British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

Theoretical Considerations of Headgear Therapy: A

Literature Review 2. Clinical response and usage

D. E. J. Bowden M.D.S., F.D.S.(Ed.), D.D.O.R.C.P.S.(G.)

To cite this article: D. E. J. Bowden M.D.S., F.D.S.(Ed.), D.D.O.R.C.P.S.(G.) (1978) Theoretical

Considerations of Headgear Therapy: A Literature Review 2. Clinical response and usage,
British Journal of Orthodontics, 5:4, 173-181, DOI: 10.1179/bjo.5.4.173

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 British Journal of Orthodontics/Vol 5/1978/173-181 Printed in Great Britai11 ©

Theoretical Considerations of
Headgear Therapy:
A Literature Review
2. Clinical response and usage
D. E. J. Bowden, M.D.S., F.D.S.(Ed.), D.D.O.R.C.P.S.(G~)
Orthodontic Department, Dental School, Heath, Cardiff CF4 4XY
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Abstract. In Part 1 the literature on the direction and moment force systems of headgear therapy was
discussed. The magnitude and duration of forces were briefly dealt with. In Part 2 the clinical response to
the main directions of headgear force as reported in the literature will be described. Recommendations on
the most appropriate direction and moment force systems for particular clinical situations wiU be made.

A large number of different directions of headgear
pull appear in the literature; however, the terms
used are often confusing. Root (1975) suggested a
simplified classification using the occlusal plane as
the demarcation line. He described two main types,
'J' hook headgear and face bow headgear, each pull-
ing either upwards and backwards, straight along or
downwards and backwards from the occlusal
plane. Thus, there are high pull and straight pull
'J' hook headgears and low pull 'J' hook neckgear.
Similarly, there are high pull and straight pull face
bow headgears and low pull face bow neckgear.
This simplifies description provided that it is
assumed that the direction of pull will be varied
by the clinician to achieve the force and moment
system required. Directions of force will be des-
cribed under these main headings, though where
literature is being reported each author's own
terminology will be used.
Low Pull Face Bow Neck Gear to Maxillary Molars
Most frequently described in the literature as
cervical traction, it was popularised by Kloehn
(1953). The linear force vectors are shown in Figure
1(2) and in it Kuhn (1968) suggested a large
horizontal and a lesser vertical force vector. It is
as well to assume that cervical pull will extrude
maxillary molars. If the cervical strap is below the
occlusal plane the resultant line of force will pass
back and downward to extrude the molar teeth.
However, Thurow (1970) and Worms et al. (1973)
by taking lateral skull radiographs of patients
wearing cervical headgears showed clearly that
the vertical force vector varies considerably and
the line of force may on occasions pass along the
occlusal plane.
Consideration of the theoretical direction and
moment force systems suggest that distal bodily
movement of the molars will most readily be
achieved when the face bow outer arms are placed
at or apical to the centre of resistance and are of
sufficient length to ensure that the resolved line of
force passes through the centre of resistance (Fig. 2).
Raising the face bow outer arms to achieve this line
of force has been suggested by a number of authors
including Gould ( 1957), Klein (1957), Newcombe
(1958), Kuhn (1968), Melsen and Enemark (1969)
and Greenspan (1970). In theory, bodily movement
may also be achieved using long outer face bow
arms at the same level as the inner arms, so that
the downward and backward pull lifts the front
of the face bow upwards and a line of force is
created which passes through the centre of resis-
tance. This is difficult to achieve in practice, but
has the merit that a smaller vertical component of
force may be present. More usually, an outer bow
level or occlusal to the inner bow will produce a

