PRESENTED BY : AKHILESH PAL ROLL NO. 04 BATCH = 06-07 B.D.S.

FINAL YEAR

CONTENTS
Introduction Sources of anchorage Classification of anchorage Type of anchorage
o o o o o o o Simple Anchorage Stationary Anchorage Reciprocal Anchorage Intra oral Anchorage Extra oral Anchorage Muscular Anchorage Intra maxillary Anchorage

o o o o o o o

Application of temporary skeletal anchorage Anchorage planning Anchorage control References

Inter maxillary Anchorage Single or primary Anchorage Compound Anchorage Reinforced or multiple Anchorage Cortical Anchorage Skeletal (absolute) Anchorage Differential Anchorage

Introduction Anchorage The term anchorage in its orthodontic application is defined in an unusual way : the definition as resistance to unwanted tooth movement includes a statement of what the dental desires.

Tooth movement during orthodontic therapy is brought about by force generated by the active component of an orthodontic applian ce. The force use to move teeth is derived from certain anatomic area which act as anchor.

According to White and Gardiner :Anchorage is the site of delivery from which a force is exerted. Sources of anchorage These are anatomical unit and/or regions which are used for the purpose of providing the resistance to movement i.e. anchorage. Anchorage during orthodontic therapy is mainly obtained from two sources 1. 2. Intra oral sources Extra oral sources

Intra oral sources of anchorage

Intra oral sources of anchorage includes

The teeth The alveolar bone The basal bone The cortical bone The musculature

The teeth

When ever some teeth are moved orthodontically. The remaining teeth of the oral cavity can act as anchorage or resistance units.
This is due to the fact that the teeth themselves can resist movement. The anchorage potential of teeth depends en a number of factors such as

Root forms Root size Number of root Root length Root Inclination

i. Root forms
The anchorage potential of a tooth depends largely on its root forms. Cross section of root can be of three types Round, flat and triangular Round root is seen in bicuspid and palatal root of maxillary molars can resist horizontally directed forces in any directions. Flat roots for example those of mandibular incisor and molars and the buccal root of maxillary molars can resist movement of the mesio-distal direction but have little resistance to movements on the thin edges found on their buccal and lingual sides.

ii. Size and number of roots Multi rooted teeth with large root & have a greater ability to with stand stress than single rooted teeth. iii. Root length In physiologic condition, the root lengths indicate the depths to which the tooth is embedded in bone and the greater is its resistance to displacement. iv. Inclination of tooth The axial inclination of a tooth is important in assessing its value as a source of anchorage a greater resistance to displacement is offered. When the force exerted to move teeth in apposite to that of their axial inclination.

v. Ankylosed teeth

Anklosed teeth are directly fixed to the alveolar bone and hence lock a periodontal ligaments. Orthodontic movement of such teeth is not possible and they can therefore serve as excellent anchorage whenever possible.

Alveolar bone
The alveolar bone that surrounds a tooth offers resistance to tooth movement up to a certain amount of force.

When force applied exceeds a certain limit. The alveolar bone permits tooth movements by bone remodeling.
Basal bone Certain area .

e. Musculature Under normal circumstances the perioral musculature play on important role in the growth and development of the dental arches.

Extra oral source of anchorage

Certain extraoral areas can be utilized is source of anchorage to bring about orthodontic or orthopedic changes.
They are mainly used when adequate resistance can not be obtained from intra oral sources for the purpose of anchorage.

The cranium The back of the neck

The extra oral sources of anchorage includes the

Cranium (occipital or parietal anchorage) Extra oral anchorage can be obtained by using head gears that desire anchorage from occipital or parietal region of the cranium. These device are used along with a face bow to restrict maxillary growth or to move the dentition or maxillary bone distally. Back of the neck (cervical anchorage) Extra oral anchorage can alternatively be obtained from the neck or cervical region. Such type of headgear is called cervical headgear.

