Need for treatment and concurrent corrections
The most common treatment headgear is used for is to correct anteroposterior discrepancies. The headgear attaches to the braces via metal hooks or a facebow. Straps or a head cap anchor the headgear to the back of the head or neck. In some situations, both are used. Elastic bands are used to apply pressure to the bow or hooks. Its purpose is to slow or stop the upper jaw from growing, thereby preventing or correcting an overjet.
Other forms of headgear treat reverse overjets, in which the top jaw is not forward enough. It is similar to a facemask, also attached to braces, and encourages forward growth of the upper jaw.
Headgear can also be used to make more space for teeth to come in. In this instance the headgear is attached to the molars, via molar headgear bands and tubes, and helps to draw these molars backwards in the mouth, opening up space for the front teeth to be moved back using braces and bands. Multiple appliances and accessories are typically used along with the headgear, such as: power chains, coil springs, twin blocks, plates or retainers, facemasks, a headgear helmet (a headgear helmet is a cervical headgear with a cap that covers the entire head), lip bumpers, palate expanders, elastics, bionaters, Herbst appliances, Wilson appliances, other headgear, hybrid twinblocks, positioner retainers, and jasper jumpers. Many patients wear a combination of, or all of these appliances at any given time in their treatment.
Forms of headgear treatment
Headgear needs to be worn approximately 12–22 hours each day to be effective in correcting the overbite, typically for 1 to 1.5 years depending on the severity of the overbite, how much it is worn and how much a patient is growing.
Orthodontic headgear will usually consist of three major components:
- Facebow: first, the facebow (or J-Hooks) is fitted with a metal arch onto headgear tubes attached to the rear upper and lower molars. This facebow then extends out of the mouth and around the face. J-Hooks are different in that they hook into the patients mouth and attach directly to the brace (see photo for example of J-Hooks).
- Head cap: the second component is the head cap, which consists of a number of straps fitting around the head. This is attached with elastic bands or springs to the facebow. Additional straps and attachments are used to ensure comfort and safety (see photo).
- Attachment: the third and final component – typically consisting of rubber bands, elastics, or springs – joins the facebow or J-Hooks and the head cap together, providing the force to move the teeth backwards.
Soreness of teeth when chewing or when the teeth touch is typical. Teenagers usually feel the soreness to 2 to 3 hours later, but younger patients tend to react sooner, (e.g., 1 to 1 1⁄2 hours). Headgear is one of the most useful appliances available to the orthodontist.
Facemask and reverse-pull headgear
Facemask or reverse-pull headgear is an orthodontic appliance typically used in growing patients to correct underbites (technically termed Class-III orthodontic problems) by pulling forward and assisting the growth of the upper jaw (maxilla), allowing it to catch up to the size of the lower jaw (mandible). Facemasks or reverse-pull headgear needs to be worn approximately 14 to 24 hours per day to be truly effective in correcting the underbite, usually anywhere from 12 to 18 months depending on the severity of the bite and how much a patient is growing.
The appliance normally consists of a frame or a center bars that are strapped to the patient's head during a fitting appointment. The frame has a section which is positioned in front of the patient's mouth, which allows for the attachment of elastic or rubber bands directly into the mouth area. These elastics are then hooked onto the patient's braces (brackets and bands) or appliance fitted in his or her mouth. This creates a forward pulling force to pull the upper jaw forward.
The orthodontic facemask consists of three major components:
- Face frame: first, the face frame is a metal and plastic structure which is adjusted to fit onto the patient's face. The frame is normally stabilized on the child's face with the aid of a chin cup and a forehead pad. These are padded to ensure patient comfort. The frame typically has a mouth-yoke, which the orthodontist will adjust so it is positioned in font of the patient's mouth. The mouth yoke has a number of hooks (four to six depending on type – see photo with six hooks), which allows the orthodontist to attach elastics or springs directly into the patient's mouth. The frame allows the patient to move his or her head freely and to talk. All other oral activities are restricted, although drinking is recommended with a straw so as not to remove the whole appliance at night or in the day when thirsty.
- Head cap: some facemasks and all reverse-pull headgear have a second part which consists of a head cap, and is made up of a number of straps fitting around the patient's head. In this case the head cap is used to stabilize the face-frame described above and to ensure it is held correctly in position (see photo example of reverse-pull headgear with head-strap/cap).
- Attachment: the third and final component is the mouth attachment – typically using rubber bands – joins the facemask from the mouth-yoke into the patient's mouth. The elastics hook on the patient's braces or other such suitable oral appliance. As the elastics are flexible, up to six elastics may be used to provide various forward and sideways forces on the patients teeth and arch, while still allowing the patient to open and close his or her jaw.
In some cases surgery is required in conjunction with a facemask or reverse-pull headgear. Many parents and doctors recommend using early intervention (ages 7 to 13) by using a facemask to avoid costly and painful surgical procedures later.
The appliance is very effective in correcting Class III orthodontic problems in younger or adolescent patients that are still growing. Initially, it can be difficult for children to wear a mask or headgear, however most doctors and parents agree that children and adolescence adapt quickly to such changes and requirements. Parents should be aware that their child is often better-off wearing a facemask or headgear to avoid later surgery and the patient, friends and school peers normally get used to the new appliance after just a few weeks of wear.
Orthodontic headgear has some unpleasant side-effects.
First and foremost, it pulls the upper jaw backwards into the airway of a growing child. The back wall of the upper jaw forms the front wall of the upper airway, so pulling backwards on the upper jaw necessarily has an impact on the upper airway. This is very dangerous to do, because when the growth of the airway is stunted, a patient can have difficulty breathing for the rest of their life in form of obstructive sleep apnea, whereby the airway is too small for the tongue, which blocks the airway during sleep. Additionally, forward grown faces tend to be more attractive, and the "headgear effect", which includes pulling the face backwards, tends to result in a more flattened cranio-facial profile, including recessive chins and flattened cheekbones. Since the early 1900's, there have been many alternatives to headgear, which were designed to push the lower jaw forward, rather than pull the upper jaw backwards.
There are also temporary side effects. These include fear of mockery and harassment with regard to the appearance of the headgear, difficulty when eating, sleeping, and performing head-and-neck motions, if the facebow is wired in, interference with relationships by the inhibition of kissing or any other closeness to the face. In some cases, eye injuries have been reported, which is minimized with the use of safety release straps.
The need for headgear in orthodontics and its application by practitioners has decreased in recent years as more orthodontists use temporary implants (i.e., temporary anchorage devices) inside the patient's mouth to perform the same tooth movements.
Soreness of teeth when chewing, or when the teeth touch, is typical. Adults usually feel the soreness 12 to 24 hours later, but younger patients tend to react sooner, (e.g., 2 to 6 hours). Adults are sometimes prescribed headgear but this is less frequent. The headgear is one of the most useful appliances available to the orthodontist, but many patients find it difficult to comply with daytime wear, so it is mainly worn in the evenings and when sleeping. A similar appliance is the reverse-pull headgear or orthodontic facemask, which pulls the patients teeth forward (rather than back, as in this case).