173
 D. E. J. Bowden
:~--fV!
~----~
0 A
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0 '
~
-vtJ
1. High
4. Low Occipital
2. Cervical
5. High Occipital
3. Straight
6. Cervical
Fig. 1. Relative horizontal and vertical force
components. Adapted from Kuhn, R. J. Angle
Orthodontist, 38, p. 345, fig 8, 1968.
line of force which passes mesial and occlusal to
the centre of resistance, rotating the molar root
mesially and the crown distally (Fig. 2).
The clinical effects of face bow cervical traction
have been investigated and the associated problems
discussed by Silverstein ( 1954), King ( 1957), Klein
(1957), Newcombe (1958), Moore (1959), Ricketts
( 1960), Weislander (1963), Creekmore (1967),
Merrifield and Cross (1970), Barton (1972),
Baumrind ( 1973) and Root (1975). Schudy ( 1963,
1964, 1965) discusses very fully the interaction of
vertical and horizontal growth upon mandibular
position and particularly describes the mechanics
of mandibular rotation. The effects of extrusion of
the maxillary molars by cervical pull, described
by Merrifield and Cross ( 1970) as 'the cervical face
bow reaction' (Kioehn reaction) have been sum-
marized by Barton (1972) as follows. Extrusion of
the maxillary molars causes the mandible to be
wedged open when the posterior teeth come into
occlusion. Barton ( 1972) estimates that extrusion
of the first maxillary molar by I mm produces
174
I
I
I
I
I
~
CERVICAL PULL
'
''
', ''
''
'
c '1'1-
''
OCCIPITAL PULL
Fig. 2. Direction of force and moment systems.
(A) Long arm, resultant line of force passes distal and
apical to centre of resistance-distal root tipping;
(B) Short arm, resultant line of force passes mesial
and occlusal to centre of resistance-mesial root
tipping; (C) Long arm, resultant line of force passes
distal and occlusal to centre of resistance-mesial root
tipping; (D) Short arm, resultant line of force passes
mesial and apical to centre of resistance-distal root
tipping.
approximately a 1·6 mm opening anteriorly, as the
mandible rotates downwards and backwards. 'B'
point is thus moved downwards and backwards
worsening the angle ANB. 'A' point is said to
move vertically downwards, the occlusal plane thus
tipping occlusally at its anterior end. The upper
incisor teeth now have to be retracted further and
with greater root axial control, to compensate for
the increased antero-posterior basal discrepancy.
Pogonion will move downwards and backwards
worsening the profile, whilst a longer lower face
height and a more prominent nose may result.
Silverstein (1954), King (1957) and Moore (1959)
all demonstrated that pogonion moved forward to
a lesser extent in cervical face bow treated groups
compared with controls, but did not measure
maxillary molar extrusion. Moore ( 1959) pointed
out that despite the apparently less favourable
 Theoretical Considerations of Headgear Therapy: A Literature Review
mandibular growth, facial convexity was main-
tained or improved in all but a single case, this
becoming more convex by only 1·0 mm. Klein
(1957) and Newcombe (1958) described maxillary
molar extrusion and associated it with the down-
ward and backward rotation of the mandible in
their treated groups, but used no controls.
Ricketts ( 1960) demonstrated that the facial
angle increased at the rate of 0·35° per year in an
untreated sample, compared with 0·2o per year
over a 30 month period, in a sample treated with
cervical face bow traction. Cervical molar traction
and class 11 elastics opened the XY axis angle by
-1·0° compared with -0·26° in the control group,
lengthening the face faster than is usually observed
in normal growth. As he detected no difference in
the Y axis length he attributed these changes to
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downward and backward mandibular rotation. He
also described tipping of the palatal plane so that
ANS moved downwards and even posteriorly. In
contrast, he commented with surprise on the
improved facial angle occurring in some retrognathic
cases treated with high pull headgear.
Creekmore (1967) found that pogonion moved
forwards 2·49 mm in a group of 50 cases treated
with cervical face bows compared with 3·48 mm in
the control group of 62 children (p < 0·05) and
felt this was associated with a highly significant
change in angle SN-MP. In the untreated group
this angle reduced by 1·03 o; but it increased by
0·68° in the treated group (p<O·OOI) the result of
measurable extrusion of posterior teeth. However,
Class Il and Class Ill elastics with additional
extrusive effects were used during the treatments.
He then compared 25 high SN-MP angle cases
with 25 low angle cases, together with the control
group and the average values from the treated
group just described. He found that the high angle
group, which had the highest average ANB, had
the least reduction in this angle following treatment.
SNA was reduced in all groups, so that the dif-
ference in the ANB changes was due to differences
in the behaviour of the mandible. In the high angle
group, the SN-MP angle enlarged whilst SNB
reduced, compared with all the other groups,
suggesting a mandibular rotation.
Melsen and Enemark (1969) compared 10
children wearing cervical face bow neckgear with
the arms bent upwards 20° to the occlusal plane
with 10 children in whom the face bow arms were
bent 20° downwards. The average skeletal age,
9·6 and 9·7 years and the age range of the two
groups, were similar. The neckgears were worn for
8 months. Implants were used in the maxilla to
aid the assessment of the tooth and skeletal changes
resulting from the treatments. Interestingly, though
the maxillary molars extruded relative to a line
connecting the anterior and posterior maxillary
implants in both groups, the difference was not
statistically significant. In the face bow arms-down
group, greater distal movement of the molars was
achieved. However, distal crown tipping occurred
and it was suggested that downward angulation
should be reserved for those molars which had
crowns tipped mesially at the start of treatment. No
influence upon the position of the maxillary com-
plex was detected. In the group with face bow
arms upwards, a lesser degree of molar distal
movement occurred, but without tilting. Examina-
tion of the changing position of the implants
suggested that the entire maxillary complex was
rotated downwards and backwards relative to the
anterior cranial base. Upward angulation they
suggested, may thus be employed to move the
upright molar distally and in the treatment of
Class 11 cases with maxillary basal protrusion.
Barton (1972) compared 20 patients treated with
cervical traction to the maxillary first molars, with
20 cases treated with a high pull canine headgear
(a high pull 'J' hook headgear to hooks soldered to
the maxillary arch wire distal to the lateral incisors).
In all 40 cases, the four first premolars were
extracted and similar treatment mechanics without
Class 11 elastics were used. The cervical face bow
group was associated with greater molar extrusion
(difference 3·48 mm, p<O·OOI) and a larger in-
crease in distance nasion to menton (difference
2·58 mm, p<O·Ol) the chin thus dropping 2·6 mm
more, than in the high pull group. No significant
difference was noted in mandibular angle (SN-MP).
Weislander (1963) also found no change in angle
SN-MP in his comparison of a cervical face bow
group (30 Class 11 children) and a similar number
of children with normal occlusion. However, ANS-
menton increased more in the headgear group
(difference 2·05 mm, p < 0·001) and the maxillary
molar also extruded more (difference 1·30 mm,
p < 0·0 I) than in the controls. Finding that the
distances Condylion- FH (difference 1·34 mm,
p<0·02) and Basion- FH (difference 1·25 mm,
p < 0·01) increased more in the headgear group,
Weislander concluded that the mandible had
dropped straight down. Thus in some cases the
mandible may rotate open and in others move
straight downwards.
Baumrind's (I 973) interesting transformations,
an attempt to correct differences in mean age and
treatment times, in a comparison of cervical,
175
 D. E. J. Bowden

