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Headgear Appliance-A Contemporary Treatment Method: A Review.

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136 International Medical Journal Vol. 24, No. 1, pp. 136 - 139 , February 2017
ORAL SURGERY

Headgear Appliance-A Contemporary Treatment Method: A

Review

Rafiqul Islam1), Mohammad Khursheed Alam2)

ABSTRACT
Background: The prime aim of the study is to evaluated headgear affects growth of class II malocclusion patients.
Material and methods: Articles published till May 2015, describing the effects of class II malocclusion by using headgear,
were performed by using several electronic databases.
Results: All abstracts were read thoroughly, and the full texts of all relevant articles were collected and reviewed. It showed
difference types of headgear combined with fixed appliance or other functional appliance to correct the class II malocclusion.
Conclusion: Headgear Appliance is effective in Class II malocclusion.

KEY WORDS
headgear appliance, functional appliance, angle class II malocclusion

INTRODUCTION
Since early 1800 the headgear has been an integral part of orthopae-
dic treatment1). Use of extraoral traction in orthopaedic treatment espe-
cially in the treatment of maxillary protrusion was first reported in the
1800s. Since then, many authors have reported its use and effects in the
treatment of Class II Division 1 malocclusions2). Headgear treatment is
effective for the correction of Angle Class II malocclusions3). Though,
the cooperation of patients plays a major role in achieving the desired
results, but cooperation is often difficult to verify4). A patient's willing-
ness to wear a headgear is important if treatment is to succeed3).
Headgear focuses to redirect maxillary growth, assuming that the
control of maxilla is easier and more predictable than that of the mandi-
ble5). It has been used to correct disto occlusions by restricting maxillary
horizontal growth, thus permitting mandibular horizontal growth, and
distal zing the maxillary dentition6). There are significant changes in ver-
tical parameters when patients were treated with headgear2).
The purpose of the study is to evaluated headgear affects growth of
class II malocclusion patients.
MATERIAL AND METHODS
An electronic search strategy was conducted in four main databases
(Table 1) with defined key word Combinations (Table 2) to systemati-
cally search for literature published until May 2015. Additionally, a
hand search of headgear appliance and Angle class II malocclusion as
well as of the reference lists of all retrieved articles were performed.
RESULTS
All abstracts were read thoroughly, and the full texts of relevant
articles were collected and reviewed. For each study, a value was given
based on the quality of the following 4 criteria: definition of success,
design of the study, description of the methodology, and control of vari-
ables. Electronic searches for the headgear appliances for Class II
patients identified the following items: 44 articles from PubMed, 24
from Science Direct, 31 from ISI Web of Knowledge and 76 from
Google Scholar. Articles that did not relate to our topic, related with a
different aim. There were eleven original articles for headgear and six
articles for forest plot were evaluated.
DISCUSSION
It is evident from the above that the success rate of orthodontic
treatment is depended on patient's willingness to wear headgear as well
as a few other factors (2414).
A number of authors have already established through their
researches that there is a positive correlation between effective Class II
malocclusion treatment and use of headgears. In relation to this, Table 4
below reveals both pre treatment and post treatment values from differ-
ent authors who used various types of headgears.
The study by Antonarakis et al.7) used high and low pull headgear
which showed the changes in the vertical skeletal relationships. The
study revealed a wide range of deviation during treatment and retention.
On the other hand, the study by Lione et al.8) used cervical headgear and
pendulum appliances. The study revealed that both of the distalizing
protocols were equally effective to treat Class II malocclusion and they
do not increase the vertical dimension at the end of all-inclusive treat-
ment. In contrary to this, Kumar et al.9) used a low pull headgear on
head position over a period of 11-12 months. The results identified that
there was no significant changes in head position either in the controlled
group or the group using headgear. Pedrin et al.10) in their study used a
combination of cervical headgear i.e. two premolar extraction and pen-
dulum appliance. The study results revealed that the result of using this
specific set of appliances is quite similar in both of the Occlusal and

Received on June 28, 2015 and accepted on March 14, 2016

1) School of Dental Sciences, Universiti Sains Malaysia
Kota Bharu, Kelantan, Malaysia
2) College of Dentistry, Al Jouf University
Sakaka, Saudi Arabia
Correspondence to: Mohammad Khursheed Alam
(e-mail: dralam@gmail.com)

C 2017 Japan Health Sciences University

& Japan International Cultural Exchange Foundation
 Islam R. et al. 137

Table 1. Electronic databases search Table 2. Key word combinations with which systematic litera-
PubMed ture search was conducted
Science Direct Headgear appliance
ISI Web of knowledge Functional Appliance
Google scholar Angle class II malocclusion

