This document provides information about extraoral appliances in orthodontics: - It discusses the history, types, uses, complications, safety considerations, and factors affecting the force of extraoral appliances. - Extraoral appliances have specific uses in orthodontic biomechanics for anchorage, dental movement, and modifying growth. - Clinicians should be familiar with the clinical indications, potential problems, and how to avoid problems when using appliances like headgear.

1. Mohammed Almuzian
BDS (Hons), MSc.Orth (Distinction), MSc.HCA/Merit (USA), Doctorate
ClinDent.Orthodontics (Glasgow), FIADFA (USA), MFDSRCS
(Edinburgh), RCS (Ireland), RCPSG (Glasgow)., MJDFRCS (England),
MOrth.RCS (Edinburgh), MRCDS.Ortho.(Australia), IMOrth.RCS
(England/Glasgow)

2.  To understand :
1. Historical background
2. Types & designs of extra-oral appliances
3. Uses
4. Complications & Safety regimes
5. Force effecting factors
6. Treatment timing

3.  Extraoral appliances have specific uses in
orthodontic biomechanics.
 Clinicians using retraction headgear and
protraction headgear should be familiar with
their clinical indications, the potential
problems and how these can be avoided.

4.  To develop the knowledge of the specialist
orthodontist in relation to extraoral
appliances in orthodontics.

5. An appliances that provide a means of applying
anterior, posterior or vertical directed forces to
the dentition and skeletal complex from an
extra-oral source.
Almuzian et al 2013

6.  Introduced in the late 1800's by Kingsley then by Angle in 1910.
 By 1920, it was disused as it was believed that intra-oral elastics would
suffice (Angle).
 Re-used again in the 1940's after lateral cephalometric radiographs
showed the adverse effects of intra-oral elastic traction
 declined over the last 20 years with the refinement of non-compliance
based treatment modalities including temporary anchorage devices.
 The use of protraction headgear has increased as more evidence of its
effectiveness for the treatment of Class III malocclusion has become
available.

7. 1. Headgear with facebow or J hook.
2. Reverse facial mask
3. Chin cap

8. 1. Anchorage appliances
2. Active dental appliance
 Retraction movement
 Transverse teeth movement (minor maxillary dental
expansion)
 Vertical teeth movement (intrusion or extrusion of
UBS or ULS)
3. Growth modification or orthopedic appliances

9. 1. Anchorage appliances
 Increasing anchorage and prevents forward
movement of anchor teeth
 Space maintainer

10. 2. Active dental appliance
Retraction movement
a. Distalize UBS
 To correct less than 1/2 unit CL2 molar relation
 To provide space to relief mild crowding
 To correct mild increased in the OJ in non-extraction cases.
 To provide extra space in sever space deficiency in which extraction
fail to provide sufficient space.
 To provide space for spontaneous eruption of ectopic canine as
interceptive treatment with a success rate of 80% compared to 50%
in control group.(Leonardi, 2004).
 To regain a lost space due to mesial migration of molars (premolar
crowding cases).
 Uprighting impacted U6s against UEs.

11. 2. Active dental appliance
Retraction movement
b. HG with J hook to retract ULS or U3
c. Rarely, retract LLS or L3 (problem with
patient toleration)
d. Differential (asymmetric) movement for
treatment of ML problems

12.  Atherton et al. (2002) came to the conclusion
that the most distal movement of the molars
that could be achieved was in the range of 2 -
2.5mm

13.  Melsen and Dalstra (2003) in their
retrospective study found that the total
displacement of the molars in patients
wearing cervical headgear for a 8-month
period did not differ from that of an
untreated group when re-evaluated 7 years
later

14. 2. Transverse teeth movement (minor maxillary
dental expansion)
3. Vertical teeth movement (intrusion or
extrusion of UBS or ULS)

15. 3. Growth modification or orthopedic
appliances
It acts by influencing the pterygopalatine,
fronto-maxillary, zygomatic maxillary
sutures.