CLASSIFICATION OF ANCHORAGE A. According to the manner of force application

1. 2. 3. 1. 2. 1. 2. Simple Anchorage Stationary Anchorage Reciprocal Anchorage Intra maxillary Inter maxillary

B. According to jaw involved C. According to the site of the anchorage

Intra oral Extra oral 1. Cervical 2. Occipital 3. Cranial 4. Facial Muscular

3.

D. According to the number of anchorage units White and Gardiner classified anchorage into six categories
1. 2. 3. 4. 5. 6. Simple Stationary Reciprocal Reinforced Inter maxillary Extra oral 1. 2. 3. Simple or primary anchorage Compound anchorage Multiple or reinforced anchorage

TYPES OF ANCHORAGE Simple anchorage It is defined as dental anchorage in which the manner & application of forces is such that it tends to changes The axial inclination of the tooth or teeth that forms the anchorage unit in the plane of space in which the forces is being applied. Thus the resistance of the anchorage unit to tipping is utilized to move another tooth or teeth.

Simple anchorage is obtained by engaging with the appliance a greater number of teeth than are to be moved within the same dental arch.

the resistance offered by the anchorage unit is greater than that offered by tooth or teeth being moved. An examples of simple anchorage, when a palataly placed premolar is pushed buccally with the rest of teeth in the dental arch as the anchorage unit.

Stationary anchorage
.

Reciprocal anchorage The term generally refers to the resistance offered by two malposed unit when the dissipation of equal and opposite forces. Tends to move each unit towards a more normal occlusion. Here two teeth or two groups of teeth of equal anchorage value are made to move in opposite direction. Example of resiprocal anchorage include closure of a midlene diastema by moving the two central incisor toward each other. The use of cross bite elastics and dental arch expansion are other example of resiprocal anchorage.

Intra oral anchorage Anchorage in which all the resistance unit are situated within the oral cavity is termed intra oral anchorage. The teeth to be moved and the anatomic area that offers an anchorage are all within the oral cavity. Various intra oral anatomic unit that may be employed are the teeth palate and lingual alveolar bone of mandible.

Extra oral anchorage Anchorage in which the resistance unit are situated out side the oral cavity is termed extra oral anchorage. Various extra oral anatomic unit used as sites of resistance are occiput, back of neck, cranium & face. Example of extra oral anchorage include the use of headgears that derive anchorage from the cervical or cranial region and facemask that derive anchorage from the facial bones. .

Muscular anchorage

The perioral musculature is not only very strong but also resilient.
The forces generated by the musculature can some time be used to bring about tooth movement. The lip Bumper appliance may be used to distalize the mandibular first molar or the transpalatal arch when kept away from the palate may cause the intrusion of the teeth to which it is attached the maxillary first molars

Intra maxillary Anchorage When all the unit offering resistance are situated within the same jaw the anchorage is described as intra maxillary. In this type of anchorage the teeth to be moved and the anchorage unit are all situated either entirely in the maxillary on mandibular arches. Intra maxillary anchorage can be further subdivided into three sub type depending upon the manner of force application as 1.Simple 2.Stationary 3.Reciprocal

Inter maxillary Anchorage Anchorage in which the resistance unit situated in one jaw are used to effect tooth movement in the opposing jaw is called inter maxillary anchorage. It is also termed as Bakers Anchorage. Class II elastic traction applied between the lower molar and upper anterior as well as class III elastic traction applied between the upper molar and lower anterior are types of inter maxillary anchorage.

Single or primary Anchorage Cases wherein the resistance provided by a single tooth with greater alveolar support is used to move another tooth with lesser support is refered to a single or primary anchorage. Compound Anchorage Anchorage where the resistance provided by more than one tooth with greater support is used to move teeth with lesser support is called compound anchorage.

Reinforced or multiple Anchorage

Anchorage in which more than one type of resistance unit is utilized is termed reinforced anchorage. Reinforced anchorage refers To the augmentation of anchorage by various mean Such as extra oral appliance upper anterior indened plane or a transpontal arch connecting the two maxillary molar.

The following are some of the method of reinforcing anchorage.