straight and high pull face bow headgear wearers, to maxillary molars must never be used in Class 11
together with a control group, must be treated with cases with a higher than average Frankfort mandi-
suspicion in view of the control group findings. bular plane angle, for these individuals would seem
Molar extrusion was greatest in this group. Never- to be particularly susceptible to the ill-effects of
theless Baumrind felt that clear differences in the 'the cervical face bow reaction'.
response of the maxillary molar to the different Low pull face bow neck gear may be used to
directions of headgear pull were apparent. The mandibular molars, Figure l (6). In clinical practice
most striking change was the intrusion of the it will be difficult to achieve a line of force which
maxillary molar produced by high pull face bow passes through the centre of resistance and some
headgear. No changes of statistical significance in distal crown tipping will usually occur. A slight
mandibular or palatal plane angle or in total intrusive or extrusive force will be present depend-
anterior face height were detected and Pearson ing on the height of the outer bow relative to
correlation coefficients showed no relationship the elastic of the neck strap and of both to the
between maxillary molar extrusion and these planes. occlusal plane. This form of traction is generally
Berman (1976) has resolved the problem of not well tolerated. The mandible is held rigidly in a
maxillary molar extrusion by using a low pull neck retruded position and this results often in muscle
gear and a high pull headgear as a single unit. pain after only a few hours wear. A low pull 'J'
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The ratio is I to l, 8 ozs (224 g) of downward and hook neck gear and sliding jigs produce an effective
backward force to the neck gear and 8 ozs (224 g) horizontal force and appear to be better tolerated
of upward and backward force to the high pull being less bulky and positioned further forward i~
headgear. the mouth.
The literature is thus large, but the exact clinical
relationship of cervical face bow traction to molar Straight Pull Face Bow Headgear to Maxillary
extrusion and mandibular rotation remains un- Molars
clear. In the investigations to date, treated and
Reference should again be made to Figure I (3).
control groups are often small, with age and sex
Straight pull to the maxillary molars produces
variation. Seldom have headgear lines of force
good distal movement. Distal crown tipping will
relative to centres of resistance within the molar
most commonly occur. The vertical force com-
teeth or the complete arch been assessed or stated.
ponent is variable, mild extrusion being probable
Inter-maxillary elastics with additional extrusive
(Baumrind, 1973). A suitable line of force will most
effect have been used as part of treatment regimes.
easily be achieved when the outer arms of the face
The main problem, however, is that average treat-
bow are related to the occlusal plane and finish at
ment and growth changes are small, whilst the wide
the level of the first permanent molar.
variation in the morphology of the characters
investigated and in treatment response is under-
lined by large standard deviations. More certain is High Pull Face Bow Headgear to Maxillary
the difference in response to treatment, by head- Molars
gears providing differing directions of force. High pull face bow headgear is used here to des-
Whilst molar extrusion undoubtedly occurs, its cribe all headgears that attach to molar tubes and
clinical effects are uncertain and may have been pull up and back relative to the occlusal plane, and
exaggerated. Although excessive molar extrusion is includes the terms variable, high and occipital pull.
usually to be avoided, it would seem acceptable to Kuhn (1968) described this direction of pull as
use cervical face bow traction to maxillary molars occipital, and once again, his diagram is used to
in Class 11 cases associated with deep overbite, illustrate the force vectors (Fig. I (4)(5)). In general,
provided the Frankfort mandibular plane angle is the higher the pull, the smaller the distal and the
low to average and particularly if angle SNB is greater the intrusive component of force. The lower
average and progress is monitored. However, on the pull, the larger the distal and the smaller the
theoretical grounds to be discussed later, a straight intrusive component of force. Merrifield and Cross
or more upward and backward direction of pull ( 1970) measured the angle made by the headgear
appears to have advantages in most Class 11 cases. line of force and the occlusal plane (DF). They
Cervical face-bow traction producing maxillary estimated that a DF of 47° (a high direction of
molar extrusion may be of particular advantage pull) placed a force which was half intrusive and
in low FMP, Class 11 deep bite cases (Creekmore, half distal upon the maxillary molars. A DF of 20°
1967; Barton, 1972). However, cervical face bows (a lower direction of pull) placed a force which

