Clinical

Orthodontic anchorage: concept and complexities

Limiting unwanted tooth movement, while producing desired positioning of other teeth, is a very important part of orthodontics. In this article, Benjamin Lewis outlines the concept of orthodontic anchorage, explains why it is important, and how to manipulate anchorage techniques to produce the best possible result for your patients.

he concept of anchorage, in orthodontic terms, is complex. It relates to techniques that can be used by the orthodontist to limit unwanted tooth movement. This article will describe what anchorage is and why an understanding of it is important in orthodontic practice, as well as demonstrating some of the many methods that can be used to reinforce and manipulate anchorage to achieve the best orthodontic result.
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What is anchorage and why is it important?

Orthodontic anchorage is a complex concept that revolves around the theoretical principles by which orthodontic techniques may be employed to limit or even prevent unwanted tooth movement. Newtons Law states that: For every action (in this case, a desired tooth movement) there is an equal and opposite reaction. The reactionary force that is created will move the other teeth that are Benjamin RK Lewis is a senior specialist registrar in orthodontics at St Lukes Hospital, Bradford and Leeds Dental Institute, Leeds. Email: benjamin.lewis@nhs.net Newtons Law states that for every action there is an equal and opposite reaction. The concept of anchorage is built around this. attached to the appliance; sometimes these reactionary tooth movements are not wanted by the orthodontist. Anchorage management is the method by which the orthodontist attempts to control these undesired tooth movements.

Achieving tooth movement

To be able to achieve tooth movement, a force needs to be applied to the tooth that is sufficient to overcome the resistance of the periodontal ligament (see the first article in the series for more detail; Lewis and Jedynakiewicz, 2007). Theoretically, if a force could be placed on a tooth that just overcame the

resistance of the periodontal ligament, but the reactionary force which was produced was distributed over sufficient teeth so that their periodontal ligaments were not pushed over their thresholds, then this would result in the movement of just the tooth that was intended to be moved (Proffit, 2000). Unfortunately, forces can not currently be placed with sufficient precision for this to occur. This is further complicated by the fact that the force required to overcome the periodontal ligament varies between teeth depending on: n The type of toothincisor, premolar or molar. The larger the root surface area of the tooth, the greater the
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Figure 1. Elastic powerchain over the maxillary incisors to close the midline diastema.

Figure 3. Shows the occlusion initially and following orthodontic treatment. This involved the extraction of maxillary first premolars to relieve the severe anterior crowding and to align the canines into a Class I position. The extraction of mandibular second premolars allowed not only the relief to the anterior crowding but also enabled the mesial movement of the molars to correct the molar relationship to Class I.

Reciprocal anchorage
Reciprocal anchorage occurs when a force is placed on two teeth or two blocks of teeth that have roughly the same root surface area, providing similar periodontal ligament thresholds. Treatment is planned so that the applied force creates equal tooth movements in both blocks of teeth. This is demonstrated in Figures 1 and 2. Figure 1 shows a median diastema being closed with elastic power chain, with each of the central incisors moving the same distance towards the midline. Figure 2 shows an upper removable appliance (URA) with a midpalatal expansion screw. This has been designed to expand the maxillary arch to correct a unilateral buccal crossbite with a displacement (see the previous article in the series for a full description of the diagnosis and management of crossbites; Lewis, 2008). The teeth opposite each other are moved the same distance buccally because they have similar periodontal thresholds.

Figure 2. Upper removable appliance to expand the maxillary arch. force required to move it n Periodontal conditiona decreased level of periodontal attachment results in a decreased periodontal threshold to tooth movement n Type of orthodontic force that is placed on the toothtipping teeth requires lower forces than those required to move teeth bodily (see Table 1). Anchorage is important in orthodontic treatment because if it is not assessed correctly at the outset of treatment and/ or not carefully monitored throughout treatment, then the final dental and facial result could be compromised.

Types of anchorage
There are four basic types of anchorage that are used in orthodontics: n Reciprocal anchorage n Planned anchorage loss n Anchorage reinforcement n Absolute anchorage.
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Planned anchorage loss

The extraction of teeth is one of the options an orthodontist has of creating sufficient space to relieve crowding or to create an optimum occlusion.

