Orthopaedic

appliances

k. prudhvi
Post Graduate
Department of Orthodontics
 CONTENTS
 INTRODUCTION

 HISTORY

 ORTHOPEDIC FORCE VS ORTHODONTIC FORCE

 PRINCIPLES OF USING ORTHOPEDIC APPLIANCES

 CLASSIFICATION

 HEAD GEAR

 CHIN CAP

 FACEMASK

 CONCLUSION

 REFERENCES
 Introduction
What is an orthopaedic appliance ?

• Extraoral devices using the neck or cranium as anchorage. These extraoral appliances have been

used to influence the maxillary and mandibular growth patterns by inhibiting and/or redirecting their

normal growth potentials in children before and during maximal pubertal growth.

• These appliances are used to improve the dental relationship between the maxilla and the mandible,

as well as the skeletal relationship between the two jaws.

3
 Introduction

Growth modification Dental camouflage Orthognathic surgery

 History
Changing views of treatment with extra-oral anchorage

5
 JOSEPH FOX
• The chin cup was first used by Cellier in 1802 & a year later by Fox ( not for anchorage but for
luxation cases).

6
 Norman Kingsley (1829 - 1913)
“Father of Orthodontics” 7
Norman Williams Kingsley

• Although Westcott & others had previously used the Head-cap for occipital anchorage, Kingsley, 20

years later, reintroduced this method, & for 40 years it proved the only successful method of

handling extreme cases of malocclusion.

8
He also made use of the Head-cap to shorten teeth by retracting them within the jaw after

they had elongated through “natural or developmental causes”.

9
Edward Hartley Angle

“Founder of Modern 10

Scientific Orthodontia”
Angle used astonishingly modern appearing appliances,
apparently with reasonable success.

11
 Class II elastics

Superimposition of cephalograms of Class II elastics

showed adverse tooth movements.

Therefore, in 1940’s HG were reintroduced as tooth

moving devices.

12
 Principle of Orthopaedic appliance:

Growth Growth
Modification Restriction

Applying pressure over sutures to

External forces over hold maxilla or mandible
Sutures
ORTHOPEDIC FORCE VS ORTHODONTIC FORCE
Sassouni ,1972

Orthodontic Forces Orthopedic Forces

Light continuous or interrupted forces Heavy Intermittent forces above 400

Less than 200gms gms per side,

Changes in Dental structures Changes in Skeletal structures

 Orthopedic force

Amount of force Duration of force Direction of force Timing of force

The recommended 12-14 hrs / day Should be through Pre-pubertal or mixed

extraoral force Usually in evenings center of resistance dentition Growth spurt

level /side(gm) is Fisherman SMI 4 to 7

400 to 600.
The recommended extraoral force level

/side(gm):

• Full mixed dentition 250 to 300.

• Mixed dentition during exfoliation (150-

250).

• Full permanent dentition 400 to 500.

• Retention in full permanent dentition 150

– 400
HEADGEAR
CLASSIFICATION

18
Headgears can be classified according to the area of attachment into

• Cervical area of the neck (cervical strap)

• Occipital area of the head (occipital strap)

• Frontal or reverse pull

• Combination of cervical and occipital (Straight pull or Combee)

• Very high pull (parietal)

20
According to the purpose of usage:

A. Growth modulators

1. Protractors 2. Retractors 3. To control verticalexcess

A. Reverse pull A. High pull A. Chin cup

B. Straight pull

C. Cervical pull

D. Combination

B. Space regaining

C. Molar distalisation

D. Intrusion of maxilla

21
 SELECTION OF
HEADGEAR:

1. Headgear anchorage location:

High pull headgear: this applies a superior (intrusive) and distal force to the maxilla and the maxillary
dentition.

Cervical pull: this produces an inferior (extrusive) and distalising force on the maxilla.

Combination headgear: no moment is produced and a distalising force is applied to the maxilla.

