Anchorage in orthodontics

PRECEPTORS:
DR. PIUSH KUMAR
DR. BHARTI

PRESENTED BY:
DR. EMAD AHMAD ANIS
P.G. 1ST YEAR

Contents

Introduction
Definitions
Classification
Sources of anchorage
Types of anchorage
Anchorage Loss
Anchorage management
References

Introduction
Orthodontic tooth movement is brought about by
forces generated by the active components of an
orthodontic appliance.
Active components Generate forces
Newtons third law of motion

Introduction
In accordance with Newtons third law, the
forces used to move teeth induce an equal and
opposite force on the anchorage units tending
to cause their movement which is not
desirable.
The resistance that the anchorage areas offer to
these unwanted tooth movements is called
ANCHORAGE

Definitions
Moyers :
Resistance to displacement.
Active elements and resistance elements.
T.M. Graber :
The nature and degree of resistance to displacement
offered by an anatomic unit when used for the
purpose of effecting tooth movement.

Definitions
Proffit :
Resistance to unwanted tooth movement.
Resistance to reaction forces that is provided
(usually) by other teeth, or (sometimes) by the palate,
head or neck (via extraoral force), or implants in
bone.

Definitions
Nanda :
The amount of movement of posterior teeth (molars,
premolars) to close the extraction space in order to
achieve selected treatment goals.
White &Gardiner
Anchorage is the site of delivery from which force is exerted.

According to the manner of

force application
Simple
Stationary
Reciprocal

According to jaws involved

Intermaxillary
Intramaxillary

According to the site of

anchorage
Intraoral
Extraoral
Cervical
Occipital
Cranial
Facial
Muscular

According to the number of

anchorage units
Single
Compound
Reinforced

Classification Moyers

Extra oral anchorage

Forces derived from EOA

Stabilize the position of the teeth

Produce tooth movement
Orthopedic changes
Extra oral anchorage

Extra oral traction

Extra oral anchorage

Cases with severe crowding and overjet

Severe cases additional space is required even after
extraction

Various Headgears

CERVICAL PULL HEADGEAR

HIGH PULL HEADGEAR

J HOOK HEAD GEAR

Face mask for the protraction of maxilla- anchorage from forehead and chin.

 If force passes through

the COR , it causes
bodily movement.
If force is above
COR , it causes distal
root tipping.
If force is below
COR , it causes distal
crown tipping.

INTRA ORAL ANCHORAGE

Source of anchorage

Teeth
Alveolar bone
Basal bone
Musculature

Teeth
The anchorage potential of teeth depend upon
certain factors:
Root form: Round, flat and triangular
Size and number of roots: Multirooted
Root length: longer the better
Inclination of tooth: A greater resistance is offered
when the force exerted to move teeth is opposite to
that of their axial inclination
Ankylosed teeeth: Lack PDL; Absolute.

Alveolar bone
The alveolar bone offers resistance to tooth
movement up to a certain amount of force.
When the force exceeds the limit, the alveolar
bone permits tooth movement by remodeling.

Basal bone
Certain areas like the hard palate and lingual
surface of the mandible in the region of the
roots may be used to augment intra-maxillary
and inter-maxillary anchorage.

Musculature
The normal tonus of facial muscles play an
important role in the normal development of
dental arches.
Abnormal hypotonic muscles may cause
flaring of teeth.
Dental anchorage may be increased by making
use of hypertonic labial musculature as in case
of a lip bumper.

