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Orthodontic reverse pull headgear is a tool used to move the upper jaw forward to catch up with the lower jaw in the case of underbites or to compensate for jaw growth issues. The equipment uses force supplied through straps and wires, which can be adjusted to give the required tension and angle of pull.
There are different types of orthodontic reverse pull headgears, and they include:
Facial mask type 1 headgear
This type of headgear is worn on the face; hence, the name facial mask. A facial mask has a frame that supports the **elastic straps** hooked onto the upper jaw or palate to pull it forward. Facial masks are usually employed for younger patients, especially with growth potential.
Cervical headgear
The cervical headgear is designed for the extension of the upper jaw. It consists of a wirework hooked onto the back teeth and a padded head strap that rests on the neck and provides support. Causally, the cervical headgear is used at an angle with a downward pull to prevent the extension of the maxilla and to guide the teeth' tilting. Cervical headgear is mostly used in growing patients who require the retracing of the maxilla.
Buccal shields
Buccal shields are side braces that connect the tooth-wires to cushion the exertion of force onto the upper jaw. The buccal shield is placed against the cheek inside the mouth near the rear molar. Buccal is made of stainless steel and includes pads to eliminate the discomfort of having the device inside the mouth. Buccal is used in conjunction with other types of headgear, including cervical and double-hat, to distribute the pulling forces correctly.
Double hat headgear
A double-hat headgear combines chin strips and a hat-shaped head strap that fits over both sides of the head. The function of the double-hat is to provide both horizontal and vertical corrections. The inward-pulling straps on the side help guide the cheeks' archwire into the molars' slots, while the front chin strap restrains the mouth from moving open. The combination of the two corrections is useful in treating conditions like spacing occlusion, where some teeth are out of alignment concerning others.
The cant of the maxilla has to be corrected concerning the mandible for successful orthodontic treatment. To choose the ideal reverse-pull headgear, one must consider several orthodontic and non-orthodontic factors.
Jaw position and growth phase
Facial masks are ideal for growing children and adolescents. The facial mask is effective at guiding oral jaw growth. Adults who have completed jaw growth need different headgear that causes less tongue thrust.
Type of malocclusion
The type of open malocclusion will determine the type of orthodontic appliance that will be used. In orthodontic open malocclusion, where the lower jaw protrudes, reverse pull headgear is used to pull the upper jaw forward and close the gap. In other types, like **Class II malocclusion** of the most common wrongtire type, other types of headgear can be used. Cervical and double-hat headgears correct maxilla extension and tooth misalignment.
Patient comfort and compliance
The headgear type will be selected based on which one will be more comfortable for the patient to wear without causing discomfort. Some types will require wearing the headgear at night only, while others will allow them to wear it for shorter times during the day. These factors impact their wear time. Facial masks are usually worn outside, so parents can encourage patients to wear them because they are colorful and look like sports gear. Cervical and double-hat headgears are designed for home use and are relatively comfortable.
Adjunct orthodontic treatment
The orthodontist will recommend specific reverse pull headgear based on the treatment plan and alongside other adjunct appliances like peek spacers and palatine expanders. **Palatal expanders** create a gap in the palate midline, allowing the two **maxilla** bones to separate and widen the mouth arch. This creates more space for misaligned teeth to shift into the correct positions during headgear treatment. Once the archwire is attached to expanders, other appliances like cervical or double-hat headgears apply guidance and correctional forces. **Tongue** thrust also helps by its tonic activity to keep the tongue down away from the palate and eliminate the pressure against the maxilla arch that could cause constriction.
Orthodontic headgear comprises various parts designed for comfort and to provide a correct pulling force onto the teeth and jaws. These materials have been selected for their properties based on what they are used for and the durability needed considering the environments in which they will be used.
Facial masks materials
Facial masks comprise padded straps made nylon, elastic, and stainless steel to balance comfort and exertion of pulling force. The inner padding allows the child to wear it comfortably without any rash or discomfort. The outer nylon material is easy to wash and dries very fast. The elastic straps are made of sturdy yet stretchy materials that help supply balanced tension. The metal framework is made of light but non-flexible stainless steel. The design enables the framework to withstand bending or breaking even with consistent exerted strains.
