Torrell L. Root, D.D.S.

Costa Mesa, Calif.

A new method of treating orthodontic malocclusion has evolved over 27 years of

clinical effort to formulate anchorage requirements, treatment timing sequences, and
treatment control. I have used a punch-card system to evaluate approximately 80
percent of my posttreatment results. Data from 20 patients were selected for
presentation. The subjects all responded well with excellent posttreatment occlusion.
Preorthodontic treatment goals such as cephalometric values, arch form, and function
were achieved to my satisfaction. Average treatment time was longer than that
estimated by only 6.5 percent. The subjects represent a wide variety of orthodontic
problems with extraction and nonextraction choices and provide corroboration for the
proposed efikiency of this method.

Key words: Anchorage, treatment predictability, preformed arches, preadjusted

appliances, orthodontic malocclusions

F unction, stability, and esthetics: these terms encompass the primary clinical
goals of orthodontic treatment. My philosophy is that function is adequate when the jaws
close in hinge relation and the teeth occlude in centric occlusion; when the mandible slides
forward from centric occlusion into protrusion, the anterior teeth function and the
posterior teeth disclude and when the mandible moves into lateral excursion, the canines
function while the posterior teeth disclude. Stability is attained when, after completion of
treatment, the teeth remain in their new position. Esthetic requirements (which are un-
compromisingly subjective) are met when the teeth and facial profile are “pleasing to the
eye of the beholder. ”
All too often these goals are not attained, or, if they are, do not remain permanent. The
causes of failure are manifold and include improper correction of the occlusion (as when
upper and lower teeth are not properly related and centric occlusion does not correspond
with hinge relation), placement of appliances was incomplete or inaccurate (e.g., faulty
positioning of second molars may cause posterior interference when sliding into lateral
excursion), and persistence of a disruptive habit (as when tongue posture opens the bite or
moves the upper denture forward).
Lack of stability may occur when lower anterior teeth are not tipped back far enough
or not brought within the balance of the musculature, when lower canine width has been
expanded, when disruptive habits remain uncorrected, and/or when the occlusion was not
corrected to the degree that allows proper function. Esthetics, if looked upon as a direct
result of proper function and stability, can be said to vary proportionally with these two
rather basic treatment goals.
000%9416/81/100395+16$01.60/0 0 1981 The C. V. Mosby Co. 395
396 Root

Table I. Materials and procedures

-- --- -.-.. -.--.--
Hardware S@vure Pr0t~edurr.r

Arch wires (3 sizes) Arch cards AP/lat photographs

Springs (push-pull) Analysis chart Cephalometric analysis
Brackets and tubes (angulated) Bands and bracket position charts Severity grading scale
Palate bars (4 sizes) Manual* Treatment steps (see text J
Face-bow headgear (high pull) Treatment plan Model impressions
High-pull “J”-hook headgear Treatment procedures, time, and self-check Patient history
Full mouth x-ray tilms
Elastics Diagnostic criteria Diagnosis
Force modules
Models
Boone gauge
X-ray film
Spurs
Crimp-on hooks

*Now being prepared

To be able to consistently achieve these goals is the prime motivation for attempting to
develop, improve, and perfect the level anchorage system (LAS). This becomes clear
when the concept of anchorage is understood; correcting a Class II malocclusion to hinge
relation requires anchorage, as does tipping lower anterior teeth upright. I believe any
orthodontic malocclusion requires anchorage, which is simply a combination of resistance
to movement and distance to move, for successful correction. The amount needed for an
individual patient is quickly and easily determined with the LAS, but this has not always
been so.

Historical perspective
Before the advent of Angle’s edgewise appliance, most orthodontists of his school
used ribbon arch appliances. Lower first molars carried a round tube and lower anteriors
carried a vertical slot attachment for the wire. Anchorage was increased by activating a tip
back on the first molar (which is easy). A ribbon arch was inserted into the anterior slots,
depressing the anteriors (which is difficult) to provide anchorage for distal tipping of the
first molar. With ribbon arch torque control of the lower anterior teeth, screwing back the
anchor molar increased distance and tip and, as a result, anchorage.
Later, Tweed’ thought that Angle’s teachings about expansion were wrong. After
graduating from the Angle school, he treated nearly all his patients without extraction, but
when he observed that most of his treatment results were neither stable nor esthetically
pleasing, he re-treated 80 percent of them. By extracting four first premolars to provide
additional anchorage (space), Tweed successfully completed his treatment of these
patients.
Other precepts Iirst espoused by Tweed gave impetus to emerging techniques and
orthodontic strategies. Among these was the precept of “limitation of the denture” which
assumed that upright lower anterior teeth were in their most stable position and that a
lower denture expanded at the canines was unstable and usually relapsed.
A prominent early strategy was anchorage preparation. As practiced by Tweed, such
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Modified Goal Final

