Anchorage in orthodontics 3 /certified fixed orthodontic courses by Indian dental academy

ANCHORAGE
IN
ORTHODONTICS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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Concept
Definition & Classification
Consideration of anchorage in three planes of
space
Anchorage planning (Methods to increase
anchorage potential)
Tweeds concept of anchorage preparation
Anchorage considerations with Begg
Anchorage considerations with PEA
Anchorage demand- minimum, moderate ,
maximum
Implants as a source of anchorage

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Whenever a force is applied the stabilized site
from where the force is exerted is the
anchorage

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Tug of warTwo equal sized people will pull each other
together by an equal amount.
A big person will pull a small one without being
moved.
If two or more smaller person combine the
chances of pulling a big person will increase.

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The pegs/ stakes driven into the ground at
an angle to support the tent
The stakes are at an angle that the pull of the
tent ropes against the stake would not
increase 90˚
The stakes driven too vertically will be pulled
upward & towards the tent.


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Newton & his laws of motion:
Law I: A thing at rest or in motion continues
to do so unless acted upon by an external
force
Law III : Every action has an equal &
opposite reaction


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We know that to create movement / displacement,
we must have a force acting on the body.

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For eg. Body (B) is at rest. Lets apply a force (F)
to move it to the left. The force (F) will have to
overcome the frictional force( Fr) bw the body (b) &
the surface (S), the gravitational force (G), only
then a particular movement will be seen.

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If the force (F) is smaller in magnitude than the
sum (Fr+G), then no movement will take place.

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For every kind of movement there exist an
optimal force level, below which that
particular movement cannot be produced.

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So this force level is the anchorage potential
of the body (B) for that particular movement


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Let us now come to oral cavity & teeth.
If an upper canine is to be retracted, with
bodily movement using a fixed appliance,
the force applied to the canine is approx. 100
gm.
Forces in the opp. direction varying from 67
gm on the 1st molar to 33gm on the upper 2nd
PM resist this.
Minimum unwanted anterior movement of the
posterior teeth.

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2 bda


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As the force level is increased to 300g the
reciprocal forces also increases with greater risk
of mesial movt. of post teeth.


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The anchorage value of any tooth is roughly
equivalent to its root surface area


Relationship of tooth movt. To force
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An obvious strategy for anchorage control
is to concentrate the force needed to
produce tooth movt where it is desired, &
to dissipate the reaction force to as many
other teeth as possible, keeping the
pressure in pdl of anchor teeth as low as
possible.


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Pressure in Pdl is determined by f/a.

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Tooth movt increases as pressure
increases up to a point, remains at the
same level up to a broader range, & then
may actually decline with extremely heavy
pressure.


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309


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The optimum force for orthodontic tooth
movement is the lightest force that
produces a maximum or near maximum
response (i.e, which brings pressure in the
PDL to the edge of the nearly constant
portion of the response curve).
Forces greater than that , though equally
effective in producing tooth movement,
would be unnecessarily traumatic &
stressful to the anchorage


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Let us consider the response of anchor teeth
(A) & teeth to be moved (M) in three
circumstances.

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In each case, the pressure in the Pdl of (A) is
less than that of (M) because there are more
teeth in the anchor unit.

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In the first case(A1-M1), the pressure for the
teeth to be moved is optimal, where as the
pressure in anchor unit is suboptimal --Anchor teeth moved less

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310


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In the second case(A2-M2), both are on
the plateau of the pressure response
curve. The anchor teeth can be expected
to move as much as the teeth that are
desired to be moved.
With extremely high force(A3-M3), the
anchor teeth might move more than the
teeth it was desired to move. Although
this is theoretic & may not be encountered
clinically.

Defination
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The term Anchorage in orthodontics refers to
the nature & degree of resistance to
displacement offered by an anatomic unit
when used for the purpose of effecting tooth
movement


Classification
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1. According to manner of force application
2. Acc. To jaws involved
3. Based on site of anchorage
4. Based on no. of anchorage units.


Manner of force application
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I. Simple Anchorage
2. Stationary Anchorage
3. Reciprocal Anchorage


Simple Anchorage
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Dental anchorage in which manner &
application of force tends to change the axial
inclination of the tooth or teeth that form the
anchorage unit in the plane of space in which
the force is being applied.
Resistance of the anchorage unit to tipping is
utilized to move another tooth or teeth.