Table 3. Characteristics of studies

Author and Population Sample size ( sex, age) Types of Methods Outcome
year headgear use
Antonarakis and Switzerland 30 patients (15 females High pull and low Cephalometric analysis. Changes in the vertical skeletal relationships
Kiliaridis.7 and 15 Males, 10.8 pull headgear that revealed a wide range of deviation during
2015 years) treatment and retention.
Lione et al.8 Italy 40 patients (25 females Cervical headgear Cephalometric analysis Effective in the correction of Class II
2014 and 15 males, 11.5 and Tukey's post hoc malocclusion without increasing the vertical
years) tests. dimension.
Kumar and India 30 patients ( 30 males, Low pull headgear Cephalometric analysis. There is no deleterious effect on head
Pentapati.9 11 years) position with the application of orthopedic
2013 force.
Pedrin et al.10 Brazil 30 patients (15 females Cervical headgear Cephalometric dental Class II treatment with extraction of
2009 and 15 males, 13.3 casts analysis. maxillary teeth was more efficient because of
years) the shorter treatment time.
Virkkula et al.11 Finland 68 patients (28 Cervical headgear Cephalometric analysis. The early headgear treatment has only a
2009 females, 40 males, 7.6 minor effect on the soft-tissue profile.
years)
Angelieri et al.12 Brazil 30 patients (19 Cervical headgear Cephalometric and The cervical headgear appliance, which
2008 females, 11 males, dental casts analysis restricted maxillary forward displacement,
13.07 years) improved the skeletal maxillomandibular
relationship.
Turkkahraman Turkey 16 patients (7 females, High pull headgear Cephalometric analysis. Retroclination of the maxillary incisors and
and Sayin.13 9 males, 13.04 years) proclination of the mandibular incisors were
2006 inevitable results of using appliances.
Ulger et al. 14
Turkey 24 patients (13 Cervical headgear Cephalometric analysis. Produced Class II correction through
2006 females, 11 males, maxillary orthopedic and orthodontic
8.85 years) changes, reductions in maxillary protrusion,
maxillary molars were moved distally and
tipped mesially.
Agar et al.15 Turkey 51 patients (34 cervical pull headgear Mann-Whitney U and The competence areas and behaviour
2005 females, 17 males, Chi square tests problems of patients are alone insufficient to
12.92 years) predict headgear compliance.

Cephalometric perspective. Due to shorter treatment time, treating a
Class II malocclusion with extraction of maxillary teeth was found to be
more efficient than the other two protocols. It was also pointed out in
the extraction group that after treatment, better retraction of the upper
lip compared to the esthetic plane was achieved through this.
Nevertheless, it could be a result of slightly greater maxillary dentoalve-
olar protrusion at the beginning of the treatment.
Virkkula et al.11) in their study used cervical headgear with long
term soft tissue response that showed that early HG treatment has a
minor effect on the soft-tissue profile. However, it had a significant
effect on the thickness of the soft-tissue of the chin and on the curve of
the lower lip. Nonetheless, there were no significant differences during
the long-term follow-up. In the study by Angelieri et al.12) two different
types of molar distalizers i.e. cervical headgear and the intraoral pendu-
lum appliance were used. The result from this study showed that both of
these distalizers were effective in treating Class II malocclusion.
However, while the pendulum appliance produced only dentoalveolar
effects, the cervical headgear appliance was able to improve the skeletal
maxillo mandibular relationship due to restricted maxillary forward dis-
placement. On the other hand, the study by Martins et al.17) was devised
to differentiate the dentoalveolar and skeletal effects to better under-
stand orthodontic treatment with the bionator and the removable head-
gear splint. The result showed that the bionator was able to cure the
molar relationships and the overjet of Class II patients through dentoal-
veolar changes. On the other hand, the removable headgear splint was
successful in correcting the molar relationships and the overjet of Class
II patients compared to the controlled group treated with bionator.
Comparing to the bionator group, there was better maxillary molar dis-
talization in the group treated with removable headgear splint.
Another study by Turkkahraman et al.13) used Andresen activator
and activator headgear combination to determine whether the activator
and activator headgear encourage mandibular growth or not. The results
showed that both the appliances resulted in retroclination of the maxil-
lary incisors and proclination of the mandibular incisors. Nonetheless,
the mandibular incisors were better controlled in the activator headgear
combination group and skeletal, dentoalveolar and soft tissue changes
significantly differed from those of normal growth.
The Ulgar et al.14) study focused to evaluate the treatment changes in
skeletal and dental parameters in developing patients by using cervical
headgear. The treatment showed significant reductions in maxillary pro-
trusion and significant increases in the anterior descent of the palatal
plane as well as increases in anterior face height with higher values in
the treatment groups than the control group. In addition, the treatment
groups also showed statistically significant rates of increase in ramus
height which resulted in relatively unchanged mandibular plane orienta-
tion.
138 Headgear Appliance