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High Pull Head-
gear

23
Cervical Pull Head-gear

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Combi-Pull Head-
gear

25
2. Age: According to proffit, the ideal age to begin modifying growth is around 8 years (because in

some cases, juvenile acceleration of jaw growth occurs at the age of 7-8 yrs just before pubertal growth

spurt).

• It is important to begin growth modification early in girls, since girls undergo pubertal changes by an

average of 2 yrs before boys.

• The treatment of skeletal malocclusions is usually done at the age of 8-9 yrs in girls and 10-11 yrs

in boys depending on the developmental status.

26
3.Selection based on MPA (according to Alexander)

• A low angle or normal growing (SN-MP< 370) case is suitable for cervical headgear.

• If SN-MP is between 37-410, a combination headgear is used.

• If SN-MP>410, then a high pull HG is used.

27
 Timing of headgear treatment

 The most optimum treatment time is between maturational stages SMI 4 to 7, a very high velocity period

of growth.

 The next most desirable time to treat is during the accelerating velocity period between stages SMI 1 to

 The least desirable time is during the decelerating velocity period between maturational stages SMI 8 to

11.

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 Clinical implications of orthopaedic devices

Orthopedic changes: Tooth movement:

Reinforcing the anchorage:
• Molar distalization
• Inhibit maxillary growth • Counteracts the side effects of
• canine retraction
intraoral mechanics • Intrusion of molars or incisors
• Redirect maxillary growth

• Reinforces posterior anchorage while • Up righting molars

• Move the maxilla distally
• Correction of rotations of
retracting anteriors
• Stimulate mandibular growth molars

• Inhibit mandibular growth.

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Components of Head-gear
•Molar tube

•Face-bow
- Inner bow
- Outer bow

•Head strap

•Force module 30
Molar Tube
Fixed appliance Removable appliance

0.045 inch

0.045 inch
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FACEBOWS

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Facebows – Types

1. Inner-outer bow type

Soldered
joint

2. J-hook type Inner bow

Outer bow

33
Standard
Facebows:

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 The Inner Bow
• Inner bow is available in either:
Inner bow
• 0.045 inch

• 0.051 inch

 Proper adjustment of the inner bow will allow the wire to slide in and out of the headgear tubes
easily.

 Adjustments to the inner bow can be made in six directions: bucco-lingually, superior- inferiorly,
antero-posteriorly.

35
The different methods of making the inner bow stop mesial to the first molar buccal

tube are

• U- loop: Advantage is that the length of the arm can be altered by adjusting

the loop

• Bayonet bend: Horizontal inset bend that keeps the anterior segment of the

bow away from the brackets.

• Friction stops: Stops can be fixed at the desirable location by crimping it

• Stop screws: The position of these screws can be changed and can be re-

used.
36
 The outer Bow
• Outer bow diameter is :

• 0.072 inch

 The outer bow must be adjusted to fit the face of the patient. Should be 5 to 10mm away
from cheeks.

 The outer bow ends anteriorly to the ears

Outer bow resting passively between

lips Outer bow several millimeters from
37
cheek
38
Facebow fitting
• Preformed face bows are available and are modified to fit the arch
form of the patient
• Inner bow should fit closely to the arch
• Stops provided in the inner bow should allow the anterior portion of
the bow to be placed about 4-5 mm away from the maxillary incisors
• Anterior portion of the bow should fit comfortably between the lips
at rest
• The outer bow is adjusted to confirm the cheeks, and should rest
several mm away from the cheeks.
Head strap

Neck strap
Used for cervical pull headgear
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Force Modules

Heavy force module Light force module

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•Available in various colours.

•Available in various force magnitudes:

350 gf – light.
500 gf – medium.
750 gf – heavy.

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TP orthodontics.
43
TP orthodontics.
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J-hook type
• An alternative method of
applying extra-oral forces to
a fixed appliance.

