Ortho Intro #5

Anchorage and Headgear

Tooth movement and anchorage

 Force generated by an orthodontic appliance has an equal and opposite reactionary force – Newton’s Third Law
 Anchorage = resistance to unwanted tooth movement
 Anchorage requirements should be considered anteroposteriorly, vertically and transversely

Assessing anchorage requirements

(B) Maximum anchorage – posterior anchorage unit contributes < 25% to space closure
(C) Moderate anchorage – posterior anchorage unit contributes 25-50% to space closure
(D) Minimum anchorage – posterior anchorage unit contributes > 50% to space closure

Space requirements
 The more of the space created to be utilized, the higher the anchorage demand
 Sometimes anchorage loss is preferred e.g. to improve molar relationship or when too much space is created

Type of tooth movement to be achieved

Tipping Crown of a tooth moves in one direction and the root moves by a lesser amount in opposite direction,
rotating around the tooth’s centre of resistance
Bodily movement Both the crown and the root move in the same direction equally
Rotation When a force is applied mesially or distally to the labial aspect of the tooth
Torque Root of a tooth moves in one direction and the crown moves by a lesser amount in opposite direction
Intrusion Bodily movement of a tooth along its long axis in an apical direction
Extrusion Bodily movement of a tooth along its long axis in an occlusal direction
 Tipping v.s bodily movement
 Centre of resistance lies within the root  if force is applied to the crown, tipping will occur
 Bracket can interact with orthodontic wire  cause the force to act as a couple  produce bodily movement
 Bodily movement requires more force than tipping  higher anchorage demand

Number of teeth to be moved

 The more the teeth to be moved, the higher the anchorage demand

Distance of movement required

 The large the distance of movement required, the higher the anchorage demand

Aims of treatment
 Half-unit Class II  cusp to cusp  less stable  molar relationship needs to be improved  anchorage loss is preferred
 Full-unit Class II  cusp to fossa  more stable  no mesial movement of molars is allowed  high anchorage demand
 Class I canine relationship is usually important for treatment success

Root surface area of the teeth to be moved

 The larger the root surface area, the higher the anchorage demand
 Force required to move a tooth is proportional to root surface area of that tooth
 Anchorage value – incisors (1); canines (2); premolars (1.5); first molars (3); second molars (2)
 Estimate by having 1 root = 1 unit; e.g. Xn 15, 25  10 root units anteriorly v.s 6 root units posteriorly  space closes 2/3
from behind & 1/3 from front

Growth rotation and skeletal pattern

 High angled cases, increased vertical dimension, backward growth rotation  increased rate of tooth movement, space
closure, anchorage loss

Occlusal interdigitation and occlusal interferences

 Good interdigitation  prevent or slow tooth movement

Bone quality
 Maxillary bone is less dense than mandibular bone
 Threshold for tooth movement in maxillary teeth is lower than mandibular teeth
 Teeth move more readily through cancellous bone than cortical bone
 Reduced quantity/quality of alveolar bone in patients with hypodontia or periodontal disease

Classification of anchorage
 Simple anchorage – one tooth pitted against another
 Reciprocal anchorage – two teeth/groups of teeth of equal size/equivalent anchorage pitted against each other 
movement of both units by a similar amount; e.g. maxillary expansion by quadhelix; power chain on upper fixed appliance
to two central incisors to close median diastema
 Anchorage reinforcement
 Intramaxillary compound anchorage – multiple teeth within same arch as an anchorage unit
 Intermaxillary compound anchorage – multiple teeth in opposing arches e.g. intermaxillary elastics
 Differential tooth movements – tipping movements are less anchorage demanding than bodily movement (e.g. crown
tipping followed by root uprighting)
 Intra-oral adjuncts – e.g. transpalatal arch with Nance button; temporary anchorage devices (TADs)
 Extra-oral adjuncts – e.g. headgear
 Stationary/absolute anchorage – only achieved by osseointegrated implant or ankylosed tooth as anchorage unit

Intra-oral anchorage
Increasing number of teeth in anchorage unit
 Incorporate as many teeth as possible into an anchorage unit
 Consider moving one tooth at a time if high anchorage demand

Differential extraction pattern

 Extracting teeth closer to the site of crowding reduces amount of tooth movement required
 Consider anchorage balance (root surface area) when selecting teeth to be extracted
 Differential extraction pattern
Xn Rationale
Class II division 1
Upper 4  Reduce overjet & correct canine relationship  higher anchorage demand  6+5 as anchorage unit
Lower 5  Reduce retraction of labial segment & improve molar relationship  prefer anchorage loss
*Could be enhanced with Class II elastics
Class III
Upper 5  Allow mesial movement of molars to improve molar relationship
Lower 4  Retroclination of lower labial segment to aid camouflage of reverse overjet

