HEADGEARS

Presented by : Guide :
Dr. Bilal Ahmed Afaq Dr. Shubhaker Rao Sir
PG Co-Guide :
Dr. Vamshilatha Ma’am
CONTENTS
 Introduction
 History
 Components of Headgears
 Ideal Patients for Extra Oral devices
 Biomechanics of Headgear
 Classification of Headgear
 Types of Headgear

2
CONTENTS
 Selection Criteria for Headgears
 Uses of Headgears
 Headgear combinations
 Disadvantages of Headgear
 Safety Precautions
 Conclusion

3
INTRODUCTION

To achieve a harmonious dentofacial relationship as a result of orthodontic treatment,

extraoral devices using the neck or cranium as anchorage have been employed.

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.

4
 Introduction

The use of headgear therapy is very common in the treatment of

Class II and class III malocclusions as well as to distalize the
maxillary dentition.

5
 HISTORY
 Kingsley is reported to have used occipital anchorage during treatment.

6
Biomechanics In Orthodontics - Micheal [Link]
 History

 Angle ( 1907) illustrated his occipital headgear and traction bar, which he replaced
with “Baker’s anchorage”.

 Angle described the use of extraoral traction combined with extraction of upper
premolars.

7
Biomechanics In Orthodontics - Micheal [Link]
 History

 Oppenheim recognised that if a force could be arranged so that it passed through the
center of rotation then a tooth, such as a molar would move bodily.

 Weber showed examples of extraoral traction designed to distalise mandibular teeth.

8
Biomechanics In Orthodontics - Micheal [Link]
 History

 Kloehn must be given the credit for

use of cervical traction as 1st phase
in 2 phase treatment of class II and
maxillary anterior crowding.

9
Biomechanics In Orthodontics - Micheal [Link]
 COMPONENTS OF
HEADGEAR
The principal components are

1. Force delivering unit

2. Force generating unit

3. Anchor unit

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Biomechanics In Orthodontics - Micheal [Link]
 COMPONENTS
The Head gear- facebow assembly mainly has three components.

1. Facebow

2. The force element

3. The head strap or the cervical strap

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Biomechanics In Orthodontics - Micheal [Link]
 Components

FACEBOW:
The facebow has an inner bow is available in either 0.045-0.051 inch, dependent on the
size of the headgear tubes on the first molars. The outer bow is usually 0.072 inch.

12
 Components

Outer bow is attached to the anchor unit and can be of different types depending on its
length.

 short- outer bow shorter than the inner bow

 medium- outer bow almost the same length as that of the inner bow
 long- outer bow is longer than the inner bow

13
 Components

Adjustments to the inner bow can be made in

 Buccolingually

 Superoinferiorly

 Anteroposteriorly

14
 Components

The different methods of making the inner bow stop mesial to the first molar tube 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.

15
CLASSIFICATION OF
HEADGEARS
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)

 Chin (chin cup)

 Frontal or reverse pull

 Combination of cervical and occipital (straight pull or combee)

 Very high pull (parietal)

16
 Classification

 
2. according to the purpose of usage:
A. growth modulators

B. for space regaining

C. molar distalisation
D. intrusion of maxilla

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 CENTRE OF RESISTANCE OF MAXILLA
Determine the Centre of resistance (CR)of
the body to which the headgear force is
being applied, whether tooth or segment
or arch or maxilla.

18
 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

19

Biomechanics In Clinical Orthodontics - Ravindra Nanda

Methods of determining headgear force system
Locating the center of resistance
of a tooth or group of teeth is
critical in determining the
direction of force exerted by a
particular type of headgear on a
given patient.

