The effects of headgear treatment timing on costs and orthodontic outcome: a follow-up study
DOI:
https://doi.org/10.2340/aos.v85.46468Keywords:
Cervical headgear, costs, outcomeAbstract
Objective: To analyze the effects of cervical headgear (CHG) timing on costs and orthodontic outcome.
Material and methods: Sixty-seven participants with Class II malocclusion were randomized into two groups. In the early group (EG, n = 33), CHG treatment began after the eruption of first upper molars. In the later-timed group (LG, n = 34), CHG treatment began nearly 2 years later. Orthodontic outcome was evaluated when CHG ended and at the end of follow-up using the Peer Assessment Rating (PAR) index and Little’s Irregularity Index (LII). Costs were calculated using medical records, estimated chairside times and average personnel and material costs.
Results: The mean total costs including personnel and material costs during the follow-up were higher in the EG (€416) compared with the LG (€364) (p = 0.043). No statistically significant differences between the groups were found in the PAR and in the LII scores at the end of follow-up. The number of visits during CHG treatment was higher in the EG (13.3) compared with the LG (10.4) (p = 0.01).
Conclusions: Earlier initiation of CHG treatment increased the personnel and material costs, number of appointments, and chairside time. Based on the PAR and in the LII scores, the orthodontic outcome of CHG treatment was equal regardless of the timing of the treatment. If orthodontic treatment during mixed-dentition stage is considered, it would be justified from an economic perspective to favor treatment during late mixed-dentition.
Downloads
References
Wheeler TT, McGorray SP, Dolce C, Taylor M, King G. Effectiveness of early treatment of Class II malocclusion. Am J Orthod Dentofacial Orthop. 2002;121(1):9–17. DOI: https://doi.org/10.1067/mod.2002.120159
Tulloch JF, Phillips C, Koch G, Proffit W. The effect of early intervention on skeletal pattern in Class II malocclusion: a randomized clinical trial. Am J Orthod Dentofacial Orthop. 1997;111(4):391–400. DOI: https://doi.org/10.1016/S0889-5406(97)80021-2
Tulloch JF, Proffit WR, Phillips C. Influences on the outcome of early treatment for Class II malocclusion. Am J Orthod Dentofacial Orthop. 1997;111(5):533–42. DOI: https://doi.org/10.1016/S0889-5406(97)70290-7
Thiruvenkatachari B, Harrison J, Worthington H, O’Brien K. Early orthodontic treatment for Class II malocclusion reduces the chance of incisal trauma: results of a Cochrane systematic review. Am J Orthod Dentofacial Orthop. 2015;148(1):47–59. DOI: https://doi.org/10.1016/j.ajodo.2015.01.030
Batista K, Thiruvenkatachari B, Harrison J, O’Brien K. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents. Cochrane Database Syst Rev. 2018;3:CD003452. DOI: https://doi.org/10.1002/14651858.CD003452.pub4
O’Brien K, Wright J, Conboy F, Appelbe P, Davies L, Connolly I, et al. Early treatment for Class II Division 1 malocclusion with the twin-block appliance: a multi-center, randomized, controlled trial. Am J Orthod Dentofacial Orthop. 2009;135(5):573–9. DOI: https://doi.org/10.1016/j.ajodo.2007.10.042
Pirttiniemi P, Kantomaa T, Mäntysaari R, Pykäläinen A, Krušinskiene V, Laitala T, et al. The effects of early headgear treatment on dental arches and craniofacial morphology: an 8 year report of a randomized study. Eur J Orthod. 2005;27(5):429–36. DOI: https://doi.org/10.1093/ejo/cji025
Kallunki J, Bondemark L, Paulsson L. Comparisons of costs and treatment effects – an RCT on headgear activator treatment of excessive overjet in the mixed and late mixed dentition. Eur J Orthod. 2022;44(1):86–94. DOI: https://doi.org/10.1093/ejo/cjab026
Sollenius O, Petrén S, Björnsson L, Norlund A, Bondemark L. Health economic evaluations in orthodontics: a systematic review. Eur J Orthod. 2016;38(3):259–65. DOI: https://doi.org/10.1093/ejo/cjv040
Jermyn O, Bister D, Jin H. Cost-effectiveness of orthodontics: a systematic review. Eur J Orthod. 2022;44(5):566–77. DOI: https://doi.org/10.1093/ejo/cjac019
Drummond M, Sculpher M, Claxton K, Stoddart G, Torrance G. Methods for the economic evaluation of health care programmes. 4th ed. Oxford: Oxford University Press; 2015.
Dyken RA, Sadowsky PL, Hurst D. Orthodontic outcomes assessment using the peer assessment rating index. Angle Orthod. 2001;71(3):164–9.
