Orthodontic headgear is an appliance designed to apply external, controlled forces to the teeth and jaw structure to correct alignment issues. It typically consists of an internal facebow connected to the upper molars and an external strap or cap anchored to the head or neck. The primary function of headgear is to create orthopedic change, meaning it influences the growth of the facial bones rather than simply moving individual teeth. Although often associated with older treatment methods, headgear is still utilized by orthodontists today. It remains a relevant tool, although its prescription rate has declined significantly due to advancements in intraoral technology.
Why Orthodontic Headgear Remains a Treatment Option
Headgear retains its place in orthodontics due to its unique ability to apply heavy, directional forces necessary for modifying skeletal growth in adolescents. The most common indication is the treatment of severe Class II malocclusions, characterized by a protruding upper jaw, or “overjet.” This condition is frequently caused by a maxilla positioned too far forward or growing too rapidly relative to the mandible.
The external anchorage allows the orthodontist to restrict or redirect the forward growth of the maxilla itself. For a growing patient, headgear can effectively hold the upper jaw in place while the lower jaw is allowed to catch up naturally. This extraoral force also provides maximum anchorage, preventing the upper molars from shifting forward when other teeth need to be pulled backward, a process called molar distalization.
Headgear is also used to correct severe Class III malocclusions, or underbites, where the lower jaw is too prominent. In such cases, a reverse-pull headgear, or facemask, is employed to stimulate the forward growth of a deficient upper jaw. For severe skeletal imbalances in a growing patient, the high-magnitude force delivered by headgear can be the most efficient method to achieve the desired bone restructuring.
Different Types of Headgear and Their Functions
Orthodontic headgear is a category of devices differentiated by the direction of the force they deliver, which dictates the type of skeletal correction.
Cervical Headgear
This type uses a strap around the neck for anchorage, delivering a force directed backward and slightly downward to the upper molars. Cervical headgear is primarily employed to correct Class II malocclusions by restricting the forward growth of the maxilla and moving the upper molars distally. The downward pull can cause a slight extrusion of the upper molars, which may be beneficial in patients with a deep bite but is avoided in those with excessive vertical growth. The extrusive force can also cause the mandible to rotate slightly clockwise, increasing the lower facial height.
High-Pull Headgear
High-Pull Headgear anchors to a strap that runs over the back and top of the head, delivering a force directed backward and upward. This upward vector is designed to control or inhibit the vertical development of the maxilla and prevent molar extrusion. High-pull headgear is often selected for patients who have a vertical growth pattern or an open bite, where the downward force of cervical headgear would be detrimental.
Reverse-Pull Headgear (Facemask)
The Reverse-Pull Headgear, or face mask, consists of pads resting on the forehead and chin connected by a vertical frame. Elastics connect this frame to the upper teeth, generating a forward and downward pulling force. This appliance is used exclusively for Class III correction, gently pulling the underdeveloped upper jaw forward to align it with the lower jaw.
Modern Appliances That Have Reduced Headgear Use
The primary reason for the decline in headgear use is the development of effective, fixed appliances that address skeletal discrepancies without relying on external forces or patient compliance.
Temporary Anchorage Devices (TADs)
TADs are small titanium screws placed into the jawbone that have fundamentally changed how orthodontists manage anchorage. These devices act as a stable, fixed point from which to apply force directly to the teeth, allowing for complex molar movements, such as distalization, entirely inside the mouth. TADs provide a level of stationary anchorage previously only achievable with extraoral headgear. This intraoral solution eliminates the need for patient cooperation regarding hours of wear, which was a major drawback of headgear treatment.
Fixed Functional Appliances
Fixed functional appliances have emerged as robust alternatives for correcting Class II malocclusions by promoting mandibular growth. Devices like the Herbst appliance and the Mandibular Anterior Repositioning Appliance (MARA) are cemented onto the molars and worn continuously. They work by posturing the lower jaw forward, encouraging the growth of the mandible and improving the relationship between the upper and lower arches. These appliances bypass the compliance issues associated with headgear by remaining constantly active. Other fixed alternatives, such as the Forsus Fatigue Resistant Device, perform a similar function using a compressed spring mechanism to push the lower jaw forward. The availability of these powerful, fixed, and compliant-free solutions has resulted in headgear being reserved mainly for the most severe skeletal cases or specific growth modification needs.