The amount of space generated by the extraction of a tooth is often not exactly the same as the amount of space required. A premolar is approximately 7 mm wide, therefore the extraction of a premolar from both sides of a dental arch provides 14 mm space. This may be too much, exactly the right amount, or insufficient space. Each of these outcomes has an impact on the orthodontists anchorage management of the case. If there is still insufficient space, further space has to be created, either by additional extractions, moving the buccal teeth distally, expansion of the arch or interproximal enamel reduction. If the space created by the extractions is just sufficient, the orthodontist must maintain the position of the posterior teeth to allow all the created space to be used to align the teeth or correct the incisal relationship. This requires absolute anchorage, which is discussed in more detail below. In cases when the extraction of teeth provides more space than is required, the orthodontist must then plan the loss of some of the anchorage; this will aim to move the posterior teeth forwards at the same time as aligning and retracting the anterior teeth (Figure 3). This may be aided during the planning process
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Figure 6. A Class II elastic being used to establish a class I canine and molar relationship towards the end of orthodontic treatment.

Figure 9. Transpalatal arch with Nance button.

Pitting a single tooth against multiple teeth

Figure 4. The maxillary second premolar and first molar are secured together to be pitted against the canine, resulting in distal movement of the canine with little mesial movement of the posterior teeth. Adding teeth together to create a block of teeth increases their root surface area and their anchorage value. This block of teeth can then be used to move a single tooth while allowing, potentially, minimal movement of the block of teeth (Figure 4).

Figure 7. Transpalatal arch. In this case it has been modified with a mesially extending arm to allow distal traction to be placed to the maxillary right canine.

Utilizing different types of tooth movement

Tooth movement requires varying levels of force depending on the types of tooth movement which are planned. As can be seen from Table 1, the tipping of teeth requires less force than that needed to achieve bodily movement. This can be utilized by the orthodontist to control anchorage during an individuals treatment, by allowing the teeth they want to move, to tip, while restricting

Figure 5. Intra-arch elastics being used to correct a centreline discrepancy. if teeth are extracted closest to the teeth that the orthodontist wishes to move the furthest. For example, if the orthodontist wanted the molars to move mesially during treatment, to correct the molar relationship, the extraction of the second premolars instead of the first premolars would make that planned tooth movement more straightforward.

Figure 8. Lower lingual arch.

TABLE 1. FORCE LEVELS USED FOR DIFFERENT TYPES OF TOOTH MOVEMENT

Type of movement Intrusion Tipping Extrusion Rotational Bodily Force (grams) 1525 3060 5075 5075 100150

Anchorage reinforcement
Anchorage reinforcement is required when a large proportion of the extraction space is needed to achieve the aims of treatment. This reinforcement, which restricts the unwanted tooth movement, can be created in a number of ways.

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Figure 10. Cross-sectional view showing the design of a transpalatal arch with a Nance button which rests against the palatal mucosa overlying the palatal vault. those they do not want to move, to bodily movement. This can be achieved by using different types of orthodontic brackets/attachments and specific bends placed into the archwire.

Interarch elastics
Interarch elastics (Figure 5) allow a connection between the maxilla and the mandible. This connection can be used to pit some of the maxillary teeth against some of the mandibular teeth, which can alter the anchorage balance in a particular arch allowing the orthodontist to move the teeth they want to achieve a good interarch occlusal relationship; i.e. allowing the mesial movement of the mandibular molars at the same time as distal retraction the maxillary incisors (Class II elastics, as in Figure 6) or moving the maxillary molars more mesially and retracting the mandibular incisors distally (Class III elastics).

Figure 12. A NITOM safety facebow used with orthodontic headgear. (A) The band on the first molar has a headgear tube attached to it; (B) the intraoral arm of the facebow in inserted into the headgear tube on the first molar; (C) the NITOM nickel titanium locking attachment secures behind the first molar tube, preventing the facebows accidental disengagement. of teeth to increase their anchorage value in addition to the maintaining intermolar width. This results in any mesial movement of the molars leading to a potential binding of the molar roots against the cortical bone of a narrower part of the maxilla, which has a decreased resorptive potential than cancellous (spongy) bone.