The most accurate method of

determining the direction of force
at the center of resistance,
however, would be to take a
lateral cephalogram with the
headgear in place
20

Method: For Determining Headgear Force Systems - MAJ STEVEN L. CURETON- JCO1992 Nov
 LEE in AJO 1997 Determined The Cres of the maxilla using holographic
inferometry. They found that the Cres of the maxilla was located at the
distal contacts of the maxillary first molars, one half the distance from the
functional occlusal plane to the inferior border of the orbit

Lee KG, Ryu YK, Park YC, Rudolph DJ. A study of holographic interferometry on 21
the initial reaction of
maxillofacial complex during protraction. American journal of orthodontics and dentofacial orthopedics.
1997 Jun 1;111(6):623-32.
Technique

Another method is by superimposing a slide of the

patient wearing the headgear over a cephalometric
tracing, thus allowing the line of force of the headgear
to be related to the center of resistance of the
maxillary first molar without taking another lateral
cephalogram

Mark the center of resistance of the maxillary first

molar on the patient's cheek, and take the slide with
the patient's head in a position similar to that of the
cephalogram.

22

Method: for Determining Headgear Force Systems - MAJ

STEVEN L. CURETON- JCO1992 Nov
• Tape the tracing to a blank wall, and project the
slide over it
• Adjust the size of the slide with the zoom lens or
by moving the projector until the image is the
same size as the tracing
• Using a marker, trace the photographic image of
the headgear, including the outer facebow, onto
the paper of the cephalometric tracing.
• Draw the inner facebow from the point of entry to
the maxillary first molar.

23

Method: for Determining Headgear Force Systems - MAJ STEVEN L. CURETON- JCO1992 Nov
 Clinical location of the Cres:

 This can be done by holding an

instrument in the maxillary vestibule
when the teeth are in occlusion and
the soft tissues and lips are relaxed.

 The Instrument 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.

Method: for Determining Headgear Force Systems - MAJ 24

STEVEN L. CURETON- JCO1992 Nov
 ASYMMETRIC HEADGEARS:

• If the direction of forces from the cervical elastic band is asymmetrical with respect to the
midsagittal line of the head, then the anterior-posterior components of the reactionary forces on
the right and left molars will be unequal

• the molar nearest the resultant of the two elastic band forces receiving the greater force.

• Small lateral forces on the molars are always developed by this eccentric design.

Hershey HG, Houghton CW, Burstone CJ. Unilateral face-bows: a theoretical and laboratory analysis. Am J Orthod. 1981
Mar;79(3):229-49. 25
 Components

Unilateral face-bows:

Power-arm face-bow. In this design, one

outer bow is longer and/or wider than the
other, with the longer or wider bow tip
located on the side anticipated to receive the
greater distal force.

26
Hershey HG, Houghton CW, Burstone CJ. Unilateral face-bows: a theoretical and laboratory analysis. Am J Orthod. 1981 Mar;79(3):229-49.
 Components

Soldered-offset face-bow. Here the outer

bow is attached to the inner bow by a fixed
soldered joint placed on the side favored to
receive the greater distal force.

27
Hershey HG, Houghton CW, Burstone CJ. Unilateral face-bows: a theoretical and laboratory analysis. Am J Orthod. 1981 Mar;79(3):229-49.
 Components

 Swivel-offset face-bow. In this design

the outer bow is attached to the inner
bow through a swivel joint located in an
offset position on the side favored to
receive the greater distal force.

28
Hershey HG, Houghton CW, Burstone CJ. Unilateral face-bows: a theoretical and laboratory analysis. Am J Orthod. 1981 Mar;79(3):229-49.
 Components

 Spring-attachment face-bow. Here an

open coil of spring is wrapped around one
of the inner-bow terminals of a
conventional bilateral face-bow. The coil
is placed distal to the stop on the side
favored to receive the greater distal
force.

Hershey HG, Houghton CW, Burstone CJ. Unilateral face-bows: a theoretical and laboratory analysis. Am J Orthod. 1981 Mar;79(3):229-49. 29
 BIOMECHANICS OF HEADGEAR
 Force systems of headgear can deliver depends on the magnitude, direction, point of
application and its line of action.

 Knowledge of the approximate location of the body’s center of resistance is essential

to choose the force system desired in treatment mechanics.
 A change in the inclination of the facebow affects the direction of the force and
ultimately the direction of tooth movement.

