Anchorage in Orthodontics

Extra oral anchorage
H E A D G E A R S

Principle use Forces derived from EOA Stabilize the position of the teeth Produce tooth movement Orthopedic changes
Extra oral traction

Mild cases Cases with severe crowding and overjet Severe cases additional space is required even after extraction

Application of EOF Face bow

Stops inner bow

J hook head gear

Directional control Effects of EOF depends on
Duration Direction Magnitude

1 ounce 28.35 gms

Types of head gears
Basic concept for types of head gears

Relationship to the occlusal plane
Low pull High pull Medium pull

Low pull head gear
Extrusion of the molars
undesirable

High pull head gear
Intrusion of the molars
undesirable

Medium pull head gear
Protraction head gear

Orthopedic effects
Restrict forward and downward movement 350-450 gms/each side 14hrs/day

Practical aspects
Good fitting bands
Inner bow passive Should not contact any teeth Ant. Segment between the lips Expansion distalization

Mandibular arch
Use of class III intermaxillary traction with head gear
Mechanical aspect of anchorage

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

Friction ??? Frictional force
Nature of surface at the interface (rough or smooth, chemically reactive or passive, modified by lubricants) Independent of the apparent area of contact

Real contact occurs only at a limited number of small spots: Asperities

Metal wire in a ceramic bracket
Stick slip phenomenon

2 other 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

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

Surface quality of the wires Changes in surface chemistry due to increased Ti content Cold weld effect

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 quality of the brackets SS brackets Ti brackets Ceramic brackets Ceramic brackets with metal slots Composite brackets Polycarbonate plastic brackets

Flexibility of arch wire and width of the bracket
Force that pulls the wire into the bracket Self ligating brackets- reduced friction that allows more effective sliding- better anchorage control

Magnitude of friction
Retraction springs Closing loops
Conventional Begg
Differential force concept 1st premolar extraction 8 teeth extraction
Begg was applying the principles of differential forces
Conventional Begg
Storey and Smith (1952) Statistical evidence confirmed the results of Beggs clinical experience Edgewise app and springs
Conventional Begg
Storey and Smith (1952) Tooth with a greater root surface area needs greater force to be moved
canine: molar = 3:8
Conventional Begg
Conventional Begg
Reason for different rates of movement of canines Storey and Smith presented the concept of undermining resorption Sandstedt (1904) Schwarz (1932)
Conventional Begg
Storey and Smith (1952) Teeth subjected to very high forces
Resorption of tooth investing tissues
Teeth are loosened within the sockets
Conventional Begg
Use of differential forces Reduction of anterior overbite Use of anchor bends
Light wires Heavy wires
Conventional Begg
Use of differential forces
Strang (1954) Treatment problems, their origin
and elimination Edgewise app Closing extraction space requires more force Use of head gears - recommended
Conventional Begg
Use of differential forces Space closure
Premolars bypassed Extra oral anchorage is not required
Conventional Begg
Means of preventing anchorage failure
Use of thin round steel wires Anchor bends Stationary anchorage Premolars not bracketed Light torquing forces in 3rd stage Use of reverse torquing auxillaries
Refined Begg ( Dr. V P Jayade )

Differential force concept was misunderstood Excessive retraction Prevented in refined begg by applying efficient brakes along with heavy differential forces

Perfect example of stationary anchorage Saggital Vertical transverse

Stage I

Active components in stage I
Light or ultra light class II elastics
Lower class I elastics

Active components in stage I Upper palatal elastics / elastics from power arm (Jyotindra Kumar)

Active components in stage I
Upper Class I are seldom used
Uneven class I ,class II for midline correction

Anchorage considerations in stage I
Palatal elastics or elastics from power arm

Upper molars to be supported with TPA

Anchorage considerations in stage I Conserving lower molar anchorage
Stiffer wires Light or ultra light elastics Molar stops

Anchorage considerations in stage I High angle cases Light anchor bends Light elastics TPA away from the palate High pull head gear

Anchorage considerations in stage I Transverse plane
Stiffer arch wires Expansion in arch wires TPA Sufficiently expanded face bow or lip bumper

