Anchorage

CONTENTS
I. INTRODUCTION 2
II. CLASSIFICATION 6
III.METHODS OF ANCHORAGE 15
IV.REVIEW OF LITERATURE 50
V. DISCUSSION 81
VI.SUMMARY & CONCLUSION 87
VII. BIBLIOGRAPHY 88
Anchorage in Orthodontics 1
INTRODUCTION
Attainment and control of anchorage is fundamental and critical in orthodontic

treatment. Anchorage control throughout the orthodontic treatment is essential for
uncompromised results. Conventional means of supporting anchorage have been using
either tooth borne anchorage or extra oral anchorage.Tooth borne anchorage is one of
the greatest limitations of modern orthodontic treatment because tooth moves in
response to forces.
Extra oral anchorage can be used to supplement tooth borne anchorage and to
deliver forces in directions not possible with intra oral forces but requires excellent
patient co-operation.
Skeletal anchorage would offer capabilities are unavailable. They expand the
range of biochemical possibilities with screws, pins or some readily removable
implants anchored to the jaws, so that forces might be applied to produce tooth
movement in any direction without detrimental reciprocal forces.
Orthodontic forces might be applied directly to the jaws through skeletal
anchorage.Intra-oral skeletal anchor units that are predictably stable, relatively non-
interfering, biocompatible and comfortable could make appliance design simplified and
more efficient.
Progress in the use of implants and in the development of specialized newer
systems has made skeletal anchorage a more reliable and standardized one. As
orthodontists begin to appreciate the efficiency of implant supported appliances, the
mechanotherapeutic procedures may undergo profound transformation.
Two decades ago, screws were introduced for orthodontic anchorage; these
presented the clinician a versatile option. With the introduction of Mini implants and
micro implants they can be placed in areas earlier impossible, in addition they are less
expensive, allow early force application and reduce treatment time.
ANCHORAGE
DEFINITION
“ANCHORAGE in orthodontics is defined as the nature and degree of Resistance
offered by an anatomic unit for the purpose of affecting tooth movement”
T.M.GRABER.
“ANCHORAGE is the site of delivery from which force is exerted” WHITE AND
GARDINER.
“ANCHORAGE is resistance to unwanted tooth movement”, PROFFIT
“Resistance to displacement”, MOYERS
“A secure hold sufficient to resist a heavy pull”,
-WEBSTERS INTERNATIONAL DICTIONARY
HISTORY OF ANCHORAGE
Pierre fauchard in 1728 described the first fixed appliance which was flat
perforated ribbon. This arch or “bandeau” was ligated to the tooth through the
perforations. A reciprocal series of forces was set up pitting against each other each of
the teeth involved. This made use of the principle of reciprocal anchorage.
A century later, in 1841, Schange devised an arch soldered to a skeleton crib which
afforded positive purchase on the teeth. He also developed the clamp band. Occipital
anchorage was introduced by Kingsley in 1866. There are many who claim that the
ultimate in anchorage was developed years ago through the use of these occipital or
extra oral forces.
With the advent of the cemented band, orthodontia became a more exact
science, and the credit for the cemented bands, according to Angle, goes to MacGill in
1871.
In 1898 Calvin Case advocated the use of reciprocal elastics to effect movement
between individual teeth in opposite arches. However, it was baker who applied those
elastics in the correction of Class II irregularities. In his seventh edition, Dr. Angle
called intermaxillary anchorage the "ideal force". The reciprocal activity of each end of
the rubber band, he claimed, provided the best anchorage for the correction of the Class
II condition and the creation of normal occlusion.
Several orthodontic texts were written and anchorage was classified into several
categories simple, compound, stationary, etc. It was decided that the best anchorage in
the mouth was one which permitted only the resistance teeth or anchor teeth to be
moved bodily. This was called stationary anchorage. As the search for better anchorage
developed, it became apparent that more control was required over the individual dental
units. As a result, Angle developed the pin and tube appliance and then the ribbon arch
to afford greater mechanical advantages.
The edgewise appliance, as first described by Angle in 1927, was designated as
the "latest and best" of the time. Even today the many possibilities afforded by it are
just being realized. However, the penduIum swings and modern orthodontics is again
applying some of the so-called simple anchorage devices very successfully in the
treatment of many types of malocclusion. Orthodontists have become aware of the
many problems that have developed because of anchorage inadequacy and many men
have advised the use of auxiliaries deriving such as muscular, tissue borne and occipital
supports.
Dr.Charles H Tweed of Tucson, Arizona, was a disciple of Dr.Angle, who had
an extraordinary clinical acumen and a highly developed sense of self-criticism. He
used the edgewise arch technique following the principle of his master and practiced
the expansion of dental arches. He found that his cases had a high degree of relapse. He
then started extracting teeth to achieve stability. By beginning the treatment with
extraction of teeth, Tweed found himself confronted with the need to preserve posterior
anchorage when an intermaxillary force was applied and during retraction.
The preparation of anchorage in the lower dental arch is a concept introduced
by Tweed and the procedure has influenced the way in which the orthodontic treatment
using the edgewise technique has been practiced for many decades. For Tweed, the
preparation of the anchorage is the first and most important objective to be
accomplished in the treatment of malocclusion. In order to carry out this preparation for
mandibular anchorage, the posterior teeth in the lower arch should be inclined in a
distal direction. When this inclined position has been obtained, true physical resistance
is created for withstanding the tendency of posterior teeth to be pulled forward toward
the mesialThis preparation as conceived by Tweed has inspired the majority of the
treatment methods for malocclusion that, utilizing the edgewise arch appliance has been
described to date.
CLASSIFICATION OF ANCHORAGE
I.ACCORDING TO THE MANNER OF FORCE APPLICATION

Simple Anchorage : Resistance to tipping , that is tooth is free to tip during movement
Stationary Anchorage : Resistance to bodily movement that is the tooth is permitted to
translate only
Reciprocal Anchorage: Two or more teeth moving in opposite directions and pitted
against each other by the appliance. Usually the resistance to each other is equal and
opposite. E.g.: cross bite elastics, dental expansion.
II.ACCORDING TO THE JAWS INVOLOVED

Intra Maxillary : Anchorage established in the same jaw
Inter Maxillary (Baker’s) Anchorage : Anchorage distributed to both the jaws
e.g.:class 2 elastic traction , class 3 elastic traction.
BAKER`S ANCHORAGE
III.ACCORDING TO SITE OF ANCHORAGE

Intra Oral: Anchorage established within the mouth, that is utilizing the teeth mucosa
or other intra – oral structures.
Extra – Oral : Anchorage obtained outside the oral cavity
 cervical – utilizing neck for anchorage e.g.: neck strap
 occipital – utilizing occipital region for anchorage e.g.: Cervical pull headgears
 cranial – utilizing cranium for anchorage e.g.: high pull headgears
 facial – involving aspects of face as a source of anchorage e.g.: face masks
Muscular : Anchorage derived from action of muscles e.g.: vestibular shields
IV. ACCORDING TO NUMBER OF ANCHORAGE UNITS

Single or Primary Anchorage : Anchorage involving only one tooth
Compound Anchorage : Anchorage involving two or more teeth
Reinforced Anchorage: The addition of non – dental anchor units e.g.: mucosa,
muscle, head, upper anterior inclined plane, transpalatal arch.
V.ACCORDING TO ANCHORAGE LOSS PERMISSABLE

Minimum Anchorage: In cases with low anchorage demand, More than half of
extraction space can be lost by anchor teeth moving mesially.
Moderate Anchorage: In these cases anchor teeth can move forward into one fourth to
one half of extraction space.
Maximum Anchorage: In these cases, anchor teeth can move forward into less than
one fourth of extraction space. The anchorage is these patients should be augmented to
avoid unwanted movement of anchor teeth.
VI.ACCORDING TO SOURCE OF ANCHORAGE

Tooth Borne Anchorage : Anchorage is derived form the teeth
Extra oral Anchorage : Anchorage derived from extra – oral sources e.g.: cervical,
occipital, cranial and facial
Skeletal Anchorage: Anchorage derived from skeletal units e.g.: basal bone of
mandible, maxilla, zygoma, alveolar process, palate etc.
VII.MARCOTTE’S CLASSIFICATION
Group A Anchorage: Also refers to maximum posterior anchorage. 75% or more space
required for anterior retraction. The biomechanical paradigm is to increase posterior
M/F ratio(beta M/F ratio) relative to the anterior M/F ratio ( Alfa M/F ratio)
Group B Anchorage: Simplest form of space closure. The requirement includes equal
translation of the anterior and posterior segments into the extraction space. Equal and
opposite moments and forces are indicated.
Group C Anchorage: Also refers to maximum anterior anchorage. 75% of space
closure achieved through mesial movement of posterior teeth. The biomechanical
paradigm is to increase anterior M/F ratio (i.e. Alfa M/F ratio ) relative to posterior M/F
ratio(i.e. beta M/F ratio)
GROUP A, GROUP B AND GROUP C ANCHORAGE
MARCOTTE’S CLASSIFICATION
ANCHORAGE PLANNING
At the time of determining the space requirement to resolve the malocclusion in
a given case is essential to plan for space that is likely to be lost due to the invariable
movement of the anchorage teeth. The anchorage requirement depends upon
1. The number of teeth to be moved -greater number of teeth being moved greater the
anchorage demand.Moving teeth in segments as in retracting the canine separately
rather than retracting the completer anterior segment together will decrease the load on
the anchorage teeth.
2. The type of teeth being moved- Teeth with large flat roots and multirooted teeth
exert more load on the anchor teeth. Hence it is more difficult to move a canine as
compared to an incisor or a molar as compared to a premolar.
3.Type of tooth movement- moving teeth bodily requires more force as compared to
tipping the same teeth.
4. Periodontal condition- teeth with decreased bone support or periodontally
compromised teeth are easier to move as compared to healthy teeth attached to a strong
periodontium.
5.Duration of tooth movement – prolonged treatment time places more strain on the
anchor.
ANCHORAGE LOSS
Anchorage loss is a reciprocal reaction that could obstruct the success of
orthodontic treatment by complicating the anteroposterior correction of the
malocclusion and possibly detracting from facial esthetics.
A major concern when correcting severe crowding, excessive overjet, and
bimaxillary protrusion is control of anchorage loss. Therefore, adjunct appliances, such
as the Nance holding arch, transpalatal bar, and extraoral traction, are often used to
augment molar anchorage.
The use of multiple teeth at the anchorage segment to form a large
counterbalancing unit and the application of differential moments has also been
described as methods to stabilize molar position.
Factors such as malocclusion, type and extent of tooth movement
(bodily/tipping), root angulation and length, missing teeth, intraoral/extraoral
mechanics, patient compliance, crowding, overjet, extraction site, alveolar bone
contour, interarch interdigitation, skeletal pattern, third molars, and pathology (ie,
ankylosis, periodontitis) affect anchorage loss.
Most of the anchorage loss studies focus on biomechanical solutions. For
example, a greater anchorage loss was demonstrated with nonsliding mechanics when
the Gjessing spring was evaluated. Tip-edge brackets showed less but not significant
anchorage loss than straight wire brackets (1.71 vs 2.33 mm). Differential moments
have been reported to reduce anchorage loss by 0.6–0.7 mm. When maximum
anchorage is required, anchorage loss was greater in Class I (0.60 mm) than in Class II
(0.28 mm) malocclusions.
Anchorage loss has also been referred to as the extent of incisor protraction
(1.8–2 mm) following molar distalization with repelling magnets or nickel titanium
open coil springs supported by a Nance appliance or the second premolar (1.6 mm).
However, minimal incisor anchorage loss (0.92) has been reported when the pendulum
appliance was used.
Molar anchorage loss had occurred supported with an implant in the center of
the anterior palate (0.7–1.1 mm), but this was probably caused by deformation of the
transpalatal bars that linked the implant to the maxillary molars.The concept of a well-
interdigitated occlusion acting to enhance molar anchorage is an accepted dogma.
Therefore, it could be hypothesized that the posterior disocclusion caused by the
anterior bite plane effect of a lingual appliance might negate this. Thus, the decision to
extract is more frequent when lingual brackets are applied in the maxillary arch.
Lingual archwires are more rigid because of the smaller interbracket distance.
Extraction site is another factor that affects anchorage loss. Studies conducted
on the effect of the Beggs appliance show that the maxillary molar occupies 33.5% of
the extraction site with first premolar extractions and 50.4% with first molar
extractions. Creekmore found that the posterior teeth occupy one-third to one-half of
the extraction space in first and second premolar extractions, respectively.
Furthermore, in another study, no significant difference in anchorage loss was
found between first or second maxillary premolar extractions (4.3 vs 4.5 mm).
However, when maxillary first premolars were extracted in conjunction with
mandibular first or second premolars, anchorage loss of the maxillary molars was
greater when the mandibular second premolars were extracted (3.7 vs 4.7 mm).
Dental crowding and its relationship to anchorage loss provide the first sign that
it is a multifactorial response. Second premolar extraction, rather than first, is carried
out far more often in cases with less crowding. This choice has been related to greater
molar mesial movement. Additionally, the maxillary chordal arch length (distance from
mesial contact point of the first molar to the contact point of the central incisors) was
reported to decrease in extraction cases by 11.3 mm according to Ong and Woods and
by 8.3 mm as reported by Luppanapornlarp and Johnston. This difference corresponds
to greater crowding found in the latter (5.8 mm) than in the former study (3.5 mm).The
effect of patient age on AL has not been widely reported. Growing patients (12.5 years)
experience 2.52 mm of AL, whereas non growing patients (27.6 years) show an
anchorage gain of 0.20 mm. The molar relationship is corrected by mandibular growth
in the adolescent group (70%) and by maintaining maxillary molar position in the adult
group. It would appear that anchorage loss is seemingly dependent on more than one
factor, which, up to now, has been investigated separately. The objectives of this study
were to examine the contribution of five such factors: extraction site (first vs second
premolars), mechanics (lingual vs labial technique), age (growing vs non growing
patients), crowding, and overjet and to determine their relative contributions to AL
(primary vs secondary anchorage loss factors).
METHODS OF ANCHORAGE
SOURCES OF ANCHORAGE
These are anatomical units and /or regions which are used for the purpose of
providing the resistance to movement i.e. anchorage.These are further divided into two
groups depending upon their location as (1) intra oral sources (2) extra oral sources.
INTRA ORAL SOURCES