30
Contasti GI, Legan HL. Biomechanical guidelines for headgear application. J Clin Orthod. 1982 May;16(5):308-12
 Biomechanics

• The magnitude of the moment produced by the

headgear is calculated by multiplying the
perpendicular distance (P) from the LF to the CR
by the magnitude of the force.

• Thus, for a given force, the greater the distance

from the CR that the force is applied, the greater
will be the moment

Contasti GI, Legan HL. Biomechanical guidelines for

headgear application. J Clin Orthod. 1982 May;16(5):308-12
 Biomechanics

Force magnitude: Recommended force values per side for

 full permanent dentition – 400-600 gms

 early mixed dentition – 150-250 gms

 late mixed dentition – 300-400 gms

 Retention in permanent dentition – 150-400 gms.

Contasti GI, Legan HL. Biomechanical guidelines for 32

headgear application. J Clin Orthod. 1982 May;16(5):308-12
 Biomechanics

Duration:

Forces of 12-16 hour duration applied as intermittent forces appear to be the most
effective for orthopedic changes. Because the headgear is tooth borne, intermittent force
minimizes tooth movement while still providing for skeletal change. An intermittent heavy
force is less damaging to the periodontium and the teeth.

Contasti GI, Legan HL. Biomechanical guidelines for headgear application. J Clin Orthod. 1982 May;16(5):308-12 33
Selection
Criteria
34
 Selection criteria

1. Headgear anchorage location

a. High pull headgear: this applies a superior (intrusive) and distal force to the maxilla and
the maxillary dentition.
b. Cervical pull: this produces an inferior (extrusive) and distalising force on the maxilla.
c. Combination headgear: no moment is produced and a distalising force is applied to the
maxilla.

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Biomechanics In Clinical Orthodontics - Ravindra Nanda
 Criteria

Timing of headgear treatment:

 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.

 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 3

 The least desirable time is during the decelerating velocity period between
maturational stages SMI 8 to 11.

Kopecky GR, Fishman LS. Timing of cervical headgear treatment based on skeletal maturation. Am J Orthod36
Dentofacial Orthop. 1993 Aug;104(2):162-9
 Selection criteria

3. Based on MPA :
1. A low angle or normal growing (SN-MP< 370) case is suitable for cervical headgear.
2. If SN-MP is between 37-410, a combination headgear is used.
3. If SN-MP>410, then a high pull HG is used.

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Biomechanics In Clinical Orthodontics - Ravindra Nanda
 Selection criteria

4. Based on occlusal plane requirements:

Action desired headgear type

[Link] and steepening cervical HG; outer bow even or low
2. extrusion and flattening cervical HG; outer bow very high
3. intrusion and steepening high pull HG: outer bow posterior to Cres
4. intrusion and flattening high pull HG; outer bow anterior to Cres
[Link] force and flattening combination; outer bow above Cres
[Link] force and steepening combination; outer bow below Cres
[Link] force and no moment combination; outer bow at Cres

Uçem TT, Yüksel S. Effects of different vectors of forces applied by combined headgear. Am J Orthod Dentofacial Orthop. 1998 Mar;113(3):316-23.
38
 IDEAL PATIENTS FOR
HEADGEAR
1. Patients with maxillary excess:
 skeletal class II malocclusion with a component of
excessive horizontal or vertical growth of the maxilla
 Biomechanics
some protrusion of In Clinical Orthodontics - Ravindra Nanda
maxillary teeth
 Reasonably good mandibular dental and skeletal
morphology as this will be minimally affected.
 Potential for continued mandibular growth

39
 Criteria

2. Patients with vertical maxillary excess:

 high pull headgear for upper molars is given

 Interocclusal bite blocks can also aid in

prevention of eruption of posterior teeth. E.g.
high pull HG with functional appliances.