Care with initial intra-arch orthodontic mechanics

 Engagement of severely displaced teeth in early stages of alignment may increase anchorage demands
 Friction in the system will also cause anchorage loss (50% of force lost as friction with pre-adjusted edgewise appliance)

Bodily movement of teeth

 Use of large rectangular stainless steel archwires will ensure bodily movement ∵ the archwire will fill more of bracket slot
 Differential tooth movements by restricting bodily movement in certain appliance systems e.g. Begg and Tip-Edge

Occurs when forces are applied at centre of resistance, which is at root trifurcation for upper first molars, and between premolar
roots for whole maxilla

Transpalatal and lingual arches

 Usually connecting first molars using an arch bar (usually 1 mm diameter stainless steel)
 Helps to prevent mesial tipping and buccal flaring of molars
 Other alternatives – (1) extend power arm apically to the level of centre of resistance, which is then connected
anteroposteriorly with rubber band; (2) use rectangular wire instead of circular wire  thicker & more rigid  less
easily distorted
 The amount of anteroposterior anchorage reinforcement provided has been questioned; mainly for transverse control

Intermaxillary anchorage
 Class II elastics: run anteriorly in upper arch to posteriorly in lower arch
 Class III elastics: reverse
 Side effects
 Possible extrusion of molars, thus reducing overbite and increasing facial height
 Class II elastics – proclination of lower labial segment in an unspaced lower arch

Removable and functional appliances

 Can be used alone or in conjunction with a fixed appliance
 Anteroposteriorly – collecting around posterior teeth with acrylic; inclined bite-blocks; incisor capping
 Transversely – e.g. maxillary expansion screw  reciprocal anchorage
 Vertically
 Reduce vertical dimension – intrusion of posterior teeth (often aided with high-pull headgear)
 Increase vertical dimension – anterior bite-plane to allow differential tooth eruption

Temporary anchorage devices (TADs)

 Osseointegrated implants
 Modified dental implants – shorter and wider diameter
 Placed in mid-palatal regions and attached to a palatal arch  provide absolute anchorage
 Disadvantages
 Need to be left for 3 months after placement to allow osseointegration
 Restricted use in edentulous area due to their size
 Requires complex surgical procedure with bone removal when treatment is completed
 Miniplate systems
 Based on maxillofacial bone plates, with transmucosal portion projecting into the mouth  connect to fixed appliance
 Miniscrews (most popular)
 Typically 6-12 mm in length & 1.2-2 mm in diameter; modified head to allow attachments of orthodontic auxiliaries
 No osseointegration is required
 Placed under LA but removed often without any LA
 Direct or indirect anchorage
 Risks – damage to adjacent structure (blood vessels, nerves, tooth roots); fracture; gingival inflammation; loosening with
anchorage loss

Extra-oral anchorage

Type Function Force (per side) Duration of force

Anchorage Holding posterior teeth in position 250-350 g 10 hrs (bed time)
Traction Moving teeth distally 400-450 g 12-14 hrs
Orthopedic Restrict forward & downward growth of maxilla 500 g 14 hrs

Three directions of pull

Direction Component Effect Indications
High/occipital pull Head cap Intrusion of molars Increased vertical proportions
Straight/combi pull Head cap + neck strap / Average vertical proportions
Low/cervical pull Neck strap Extrusion of molars Decreased vertical proportions
*Low-pull in Class II cases may lead to clockwise rotation of mandible (downwards & backwards) which worsen Class II

Components
 Face-bow – NitomTM or Hamill type with reverse loop attachment (simpler but higher risk of disengagement)
 Headcap or neck strap
 Spring mechanism/strap – connect the face-bow to headcap or neck strap

Safety concerns
 Ends of face-bow pulled out of the mouth and recoiled back into the face  direct trauma to the eyes  blindness
 Masel strap – resist dislodgement of face-bow; effectiveness affected by head position
Reverse headgear
 Tooth movement – mesialization of upper posterior teeth
 Skeletal changes – maxillary advancement e.g. in Class III cases
 For growing patients with normal/short maxilla & normal mandible
 Not effective for patients with normal maxilla and long mandible (cannot bring mandible back)

Other remarks
 Rate of tooth movement in growing patient = 1.2 mm per month (less in adult)
 Rubber bands – elasticity & force will drop over time
 Ideal force for single rooted teeth – 25-40 grams for tipping; 120-200 grams for bodily movements
 Orthodontic review visit every month
 Keep active forces light – pressure-tension theory
 Bone is laid down on the tension side of PDL and resorbed on the pressure side
 When the applied force is light, multinucleate cells resorb bone directly on the pressure side
 But if the force is heavy and exceeds capillary blood pressure, cell death may occur and a cell-free area forms
 This is described as hyalinization
 Resorption of these areas proceeds at a much reduced rate = undermining resorption  slower tooth movement;
greater pain and discomfort for the patient
 Hyalinization will occur even under light force (30g), and occurs more frequently with tipping than bodily movement
in which the force is dissipated more evenly through PDL