Cervical headgear materials
The head strap includes cushioned polyester that absorbs pressure at the neck. The strap is adjustable to fit securely without being overly tight. The **molar bands** are constructed of durable stainless steel to endure heavy chewing and exerted forces during daily wear. The cushioned straps are hooked onto the cervical molar bands to prevent slipping and enable the even exertion of forces away from the invalid bouncy cervically.
Bucal shield materials
The buccal shield is made of stainless steel, which is equally durable and resistant to rusting as other parts that will be experiencing chewing and salivary effects. The buccal part is designed with comfort in mind too. It's padded for a cushy feel against the inside of the cheeks, hindering the user from feeling irritated. The low profile shape ensures that it fits snugly without causing obstruction to the tongue or its activities.
Double hat headgear materials
The double hat design comprises two parts – a top strap resembling a cap and a bottom chin strap. The top "hat" part is composed of the same adjustable cushioned polyester as the cervical headgear. This provides support without excessive pressure on the head. The chin strap is tough cotton-nylon blend, **adjustable** and made to endure the harshest daily activities.
The orthodontic reverse pull headgear is effective in several scenarios where adjustments of the maxilla concerning the mandible are required.
Mild underbites caused by jaw discrepancies
One of the primary applications of reverse pull headgear is correcting mild underbites caused by jaw discrepancies. If the condition is left unattended, it causes difficulties while chewing, affects speech, and, at times, leads to a person's self-consciousness over their facial features. An orthodontal practitioner will employ reverse pull headgear during the treatment of mild underbites, pushing the maxilla forward and realigning it with the mandible. This gives a pleasing outcome and discourages the need for invasive surgical methods.
Delaying or preventing surgical interventions
For adults close to finishing jaw growth, reverse pull headgear can delay or even prevent the need for surgery. Surgical options like **orthognathic surgery** involve repositioning the jawbones and are considered a last resort after all other methods have failed. Surgery is highly invasive, comes with longer recovery times, and has complications. Using reverse pull headgear allows the orthodontist to guide the jaw into a more favorable position without surgery. This is especially useful for adults with mild to moderate underbites or midface deficiencies who are out of the typical growth range.
Midface deficiency treatment
People diagnosed with midface deficiency show sunken cheeks and facial appearance due to the underdeveloped maxilla. The condition is more common in individuals with cleft lip and palate and warrants multiple corrections. The orthodontist can use reverse-pull headgear to project the maxilla forward and create a more balanced lower-third face. This improves aesthetics and lessens the functional issues associated with the deficiency. Midface deficiency treatment requires teamwork between orthodontists and other medical practitioners to deliver long-term solutions for patients.
Pre-surgical orthodontic preparation
In patients who need surgery to correct severe jaw misalignments, the orthodontist will use reverse pull headgear before the operation. This puts the jaws in the correct position, making the surgery easier and improving the results. It applies too much force to the maxilla and trains it to be in the correct position before surgery. It reduces the surgery time and decreases post-surgery complications. Patients needing surgery, such as **BSSO** (bilateral sagittal split osteotomy), benefit from wearing reverse pull gear during the waiting period.
The reverse pull headgear applies outward pressure on the maxilla to move it in the desired forward position, where it resides concerning the mandible. This makes it particularly effective for growing patients, guiding jaw growth and bone development into a favorable direction. Used correctly and for long, it can treat underbites and jaw misalignments without the need for surgery in younger patients.
Like any orthodontic treatment, headgear may have potential side effects. Prolonged wear may irritate the cheeks or the inside of the mouth, especially if the straps are poorly cushioned. Unbalanced force can slow the lower incisors and cause the **anterior** to protrude or tip. Uneven force application can affect the **front teeth** and cause misalignment or slow **anterior** tooth movement. Poorly fitting headgear may also exert excessive pressure on the jaw joints and cause discomfort around the TMJ area.
The ideal wear time for orthodontic reverse pull headgear varies by age, jaw condition, and the type of headgear used. Growing patients with midface hypoplasia wear facial masks for around 12-16 hours daily. The cervical and double-hat types are worn for only a few hours daily. For surgical preparation cases, it could be for several months until the surgery.
Adults can use reverse pull headgear, especially those who have completed jaw growth and are at risk of undergoing surgery. Such headgear can delay surgery and render it unnecessary in mild cases of misalignment.
Reverse pull headgear is mainly designed to address underbites and midface deficiencies. It can help other issues with the spatial and rotational corrections like **Class II** malocclusion, which concerns the teeth' alignment concerning each other.