• The hooks are termed ‘J’

hook on account of their
shape and are attached
directly to the arch wire
usually in the incisor region. 45
• Each J-hook consists of a 0.072 inch wire contoured
so as to fit over a small soldered stop on the arch
wire.

1 3 1 2 1 1 1 1 2 1 3 1

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Biomechanics
1. Direction
2. Magnitude
3. Duration

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Center of
Resistance
• Applying a force through the center of resistance will

lead to a pure translatory movement along the force

vector.

• Unless the force direction is parallel with the occlusal

plane, tooth will also move vertically (intrusion &

extrusion).

50
• Applying a force away from the center of resistance will lead

to a combination of translatory and rotational movement.

• The amount of rotational effect will depend on the distance of

the force vector at right angle from the center of resistance.

• Moment = force * perpendicular distance from pivot

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 • Zygomatico-frontal
• Fronto-maxillary
• Naso-maxillary
• Zygomatico-maxillary
• Zygomatico-temporal
• Palato-maxillary

Naso-maxillary complex sutures 52

• According to observed clinical

reactions the location of the center of

resistance of the maxillary complex

must be somewhere in the area of

the postero-superior aspect of the

zygomatico-maxillary suture.

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Click icon to add clip art
• Miki 1979 and Hirato 1984 reported that the location of the
center of resistance in the midface of the human skull is between
the first and second upper premolars anteroposteriorly, and
between the lower margin of orbitale and the distal apex of the
first molar vertically in the sagittal plane.

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Ideal Line of Action of Force

• Application of 500 gms per side of force

applied 15 mm above the occlusal plane and

directed 200 to the occlusal plane produced

pure translatory movement of maxilla.

56
Clinical location of the Cres: (angle 1999 Stanley Braun)

• This can be done by holding an amalgam plugger or

similar instrument in the maxillary vestibule when the

teeth are in occlusion and the soft tissues and lips are

relaxed.

• The amalgam plugger is positioned at the Cres of maxilla.

The instrument is then palpated externally and a mark is

made on the skin surface corresponding to it. The

procedure is done for the other side also. The outer bow

may then be adjusted so that the force vector passes

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through this point.
 Cureton1992 JCO
Nov

Lateral cephalogram taken with Profile photograph of same Profile slide of patient wearing
headgear in place; stainless steel patient. headgear projected over
wires taped to headgear straps cephalometric tracing.
show lines of force.

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Cervical Headgear
Translation

Clockwise
Rotation

Anti-clockwise
Rotation

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 (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

CERVICAL PULL
mesial and occlusal to centre of resistance -
mesial root tipping.

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• INDICATIONS
• Short face
• Class II max protrusive cases with low mandibular plane angle
• Deep bite
• CONTRAINDICATIONS
• long faces
• High mand plane angle
• Deepbite
Advantages

• Direction of pull is advantageous in treatment of short face class II maxillary protrusive cases with

low MPA and deep bites.

Disadvantages:

• It normally causes extrusion of the upper molars. This movement is seldom desirable except in

patients with reduced lower anterior facial height. It is contraindicated in patients with steep

mandibular planes and in open bite cases

71
 Studies on cervical headgear:

• Cook et al in AJO 1994 studied growing children with Class II, Division 1 malocclusions who were
treated with two different techniques: one group with orthopedic cervical headgear/lower utility
arch (CHG/LUA) and another with cervical headgear alone. The outer bow was bent 200 upward and
the inner bow was expanded. A force of 450 gms was used on either side.

• The authors found that CHG produced Class II correction through maxillary orthopedic and
orthodontic changes, did not cause the upper molar to extrude beyond the amount seen with
normal eruption, and did not produce an opening rotation of the mandible even in those patients
who had Dolichocephalic facial patterns.

72
73
High Pull Headgear

 High pull headgear always produces an intrusive and posterior

direction of pull, due to the position of the headcap.

