Why this topic matters clinically
Every orthodontic student reaches a moment in clinic where a 9-year-old with Class II malocclusion is sitting in the chair—and the faculty asks:
“So… headgear or functional appliance?”
The confusion is understandable. One appliance pulls the maxilla back, the other pushes the mandible forward.
But do they actually produce different outcomes?
Evidence says something interesting:
👉 They reach the same destination—using different roads.
Let’s break this down logically.
The Clinical Question
Are headgears and functional appliances equally effective in correcting Class II malocclusions in children before comprehensive treatment?
Short answer
✅ Yes.
Both appliances produce similar overall Class II correction, especially in terms of ANB reduction and overjet correction.
Evidence at a Glance
- 5 prospective randomized clinical trials
- Children aged 7–10 years
- Phase I treatment only (no fixed appliances)
- Compared headgear vs functional appliances vs controls
📚 Databases used: PubMed & Cochrane Library
| Study | N | Age | Duration | Appliances | Key Design |
|---|---|---|---|---|---|
| Jakobsson (1990) | 57 | 8.5 yr | 18 mo | Cervical headgear vs Andresen activator vs control | Random, all Class II |
| Tulloch (1998) | 166 | 9.4 yr | 15 mo | Straight-pull headgear vs mod. Bionator vs control | OJ >7 mm, randomized |
| Keeling (1990s) | 249 | 9.5 yr | To Class I or 2 yr | Headgear + biteplate vs Bionator vs control | MPA-based headgear type |
| Ghafari (1998) | 63 | 7-13 yr | To Phase II | Straight-pull headgear vs FR-II | No control, ANB ≥4.5° |
| Final study (1990s) | 90 | 10 yr | 1.5-1.8 yr | Headgear/biteplate vs Bionator vs matched control | Bilateral >½ cusp distal |
Skeletal Effects: Who does what?
| Parameter | Headgear | Functional Appliance |
|---|---|---|
| SNA | ↓ (0.5–3°) | Minimal change |
| SNB | No significant change | ↑ (0.6–2°) |
| ANB | ↓ ≈ 1° | ↓ ≈ 1° |
| Mandibular length | Minimal / inconsistent | Minimal to slight increase |
Dental Effects: The Real Workhorses
| Dental Change | Headgear | Functional Appliance |
|---|---|---|
| Maxillary molars | Distalized (up to 3–3.7 mm) | Minimal / mesial |
| Mandibular molars | Minimal | Mesial (≈3 mm) |
| Maxillary incisors | Uprighting | Uprighting |
| Mandibular incisors | Uprighting | Proclination |
| Overjet reduction | Moderate (~1.5 mm) | Large (≈ 4 mm total) |
Vertical Effects: Should we worry?
- Headgear: Slight increase in SN–MP angle
- Functional appliances: Mostly neutral, occasionally slight decrease
📌 Clinically mild and usually not decisive
What about Headgear + Bite Plate?
🧠 Important exam insight
- Bite plate does NOT add additional skeletal benefit
- ANB, SNA, SNB changes are similar to headgear alone
- Maxillary molar distalization remains unchanged
➡️ Bite plate = optional, not essential
So… Are They Equally Effective?
✅ Yes—because:
- Both reduce ANB by ~1°
- Both reduce overjet
- Both correct Class II molar relationship
❌ But they are NOT identical:
- Headgear = skeletal restraint of maxilla
- Functional appliances = dental compensation + mandibular positioning
| Study | Appliance | SNA/A-pt | SNB/B-pt | ANB | Max Molar | Mand Molar | Overjet |
|---|---|---|---|---|---|---|---|
| Jakobsson | Headgear | -1.6 mm | No Δ | ~1° | -3.7 mm distal | No report | ~1.5 mm ↓ |
| Jakobsson | Activator | -0.7 mm | No Δ | ~1° | -1.2 mm distal | No report | ~4 mm ↓ (LI proc) |
| Tulloch | Headgear | -0.9°/yr | +0.6 mm/yr | -1°/yr | NR | NR | -1.4 mm/yr |
| Tulloch | Bionator | No Δ | +1.3 mm/yr (+0.6°/yr) | -1°/yr | NR | NR | -2.5 mm/yr |
| Keeling | Headgear/BP | -0.5° | 0.2° | -0.7° | Distal | Mesial > ctrl | ~2-3 mm ↓ |
| Keeling | Bionator | +0.5° | +1.4° | -0.9° | NR | Mesial > ctrl | ~2-3 mm ↓ |
| Ghafari | Headgear | -3° | Similar | -1.3° > FR-II | +3 mm neutro | Similar | Moderate ↓ |
| Ghafari | FR-II | +0.1° | +2 mm B-pt | Reduced | Less shift | Similar | Larger ↓ |
| Final | Headgear/BP | -1° | No SNB Δ | -1° | -1.2 mm distal | +2.7 mm mesial | Moderate |
| Final | Bionator | No Δ | +0.8° | -1° | Slight mesial | +3.3 mm mesial | LI proc 4.2° |
Final Take-Home Message (Highlight-worthy ✨)
Headgears and functional appliances are equally effective in early Class II correction in children. The difference lies not in how much correction occurs, but in how that correction is achieved—headgear acts mainly on the maxilla, while functional appliances rely largely on dentoalveolar changes and mandibular positioning.
Dentowesome 