ORIGINAL ARTICLE

Unequal outer and inner bow configurations:

Comparing 2 asymmetric headgear systems
Tamar Brosh,a Schay Portal,b Ofer Sarne,b and Alexander D. Vardimonc
Tel Aviv, Israel

Introduction: Asymmetric headgear is used when different molar distalization forces (MDF) are needed on
the right and left sides of the jaw to correct a Class II molar relationship. Methods: We investigated 2
asymmetric headgear configurations, the outer-bow and the inner-bow, on cervical-pull headgear. In the first
configuration, 5 hooks were soldered on 1 side of the outer bow at 10-mm intervals, making this side shorter;
in the other, 4 stops (1.5 mm) were added to 1 side of the inner bow, making this side longer. The right and
left MDF and the extraoral force (EF) were measured simultaneously with 2 fork transducers and a testing
machine, respectively. Results: A 40-mm difference between the long and short outer bows resulted in a
2.17-fold greater MDF on the long-side molar (7:3 ratio). The 3-4 stop configuration provided the optimal
inner-bow arrangement, with stop/no-stop MDF ratios of 7:3 and 10:0, respectively, at 10 N EF. At
low-to-medium EF levels, a unilateral MDF developed on the stop side with zero MDF on the no-stop side.
The sum of the right and left MDF nearly equaled the EF in the outer-bow asymmetry and was 60% in the
inner-bow setting; this suggests strong lateral forces in the latter. Conclusions: Clinically, for a bilateral
unequal Class II relationship, the system of choice is outer-bow asymmetric headgear. For a unilateral Class
II relationship with 1 side in a Class I molar relationship (Class II subdivision), inner-bow asymmetric headgear
is recommended. (Am J Orthod Dentofacial Orthop 2005;128:68-77)

H
eadgear is used to restrain maxillary growth, bow (shortening or elongating 1 arm, ie, the power
retract maxillary molars with or without the arm), diverse lengths of the right/left inner bow, diverse
maxillary dental arch, or hold the molars in right/left angulations between the outer and inner bows,
place while retracting the canines and anterior segment swivel offset, hinged inner bow, diverse toe-in bends in
into a posterior extraction space.1-3 Commonly, these the inner bow, and combinations.
objectives are required in a symmetric fashion. How- These asymmetric headgear systems exert greater
ever, occasionally, the requirement on the right side of MDF on the side with the longer outer bow, with
the dental arch does not equal that of the left side, greater angulation between the outer and inner bows,
and an asymmetric extraoral force system is recom- with a longer inner bow, with the swivel, opposite the
mended.4-11 For example, orthodontic correction of a side with the inner-bow hinge, and with less toe-in
unilateral Class II malocclusion (Class II subdivision) bend.5,10,11 Sander12 and Wichelhaus et al13 found that
in which the molar relationship is Class II on 1 side and adding a swivel on the not-distalized side combined
Class I on the other would require an asymmetric force with a short outer bow on the same side provides a
system generating distalization of the Class II molar
better asymmetric effect. Nevertheless, in all asymmet-
while holding the Class I molar in place.
ric MDF systems, simultaneous asymmetric moments
Six headgear systems can exert an asymmetric
developed, which tended to rotate the more mesially
molar distalization force (MDF) in the horizontal plane,
located molar distally.9,11 Additionally, a lateral force
when the change is performed in the face bow only.
develops in the system, causing an increase in crossbite
These include dissimilar lengths of the right/left outer
on the distally located molar.6,7,11,14 However, Breier et
From the Maurice and Gabriela Goldschleger School of Dental Medicine, Tel al15 found expansion on both molars when short/long
Aviv University. outer-bow or inner-bow asymmetric headgear was
a
Biomechanical Laboratory, Department of Oral Biology.
b
Instructor, Department of Orthodontics. used.
c
Chairman, Department of Orthodontics. Clinically, the most practical configurations of
Reprint requests to: Dr Tamar Brosh, Department of Oral Biology, The
Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv
asymmetric headgear design are shortening 1 outer bow
University, Tel Aviv 69978, Israel; e-mail: [email protected]. or elongating 1 inner bow. It is feasible to convert a
Submitted, March 2004; revised and accepted, July 2004. symmetric headgear at any treatment time into one of
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists. these configurations. Other systems, such as an elon-
doi:10.1016/j.ajodo.2004.07.040 gated power arm or a swivel offset, require stocking a
68
American Journal of Orthodontics and Dentofacial Orthopedics Brosh et al 69
Volume 128, Number 1