SNA
-SNB
ANB
mmlln
0 front of NA
YT, NA
curve ot
Spee
FMA m.crepancv
0
+io NB -
mm 1 I” front
SN-ML
J of NB -
PO

Fig. 1. Schema for recording cephalometric and model measurements and selecting treatment goals.

REGULAR MAJOR

6”

Fig. 2. Band and bracket placement to provide regular and major anchorage.

preparation used with the standard edgewise appliance required first-order (in-out, hori-
zontal), second-order (tip, vertical) and third-order (torque) bends. These must be in-
creased or duplicated in succeeding arches as treatment progresses. The need for repeated
precision bending challenges and may even discourage many orthodontists. Attempts to
escape these tedious arch bending requirements included Angle’s suggestion2 in 1929 to
angulate brackets and Holdaway’s proposal3 in 1952 to angulate brackets and tubes.
Holdaway angulated maxillary central, lateral, and canine brackets and all mandibular
brackets and tubes. He altered the amount of angulation in the lower buccal segments
depending on severity of the malocclusion. In 1963, Lee4 advocated placing torque in
anterior brackets, while in 1972 Andrews5 recommended an edgewise appliance that
prescribed in and out, tip and torque for all teeth in the denture.
Along with these developments, Steiner6 introduced his cephalometric analysis in
1953. This analysis helped the orthodontist measure severity, determine anchorage re-
quirements, and prescribe an ideal cephalometric end result and yet still allowed him to set
his own treatment goals. Tweed used models to measure arch-length discrepancy, curve of
Spee, and molar relationship. Photographs aided his study of esthetics, and the
Table II. Treatment variables and their control

Variable I How r~ontrolled

Dynamic forces
Retract canines
Coil spring (specific size, length)
Retract upper anterior teeth
Close mandibular extraction space Arch wire (specific size, loop diameter, monthly changes in verti-
cal loop opening)
Arch wires* Three sizes:
Initial: 0.018-inch round nitinol
Working: 0.017 X 0.025 inch nitinol
Anchorage: 0.018 X 0.025 inch high-spring steel
Patient
Habits
Tongue thrust Spurs
Thumb/finger sucking Rugae area spurs
Headgear wear Analysis chart prescribes time
Elastic wear Uniform elastic size and force of tie-on calibrated force modules
Orthodontist Prescribed treatment plan with specific self-check intervals

*Precisely preformed for use in LAS

Table III. Bracket configurations for regular or major anchorage requirements

Tooth First order Second order Third order

1 Medium thick 4” mesial crown 15” labial crown

2 Thick 7” mesial crown 7” labial crown
? Thin 6” mesial crown 0” labial crown
4 Thin 0” 7” lingual crown
5 Thin 0” 7” lingual crown
6 15” 0” 10” lingual crown
I 10” 15” distal crown 10” lingual crown
I Thick 2” mesial crown 0”
5 Thick 2” mesial crown 0”
5 Thin 6” mesial crown 0”
4 Thin 4” distal crown 11” lingual crown

Regular Major

J Thin 4” distal crown 6” distal crown 1 I0 lingual crown (Same as 17” lingual
crown because of low fit)
6 10” 6” distal crown 10” distal crown 22” lingual crown
5 10” 10” distal crown 15” distal crown 25“ lingual crown

cephalometric triangle was used to determine space required to upright lower anteriors. To
help establish anchorage requirements to correct the denture bases, he used the ANB angle
and increased anchorage needs according to the severity of the malocclusion.
Mindful of these events, I began using the angulated appliances of Holdaway in 1954
and, since that time, have recorded complete before- and after-treatment data on about 80
percent of my patients. These data include precise timing of treatment steps. Also in-
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REGULAR