Richmond S, Daniels CP. International comparisons of professional assessments in orthodontics: part 2 – treatment outcome. Am J Orthod Dentofacial Orthop. 1998;113(3):324–8. DOI: https://doi.org/10.1016/S0889-5406(98)70304-X
Richmond S, Daniels CP. International comparisons of professional assessments in orthodontics: part 1 – treatment need. Am J Orthod Dentofacial Orthop. 1998;113(2):180–5. DOI: https://doi.org/10.1016/S0889-5406(98)70290-2
Khandakji MN, Ghafari JG. Evaluation of commonly used occlusal indices in determining orthodontic treatment need. Eur J Orthod. 2019;1:107–14. DOI: https://doi.org/10.1093/ejo/cjz042
Richmond S, Shaw WC, O’Brien K, Buchanan I, Jones R, Stephens C, et al. The development of the PAR Index (Peer Assessment Rating): reliability and validity. Eur J Orthod. 1992;14(2):125–39. DOI: https://doi.org/10.1093/ejo/14.2.125
Shaw W, Richmond S, O’Brien K. The use of occlusal indices: a European perspective. Am J Orthod Dentofacial Orthop. 1995;107(1):1–10. DOI: https://doi.org/10.1016/S0889-5406(95)70151-6
Richmond S, Shaw W, Roberts C, Andrews M. The PAR Index (Peer Assessment Rating): methods to determine outcome of orthodontic treatment in terms of improvement and standards. Eur J Orthod. 1992;14(3):180–7. DOI: https://doi.org/10.1093/ejo/14.3.180
Little RM. The irregularity index: a quantitative score of mandibular anterior alignment. Am J Orthod Dentofacial Orthop. 1975;68(5):554–63. DOI: https://doi.org/10.1016/0002-9416(75)90086-X
Bernabe E. Estimating arch length discrepancy through Little’s Irregularity Index for epidemiological use. Eur J Orthod. 2005;28(3):269–73. DOI: https://doi.org/10.1093/ejo/cji112
Macauley D, Garvey T, Dowling A, Fleming G. Using Little’s Irregularity Index in orthodontics: outdated and inaccurate? J Dent. 2012;40(12):1127–33. DOI: https://doi.org/10.1016/j.jdent.2012.09.010
Julku J, Pirilä-Parkkinen K, Pirttiniemi P. Airway and hard tissue dimensions in children treated with early and later timed cervical headgear – a randomized controlled trial. Eur J Orthod. 2018;40(3):285–95. DOI: https://doi.org/10.1093/ejo/cjx088
Julku J, Pirilä-Parkkinen K, Tolvanen M, Pirttiniemi P. Comparison of effects of cervical headgear treatment on skeletal facial changes when the treatment time is altered: a randomized controlled trial. Eur J Orthod. 2019;41(6):631–40. DOI: https://doi.org/10.1093/ejo/cjz053
Hannula M, Tolvanen M, Pirttiniemi P, Pirilä-Parkkinen K, Julku J. Effects of headgear timing on dental arch changes from 7 to 18 years of age: a follow-up study. Eur J Orthod. 2023;45(5):496–504. DOI: https://doi.org/10.1093/ejo/cjad045
Julku J, Hannula M, Pirilä-Parkkinen K, Tolvanen M, Pirttiniemi P. Dental arch effects after early and later timed cervical headgear treatment – a randomized controlled trial. Eur J Orthod. 2019;41(6):622–30. DOI: https://doi.org/10.1093/ejo/cjy083
Käsmä K, Silvola AS, Vuollo V, Julku J. Effects of early and later timed cervical headgear treatment on the eruption timing and pattern of permanent upper canines and molars from 7 to 18 years of age: follow-up of a randomized controlled trial. Eur J Orthod. 2025;47(4):cjaf056. DOI: https://doi.org/10.1093/ejo/cjaf056
Mäntysaari R, Kantomaa T, Pirttiniemi P, Pykäläinen A, Krušinskiene V, Laitala T, et al. The effects of early headgear treatment on dental arches and craniofacial morphology: a report of a 2 year randomized study. Eur J Orthod. 2004;26(1):59–64. DOI: https://doi.org/10.1093/ejo/26.1.59
National Board of Health. Instruction letter no. 6/88: organization of orthodontic treatment. Helsinki: National Board of Health; 1988.
Statistics Finland. Local government sector wages and salaries [Internet]. 2021 [cited 2025 Mar 18]. Available from: https://pxweb2.stat.fi/PxWeb/pxweb/en/StatFin/StatFin__ksp/statfin_ksp_pxt_11ap_fi.px/
Pietila I, Pietila T, Svedstrom-Oristo AL, Varrela J, Alanen P. Orthodontic treatment practices in Finnish municipal health centres with differing timing of treatment. Eur J Orthod. 2009;31(3):287–93. DOI: https://doi.org/10.1093/ejo/cjn109
Krušinskiene V, Kiuttu P, Julku J, Silvola A, Kantomaa T, Pirttiniemi P. A randomized controlled study of early headgear treatment on occlusal stability – a 13 year follow-up. Eur J Orthod. 2008;30(4):418–24. DOI: https://doi.org/10.1093/ejo/cjn021
Pietilä I, Pietilä T, Varrela J, Pirttiniemi P, Alanen P. Trends in Finnish Public Orthodontic Care from the professionals’ perspective. Int J Dent. 2009;2009:945074. DOI: https://doi.org/10.1155/2009/945074
Pietila I, Pietila T, Pirttiniemi P, Varrela J, Alanen P. Orthodontists’ views on indications for and timing of orthodontic treatment in Finnish public oral health care. Eur J Orthod. 2007;30(1):46–51. DOI: https://doi.org/10.1093/ejo/cjm085
Arpalahti A, Saarnio-Syrjäläinen A, Laaksonen S, Arponen H. Early orthodontic treatment in a Finnish public health centre: a retrospective cross-sectional study. Acta Odontol Scand. 2023;81(5):396–401. DOI: https://doi.org/10.1080/00016357.2022.2161623
Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology. 1990;1:43–6. DOI: https://doi.org/10.1097/00001648-199001000-00010
Saville J. No multiple comparison procedures: the practical solution. Am Stat. 1990;44:174–80. DOI: https://doi.org/10.1080/00031305.1990.10475712
Published
Issue
Section
License
Copyright (c) 2026 Matti Hannula, Mimmi Tolvanen, Pertti Pirttiniemi, Kirsi Pirilä-Parkkinen, Anna-Sofia Silvola, Johanna Julku

This work is licensed under a Creative Commons Attribution 4.0 International License.
Acta Odontologica Scandinavica publishes high quality original research papers as well as critical reviews relevant on diseases of the oral cavity, their treatment, epidemiology and associated biomaterials and their development.