Classification
Nanda :
1. A anchorage : critical / severe
75 % or more of the extraction space is needed for
anterior retraction
.
2. B anchorage : moderate
Relatively symmetric space closure (50%)
3. C anchorage : mild / non critical
75% or more of space closure by mesial movement
of posterior teeth

Classification- Burstone

Group A: Post. teeth contribute less than one

quarter to total space closure

Group B: Post. teeth contribute from one

quarter to one half to total space closure

Group C: Post. teeth contribute more than one

half to total space closure

Biologic Aspect Of Anchorage

Anchorage value
Teeth to be moved
Active components
Anchorage

Relationship of tooth movement to force

Strategy for anchorage control would be to
concentrate the force needed to produce tooth
movement where it is desired and then to
dissipate the reaction force over as many other
teeth as possible.
For a tooth or group of teeth acting as
anchorage unit, pressure within the PDL
should be kept as low as possible.

Theoretical representation of the relationship of

pressure within the PDL to the amount of tooth movement.

Force magnitude

Physiologic force
concept
Basis of Reciprocal Tooth movement

Optimal force
The optimum force level for orthodontic
movement is the lightest force and resulting
pressure that produces a near maximum
response.
Forces greater than that, though equally
effective in producing tooth movement, would
be unnecessarily traumatic and stressful to
anchorage.

Heavy forces

Anchorage value of a tooth

Anchorage value of a tooth is its resistance to
movement, can be thought of as a function of
its root surface area, which is the same as its
PDL area.
The larger the root, the greater the area over
which a force can be distributed.

Basis of Reinforced anchorage

Root surface area of each tooth

1st M+1st PM= Canine+LI+CI
In order to reinforce anchorage 7 can be added
2nd M+1st M+1st PM > Canine+LI+CI

Biologic Aspect Of Anchorage

Pressure Response Curve for Anchor Teeth (A) and
Teeth to be Moved (M)

Pressure in the PDL of A is less than the pressure in the PDL of M.

Basis of stationary anchorage

Biologic Aspect Of Anchorage

Neighboring structures play an important role
Quality of the alveolar bone
Traumatic extraction and narrowing of ridge and
cortical bone formation.

Types of anchorage

Simple Anchorage:
Dental anchorage in which the
manner and application of force
tends to displace or change the
axial inclination of the teeth
that form the anchorage unit in
the plane of space in which the
force is being applied.

 Stationary Anchorage:
Dental anchorage in which the manner and
application of force tends to displace the anchorage
unit bodily in the plane of space in which the force is
being applied.
Refers to the advantage that can be obtained by
pitting bodily movement of one group of teeth against
tipping of another
Eg: Retraction of mandibular
incisors using first molars as
anchorage

 Reciprocal Anchorage:
Anchorage in which the resistance of one or more
dental units is utilized to move one or more
opposing dental units
Dissipation of equal and opposite forces
eg: Diastema closure, Correction of posterior cross
bite through cross elastics

Types of anchorage
Multiple or Reinforced Anchorage:
Multiple dental anchorage: Reduces
pressure on the anchor units moving
them down the slope of the pressureresponse curve
Tissue - borne anchorage:

 Cortical Anchorage:
Cortical bone is more resistant to resorption, and
tooth movement is slowed when a root contacts it.
Some authors have advocated torquing the roots of
posterior teeth outward against the cortical plate as a
way to inhibit their mesial movement .
However, as a general rule:
When a root is forced against cortical bone; it is greatly
slowed down and root resorption is likely to occur.

 Intramaxillry anchorage/ traction

Resistance units are situated within the same jaw

Palatal and lingual arches

Maintain intermolar width

Restrict mesial tipping
Correction of rotations

 Intermaxillary anchorage/ traction

Resistance units situated in one jaw are used to
effect tooth movement in the other jaw

Class III traction

Class II traction

Skeletal Anchorage
Until the 21st century, extra oral force such as
head gear and to a lesser extent the anterior
palate were the only ways to obtain anchorage.
Headgear had 2 main problems:
1)It was impossible to wear all the time.
2)The force against the teeth is larger than
optimal.

 A number of skeletal anchorage devices exist

at present, the principal one being titanium
screws that penetrate through the gingiva into
the alveolar bone.

