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Orthodontics/best time to begin wearing reverse pull headgear


Hi Dr. Supan,

My 10-year old son has an under bite and overcrowded teeth. We’ve seen several orthodontists and found that he will need to use a palate expander and reverse pull headgear to address both issues with the understanding that the under bite may reappear if his lower jaw ends up growing much more than anticipated.  We’re trying to determine which of two orthodontists our son will see. The question I have is when is the best time to start wearing the headgear for optimum results. Many of the orthodontists we’ve seen have their young patients with the same issues as our son start wearing the headgear a few months after the palate has been expanded (using the Rapid Palate Expander (RPE)) and has stabilized. One orthodontist has them starting the day that RPE is inserted indicating that it is best to start immediately for best results.  I wasn’t clear on reasoning, and I was going to ask her soon. However, I thought I would pose this question to you. I guess the idea is that you can get better results on moving the upper jaw forward while the palate is in the process of getting expanded. She seemed to imply there are other parts of the jaw/skull (?) that are being moved at the same time and best results could be attained when using the RPE and headgear in conjunction during the palate expansion process.  This orthodontist has parents turn the key once every 3 days for a period of 3 months (total of 30 turns). The headgear would be worn for a total 9 to 12 months. The other orthodontist we’re considering requires the key is turned once a day for approximately 3 weeks. Then the headgear would be worn after a few months. The total treatment would be approximately 12 to 14 months. We will start treatment within a week.



Hi Phyl,

You have posed a classic question which undergoes much debate in the orthodontic community. The situation which you describe is an extremely difficult orthodontic challenge. let us break it down into components.

The crowding of the teeth which you describe likely is due to an undersized and small upper/ and or lower jaw. The upper dental arch expander which you describe is designed to create more "parking space" for the upper teeth and therefore allow them to "uncrowd" and better align. This transverse expansion of the upper jaw is permissable because of a growth suture which runs down the middle of the palate ( the roof of the mouth). There are two school of thought on the expansion, namely "RPE" or raid palatal expansion which some interpret as 2 activations a day, either down simultaneously or in the morning and evening.  The other is  a more gentle expansion meaning an activation every day or every other day. Success has been achieved via both means, and sometimes patient compliance and / or patient comfort and tolerance to discomfort will guide the choice of which activation method.

So in answer to your first question, there are two pathways and Evidence based dentistry is hard pressed to truly single out one method or the other as the " right" one to use. Again this is all targeted on addressing the crowding issue and the challenge of achieving an increase in the transverse ( or width) dimension of the upper jaw.

Now the second issue you raise has to this device do with the reverse head gear also known as a face mask (FM). The FM is designed to address the skeletal under-bite. The fact that the upper and lower front teeth very likely come together either in an edge to edge fashion or a crossbite can be due to two reasons. The teeth alone dentally may be angulated incorrectly and therefore meet or occlude improperly. A second scenario is that the upper and lower ja are in an architectural mismatch. For example,  a small and undersize upper jaw (this would explain the upper crowding)  when mated to a large and over-sized lower jaw would result in an underbite, that is the lower teeth protruding forwards of the upper teeth. A combination of dental and skeletal contributions to an underbite is possible as well.

The face mask is designed to help promote the forward development of the upper jaw, causing it to "stretch" so to speak more forwardly when seen for example from  an anterior posterior profile perspective. patients with cleft palate conditions who may have undersized jaws may benefit fro such FM  applications.

Now Phyl, to your keen question, namely how should these to be used in combination. I hope that it comes as no surprise that beneficial results may indeed be achievable with either approach. I have heard various lecturers, assert that contemporaneous expansion and forward traction with a face mask is verify very successful. The transverse expansion helps to separate the various upper jaw components so that they will mod and change in a more plastic like manner. I am not aware of any random clinical trials which would fulfill the higher levels of the evidence based dentistry pyramid, so that these reports should be taken as anecdotal opinion, albeit from clinical experts, but just opinions nevertheless.

My deep inner feeling and opinion..and that is far as I would qualify it...would be to perform rapid palatal expansion all the while exerting forward skeletal traction forces. After the twice a day expansion has been completed the FM anterior traction would of course continue.

In summary Phy, I have tried to answer your question as completely as possible without the benefit of clinical records or an examination. Please resubmit your question in a week or two if you have any follow up question. The service here right now limits things to two questions per week.

Paul Supan DS, MA, MPH  


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Paul Supan, DDS, MA, MPH


First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites and are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.


Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

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BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

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