What Is Orthodontic Headgear?
Orthodontic headgear is a removable appliance worn outside the mouth that connects to braces or other fixed devices inside the mouth. It uses the back of the head, neck, or chin as an anchor point to apply force to the teeth and jaws.
Braces are effective at moving individual teeth, but they have limits. When the upper jaw sits too far forward, the lower jaw is too small, or there is severe crowding, braces alone may not produce the right result. Headgear adds an external source of force that can influence how the jawbones grow and where the teeth end up. This is a well-established principle in orthodontic practice.
Most patients who need headgear are children or adolescents. Their jawbones are still growing, which makes them responsive to the gentle, consistent pressure headgear provides. In adults, jaw growth is complete, so headgear has more limited effects and jaw surgery may be considered instead.
Headgear has been used in orthodontics for decades. While newer techniques like temporary anchorage devices (small screws placed in the jawbone) have reduced headgear use in some clinical settings, headgear remains a well-established tool for certain bite corrections. A Cochrane review found no randomized controlled trials directly comparing surgical anchorage methods to conventional methods like headgear, highlighting a lack of high-quality comparative evidence rather than a clear advantage for either approach. [6]
How Does Headgear Work?
Headgear works by applying steady, directional force from an external anchor point to the teeth or jaws, guiding growth and tooth movement over time.
The basic mechanics are straightforward. Every headgear setup has three components: a head or neck strap that provides the anchor, a facebow or frame that connects the strap to the mouth, and an attachment inside the mouth (usually bands cemented to the back molars or hooks on the braces). The strap creates tension. That tension transfers through the facebow to the teeth and underlying bone.
The direction and angle of the force determine what the headgear does. Pulling backward on the upper jaw slows its forward growth and moves upper molars back. Pulling forward on the midface encourages the upper jaw to grow forward. Pulling upward controls downward growth of the back part of the jaw. Your orthodontist adjusts the force level and direction based on the specific problem being treated.
Force Levels and Wear Schedule
Headgear typically applies between 150 and 500 grams of force per side. Your orthodontist sets the force by adjusting the tension in the strap or the shape of the facebow. Higher forces are not always better. Consistent, moderate force over many hours produces the most predictable results.
Most orthodontists prescribe 12 to 14 hours of daily wear. Patients usually wear headgear from after school through the night, removing it for meals, sports, and school. The total treatment duration ranges from about 12 to 18 months in many cases, though this varies based on the severity of the problem and how consistently the patient wears the appliance.
What Is Anchorage in Orthodontics?
Anchorage is the resistance to unwanted tooth movement. When braces push one tooth forward, something must resist being pushed backward. In traditional braces, other teeth serve as the anchor. Headgear provides anchorage from outside the mouth, meaning it can move teeth or influence jaw growth without relying on other teeth to hold still. [6]
A Cochrane review examined whether surgical methods like mini-screws could replace headgear for anchorage reinforcement but found insufficient high-quality evidence to draw strong conclusions. [6] This means headgear remains a commonly used anchorage option, especially for growing patients.
What Conditions Does Headgear Treat?
Headgear treats jaw-related bite problems, including overbites, underbites, and certain types of crowding that braces alone cannot fully correct.
Class II Malocclusion (Overbite with Protruding Upper Teeth)
Class II malocclusion means the upper teeth and jaw sit too far forward relative to the lower teeth. This creates what many people call an overbite or "buck teeth." It is one of the most common reasons orthodontists prescribe headgear.
Cervical-pull headgear attaches to a strap around the back of the neck. It pulls the upper molars backward and restrains forward growth of the upper jaw. High-pull headgear connects to a strap over the top of the head, applying an upward and backward force. High-pull headgear is often chosen when the orthodontist also wants to control vertical jaw growth.
A Cochrane systematic review of orthodontic treatment for Class II malocclusion in children and adolescents found that providing treatment in one phase during adolescence appeared as effective as two-phase treatment starting earlier, though the evidence quality was low to very low. [3] Headgear was one of several appliances evaluated in the included studies.
Class III Malocclusion (Underbite)
Class III malocclusion occurs when the lower jaw is positioned too far forward or the upper jaw is too far back. The lower front teeth close in front of the upper front teeth, creating an underbite.
Reverse-pull headgear, also called a facemask or protraction headgear, treats this problem. It attaches to a frame that rests on the forehead and chin. Elastic bands connect the frame to hooks on the upper braces or a palatal expander inside the mouth. The elastics pull the upper jaw forward, encouraging it to grow into a more balanced position.
A Cochrane systematic review on treatment for Class III malocclusion in children found very low-certainty evidence regarding the effectiveness of different interventions, including facemask therapy. [1] The review noted that the limited number and quality of available studies make it difficult to identify one clearly superior approach. Still, reverse-pull headgear remains one of the most commonly used methods for early Class III correction in growing children.
Crowding and Anchorage Support
When teeth are severely crowded, an orthodontist may need to create space by moving back molars further back in the mouth. Headgear can accomplish this by using external force to push molars backward without affecting the position of front teeth. This technique, known as molar distalization, is a well-established approach in clinical orthodontics.
A Cochrane review on orthodontic treatment for crowded teeth in children found insufficient evidence to determine the most effective methods and timing for managing crowding. [2] The review highlighted the need for more well-designed studies. Headgear is one of several techniques orthodontists use to manage anchorage when treating crowding.
Deep Bite Correction
A deep bite (also called deep overbite) occurs when the upper front teeth cover too much of the lower front teeth vertically. In some cases, this is associated with retroclined (tilted backward) upper front teeth.