16. Studies regarding the effects of HG
 RCT by Tulloch (1997) early treatment with
headgear or functional appliance therapy can
both reduce the severity of a class 2 skeletal
pattern. 75% chance of this occurring.
 Mills 1978 in a review, stated a maxillary
growth suppression effect of 1-2 mms is
possible in humans with Kloehn bows
 1mm of maxillary growth restraint achieved
over a 10 year period that persists post-
treatment (Wieslander, 1993)

18. 1. Original Kloehn bow invented by Kloehn 1947 after
world war II
2. Kloehn loop style facebow
3. Asher Facebow
4. Bite Plate Facebow
5. J hook facebow (not used anymore in UK for safely
reasons)
6. Asymmetric Headgear
POWER-ARM FACE-BOW
SOLDERED-OFFSET FACE-BOW
SWIVEL-OFFSET FACE-BOW
SPRING-ATTACHMENT FACE-BOW
7. Nudger appliance HG
8. Headgear to upper part of the Twin block
9. The Intrusive Myofunctional Appliances
 THE VAN BEEK APPLIANCE
 The Buccal Intrusion Splint (BIS)
 The Maxillary Intrusion Splint (MIS)
 The Maxillary Intrusion Splint and Lower Traction Plate (CONCORDE)

19.  Original Kloehn bow invented by Kloehn
1947 after world war II

20.  Kloehn loop style facebow

21.  Asher Facebow
- Used by Dr.
Ron Roth
- Intrudes anterior
teeth
- Pushes on
Archwire

22.  Bite Plate Facebow
 - Intrudes anterior
teeth
- Pushes on
anterior teeth
- two main styles:
loop style or
regular style

23.  J hook facebow (not used anymore in UK
for safely reasons)

24.  J hook traction
engaged in stops
soldered or crimped
onto the archwire
between the lateral
incisor and the canine
or attached to an
attachment on the
tooth directly.
 Hickman (1974) -
devised a headgear
which will accept 2 or
even 3 "J" hooks each
side.

25.  Uses of J hook HG
1. Translate the U or L canine distally.
2. If force heavy enough - then it can move 5/5
and 6/6 distally also.
3. It also restrains maxillary development.
4. "J" hook headgear can also be used
asymmetrically to resolve a centre line
problem by judicious use of the hooks to
contralateral upper and lower canines e.g.
UL3 & LR3.

26.  Problems of J hook:
1. Accidental injuries
2. Root resorption.
3. "J" Hook straight pull headgear to the lower
arch in Class III cases cause the mandible to
rotate in clockwise direction.
4. "J" Hook to fixed appliance archwire -
important to contract the arch wire from the
canines distally in order to resist the
headgear's expansion effect on the arch wire
(Berman, 1976).

27. Asymmetric Headgear
 results in more movement on the side with
the longer outer bow according to
Castagliano's Theorum
 It will also lead to that same tooth becoming
susceptible to lingual crossbite

28.  1. POWER-ARM FACE-BOW

29.  2. SOLDERED-OFFSET FACE-BOW

30.  3. SWIVEL-OFFSET FACE-BOW

31.  4. SPRING-ATTACHMENT FACE-BOW

32. Nudger appliance HG
 Band molar teeth; fit URA with
palatal cantilever spring 0.7mm
SS on the molar requiring distal
movement.
 Retention from premolars and
incisors
 Used for true unilateral space
loss
 Alternative ways of differential
movement of 6/6: asymmetrical
extraction of the 7s with normal
Kloehn Bow and/or URA screw
appliance

33.  Headgear to upper part of the Twin block

34. The Intrusive Myofunctional Appliances
THE VAN BEEK APPLIANCE
 Described by Pfeiffer (1972) to reduce the duration of treatment
significantly.
 This prompted Van Beek to design a simplified short outer arm
facebow embedded in the acrylic part of the Harvold activator
(Myotonic functional appliance)
 Modifications of the combined activator and headgear were
described by Teuscher, Thurow, and Bass
 300 gms of force/12 hours a day

35. The Intrusive Myofunctional Appliances
The Buccal Intrusion Splint (BIS)
 This appliance consists of an acrylic palatal
baseplate which is clear of the upper anterior
teeth and with occlusal capping on the teeth
in occlusion. There are double Adams cribs
present on the upper first permanent molars
and second premolars and molar tubes
embedded in the occlusal capping acrylic to
accept a Kloehn facebow. There is a midline
screw present in the palatal acrylic