176
 Theoretical Considerations of Headgear Therapy: A Literature Review

was one-third intrusive and two-thirds distal upon

soldered or loops bent into an arch wire. The three
the maxillary molars. The relationship of the directions of pull as defined by Root (1975) have
length and height of the outer face bow arms already been explained. High pull 'J' hook head-
to the centre of resistance and the resultant gear to the incisor region of the arch wire will be
moment force system thus created, is reviewed byconsidered first. This type of pull places an intrusive
Greenspan (1970) was stressed in Part I. Upright and distal force upon the upper incisors. Theoretical
bodily movement of the maxillary molar will most considerations (Fig. I (I)) suggest that a line of
readily be achieved when the face bow outer force passing labially to the upper incisor will tip
arms are bent upwards so that the line of force the root palatally and the crown labially. A line of
force passing palatally to the upper incisor may
passes along their long axes through the centre of
resistance to the headgear. When the outer and rotate the root labially and the crown palatally.
Thus, in theory, high pull should be placed to
inner face bow arms are at the same vertical level,
short outer arms will be necessary to produce a produce a line of force which passes labially to the
line of force passing through or apical to the centre of resistance. In practice, this is usually
centre of resistance, to produce upright or move-difficult to achieve unless the incisors are proclined
ment with distal root tipping (Fig. 2). Long outer
or the pull nearly vertical. However, when used with
arms producing a line of force commencing rectangular wire, these considerations are probably
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of small importance compared with the palatal