Stage II easiest Objectives
Maintain all the corrections of stage I Closure of extraction spaces Controlled tipping of anteriors Protraction of posteriors Correction of molar relation Correction of premolar crossbites and rotation

Stage II Archwires used Reduction in the anchor bend

Braking mechanics Reversal of anchorage Def the brakes reverses the anchorage site from posterior to anterior segment by permitting only bodily movement of the anterior teeth, instead of allowing them freedom to tip Braking springs/ T pins Torquing components

Braking springs

Angulated T pins

Combination wires
Material Ant. Seg rectangular (022 x 018) Post. Seg round 018

Torquing auxiliaries 2 spur or 4 spur MAA 010 / 011 Strong base wires

Active components in stage II



Stage III most complicated and anchorage consuming Objectives of stage III
Maintain all the corrections
Distal root uprighting auxilliary
Palatal root torquing auxilliary

Stage III - objectives To achieve desired root movements Monitor anchorage in all 3 planes To correct the position of 2nd molars To monitor undesirable effects

Stage III Reciprocal mesial crown moving forces Upper arch Lower arch

How to overcome stage III problems??? Proper diagnosis and treatment planning Using efficient brakes Controlled tipping of incisors Use of heavy base arch wires Lighter auxiliaries and uprighting springs Light cl II elastics Reinforcement of anchorage Contraction and toe in built into the wires
Tweeds anchorage preparation Tweed Merrifield appliance Level Anchorage System Vari Simplex Discipline Ricketts Bioprogressive Therapy MBT appliance
Tweeds anchorage preparation

Tipping the posterior segment distally Lower posterior segment

When teeth are tipped distally as they are in anchorage preparation, osteoid tissue appears to be laid down adjacent to the mesial surface of the tooth being moved distally.
- Kaare Reitan
Such conclusions do not make the necessity of anchorage preparation obselete
Clinical orthodontist who routinely create excellent facial changes are those who recognize the importance of and prepare anchorage in their practice

Concept Upright the mesially inclined lower posterior segment Terminal molar to be tipped distally Angle formed between the class II elastic and long axis of terminal molar
Mandible will be much more stable and will resist forward displacement

After anchorage preparation, if movement does occur
Slow mesial bodily movement Anchorage not prepared Uprooting and elevation of the molars

Tweed classified anchorage preparation
First degree Second degree Third degree

First degree / minimal anchorage preparation ANB 0- 4, facial esthetics are good Discrepancy < 10 mm Mandibular terminal molars must be uprighted
Direction of intermaxillary elastic pull should not exceed 90

Second degree ANB exceeds 4.5 Class II
Mandibular second molars should always be banded Must be tipped distally so that their distal marginal ridges are at gum level Direction of pull of intermaxillary elastics should always be > 90

Third Degree or Total Anchorage Preparation ANB does not exceed 5 Discrepancy 14 -20 mm All posterior teeth (second premolar to terminal molars) are tipped distally Distal marginal ridges of terminal molars are below gum level

Severe cases anchorage prepared in both the arches How to tip lower posterior segment ???
Sliding jig
Lower anchorage preparation completed Lower canines and incisors retracted Upper extractions Class II elastics distal tipping of upper posterior segment
Tweed Merrifield appliance

Attachments
022 edgewise slot Permits variety of archwire use

Highlighting points Anchorage preparation
Sequential banding and bonding Sequential tooth movement Sequential anchorage preparation Directional force system

Sequential banding and bonding
Less traumatic Longer interbracket span Heavy wires

Sequential tooth movement
Enmasse retraction Placing all bends at a time Not followed

Sequential anchorage preparation
High pull head gear Vertical spurs soldered Distal to Mb. Lateral incisor
10 2 anchorage system

Distal tip achieved Read out 15

Before tipping premolars Read out to be performed
Distal tip achieved

During the course of treatment, various hooks are soldered

Directional force system Defined as controlled forces which place the teeth in most harmonious relation with their environment
Favorable
Unfavorable
Level anchorage system

Terrell L. Root Aim quantify the anchorage requirement 018 edgewise slot Mandibular molars 2 choices of distal crown tip