Factors important for assessing
resistance value of an anchorage
unit( tooth)
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The part of tooth which is anchored in the
alveolar bone
No. of roots
Shape, size & length of each root– A
triangular shaped root offers greater
resistance to movement than a conical or
ovoid shaped root

Or it can also be expressed as the approximate
root surface area.
A tooth with a larger R.S.A is more resistant to
displacement than one with a smaller R.S.A
Other factors are also involved such as
-- Relation of contiguous teeth
-- the forces of occlusion
--The age of pt
--individual tissue response variables

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It is also imp. to check inclined plane
relationships & muscular forces in
assessing value of an anchorage unit.

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Amt. of force used is also imp. The forces
should be below the threshold needed for
movt. of post. teeth while serving light
forces against the ant. teeth.


Stationary Anchorage
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Dental anchorage in which manner &
application of force tends to displace the
anchorage unit bodily in the plane of space in
which the force is being applied is termed
Stationary anchorage.
Anchorage provided by a tooth which is
resisting bodily movt. Is considerably greater
than one resisting tipping force


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This refers to the advantage that can be obtained
by pitting bodily movement of one gp. of teeth
against tipping of another.
For eg. If the appliance were arranged so that the
anterior teeth could tip lingualy while the posterior
teeth could only move bodily, the optimum
pressure for the anterior segment would be
produced by abt. 1/2 as much force as if the
anterior would be to be retracted bodily.
This would mean that the reaction over the post
teeth would be reduced by ½, so these teeth would
move ½ as much.

Reciprocal Anchorage
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Refers to resistance offered by two malposed
units when the dissipation of equal & opp.
forces tends to move each unit towards a
more normal occlusion.
Two teeth or two gp. of teeth of equal
anchorage value are made to move in opp.
direction.


Egs of Reciprocal Anchorage


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Site of anchorage
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classification……

Intraoral Anchorage Extra oral Anchorage
Cranium (occipital or
Teeth
parietal anchorage)
Back of neck (Cervical
Alveolar bone
anchorage
Basal bone
Facial bones
musculature


classification……

According to jaws involved
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Intramaxillary Anchorage

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All the resistance units are situated in the
same jaw


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Intermaxillary Anchorage
Anchorage in which resistance units
situated in one jaw are used to effect tooth
movement in the opposing jaw.
Also termed Baker’s anchorage


Class II
intermaxillary
elastics

Class III
intermaxillary
elastics

classification……

Based on no. of anchorage units
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Single or primary anchorage
Cases wherein the resistance provided by
a single tooth with greater alveolar support
is used to move another tooth with less
support


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Compound Anchorage
Here the resistance provided by more
than one tooth with greater support is
used to move teeth with lesser support


Multiple / Reinforced Anchorage
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More than one type of resistance unit is
utilized
Refers to augmentation of anchorage by
various means
-- extraoral forces
-- adding 2nd molars to the post unit to
augment post achorage
--Traspalatal arch

Three Dimensional Anchorage evaluation
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Considering anchorage in all the three
planes (sagittal, vertical & transverse)
And subsequent anchorage planning is
very important before initiating any tooth
movements.


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Horizontal anchorage control means limiting
the mesial movt. Of post. Segment while
encouraging distal movt. Of ant. Segments.

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For example, a "maximum anchorage Class II,
division 1 case" is one in which no forward
movement of the upper posterior segments is
allowed, but preparation is made for maximum
retraction of the upper anterior segment.

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Vertical anchorage control involves limitation
of the vertical skeletal & dental development in
the post. Segments & the limitation of the
vertical eruption or even intrusion of the ant.
Segment.


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In the transverse plane, it comprises of
maintenance of expansion procedures & the
avoidance of tipping or extrusion of posterior
teeth during expansion.


ANCHORAGE PLANNING
Methods to increase anchorage potential
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I . By increasing the resistance to
displacement

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II. By decreasing the displacement
potential


Increasing the resistance to displacement
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1. Increase the no. of teeth in the anchorage
unit ( increase root surface area)
2.Create Buccal segments
The post. teeth are connected by rigid sectional
arch wire(18×25, 19×25).Alternatively, in the
absence of brackets a rigid sectional arch wire
can be bonded to the teeth, to create a buccal
segment which acts like a large multirooted
tooth generating good post. anchorage.

