
1944.

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References 11