I.ALVEOLAR BONE
Within limits the alveolar bone resists deformation. This can be seen from the
arrangement of trabecular pattern with the alveolar bone. Once the forces generated
exceed those that can be resisted by the alveolar bone it permits tooth movement by
bone remodeling.
Less dense alveolar bone offers less anchorage. More mature bone increases
anchorage. This takes place because of two factors- one the bone becomes more
calcified and dissolution takes time and two, the regenerative capacity of the bone
increases. Forces that are dissipated over a larger bone surface area offer increased
anchorage.
II.TEETH
Teeth by themselves resist movement. Forces can be exerted from one set of
teeth move certain other teeth. The anchorage potential of teeth depends upon a number
of factors including- the root form, size of the roots, the position of the teeth, the axial
inclination of the teeth, their intercuspation, etc.
Roots form –the root form to a large extent is responsible for the degree of anchorage
provided by a tooth. The root in cross section can be either round, flat (mesio distally)
or triangular. The distribution of the periodontal fibers on the root surface aids in
anchorage. The more the fibres the better is the anchorage potential. The direction of
attachments of fibres also effects anchorage offered by a tooth. Round roots have only
half of their periodontal fibres stressed in any given direction. Hence offers least
anchorage. Mesiodistally flat roots are able to resist mesiodistal tooth movement better
as compared to the relatively narrow labial and lingual surfaces. Triangular roots, like
those of the canines are able to provide greater anchorage. Their flatness adds to the
resistance.
The tripod arrangement of roots, like that seen on maxillary molars also aids in
increasing the anchorage. The round palatal root resists extrusion and the two flat
buccal roots resist intrusion and the mesiodistal stresses. Under clinical situations
where the buccal tube is bonded/welded on the buccal aspect of these teeth they show a
tendency to roll mesially, the crown rotating mesiopalatally under mesially directed
forces.
Size of the roots- The larger or longer the roots there is more anchorage potential. The
maxillary canines because of their longer roots can be, at times, be the most difficult
teeth to move in certain clinical situations.
Number of roots- the greater the surface area the greater the periodontal support and
hence, greater the anchorage potential. Multirooted teeth provide greater the anchorage
as compared to single rooted teeth with similar root length.
Position of tooth- sometimes the position of the teeth in the individual arches also helps
in increasing their anchorage potential. As in the case of mandibular second premolars,
which are placed between two ridges- the mylohyoid and the external oblique, they
provide an increased resistance to mesial movement.
Axial inclination of the teeth- when the tooth is inclined in the opposite direction to that
of the force applied. It provides greater anchorage resistance or anchorage.
Root formation- Teeth with incomplete root formation are easier to move and are able
to provide lesser anchorage.
Contact points- Teeth with intact contacts and /or broad contact provide greater
anchorage.
Intercuspation- Good intercuspation leads to greater anchorage potential. This is mainly
because the teeth in one jaw are prevented from moving because of the contact with
those of opposing jaw, this is especially true for teeth, in the posterior segment which
also show the presence of attrition facets.
III.BASAL BONE
Certain areas of the basal bones like the hard palate and the lingual surfaces of
the mandible in the anterior regions can be used to augment the anchorage. The Nance
palatal button is one such appliance that makes use of the hard palate to provide
resistance to the mesial movement of the maxillary molars.
IV.CORTICAL BONE
Ricketts floated the idea of using cortical bone for anchorage. The contention
being that the cortical bone is denser with decreased blood supplies and the bone turn
over. Hence, if certain tooth torqued to come in contact with the cortical bone they
would have a greater anchorage potential. The idea as such remains controversial as
tooth roots also show resorption in such conditions and the risk of non-vitalilty of such
teeth is also more.
V.MUSCULATURE
Under normal circumstances the perioral musculature plays an important part in
the growth and development of the dental arches. Hypertoncity of the perioral
musculature and enhances the anchorage potential of the mandibular molars preventing
their mesial movement.
METHODS OF CONSERVING ANCHORAGE

1. REINFORCEMENT OF ANCHORAGE
Depends on the type of the teeth movement desired. Anchorage can be
reinforced by including as many teeth as possible in the anchorage unit. The ratio of
PDL area of anchorage unit to PDL area of tooth movement unit should be 2:1 without
friction and 4:1 with friction. By addition of teeth from the opposite dental arch to
anchor unit By patient wearing extra oral appliance (head gear) placing backward force
against the upper arch.Use of skeletal anchorage systems
2. SUBDIVISION OF DESIRED TOOTH MOVEMENT
A common way to improve anchorage control is to pit the resistance of a group of
teeth against the movement of a single tooth rather than dividing the arch into or less
equal segments e.g. to reduce strain on posterior anchorage – retraction of canine
individually.
3. TIPPING /UPRIGHTING
Another possible strategy for Anchorage control is to tip the teeth and then
upright them rather than moving them bodily.
4. FRICTION AND ANCHORAGE CONTROL STRATEGIES
In a typical extraction case it is desired to close the extraction space 60% by
retraction of anterior teeth and 40% by forward movement of posterior segments. This
can be obtained by 3 approaches:
 One step space closure with a frictionless appliance.
 Two step procedure by sliding the canine, then retracting the incisors.( tweed
technique )
 Two step closure by tipping the anterior segment with some friction and then up
righting the tipped teeth.
5. CORTICAL ANCHORAGE:
Cortical bone is more resistant to resorption; tooth movement is slowed when
root contacts it. By torquing the roots of posterior teeth outward against the cortical
plate it inhibits the mesial movement when extraction spaces are to be closed.
6 TRANSPALATAL ARCH, NANCE HOLDING ARCH, LOWER LINGUAL
HOLDING ARCH
The Nance holding arch can be used to maintain maxillary arch length. The arch
consists of a wire embedded in an acrylic button on the anterior palate and soldered to
bands on the maxillary first permanent molars.
NANCE HOLDING ARCH

A Transpalatal arch consists of a wire passing over the palatal vault and
soldered to the first permanent molars. The purpose of these arches is to maintain arch
width and molar position after buccal expansion of the maxillary arch and to keep
molars from tipping buccally in response to forces from an occipital pull face bow head
gear.
Fixed, removable transpalatal arches used to maintain, expand or constrict
intermolar width to rotate, upright mesialy tipped molars and to torque maxillary
molars.
TRANSPALATAL ARCH
Lower lingual holding arches comes in fixed and fixed-removable versions. The
fixed holding arch is most commonly used to maintain arch width and arch length. A
wire with adjustment loop is soldered to bands cemented on the first permanent molars.
The wire should rest on the cingula of the mandibular incisors. Adjustment loops allow
clinicians to shorten, lengthen raise or lower the wire into passive contact with the
incisor cingula.
LOWER LINGUAL HOLDING ARCH
7. CLASS II ELASTICS
Intermaxillary elastics pit the upper teeth to the lower teeth and are common
means of gaining differential tooth movement. The direction of the elastic defines its
force vector and the terminology used to describe it. Class II elastics attach to the
anterior maxillary teeth and the posterior mandibular teeth. Thus a class II elastics acts
to correct a class II relationship by proving a retraction force to the upper anterior teeth
and a simultaneous protraction force to the lower molars.
Alternatively a class III elastic hooks from the lower anterior teeth to the upper
posterior teeth, creating a force for lower anterior retraction and upper protraction for
the resolution of a class III occlusion.
CLASS II
The major limitation of elastics as an anchorage technique is their dependence
on patient compliance. Without patient co operation these methods are incapable of
influencing the treatment results Many approaches have been devised to eliminate
patient compliance as a crucial factor in anchorage control. Ultimately these techniques
attempt to establish anchorage with intra arch appliance designs.
8. DIFFERENTIAL FORCE (tip edge concept)
Obviously simple tipping free tipping requires far less anchorage than moving
the same teeth bodily, although this would itself amount to incomplete treatment.
However it makes initial decrowding and reduction of big over jets dramatically easy as
well as together with attainment of class I buccal segment occlusion. Both are achieved
early in treatment. This in turn lends stability to root uprighting process both by
bringing labial segments within the safety of normal lip control as opposed to adverse
influence of lip trapping.
Of course this constitutes only half the treatment and the root uprighting,
necessary to produce finishing root angulations may occupy latter half of the treatment
time. However it is a striking feature of differential tooth movement that total
anchorage requirement and duration of treatment, seems significantly less than straight
wire or edgewise systems particularly in difficult cases.
A TIP EDGE APPLIANCE (ACCORDING TO DIFFERENTIAL STRAIGHT ARCH

WIRE TECHNIQUE)
9. SEGMENTAL MECHANICS
Three-dimensional control during retraction of the upper anterior teeth is
essential not only for facial esthetics, but also for function of the stomatognathic system
and stability of orthodontic treatment.
Unfortunately, the many active and reactive forces produced by a continuous
arch can combine to produce extrusion of the posterior teeth rather than intrusion of the
incisors. Controlled distribution of forces between the anterior and posterior parts of a
fixed appliance can only be accomplished by dividing the arch into segments. Each
segment is consolidated into a rigid unit by a section of heavy rectangular wire, with
little or no play between wire and bracket slot.
The anterior segment, usually including the four incisors and possibly the
canines, forms the active unit, and the two posterior segments, including the premolars
and molars, are the reactive units. When necessary, the reactive units are connected by
a transpalatal bar to form a single rigid, multirooted entity.
The planned displacement of the anterior unit and the corresponding reaction of
the posterior units are carried out by connecting the anterior and posterior units with
active elements, such as retraction spring. Clinically, the point of force application is
the bracket. If a pure force is directed distally through the bracket, the tooth will
undergo a distal tipping movement.
If a pure translational movement of the tooth is desired, the moment must be
neutralized. This can be done by calibrating the retraction spring to produce a couple at
the canine bracket.
ANCHORAGE IN DIFFERENT APPLIANCE SYSTEMS
ANCHORAGE IN REMOVABLE APPLIANCES
Removable appliances mainly obtained anchorage from base plate.
Base plate which gives:
1. Point of attachment for the active components.
2. Distribution of reactionary forces to the teeth and tissues.
To ensure adequate anchorage from base plates:
1. Extension as far as possible, also for stability
2. Close fit to the tissues.
3. Contouring along the lingual gum margins.
4. Adequate bulk of acrylic.
Wire components- The Labial bow-which prevents the proclination of incisors which
aids in the stationary anchorage.
Intermaxillary anchorage- Elastics act as intermaxillary anchorage.
Head gear -- Extra oral anchorage can be gained by various types of head gears.
(Anchorage reinforcement).
ANCHORAGE IN FUNCTIONAL APPLIANCES

In removable functional appliance:
Tooth borne appliances such as bionator, activator and twin block obtained anchorage
by:
1. Capping of incisal margins of lower incisors and proper fit of cups of teeth into
acrylic.
2. If decidous molars are present, it is used as anchor teeth.

3. Edentulous areas after loss of decidous molars
BIONATOR
4. Noses in the upper and lower interdental spaces.
5. Labial bow prevents anterior flaring and posterior displacement of the appliance.
BIONATOR ACTIVATOR
TWIN BLOCK
Tissue borne appliances such vestibular screen and frankels functional regulator
obtained anchorage by extending acrylic into vestibule. Head gears can be used for
extra oral anchorage for these appliances.
ANCHORAGE OBTAINED BY EXTENDING ACRYLIC INTO VESTIBULE
In fixed functionals
Conventionally in the maxillary arch the 1st premolars and permanent 1st
molars are interconnected on each side. In mandibular arch the 1st premolar bands are
connected. This type of anchorage is called partial anchorage.
In some instances this type of anchorage is insufficient and therefore must be increased
by the incorporation of additional dental units. In the maxillary arch labial sectional
wire is placed in the brackets of premolars, canines, incisors. In the mandibular arch
lingual sectional wire is extended to 1st permanent molars which are banded. This form
of anchorage is called total anchorage.
In the deciduous and mixed dentition period bonded type of herbst is used
because of absence of 1st premolars. This system is called splint anchorage system.
Pellot anchorage system: in the mandibular arch with the lingual arch wires acrylic
pelott is fabricated and fixed touching the lingual mucosa about 3mm below the
gingival margin. This system is most efficient in withstanding the stresses placed on
lower anterior teeth.
Anchorage system in fixed twin block

Fixed twin block obtains anchorage from transpalatal arch. This component
consists of a transpalatal arch with occlusal inclined planes over the posterior teeth that
can be cemented in place. The inclined planes are secured by occlusal wire tags that are
an extension of the transpalatal wire. The entire assembly secured in Wilson lingual
tubes on upper molar bands by the standard Wilson plug-in attachment.
The lingual arch combined with the wilson 3d lingual arch, extends over the
occlusal surfaces of the lower deciduous molars, or premolars, depending on the stages
of the development. the appliance may be used in mixed dentition, where functional
correction can be combined with interceptive treatment. the omega loops should be
omitted to provide a more rigid attachment. fixed twin block is attached to the teeth by
bands. the bands are cemented to the 1st molars. thus anchorage is obtained from 1st
molars.
Anchorage in begg appliance
The Beggs appliance offers an economy in the use of intra oral anchorage. This
is brought about in the first place, through bodily control given to anchor units with the
help of anchor bend and, the freedom to tilt offered to the units that are to be moved
and the light Differential forces employed.
The light forces are inadequate to cause rapid movement of the anchorage unit,
and forces applied to correct the axial inclinations of the tilted units, in the later stage of
the treatment partially counterbalance one another. When intermaxillary elastics are
added, the two dental arches virtually becomes one unit, the whole being resistant to
any displacing force created by the balance action of the spring axillaries.
The total effect leads to the fact that additional anchorage, supplied through
head gear is seldom needed with the Beggs appliance. Nevertheless, it would surely be
wrong to advice that head gear should never be employed, or that it cannot be used to
advantage. Accidents, resulting in anchorage loss can happen. The Beggs appliance
rarely needs extra-oral support, unless mistakes and misjudgments have taken place. If
headgear should become necessary, high or straight pull can be applied.
EXTRA ORAL METHOD OF ANCHORAGE