occlusally and passing distally to the centre of resist-
root torque placed within the arch wire. More
ance will have an intrusive and mesial root tipping
certainly, high pull augments palatal root torque
effect (Fig. 2). Barton ( 1972) suggested that such
placed in the rectangular arch by preventing the
a line of force, made as vertical as possible, would
incisor segment of the arch wire flexing during
exaggerate maxillary molar intrusion, whilst tipping
overjet reduction, which produces convergence of
their roots mesially and rotating the fully banded
the upper incisor roots, hindering effective root
maxillary arch, the incisor end moving occlusally.
It might thus be employed to improve overbite in torque and spoiling aesthetics. Hooks pointing
high Frankfort-mandibular, anterior open bite occlusally and soldered distal to the upper central
incisors, rather than the upper lateral incisors, make
cases. A rigid palatal arch must secure each molar
this vertical support more effective. Moreover, if
to prevent the high direction of pull rolling them
buccally (Kuhn, 1968). intrusion of the upper incisors is achieved, more
bone in the anterior portion of the palate becomes
It is felt that an upward and backward direction
of pull is the method of choice to achieve available to assist the palatal movement of the
both bodily distal movement of the maxillary incisor roots (Edwards, 1976).
molar alone, or of the entire maxillary arch. The Poulton ( 1959) examined the effects of occipital
distal component of force may be as great as thatpull to 'J' hooks soldered to the arch wire between
produced by low pull face bow neckgear (Kuhn, the upper central and lateral incisors. He com-
1968) but without molar extrusion and the attendant
mented upon the deepening of the overbite, the
risk of mandibular rotation (Merrifield and Cross,poor improvement in molar relationship and
1970; Armstrong, 1971 ). Indeed Baumrind ( 1973) mandibular growth which occurred in some of the
found the intrusive effect upon the maxillary cases and described the ill effects of mandibular
molars of high pull face bow headgear to be most rotation, discussing previous findings in the literature.
striking. Moreover, by preventing the eruption of He reported an increase in angle between the
the maxillary arch, the mandibular arch may be occlusal plane and the anterior cranial base of
permitted to use a greater proportion of the grow-2·8 ± 2·4 o in the treated sample of 29 children in
ing inter-maxillary space, by erupting forwards asthe mixed dentition. A matched sample of children
well as occlusally, in the manner suggested by did not demonstrate this change. By means of a
Harvold ( 1974). It is suggested that this direction of
scatter diagram he demonstrated that the more
force opposes downward and forward growth of the occlusal plane tipped anteriorly (ANS moving
the naso-maxillary complex, although high pull in an occlusal direction) the less the forward
'J' hook headgear to the incisor region would havegrowth of pogonion (R = - 0·86). He showed that a
a greater orthopaedic effect (Merrifield and Cross,
line of force produced by his occipital pull could
1970). pass apical or occlusal to 'M' (Part I, Fig. 2). If it
passed apically, then the anterior portion of the
'J' Hook Headgears to the Arch Wire arch would be intruded and moved distally. If the
Headgears may be attached by 'J' hooks to hooks line of force passed occlusally, as occurred fre-