Increasing the resistance to displacement…..
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3. Cortical anchorage
Moving the roots of anchor molar into the
cortex increases their resistance to
displacement.
4. Palatal , lingual arches , Nance’s
button
The bilateral buccal segments thus
connected offer significant benefits.
Incorporation of anterior vault of palate
enhances post. Anchorage.

Increasing the resistance to displacement…

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5. Extraoral anchorage

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6. Muscular forces can be used to
augment anchorage such as through use
of lip bumper


Increasing the resistance to displacement…
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7. Moments generated through cantilever
springs or base intrusion arches are
applied to anchor teeth. These create
distal tipping forces, which help to resist
anterior displacement of anchor units.

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8. Implants, Ankylosed teeth
They are perfect egs of stationary
anchorage

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Decreasing the displacement potential
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1. Reduce forces
2. Reduce friction
3. Sequential loading

1. Reduce forces ..movt. In stages
..using movements which require less force


Decreasing the displacement potential….
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2. Reduce friction .. Using frictionless mechanics
..use of optimal clearance bw bracket & arch wire.
0.002 clearance is advocated for using sliding
mechanics
… Optimal leveling to reduce binding effect
3. Sequential loading …Gradual progression
towards stiffer slot filling arch wires


Tweed’s Classification of anchorage
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First Degree Anchorage preparation
It is applicable to all malocclusions with ANB
angles ranging from 0˚ to 4˚ in which facial
esthetics are good and in which total
discrepancy does not exceed 10 mm.
It is mainly limited o high cuspid, crossbite
pseudo-Class III, and true Class III cases.


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The degree to which anchorage should be
prepared is minimal.

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Mandibular terminal molars must always
be uprighted and / or maintained in such
an upright position as to prevent their
being elongated when Class II
intermaxillary force is used


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As a general rule, this means that the
inclination of the mandibular terminal molars
should be such that the direction of pull of
the intermaxillary elastic force during function
will not exceed 90˚ when related to the long
axis to these teeth.


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Second degree anchorage preparation

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Indicated when ANB exceeds 4.5˚and facial
esthetics make it desirable to move point B
anteriorly and point A posteriorly
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These cases are usually Class II in nature
and require prolonged Class II intermaxillary
mechanics

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They are accompanied by Type A, Type A
Subdivision, Type B and Type B
subdivision growth trends

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The mandibular terminal molars must be
tipped distally so that their distal marginal
ridges are at gum level.


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The direction of pull of the Class II elastics
when related to the long axes of the terminal
molars should be greater than 90˚ during
function, so that the terminal molars will be
further depressed rather than elongated


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Third degree or total anchorage
preparation
It is necessary in extremely severe
malocclusion in which total discrepancy vary
from 14 to 20 mm or more but the ANB angle
does not exceed 5˚
Class I in nature, with exceedingly irregular
teeth.
Jigs are necessary for third degree or total
anchorage preparation in the mandibular
arch.

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In these all three posterior teeth from and
including the second PM’s to and including the
terminal molars must be tipped distally to
anchorage preparation positions

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This means that both second PM’s and first
molars must be tipped to such distoaxial
inclinations that the distal marginal ridges of the
terminal second molars are below gum level


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In such positions, their mesial displacement
& elongation will not be great, during the
period when prolonged and vigorous
intermaxillary force is being used


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Conventionally Begg technique is
considered to be kind on to the anchorage
& the PEA anchorage taxing


Begg & PEA
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Pinning of base arch wire
into anteriors generates
powerful posterior
anchorage by activating
the anchor bend
Simultaneous aligning,
leveling & retraction of
U/L anteriors

Anchorage is to be
actively created
Discreet phases of
aligning
Levelling /& retraction
of U/L anteriors, each
with its anchorage
considerations.


Movts of ant. are in
2 stages, tipping &
uprighting which is
kind to the anchorage
Anteriors have the
freedom to tip in both
LL but importantly
mesiodistally.

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Movt of ant. Are with
torque control which
places strain onto
the anchorage

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No MD tipping
freedom


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Loosing anchorage is
a definite & positive
decision

Conserving

anchorage is a definite
& positive decision


Anchorage considerations with PEA
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Anchorage control in PEA is very imp.
Because of the features built in the
appliance, which tend to procline the teeth
Let us examine diff. phases of treatment, &
how the anchorage can be controlled.