Fig 1. Asymmetric headgear: A, outer-bow asymmetry,

with 5 hooks soldered on 1 outer bow in 10-mm
intervals; B, inner-bow asymmetry, with 4 stops, 1.5 Fig 2. Fork transducer: A, schematic illustration of fork
mm each. transducer with strain gauge rosette; B, before inserting
headgear in molar tubes, 2 fork transducers are
threaded on headgear inner bow.
special inventory. Outer-bow shortening16 and inner-
bow elongation7 are insufficient in accomplishing the
asymmetric effect. However, these few studies were Two small U-shaped stainless steel fork transducers
limited. The objectives of the present study were: modified after Bratcher et al16 were developed (Fig 2).
Each transducer resembled a 2-pronged fork, with
1. To evaluate the asymmetric reaction—right vs left
overall dimensions of 7 x 13 x 2.1 mm. A 1.3-mm
molar MDF with respect to differential shortening
diameter orifice passed through both prongs of the fork.
of 1 outer bow in relation to progressive increases
The headgear inner bow was threaded through this
in the applied extraoral force (EF).
orfice on both sides before insertion into the headgear
2. To assess the asymmetric reaction (right vs left
tube of the molar band (Fig 2, B). The size of the fork
MDF) while elongating 1 side of the inner bow in
transducer, especially the thickness of each prong and
relation to progressive increase in EF.
the gap between them (0.7 mm each), was designed to
3. To evaluate the more effective system, either the
accept an MDF load of 10 N, with no permanent
asymmetric outer bow or the asymmetric inner
deformation and no contact between the 2 prongs, ie,
bow.
each prong reacted as a cantilever beam.
The scope of this study was to analyze the MDF A miniature 45° rectangular strain gauge rosette
developed in the 2 asymmetric configurations. The (EA-06-031RR-120, Vishay Measurements Group, Ra-
moments and lateral forces developed in these systems leigh, NC) was attached to the mesial prong of each
will be addressed in a future study. transducer to acquire the strain developed during head-
gear loading (Fig 2, A). For this study, only the middle
MATERIAL AND METHODS strain gauge that measured the bending strains of each
A series 5 (328-251, 3M Unitek, Monrovia, Calif) rosette was used. Strain gauges from both transducers
headger with step-in bayonet bend was used. For the were simultaneously connected through a quarter
first asymmetric method, 5 hooks were soldered on 1 Wheatstone bridge to a strain indicator (model 2100,
outer bow at intervals of 10 mm (Fig 1, A) to simulate Vishay Measurements Group). The transducers were
5 positions of asymmetric shortening of the outer bow. calibrated by using a specially constructed calibration
For the second asymmetric method, 4 stops, 1.5 mm jig, designed to apply loads perpendicular to the trans-
each, were successively added on 1 inner bow (Fig 1, B) ducer’s prongs simulating the MDF.
to simulate 4 positions of asymmetric elongating of the An experimental assembly was designed to fit in the
inner bow. universal testing machine (Instron model 4502, High
70 Brosh et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2005

Fig 4. Strain-load diagram with calibration curves for

each fork transducer. Calibration curves were used to
translate strain developed in specific fork transducer
into force unit providing MDF.