 This force system would be beneficial in a long-face Class II patient

with a high mandibular plane angle

 It can also be used in certain open bite cases caused due to excessive
eruption of buccal teeth.

 High pull headgear using J-hook can be used in the anterior segment
for deep bite correction and for correction of gummy smiles.

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 Translation

Clockwise
Rotation

Anti-clockwise
Rotation

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 Straight Pull Headgear or Interlandi
or Combination headgear

 This is a combination of the high-pull and cervical headgear, with the

advantage of increased versatility.

 The prime advantage of this headgear is its ability to produce an

essentially pure posterior translatory force.

 This is accomplished by placing the LFO through the center of resistance,

parallel to the occlusal plane.

 Clinically, this means bending the outer bow to the same level as CR, and

hooking the elastic to a notch at the same vertical level.

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 ASYMMETRIC FACE-BOWS

• Asymmetrical face-bows have been designed to move the teeth distally on one
side more than on the other.

• The simplest effective type is the power-arm face-bow in which the outer arm is
made longer and wider on the side anticipated to receive the greater distal force.
This side is often referred to as the favored side.

• When activated, face-bows are known to apply not only distal forces to the
molars, but also unwanted lateral forces.

86
Asymmetric Headgear
 Asymmetric Headgear

• Distal forces are 3 times greater on the long outer bow side than the short outer bow side.
• Short outer bow side – more amount of lateral forces can result in cross bite.
88
91
 Based on occlusal plane requirements:

ACTION DESIRED HEADGEAR TYPE

1. Extrusion and steepening 1. Cervical HG; outer bow even or low

2. Extrusion and flattening 2. Cervical HG; outer bow very high

3. Intrusion and steepening 3. High pull HG: outer bow posterior to cres

4. High pull HG; outer bow anterior to cres

4. Intrusion and flattening
5. Outer bow above cres
5. Distal force and flattening combination;
6. Outer bow below cres
6. Distal force and steepening combination;
7. Outer bow at cres
7. Distal force and no moment
94
Recent modification

• A standard facebow may be contoured to insert in the

maxillary molar tube from the distal end.

• Then the outer bow is adjusted so that the line of action of

the protraction forces is controlled.
95
HEADGEARS WITH REMOVABLE APPLIANCES:

• Margolis in 1976 incorporated

extraoral force with removable
appliances for pts with class II
malocclusions

• The Margolis appliance is called

an ACCO(Acrylic Cervical Occipital
Anchorage)

• Modified maxillary removable

Hawley type appliance permits
the use of extraoral forces against
the maxillary dentition
97
Splint headgear

• Headgear tubes are embedded in the acrylic

between the first molar and second premolars .

• The acrylic splint should be made evenly to

contact all the lower teeth , to prevent any
supra-eruption .

98
 Headgears with functional
appliance
• Head gear can be used in combination with
activator, bionator, frankel & twin block.

• The addition of high-pull headgear to the

Twinblock allowed effective vertical and sagittal
control of the maxilla and, consequently, there
was no increase in the LFH

99
 High pull headgear to a functional
appliance with bite blocks
• In Class II cases associated with severe denture-base discrepancy in the growth period, it is logical to
restrict the forward growth of the maxilla or maxillary dentition and, simultaneously, to stimulate all
possible forward growth of the mandible.

• Most effective approach to growth modification involving vertical maxillary excess and a class II
relationship.

• Here the force is directed entirely on to the maxilla,controls eruption of posteriors.

100
 Mandibular growth Advancer. MGA

• It is a modified activator.

• Functional appliance (MGA, mandibular growth advancer) with headgear

have obtained jaw and occlusal relationships, that are well-balanced,

both anatomically and functionally, producing a harmonious profile.

• The MGA is a modified activator for gradually accommodating the

muscle function by progressively advancing the mandible

101
Activator with Headgear.

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Face bow soldered to functional appliance.
Nitom locking Face bow
105
Kloehm face bow with safety catch mechanism.
Headgear
timers
• Northcutt was one of the first to
introduce a timing headgear.