Head gear they are again classified according to the point of origin of force
as follows:
1.Cervical-Anchorage derived from the napeofneck.
2 .Occipital-Anchorage obtained from the back of the head.
3.Parietal-Anchorage obtained from the upper part of the head’
Another classification as follows:
1.High pull head gear: Anchorage obtained from the upper part of the head and
direction of the pull is always above the centre of resistance of the dentition.
2.Straight pull head gear: Anchorage obtained from the back of the line of
traction is parallel to the occlusal place.
3.Cervical pull head gear: the combination of cervical pull and high pull head
gear with varying proportions of force to each, depending on case requirements.
Another variable in the head gear is the outer bow of the face bow. The outer
bow can be long,medium and short. The site of the point of origin of force is the
relatively fixed by the position of the head gear strap and the centre of resistance of the
molar remain constant till the tooth has moved. Therefore inclination of the line of
action may be altered only by variations in the position of the bow. They can be
achieved by varying the length of the outer bow, the angulation between the inner and
outer bow or a combination of both. The centre of resistance of the maxilla is in the
area of postero-superior aspect of zygomatico maxillary suture. The centre of resistance
of the maxillary dentition is situated between the roots of the premolars. The centre of
resistance of maxillary molar is in the trifurcation area.
Cervical pull head gear: In this head gear when the inner and the outer bow are in the
same plane there is a clockwise rotation of both the maxilla and the dentition. The
incisor region will move inferiorly to a greater extent than the molar region. If the
outerbow is bend upwards so that the direction of the traction between the centre
resistance of the maxilla and the dentition in an anticlock wise direction. Hence the
molars will experience a more downward pull than incisors.
Parietal pull/high pull head gear: when the direction of traction is placed behind the
center of resistance of the maxilla and the dentition, a clockwise rotational effect on
maxilla and the dentition is observed. Hence the molars intrude incisors extrude. Least
vertical dimension and rotational changes are observed when the applied force vector
passes through the centre of resistance of the maxilla and the dentition. This is
therefore, the preferred setup for the vertical control. But so far it has not been possible
to construct a stable head strap for anchoring such a steep force vector.
Combee type head gear: This allows a distal force through the centre of resistance of
the dentition having equal parietal and cervical components. When the outer bow is
angled upward to pass through the center of resistance. Hence the center of rotation is
at infinity. This allows for more distalization of the molar with minimum rotational
effect.
Force and duration of wear
Most of the authors agree that the amount of force applied to the maxilla by the
head gear should be between 400-800 grams. According to marcotte force value of
200grams per side in mixed dentition and 500 gms per side in mixed dentition and
500gms per side in permanent dentition for 18 hours per day is suggested.
Graber advocates force application of more than 400gms for10hours per day.
Alexander used force of 16 ounces per side once the patient acquainted with the head
gear assembly. Duration of wear depends on severity skeletal discrepancy and the ANB
angle.
Roth used the Ascher’s face bow on both the arches applying a force of-
15ounces to upright and retract procumbent incisors. He uses it for short duration till
they get uprighted. .
HEAD CAP
HIGH PULL STRAIGHT PULL CERVICAL PULL
THE DELAIRE FACE
FACE MASK
FACE MASK
Extra oral force aligned via a chin cup is not completely analogous to the use of extra
oral force against the maxilla because there no sutures to influence. If the cartilage of
the mandibular condyle were a growth centre with the capacity to grow independently,
one would not expect chin cup therapy to be particularly successful. From the opposite
and more contemporary view that condylar growth is largely a response to translation
as surrounding tissues grow, a more optimistic view of the possibilities for growth
restraint would be warranted.
There are two ways to direct force against the mandible. The first is to apply it on a line
directly through the mandibular condyle, with the intent of impeding mandibular
growth in exactly the same way that extra oral force against the maxilla impedes its
growth. This works in experimental animals, but in humans the changes are
considerably less impressive. Perhaps the difficulty can be attributed to the nature of
the temparomandibular joint, which makes it difficult to create a restraining force
against the condyle , or it may reflect a more fundamental difference between maxillary
and mandibular. A second approach to chin cup therapy is to orient the line of force
application below the mandibular condyle, so that the chin is deliberately rotated
downward and backward. Less force is applied than when direct growth restriction is
obstructive. In essence, an increase in facial height is traded for a decrease in the
prominence of the chin. This can be quite effective within the limits established by
excessive face height. Obviously, it would work best in individual who had short facial
vertical dimensions initially.
ROTH CONCEPT OF ANCHORAGE

Roth prescription
Roth’s rationale for modifying the andrew’s setup was to provide over-corrected
tooth positions prior to the appliance removal that would allow the teeth in most
instances to settle to what was found in non-orthodontic individuals.
Roth states that the lower first pre-molars through the second molar should be
up righted 3 degrees distal from a normal mesio-axial inclination of 2 degrees. Hence
lower pre-molars and molars have a distale tip of -1degree. This serves to prepare
anchorage in mandibular buccal segments.
According to him, the factors that tend to slip the anchorage forward are;
1. The use of large resilient wires and continues wires in attempting to level a
deep curve of spee.
2. Attempting to upright distally inclined canines.
3. Attempts at moving the roots of maxillary incisor teeth lingually.
4. Attempts at arch expansion with& labial wire.
5. Attempts to retract proclined anterior teeth through the extraction site using
reciprocal force system between first molars, second premolar and the
anterior, since labially tipped anterior provide excellent anchorage to resist
displacement.
The banding of second molars at the onset of treatment can minimize the need
for extra oral reinforcement of anchorage. In most retraction which he advocates the six
anterior teeth are pitted against six posterior teeth thus reinforces the anchorage.
Leveling and alignment:initially leveling and alignment procedure attempted on a

small flexible wire helps conserve anchorage. Small wires exert light forces on teeth
and the overbite and occlusion hold the arches in the respective positions and prevent
forward migration.
Leveling the curve spee : leveling with a continuous wire will lead to slippage of
anchorage. This can be avoided by assessing the incisor portion and if permitted by
intruding them.
Retraction of the canines and incisors : Roth advocates only inmost retraction of the
anterior. Because contrary to popular notion that more of the anchorage lost while
attempting inmost retraction, he found that if and when the second molars banded
anchorage does not present a problem. Also while attempting retraction importance
sould be given to position of the anterior. Retracting procumbent incisors using
reciprocal forces burn up more anchorage than that which can be anticipated. Hence
initially to retract and the upright these anterior, an Ascher’s face bow can be used in
both the upper and lower arches, for upto6-8 weeks. Once incisors upright, they offer
very little resistance as anchor unit and can be easily retracted.
Space closure : if one attempts to close the space faster regardless of wire size tipping
will occur inevitably. It is possible to close extraction spaces on an 0.016” round wire at
a well modulated rate without tipping whereas one can take a large rectangular wire
with closing loop mechanics and end up tipping if the activation of the loop is done too
frequently.
Counter buccolingual tip: this feature is added only to the maxillary molar translation
brackets. As the molar translates mesially during space closure, due to the presence of
the prominent palatal root, it tips baccally thus rendering the buccal cusps more
gingival to the palatal cusps. This effect is resolved by counter bucco-lingual tip feature
in tube by placing buccal root torque.
Minimum – 4o more torque
Medium - 5o more torque
Maximum- 6o more torque
Adjuncts used
Head gear : Roth does not encourage prolonged use of head gear either for
distalization or for preventing forward migration of dentition. He states that the use of
extra oral force can be avoided by
a. Using small flexible wires for leveling and alignment
b. Bonding second molars at the onset oftreatment
c. Leveling and curve of spee using utility arches to intrude incisors.
The Ascher’s face bow that he advocated connects directly to the anterior teeth, with a
force of12-15 ounces and the duration is kept to a minimum of 6-8weeks till the
anterior upright.Roth also use the Goshgarian type TPA and lip bumber.
VARI-SIMPLEX DISCIPLINE
Alexander through vari-simplex discipline has succeeded in changing some of
the basic concepts in pre adjusted edgewise therapy.
The initiation of treatment in the mandibular arch was advocated in airlock
philosophies. But Alexander begins treatment in the maxillary arch and lets the
mandibular anterior drift distally. According to him, the mandibular molars also drift
mesially, but much more slowly. He calls this practice as “driftdontics” caution is
advised while using this maximum anchorage cases.
Wick Alexander gives – 6 o
tip in the lower molars to conserve anchorage.
This is in alignment with the original Tweed’s principles. It promote leveling of the
arch and also helps to gain arch length. In a study it was reported that the distal tip
caused the root tips to move anteriorly by 0.5mm whereas the crown tipped back by
1mm. thus by uprighting both the lower first molar,2 mm of space was gained.
Alexander does not advocated distal tipping of lower premolar for anchorage.
Along with distal tipping of the lower first molars, banding of lower second
molar also increases the anchor value of the buccal segments. If the need increases the
second molar can also be tipped back.
The maxillary second molar is not routinely banded. Instead a head gear
retractor is used. The choice of head gear depends on the SN-MP angle. For an angle of
less than 37o a cervical pull head gear is advocated. It allows for extrusion of molars,
holds the maxilla in the horizontal direction thereby reduces the SA angle. In high angle
cases (SN>MP>42O a high pull head gear should be used as it prevents both the
downward and forward descent of the maxilla.
Headgear was used by Alexander in 75% if all his cases. Initially a light force of 8
ounces should be applied per side. After 4 weeks the force is increased to15ounces per
side. Duration of wear depends on the severity of the skeletal pattern. Pre-treatment
ANB of 3o and 5o -10 hours per day and ANB>5O -14hours or more.
The patient should be asked to wear head gear for the forst 12months regularly.
Once the skeletal problem is corrected and class 1 molar relation is attained, patient
may be asked to discontinue wearing head gear or asked wear only during sleeping
hours.
Alexander also uses the TPA, Nance arch, lingual holding arch and the
lipbumper as the case suggests.
MBT CONCEPT OF ANCHORAGE (McLAUGHLIN, BENNET,

TREVISI)
Anchorage control can be discussed in three planes: horizontal, vertical and
lateral planes. Anchorage control in all the three planes is inter-connected and failure to
control one plane can cause problems with another.
.
Control of anchorage in horizontal plane
Anchorage in horizontal plane includes the achievement of the correct antero
posterior position of the teeth at the end of the treatment and involves limiting the
mesial movement of the posterior teeth while encouraging the distal movement of the
anterior teeth.
This can be further divided into
1. Control of anterior segments
2. Control of the posterior segments in the upper and lower arch.
Control of anchorage in anterior segments:
 Lacebacks and bend backs – to prevent proclination of anterior teeth during
aligning and leveling phase.
 Reduce the anchorage needs during leveling & aligning.
 Bracket design – reduced tip.
 Arch wire forces – use of very light arch wire forces.
 Avoidance of elastic chain
LACE BACKS
EFFECT OF LACE BACKS ON CUSPIDS DURING LEVELING AND ALIGNING
Control of anchorage in upper posterior segments

Posterior anchorage requirements are normally greater in the upper arch than in the
lower arch because of the following reasons
 Upper molar moves mesially more easily than the lower molars.
 Upper anterior teeth are bigger.
 Upper anterior brackets have more tip built into them
 Upper incisors require more torque control & bodily movement than lower
incisors which require distal tipping or uprighting.
 Most of cases are class II type of malocclusion.
Due to these factors extraoral force is the most effective way to provide Control of
anchorage in upper posterior segments
i. A transpalatal arch can be used in moderate anchorage cases.
ii. The Nance holding arch can be used during leveling,allining and canine
retraction stages.
iii. Control of anchorage in lower posterior segments
iv. When extra anchorage support is needed in lower posterior segments it
can be effectively obtained by
v. Lingual holding arch.
vi. Class III elastics (by not taxing the lower anchorage)
vii. Head gear.
CLASS III ELASTICS
LOWER LINGUAL ARCH
Control of anchorage in vertical plane
Anchorage control in vertical plane involves prevention of the vertical skeletal
and dental development in the posterior segments (as with high mandibular plane angle
cases ) and prevention of vertical eruption or intrusion of anterior segments
Vertical control of incisors:

Because of the tip built in the canine brackets a transient deepening of bite
occurs in the initial aligning and leveling phases.if canines are distally tipped to begin
with as the arch wire is encaged in the canine slot it lies incisal to the incisor bracket
slots causing undesiarable extrusion incisors when the wire is encaged.This effect can
be minimized by either not encaging the wire in incisor brackets or not bonding the
incisors until canines are uprighted.
Vertical control of canines:

High labial canines should not be engaged with arch wire because it causes
unwanted vertical movement of lateral incisors and premolars.
The unwanted effects of fully encaging the arch wire in the brackets of high
labial canines may be minimized by lightly tying the canines into the primary arch wire
with elastics thread.
Vertical control of molars in high angle cases:
Vertical control of molars is critical in high angle cases:
1.Transpalatal arch should lie about 2mm away from palate so that the tongue
can exert a vertical intrusive effect.
2. When headgears are used in high – angle cases either a combination pull or
a high pull headgear is used. Cervical pull headgear is avoided.
3. Upper or lower posterior bite planes in molar region is helpful to minimize
extrusion of molars.
4. Upper 2nd molars are generally not initially banded, to minimize extrusion of
these teeth.
5. If upper molars require expansion, an attempt is made to achieve bodily
movement rather than tipping.
Control of anchorage in transverse plane
Anchorage control in transverse plane involves the maintenance of expansion
procedures, primarily in the maxillary arch, and the avoidance of tipping and extrusion
of the posterior teeth during expansion
 Inter canine width should not be altered to great extent during the treatment. It
should be kept as close as possible to starting dimensions for stability. Care
should be taken to ensure that crowding is not relieved by uncontrolled
expansion of the upper & lower arches.
 Molar cross bites should be corrected by bodily movement of molars. As far as
possible the tipping should be avoided.
 If maxilla is too narrow, early rapid expansion should be considered prior to
leveling & aligning. If adequate maxillary bone exists, a fixed quad helix
expander is used. Minimal molar cross bites are usually corrected by using
rectangular wires which are slightly expanded from normal & which carry
buccal root torque.
ANCHORAGE CONTROL IN RICKETTS BIOPROGRESSIVE THERAPY

Cortical bone anchorage:
Rickets used cortical anchorage in maximum anchorage cases. The concept of
cortical bone anchorage implies that, to anchor a tooth, its roots are placed in proximity
to the dense cortical bone under a heavy force that will further squeeze out the already
limited blood supply and thus anchor the tooth by restricting the physiological activity
in an area of dense laminated bone.
Three main aspects of tooth movement & cortical bone support:
1. Cortical anchorage can be derived by placing roots of anchor adjacent to the
denser cortical bone
2. whenever tooth is to be moved avoid cortical bone support & direct the roots
through the less dense & more vascular trabecular bone. Light forces are used.
3. When treatment objectives necessitates to move teeth through the supporting
cortical bone, the forces must be kept even lighter to respect the character of
bone and its limited blood supply & physiological response.
Upper molar anchorage
Maximum upper molar anchorage:
Nance plastic button followed by headgear should be used for maximum
anchorage of upper molars. A modified nance palatal arch can be used, with plastic
button against the rugae with addition of a distal loop on the mesial lingual aspect of
the upper molar bands to achieve molar expansion& rotation.
Advantage of expansion & rotation of molars
Expansion places the molar roots out under the zygomatic process where
cortical bone support resists change and thus anchors and limits the movement of
molars.. The molars, placed in distal rotation, tend to resist the forward mesial pull as
the cuspids are being retracted on sectional arch springs.
Moderate upper molar anchorage:
 Quad helix expansion arch.
 Palatal bar without plastic button support will stabilize the molar & give
moderate anchorage support.
 The lingual arch limits molar eruption & vertical height development.
 Use of upper utility arch during cuspid retraction with or with out the lingual
arch has a moderate anchorage effect to the upper molars, since the intrusion
action to the upper incisors produces a tip back to the upper molars, which acts
to stabilize them.
Minimum upper molar anchorage:
 Class III extraction treatment usually calls for upper second bicuspid extraction
with advancement of 1st molar.
 Since upper molar has a natural tendency to rotate & migrate mesially as it
erupts, the advancement of upper molar is a matter of encouraging & supporting
this natural process.
 A vertical closing loop or double delta loop will assist in its forward closure.
 The forward migration of the upper molar usually carries it into mesial rotation
& treatment mechanics will need to compensate by uprighting with distal
rotations for a better final fit & occlusion.
Lower molar anchorage:

Maximum molar anchorage:
 Maintained through the action of long lever arm of the lower utility arch.
 Buccal root torque that places roots against the cortical support to limit their
movement. Up to 45 degrees buccal root torque is placed in a 0.016 X 0.016
elgiloy wire.
 Buccal expansion of the molar section of 10mm on each side is necessary to
support the buccal torque.
 Tip back of 30 – 40 degrees keeps the molar upright & resists the forward pull
in response to the cuspid retraction springs.
 Distal molar rotation of 30 – 45 degrees is placed in the molar section of the
utility arch in extraction cases.
Moderate lower molar anchorage:
Modifies the lower utility arch mechanics to allow the molar to come forward
during cuspid & incisor retraction. A contraction utility arch is stepped ahead of the
molar tube to advance the molar.
Minimum anchorage mechanics:
To advance the lower molar forward the four anchoring factors of torque, tip
back, expansion & rotation are minimized. Round wire in the molar tube may be used
to eliminate the binding & torquing to the molar & there by reduce the anchorage.
Muscular anchorage
The facial type described by the cephalometric morphology reflects the
musculature which supports the occlusion. When the musculature is strong as
characterized by the deep bite, low mandibular plane angle, brachy facial type, the teeth
demonstrate a natural anchorage. In the open bite vertical dolichofacial patterns, the
musculature seems weaker & less able to over come the molar extruding
SKELETAL ANCHORAGE
Skeletal anchorage is applied to orthodontic tooth movement when ‘Absolute
anchorage’ is necessary. With various skeletal fixtures forces might be applied to
produce tooth movement in any direction without detrimental reciprocal forces
METHODS OF OBTAINING SKELETAL ANCHORAGE

1. Conventional Dental Implants
2. Palatal Endosseous Implants
3. Onplant
4. Mini implant
5. Spider Screw
6. Microimplant
7. C-orthodontic Microimplant
8. Impacted Titanium Post
9. Transitional Implants
10. Mini Plate
11. Zygoma Anchorage System
12. Zygomatic Ligatures
IMPLANTs
“Implants are alloplastic devices which are surgically inserted into or onto jaw
bone” BOUCHER
“An oral or dental implant is a biologic or alloplastic biomaterial surgically
inserted into the soft or hard tissues of the mouth for functional or esthetic purposes”
“Implant is a mechanical device made from one or more biomaterials that is
intentionally placed within the body either totally or partially buried beneath an
epithelial surface.”
IMPLANTS IN ORTHODONTICS
Implants solve one of the orthodontists’ dilemmas, anchorage control. The
innate ability of an Osseo integrated implant can provide this advantage.The reliance on
patient cooperation would be minimized because the use of head gear and elastics
would be eliminated.
PARTS OF AN IMPLANT
The commonly used implant screw has two parts
1. Implant head:
It serves as the abutment and in the case of an orthodontic implant, it is the
source of attachment of elastics or coil springs
2. Implant body:
It is the part embedded inside bone. This may be a screw type or a plate
type
Implant head Threads in the Implant body
SITES FOR IMPLANT PLACEMENT

The various sites for implant placement reported are
Maxillary zone:
1. Infrazygomatic crest area
2. Maxillary tuberosity area
3. Anterior nasal spine
4. Midpalatal area
5. Alveolar ridge
6. Extraction site
Mandibular zone:
1. Retromolar area
2. Symphysis area
3. Lingual plate
4. Interdental region
Extra orally
1. Temporal buttress
2. Zygomatic buttress
SELECTING THE SITE FOR INSERTION OF AN IMPLANT

It involves considering several factors
 The primary purpose of the implant (is it exclusively orthodontic or will it also
be used prosthetically)
 The patient's skeletal age
 The quality and quantity of bone available.
 Pathologies in operation site
 Anatomical structures
 Biomechanical requirements and The specific therapeutic indication
APPLICATIONS OF IMPLANTS IN ORTHODONTICS

The anchorage derived from implants is categorized into:
1. Direct anchorage in which an endosseous implant used for as an anchorage site
2. Indirect anchorage in which implants are used for preserving anchorage.
The various applications of implants in orthodontic perspective includes
1. Orthopedic anchorage
2. Maxillary expansion
3. Maxillary protraction
4. Head gear like effects
5. Dental anchorage
6. Space closure
7. Intrusion of anterior teeth
8. Intrusion of posterior teeth
9. Distalization
10. In conjunction with prosthetic rehabilitation (Direct anchorage)
ANCHORAGE CONTROL IN LINGUAL ORTHODONTICS
When using the lingual technique specific problems relating to the provision of
adequate anchorage may be attributed to a number of factors.
 The majority of the patient is seeking lingual orthodontics are non growing
adults.
 Many have mutilated malocclusions with one or more missing teeth.
 Often there is a compromised periodontal condition with reducing the
anchorage value of the posterior condition.
 There patient as a group of high esthetic demands precluding the use of many
conventional orthodontic anchorage devices such as extra oral appliances,
pendulum, lip bumper, or intermaxillary elastics.
The placement of lingual brackets invariably causes anterior bite opening and
posterior disocclusion in cases with normal or deep overbite. While the contribution of
an intercuspated occlusion to the provision of a degree of anchorage may be debatable
and vary with different malocclusions, the bite plane effect of the lingual appliance
with resulting loss of occlusion and intercuspation may in certain cases reduce the
anchorage achieved with the lingual technique.
A LINGUAL APPLIANCE
Takemoto suggested anchorage value of posterior teeth in the lingual technique

is higher than that of the labial technique due to proximity of the lingual brackets to the
centre of resistance of the tooth. In addition, the direction of forces during space closure
creates a degree of buccal root torque and distopatal rotation of the molar crown, which
in turn produces cortical bone anchorage.
In certain cases were anchorage need to be reinforced, a modified pendulum
appliance can be placed to reduce anchorage loss. Good anchorage control is achieved
with lingual orthodontic sliding mechanics when following simple anchorage
principles. Cases presenting with difficult anchorage situations and and with unusual
extractions sites can be treated successfully with this technique.
REVIEW OF LITERATURE
George et al (1937)14 Considered the value of the second molars in the establishment
of stationary anchorage in the treatment of Class II cases. Second molars offer two
additional units of anchorage in the mandibular arch and, because of their large roots
and their positions close to the dense bone forming the anterior border of the ramus,
they add materially to the anchorage of the other mandibular teeth. In the treatment of
Class II cases it has been noted where the first permanent molar has been used as the
last anchorage tooth for the attachment of the intermaxillary elastics that there is a
tendency for extrusion of this tooth due to the semivertical pull of the intermaxillary
elastics.
CHESTER et al (1939)92.considered anchorage as a biological problem, with bone as

the fundamental consideration. According to them the undisturbed tooth represents
maximum resistance and true anchorage is not available within the mouth. Resistance
to movement of anchor tooth may be increased or decreased by mechanical
manipulation. Rigid attachments provide maximum resistance, while hinge attachments
least resistance.
HOMER et al (1940)81 advocated the use of head cap in patients requiring occipital or
cervical anchorage instead of head straps. This type of head cap is advantageous since
a direct distal pull is obtained and is more secure than the strap type.
WILL et al (1940)87 said that Occipital anchorage is that form in which the resistance is
borne by the top and back of the head and force transmitted to the teeth by means of the
headgear and heavy elastics connected with attachments upon the teeth.1) The
auxillaries and head cap attachments that used has proved satisfaction from both stand
point of the operator and the patient.2) There is a definite need in certain types of
malocclusion for such an auxillary as the occipital anchorge.
3) Tooth movements can be produced with the occipital head cap without the
intermaxillary elastics.4)The most use of the head cap and auxiliaries is in the form of
anchorage in the treatment of case presenting mesial drift of all four buccal segments.
ROBERT et al(1941)84 has proved the ability to successfully manipulate any
orthodontic mechanism depends upon three factors of equal importance. The first of
these is a keen appreciation of tissue reactions and the limitations of tissue tolerance;
the second is a thorough understanding of the mechanical principles involved in the
application of the appliance that is to be used; and the third is a complete
comprehension of the anchorage available in the structures that are to be modified.
There is no true anchorage is available intra orally.
CHARLES et al(1941)52 said that there is a place for occipital anchorage as an

auxiliary in the treatment of malocclusion. The head cap and its accessories for
attachment to the intra-oral appliance can be made comfortable, and its psychological
disadvantage to overcome by careful patient management.. Occipital anchorage can be
applied to either the upper or the lower jaw. Occipital anchorage can stimulate tipping
tooth movement although in a lesser degree than inter-maxillary elastics. Occipital
anchorage was found to be less effective than inter-maxillary elastics in activating the
intra-oral appliance for mass movement of buccal segments. The advantage of occipital
anchorage over inter-maxillary anchorage lies in the stability of the former as an
anchorage unit. A disadvantage of occipital anchorage lies in the difficulty of
maintaining a continuous force; since for all practical purposes the head cap can only
be worn at night.
ALLAN et at (1948)10 mentioned that Oppenheim advocated the use of extra-oral

anchorage (head caps) applied at night only for the treatment of class II div1 cases, and
showed its usefulness for mass movement of teeth.
BEULAH G NELSON (1953)65 has said that teeth can be held or moved distally with
extra-oral anchorage and correction of mesiodistal relationships of teeth can be made.
Extra-oral anchorage permits the use of light intermittent force, of a simple appliance
with a minimum of banding, which- seems to influence teeth to grow into their normal
positions by exerting pressure for ten or twelve hours and allowing rest and repair
during the remaining hours of the day. This gentle force is effective and inflicts a
minimum of pain to the patient and damage to the tissues. Using extra-oral anchorage
makes treatment extend over a longer span of months than intra-oral anchorage, though
the hours and degree of force are less for extra-oral anchorage than for inter-maxillary
traction.
WALDO et al(1955)88said that Definite improvement can be accomplished in the

treatment of selected cases of malocclusion by the use of upper appliance only,
activated by occipital anchorage. Some of the improvements to be accomplished are :
(a) Normal arch relation may be established.(b) Dental interferences with a normal
mandibular path may be removed. (c) Labioversion of anterior teeth may be reduced
and interdental spaces may be closed.(d) Improvement in facial profile may be
accomplished.(e) Normal respiration and lip function may be encouraged.(f) The
dentures may be placed in a position of mechanical advantage so that the patient can
practice normal posture and function.(g) Advantage may be taken of mandibular
growth and possible spontaneous forward adjustment of the mandible. The factors
which may be considered to contribute to the improvement in denture and facial profile
in cases treated by this method are: (a) Distal movement of upper teeth.(b) Forward
adjustment of the mandible.(c) Mandibular growth.
Morris et al(1958)86has said that it is interesting to note that Pierre Fauchard in 1728
described the first arch which was a flat perforated ribbon. A century later, in 1841,
Schange devised an arch soldered to a skeleton crib which afforded positive purchase
on the teeth. He also developed the first clamp band. Occipital anchorage was
introduced by Kingsley in 1866. There are many who claim that the ultimate in
anchorage was developed years ago through the use of these occipital or extraoral
forces. The early bands were problems because of tooth decay. With the advent of the
cemented band, orthodontia became a more exact science, and credit for the cemented
bands, according to Angle, goes to MacGill in 1871. Dr.Angle, in 1886, wrote about the
use of small delicate tubes and shortly thereafter he described in the literature the "E"
arch, or expansion arch.
W. W. WALKER et al (1967) 91 said that Maximum anchorage types of cases show
that the crowded maxilla was forward of the crowded mandible a full step. This would
mean that the maxilla would still be a full step forward of the mandible after the
crowding was corrected since all the extraction space would be utilized to align the
anterior teeth, instead of reducing the Class II condition.
L. B. Higley et al(1969)41 said that Anchorage is an important consideration in

orthodontics, particularly, if force is applied entirely to the teeth, for the following
reasons:1. It indicates the resistance necessary to prevent tooth movement where not
desired while permitting movement where it is desired.2. Being indicative of the type of
resistance the tooth or teeth will offer, it likewise indicates the type of movement that
may be expected.3. It is a factor in determining the type of appliance that must be used
to produce the type of tooth movement desired.
.
M.B.LEVIS et al(1974)53said that the Levis Retraction Assembly eliminates the
orthodontist's concern for the loss of anchorage by eliminating the use of inter-
maxillary elastics for the retraction of anterior teeth. It is a very simple mechanism to
use and the results are dramatic. Overbite is eliminated without extrusion of molars.
The whole anterior segment moves with ease and under control at all times.
CHARLES et al(1977)45 has mentioned that most Class II correction is now done
mainly with extra oral force. This is an excellent way to obtain a Class I dental and
skeletal relationship, but the long range effect of the extra oral traction to the facial
skeleton must be taken into consideration, and monitored by means of cephalometric
head films. Unfortunately, some otherwise well-treated orthodontic cases suffer from
poor orthopedic management. A common use of extraoral traction is to reinforce the
maxillary molar anchorage in a Class I extraction case. Thought should be given to the
orthopedic effect of twelve to fourteen hours of headgear wear and the growth rate of
the patient at that time. This effect can be minimized by using a light force headgear
and monitoring treatment response regularly, or using another method of anchorage for
anterior tooth retraction.
James et al (1983)38 has said that Pairs of Bioglass-coated Vitallium implants and pairs
of Vitallium implants of the same size were implanted into the femurs of twelve rabbits.
After a 28-day healing period, these implants were loaded with forces of 60, 120, and
180 Gm.Analysis of implant movement after 28 days revealed no statistically
significant movement at either force level for either type of implant. The histologic
observations were consistent with other histologic observations of endosseous inert and
ceramic controlled surface-reactive biomaterials. No significant differences were noted
for implants subjected to different force levels. The observations were also consistent
with the resistance to movement demonstrated by the implants. The cellular response
seen in an active periodontal ligament was not evident in the connective tissue capsule
enveloping the implants.
W. Eugene et al (1984)78 has mentioned that the present results indicate that seven
major factors contribute to bony fixation ("ankylosis") of the implant: (1) maintenance
of vital osseous margins around the surgical defect prepared to receive the implant, (2)
preservation of sub periosteal osteogenic capacity, (3) firm stabilization of the implant
within bone, (4) close adaptation of the periosteal bony margin to the implant,
restricting access of the fibrous layer of the periosteum, (5) avoidance of unessential
radiation exposure, (6) lack of immediate loading to avoid propagating stress risers
(cracks) which can critically weaken adjacent bone before physiologic compensation
occurs, and (7) an adequate, unloaded healing period (6 weeks in rabbits which is
equivalent to 4 to 5 months in man) to allow sufficient mature, lamellar bone to adhere
directly to the implant surface, as well as fill in the immature woven lattice which
forms during initial healing. Also, a rigidly stabilized healing phase allows for some
new secondary osteons to be propagated at or near the implant surface.
TURLEY et al(1988)74 has said that Orthodontic anchorage is usually achieved by

