June 24, 2019

Orthodontic patients do not wear headgear!

A fair proportion of orthodontists still use headgear.  This blog post is about how much co-operation we can expect using this treatment.

I stopped using headgear many years ago.  This was because I was not sure whether my patients were wearing it.  I do also wonder if I got such low co-operation because I did not really believe that they were going to wear this type of appliance, and the self-fulfilling prophecy occurred.  Putting my deficiencies as a headgear orthodontist aside. It is clear that headgear wear requires considerable co-operation.  Some of us have wasted a fair amount of time on headgear charts to record headgear wear. (My patients did not bring theirs back, or it was clear that they had completed them the day before!). But now we have headgear timers to help us calculate headgear wear.  This new paper reports on a study that looked at headgear compliance in a group of Swiss orthodontic patients.

Headgear compliance as assessed by a temperature-sensitive recording device: a prospective clinical study
Luis Huanca Ghislanzoni

European Journal of Orthodontics, 2019, 1–5 doi:10.1093/ejo/cjz036


The author has also included a pdf of this paper on Research Gate

In the literature review, they pointed out that 62% of the USA and Canadian orthodontists use headgear according to a survey published in 2016.

What did they ask?

They asked this simple question.

“What is the patient compliance in headgear wear over 8 months”?

What did they do?

They did a straightforward prospective cohort study. The PICO was

Participants: 8-12-year-old children with Class II malocclusion (OJ>6mm)

Intervention:  Orthodontic headgear

Comparison: None

Outcome: Hours and days of wear.

They enrolled 20 children into the study and asked them to wear their headgear for a minimum of 12 hours a day.

They measured the amount of headgear wear using a temperature and force sensitive timer. They saw the patients every month. The patients were aware that their treatment was being monitored.

At the end of the 9 months, they calculated the number of days that the patients used the headgear, the number of hours per day and percentage compliance.

What did they find?

All the patients completed the study.  These were the main findings.

  • The mean duration of treatment was 8.3 months.
  • Actual headgear wear (at least once per day) was 5.8 months (70% of the time)
  • Average daily wear was 6.4 hours (54% of the 12 hours requested).  This included the days of no wear.

When they looked at the wear during times of the day. They found:

  • During the night from 24.00 to 07.00 there was average compliance of 50%
  • During the day (11.00-20.00), the compliance was zero.
  • Compliance during the summer was particularly low.

Their overall conclusion was that compliance with headgear was poor.

What did I think?

I thought that this was a fascinating and straightforward study that answered a clinically relevant question.  You may feel that the results are nothing new, however, the low amount of co-operation surprised me.

I felt that the good points were that it was a prospective study, and all the patients completed the data collection period.  The data were analysed in a simple and set out in a set of nice descriptives. Importantly, the investigators did not over-analyse the data. I also thought that their findings were clinically relevant.

I looked carefully at the limitations of the study. The first is that the patients knew that they were being monitored. This means that the study is susceptible to the Hawthorne Effect. As a result, they may have worn their headgear for longer than they would under “unmonitored” conditions.  However, the findings are relevant to patients who are being watched.

Some may feel that the sample size was low, and they did not do a sample size calculation. However, this is a descriptive study, and the results do appear to have some validity because they are similar to other studies.

It is also interesting to see that these results are similar to other studies using timers in Twin Block appliances.

Clinical implications

I think that there are several clinical implications. Firstly, should we just “give up” on headgear and consider other methods of applying distal force?  Indeed, the advent of alternative anchorage solutions from TADs has considerable advantages.

We also need to consider whether this limited wear has resulted in clinically meaningful change to the molars.  This data is part of a larger clinical trial with a control group, and we will find out the answer to this question in due course. I look forward to seeing this paper.

It is nice to see a simple clinical study with straightforward, clinically relevant results.  I thought that this was great.


Related Posts

Have your say!

  1. ***be careful – the following comment is supposed to be a joke***

    How comes that the Orthotropics fanatics are accusing the Orthodontists of „dashing patient‘s faces“ when
    a) the patient aren‘t wearing their Headgear and
    b) we are actually not even prescribing it…?

    Have a nice day, yours, Dr. Martin Baxmann

  2. I tell my patients that we orthodontists have a joke “I use headgear but my patients don’t”.

  3. I gave up using headgear mainly for safety reasons, even with the “safety” type!

  4. I stopped using Headgear since years because of poor patient compliance.
    I think the findings of this study is realistic.
    thanks Kevin for this post.

  5. W needed a study for this? I know academics have to publish, but come on. Just hope no grant money was wasted on this nonsense.

  6. So here’s one – do you think protraction headgear has more compliance?
    Younger patients usually and quite probably a problem that is visible to patients and parents. Obviously I use it a lot less, but I never had my doubts about compliance with it, whereas I almost always have them about retraction headgear.

    Stephen Murray
    Swords Orthodontics

  7. Thank you Kevin for your review. I would say that this paper was an illegitimate son of your blog =)
    As an early bird reader I am following you on a weekly basis since the very first post and appreciate a lot your work and your inputs.
    A little anticipation regarding the dental results of this trial: they are not brilliant (at all) but at least tend to be linked to compliance (and other factors). We are writing it right now.

    • Funny thing: many have given up on Cervical HG saying patients won’t/don’t wear it. But as soon as a kid walks in with anterior crossbite they will immediately prescribe a facemask. More than curious…maybe the study should focus on clinician attitudes even more than patient compliance. Anybody have a better maxillary orthopedic growth restraint appliance? What’s better for gingival display/occlusal plane CHG, Cl II elastics, retraction mechanics, or mandibular re-positioning appliances? It’s unfortunate so many of the lessons of great thinkers (Ricketts, etc) have been forgotten.
      CHG is not right for many cases but it does have a place in Cl II correction.
      Attitudes do change but the herd mentality persists.

  8. Head gear is acceptable as long as it does not distalise the mandible , which CHG definitely can and does sometimes do.
    This is where the head and neck physiology goes awry .
    Not well taught or understood , but very bitter 25 year experience of orthodontically
    induced tmj and migraine problems has burnt the lesson in well for me.
    Facemask obviously doesn’t do this . Good post .

  9. In reference to the title of this post “ “THE CARRIERE DISTALIZER DOES NOT APPEAR TO WORK? THE FIRST RESEARCH PAPER. Reading the article and referring to Dr O’Brien and Dr Carriere’s analysis on it, this article should not be classified as the first scientific article on Carriere Motion. Clearly, this publication does not meet the necessary requirements or standards to be recognized as “the first research paper”. I wonder why it was accepted and published in a journal like Progress in Orthodontics?

  10. I find it hard to believe that after you fit a headgear to a teenager and tell him/her that “Your treatment time is 16-22 months if you wear it every night, and 24-30 months if you don’t, that you wouldn’t get 80-100% cooperation

  11. In the early 1980s, a timing headgear appeared on the market in Australia ( Rocky Mountain ,I think).
    I used headgear in those days but only at night for 12 hours.
    I noted that some of my patients achieved the desired hours for weeks on end but no clinical progress.
    One of the parents confessed that they had found the headgear under their child’s bed on a piece of timber stretched between 2 nails.
    See headgear can be fun for our patients so perhaps it wasn’t only the “Hawthorn Effect”.
    Everything old is reinvented again in orthodontics if you wait long enough.
    Thanks for keeping this blog going, Kevin.

Leave a Reply

Your email address will not be published. Required fields are marked *