36. The Intrusive Myofunctional Appliances
The Maxillary Intrusion Splint (MIS)
 This appliance consists of an acrylic
baseplate which extends over the
occlusal surfaces of all teeth and onto
the labial surfaces of the upper
anterior teeth. There are headgear
tubes present within the molar
capping

37. The Intrusive Myofunctional Appliances
The Maxillary Intrusion Splint and Lower Traction
Plate (CONCORDE)
 This is a two part appliance which consists of a
maxillary intrusion splint and the lower appliance
consists of an acrylic baseplate with lingual hook
on the lingual aspect of the acrylic baseplate to
enable elastics to be attached to the midpoint of
the facebow.

39. Teeth related
1. Anterio-posteriorly:
 Worsening of Class III relationship
 Distal tipping of the teeth
 Incisor retroclination.

40.  Teeth related
2. Transversely:
 Increased crown buccal torque (reduced by
rigid TPA).
 Scissor bite effect of J hook ,cross bite effect
of Kloehn bow and asymmetrical HG( in the
latter situation, this adverse tooth movement
can be counteracted with either a removable
upper appliance with screw expander or by
widening (expanding) the inner bow).

41.  Teeth related
3. Vertically:
 Reductions in the OB in case of low pull HG.
 Increase anterior facial height and gingival
show due to mandibular clockwise rotation as
a result of molar extrusion and the patient
will show CL2 profile (O'Reilly et al.1993).

42.  Teeth related
4. Disto-lingual or mesio-buccal rotation of
the molars and canines
5. Root resorption is a possibly with J hook
headgear and this should be monitored
radiographically, e.g. long cone Periapical

43.  Patient related
1. Patient Cooperation
 Not all patients are honest in actual
compliance. Using time charts can increase
co-operation (Cureton et al. 1992, 1993).

44.  Patient related
2. Biological variability: Growth may be
unfavorable
3. Pain
4. Difficulty with insertion
5. Nickel allergy – Contact dermatitis-type IV
delayed hypersensitivity immune response
(Rahilly and Price, 2003).

45.  Patient related
6. Extra/Intra-oral injuries: Eye injuries
 (Samuels and Jones, 1994; Booth-Mason and
Birnie, 1988)
 Rarely eye injuries can occur whilst wearing
headgear
 Serious consequences (ocular bacteria
infection, impaired vision, loss of eye,
sympathetic opthalmitis, cavernous sinus
thrombosis) - Chaushu, 1997.

46. Safety headgears (Anti-recoil device)
 Means that they are design to break-away
when excessive force applied to HG. NOLA
SYSTEM: same as anti-coil device but the
device attached to the face bow not the HG

47. Safety facebows
 a. Locking mechanism: helps to avoid
accidental remove of the facebow which act
by special locking device behind the distal
end of the inner bow thus preventing
accidental dislodgment of the facebow.

48. Safety facebows
 b. (re-curved reverse entry inner bow)
designed by Lancer Pacific but it is difficult to
use by the patient.
 c. SAFE END (blunt end)
 d. LOCATING ELASTIC. Like CLASS 1 elastic
attached the inner bow to the teeth to
stabilize the facebow.

49. 3. Miscellaneous safety products
 MASEL SAFETY STRAP (rigid neck strap) easy
and cheap. Works by adding a additional rigid
safety strap to the HG to minimize facebow
movement and dislodgment.

50. 4. in case of HG+URA.
 a. CLIP-OVER APPLIANCE. It means that the
facebow should attached securely to molar
band while the URA clip over the bands
 b. INTEGRAL FACE BOW (soldering the inner
bow to the URA)
 c. LOCKING MECHANISM (same as point B)

51. 5. INSTRUCTION
 Written and verbal advice for example:
 At night always ensure that the safety mechanisms
 If the headgear comes detached during sleep, stop wearing the
headgear immediately and contact your orthodontist the next day.
 Remove external headgear attachment before the inner bow. Never
remove or fit the headgear in one piece
 Do not wear headgear while playing sports.
 If any eye injury associated with the headgear occurs; it must be
treated as a Medical emergency.
 Bring your headgear to each appointment and report any problems
to your orthodontist.