using a tooth or group of teeth to effect the movement of other malpositioned teeth.
Adequate anchorage becomes difficult if not impossible to obtain when key teeth that
might be used for anchorage are missing. Such circumstances would benefit from an
anchorage unit that could be placed in the mouth to receive forces of a magnitude
sufficient to effect tooth movement without becoming displaced by the applied forces.
All eight titanium endosseous implants that were loaded with orthodontic or orthopedic
forces remained stable throughout the period of force activation, indicating their
potential as orthodontic and orthopedic anchorage units. Orthodontic tooth movement
ranged from 0.6mm to 4.0mm, with no detectable implant movement. Implant mobility
ranged from 0 to + 1.The large (6 × 4.75mm) two-stage titanium endosseous implants
showed a 100% success, compared to 47% for the smaller (6 × 2.4mm) one-stage
implants. Small one-stage titanium endosseous implantsshowed a lower incidence of s
uccess when placed in an area of early occlusal loading or in non-keratinized tissue
(unattached gingivae).
William et al (1988)85 has said that a technique of orthodontic mechanics has evolved
that is called combination anchorage technique (CAT). The technique is designed to
broaden the treatment effectiveness of the orthodontist by providing a combination of
orthodontic technical capabilities. Use of the two different bracket slots provides a
simple and efficient means to vary (1) anchorage (dynamic or static), (2) movement
(tipping or bodily), (3) technique (light wire or straight wire), (4) resistance (one tooth
or multiple teeth), and (5) treatment compensation (skeletal or dental)
RICHARD et al (1991)63 has said that the Anchorage control can be maintained during
leveling and aligning with preadjusted appliance systems, as long as the following
principles are kept in mind:1) Leveling and aligning is more difficult with preadjusted
systems than with standard edgewise appliances, because of the immediate
repositioning of crowns and roots. 2) Evaluation of upper and lower canine positions is
the key factor in planning anchorage control in the sagittal plane.3)Lace backs are
effective in preventing unwanted tipping and rotations. Bending the archwires back
immediately behind the most distal banded molars also helps minimize incisor
tipping.4) Light force levels are critical in the leveling and aligning phase.
Prosterman beth(1995)76 et al have stated that inadequate anchorage is one of the
most limiting aspects of orthodontic therapy. Brånemark introduced the concept of
osseointegrated, pure titanium threaded implants in the clinical treatment of edentulism.
This concept of osseointegration has now been applied in orthodontic therapy, giving
full meaning to the term stationary anchorage.
Thomas et al(1995)83 mentioned that the present study rigid endosseous implant
anchorage proved superior to dental anchorage for intrusion of teeth with the use of
segmental arch wire mechanics. The implant anchor remained fixed, whereas dental
anchor underwent adverse reactive tipping movement. Premolar intrusion on the
implant anchor side was successful: The curved intrusive movement would be ideal for
anterior tooth intrusion to keep the tooth roots in the alveolus. On the other hand,
intrusion on the dental anchorage side proved unsuccessful.
Birte Melsen, (1997)60 has mentioned that Orthodontic treatment outcome is often
compromised by the loss of anchorage. The forces acting on the anchorage unit have,
however received surprisingly little attention, and the loss of anchorage is most
frequently expressed in the sagittal occlusal relationship. The biological background for
anchorage is reviewed, i.e., the impact on the cellular reaction of the periodontal
ligament around the teeth of the anchorage unit from the orthodontic force system and
from occlusion. A new rigid appliance consisting of two occlusal splints connected with
transpalatal arches is introduced. The advantage of using the patient’s sense of
occlusion as part of anchorage by means of this appliance is demonstrated in a number
of case presentations.
PHILIP et al (1998)20 has said that the preservation of maxillary molar anchorage,
either after molar distalization or as an adjunct to bicuspid extraction therapy, remains
one of orthodontists’ most persistent and troubling technical problems. The following
technique reliably maintains maxillary molar anchorage with a minimum of expense.
The maxillary molar bands must have lingual sheaths if the appliance is to be fitted at
the chair. While the patient is seated, adapt two .036" wires with terminal loops to fit
into the sheaths and meet at the midline. The use of two separate wires simplifies
construction of the Nance appliance, because a single arch wire requires passive torque
on each side. This means that a single arch usually has to be removed and replaced
several times while each side is made passive in relation to the other.
Adapt a small pad of light-cured acrylic (Triad VLC) to the wires and palate, and cure it
with a light gun. The acrylic button will join the two wires and produce a rigid
appliance that preserves anchorage for three to six months while the molars stabilize,
then remains in place during the cuspid retraction phase.
.
BIRTE et al (1998)62 have said that Compared to alternative solutions such as implants
or mini-plates, zygomatic ligatures have the following advantages:
• No special equipment is required.
• Materials are inexpensive.
• Anchorage can be used immediately after insertion.
• Treatment is rapid.
• Removal is quick and easy.
ALBERTO et al(1998)56 has said that an intact mandibular arch (from first molar to
first molar) usually provides enough anchorage for mesial translation of a third molar to
close a second molar space. However, this may not be appropriate in cases with Class I
occlusion and good facial form, because of the relatively large size of the second and
third molars.ETA Exacta is a dental root-form implant made of pure titanium. Besides
the usual healing caps and prosthodontic abutments of other osseointegrated systems,
ETA Exacta has an acrylic abutment that can be adapted to an orthodontic band or
temporary crown in the office, without complicated surgical or prosthodontic
procedures.
Takayoshi Daimaruya et al(2001)29The skeletal anchorage system (SAS) was

developed as intra-oral rigid anchors for open-bite correction by intrusion of molars.
Since the application of SAS is a new modality in orthodontic treatment, the influences
of radical molar intrusion on the root and the inferior alveolar neurovascular bundle
were unknown. SAS utilizing transmucosal titanium miniplates as an immovable
orthodontic anchorage could provide a new modality for molar intrusions without
serious iatrogenic problems.
Monica et al (2001)90Endosseous implants have been used as orthodontic anchorage in

recent years. A 3-dimensional mathematical model was constructed that uses the finite
element method, which simulated an endosseous implant and an upper canine with its
periodontal ligament and cortical and cancellous bone. Levels of initial stress were
measured during types of canine retraction mechanics (friction and frictionless). The
lower magnitude and more uniform stresses in the implant and its cortical bone were
found to have a moment-force ratio (M/F) of 6.1:1, whereas the canine and its
supporting structures exerted a M/F ratio of 10.3:1. On the basis of these results, when
the anchor unit is an endosseous implant, it seems better to use a precalibrated
retraction system without friction (T-loop) where a low load-deflection curve would be
generated.
SEONG-MIN et al(2002)4 has said that methods of bone anchorage such as retromolar
implants, onplants ,zygomatic wires, ankylosed teeth, palatal implants, mini plates,
mini screw, and mini-implants make it possible to over come previous limitations of
orthodontic tooth movement and for example, move an entire dentition in the same
direction or correct an open bite with molar intrusion. These procedures may eventually
change the way orthodontic treatment is planned and carried out.
Hans-Peter et al(2002) 6 has done an overview with clinical examples has been
presented regarding the use of osseointegrated implants(Straumann Orthosystem)
placed in the palate for orthodontic anchorage purposes. The authors’ experience
suggests the following conclusions: The 4-mm implants are adequate for orthodontic
purposes. In non-growing adults, the palatal implant should be inserted in the
midpalatal region. A safety zone of 2 mm from the nasal sinus, as viewed on a lateral
cephalogram, is recommended. In the majority of growing patients, the para median
region of the hard palate may offer sufficient bone volume for placement of a 4-mm
implant. A low-dose CT scan is recommended to verify that sufficient bone height is
available. The palatal implant with a screw-connected transpalatal bar offers a new
possibility to avoid extra oral appliances in orthodontic treatment.
Lars et al(2002)9 has said that an intra-arch device provided with the Onplant system
for absolute anchorage is suitable for distal molar movement of maxillary first and
second molars simultaneously. Moreover, in contrast to other intra-arch appliances for
distal movement of maxillary molars, this appliance did not cause any anchorage loss,
ie, there was no forward movement of the anterior teeth. The surgical procedures of the
Onplant system Did not result in any major problems, since the placement was a minor
procedure performed under local anesthesia. Compared to a conventional implant
system, there are some obvious advantages of the Onplant system, which is not
dependent on a sufficient amount of bone and does not require drilling of bone during
placement or when removed.
Giuliano (2002)59 described the two-piece osseointegrated orthodontic anchorage

system in this article, the Mid plant, expands the horizons of orthodontic treatment
because it allows treatment to proceed successfully with virtually no anchorage loss and
minimal patient cooperation. This system is for stable anchorage provides the ability to
move groups of teeth simultaneously rather than move each tooth in sequential fashion,
as is commonly done. A benefit of this procedure is reduced treatment time. This
system can be used in both growing and adult patients, and the two-piece design of the
Midplant gives post pubertal and adult patients the option of leaving the infra bony
Core in place after treatment, avoiding the necessity of a second surgery. This makes
the Midplant system more easily acceptable to the patients. The authors have observed
patients for up to 4 years after treatment, with the implant in position, and have noted
no complications
.
ALDO GIANCOTTI(2002)31 has done a study to show the evolution of authors
experience in the clinical experience in the application of the straumann orthosystem
method for anterior anchorage in non-extraction cases. The straumann ortho system can
be used with a direct or indirect load, but authors suggest its use with direct loading
method to avoid reciprocal force in the anterior sector and to aid the contemporaneous
distalization intermediate dental elements. The surgical implant insertion is simple and
without serious risks and the patient compliance is not required.
Nejat Ervedi(2002)25The zygomatic area was found to be a useful anchorage site for
intrusion molars over a short period of time. Long term stability of bite closure should
be assessed in future studies.
Keith et al (2002)82 has said that Kanomi reported the use of mini implants as
anchorage to intrude and retract anterior teeth. More recently, Sherwood et al and
Umemori et al reported the use of titanium miniplates for skeletal anchorage to intrude
posterior teeth in an effort to close anterior open bites. Titanium mini plates are
commonly used to stabilize facial fractures and osteotomy segments. The use of mini
plates for skeletal anchorage in orthodontics is recommended for the following reasons:
Mini plates have a long history of use and biocompatibility in stabilizing facial
fractures and osteotomy segments. Mini plates come in a variety of convenient shapes
and sizes and are easily adaptable to most bony surfaces. Mini plates can be used for a
variety of anchorage purposes. Mini plate placement is minimally invasive and
appropriate to an office setting. Mini plates, when used properly have little or no risk of
causing damage to nerves or tooth roots.
Ahmet et al (2003)49 has mentioned that Palatal implants have been used over the last
two decades to eliminate headgear wear and to establish stationary anchorage. palatal
implants can be used effectively for anchorage maintenance and in space-gaining
procedures. Use of a three-dimensional surgical template eliminated implant placement
errors, reduced chair time, minimized trauma to the tissues, and enhanced
osseointegration. This method can be used effectively to achieve distalization of molars
bodily without anchorage loss.
Takayoshi et al (2003)48 has mentioned that the skeletal anchorage system (SAS) was
developed as intraoral rigid anchors for open-bite correction by intrusion of molars.
Since the application of SAS is a new modality in orthodontic treatment, the influences
of radical molar intrusion on the root and the inferior alveolar neurovascular bundle
were unknown. The purpose of this research is to verify the effect of molar intrusion on
the neurovascular bundle, the level of Osseointegration of the bone screws, and root
resorption. The results of this study showed mandibular molars were intruded 3.4 mm
on the average over 7 months in dogs. The miniplates were well stabilized with
osseointegrated bone screws and the peri-implant soft tissues showed slight
inflammatory changes. Neither nerves nor blood vessels were damaged. Root
resorption was observed but was repaired with new cementum. They concluded that the
SAS utilizing transmucosal titanium miniplates as an immovable orthodontic anchorage
could provide a new modality for molar intrusions without serious iatrogenic problems.
Silvia et al 2003)36have mentioned that Anchorage loss (AL) is a potential side effect of
orthodontic mechanotherapy. It is defined as the amount of mesial movement of the
upper first permanent molar during premolar extraction space closure. In addition, AL
is described as a multi factorial response in relation to the extraction site, appliance
type, age, crowding, and over jet. As the severity of dental crowding increased, AL
significantly decreased (r = −0.66, P = .001). Labial edgewise appliances demonstrated
a significantly greater AL than did lingual edgewise appliances (1.15 ± 2.06 mm, P
< .05). A greater, though not statistically significant, AL was found in adults than in
adolescents (0.73 ± 1.43 mm). There was a slight non significant increase in AL
between maxillary second compared with first premolar extractions (0.51 ± 1.33 mm).
Over jet was weakly correlated to AL. These results suggest that AL is a multi factorial
response and that the five examined factors can be divided into primary (crowding,
mechanics) and secondary factors (age, extraction site, over jet), in declining order of
importance.
Aldo et al (2003)34has said Palatal implants provide stationary anchorage and can
eliminate the need to wear head gear. The combination of implants and sliding
mechanics with NiTi coil springs can reduce reliance on patient co operation, and the
teeth can be moved either mesially or distally, Implants will conserve anchorage during
torquing movements and may eliminate the need for some extractions. Implants
required for only part of the treatment may be left in situ until the finishing phase of
treatment when it is clear that additional posterior anchorage is no longer needed. The
transpalatal bar can be removed and replaced with a healing cap at any stage during
treatment. Insertion and removal of this implant is straight forward and without
complications. Experience has shown that management of malocclusions requiring
stationary anchorage and/or requiring. co operation greatly simplified using this
device. It has been well-received by patients who have not reported any inconvenience
or problems due to the implant.
Shingo et al(2003)56 has said that anterior open bite is often caused by a downward
rotation of the mandible and/or by excessive eruption of the posterior teeth. In such
cases, it is difficult to establish absolute anchorage for molar intrusion by traditional
orthodontic mechanics..Results suggest that titanium screws are useful for intrusion of
molars in anterior open-bite cases.
Hyo-Sang et al(2003)68 has said in that three cases are illustrated. One was treated with
maxillary microscrew implants, another with mandibular micro screw implants, and the
third with both maxillary and mandibular microscrew implants. With the maxillary
microscrew implants, the maxillary anterior teeth were retracted bodily with a slight
intrusion and all the premolar extraction space was closed without loss of anchorage.
Furthermore, the maxillary posterior teeth showed distal movement. The mandibular
micro screw implants controlled the vertical position of the mandibular posterior teeth
and played an important role in improving the facial profile. The efficacy of sliding
mechanics with microscrew implant anchorage on the treatment of skeletal Class II
malocclusion is also discussed.
HYO-SANG et al(2004)69 has said that microscrews offer orthodontic clinicians a
minimally intrusive method of intra oral anchorage that can translates entire quandrants
with no untoward reciprocal results that afflict inter arch techniques. Clinician can
correct sagittal descripancies and midline deviations and gain space for arch length
discrepancies with judicious use of microscrew anchorage.
Masayoshi et al(2004)48 has said in that a lingual orthodontic technique enables an