Ideal patients are

 long face patients

 skeletal open bite

40
 Criteria

3. Patients with horizontal maxillary deficiency:

 normally positioned or slightly retrusive but

not protrusive maxillary teeth

 normal or short but not long anterior facial

height

 ideal age of 8 yrs

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Types of
Headgears
42
 Cervical pull headgears:

 SILAS KLOEHN in 1947

 Component parts:
1. Molar tubes with headgear tubes
2. Inner and outer bow soldered together
in the center
3. A neck strap

BIOMECHANICS IN ORTHODONTICS MICHEAL

[Link] 43
 Types of Headgear

Effects of cervical headgear:

 to erupt the entire upper jaw

 tends to move the upper jaw distally

 Steepen the occlusal plane.

 Expansion of the upper arch.

Henriques FP, Janson G, Henriques JF, Pupulim DC. Effects of cervical headgear appliance: a
systematic review. Dental Press J Orthod. 2015 Jul-Aug;20(4):76-81 44
 Types of Headgear

Effect of different positions of the outer bow:

Henriques FP, Janson G, Henriques JF, Pupulim DC. Effects of cervical headgear appliance: a systematic review. 45
Dental Press J Orthod. 2015 Jul-Aug;20(4):76-81
 Types of Headgear

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.

Henriques FP, Janson G, Henriques JF, Pupulim DC. Effects of cervical headgear appliance: a systematic review. Dental
Press J Orthod. 2015 Jul-Aug;20(4):76-81 46
 Types of Headgear

Occipital Headgear:

The occipital headgear consists of a

facebow which fits over the occiput of the
head.
• Distalising and intrusive forces since the
force is exerted above the occlusal plane.
• High pull headgear can decrease the vertical
development of the maxilla, thereby
allowing for autorotation of the mandible
and maximizing the horizontal

BIOMECHANICS IN ORTHODONTICS MICHEAL 47

[Link]
BIOMECHANICS IN ORTHODONTICS MICHEAL 48
[Link]
 Types of Headgear

Advantages:

These headgears can be used in patients with steep mandibular planes and in cases wherein
mandibular growth is more vertical than horizontal. They can also be used in certain open
bite cases caused due to excessive eruption of buccal teeth.

BIOMECHANICS IN ORTHODONTICS MICHEAL 49

[Link]
 Types of Headgear

High Pull Headgear:

• This type of headgear always produces an
intrusive and posterior direction of pull,
due to the position of the headcap

50
BIOMECHANICS IN ORTHODONTICS MICHEAL.R MARCOTTE
 Types of Headgear

Combi Pull Headgear:

• Straight Pull Headgear or Interlandi or
Combination headgear
• pure posterior translatory force.
• Combination headgears have both
occipital and cervical traction springs.

51
 Types of Headgear

• Placing the outer bow above the LFO will

produce a posterior force, counterclockwise
rotation
• If the outer bow is below the LFO, the force
produced will be posterior and superior, and
the moment will be in a clockwise direction.

52
 Types of Headgear

Asymmetric Headgear:
If buccal occlusion is asymmetric e.g. Class I
on one side and class II on the other side,
without asymmetries either in molar axial
inclinations or in rotations, then it is most
logical to achieve the correction with
asymmetric headgear.

53
 Types of Headgear

J Pull head headgear:

54
 Types of Headgear

• The hooks are termed ‘J’ hook on account of their

shape J hook: each J hook consists of a 0.072 inch
wire contoured so as to fit over a small soldered
stop on the archwire, usually between the upper
lateral incisors and the canines.
• This HG is mainly used to retract and intrude the
maxillary incisor teeth and to prevent or correct
‘gummy smiles’.
• J hook HG is limited in use only with a maxillary
fixed appliance and a continuous arch wire.

55
 Types of Headgear

Disadvantage is that the flexibility of arch wire results in unavoidable

deformations which subject the teeth near the attachment to diurnal reversals of
force application as the extraoral appliance is attached or disengaged.

56
HEADGEARS WITH REMOVABLE APPLIANCES

57
 Headgear with removable appliances

Margolis acrylic cervico occipital anchorage:

Modified maxillary removable Hawley type

appliance permits the use of extraoral forces
against the maxillary dentition. Multiple ball
end clasps and occlusal coverage can increase
the resistance to dislodgement by extraoral
traction. Margolis used this appliance to hold
the torque correction achieved with fixed
appliances.