52. Samuels 1994 (23 countries studied)
 1. Accidental disengagement while playing
(17%)
 2. Incorrect handling during fitting or removal
(8%)
 3. Bully pulls headgear (4%)
 4. Unintentional nighttime disengagement
(71%)

53. According to the study of Stafford on 1998, the ideal safety
system should have the following features:
 1. Extension: it means the amount of extension of the
facebow from its attachment with the molar bands before it
break-away (stop releasing force). So if accidental force
applied in a direction to dislodge the facebow, this system
(Anti-recoil device) will start working
 2. Force: it means the amount of force applied to the facebow
before it stops release the force or break-away (Anti-recoil
device)
 3. Consistency: which means the release point should be
constant in all types of HG after prolonged repeated use.

55.  High pull headgear is claimed to intrude the first
molars or at least reduce their vertical
development. The point of application of the force
however tends to result in more intrusion of the
buccal cusps than the palatal cusps. A transpalatal
bar is mandatory under these circumstances.
 In a study by Wise et al (1994) which compared 20
non-extraction patients in which a transpalatal bar
was used for at least 5 months with similar patients
in whom it was not used, no significant differences
were found between the two groups. The
transpalatal bar design used was fitted 1-2 mm off
the palate.

56. ◦ Direction
 Theory of Directional Forces (DF) - Merrifield and Cross
(1970), DF angle = "directional force angle" = angle made by
the headgear line of force and the functional occlusal plane.
 If DF > 60º. (vertical pull) - a force is produced which is 0
distal movement and 3/3rds intrusion upon 6/6.
 If DF 20-50º. (high pull) - a force is produced which is 1/3rd
distal movement and 2/3rds intrusion upon 6/6.
 If DF = 0-10º. (straight pull) - a force is produced which is
3/3rd distal movement and 0 intrusion upon 6/6.
 If DF = -10 to -20º (low pull) - this gives the force which is
1/3rd extrusive and 2/3rds distal upon 6/6.

57. Position in relation to centre of resistance
 Outer Arm short -.
If above centre of resistance i.e. high pull - causes intrusion
and distal tipping of the root.
If below centre of resistance i.e. low pull - causes extrusion and
distal tipping of the crown.
 Outer arm long –
If above centre of resistance i.e. high pull - causes intrusion
and distal tipping of the crown.
If below centre of resistance i.e. low pull - causes extrusion and
distal tipping of the root.
 Outer bow at the trifurcation point of 6/6 (centre of
resistance. The result is pure translation.

59. ◦ Magnitude
 Different level of force for different requirements (and
different clinicians!)
 I have recently placed HG to distlize UBS at a force of 500g
per side
 Weislander (72) achieved 2mm of distillation of A point over 3
years with only 300g of force
 Armstrong (1971), Graber (1977) all used forces in excess of
400g, and sometimes 2 or 3 times that amount to achieve
rapid orthopaedic translations
 Firouz (92) showed that the rate of anterior displacement of A
point was significantly decreased by applying 500g.
 Watson (1978) demonstrated that the ANS could move distally
by as much as 4mm in 1 year by applying 1000g bilaterally

60. Conclusion:
 (higher force cause growth restraints)
 Force levels of 250-300g per side is adequate
for anchorage
 Force levels of 400-500g per side is adequate
for teeth movement.
 Force levels of 800-1000g per side is
adequate for skeletal effects

61. Duration (longer duration cause teeth movement
and growth restraints)
 Supportive (anchorage) 10 hours per day
 Active (distal movement12-14 hrs minimum/day
(100 hrs/week).
 Orthopaedic - 12-14 hours per day.
 Cureton et al. (1993) recommend the use of
headgear charts routinely.
 (Clark et al 2003) monitoring device like the Affirm
headgear traction module has been used
(electronic timer)

62. • functional appliances which have better
compliance
• fixed functionals
• more class 2 elastics being employed
• self-ligating brackets seem to reduce
anchorage demands (not proven) and favour
earlier use
of lighter class 2 traction
• more lower incisor proclination accepted
• more arch expansion accepted
• TADs have revolutionised intra-oral anchorage
possibilities

64. Definition
 Means of applying anterior directed forces to
teeth and/or skeletal structures from an
extra-oral source

65. History
 The technique of maxillary protraction is
based on work by Nanda (1978), with rhesus
monkeys in which he showed that a force of
approximately 500g could produce anterior
displacement of the maxilla
 It is appropriate to refer to this type of
treatment as facemask therapy.