• The timing headgear unit consists of a

miniature electronic timer and is used
with a digital readout meter.

• It was initially used with a cervical

pull appliance, but was later available
in a high-pull mode.

• With the ability to control direction of

force and to measure intensity, it is
now possible to have an equally
accurate measure of the third element
of the triad—duration of wear. 107
Disadvantages of headgear treatment:

• Accidental disengagement when the child

was playing while wearing the headgear

• Incorrect handling by the child during the

fitting or removal of the headgear

• Deliberate disengagement of the headgear

caused by another child

• Unintentional disengagement or detachment

of the headgear during sleep.
108
Assessment of patient compliance

The methods currently used to determine

headgear wear are subjective. Some methods used are
• Molar mobility,
• Cleanliness of headgear tubes,
• Cleanliness of headgear strap,
• Ease of placement by patient,
• Questioning patient,
• Space creation between teeth,
• Molar positioning comparing pretreatment models
and/or cephalograms,
• The position of the junction of the inner and outer
bow of the headgear compared with the previous
appointment, and
• Anchorage maintenance.
109
Follow up in headgear treatment
1. Routine use of Visual Treatment Objective of some type of comparative treatment
goal.

2. Routine cephalometric x-rays at six to nine month intervals to evaluate treatment

changes and progress.

3. Knowledge of normal growth and the effects of orthodontic treatment and extraoral
forces to the patient.

4. A prediction of the future skeletal pattern of the patient, the accuracy of which can
be enhanced by the control that can be exerted upon the skeletal pattern by proper
orthodontic and orthopedic treatment.
110
 SAFETY MEASURES

American Journal of Orthodontics and Dentofacial Orthopedics; March 2000

111
 FACE MASK/REVERSE PULL HEADGEAR
• Orthopedic facial mask is appliance of choice For the treatment of maxillary
deficiencies in Class III malocclusion cases in late deciduous dentition or early
mixed dentition.

• The ideal stage of dental development in which to begin facial mask therapy is
at the time of eruption of the upper permanent central incisors.

• Apply tensile force on the circumaxillary sutures and thereby stimulate bone
apposition in the suture areas; The maxillary teeth become the point of force
application, and the face (forehead, chin, zygoma) or occipital area becomes the
anchorage source 112
INDICATIONS
• Mild to moderate class III cases: It can be used in a growing patient
having a prognathic mandible and a retrusive and a hypodivergent
growth pattern.
• It can also be used for selective rearrangement of the palatal shelves
in cleft patients.
• It can be used in correction of post surgical relapse after osteotomies
(or uncontrolled post surgical adaptation).
• It can be used along with maxillary expansion
 Sutures involved in maxillary protraction:

Several circum-maxillary sutures play an important role in development

of the naso-maxillary complex. A change in these sutures during
treatment in the growing period occurs. The sutures are

a. Frontomaxillary,

b. Nasomaxillary,

c. Zygomaticomaxillary,

d. Zygomaticotemporal,

e. Pterygopalatine,

f. Intermaxillary,

g. Ethmomaxillary,

h. Lacrimomaxillary and

i. Zygomaticofrontal.
COMPONENTS
• Bickham (1972) claims he was the first to use a reverse headgear
• Metal framework
• Chin cup/pad
• Forehead cap
• Intraoral appliance
• Heavy elastic
Chin cup

Anchorage

Can be fabricated manually or commercially available.

Forehead cap

Cap or strap used for anchorage from forehaead

ELASTIC TRACTION

• The facial mask is secured to the face by stretching elastics from

the hooks on the maxillary splint to the crossbow of the facial

mask.

• Heavy forces (14 OZ force) are generated usually through

the 5/16" elastics.