58
Biomechanics In Clinical Orthodontics - Ravindra Nanda
 Headgear with removable appliances

Modification:

 Addition of 1 mm buccal tubes to the labial wire and soldering them vertically at the
canine-lateral incisor embrasure to receive the J-hook extraoral force arms

 Inclined plane was added to eliminate functional retrusion and free the mandible for
all possible forward growth.

 The ACCO should be worn both day and night with a minimum of 12 hrs nocturnal
headgear wear.

59
Biomechanics In Clinical Orthodontics - Ravindra Nanda
 Headgear with removable appliances

Jacobson’s splint
• The force magnitude for this type of
removable appliance must not be too great
to prevent dislodgement of the appliance.
• The direction of pull of the extra oral force
should coincide roughly with that of the Y-
axis.

60
Biomechanics In Clinical Orthodontics - Ravindra Nanda
 Headgear with removable appliances

Graber appliance:

It was used for the treatment of class II division I malocclusions. The direction of force is high
and the appliance stands away from the molar and premolar areas to allow expansion of the
arch. This acts similar to the buccal shields of Frankel appliance.

61
Biomechanics In Clinical Orthodontics - Ravindra Nanda
HEADGEARS WITH FIXED APPLIANCES

62
 Headgear with removable appliances

Edgewise appliance::
Kloehn type of headgear :
• to reinforce anchorage
• opening of the bite due to extrusion of molars.

Straight pull headgear

• intrude molars in selected cases of open bites
• correction of gummy smiles.

Biomechanics In Clinical Orthodontics - Ravindra Nanda 63

 Headgear with removable appliances

Straight wire appliance:

When anchorage is critical, the anterior teeth are retracted by the use of a modified
Asher’s face bow which can be hooked either to a neck strap to retract the lower or upper
anteriors or an anterior high pull headcap to retract and intrude the upper incisors. Ashers high
pull facebow with headcap is used to retract the incisors using 12-15 oz of force.

Biomechanics In Clinical Orthodontics - Ravindra Nanda 64

 Headgear with removable appliances

Begg appliance:

Headgears can be used in isolated cases for distalisation of teeth or when orthopedic
control of maxilla is favored over extraction or orthognathic surgery. .

65
Biomechanics In Clinical Orthodontics - Ravindra Nanda
HEADGEARS WITH FUNCTIONAL APPLIANCES

66
 Headgear with removable appliances

Headgears with activator:

• activator cervical headgear therapy results in a
simulation of normal mandibular occlusal development
and a redirection of maxillary dentoalveolar
development.

• use cervical headgear, where necessary, for two

reasons: (1) to extrude maxillary molars, and (2) to
apply orthopedic traction to the maxilla, restrain
maxillary growth, and cause selective eruption of
teeth.

Kallunki J, Bondemark L, Paulsson L. Early headgear activator treatment of Class II malocclusion with excessive overjet: a randomized controlled trial. Eur J
Orthod. 2021 67
Dec 1;43(6):639-647.
 Headgear with removable appliances
Headgears with herbst appliance:

Baccetti T, Franchi L, Stahl F. Comparison of 2 comprehensive Class II treatment protocols including the bonded Herbst and headgear appliances: a double-blind study of68
consecutively treated patients at puberty. Am J Orthod Dentofacial Orthop. 2009 Jun;135(6):698.e1-10; discussion 698-9.
 Headgear with removable appliances

 It is indicated only in cases of severe class II MO in early mixed dentition.

 forces in the magnitude of 500 to 1,000 gm of pressure on each side were

suggested

 When the total maxillary dental arch is used as anchorage, forces up to 1,500 gm
on each side can be applied without discomfort to the patient.

Baccetti T, Franchi L, Stahl F. Comparison of 2 comprehensive Class II treatment protocols including the bonded Herbst and headgear appliances: a double-blind study of69
consecutively treated patients at puberty. Am J Orthod Dentofacial Orthop. 2009 Jun;135(6):698.e1-10; discussion 698-9.
 Headgear with removable appliances

Headgears with Bionator:

● The headgear was worn every night (8 to 10 hours)
during the first year of treatment. They concluded
that the combination of a bimaxillary appliance
with extraoral forces leads to rapid changes in the
correction of Class II, Division 1 skeletal
conditions.