High-pull headgear can help manage deep bites by intruding (pushing upward) the back teeth or controlling the downward growth of the back portion of the jaws. A Cochrane review on deep bite treatment in children found insufficient evidence to recommend one treatment approach over another, and noted that more research is needed. [4] [5]
What Does the Research Say About Headgear?
Headgear is supported by decades of clinical use, but systematic reviews consistently note that high-quality evidence from randomized controlled trials remains limited.
Headgear does not require FDA clearance or approval as a standalone device in the same way that medical devices like lasers or implants do. It is classified as a component of orthodontic treatment and is used with standard orthodontic hardware (bands, brackets, wires) that are FDA-cleared Class II medical devices.
Several Cochrane systematic reviews have examined the conditions headgear treats. For Class II malocclusion, a 2018 review found that treatment with functional appliances or headgear during adolescence produced results comparable to two-phase treatment started earlier, though evidence certainty was low to very low. [3] For Class III malocclusion, a 2024 review found very low-certainty evidence across all studied interventions, including facemask headgear. [1]
A 2007 Cochrane review specifically examined whether surgical anchorage methods (such as mini-screws or mini-plates) are better than traditional methods like headgear for reinforcing anchorage. The review found no randomized controlled trials meeting its inclusion criteria, meaning there was no high-quality comparative evidence available at that time. [6] This does not mean headgear is ineffective. It means the field lacks the rigorous comparative studies needed to rank one approach definitively above another.
The American Association of Orthodontists recognizes headgear as a valid treatment tool and includes it in patient education materials about orthodontic appliances. [7] The American Dental Association also provides patient resources about orthodontic treatment options, including headgear. [8]
Benefits and Limitations of Headgear
Headgear offers unique advantages for jaw-level correction, but it also has real drawbacks that patients and families should understand.
Advantages
Headgear's primary advantage is its ability to influence jaw growth, something that aligners and braces alone typically cannot do. For children with significant jaw discrepancies, headgear may reduce or eliminate the need for jaw surgery later in life.
It is also non-invasive. Unlike temporary anchorage devices that require placing small screws into the jawbone, headgear is fully removable and requires no surgical procedure. [6] This can be appealing for younger patients and their parents.
Headgear provides strong anchorage from outside the mouth. This allows orthodontists to move specific teeth in specific directions without compromising the position of other teeth. The force levels and direction can be adjusted at each appointment.
- Influences jaw growth in ways braces alone typically cannot
- Fully removable with no surgical component
- Adjustable force direction and level
- May reduce the likelihood of needing jaw surgery in adulthood
Limitations
The biggest limitation of headgear is patient compliance. Headgear only works when it is worn. If a child wears it fewer hours than prescribed, treatment slows or stalls. Studies consistently identify compliance as a major factor in headgear outcomes.
Comfort is another concern. Headgear can cause soreness around the molars, especially during the first few days and after adjustments. The straps can feel awkward. Some patients experience mild skin irritation where the strap contacts the neck or head.
Appearance matters to many patients. Headgear is visible and can be a source of self-consciousness, particularly for teenagers. This is one reason orthodontists typically prescribe evening and overnight wear rather than full-day wear.
Finally, headgear is most effective during active jaw growth. For adults whose growth is complete, headgear has much more limited effects on jaw position. Adult patients with significant jaw discrepancies may need orthognathic (jaw) surgery instead.
- Effectiveness depends heavily on consistent daily wear
- Can cause temporary soreness and mild discomfort
- Visible appliance that some patients find socially difficult
- Limited effectiveness in adults whose jaw growth is complete
- Systematic reviews report low to very low certainty in much of the available evidence [1] [3]
How Much Does Headgear Cost?
Headgear is typically included in the overall cost of orthodontic treatment rather than billed as a separate item.
The cost of full orthodontic treatment with braces ranges from roughly $3,000 to $7,000 or more. Costs vary by location, provider, and case complexity. Cases requiring headgear may fall toward the higher end of that range because they tend to involve more complex bite problems and longer treatment times.
Most dental insurance plans with orthodontic benefits cover a portion of braces and related appliances, including headgear. Coverage amounts vary widely. A common lifetime orthodontic benefit is between $1,000 and $2,000, but your specific plan may differ. Check with your insurance carrier before starting treatment to understand your coverage.
Many orthodontic offices offer payment plans that spread the cost over the duration of treatment. Ask about financing options during your initial consultation. If headgear is recommended, confirm whether the headgear appliance and all related adjustments are included in the quoted treatment fee.
Questions to Ask Your Orthodontist About Headgear
If headgear has been recommended, asking the right questions helps you understand the treatment plan and set realistic expectations.
Not every bite problem requires headgear. Your orthodontist should explain why headgear is the best option for your specific case and whether alternatives exist. Understanding the reasoning helps with motivation and compliance, especially for younger patients.
Here are specific questions worth asking during your consultation:
- Why is headgear recommended instead of, or in addition to, braces alone?
- What type of headgear will be used, and what does it specifically correct?
- How many hours per day should the headgear be worn, and for how many months?
- What happens if the headgear is not worn consistently?
- Are there alternative treatments, such as temporary anchorage devices or functional appliances, that could achieve similar results?
- Is the headgear cost included in the total treatment fee?
- What should I do if the headgear causes pain beyond normal soreness?
- How will progress be monitored, and how will I know the headgear is working?
Find an Orthodontist Near You
An orthodontist can evaluate your bite, explain whether headgear is appropriate, and walk you through the full treatment plan. Visit the orthodontics page on My Specialty Dentist to search for a qualified orthodontist in your area and learn more about what to expect from orthodontic treatment.
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