• Lighter forces may be used during the break-in period but forces

should be increased as the patient adjusts to the appliance

118
• I. TIGER ELASTIC (3/8" 8 oz.) This type of elastic usually is worn during
the first few weeks during the initial break-in period. This elastic
creates about 200 grams of force.
• II. WHALE ELASTIC (1/2" 14 oz.) This elastic increases the force of the
appliance on the dental arches. Usually, this type of elastic is worn for
one or two weeks following tiger elastic wear. This elastic has
approximately 350 grams of force.
• III. WALRUS ELASTIC (5/16" 14 oz.) The heaviest of the three (600
grams), this elastic generates the appropriate amount of force and
usually is well tolerated by the patient.
BONDED MAXILLARY SPLINT (intra oral appliance)

• Maxillary splint incorporating all the teeth with an expansion appliance if required.

• The patient is instructed to turn the midline expansion screw of the appliance once per

day, generally before bedtime.

• In the majority of class III individuals for whom the use of an orthopedic facial mask is

indicated, some maxillary expansion is beneficial

120
• Baik found significantly greater forward movement of the maxilla (+2 mm) in

protraction with RME compared to protraction with out RME (+0.9mm).

• Greater forward movement of the maxilla (+2.8mm) was found when

protraction was initiated during maxillary expansion compared with

protraction after expansion.

• The maxilla moves downward and forward with a slight upward movement in

the anterior and downward movement in the posterior palatal plane as the

result of protraction force;

• Force is applied in the canine area, 20° to 30° below the occlusal plane.
123
 Bio mechanical considerations

Amount of force Duration of force Direction of force Timing of force

The recommended 12-14 hrs / day Downward pull at 15- 20 Early developing Class III

extraoral force 2-4 mm forward degrees to occlusal plane

level /side(gm) is over 8-9 months produces transalatory

400 to 600. motion

Petit Facemask
Side effects are almost inevitable when reverse headgear is used:

1. forward movement of maxillary teeth relative to maxilla and

2. downward and backward rotation of the mandible.

Hence ideal patients for this method should have both

a) Normally positioned or retrusive, but not protrusive, maxillary teeth

b) Normal or short, but not long, anterior facial vertical dimensions.

131
 CHIN CUP
• OPPENHEIM

• Class III malocclusion with Normal maxilla

• Chin cup is a restraining device that attempts to inhibit the

growth of the mandible, at least preventing it from projecting

forward and downward

• slowing down the rate of growth of condylar cartilage.

 CHIN CUP
Chin cups are divided into two types

(1) The occipital chin cup that is used in cases of mandibular

prognathism

(2) vertical pull chin cup that is used in cases of steep mandibular

plane angle and excessive anterior facial height, the so called

"backward rotator" patient.

133
OCCIPITAL PULL CHIN CUP

• Indicated in mild to moderate mandibular prognathism.

• Success is greatest in those patients who can bring their incisors close

to an edge-to-edge position when in centric relation.

• The occipital chin cup generates some force against the soft tissue in

the chin region, some backward tipping of the lower incisors often is

observed.

135
• If the pull of the chin cup is directed below the

condyle, the force of the application may lead

to a downward and backward rotation of the

mandible.

• If no opening of mandibular plane angle is

desired, the force should be directed through

the condyle to help restrict mandibular

growth. This therapy is best initiated in the

late deciduous or early mixed dentition.

136
a) The face grows but the chin is restrained
b) The chin grows downwards and backwards

a b 137
 Vertical pull chin cup
• Vertical pull chin cup are applicable in class III patients with anterior open bite & increased anterior vertical

dimension.

• It can result in a decrease in the mandibular plane angle and the gonial angle and an increase in

posterior-facial height.

• Whenever chin cup used it will create a pressure on the TMJ .The clinician should monitor for any signs of

TMJ disorders. If any are noted, the use of the chin cup should be discontinued immediately.