which was connected to a 100-N load cell on the

machine.
Nine asymmetric configurations were examined, 5
outer bows and 4 inner bows. Additionally, for each of
the 2 systems, 1 symmetric configuration was exam-
ined. The testing machine applied EFs of 0 to 10 N for
the outer-bow and 0 to14 N for the inner-bow config-
urations. MDF registration was taken by the fork
transducer continuously along the total EF range. Strain
values were then converted into force units according to
the calibration curves. Each measurement was repeated
3 times; the whole system was disengaged between
experiments. Three loading repetitions were conducted
Fig 3. A, Assembly consisting of 2 molars, each em- each time. Descriptive statistics and coefficient of
bedded in polycarbonate container filled with viscoelas-
variation were calculated.
tic material and separated transversely at average in-
termolar distance; B, headgear was linked to molars RESULTS
with its 2 fork transducers and attached with its neck
strap to testing machine to enable concurrent recording The coefficient of variation was calculated to define
of right and left MDF with strain indicator and EF with the reliability of replicated mesurements. For example,
testing machine. at 20 mm short/long outer-bow difference, the MDF
coefficients of variation were 5.4% on the short outer-
bow molar and 7.8% on the long outer-bow molar. The
Wycombe, United Kingdom) (Fig 3), consisting of 2 MDF coefficient of variation was even lower for the
polycarbonate containers filled with elastic material stops configuration. For example, for 3 stops, it was
(PL-2, Vishay Measurements Group) with elastic mod- 1.1% for the no-stop side and 2.3% for the stop side.
ulus of 0.21 GPa and Poisson ratio of 0.42. One plastic Figure 4 presents the strain-load diagrams and
molar was embedded in each container. The 2 blocks calibration equations of the right and left fork transduc-
were set 45 mm apart, simulating the intraoral trans- ers. The data showed a linear relationship and a curve
verse distance between the maxillary molars. Ortho- fitting for each strain gauge with r2 ⫽ 0.98 (P ⬍ .001).
dontic molar bands were placed on each tooth. The Moreover, in both fork transducers, the MDF strain up
headgear, with the 2 fork transducers threaded on the to 10 N imply prong bending in the form of a cantilever
inner-bow ends, was placed in the molar tubes (Fig 3, beam with no plasic deformation.
B). The whole complex was positioned in the testing
machine. An elastic neck strap was then attached to the Outer-bow asymmetric headgear
outer-bow hooks of the headgear around a polycarbon- Figure 5 presents the results obtained with 1 sym-
ate half cylinder (diameter, 6 cm), simulating the neck, metric headgear and 5 asymmetric configurations with
American Journal of Orthodontics and Dentofacial Orthopedics Brosh et al 71
Volume 128, Number 1

Fig 5. MDF/EF diagrams: A, for symmetric headgear; B-F, for asymmetric headgear by shortening
1 outer bow—ie, difference between long and short outer bow is B, 10 mm, C, 20 mm, D, 30 mm,
E, 40 mm, and F, 50 mm.

the 1 outer bow shortened by 10, 20, 30, 40, and 50 mm (Table I). For 10 N applied EF, at 10 mm outer-bow
compared with the other side. Four characteristics were difference, the MDF difference was 1.28 N, and, for
distinguishable: a 40-mm outer-bow difference, it was 4.03 N
1. In contrast to the symmetric outer bow with equal (Table I). In other words, MDFL was 56% and
MDF delivered to both molars, in all asymmetric MDFS was 44% of the total MDF at the 10-mm
outer-bow configurations, the MDF on the long outer-bow difference and 69% and 31% at the 40-mm
outer-bow side (MDFL) was greater than the MDF outer-bow difference, respectively (Table I).
on the short outer-bow side (MDFS). The difference 2. With an increase in long vs short outer-bow differ-
in MDF (long minus short outer bow) increased ence, the increase in MDFL was basically similar to
with an increase in the applied EF and with an the decrease in MDFS. From 10 to 40 mm outer-
increase in outer-bow length difference. From 4 to bow difference and at 10 N EF, the MDFL
10 N EF, the difference in MDF increased, gradu- increased from 6.00 ⫾ 0.55 N to 7.46 ⫾ 0.30 N,
ally reaching the greatest difference at 10 N EF and MDFS decreased from 4.72 ⫾ 0.09 N to
(MDFS ⫽ 4.72 ⫾ 0.09 N, MDFL ⫽ 6.00 ⫾ 0.55 N) 3.43 ⫾ 0.42 N. That is, the increase of MDFL
72 Brosh et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2005