Keeling SD, Wheeler TT, King GJ, Garvan CW, Cohen DA, Cabassa S, McGorray SP, Taylor MG. Anteroposterior skeletal and dental changes after early Class II 70

treatment with bionators and headgear. Am J Orthod Dentofacial Orthop. 1998

 Headgear with removable appliances

Headgears and Twin block:

The maxillary plane appeared to have rotated in

an anticlockwise direction. Vertical eruption of
the maxillary molars was restricted by headgear.
A restraint in the anteroposterior position of the
maxilla was demonstrated.

Kallunki J, Bondemark L, Paulsson L. Early headgear activator treatment of Class II malocclusion with excessive overjet: a randomized
controlled trial. Eur J Orthod. 2021 71
Dec 1;43(6):639-647.
 Headgear with removable appliances

Headgears with Frankel appliance:

 The vertical dimension or anterior facial height (ANS-Me) could be held constant or even
decreased through the holding or intrusion of the upper molars.

Biomechanics In Orthodontics - Micheal [Link] 72

 SAFETY MEASURES

 Check the fit of the locking facebow in a mirror, and confirm the lock by lightly pulling
forward on the facebow. Then attach the safety head or neck strap at the prescribed
tension (mark the appropriate holes) while holding on to the facebow.

 Never wear the headgear while playing.

73
Contasti GI, Legan HL. Biomechanical guidelines for headgear application. J Clin Orthod. 1982 May;16(5):308-12.
 Safety Measures

 If someone else grabs the headgear, take hold of it until the other person lets go.
Then take the headgear and facebow apart to make sure nothing has been dislodged
or broken.

 If the headgear or facebow ever comes off at night, or if there are any other
problems, stop wearing it and schedule an appointment as soon as possible.

 Always remove the head or neck strap before removing the facebow.

 An eye injury, however minor, see an ophthalmologist immediately. Penetrating

injuries may appear relatively asymptomatic, but immediate antibiotic therapy is
required to reduce the likelihood of infection.

74
Contasti GI, Legan HL. Biomechanical guidelines for headgear application. J Clin Orthod. 1982 May;16(5):308-12.
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.

75
 References
 Biomechanics In Orthodontics - Micheal [Link].

 Biomechanics In Clinical Orthodontics - Ravindra Nanda.

 The Alexander Discipline - R.G”wick” Alexander.

 Biomechanics And Aesthetic Strategies In Clinical Orthodontics -

 Ravindra Nanda.

 Orthodontics And Dentofacial Orthopedics- James Mcnamara, William

 Brudon.

 Contemporary Orthodontics -William [Link] , Henry W. Fields.

 Orthodontics- Current Principles And Techniques-vol-1- T.M Graber, Robert

Vandarsall.
76
 S. J. Kloehn; Evaluation Of Cervical Anchorage Force In

Treatment. Angle Orthod 1 April 1961; 31 (2): 91–104.

• Nanda R. Biomechanical and clinical considerations of a modified

protraction headgear. Am J Orthod. 1980 Aug;78(2):125-39.

• Pfeiffer JP, Grobéty D. A philosophy of combined orthopedicorthodontic

treatment. Am J Orthod. 1982 Mar;81(3):185-201.

• Contasti GI, Legan HL. Biomechanical guidelines for headgear

application. J Clin Orthod. 1982 May;16(5):308-12.

• Cureton SL. A method for determining headgear force systems. J Clin Orthod.
1992 Nov;26(11):724-9.

77
 Henriques FP, Janson G, Henriques JF, Pupulim DC. Effects of cervical
headgear appliance: a systematic review. Dental Press J Orthod. 2015 Jul-
Aug;20(4):76-81.

 Uçem TT, Yüksel S. Effects of different vectors of forces applied by combined

headgear. Am J Orthod Dentofacial Orthop. 1998 Mar;113(3):316-23.

78