Various types of skeletal anchorage options

1. Microimplants
2. Miniplates
3. Zygomatic ligatures
4. Conventional implants
5. Ankolysed teeth
6. Palatine implants
7. Onplants

 There are two basic forms of absolute anchorage

Direct anchorage :
When active segment is pulled directly from microimplant.

Indirect anchorage :
When active segment is pulled from the reactive segment, and
this segment is fixed to microimplant to incrase anchorage.

CLASSIFICATION OF IMPLANT
Based on the location
Subperiosteal : In this design, the implant body lies over the bony
ridge.
The subperiosteal design currently in use for orthodontic purposes
is the 'Onplant
(Block and Hofman, 1995)

 Transosseous ;

In this particular variety, the implant body

penetrates the bone completely.

DISADVANTAGE:
Damage to the intrabony soft tissue structures like
the nerves and vessels .

 Endosseous :

These are partially submerged and anchored within bone.

These have been the most popular and the widely used ones.
The endosseous implants are most commonly
employed types for orthodontic purposes.

Surgical miniplates:

Modified or conventional L or T shaped surgical titanium

miniplates are used with an intraoral extension.

These are placed in the areas of thick cortex similar to

zygomatic region and the buccal cortex of the mandible.

Skeletal anchorage system has been successfully used for

enmass distalization of lower arch in Class III cases, in maxilla
for intrusion of buccal segments in open bite cases, for en mass
molar distalization.

These offers absolute anchorage but involves extensive surgical

procedure.

 based on the site of placement:

Buccal
Palatal

Based on technique of placement:

Self drilling
Tapping

Based on shape:
Cylindrical
Tapered
Combinition

 based on the size:

Length 4-12 mm (small, medium, large)
Diameter 1.15 2.5 mm (small, medium, large)

based on head type:

Small
Long
Circle
Fixation
Bracket
Hook

Mechanical aspect of anchorage control

Sliding mechanics
Force is required for 2 purposes
Bone remodeling
Frictional resistance
Controlling and minimizing friction is an important Aspect of anchorage control

Mechanical aspect of anchorage

Two factors can affect the resistance to sliding
Interlocking of surface irregularities
Extent of plowing

In clinical practice friction is largely determined by

the shearing component

 When two solid surfaces are pressed together

or slides over the other, real contact occurs
only at the limited number of small spots
called asperities.

Surface quality of the wires

NiTi > Ti > SS

Roughness

There is no correlation between surface roughness

and coefficient of friction

Ti has greatest frictional resistance

 Possible solution to this problem

Alteration of the surface of Ti wires

Among all, SS/SS couple is most effective for sliding

followed by CoCr/SS, NiTi/SS, Ti/SS

Surface qualities of Brackets

SS: relatively less friction than all.
Titanium brackets: large amount of friction .
Ceramic brackets: Increased friction.
Ceramic brackets with metal slots: Less friction
Composite plastic brackets: Less friction than
ceramic

Elastic and inelastic binding in resistance to sliding

The amount of force between wire and bracket

strongly influence the amount of resistance to
sliding.
This is determined by 2 factors:
Friction between the surface of the wire and
bracket.
Elastic and inelastic binding as the wire contacts
the corners of the bracket. (this plays a major role
in the resistance to sliding)

ANCHORAGE LOSS

What is anchorage loss?

A certain amount of unwanted movement
of the anchor teeth invariably occurs
during orthodontic treatment.
Such unwanted movement of anchor teeth
called ANCHORAGE LOSS.
Three types of Anchorage:
Maximum
Moderate.
Minimum

A. Maximum : 1/4th of the extraction space should be lost by forward monement.

B. Moderate : anchor teeth permitted to more 1/4th to .
C. More than half of the extraction space can be lost by teeth moving mesially.