Table I. MDF (N, %) for each molar at 10 N EF loading for asymmetric outer-bow headgear
Long outer-bow side molar Short outer-bow side molar
Outer-bow length
difference (mm) MDFL (N) % of total MDF MDFS (N) % of total MDF

Symmetric 5.25 ⫾ 0.50 52 4.85 ⫾ 0.3 48

10 6.00 ⫾ 0.55 56 4.72 ⫾ 0.09 44
20 6.60 ⫾ 0.52 63 3.83 ⫾ 0.21 37
30 6.57 ⫾ 0.25 66 3.46 ⫾ 0.55 34
40 7.46 ⫾ 0.30 69 3.43 ⫾ 0.42 31
50 7.50 ⫾ 0.17 69 3.37 ⫾ 0.55 31

(1.46 N) was similar to the decrease of MDFS sence of MDFNo-stop on the no-stop side was up to
(1.29 N). an EF of 4.3, 7.1, and 11.1 N for the 2, 3, and 4-stop
3. In all long/short outer-bow configurations, a linear configurations, respectively. That is, for the 3-stop
ratio of MDF to EF developed. The relationship configuration, any EF below 7.1 N would generate
(MDF to EF) was direct and linear for both long a unilateral MDF on the stop side only, whereas, on
and short sides. For example, with a 40-mm long- the no-stop molar, no MDF develops.
short difference, MDFS ⫽ 0.34 X EF and MDFL ⫽ 4. With an increase in EF and stop number, the sum of
0.75 X EF. the MDFStop and MDFNo-stop was less than the
4. The total of the long and short outer-bow MDF applied EF. This suggests that part of the applied
(MDFS ⫹ MDFL) almost equaled the applied EF. EF was converted into moments and lateral forces.
The totals of the long and short MDF were 10.72 N This “burn off” of EF (up to 40%) is presumably
for a 10-mm outer-bow difference and 10.89 N for the major cause for the clinical scissors bite that
40 mm (Table I). That is, no “burn out” in the develops on the no-stop side and the crossbite on
applied EF (10 N) occurred with an increase in the other side. This is why MDF can develop
outer-bow difference. Moreover, the total MDF was exclusively on 1 molar while the distal movement
never less but slightly greater than the applied EF. of the other side is counteracted by lateral force.
This “burn out” of applied force increased with the
Inner-bow asymmetric headgear stop numbers. For example, at 10 N EF, the total
Figure 6 presents the results obtained with 1 sym- stop and no-stops MDFs were 9.69 N for 1-stop
metric headgear and 4 asymmetric configurations with configuration and 7.01 N for the 3-stop configura-
1 inner bow elongated by 1, 2, 3, and 4 stops. Four tion—ie, a lack of 0.31 N (3.1%) for the 1-stop
characteristics were distinguishable: configuration, and 2.99 N (29.9%) for the 3-stop
configuration.
1. With the exception of the 1-stop configuration, the
molar on the stop side received more MDF (MDFStop)
than the molar on the no-stop side (MDFNo-stop) in DISCUSSION
all other asymmetric stop configurations (2-4 Outer-bow asymmetric headgear
stops). For example, at EF of 10 N, the MDF ratios The first characterisitic of the asymmetric headgear
between the stop and no-stop sides were 5:5, 6:4, with a shorter outer bow was greater MDFL than MDFS
7:3, and 10:0 for the 1, 2, 3, and 4-stop congfigu- even for small long/short outer-bow difference of 10
rations, respectively (Table II). The ratio increased mm. This is in contrast to the results of Bratcher et al,16
with each increase in stop number. who found hardly any differences when shortening 1
2. With the increase in the stop number, the decline of outer arm by half. A possible explanation to this
MDFNo-stop was greater than the increase in MDFStop. discepancy is that, in Bratcher et al,16 the outer arms
This indicated that with an increase in stop number were bent an additional 20° in the vertical plane, thus
(from 1 to 4), at 10 N EF, the MDFStop increased creating a 3-dimensional force system. MDFL, for the
slightly from 4.87 ⫾ 0.07 N to 6.08 ⫾ 0.05 N, while 40-mm outer-bow difference was 69% of the total
the MDFNo-stop decreased sharply from 4.82 ⫾ 0.08 N MDF; this agrees with the results of Yoshida et al11
to null (Table II). (68%) and Hershey et al8 (72%-74%). That is, MDFL
3. At the onset of the EF, there was a lag period where was 2.17-fold greater than MDFS. The second feature
no MDFNo-stop developed. The range of the lag demonstrated that, in contrast to the stop system, in the
phase increased with the stop numbers. The ab- outer-bow system, both long and short outer bows
American Journal of Orthodontics and Dentofacial Orthopedics Brosh et al 73
Volume 128, Number 1