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McLAUGHLIN & BENNETT defined
anchorage control during leveling and
aligning as "the maneuvers used to restrict
undesirable changes during the initial phase
of treatment, so that leveling and aligning is
achieved without key features of the
malocclusion becoming worse".


Control of anchorage in the horizontal
plane
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Anchorage control in the ant segment

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Anchorage control in the post segment


Anchorage control in the ant segment
In initial wires with preadjusted system,
tip built into anterior brackets increases
tendency of anterior teeth to tip forward.


Early attempts were
made to minimize
tipping by connecting
the anterior and
posterior segments,
usually with elastic
forces.
But this created a
greater demand for
anchorage control,&
there was a tendency
for the anterior teeth
to tip and rotate
distally, increasing
the curve of Spee
and deepening the
bite.


1. Lacebacks For A-P canine control
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These are .010 or .009 ligature wires which
extend from most distally banded bracket to
the canine bracket.


They restrict canines from tipping forward during
leveling & aligning.
In extraction cases, these prevented cuspid
tipping & are an effective means of distalizing the
canines without the unwanted tipping.


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Robinson investigated 57 PM Xn cases, ½
of which were treated with lace backs & ½
without.
His findings confirm that Lower canine lace
backs have beneficial effect in controlling
lower incisor proclination.
Without lace backs, the L.I moved forward
1.4 mm, in contrast, with lace backs in
place, the L.I moved 1mm distally.


2. Bend backs for A-P incisor control
Bending the arch wire behind the most distally
banded molar also minimizes forward tipping
of incisors.


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Like lacebacks, bendbacks are continued
throughout leveling & aligning archwire
sequence.

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In cases where it is necessary to increase
arch length, & where A-P control is not
required, bendbacks should be placed1 or 2
mm distal to molar tubes.


Anchorage control in the post segment
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In certain cases, it may be necessary for
the upper post segments to be limited in
their mesial movt, maintained in their
position or even distalized.
Headgear
Palatal Bar
Lingual arch
Lip Bumper
Class III elastics

Headgears
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Extra oral force is most effective method of
post anchorage control in U arch.

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Anchorage reinforcement in vertical and
anteroposterior plane in extraction cases
with critical anchorage requirement


According to the direction,
extra oral assemblies can be
grouped into:
(a) cervical – anchorage obtained from the
nape of the neck
(b) occipital – anchorage obtained from back of
the head
(c) parietal – the upper part of the back of the
head is used as anchorage


High pull

Cervical pull


Combi pull Headgear


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If the LF passes below the CR of the tooth,
as in cervical traction, an extrusive
component of force will be present.

If it passes above the CR of the tooth then
intrusive component of force will be present.


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The combination headgear is useful in
most cases.
It minimizes the tendency for extrusion of
upper posterior teeth, While
simultaneously allowing effective
distalization of the molar


Palatal Bar
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Anchorage control –
Constructed of heavy .045 or .051 inch (1.1 or
1.3 mm) round wire extending from molar to
molar with a loop placed in the middle of the
palate& the wire abt 2mm from the roof of the
palate. It is soldered to the molar bands.


The Nance holding arch
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It extends from upper molars to the anterior
portion of the palatal vault.
A steep anterior palatal vault has a buttressing
effect so is a useful source of anchorage


Lingual arch
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Used as space maintainers
Used for max anchorage PM Xn cases
It restricts the mesial movt. of the lower
molars & ensures that most of the Xn space
is available for anterior alignment


Lip Bumper
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It transmits the lip pressure on the lower
molars & support the post anchorage.


Muscular Anchorage


ClassIII Elastics & headgear
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In cases with severe lower incisor crowding,
where more anchorage support is needed
that can be provided by a lingual arch alone,
Class III elastics can be worn to Kobayashi
tiewires in the lower canine region, at the
same time as a head gear.


Vertical anchorage control
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In case of distally tipped canines, the incisors
may be entirely bypassed, till the canines are
uprighted, to prevent deepening of the bite
anteriorly.
It is important to avoid early archwire
engagement of high labial canines, so that
unwanted vertical movement of laterals &
PM does not occur.