177
 D. E. J. Bowden
quently in his treated sample, then the effect would
be to tip the incisor end of the occlusal plane
downwards and backwards. He recommended an
increase in the steepness of pull towards today's
direction of high pull for Class 11, normal or deep
overbite cases. Barton ( 1972) pointed out that a
line of force which passed occlusally to 'M', pro-
duced by a low pull 'J' hook neck gear to hooks
upon the incisor region of the arch wire, might be
employed in the correction of Class 11 cases with an
open bite, though some upper posterior tooth
extrusion will also probably occur.
Barton ( 1972) described the effects of high pull
to hooks soldered distal to the lateral incisors and
named this, high pull canine headgear. The direction
of this line of force was higher than that of Pout-
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ton's experiment and passed apically to or through
the centre of resistance. He demonstrated that
sufficient horizontal force was exerted to retract
the maxillary teeth, though he felt it was not ideal
for severe Class II malocclusions. Reference was
made earlier to Barton's (1972) comparison of two
groups of headgear patients. He found that cervical
face bows extruded the maxillary molars by 6·28
mm against 2·8 mm (p < 0·001) by the high pull
headgear. Similarly the former extruded the
maxillary incisors 2·42 mm while the latter intruded
them- 0·25 mm (p<O·OI). Barton felt that high
pull canine 'J' hook headgear was the treatment of
choice in Class I I cases where extrusion of the
molars and incisors was contra-indicated.
Merrifield and Cross (1970) suggested that a
deliberate rotation of the mandible to carry
pogonion and B point downwards and backwards
might be useful in the treatment of some Class Ill
malocclusions. A low pull 'J' hook neckgear
attached to the mandibular arch wire in the incisor
region, pulled the mandible down and backwards.
Class Ill elastics extruded the maxillary posterior
teeth into the increased vertical space, so that the
Frankfort mandibular plane angle would be
increased and angle ANB reduced.
'J' Hook Headgears to the Teeth
Headgear forces may be applied to individual teeth.
The 'J' hooks are slipped around the arch wire and
apply a force to the mesial of the tooth, sliding it
distally along the arch wire. Berman (1976) dis-
cussed headgears used in this manner and suggested
high pull headgear to maxillary canines and straight
pull to mandibular canines. He suggested a force
of up to one pound to each canine was suitable.
He further pointed out that the direction of head-
gear pull caused an expansion of the arch wire and
178
stated that it was important to contract the arch
wire from the canines distally, to resist these
expansive forces.
The growing interest in force direction and
moments is apparent in the literature. Whilst
Merrifield and Cross (1970), Arm strong (1971) and
Barton ( 1972) drew attention to its importance
primarily, though not entirely, in face bow usage,
others, notably Hickham (1974) and Berman (1976),
suggested attention to directional forces in the
use of 'J' hook headgears. Indeed, Hickham (1974)
has developed a treatment system based on this
concept. He has devised a headgear which will
accept two or even three 'J' hooks each side. By
choosing the appropriate point of fixation of the
'J' hook to the headgear, the direction of pull may
be varied. In this way attention may be paid to
force direction and moments, to intrusive and
extrusive forces or to growth direction. The 'J'
hooks may be directly applied to the mesial surface
of the canines or to sliding jigs to move posterior
teeth distally or maintain molar anchorage. They
may be attached to soldered hooks in the incisor
area of the arch wire, and a direction of pull is
chosen to produce intrusive and or distal movement
of the upper incisors. The versatility of this ap-
proach is immediately apparent, and additionally,
as pointed out by Berman (1976), it is also 'fail
safe', since if it is not worn, neither movement or
reaction can occur.
Conclusions
Headgears of all types and embracing a wide range
of force directions have been employed success-
fully to treat a number of different malocclusions.
A co-operative patient and a clinician prepared to
monitor progress and able to re-direct the course of
treatment at the right moment may successfully
treat a wide range of malocclusions with a single
headgear approach. However, the literature indi-
cates that headgear capable of producing different
force directions and moments may have advan-
tages in particular situations.
These may be summarized as follows:
I. Low pull face bow neckgear.
(a) A large horizontal component of force is pre-
sent, but also a vertical component, which may
extrude the maxillary molar.