MAJOR

Fig. 3. Marginal ridge integrity with (A) regular and (B) major anchorage.

eluded is the anchorage needed to reduce ANB angle, correct Class II molar relationships,
close extraction space, and level the curve of Spee. Measurements were made of space
closure using calibrated coil springs on edgewise nitinol wire or polished edgewise steel
arches. When Class III elastics were used, the amount of distal tip (anchorage space
gained) was noted.
In 1975 I began using a completely preadjusted appliance, varying the amount of
angulation in the buccal segment by severity of the malocclusion. A generalized, step-
by-step treatment procedure has emerged from 27 years of investigation and clinical
experience. The data base has enabled formulation of an analysis and treatment plan chart.
Using it permits more accurate timing of each step in therapy and more treatment control
by means of periodic self-checks. This is what I call the “level anchorage system. ” When
its precepts are scrupulously followed, it is believed that predictability of response is
greatly enhanced.
Table IV. Key treatment variables before and after orthodontic treatment

Variable Range .r Final rrsull

Spee curve (mm.) 0 to 3 I .9 0

Discrepancy (mm.) 0 to 9 3.2.5 0
Upright IJ (mm.) 2to12 4. I Reached goal (14)
0.5 mm. > upright than goal (4)
I mm. > upright than goal (1)
I mm. < upright than goal (1)

ANB (degrees) 2to10 s.3 0 to 3 I .65

FMA (degrees) 17to35 26.95 16to35 25.9

Table V. Preselected treatment goals based on analysis of orthodontic malocclusion

No. of patients I Treatment goals I Type of goal

Ideal

Modified

Acceptable

Table VI. Actual vs. predicted time in months (X values) for each prescribed
treatment step
Treatment s!eps

Time (months) I 2 3 4 5 6 7

Predicted 5.6 3.0 3.4 3.2 2.8 6.2 3.0

Actual 7.3 3.2 2.x 3.3 2.8 6.1 3.6

Materials and methods

Basic diagnostic criteria for optimal results are few. The patient should be growing,
have 28 teeth present (or second molars nearing eruption, excluding third molars). The
ANB angle can vary within a range of zero to 10 degrees, the SN-mandibtk angle
between 25 and 42 degrees, and the FMA angle between 17 and 35 degrees. The patients
selected for discussion here met these criteria; they included both those requiring and not
requiring extraction and exemplified the spectrum of orthodontic problems met in practice.
Severity of the orthodontic malocclusion was arbitrarily quantified on a scale of 1 to 30
to facilitate analysis and presentation of the data. The scale comprises the sum of a
singular datum from each of seven variables: depth of the curve of Spee, lower arch
discrepancy, space needed to upright lower anteriors, anchorage loss during retraction of
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.*

1 I I ,
IO 20 30
X
INITIAL SEVERITY
Fl@. 4. Initial malocclusion severity vs. actual months of treatment. (See text for method of severity
calculation.) Very high correlation was seen for this small number of patients (0.6690) so that it is 95
percent certain that predicted treatment duration will be accurate within k7 months. ‘Atypical patient;
extremely cooperative.

lower canines and anterior teeth, anchorage needed to correct the ANB angle, anchorage
needed to retract upper anterior teeth in an extraction case, and addition of 1 to the scale if
the mandibular plane angle is 8 degrees above normal.
Patients examined here included twelve males and eight females, all Caucasian with
an +ge range from about 11 to 16 years old (average 13.4). Thirteen patients had four first
premolar extractions, two had upper second and lower first premolar extractions, and one
had upper first and lower second premolar extractions; four were treated without premolar
extraction.
Materials and procedures used (Table I) were those generally available. Some
software (i.e., analysis chart, treatment plan, etc.) was peculiar to this systematic treat-
ment approach, as were some of the procedures. (These are too lengthy and detailed to
include here and are being prepared for separate publication.) To make cephalometric
402 Root

Fig. 5A. Patient K. 0. (four first premolar extraction) before treatment

Fig. 58. Cephalometric tracing for patient K. 0. before treatment.

 Level anchorage system 403

Fig. 5C. Model of patient K. 0.‘~ occlusion before treatment.