Transpalatal arch/lingual arch

Transpalatal arches and lingual arches are designed to maintain the intermolar distance by connecting the opposing molars in an arch with a 0.9 mm diameter wire soldered to the molar bands. Figures 7 and 8 show a transpalatal arch and a lingual arch respectively. These devices aim to restrict movement of the individual molars by creating a block

Transpalatal arch with Nance button

Transpalatal arches with a Nance button (Figure 9) work on the same principle as the conventional transpalatal arch but the Nance button allows the palatal vault to be utilized. Nance buttons are designed to rest on the palatal mucosa of the sloping palatal vault (Figure 10) and therefore utilize the palatal vault
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Figure 11. A Nance button has dug into the palatal mucosa (A), which has resulted in ginigival ulceration (B). Removal of the Nance button allows complete gingival healing (C).
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Figure 13. Orthodontic headgear. (A) High pull (occipital pull) headgear; (B) low pull (cervical pull) headgear; (C) combination pull headgear (also showing a Masel rigid cervical neck strap safety device in situ). and its overlying mucosa to resist the mesial movement of the molars. However, because the button rests on the mucosa, which can be compressed, it does not provide absolute anchorage, and unless careful treatment mechanics are employed it can lead to the Nance button digging in to the soft tissue resulting in trauma (Figure 11). anteriorposteriorly and vertically). It is possible to achieve orthopaedic effects with headgear in addition to orthodontic effects. However, to achieve an alteration of a patients growth requires the headgear to apply large forces (>500 g per side, compared with 250 g per side for anchorage reinforcement) for the duration of an individuals growth, and most patients do not find this sustained wear practical. Protraction headgear can be used as an interceptive measure to encourage additional maxillary growth in patients with a skeletal Class III malocclusion due to maxillary hypoplasia. It is initiated between the ages of 8 and 9 years and has to be worn for 16 hours a day for 912 months. Although this can lead to impressive skeletal correction in the short term, the long term effects are unknown and are currently being investigated. An important aspect of using headgear in clinical practice is the concurrent use of safety devices to prevent unwanted disconnection of the headgear apparatus during sleep or play. There have been reports that headgear can become detached during sleep (Samuels et al, 1996) which may, in some cases, result in facial trauma (Booth-Mason and Birnie, 1988). The British Orthodontic Society (BOS) recommend that at least two safety devices are incorporated into the headgear appliance (BOS advice sheet No. 8). These may be: n Safety ended or locking facebows (Figure 12), designed either to provide

a blunt facebow tip to prevent/ minimize injury once the facebow has become detached, or to lock the facebow securely to the first molar bands to prevent its unintentional disengagement (Samuels et al, 2000) n Masel neck strapa rigid plastic strap designed to prevent the facebow from inadvertently coming out of the headgear tubes on the first molar bands, and if it still became detached, to maintain the facebow within the mouth to prevent extraoral injuries n Snap away anti-recoil safety straps designed as a device to prevent recoil injuries resulting from accidental disengagement or incorrect handling (Postlethwaite, 1989).

Absolute anchorage
Headgear can be used to move teeth in all directions depending on the modifications and adjustments made to the apparatus. However, its success is very much dependent on patient cooperation, and other methods have recently been introduced which offer the potential benefits of absolute anchorage without as much reliance on the patient. The two main developments in this area are midpalatal implants and miniimplants.

Headgear
This is a form of extraoral anchorage (EOA) as it utilizes the neck and/or the back of the head to resist unwanted tooth movement. It is also able to produce distal movement of the molars enabling space to be created (extraoral traction; EOT). It uses a facebow, which acts as an interface between the fixed appliance and the extraoral headgear apparatus. The facebow has intraoral arms that insert into the headgear tubes which can be placed on the buccal aspect of the maxillary first molar orthodontic bands (Figure 12). The extraoral arms of the facebow attach to the headgear apparatus via elastic straps. There are four difference type of headgear appliance (Figure 13): n High-pull (occipital pull) headgear (13A) n Cervical pull headgear (13B) n Combination pull headgear (13C) n Protraction headgear. The particular type of headgear used depends on a number of factors including the patients skeletal type and the desired tooth movements (both
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Midpalatal implants
These are an adaptation of standard restorative implants used for the replacement of missing teeth. They are designed with a smaller length (4 6 mm with a 2.54.5 mm neck length) than conventional restorative implants and are inserted into the bone of the palate after a profile hole is cut using a slow-speed handpiece under local anaesthesia (Tinsley et al, 2004). These implants need to osseointegrate, similar to a standard restorative implant, so no orthodontic traction must be placed for at least 3 months. It is necessary to place these implants in the middle of the palate to ensure there is sufficient bone
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Figure 14. Midpalatal implants which have osseointegrated into the palatal vault (Courtesy of Drs Jonathan ODwyer and David Tinsley). (A) Midpalatal implant being used to hold the first molars in their current position; (B) midpalatal implant being used to move the first molars in a distal direction.