138
HICKAM CHIN CUP

The molded chin cup has two vertical metal posts (0.072 inch), which are used

to attach the elastics to the molar bands or soldered hooks on the arch wire.

• The chin cup assembly is held to the head by two long arms positioned below

the ears, and is attached to the back of the head with a small leather strap.

• The level of the mesial force delivered to the upper teeth / arch can be

adjusted by sliding / crimping the washers vertically on the metal posts.

• Unfortunately, the level is really determined by the lip position and makes the

mesial force usually somewhat below the CRcs of the upper arch / segment.
140
Effects
• Redirection of mandibular growth in a downward or backward
direction
• Remodeling of the mandible and a decrease in mandibular plane
angle or gonial angle
• Lingual tipping of lower incisors
• Improvement in skeletal and soft tissue profile.
 FORCE PRESCRIPTION FOR CHIN CUP THERAPY

A force of 150-300 grams per side is used initially. Over the next two months, the force level is increased to 450-700

Gms per side, if the force is directed through the condyle and slightly less if the force is directed below the condyle.

• The patient is instructed to wear the chin cup 14 hours per day with an acceptable range of wear being 10-16 hours

per day.

• To stop the growth of mandible 1200 gm (600g/side) is required. To redirect the growth 800 gm (400 g/side) is

required. This results in 4-5 g per sq mm at condylar region to effect the changes .

• After the correction of a pre-existing anterior cross bite has been accomplished, the patient wears the appliance

during night only as a retention appliance.

142
 Conclusion.

There are a number of ways to attempt the correction of class II malocclusions. The method chosen

depends on a series of factors that must be carefully evaluated before each therapy. The right indication

is the formula for success.

Only a careful and complete diagnosis and a continued diagnostic monitoring during treatment enables

the choice of the right appliance for the individual case to assure optimal treatment.
REFERENCES
• Contemporary orthodontics- william R. proffit (4th edition).

• Orthodontics : current principles and techniques- Graber &vanarsdall.

• Orhodontics In 3 Millenia – Anquity to the mid 19thcentury (AJO 2005;127:255-9)

• Ravindra Nanda - Biomechanics in clinical orthodontics

• A review of orthodontic face-bow injuries and safety equipment Samuels et al AJO 1996
144
• Adult Class lll Treatment Using a J-Hook Headgear to the Mandibular

Arch(Angle Orthod 2010;80:336–343.)

• The Role of a High Pull Headgear in Counteracting Side Effects from
Intrusion of the Maxillary Anterior Segment(Angle Orthod 2004;74:480–
486.)

• Unilateral face-bows – Hershey Am J Orthod Dentofac Orthop 1981

• The Role of the Headgear in Growth Modification(Semin Orthod

2006;12:25-33.)

• Headgears with activator -Levin et al in AJO 1985

• Biomechanical reevaluation of orthodontic asymmetric headgear(Angle

Orthod. 2012;82:682–690.) 145

• Dentofacial Effects of Asymmetric Headgear and Cervical Headgear with Removable Plate
on Unilateral Molar Distalization Angle Orthod 2005;75:584–592

• Unequal outer and inner bow configurations: Comparing 2 asymmetric headgear

systems (Am J Orthod Dentofacial Orthop 2005;128:68-77)

146
• Clinical application of the ACCO appliance. Part 1 AJO 1992 Feb;101(2):101-
11

• Comparative evaluation of a New Removable Jasper Jumper Functional

applaince vs an Activator- Headgear combination. (zafer Sari, Yasar Goyenc;
AO 2003).

• Safety Catch Mechanism (JCO 1993 Mar)

• A clinical evaluation of a locking orthodontic facebow(American Journal of
Orthodontics and Dentofacial Orthopedics March 2000)

• Comparison of treatment outcomes between skeletal anchorage and

extraoral anchorage in adults with maxillary dentoalveolar protrusion(Am J
Orthod Dentofacial Orthop 2008;134:615-24)

147