Fig. 5D. Patient K. 0. after treatment.

tracings the anterior cranial base was used for superpositioning. The original SN angle
was drawn on progress tracings for follow-up evaluations. Standard measurements were
made of SNA, SNB, ANB, FMA, and SN mandibular angles; long axes of upper and
lower incisors were specified by degree of angulation to NA and NB, respectively, and
anteriority (in millimeters) between these lines and the most prominent aspects of these
teeth.
Tooth crowding or spacing in the lower arch were determined with models. The curve
of Spee was measured from occlusal surface of the lowest premolar to a plane between the
lower anterior teeth and the buccal groove of mandibular second molars. Examination of
 I
j/
-\. ,.<2q”: ,’
h., ,’
_’

,’

Fig. 5E. Cephalometric tracing for patient K. 0. after treatment

anterior bite usually revealed evidence of habits such as tongue thrust or thumb sucking.
These observations coupled with an adequate history yielded important information about
physical or behavioral disorders such as airway obstruction, disease or surgical removal of
tonsils and adenoids, harmful sleeping postures, congenital growth deficits, allergies, or
past dental problems.
Data from the above measurements and observations were placed on a special analysis
chart* to identify the orthodontic problem and anchorage needed to correct it.
*Send self-addressed stamped envelope to Terre11 L. Root, D.D.S., 1879 Newport Blvd., Costa Mesa, Calif.
92627. for more details.
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Fig. 5F. Model of patient K. 0.3 occlusion after treatment.

Fig. 6A. Patient P. Y. (four first premolar extraction) before treatment.

Once identified, the problem is visualized (Fig. 1) and the practitioner must preselect
his treatment goal- “ideal, ” “acceptable” or “modified.” At the same time a determi-
nation of anchorage requirements (regular or major) (Fig. 2) is made. This is based on
lower arch crowding, curve of Spee, distance to upright lower incisors and correct ANB,
and consideration of a high or low mandibular angle. Other factors are anchorage loss
during canine retraction and procedures by which anchorage is gained, including delaying
premolar extraction (and other extraction choices) and wearing a palate bar, headgear, or
Class III elastics.
In addition to charting specific parameters of malocclusions and the anchorage needed
to correct them, a unique quality of LAS is predictability. This becomes possible and is
enhanced by control of as many variables influencing treatment as can be controlled or by
eliminating them as variables (Table II). The preadjusted appliance is a constant and is
 Flg. 6B. Cephabmetrii tracing for patient P. Y. before treatment.

Flg. 6C. Model of patient P. Y.‘s occlusion before treatment.

superior to manual bending of first-, second-, and third-order bends. Treatment steps are
routine and easily duplicated by any orthodontist willing to accurately place the appliance.
With nitinol arch wire, predictable and precise tooth movements occur because it has a
high resistance to deformation; because of this resistance it provides a uniform force for
rotation, leveling, and tipping. ’
Brackets and their respective configurations contribute importantly to the therapeutic
efficacy of this system by guiding tooth movement. These configurations, individually
considered, are shown in Table III; they provide regular anchorage, but major anchorage
requires greater degrees of distal tipping (Fig. 2). Placements of brackets and tubes on
these lower posterior teeth also serve to maintain marginal ridge integrity (Fig. 3).
In actual treatment, only seven steps are required to treat a four premolar extraction
patient with major anchorage. If fewer extractions are needed-or none at all-several
steps can be eliminated. The abbreviated steps are:
1. Stabilize upper arch.
2. Level curve of Spee (lower arch).
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Fig. 6D. Patient P. Y. after treatment.

3. Retract lower canines.

4. Band lower anteriors, tip them upright, and close anterior space.
5. Place stainless steel anchorage arch in lower with loops in extraction space and
correct Class II molar, if necessary.
6. Retract upper anterior teeth.
7. Finish.
Guidance for estimating time for each step is given along with self-check instructions.
Results
Key variables denoting treatment efficacy (Table IV) indicated clear and consistent
response to treatment in all patients. The curve of Spee and discrepancy were reduced to
zero. Uprighting lower incisors was successful in all patients; fourteen reached their
prescribed goal, four had incisors 0.5 mm. more upright than their goal, one had incisors 1
mm. more upright, and one had incisors 1 mm. more protrusive than the goal. The ANB
angle responded well, moving from a pretreatment mean value of 5.3 degrees to a final
mean value of 1.65 degrees. Changes in the FMA angle showed consistent control of the
vertical dimension.
Based on the anchorage problems presented by these twenty patients, fifteen were
slated to achieve an ideal treatment goal (Table V) and did so. Modified goals were chosen
for two patients with large ANB-type malocclusions and three patients with a tendency for
a Class III type of malocclusion (low ANB). All five results were adequate, with slight
over-run in terms of the uprighting of lower anteriors (alluded to above).
Consistent with these orthodontic goals were those of improved accuracy in predicting
 ,’