esthetically pleasing appearance along with an invisible treatment; however, just as
with labial treatment, the anchorage requirement is critical. En masse retraction of the
six anterior teeth requires stationary or absolute anchorage and acceptance of
conventional intra- or extra oral reinforcement such as the use of a headgear. However,
adult patients who require the lingual appliance often reject use of the headgear because
of social and esthetic concerns, and this can result in anchorage loss and unsatisfactory
treatment results. The introduction of temporary implants as an alternative to
orthodontic anchorage can resolve this problem. He considered that lingual treatment
combined with implant anchorage would provide reliable and comfortable results for
the patients who request invisible treatment today.
Hidetake et al(2004)67has described that the orthodontic treatment of a 19-year-old

female patient with anterior crowding. There was a moderate arch length discrepancy in
the lower dental arch, a significant deep overbite, and a “gummy smile.” They inserted
an orthodontic mini-implant as anchorage for the intrusion of the upper incisor
segment, followed by alignment of the upper and lower dental arches with an edgewise
appliance without tooth extraction. The overbite was corrected from +7.2 mm to +1.7
mm by upper incisor intrusion, and the gummy smile was improved. Good occlusion
and facial esthetics were achieved, and these results have been maintained for two years
after completion of the active treatment.
Hyo-Sang et al(2004)68has described that purpose of this study was to quantify the
treatment effects of distalization of the maxillary and mandibular molars using
microscrew implants. The success rate and clinical considerations in the use of the
microscrew implants were also evaluated. Thirteen patients who had undergone
distalization of the posterior teeth using forces applied against microscrew implants
were selected. Among them, 11 patients had mandibular microscrew implants and four
patients had maxillary implants, including two patients who had both maxillary and
mandibular ones at the same time. The maxillary first premolar and first molars showed
significant distal movement, with no significant distal movement of the anterior teeth.
The mandibular first premolar and first and second molars showed significant distal
movement, but no significant movement of the mandibular incisor was observed. The
microscrew implant success rate was 90% over a mean application period of 12.3 ± 5.7
months. The results might support the use of the micro screw implants as an anchorage
for group distal movement of the teeth.
Fengshan Chen et al(2004)16 has mentioned that purpose of this study was to compare
the anchorage effect of the osseointegrated implant with different fixation types using
finite element analysis. Three fixation types were investigated. fixation type 1: implant
neck in the oral-palatal cortical bone and implant tip in the cancellous bone; fixation
type 2: implant neck in the oral-palatal cortical bone and implant tip in the nasal-palatal
cortical bone; fixation type 3: implant neck in the oral-palatal cortical bone and implant
tip projecting into the nasal cavity. Three finite element models were constructed. Each
consisted of two maxillary second premolars, their associated periodontal ligament
(PDL), alveolar bones, palatal bone, palatal implant, and a transpalatal arch. Another
model without an implant was used to compare with the previous models. The
horizontal force (mesial five N, palatal one N) was loaded at the buccal bracket of each
second premolar. The stress was calculated in the PDL and implant surrounding bone.
The result showed that the palatal implant could significantly reduce von Mises stress
(maximum von Mises stress was reduced 30%) and evenly distribute stress in the PDL.
The stress magnitude and distribution in the PDL was almost the same in the three
implant models. These results suggest that different implant fixation types have almost
the same anchorage effects.
Chung-Chen et al(2005)18has mentioned that the intrusion of an overerupted maxillary
molar using traditional orthodontic treatment is a real challenge. The aim of this study
was to investigate the envelope of intrusive movements of a maxillary molar in cases
using mini-implants as anchorage with partial or full-mouth fixed edgewise appliances.
The cusp tips of the pretreatment and post intrusion dental casts were recorded by a
three-dimensional (3D) digitizer. The 3D data of the serial dental casts were analyzed
to distinguish the direction and magnitude of individual tooth movement. The mean
intrusive movement of the maxillary first molars was three to four mm
with a maximum of over eight mm. For the adjacent maxillary second molars and
second premolars, the amount of intrusion was two mm and 1–2 mm, respectively. This
study demonstrated that significant true intrusion of maxillary molars could be obtained
in a well-controlled manner by using fixed appliances with titanium mini-implants as
bony anchorage.
Nejat Erverdi(2005)25has said that an adult female patient who presented with a severe
Class II division 1 malocclusion was treated by en masse retraction of upper anterior
teeth against zygomatic anchorage. This case report describes the surgical and
orthodontic procedures followed during the treatment. En masse retraction of the six
anterior teeth by using zygomatic bone anchorage proved to be an efficient method for
the correction of a severe overjet problem.
He hong et al(2005)44 has said that a hexagonal onplant of 7.7 mm diameter was placed
on the palatal bone of the maxilla in an 11-year five-month-old female patient with a
Class III malocclusion and midface deficiency. Elastic traction (400 g per side) was
applied from a facemask to the onplant at 30° to the occlusal plane 12 hours per day for
12 months. The maxilla was found to have displaced forward and downward by 2.9
mm. The mandible was rotated downward and backward. There was a 3° increase in
mandibular plane angle and an increase in the lower face height. Clinically, there was a
significant improvement in midface esthetics, noted by an increase in fullness of the
infraorbital region and correction of the skeletal discrepancy between the maxillary and
mandibular jaw relationship. Contrary to the reports that use teeth rather than onplants
as anchorage, there was no forward movement of the maxillary molars and minimal
extrusion of the maxillary molars. These results suggest that onplants can be used as an
extremely stable anchorage for maxillary orthopedic facemask treatment
Arlien et al(2005)2 has said that Small osseointegrated implants inserted in the palate
provide a reliable anchorage control during orthodontic treatment. When these implants
are inserted in the median palatal suture in growing individuals, the possible effects on
normal transverse maxillary growth are still unknown. Therefore, the aim of this study
was to evaluate the influence of orthodontic anchorage implants on transverse maxillary
growth when inserted in the median palatal suture of growing dogs. Five growing dogs
were used, one of them randomly selected as a control dog. The test dogs each received
two implants in the median palatal suture. Impressions and occlusal radiographs of the
upper jaws were taken at baseline (T0), after 84 days (T1), and at the end of the study
after 168 days (T2). Measurements to compare increases in maxillary width between
test dogs and control dog were performed on study casts and occlusal radiographs at
T0, T1, and T2. Restricted transverse growth was observed in the test dogs in the
canine region. Transverse growth in the region of second and fourth premolars was
similar for the test dogs and the control dog. These results may be of some clinical
relevance when orthodontic anchorage implants are to be inserted in growing
individuals. An alternative insertion site, for example the parasagittal region, should be
considered in these cases, to avoid possible negative effects on normal transverse
maxillary development.
Dominique et al(2005)93has mentioned that none of the three mandibular anchorage

forms (mandibular premolar banded anchorage, mandibular premolar-molar banded
anchorage and mandibular cast splint anchorage) used in Herbst treatment could
prevent an anchorage loss. Against all expectations, the cast splint anchorage was not
better than the two banded anchorage forms.
BIRTE et al(2005)62 has said that skeletal anchorage is clearly not a replacement for
other proven anchorage systems. Skeletal anchorage should serve merely to expand the
orthodontic services. Skeletal anchorage system has evolved from two lines. One
category originated as osseointegrated dental implants, which have a solid scientific
base of clinical, biomechanical and histologic studies. The other category developed
from surgical mini-implants.
Arzu et al(2005)22 has said that the aim of this study was to evaluate radio graphically
the apical root resorption of maxillary first molars after their intrusion was done using
zygomatic miniplates as skeletal anchorage in open-bite cases. The study group
comprised 16 consecutively treated open-bite cases who had received special titanium
miniplates in their zygomatic bones for use as anchorage to apply orthodontic intrusive
forces to the maxillary posterior region. The control group consisted of 16 patients, who
were matched regarding age, sex, and treatment duration but who had undergone fixed
orthodontic treatment without intrusion mechanics for molars. Tooth lengths were
measured on pretreatment, and post treatment panoramic radiographs of all patients and
mesiobuccal and distobuccal roots of left and right maxillary first molars were
measured on-screen using a software program. The difference between the pre- and
post treatment tooth lengths were defined as apical root resorption. Comparison of the
differences in root resorption of the two groups using the t-test for independent samples
showed a statistically significant difference (P = .004) only for mesial roots on the right
side. But because the mean difference in apical root resorption was only 0.5 mm, it was
concluded that the apical root resorption of maxillary first molars after intrusion was
done using zygomatic skeletal anchorage was not clinically significant.
Karlien et al(2005)35 has said that the insertion of orthodontic anchorage implants in
the median palatal suture in adolescent beagle dogs could cause a restriction of the
normal transverse expansion of the maxilla in the canine region. Whether sutural
growth in beagle dogs is comparable with sutural growth in humans is not proven.
However, it is advised to take safety measurements to avoid possible negative effects
on growth and development, and therefore, it is considered more safe to insert the
orthodontic palatal implants in the paramedian (parasutural) area of the anterior palate,
in growing individuals, to prevent interactions with potential residual intermaxillary
suture growth changes (transverse plane).
Dayse et al(2005)89 has said that Orthodontic techniques with different concepts and
philosophies have emerged to provide adequate anchorage control. The purpose of this
study was to compare the effectiveness of the Bioprogressive and Straight-wire
techniques in the control of lower anchorage. Data were obtained from the records of
40 patients presenting Class I and II malocclusions treated with first bicuspid
extractions. One group of 20 patients was treated with a utility arch used to set up
cortical anchorage in the lower arch and sectional retraction mechanics for space
closure. The second group was treated with straight wire with a preadjusted appliance
system. Treatment evaluation revealed no significant between-group differences in
the amount of skeletal growth relative to cranial base and lower mesial movement of
first molars. Mean lower anchorage loss was 3.1 mm in the Bioprogressive patients and
four mm in the Straight-wire patients. The apical base change was the most important
component to molar correction. Although cortical anchorage did not impede lower
molar movement, it was no less effective in controlling molar movement with a partial
appliance than was the fully banded Straight-wire appliance.
Lars et al(2005)9 has compared the anchorage provided with the Nance appliance (NA)
and the fixed frontal bite plane (FBP) during intra-arch distal molar movement. After a
sample size calculation, 20 patients were recruited and randomly selected for each
group from patients who fulfilled the following criteria: use of an intra-arch Ni-Ti coil
appliance with either NA or FBP to provide anchorage during a six-month molar
distalization period, no orthodontic treatment before molar distalization, and first and
second maxillary molars in occlusion. In both groups, the overbite was significantly
reduced and the overbite was decreased significantly more in the FBP group. Because
neither the NA nor FBP provided stable anchorage, a second treatment phase is
recommended to reverse the anchorage loss after distal molar movement. If molar
distalization is planned in deep bite cases, the FBP is the anchorage system of choice.
Fengshan et al(2005)18 has compared the anchorage effects of different palatal
osseointegrated implants using a finite element analysis. Three types of cylinder
implants (simple implant, step implant, screw implant) were investigated. The results
showed that the palatal implant could significantly reduce von Mises stress in the PDL
(maximum von Mises stress was reduced 24.3–27.7%). The von Mises stress
magnitude in the PDL was almost same in the three models with implants. The stress in
the implant surrounding bone was very low. These results suggested that the implant is
a useful tool for increasing anchorage. Adding a step is useful to lower the stress in the
implant and surrounding bone, but adding a screw to a cylinder implant had little
advantage in increasing the anchorage effect.
HYO-SANG et al (2005)70 has proved that a micro-implant placed in the alveolar bone
buccal to the mandibular second molar can provide both a buccaly directed force and an
intrusive force without any orthodontic applications on the anchorage unit. Other than
the bonded buttons, only a temporary bite plane may be needed to avoid occlusal
contact during mandibular advancement. The clinician should be careful not to rotate
the teeth during correction, however because this force system controls only the mode
and direction of tooth movement.
Ingalill Feldmann;et al(2005)30 has said that two main anchorage situations were
identified: anchorage of molars during space closure after premolar extractions and
anchorage loss in the incisor or premolar region (or both) during molar distalization.
Because of contradictory results and the vast heterogeneity in study methods, the
scientific evidence was too weak to evaluate anchorage efficiency during space closure.
Intraoral molar distalization leads to anchorage loss in various amounts depending on
the choice of distalization unit.
YOUNG-CHEL et al(2005)15 has said that extraction space closure with vaccum-
formed splints and miniscrew anchorage was esthetically acceptable to the patient and
biomechanically effective, minimizing the time needed for visible brackets. The
clinician can control the direction of retraction force by using ever arms embedded in
the acrylic splints, and miniscrews provide skeletal anchorage control. This method can
help overcome the limitations of clear positioners or invisalign appliances in cases
requiring extraction space closure.
ALDO et al(2005)32 has said that the use of a palatal implant for skeletal anchorage
offers three main advantages:1.Osseo intergration ensures the stability of the implant
after loading, so that all the reactive forces are borne by the implant, rather than by any
dental structures.2.The active arms can be directly soldered to steel cap to exert either
vertical or horizontal forces without loss of anchorage. The TMA spings, in contrast to
stainless steel cantilever springs, exert a gradual and effective force and can be easily
reactivated if necessary.3. No special co operation is required from the patient. This is
particularly useful in the treatment of impacted canines which is often lengthy.
Fariba et al(2005)5 has said that 1.Both the VAST(variable anchorage straight wire
arch technique) and the SW(straight wire technique) technique seemed to produce equal
treatment results.2.In hands of one experienced orthodontist, the VAST required no
extra oral traction and fewer scheduled appointments than the SW technique.
Lie-hui et al(2005)46 has mentioned that dental implants have become predictable and
reliable adjuncts for oral rehabilitation. Osseointegration can be used to provide rigid
orthodontic or orthopaedic anchorage. Although initial results are encouraging, the
risks and benefits must be thoroughly evaluated.
Gallas et al(2005)33 has said that Endosseous oral implants have been used as
orthodontic anchorage in subjects with multiple tooth agenesis and their application
under orthodontic loading has been demonstrated clinically and experimentally. The
aim of this investigation was to three-dimensional(3D bone) and implant finite
element(FE) models. The first model model assumed that there was no osseointegration
and the second that full osseointegration has occurred. These models were used to
determine the pattern distribution of stresses within the ITI-bonefit endosseous implant
and its supporting tissues when used as a orthodontic anchorage unit. The study
examined a threaded implant placed in an edentulous segment of human mandible with
cortical and cancellous bone.
Mommaerts et al(2005)56 has mentioned about complications leading to ,or possibly