(b) Molar extrusion may assist the treatment of
Class 11, low Frankfort-mandibular angle,
increased over bite cases.
(c) Limited molar extrusion will probably not
affect Class 11 cases with an average Frankfort-
 Theoretical Considerations of Headgear Therapy: A Literature Review
mandibular angle, particularly if angle SNB is
average. Facial changes must be monitored
during treatment.
(d) High Frankfort-mandibular angle, Class 11
cases, should never be subjected to this line
of force to avoid the creation of an unfavour-
able mandibular rotation, with consequent ill
effects upon the face.
(e) Outer arms bent downwards will tilt distally the
crowns of mesially tilted molars.
(f) Outer arms bent upwards appear to result in
more upright, but less distal movement.
2. Straight pull face bow headgear.
(a) A very large horizontal component of force is
present.
(b) A small vertical force component may produce
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mild extrusion.
(c) It wiii probably effect less distal movement of
the root, than of the crown.
3. High pull face bow headgear.
(a) Root axial control may be achieved to produce
effective upright distal movement of the molar
teeth or tilting as is required.
(b) The molar will be intruded and the ratio
between distal and intrusive movement will
depend upon the steepness of the angle of pull.
(c) It is a suitable line of force to move distally the
fully banded maxillary arch, intruding the
molar end and less certainly the incisor end. (A
Khan spur and a line offorcep assing mesial and
apical to 'M' will exaggerate incisal intrusion).
(d) In high-Frankfort-mandibular angle, Class 11
cases, with reduced or even average over bite,
distal movement with extrusion of maxillary
molars is probably to be avoided, and high
pull anchorage control may be advantageous.
(e) In high Frankfort-mandibular angle, Class 11
cases, with anterior open bite, a vertical line of
force commencing occlusally and passing dis-
tally to the centre of resistance, will intrude the
maxillary molars and may rotate downwards
the incisal end of a fully banded arch. Use a
supporting palatal arch.
4. Low pull 'J' hook neckgear.
(a) Used to the maxillary incisor region, a tipping
of the incisal end of the occlusal plane in a
downward direction may result, with a reduc-
tion of open bite. However, molar extrusion is
probable.
(b) Used to the mandibular incisor region, it may
depress the chin creating more vertical space
into which maxillary teeth may be extruded
during Class Ill treatment. The resultant
downward and backward mandibular rotation
reduces the antero-posterior basal discrepancy.
5. Straight pull 'J' hook headgear.
(a) It is suitable for moving mandibular canines
distally.
(b) Attached to the maxillary incisor region, distal
arch movement occurs, but a downward tipping
of the incisal end of the arch is probable.
6. High pull 'J' hook headgears.
(a) A line of force to the maxillary incisor region
passing mesial and apical to the centre of
resistance, will intrude the upper incisors,
move them distally and augment palatal root
torque.
(b) A line of force to the maxillary incisor region
passing through the centre of resistance will
have a larger distal and smaller intrusive effect
upon the incisor region. Theoretically this may
produce greatest orthopaedic effect.
(c) A line of force to the maxillary incisor region,
passing occlusal to the centre of resistance may
have a mild downward tipping effect upon the
incisal end of the occlusal plane.
(d) It is the direction of choice for distal movement
of maxillary canines, or to sliding jigs for
maxillary molar distal movement or anchorage.
7. Centres of rotation within a tooth and within
an arch will alter during movement. Force
direction and moment systems, force magnitude
and duration should be constantly reviewed.
Summary
The literature of headgear therapy has been review-
ed in an attempt to explain the theoretical and
mechanical principles involved in the movement of
teeth by this method. Some of the theoretical
advantages of the use of different directions of
force have been suggested. Some of these suggested
advantages have been investigated by clinical
research, others remain hypothetical and await
investigation.
Acknowledgements
Grateful thanks are expressed to the Editors and
Publishers of the American Journal of Orthodontics and
of the Angle Orthodontist for permission to reproduce the
figures which have appeared in these Journals respectively.
I would also like to thank Professor J. R. E. Mills and
Mr M. S. Berman for their helpful comments and my
colleagues at the Welsh National School of Medicine for
their help and advice in the preparation of this paper.
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