Fig 6. MDF/EF diagrams: A, for symmetric headgear; B-E, for asymmetric headgear by elongating
1 inner bow—ie, difference between long and short inner bow is B, 1 stop ⫽ 1.5 mm; C, 2 stops ⫽
3 mm; D, 3 stops ⫽ 4.5 mm; and E, 4 stops ⫽ 6 mm.

Table II. MDF (N, %) for each molar at 10 N EF loading for asymmetric inner-bow headgear
Stop-side molar No-stop–side molar

No. of stops MDFStop (N) % of total MDF MDFNo-stop (N) % of total MDF

Symmetric 4.74 ⫾ 0.11 49 4.91 ⫾ 0.06 51

1 stop 4.87 ⫾ 0.07 50 4.82 ⫾ 0.08 50
2 stops 5.00 ⫾ 0.03 60 3.83 ⫾ 0.05 40
3 stops 5.12 ⫾ 0.13 73 1.89 ⫾ 0.23 27
4 stops 6.08 ⫾ 0.05 100 0 0

contributed equally to the MDF asymmetry, increasing ratio, ie, MDFL/MDFS. In symmetric headgear, where
in the former and decreasing in the latter. Regarding the equal forces act on the right/left molar, the MDF ratio
third character, an accurate way to interpret the efficacy is 1:1. For 10- and 20-mm outer-bow differences, the
of the asymmetric headgear was to examine the MDF ratio MDFL/MDFS was 6:4, and, for 30- and 40-mm
74 Brosh et al American Journal of Orthodontics and Dentofacial Orthopedics
July 2005