66.  Uses
 Treatment of maxillary retrusion
 Dental protraction allowing closure of space
from behind in patients suffering from
hypodontia
 Stabilization following maxillary
osteotomy/distraction osteogenesis
 Rotate arch segments in cleft palate patients
 Remove hyper-anterior contact in TMJ
internal derangement cases,
 Reinforcement of anterior anchorage

67. 1. Correction of a centric occlusion-centric relation
discrepancy. This correction happens relatively
rapidly in patients with an edge to edge
relationship and associated displacement
2. Maxillary skeletal protraction, with up to 3mm of
forward movement of the maxilla possible
3. Forward movement of the maxillary dentition
4. Lingual tipping of the lower incisors (except
suborbital types)
5. Redirection of mandibular growth in a downward
and backward direction, resulting in an increase in
lower anterior facial height

68.  Depending on dental age
McNamara (1987) suggested that the optimal time for
treatment is in the early late mixed dentition, coincident
with the eruption of the upper permanent incisors.
 Depending on the chronological age
Other investigators have suggested that for optimal
orthopaedic effects, treatment should be initiated
before the patient is 9 years old ( Proffit, 2000).
 Depending on the skeletal age
The early treatment group (CV3-CV4) showed effective
forward displacement of the maxillary structures
whereas the late treatment group (CV5-CV6) showed no
change compared with controls . Baccetti et al (1998)

69. Force
1. Moving maxillary anterior teeth forward:
400g per side
2. Forward movement of lower molars : 600g
per side
3. Maxillary sutural protraction : 800g per side

70. NB:
 To avoid bite opening, place protraction
elastics near maxillary bicuspids
 Avoid Class III elastics as they rotate occlusal
plane
 Pay special attention to airway and tongue
posture
 Overcorrect to compensate for mandibular
growth

71.  Mild to moderate skeletal III base
 Better results with average or reduced lower
face height. Yoshida et al (2007)
 Patient 8-10 years of age

72. • Protraction Headgear (Hickham)

73. • Facial Mask (Delaire)

74. 3. Suborbital
Protraction Appliance
(Grummons)
 -uses, forehead,back
of head and
zygomatic areas for
support
-advantages-frame
more rigid, no force
on TMJ,easy to adjust
and wear during
sleep
 -Disadvantages- not
esthetic due to
midfacial support

75. 4. Nola protraction appliance

76. Petit style face mask
 The Petit style
with a single
central vertical
bar is also well
tolerated and
recent price
changes have
made it
economically
much more
attractive

77. Rapid maxillary expansion seeks to
exploit two effects:
1. the forward movement of the
maxillary complex which often
accompanies maxillary expansion
2. the sutural loosening which occurs
during maxillary expansion

78. Evidences
 Baccetti et al (1998) Significant skeletal effects of early
treatment of Class III malocclusions with maxillary expansion
and face-mask therapy
 Kim et al (1999). A meta-analysis of the effectiveness of
protraction facemask therapy. Patients who did not have
palatal expansion had longer treatment times and ended up
with more upper incisor proclination - i.e.: more dental
change and less skeletal change.
 Franchi et al (2004) concluded that it was possible to achieve
a 2 mm advancement of the maxilla that would withstand the
active growth period if RME and protraction head gear was
undertaken in the deciduous dentition or early mixed
dentition