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Vertical control of molars in high angle
cases

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Upper 2nd molars are usually not initially
banded, to minimize extrusion of these
teeth.
If they reqire banding an arch wire step
can be placed behind the 1st molar to avoid
extrusion

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If palatal bars are used, they are designed to
lie away from the palate by approx 2mm so
that tongue can exert an intrusive force.
Combination pull or high pull headgears are
used. Cervical pull HG is avoided.
In some cases, U/ L post bite plate in molar
region is helpful to minimize extrusion of
molars.


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VHA, is essentially a
transpalatal arch with
an acrylic pad.
The VHA uses
tongue pressure to
reduce the vertical
dentoalveolar
development of
maxillary permanent
first molars.

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The VHA was fabricated with banded
maxillary permanent first molars
connected with a 0.040-inch chrome
cobalt wire with a dime-size acrylic button
at the sagittal and vertical level of the
gingival margin of the molar bands.

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Four helices were incorporated into the
wire configuration for flexibility.

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VHA restricts and even helps to reduce
the percentage of lower anterior vertical
face height.
Evaluation of the vertical holding
appliance in treatment of high-angle
patients
Marcsss DeBerardinis, Tony Stretesky,
Pramod Sinha, and Ram S. Nanda,
Oklahoma City, Okla,
AJO 2000, volume 117

Anchorage control in transverse plane
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Inter canine width
Maintenance of intercanine width is
important for stability. They should be kept
as close as possible to the starting
dimensions.
Molar crossbites
They should be corrected by bodily movt.
Rather than tipping which extrudes the
palatal cusps.

Summary
1.
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Horizontal plane (anteroposterior)
A Control of anterior segments
Lacebacks
Bendbacks
B Control of posterior segments
Upper arch
Headgears
Transpalatal arch
Nance holding arch

Lower arch
Lingual arch
Class III elastics
Lip bumper


2. Vertical plane

A Incisor control
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Avoid engaging the incisor when the
canines have negative angulations.
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Utility arches
B Molar control
 Upper second molar banding to be avoided
initially (in high angle cases).

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Expansion if required should be achieved by
bodily movement of the posterior teeth (in
high angle cases).
Transpalatal arch should be 2-3 mm away
from the palate.
High pull or combi pull headgear to be used.
Posterior bite planes or bite blocks


3. Lateral or transverse plane
A Maintenance of upper and lower intercanine
width.
B Correction of molar crossbite
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Rapid maxillary expander,
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Quad helix
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Transpalatal arch.


Retraction or space closure
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ANCHORAGE CLASSIFICATION
Anchorage needs of an individual treatment
plan could vary from absolutely no mesial
movement of the molars/ premolars permitted
(or even distal movement of the molars
needed) to 100% of the space closure by
mesial protraction of the posterior teeth
Anchorage can be classified as:


A Anchorage. This category describes the
critical maintenance of the posterior tooth
position. Seventy-five percent or more of
the extraction space is needed for anterior
retraction
B Anchorage This category describes
relatively symmetric space closure with
equal movement of the posterior and
anterior teeth to close the space. This is
the least difficult space closure problem


C Anchorage This category describes non
critical anchorage. Seventy-five percent or
more of the space closure is achieved
through mesial movement of the posterior
teeth. This could also be considered to be
critical anterior anchorage .


COMPONENTS OF FORCE SYSTEM
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Alpha Moment
This is the moment acting on the anterior
teeth (often termed anterior torque).
Beta Moment
This is the moment acting on the posterior
teeth Tip-back bends places mesial to the
molars produce an increased beta moment

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Horizontal Forces
These are the mesio distal forces
acting on the teeth. The distal force acting
on the anterior teeth always equal the
mesial forces acting on the posterior teeth.


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Vertical Forces
There are intrusive-extrusive forces acting on
the anterior or posterior teeth. These forces
generally result unequal alpha and beta moments.
When the beta moments is greater than the alpha
moments, an intrusive forces acts on the anterior
teeth, if alpha moment is greater than the beta
moment, then extrusive forces act on the anterior
teeth while intrusive forces act on the posterior
teeth.
The magnitude of the vertical forces is dependent
on the difference between the moments and the
interbracket distance.