difference, the ratio was 7:3. Although length differ- thus, no disproof of the equilibrium theory occurred.
ences are not discussed, similar ratios (6:4-7:3) were However, the tendency toward cross-bite on the stop
reported by Wichelhaus et al.13 Consequently, the first side is not necessarily due to unequal lateral forces
objective suggests that the optimal difference between developed in the system, but can also be the result of
long/short outer bow was about 40 mm. Because the maintaining the upper/lower transverse dimension on
relationship between an increase in EF and MDF to the nondistalized maxillary molar, while positioning
each molar is linear8 (Fig 5), the MDF ratio was not the distalized molar into an interarch relationship where
affected by the applied extraoral force. However, the the mandibular dental arch has a greater transverse
greater the applied EF, the greater the difference dimension. This issue will be discussed in a future
between MDFL and MDFS. Our study agrees with that article. The lateral forces and moments developed in
of Bratcher et al16 regarding the fourth characteristic, the system were probably the major reason that unilat-
the total MDF was slightly greater than the EF. Theo- eral MDF developed only on the stop molar. A similar
retical explanations of the differential distal forces due effect of unilateral expansion is produced with a trans-
to asymmetric headgear can be found elsewhere.5,9,10 palatal arch while the contralateral side receives torque
moment.17
Inner-bow asymmetric headgear
The stop system used to create an asymmetric Clinical implications
headgear by elongating 1 side of the inner bow pro- This study focused on asymmetric dental arch
vided a clear-cut reaction of a vast difference in MDF distalization when the line of force was relatively close
magnitude (first characteristic); this is in contrast to the to the center of resistance of the molar. No inferences
results of Hershey et al.8 The 3-stop configuration should be drawn when the headgear is used for growth
provides the optimal force arrangement. At 10 N control and the line of force is relatively close to the
extraoral force, 73% of the total MDF was expressed on center of resistance of the dentomaxillary complex.18
the stop side and 27% on the no-stop side. These Clinically, the outer bow is superior to the inner-bow
findings support the second objective of an optimal asymmetric headgear because almost all EF is trans-
configuration for the inner-bow asymmetric configura- mitted to MDF—ie, minor conversion to lateral forces
tion. This extreme difference in MDF level was mainly or moments (third objective). However, clinically, 2
due to the decline on the no-stop side (second chracter- asymmetric situations are often encountered. In the
istic). The lag period (third characteristic), where no first, both right and left molars are in a Class II
MDFNo-stop is expressed at a certain EF level, provides relationship, and severity is greater on 1 side than on
a tool for exclusive unilateral distalization on the stop the other, eg, a full cusp distocclusion on 1 side and a
side. The range of this unilateral activity increased with half cusp on the other. The second is related to Class II
the stop numbers. At 2 stops, no MDFNo-stop developed subdivision, where 1 side is in a Class II molar
when up to 4.3 N of EF was applied, at 3 stops up to 7.1 relationship and the other in Class I.19 In the former
N of EF, and at 4 stops up to 11.1 N of EF. Hershey et situation, an asymmetric headgear of the 30- to 40-mm
al8 did not find an effective asymmetric response with outer-bow difference is indicated, because distalizing
a coil spring wrapped around 1 inner-bow terminal. The forces are exerted on both sides, althuogh unequally in
discrepancies between that study and ours can be a 7:3 ratio, and the loss of extraoral force is minimal. In
explained by the rigidity of the stops compared with the the latter clinical configuration, the inner-bow system
spring compression during EF loading; this resulted in meets the requirement of altering the anteroposterior
an immediate decrease in inner-bow elongation. How- position of 1 molar while unchanging the other. For
ever, our findings agree with those of Breier et al.15 The example, using the 4-stop system in the range of 1 to10
2-stop configuration delivered 56% of the total MDF on N EF, no MDFNo-stop develops on the Class I side while
the stop side in that study and 60% in our study. simultanously a MDFStop in the range of 0.8-6.1 N acts
It seems as if the inner-bow system violated New- on the Class II side.
ton’s force-equilibrium theory, because EF was not Under normal circumstances, a patient might keep
equal to the sum of the MDF (fourth characteristic). his or her head turned to or sleep on the stop side.12,13
However, not all force components acting in an antero- For this reason, it is recommended to use half of the EF
posterior direction were considered. The lateral forces magnitude when initial MDF develops on the no-stop
that developed in the system on both molars were not side. This provides a safety net so that, even at strong
perpendicular to the sagittal plane and thus contained head turns, the asymmetric system prevails. For exam-
anteroposterior force components. The “burn off” of EF ple, for the 4-stop system, an intial MDF response on
was presumably incorporated in these lateral forces; the no-stop side develops at 11.1 N EF. Using an EF of
American Journal of Orthodontics and Dentofacial Orthopedics Brosh et al 75
Volume 128, Number 1

5.5 N will assure adequate and exclusive MDF on the Medicine, Tel Aviv University, for their valuable assis-
stop side of 2.9 N, and, even with a full head turn or tance and comments.
sleeping on the stop side, no MDF will develop on the
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We thank Dr M. Davidovitch, Department of Ortho- COMMENTARY
dontics, and Ms R. Lazar, Scientific Editor, at The To fully understand the effects of asymmetric
Maurice and Gabriela Goldschleger School of Dental headgear, one must examine the biomechanics in-