80. 1. fabricate and bond/cement the rapid maxillary expansion appliance
2. Appliance is activated once per day until the desired increase in maxillary
width has been obtained.
3. If patients do not need an increase in maxillary width, the appliance is still
activated for 7-10 days to disrupt the maxillary sutural system (Haas,
1965)
4. then protraction headgear is fitted.
5. A heavy orthopaedic force of 400g per side is applied to the maxillary
complex
6. Force vector should be 15-30 degree below the horizontal
7. The patient wears the facial mask for at least 12-14 hours per day
8. Active treatment should be limited to 9-12 months because of the risk of
decalcification of the dentition
9. Retention with a number of appliances: acrylic maxillary retainer, FR-3
appliance or a chin cup (seldom used).
10. Patient should be warned of the possibility of orthognathic treatment if
growth is unfavorable
11. Labial root torque: Most class 3 patients demonstrate considerable proclination
of the upper labial segment at the end of treatment.. Catania et al (1990)
recommend in his case report to use inverted U incisor bracket to counteract the
effect of proclination.

82.  The idea of this appliance is that because the
condyle is a growth site, the growth impeded by
extra-oral force (Graber, 1977).
 Despite success in animal experiments, most
human studies have found little difference in
mandibular dimensions between treated and
untreated subjects (Sugawara et al, 1990) .
Chincup appliances greatly improve the skeletal
profile in the short term such changes are
however rarely maintained during the pubertal
growth spurt
 Force 500g per side 12-14 h/day

83. Best patient for Chincup therapy. Ko et al
(2004)
1. Mild Sk III, ability to achieve edge to edge
incisors
2. Short vert face ht (.Chincups cause clockwise
rotation of the mandible.
3. proclined or upright LLS (Chincups cause
lingual tipping of the lower incisors
(Thilander 1963) )
4. absence of severe facial and dental
asymmetry

84. The effects of chincup therapy have been
reported as:
1. redirection of mandibular growth vertically
2. retardation of mandibular growth
3. remodeling of the mandible with closure of
the gonial angle
4. retardation of downward growth and
reinforcement of forward growth in the
maxilla

85. 1. Van Beek H. – Combination Headgear-Activator – JCO, March 1984.
2. Van Beek H. – Overjet Correction by a Combined Headgear and Activator – EJO,4(1982) 279-290.
3. Orton H.S. – Functional Appliances in Orthodontic Treatment – An atlas of clinical prescrption and
laboratory construction – Quintessence Books, 1990.
4. Skeletal effects of early treatment of Class III malocclusions with maxillary expansion and face-mask
therapy Baccetti T et al (1998) AJODO 113: 333 – 343
5. The early management of Class III malocclusions using protraction headgear Marcey-Dare LV (2000) Dental
Update 27(10): 508-13
6. Biomechanical and clinical considerations of a modified protraction headgear Nanda R (1980) AJO 78: 125 –
139
7. The management of Class III and Class III tendency malocclusions using headgear to the mandibular
dentition Orton HS (1983) BJO 10: 2 – 12
8. A philosophy of combined orthopedic-orthodontic treatment PfeifferJP & Grobety D (1982) AJO 81: 185 –
201
9. Protraction of the cleft maxilla Ranta R (1988) EJO 10: 215 – 222
10. Bioprogressive therapy Ricketts et al (1979) Section 1 Part 5:Orthopaedics in Bioprogressive therapy and
Section 7 Part 7: Factors in headgear design and application
11. Chin cup therapy for mandibular prognathism Graber LW (1977) AJO 72: 23 – 41.
12. The management of Class III and Class III tendency malocclusions using headgear to the mandibular
dentition Orton HS (1983) BJO 10: 2 – 12.
13. Effects of chin cup force on the timing and amount of mandibular growth associated with Class III
malocclusion Mitani et al (1986) AJO 90: 454 – 463.
14. Stability of changes associated with chin cup therapy Deguchi et al (1996) Angle O 66: 139 – 145.
15. A Randomised linical Trial, Tulloch JFC, Phillips C, Koch and Proffit WR. AJODO 1997; 111: 391-400
16. BOS advices, http://www.bos.org.uk/OneStopCMS/Core/CrawlerResourceServer.aspx
17. Contemporary orthodontics, Fourth Edition, 2007
18. VLE, National orthodontic Program
19. Excellence in Orthodontics
20. Postgraduate notes in orthodontics, 5th edition