leading to treatment failure, related to the use of the orthodontic bone anchor.(OBA).
The OBA is a potential means of providing absolute anchorage and consists of a base-
plate fixed with mono-cortical screws, a neck piercing the soft tissues and a coronal
part with conventional orthodontic hooks, tubes or slots. Because of its unique design,
the OBA can be loaded at the level when indicated. It can be placed at any site at the
circumferences of the jaws, given a good quality and thickness of the bony wall.
James et al(2005)38 has said that The term “temporary anchorage device” refers to all
variations of implants, screws, pins and onplants that are placed specifically for the
purpose of providing orthodontic anchorage and are removed upon completion of
biomechanical therapy. Although there was no general agreement on one term to be
used, it was noted that “mini-implant” is more appropriate than micro-implant from the
perspective of scientific nomenclature. The shape and design of these devices would
make “screw” an appropriate name, but to avoid negative connotations, the group
favored words such as “pin”, “implant” or “device.”
Tomohiro et al(2006)27 has said that because the number of adult patients seeking
orthodontic treatment is increasing, orthodontists are becoming more likely to
encounter patients with adult periodontitis. However, it is sometimes difficult to
establish anchorage because of poor periodontal tissues in patients with adult
periodontitis. Skeletal anchorage is useful for retraction and intrusion of upper incisors
in cases of maxillary protrusion with severe adult periodontitis.
Fengshan Chen et al(2006)18 has said that the Palatal implants can be used with a
transpalatal arch (TPA) connected with the second premolar to provide anchorage. He
has compared the anchorage effects of an osseo integrated palatal implant (OPI) with a
non osseointegrated palatal implant (NOPI), using finite element analysis. The NOPI
showed almost the same anchorage effect as OPI. The stress on the NOPI surface was
higher than that on the OPI surface, but the stress was not high enough to result in
failure of the implant. These results suggested that waiting for osseointegration might
be unnecessary for an orthodontic implant.
MARIE et al(2006)3 has said that the biomechanics involved in skeletal anchorage are
slightly different from those in conventional sliding mechanics because of the absence
of some reactive forces. The reliability of this absolute anchorage improves treatment
efficiency and reduce treatment time, which largely compensates for the discomfort and
cost associated with the placement and removal of the bone anchors. Furthermore in
class II cases treated with premolar extractions, skeletal anchorage reduces need for
extra oral devices and other auxillaries such as Nance appliances and class II elastics,
thus improving both patient comfort and patient compliance.
HUGO et al(2006)26 has said that the conventional non extraction treatment of class II
cases depends greatly on patient compliance, especially when extra oral anchorage is
needed. Skeletal anchorage with a modified miniplate as described in this series has
proven to be a stable alternative, even after long-term loading. Depending on the
severity of the initial class II malocclusion, it takes six to nine months to distalize both
molars into a class I relationship. Because the premolar and canine occlusion is also
improved and the overjet is usually reduced during this stage the over all result is a
marked reduction in time. In addition this approach will further reduce the need for
premolar extractions to correct class II malocclusions or to eliminate severe anterior
crowding.
CANDAN et al(2006)66 has done a study to compare the effect of 2 mandibular

anchorage systems used with a 3-dimensional bimetric maxillary distalizing arch. The
Wilson rapid molar distalization appliance for class II molar correction was used with
26 patients.1st group (9girls,4boys) mandibular anchorage gained by modified bumper
with a standard lingual arch.2nd.(7girls,6boys)by utility arch, with a 3-dimensional
lingual arch for anchorage. At the end of the treatment, a class I molar relationship was
obtained. Both anchor units similarly enhanced mandibular first molar anchorage. The
increase in the mandibular occlusal plane was found to be statistically significant
extrusion of the mandibular first molars. The incisors protruded and proclined more in
the utility arch group than in the lip bumper group; therefore the mandibular incisor
anchorage control seemed to be inadequate, especially in the utility arch group.
Nejat erverdi et al(2006)25 has said that the use of zygomatic anchorage enables en
masse impaction of the posterior segment without any side effects such as labial flaring.
zygomatic anchorage can be used effectively for molar intrusion and anchorage
maintenance. However, further clinical studies with larger samples are required to
confirm its effectiveness.
Beyza et al(2006)42 said that Multipurpose titanium miniplates were placed on the
lateral nasal wall of the maxilla as anchorage for face mask protraction in an 11-year-
old girl presenting with severe maxillary hypoplasia and hypodontia. Applying
orthopedic forces directly to the maxilla resulted in an eight mm maxillary
advancement. Intra osseous titanium screws were also placed on the palatal bone, near
the alveolar crests, to provide anchorage for the expansion appliance. The maxilla was
expanded from the median palatal suture, and seven mm of expansion was achieved
across the buccal segments. No other tooth support was used for the expansion or the
protraction of the maxilla.
Silvia geron et al(2006)37 has said that the anchorage provision and management in
lingual orthodontics requires special consideration. The anchorage strategy using the
mechanics and principles described in “six anchorage keys” proves the tools for
treating moderate, severe and multilated malocclusions. Good anchorage control can be
achieved with lingual orthodontic sliding mechanics when following simple anchorage
principles. Cases presenting with difficult anchorage situations and with unusual
extraction sites can be treated successfully with this technique.
RECENT ADVANCES
MINI SCREW IMPLANTS
The material generally used for miniscrews is medical grade 4 or 5 titanium,
although stainless steel has been proposed as an alternative. Recent histological studies
in animals have shown that the osseointegration of titanium miniscrews is less than half
of conventional dental implants. There was no significant difference in the bone
surrounding the minisrew sites whether the minisrews were loaded or unloaded with
force. The presence of more compact bone in the mandible may account for some
differences in miniscrew performance found between the maxillary and mandibular
arches. Incomplete osseointergrations represents a distinct advantage in orthodontic
applications, allowing for effective anchorage with easy insertion and removal. The
mini screw material and the specific design of the self tapping portion are still
important, however in determining resistance to breakage. Even though orthodontic
forces are not normally great enough to break the screws, the rotational forces
associated with placement and removal can cause mini screw failure, especially if the
bone consistency is high or partial intergration occurred. Differences among various
mini screw head designs have also been noted with regard to soft tissue healing.
Miniscrew design
The conical screws used in the miniscrew anchorage system (MAS) name of
medical grade 5 titanium are available in three sizes.
1. Type A has diameter of 1.3mm at the top of the neck and 1.1 mm at the
tip.11mm long
2. Type B has a 1.5mm in diameter at the neck and 1.3mm at the tip.11mm long
3. Type C 9mm long has a diameter of 1.5mm at the neck and 1.3m at the tip.
The screw head consist of two fused spheres (upper 2.2mm in diameter the lower
2mm) with an internal hexagon for the placement of the screw driver. A .6mm
horizontal slot at the junction of the two spheres allows for the attachment of the
elastics, chains, coil springs, ligature wires or auxillary hooks.
Placement sites
Miniscrews are used in place of traditional appliances such as headgear and lingual
arches in cases where absolute anchorage is necessary. From a biomechanical
standpoint, mini screws allow more bodily tooth movement during space closure by
placing the force vectors closer to the center of resistance of the teeth.
The sites most often utilized for MAS insertion the maxilla include:
1. Inter radicular spaces, both buccal and lingual.
2. Extraction spaces.
3. Inferior surface of the anterior nasal spine.
In the mandible the most common mini screw placement sites are
4. Inter radicular spaces, both buccal and lingual
5. Lateral to the mentalis symphosis.
Orthodontic treatment using a skeletal anchorage system not only more
effective but offers a variety of treatment alternatives in challenging cases where
traditional mechanics cannot be used.
Advantages of mini screw over other forms of anchorage include:
1. Optimal use of traction forces regardless of the number or positions of the teeth.
2. Applicability at any stage of development including interceptive therapy is
shorter treatment time with no need to prepare dental anchorage.
3. Independence of patient co operation
4. Patient comfort
5. Low cost.
6. Of course there are potential complications common to all implant procedures
including damage to anatomic structures such as nerves, vessels, and roots.
Screw can be lost during placement or loading breakage of a screw within the
bone during insertion or removal.
Inflammation can occur around implant sites.
Further more MAS offers several advantage compared to more invasive osseointegrated
systems.
 Increased selection of insertion sites
 Ease of insertion and removal
 Ability to withstand immediate loading
 Applicability in growing patients
 Low cost
TEMPORARY ANCHORAGE DEVICES
The term temporary anchorage device refers to all variations of
implants ,screws, pins, and onplants that are all placed specifically for the purpose of
providing orthodontic anchorage and are removed upon completion of biomechanical
therapy.
INDICATIONS
Two major areas for use of TAD were discussed
1. Correction of skeletal discrepancies
2. Correction of dental discrepancies.
In the first category clinical uses were shown were TAD were TAD were used
to assist in the correction antero posterior and vertical discrepancies. In one case TAD
were used for direct intermaxillary fixation following orthognathic surgery. A common
concern however was the stability of skeletal correction produced by TADs. Surgery
more likely to change neuro muscular imbalances which may need lead to a more stable
correction, but its superiority over TADs has not been demonstrated. Although several
cases of long term success (more than two years) with TADs have been reported, the
group called for more long-term stability studies.
Application of TADs is in the correction of dental discrepancies were shown for
antero posterior tooth movements, molar uprighting, and intrusion or extrusion of single
and multiple teeth. In most cases TADs were used to supplement dental anchorage. In
some however they were used as the sole source of the anchorage.
Overall the group believed that there are many possible indications and
applications for TADs and that they can serve as an invaluable component of the
orthodontic armamentarium. It was also noted that biomechanics need to be designed to
optimize the use of TADs.
Some participants voiced skepticism about placing these devices in young
growing patient The consensus was that use in a growing patient would not necessarily
be contra indicated, but that studies on this topic would be important in broadening the
scope of usage of TADs.
Design
There was a solid consensus on the design of TADs. A diameter of 1.2mm-2mm
seemed to be adequate , although some manufactures refer to the core diameter of the
implant without threads, while others include threads in their measurement. The major
concern with devices of core diameter smaller than 1.2mm was breakage. A call was
issued for slightly larger-diameter “emergency” implants that could be used in
situations where a good mechanical interlocking does not occur with the threads of the
planned implants.
The currently available lengths –generally about 6mm,9mm, and 12mm-were
considered suitable for most situations.. A tapering conical design was preferred over a
straight screw.
The group favored a head design with an .022”slot for connection to the arch
wire. There was also a preference for design that could be used for retention by
stabilizing the archwire with light cured composite. Another popular configuration was
the O-ball head, with a retentive cap for rapid attachment and suppression of the soft
tissue(particularly the mobile alveolar mucosa). It was believed that these head systems
allow for good hygiene and stability, two important factors in the success of TADs.
The group agreed that skeletal anchorage devices should have smooth , polished
surfaces. This is important both at the collar , to minimize irritation and inflammation
of the gingival mucosa and on the threads to prevent osseointergration and allow easy
removal.
FAILURES AND COMPLICATIONS

Early reports on the success of TADs ranged from 60-85% , although some
researchers included all failures during the development and prototyping of various
designs and refinements of their procedures. Recent reports, using the latest TAD
designs and placement techniques, have shown dramatically higher success rates. Still it
was noted that TADs seem to be more successful in the maxilla than in the mandible
and in adults than children.
The major complications discussed were breakage and damage to adjacent tooth
roots. It seems that recent designs and proper placement techniques have made device
breakage a problem of the past. If a TAD does break, the group recommended
removing it with a root-tip plier and leaving deeply embedded fragements in place.
Minor root damage can heal with little consequence. It was noted however, that
relatively few reports on this topic, the teeth were not moved subsequent to root
damage, and that additional movement could exacerbate the situation. Another possible
complication would be the movement of the teeth into a TAD.
MINI IMPLANTS WHERE ARE WE…..?(CHANGING CONCEPTS)

EVALUATION OF SKELETAL ANCHORAGE
Skeletal anchorage systems have evolved from two lines. One category
originated as osseo intergrated dental implants, which have a solid scientific base of
clinical , biomechanical , and histologic studies. The orthodontic mini-implants were
smaller than the dental implants, but their surfaces were treated in the same way.
Included this category are the retromolar implants described by Roberts and collegues
and the palatal implant introduced by wehrbein and merz. Both are used for indirect
anchorage , meaning they are connected to teeth that serve as the anchorage meaning
they are connected to teeth that serve as the anchorage units.
The other category developed from surgical mini-implants . creek more and
eklund inserted such device below nasal cavity in 1983, but it was not until 1997 that
kanomi described mini-implants specifically designed for orthodontic use. Both of
these were used as a direct anchorage. The following year costa and colleague
described a screw with a special bracket-like head that could be used for either direct or
indirect anchorage system. In contrast to the osseo intergrated implants , these devices
are smaller in diameter have smooth surfaces and are designed to be loaded shortly
after insertion.
Few of surgical miniscrews have been subjected to systematic studies analyzing
the tissue reaction to loading. Aarhus mini- implants were placed in monkeys and
immediately loaded with 25-50cN of force by melsen and collagues. Titanium screws
were inserted in dogs and loaded after six weeks with 150g coil springs by phmae and
colleagues. Deguchi and colleagues also loaded titanium screws in dogs after three
weeks with 200-300g elastomeric chains. All three studies confirmed that mini-
implants loaded immediately or shortely after placement can be successfully used for
anchorage.
INDICATIONS
Precise indication for the skeletal anchorage is not well documented. Most of
the published articles have been case reports in which new devices have been described
as alternative to other anchorage methods- for example in extraction cases using
implants instead of head gear .
LEIBINGER SKELETAL ANCHORAGE PLATES
The Leibinger Micro Implants Universal Skeletal Anchorage System is intended

to be placed in the mouth for use as an anchor in orthodontic procedures. The system
encompasses three different styles of implants to give a comprehensive selection when
facilitating tooth movement. Additional range of adaptability - allows to place away
from tooth roots & attain difficult angles.
RMO DUAL TOP ANCHOR SYSTEM
RMO’s Dual-Top Anchor System enhances treatment capabilities. Treatment is faster,
more precise, and efficient with the Dual-Top Anchor System. RMO’s Dual Top
Anchor System is recently FDA approved. The mini-orthodontic implants are radically
changing and improving orthodontic treatment according to recent journal articles.
These screws can hold wires where teeth are missing or where movement requires
headgear. The RMO Dual Top mini screws are simply removed after the teeth are
moved.
TOMAS (TEMPORARYORTHODONTIC MICRO ANCHORAGE

SYSTEM)
Tomas (temporary orthodontic micro anchorage system) is a new concept for temporary
skeletal anchorage in orthodontic treatment, e.g. for active tooth movement or passive
stabilization. Its special design, as well as the complete product range and
comprehensive service make tomas® the premium modern system. This is a patient
friendly temporary orthodontic anchorage system. Anchorage is independent from
teeth; Distalization (especially lower molars), Mesialization and Intrusion; extraction-
free treatment.
DISCUSSION
“ANCHORAGE is resistance to unwanted tooth movement”75- PROFFIT
Pierre Fauchard in 1728 described the first fixed appliance, the bandellate
appliance which used the principle of reciprocal anchorage. A century later, occipital
anchorage was introduced by Kingsley in 1866. The demands on anchorage became
greater as more refinements in force control were developed. As the search for better
anchorage developed, it became apparent that more control was required over the
individual dental units. As a result, Angle, expanding on this thesis, developed the pin
and tube appliance and then the ribbon arch to afford greater mechanical advantages.
This was an aftermath of the use of intermaxillary force which required all of the teeth
to be resistance factors or anchorage units in the arches.
The edgewise appliance, as first described by Angle in 1927, was designated as

the "latest and best" of the time. Even today the many possibilities afforded by it are
just being realized. However, the pendulum swings and modern orthodontics is again
applying some of the so-called simple anchorage devices very successfully in the
treatment of many types of malocclusion. They become aware of the many problems
that have developed because of anchorage inadequacy and many men have advised the
use of auxiliaries such as muscular, tissue borne and occipital supports.
An excellent review of the anchorage problem was published by Earle