Anchorage management
in different techniques

 Tweed Merrifield
Ricketts Bioprogressive Therapy
MBT appliance

Tweed Merrifield appliance

Anchorage preparation

Sequential banding and bonding

Sequential tooth movement
Sequential anchorage preparation
Directional force system

Tweed Merrifield appliance

Sequential banding and bonding

Less traumatic
Longer interbracket span
Heavy wires

Tweed Merrifield appliance

Sequential tooth movement

Enmasse retraction
Placing all bends at a time
Not followed

Tweed Merrifield appliance

Sequential anchorage preparation

High pull head gear

Vertical spurs soldered
Distal to Mb. Lateral incisor
10 2 anchorage system
10 teeth as anchorage units to tip 2 teeth

Tweed Merrifield appliance

Sequential anchorage preparation
The 2nd molar is tipped
Then space is closed, a compensating bend is given
mesial to second molar to maintain its tip.
The 1st molar is tipped
Then compensating bend is given mesial to to
maintain its tip.
2nd PM is tipped distally to its anchorage preparation.

Tweed Merrifield appliance

Directional force system
Defined as controlled forces which place the teeth
in most harmonious relation with their environment
Resultant vector of force should be upward and
forward.

Ricketts Bioprogressive Therapy

Muscular anchorage
Cortical anchorage
When a root is forced against
cortical bone; it is greatly slowed
down and root resorption is likely
to occur.

Nance button
Quad helix
Headgears: cervical, combination and
high pull

Anchorage control in MBT

Two main aspects in anchorage control

Reduction of anchorage needs during
leveling and aligning.
Anchorage support during leveling and
aligning.

Anchorage control in MBT

1st Orthodontic objective

Defined as Tooth movement needed to achieve

passive engagement of steel 19 x 25 wire of suitable
arch form into a correctly placed 022 preadjusted
bracket system
Anchorage loss maximum in the first stage

Anchorage control in MBT

Major reason for anchorage loss
Mesial tip built into the bracket system
Anchorage control
The maneuvers used to restrict undesirable changes
during the opening phase of treatment, so that
leveling and aligning is achieved without key
features of the malocclusion becoming worse.

Anchorage control in MBT

1st step in anchorage control

Recognize the anchorage needs of the case

Diagnosis and treatment planning stage

 For example class II div 1

Goal is set for incisor position Planned Incisor
position

Class I

Class III

 Mistakes in tooth leveling and aligning during

early years

Roller coaster effect

 Roller coaster effect has been eliminated from the

present day practice
Reduced tip in bracket system
Light arch wire forces
Use of lacebacks instead of elastic forces

 Lacebacks for A/P canine control

Restrict canine crown from tipping forward

 Lacebacks for A/P canine control

Robinson investigated 57 PM extraction cases

Restrict canine crown from tipping forward

Distalizing canines without causing unwanted
tipping

Continued till rectangular SS wire stage

Discontinued if space appears between lateral &
canine

 Bendbacks for A/P incisor control

 Bendbacks for A/P incisor control

Bend is placed 1-2 mm

distal to molar tube

 A/P anchorage control of

lower molars the lingual arch

Class III elastics & headgear

 A/P anchorage support & control for upper molars

The upper molars move mesially more easily
than lower molars
Upp ant segment has larger teeth than low ant
Upp ant brackets have more tip built
Upp incisors require more torque control &
bodily movement
More Class II type malocclusions than Class III

 A/P anchorage support & control for upper molars

Head gears

TPA

 Vertical anchorage control of incisors

 Vertical control of canines

 Vertical control of molars in high angle cases

Palatal bar

Upp 2nd molars not initially banded

Headgear high pull or combi pull.

 Anchorage control in Transverse plane

Intercanine width

Molar crossbites

Conclusion
Anchorage is the resistance to unwanted tooth
movements.
Anchorage demands need to be assessed at the outset
as an essential component of treatment planning or
the desired result may not be achieved.
Anchorage needs differ from case to case and plays a
vital role in deciding the duration of treatment and its
outcome.

References

Proffit
Nanda
Graber Vandersal
Begg
MBT