1
/’

,,,’
--_ _.._--

Fig. 6E. Cephalometric tracing of patient P. Y. after treatment.

treatment time duration (Table VI). Overall results indicated good correspondence be-
tween predicted and actual time of treatment, the only significant exception being at step
1. Here, actual time exceeded that predicted by about 23 percent. When all steps are
considered together, this error factor is reduced to only 6.5 percent (“predicted ” 27.2
months vs. “actual” 29.1 months).
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Fig. 6F. Model of patient P. Y.‘s occlusion after treatment.

These results agree with considerations of treatment duration as a function of initial

severity of the orthodontic condition so that a near linear relationship is seen when these
two factors are contrasted (Fig. 4).
Supporting data from two patients exemplify the salutory results obtained in this
sample group. Both patients had four first premolar extractions; therefore, all seven
treatment steps were taken (Figs. 5 and 6).

Discussion
If this system of orthodontic care has value, it lies in five primary areas. First, by this
type of in-depth analysis the malocclusion is minutely delineated and therefore
understood-in accordance with the adage that to fully state a problem is to be more than
halfway to its solution. Second, a precise and repeatable treatment plan is mandated by
defining the problem. This facilitates understanding by the doctor and his ancillary per-
sonnel and by the young patient and his parents. Third, as treatment progresses the
practitioner can periodically run a self-check to assure both himself and his patient that all
is going well. Orthodontic assistants soon learn the treatment steps, with self-checks, and
become more efficient in preparatory work.
A fourth factor concerns predictability. Use of LAS has enabled much higher degrees
of accuracy in estimating treatment duration and, as a corollary, treatment costs. The last
area of great interest lies in the applicability of special brackets and bands automatically
coordinated with a straight arch wire. Instead of having to seat an arch wire with first-,
second-, and third-order bends, the coordinated unit slips easily into place by comparison.
The reason for this is obvious: a standard edgewise lower arch bent so as to duplicate a
LAS arch wire would require thirty-two different bends and additional time coordinating
each side.
Nitinol arch wire is gentle yet exerts its force continuously with little distortion.
Torque can be controlled early in treatment because successive arch wires fit with preci-
sion and ease. They also greatly facilitate correction of major rotations. Each patient can
know his rate of progress (initial severity of malocclusion vs. time) and approximately
how many months headgear need be worn.
For parents, LAS simplifies understanding of the importance of discrete treatment
steps to achieve an ideal goal. They like the positive approach taken by an orthodontist
who predetermines both treatment steps and time sequence. All of these factors combine
to make the practice of orthodontics more rewarding for a practitioner.
Technical and editorial help were provided by Unitek Corporation, Monrovia, Calif., and
editorial help and encouragement were provided by Eldor G. Sagehom, D.D.S.
REFERENCES
I. Tweed, C. H.: Indication for extraction of teeth in orthodontic procedure, A~I. J. OKIHOU. ORAl. St,so.
30:405-28, 1944.
2. Angle, E. H.: The latest and best in orthodontic mechanism, Dent. Cosmos. 71:260-70. 1929.
3. Holdaway, R. A. Bracket angulation as applied to the edgewise appliance. Angle Orthod. 22:227-36. 1952.
4. Lee, 1. F.: Torqued brackets for upper and lower anteriors, Paper presented at the Pacific Coast Society of
Orthodontics, September, 1963.
5. Andrews, L.: The six keys to normal occlusion, AM. J. ORTHOD. 61:297-309, 1972.
6. Steiner, C. C.: Cephalometrics for you and me, AM. J. ORTHOD. 39:72Y-44, 1953.
7. Andreasen, G. F., and Morrow, R. E.: Laboratory and clinical analysis of nitinol wire, Am. J. Clin. Orthod.
73:142-151. 1978.