Renfroes, who analyzed the resistance factors of all the known sources of anchorage –
the teeth, bone, musculature and extra oral areas. He stresses the application of some of
the early principles advocated by Angle, Case, Dewey, McCoy, and others. He had
analyzed the efficiency of the several auxiliaries as anchorage mechanisms.
The force exerted by the edgewise mechanism, as it was originally intended by

Dr. Angle, involved the principle of short reciprocal levers directed from each tooth
through the arch to its adjacent tooth on either side. The use of prepared mandibular
anchorage has some decided advantages in the correction of certain Class II
discrepancies and bimaxillary protrusion cases. For instance, it reduces distortion of the
occlusal plane. It is very effective in minimizing overbite problems; it permits control
in positioning of the lower anterior teeth during treatment and minimizes total arch
displacement. It effectively offers additional anchorage for bodily retraction of the
maxillary incisors. It also seems to be followed in some cases with mandibular growth
and in others offers resistance factors which permit the maxillary base to change. On
the negative side it is a complicated technique.
Much has been written about the effect of occipital and cervical forces as
sources of anchorage during treatment. The present day application of occipital
anchorage was advocated by Kloehn. Nelson and others had demonstrated the positive
effect of such force on the development of the dentition. There are many refinements of
application of this force which have specific advantages. Occipital force may be
directed to the arch wire by a hook in the canine area. The direction of pull can be
controlled to exert distal traction along the line of the arch or even in an upward
direction. The disadvantage of the downward pull of cervical anchorage when directed
to the anterior section of the maxillary canine area results in an elongation of the
anterior teeth and deep overbite problems at the termination of treatment.
In addition to being used as an active force in the movement of teeth or as a

device in the control of growth, occipital anchorage has much other anchorage
possibilities in modern orthodontics. There is the currently popular method of
reinforcing the existing anchorage by extra oral means. The headgear is used in the
mandibular arch to reinforce the Class II mechanics. It may be directed against the
lower molar teeth by means of a bow and Fischer attachment to the archwire in the
molar area or through the use of additional round tubes on the upper molars. The
headgear can be used as an added anchorage factor in space closure when moving
canines. The use of occipital force by itself in selected cases can eliminate the
complicated mechanics of anchorage preparation. The disadvantage of this is that it
may take longer; its effect varies considerably in different patients and is especially
difficult in those cases where cooperation is a problem. The use of anchorage units
outside the mouth certainly has an advantage in some hands over a poorly manipulated
and improperly prepared anchorage arch. However, in using this technique one must
recognize the limitations imposed by such technique.
There are many problems created through improper use or attention to

anchorage control. Many experienced excessive tipping of buccal segments and
undesirable labial inclination of mandibular incisors when injudicious application of
elastic force was applied. Lack of attention to the rotations during treatment creates the
problem of correction at the end of treatment. Care must be taken to avoid such
conditions, for they become a tax on the anchorage units. For instance, correction of a
rotated anterior tooth with a removable lever is usually quite simple. However a highly
resistant rotation or several highly resistant rotations may tend to exert an undesirable
effect on the anchor arch, especially when the arch is also being used for the correction
of Class II or Class III problems. In extraction cases there is the problem of root
paralleling. Correction of this tipping problem will eliminate taxation on anchor areas
and substantially reduce treatment time. Many a well-treated case has been ruined by
loss of anchorage in the correction of minor irregularities. Proper appliance
manipulation could have avoided these troubles in the first place. Whenever the
mechanics are such that undesirable anchorage responses are created, then one must
reinforce anchorage or change mechanics in such a manner as to prevent or eliminate
the unwanted tooth movements.
The reduction of natural anchorage values in the opposing arch is also

important. In Class II cases one must accept the fact there will probably be migration of
the buccal segments. This may be desirable in certain cases. If the mechanics are such
that there is maximum response and the case ends with a stable denture with desirable
improvement in facial form, then it has properly applied the modern concept of
anchorage.
The timing of force application within favorable growth periods is undoubtedly
a major factor in the success of a given technique. Proper timing of treatment will
reduce the strain on anchorage. This necessarily implies that treatment be instituted
during a period of active growth. Dr.Angle's contention that the reciprocal effect of
intermaxillary force had considerable benefits in both arches seems even more valid
today. Through the years certain undesirable effects of inter maxillary elastics have
shown up. The use of anchorage preparation tends to minimize these effects and
increase the treatment potential of many cases. Recognition must be made, however, of
exceptions in very severe growth patterns. Little benefit will result if anchorage is
prepared in cases represented by exceptionally steep mandibular planes coupled with
the exceptionally large A-N-B angular relationships. Compromises in treatment must be
made in such cases. During treatment if it is found that the existing anchorage is not
sufficient, occipital or cervical forces can reinforce this anchorage. Such procedure may
be used in non-extraction Class II cases or in Class II, Division 2 arch length cases
where additional arch or loss of arch length will upset treatment. Reinforcement of the
existing anchorage with intermaxillary elastics to prevent the buccal segments from
being carried forward when using vertical loop sections to retract the canines or the
maxillary incisors is possible.
There are other devices that may be used to reinforce existing anchorage. The
soldered lingual arch and the removable lingual arch or palatal plates with finger
springs are helpful in space closures. Extra oral anchorage may by itself be used as the
motivating force in the correction of selected cases. If used wisely with proper
cooperation in many cases, much satisfaction is derived in reducing the severity of the
malocclusion.
In consideration of the entire problem of present day concepts of anchorage, the

selection of the method of anchorage control in the future will depend upon information
derived from the study of treated cases with selected types of mechanics and a
comparison of the end results in terms of facial balance, stability, and ease of
manipulation. Dr.Angle recommended the distal tipping of the lower molars. As a
central project of orthodontic treatment, he proposed the expansion of the dental arches
with a view towards conserving the number of teeth with which nature had endowed
the patient. By reviewing the first technique that appeared after the one described by
Angle and which introduced a fundamental concept with respect to anchorage and it
preparation is Tweed technique. This technique had a great impact on all those
followed and has influenced them until the present day. The anchorage requirement
depends upon the number of teeth to be moved depends on the greater number of teeth
being moved greater the anchorage demand, the type of teeth being moved are with
large flat roots and more than one root exert more load on the anchor teeth, type of
tooth movement moving teeth bodily requires more force as compared to tipping the
same teeth.
In the Begg’s appliance the upper and lower archwires have anchorage bends.
By using this archwire, the molars tip back more and anterior teeth are less depressed.
The purpose of the anchor bend is, as the name suggests to provide anchorage to the
molar teeth. This is due to the fact that the molars are tipped distally and resist anterior
movement. If too much anchorage bend is given in the 0.016” archwire it causes
greater tip back force exerted on anchor molars. It reduces the anchorage value and
causes sinking back of mesial marginal ridges and relapse occurs. The anchorage bend
helps to bestow upon the anchor molars, the power to resist the forward pull of class II
intermaxillary elastics. And helps to activate the archwires so that they depress the
upper and lower anterior teeth in their socket in order to open up deep anterior overbite.
But according to Dr. D.L. Kesling, it is misnomer, it was called as tip back bend in past.
He gave the name anchorage bend or bite opening bent. Begg’s appliance uses
differential force technique (controlled tipping followed by root uprighting) which
helps to reduce anchorage requirements compared bodily movement in pre-adjusted
edgewise appliance which requires more anchorage.
The Begg’s appliance offers an economy in the use of intra oral anchorage,
because it uses simple tipping mechanics. Tipping movements can be achieved by light
forces. When the time comes to correct the axial inclinations of the tilted units, the
forces employed often partially counterbalance one another. When this not the case or
only partly true, the reciprocal forces from the root movement auxillaries are born by
the dental arch as a unit, not by a section of the dental arch. The art of handling
orthodontic anchorage is the capacity to judge total tooth movement response from the
force promoted at any one time and the resistance given by the passively held units so
that, by suitable appliance adjustment, the balance movement favors treatment
objectives. By the reason of its economic use of intra-oral anchorage, the Beggs
appliance rarely needs extra-oral support, unless mistakes and misjudgments have taken
place. If headgear should become necessary, high or straight pull can be applied either
to the front or, if suitable precaution is taken, the posterior of the arch.
The anchorage considerations are very important in straight wire technique as it

uses bodily movements instead of tipping movement in Begg’s. Bodily movements
always needs more amount of forces than tipping. The straight wire technique always
adds comfort than Begg’s appliance. The anchorage can be reinforced by transpalatal
arch, nance palatal arch, lower lingual arch, implants and by extra oral forces such as
head gears. Anchors are seen in straight wire technique. The horizontal bracket slot of
the edgewise appliance can provide full axial control. If the forces employed with
edgewise mechanics becomes excessive, anchorage may be lost; but at least the axial
control of the bracket slot will prevent sudden detrimental tilting. The rate of anchorage
loss will be relatively slow, giving the operator the opportunity to intervene before the
situation becomes out of hand. The bodily control balance of anchorage in edgewise
technique consume intra-oral anchorage rather readily, as a result of which extra-oral
support from the headgear usually has to be called upon. Such a form of anchorage is
virtually inexhaustible. These factors make edgewise mechanics safer than Beggs in the
hands those whose appreciation of intra-oral anchorage has not yet been sufficiently
developed.
The various methods of anchorage preparations which is done in the pre-

adjusted appliance include banding of second molars, transpalatal, lingual and Nance
arches, individual canine retraction, use of frictionless mechanics for retraction, cortical
anchorage, intermaxillary elastics, extraoral force, implants, etc.
Different types implants used for anchorage are miniscrew implants, micro
implants, spider screw implants, endosseous implants, c-orthodontic implants,
transitional implants. The proper bone support is mandatory for implants. Anchor loss
is 0 to 1mm in implants. If posteriors are lost and anteriors are to be aligned, the
anchorage can be gained through implants. But implants cannot be afforded by every
patient as it is expensive.
The most important consideration when it comes to anchorage is that it should
be planned well ahead of the commencement of treatment and should be an integral
part of treatment planning, as the old adage goes “ a stitch in time saves nine”. This
simple step will ensure the realization of the pretreatment goals.
SUMMARY & CONCLUSION
Anchorage should be of prime consideration before the treatment plan is
formulated. The skeletal and dental anchorage should be judiciously planned for a
better finish and complete success in orthodontic therapy. Anchorage plays a prominent
role in utilization of extraction spaces, use of head gears, retraction mechanics ,etc
Derivation of anchorage and the number of units in the anchorage is the key to
successful anchorage management.
Anchorage loss is a potential problem in orthodontics. However many recent
advancements in the field of anchorage such as implants, zygomatic ligatures are
available.
To conclude we will summarize briefly what we consider the so called modern
concept of anchorage. It involves the use of existing anchorage, prepared anchorage,
and reinforced anchorage. Proper diagnosis through recognition of anchorage
availability must be made for better finishing of the case.
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CONTENTS

VI.SUMMARY & CONCLUSION 87

Attainment and control of anchorage is fundamental and critical in orthodontic

I.ACCORDING TO THE MANNER OF FORCE APPLICATION

II.ACCORDING TO THE JAWS INVOLOVED

III.ACCORDING TO SITE OF ANCHORAGE

Muscular : Anchorage derived from action of muscles e.g.: vestibular shields

IV. ACCORDING TO NUMBER OF ANCHORAGE UNITS

V.ACCORDING TO ANCHORAGE LOSS PERMISSABLE

VI.ACCORDING TO SOURCE OF ANCHORAGE

INTRA ORAL SOURCES

METHODS OF CONSERVING ANCHORAGE

NANCE HOLDING ARCH

LOWER LINGUAL HOLDING ARCH

A TIP EDGE APPLIANCE (ACCORDING TO DIFFERENTIAL STRAIGHT ARCH

ANCHORAGE IN FUNCTIONAL APPLIANCES

2. If decidous molars are present, it is used as anchor teeth.

Anchorage system in fixed twin block

EXTRA ORAL METHOD OF ANCHORAGE

HIGH PULL STRAIGHT PULL CERVICAL PULL

ROTH CONCEPT OF ANCHORAGE

Leveling and alignment:initially leveling and alignment procedure attempted on a

MBT CONCEPT OF ANCHORAGE (McLAUGHLIN, BENNET,

Control of anchorage in upper posterior segments

CLASS III ELASTICS

LOWER LINGUAL ARCH

Control of anchorage in vertical plane

Vertical control of incisors:

Vertical control of canines:

ANCHORAGE CONTROL IN RICKETTS BIOPROGRESSIVE THERAPY

Lower molar anchorage:

METHODS OF OBTAINING SKELETAL ANCHORAGE

Implant head Threads in the Implant body

SITES FOR IMPLANT PLACEMENT

SELECTING THE SITE FOR INSERTION OF AN IMPLANT

APPLICATIONS OF IMPLANTS IN ORTHODONTICS

Takemoto suggested anchorage value of posterior teeth in the lingual technique

CHESTER et al (1939)92.considered anchorage as a biological problem, with bone as

CHARLES et al(1941)52 said that there is a place for occipital anchorage as an

ALLAN et at (1948)10 mentioned that Oppenheim advocated the use of extra-oral

WALDO et al(1955)88said that Definite improvement can be accomplished in the

L. B. Higley et al(1969)41 said that Anchorage is an important consideration in

TURLEY et al(1988)74 has said that Orthodontic anchorage is usually achieved by

Takayoshi Daimaruya et al(2001)29The skeletal anchorage system (SAS) was

Monica et al (2001)90Endosseous implants have been used as orthodontic anchorage in

Giuliano (2002)59 described the two-piece osseointegrated orthodontic anchorage

Masayoshi et al(2004)48 has said in that a lingual orthodontic technique enables an

Hidetake et al(2004)67has described that the orthodontic treatment of a 19-year-old

Dominique et al(2005)93has mentioned that none of the three mandibular anchorage

Mommaerts et al(2005)56 has mentioned about complications leading to ,or possibly

CANDAN et al(2006)66 has done a study to compare the effect of 2 mandibular

FAILURES AND COMPLICATIONS

MINI IMPLANTS WHERE ARE WE…..?(CHANGING CONCEPTS)

The Leibinger Micro Implants Universal Skeletal Anchorage System is intended

TOMAS (TEMPORARYORTHODONTIC MICRO ANCHORAGE

“ANCHORAGE is resistance to unwanted tooth movement”75- PROFFIT

The edgewise appliance, as first described by Angle in 1927, was designated as

An excellent review of the anchorage problem was published by Earle

The force exerted by the edgewise mechanism, as it was originally intended by

In addition to being used as an active force in the movement of teeth or as a

There are many problems created through improper use or attention to

The reduction of natural anchorage values in the opposing arch is also

In consideration of the entire problem of present day concepts of anchorage, the

The anchorage considerations are very important in straight wire technique as it