Figure 16. Placement of a miniimplant, which uses mechanical retention to remain in the alveolar bone.

Mini-implant anchorage
Sometimes known as temporary anchorage devices, mini-implants are a relatively recent addition to the orthodontists armoury. They are based on the surgical screws used by maxillofacial surgeons to repair fractured

mandibles. The implants range in size (69 mm long and 12 mm diameter) and are screwed into the bone of the maxilla or mandible (sometimes after a pilot hole has been drilled) under local anaesthetic (Figures 15 and 16). One benefit is that they can be placed

KEY POINTS
n Orthodontic anchorage is fundamentally the resistance to unwanted tooth movement. Figure 15. Close up of a mini-implant (temporary anchorage device). available to allow the implants to be initially stable and then to osseointegrate (Figure 14). This can make the design of the orthodontic attachment difficult because the dictated placement site may not be close to the teeth the anchorage of which needs to be reinforced. When the additional anchorage is no longer required, the midpalatal implants will need to be removed, which can be difficult because of the degree of osseointegration.
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n The forces needed to orthodontically move a tooth will vary depending on the type of tooth and its periodontal condition, as well as the type of orthodontic tooth movement desired. n The four basic types of orthodontic anchorage are: reciprocal anchorage, planned anchorage loss, anchorage reinforcement, and absolute anchorage. n There are many different mechanical techniques which may be utilized by the orthodontist to achieve different these different types of orthodontic anchorage. n Anchorage control needs to be properly assessed during treatment planning and monitored throughout a patients treatment to obtain the optimum aesthetic and functional results.

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by the orthodontist in the exact place where the anchorage reinforcement is required because they are much smaller than the midpalatal implants and do not need to osseointegrate; this also means that the mini-implants are easier to remove than the midpalatal type once they are no longer needed. Attachments can be placed onto the mini-implants to either prevent teeth from moving or, conversely, to apply traction to teeth that the orthodontist wishes to move. orthodontist to enable correct treatment planning. Without this knowledge, inappropriate teeth might be extracted and the optimal treatment result may not be achievable. This article has provided an overview of the most common methods that are available to the clinician to help them manage the anchorage during a case and achieve the desired tooth movements to get the best possible aesthetic and functional result.
Booth-Mason S, Birnie D (1988) Penetrating eye injury from orthodontic headgear A case report. Eur J Orthodont 10: 1114 British Orthodontic Society (2006) Development and Standards Committee of the British Orthodontic Society. The Use of Headgear and Facebows. British Orthodontic Society Advice Sheet Number 8 (Revised 2006) Lewis BRK (2008) Orthodontic correction of crossbites. Dental Nurs 4 (4): 196202. Lewis BRK, Jedynakiewicz N (2007) Fundamentals, uses and benefits of orthodontics. Dental Nurs 3(8): 4309 Postlethwaite K (1989) The range and effectiveness of safety headgear products. Eur J Orthodont 11: 22834 Proffit WR, Fields HW (2000) Contemporary Orthodontics 3rd edn. Mosby Inc, Missouri: 30811 Samuels RHA, Willner F, Knox J, Jones ML (1996) A national survey of orthodontic facebow injuries in the UK and Eire. Br J Orthodont 23: 1120 Tinsley D, ODwyer JJ, Benson PE, Doyle PT, Sandler J (2004) Orthodontic palatal implants: clinical technique. J Orthodont 31: 38

Conclusions
Anchorage control during orthodontic treatment can be complex. A thorough understanding is required by the

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