Table 4. Pre treatment and post treatment value by using various types of headgear.
Author Year No. of subject (sex, age) Types of headgear Cephalometric characteristics Pre treatment Post treatment
Mean SD Mean SD
Antonarakis and 2014 30 patients (15 females and 15 High pull headgear SNA(0) 80.8 3.5 79 6
Kiliaridis.7 Males, 10.8 years) SNB(0) 74.6 2.9 75.1 5.1
ANB( )
0
6.2 1.9 3.9 3.6
Overjet (mm) 5.8 1.9 3.2 4.1
Overbite (mm) 3.5 1.9 2 3.8
Low pull headgear SNA( )
0
81.4 4.0 79.8 5.8
SNB(0) 76.4 3.2 76.9 5
ANB(0) 5.0 1.9 2.9 3.1
Overjet (mm) 5.3 2.1 2.6 4.4
Overbite (mm) 4.6 2.2 2.9 4.5
Lione et al. 8
2014 40 patients (25 females and 15 Cervical headgear SNA( )
0
80.1 3.7 78.9 5.7
males, 11.6 years) SNB(0) 75.7 3.0 76.2 4.9
ANB(0) 4.4 2.4 2.6 4.1
Overjet (mm) 4.5 2.4 2.4 4.7
Overbite (mm) 2.8 1.5 2.1 2.7
Molar relationship (mm) 0.1 1.1 3 2.6
Lee et al. 16
2013 28 patients High pull headgear SNA( )
0
81.36 2.74 81.02 2.73
SNB(0) 77.55 3.98 77.36 3.98
ANB(0) 3.80 2.11 3.66 2.17
Overjet (mm) 4.86 3.52 3.07 0.66
Overbite (mm) 1.93 2.15 1.57 0.49
Molar relationship (mm) -2.54 2.38 -2.23 2.64
Pedrin et al.10 2009 30 patients (15 females and 15 Cervical headgear SNA(0) 82.1 3.2 81.3 4.2
males, age 13.3 ± 1.6 years) SNB(0) 77.8 3.4 78.2 4.3
ANB( )
0
4.2 2.2 3 3
Overjet (mm) 5.3 3.0 3.7 4.7
Overbite (mm 3.4 1.5 2.7 2.6
Molar relationship (mm) 0.3 1.3 -1.0 2.4
Angelieri et al.12 2008 30 patients (19 females and 11 Cervical headgear SNA(0) 82.29 3.2 81.05 4.73
males, age 13.07 years) SNB(0) 77.85 3.47 78.28 4.85
ANB(0) 4.45 2.01 2.78 3.22
Overjet (mm) 5.28 3.08 3.05 5.85
Overbite (mm 3.53 1.52 2.59 2.99
Molar relationship (mm) 0.43 1.28 -1.38 2.93

Figure 1. Forest plot for the treatment changes in SNA (0). Figure 2. Forest plot for the treatment changes in SNB(0).
 Islam R. et al.
Figure 3. Forest plot for the treatment changes in ANB(0).
Figure 5. Forest plot for the treatment changes in overjet.
The study by Hagg et al.18) tried to investigate the long term out-
come of treatment with reverse headgear in young individuals with a
reverse overjet and a skeletal class III malocclusion resulted from max-
illary deficiency. The result showed that early treatment of maxillary
deficiency with reverse headgear resulted in positive Overjet among all
patients. However, it should be noted here that the long term follow up
of the positive overjet cases was maintained only in two out of three
patients. One out of these patients developing a negative overjet had a
comprehensive orthodontic treatment while the remaining patients were
considered as candidates for orthodontic surgery. Agar et al.15) conducted
a study to identify the role of psycho-social factors in headgear compli-
ance. Unfortunately, the results of this study revealed that the compe-
tence areas and behaviour problems of patients are inadequate to predict
headgear compliance.
Figure 1, 2, 3, 4, 5 and 6 show the forest plot for the SNA, SNB,
ANB, Molar relationship, over jet and overbite respectively.
CONCLUSION
Head Gear Appliance is very much effective in orthopedic treatment
especially in Class II malocclusion treatment it has been very much of
success.
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View publication stats
139
Figure 4.
Figure 6. Forest plot for the treatment changes in overbite.
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