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Symmetric Space Closure – Group B
Anchorage
The requirement for space closure include
equal translation of the anterior and posterior
segments into the extraction space. Equal and
opposite moments and forces are indicated.
A T-loop spring centered between the anterior
(canine) and posterior (molar) attachments
produces this force system.


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Maximum Posterior Anchorage – Group A
Space Closure
The biomechanical paradigm for this space
closure problem is to increase the posterior M/F
ratio (beta M/F ratio) relative to the anterior M/F
ratio (alpha M/F ratio).
Utilizing the V-bend principle, the T-loop is
positioned closer to the posterior attachment or
the molar tube. The beta moment is greater
than the alpha moment, a vertical intrusive
force acts on the anterior segment.

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Maximum Anterior Anchorage – Group C
Space Closure
The biomechanical principle reverses the
approach to Group A space closure. The alpha
(anterior) moment is increased relative to the
beta (posterior) moment.
The primary side effect is an extrusive force
acting on the anterior teeth. The difficulty
results from this extrusive force, thus
deepening the overbite.


In Group C space closure with a segmented Tloop, the spring is positioned closer to the
anterior segment. It is important that the
anterior wire segment achieve full bracket
engagement; otherwise, the play within the
brackets reduces the effectiveness of the
moment differential.

Implants as a source of anchorage
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In contemporary orthodontics Implants is the
best source of anchorage, which doesn’t rely
on patient compliance.

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The pioneering studies on oral implants was
done by LINKOW who is rightfully called the
Father of Oral Implantology


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Implants are defined as alloplastic devices
which are surgically inserted into or onto the
jaw bone-Boucher.

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Implants can be used for Space Closure.
They are used in the retromolar region to
move teeth distally or anteriorly for mesial
movement

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Skeletal Anchorage System
(For open bite correction)
Sugawara; Umemori et al (AJO 1999;115)
They developed skeletal anchorage
system using Titanium plates as a source of
anchorage for intruding the molars.
The implants used are ‘L’ shaped Titanium
implants.



Surgical Procedure




Done under LA.



A mucoperiosteal flap is raised in the apical
region of the 1st or 2nd molar and the cortical
bone is exposed.



The ‘L’ shaped miniplate is adjusted to fit the
contour of the cortical bone and fixed to the
bone by using screws, with long arm exposed
to the oral cavity.



After wound healing occurs and elastic force
was applied from molar to the miniplate for
intrusion .



Lingual crown torque was applied in the
lingual arch to prevent the buccal flaring as
the molar intrudes and after the treatment the
miniplates are removed.





Skeletal Anchorage System
(For deep bite correction)



Creekmore;Eklund et al, the possibility of
skeletal anchorage (JCO 1983;17)



They inserted a surgical vitallium bone screw
just below anterior nasal spine.



Ten days after the screw was placed,a light
elastic thread was tied from the head of the
screw to the archwire



The elastic thread was renewed throughout
treatment,so that a continous force was
maintained 24 hrs a day.



After 1 year they found that the maxillary CI
were elevated 6mms and torqued lingually
about 25 degrees.





MiniImplant:Ryuzo kanomi; Miniimplant for
orthodontic anchorage ;(JCO 1997;31)



The author used an implant made of
miniscrews to fix the bone plates.



Minimplant-1.2mm in diameter
6mm in length




Placement of mini-implant.

Placement of mini-implants for cuspid retraction.


Placement of mini-implants for molar
intrusion.

Conclusion




It is very important to plan anchorage right
before hand so as to have a smooth
progression on to a predetermined optimal
end result.
Kind action always invoke kind reactions,
so always use kind action forces to have
kind reactions forces on the anchorage.


References
1. Graber T.M: Orthodontics: Principles
& Practice. WB Saunders,1988
2. Profitt WR: Contemporary Orthodontics, Sr Louis, CV
Mosby,1986
3. Robert E Moyers: Handbook of Orthodontics,Year book
medical publishers,inc,1988
4. Thomas M Graber, Robert L Vanarsdall: Orthodontics
current principles& techniques,Mosby year book
inc,1994
5. Evaluation of the vertical holding appliance in

treatment of high-angle patients
Marcs DeBerardinis, Tony Stretesky, Pramod
Sinha, and Ram S. Nanda,
AJO 2000, volume 117

Thank you
Leader in continuing dental education


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