Anchorage Resistance to movement Distance to move Anchorage savers Those orthodontic adjunctive procedures that reduce the amount of tooth anchorage necessary to correct the malocclusion

High pull headgear to maxillary 1st molars or J hook headgear to anteriors: reduction in ANB by 1 degree every 6 months Palatal bar: decreases vertical descent due to tongue pressure. Delaying upper first premolar extraction by one year: reduces mandibular anchorage space by 1mm Class III elastics worn 24 hrs: flatten the curve of Spee and upright buccal segments at the rate of 1mm / month
Vari-simplex discipline-Alexander
Vari variety of bracket used Simplex KISS principle fewer archwire changes Treatment philosophy Tweeds fundamentals Anchorage preparation Positioning Mb incisors over basal bone Orthopedic alteration using head gear
1. 2. 3.
Key objective Non extraction therapy as far as possible
Interproximal enamel reduction Control of Mb incisor position with ve torque
Bracket selection Twin brackets Lang brackets Lewis brackets
Anchorage considerations
Tip values
Gain in the arch length Promotes leveling

0 angulation in Mb 2nd molar Need not to be uprighted excessively
-5of labial root torque Holds the Mb incisors to their original position
Major change
Head gears / Retractors Retractors ( Dr. Fred Schudy) Cervical, combination or high pull depending on growth pattern and control needed
Other intra oral appliances to control anchorage:
Other intra oral appliances to control anchorage: Mandibular lingual arch: sagittal and transverse control Lip bumper: - uprighting of mandibular first molars - distal force on lower molars - muscular anchorage
Ricketts Bioprogressive Therapy

Muscular anchorage Cortical anchorage
Nance button Quad helix Headgears: cervical, combination and high pull
Anchorage control in MBT

2nd principle of orthodontic anchorage Anchorage loss maximum in the first stage Def 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

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.

1st step in anchorage control
Recognize the anchorage needs of the case
Diagnosis and treatment planning stage

Eg class II div 1
Goal is set for incisor position - PIP
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 57 PM extn cases

Restrict canine crown from tipping forward Distalizing canines without causing unwanted tipping

Continued till rectangular SS wire stage Discontinued if space appears betn 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

Anchorage control in Transverse plane
Intercanine width Molar crossbites

Anchorage in Orthodontics

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Anchorage in Orthodontics

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Extra oral anchorage

Extra oral anchorage

Extra oral anchorage

Extra oral traction

Extra oral anchorage

Extra oral anchorage

Extra oral anchorage

Extra oral anchorage

Extra oral anchorage

Duration Direction Magnitude

Extra oral anchorage

Extra oral anchorage

Basic concept for types of head gears

Extra oral anchorage

Low pull High pull Medium pull

Extra oral anchorage

Extrusion of the molars

Extra oral anchorage

Extra oral anchorage

Extra oral anchorage

Intrusion of the molars

Extra oral anchorage

Extra oral anchorage

Protraction head gear

Extra oral anchorage

Restrict forward and downward movement 350-450 gms/each side 14hrs/day

Extra oral anchorage

Extra oral anchorage

Good fitting bands

Extra oral anchorage

Use of class III intermaxillary traction with head gear

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Stick slip phenomenon

Mechanical aspect of anchorage

Mechanical aspect of anchorage

There is no correlation between surface roughness and coefficient of friction

Ti has greatest frictional resistance

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Alteration of the surface of Ti wires

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Mechanical aspect of anchorage

Retraction springs Closing loops

Begg was applying the principles of differential forces

canine: molar = 3:8

Resorption of tooth investing tissues

Teeth are loosened within the sockets

Light wires Heavy wires

Premolars bypassed Extra oral anchorage is not required

Refined Begg ( Dr. V P Jayade )

Refined Begg ( Dr. V P Jayade )

Refined Begg ( Dr. V P Jayade )

Refined Begg ( Dr. V P Jayade )

Light or ultra light class II elastics

Lower class I elastics

Refined Begg ( Dr. V P Jayade )

Refined Begg ( Dr. V P Jayade )

Upper Class I are seldom used