A. Extra oral force to Augment anchorage Force generated from extra oral area such as cranium back of the neck and face can be used to reinforce anchorage. B. Upper anterior inclined plane Removable appliances incorporating an upper anterior inclined plane result is forward glide of the mandible during closure of the jaw this result in streching of the retracter muscle of the mandible which is subsequently contracts and forces the mandible against the upper inclined plane.

Thus a distal force is applied an the maxillary teeth thereby reinforcing maxillary anchorage. C. Use of transpalatal arch and lingual arches

Transpalatal arch is a wire that spons the palate in a transverse direction connecting the first permanent molar of either side they are used in fixed mechano therapy to Augment anchorage. Similaraly on arch connecting the contra lateral. Lower molar running along the lingual aspect of the mandibular arch prevent mesial movements of lower molar. This is called the lingual arch. The lingual and transplalatal arch are soldered to the lingual aspect of the molar bonds that are cemented to these teeth.

D. Use of implants

Implants are slowly being introduces a source of anchorage. They are specially use full in patient who have last lot of teeth or hypodontia.
When maximal anchorage & required during orthodontic treatment additional aids are often needed to support the anchorage teeth. While intra oral aids may be limited in their anchorage potential, extra oral anchorage aids using. Head gears are often Rejected by the patient. Endosseus implant may therefore be a valuable alternative for stable intra oral anchorage. Micro implants as a source of anchorage in orthodontic treatment is relatively new.

Type of microimplants According to the exposure of the head 1.Open method : The head of the micro implants is exposed to the oral cavity. This method is used when implants is placed in an area where. The soft tissue are not movable such as the attached gingiva. 2.Closed method : The head of the microimplant is embaded under the soft tissue. This method is used when implant is placed in an area where the soft tissue movable. .

According to method of placing of implants 1.Self tapping method : In this method a tunnel in first drilled into the bone and the implant is then tapped in : This method is used for smaller diameter microimplants 2.Self drilling method : In this method it self dril of self into bone. This method is used for larger diameter microplants.

According to the path of microimplant insertion 1. Oblique direction : The microimplant is inserted diagonally at an angle 3060 degree to the long axis of the tooth. This method in used in area where the inter redicular bone is very narrow. Perpendicular : The microimplants is inserted perendicular to the bony surface. This method is used of there is sufficient interaredicular bone.

2.

Sites for placement of microimplant

Maxillary area 1.Maxillary tuberosity : for retraction of maxillary posterior teeth. 2.Infrazygomatic crest area : Retraction of maxillary anterior & intrusion of maxillary posterior. 3.Buccally between the maxillary first and second molar : Retraction of maxillary anterior and intrusion of maxillary molars. 4.Buccally between the maxillary canine and first premolar : Distal < mesial movement of maxillary molar and intrusion of the maxillary buccal teeth. 5.Bucally between maxillary first molar and second premolar : Retraction of maxillary anterior and intrusion of maxillary buccal teeth.

6. Labially between the maxillary incisor : Intrusion and tongue control of maxillary incisors. 7. Palatally between the maxillary second premolar and the first molar : Retraction of maxillary anterior and intrusion of maxillary molars. 8. Mid palatal area : for correction of unilateral cross bite

Mandibular area 1. Retromolar region : for up righting mandibular molar and retraction of mandibular teeth. 2. Buccally between mandibular first and second molar : Intrusion and distal movement of mandibular molar and retraction of mandibular anteriors. 3. Buccally between mandibular first and second premolar : Intrusion of mandibular molar and retraction of mandibular anteriors. 4. Buccaly between mandibular premolar and canine : Protracten of mandibular molars. 5. Facially in the symphyseal region : for intrusion of mandibular anterior.

Cortical Anchorage
Another consideration in anchorage control is the different response of control compared with medullary bone. Cortical bone is more resistant to resorption and tooth movements is slowed with a root contacts it some authors have advocated torquing the root of posterior teeth. Out word against the cortical plate as a way to inhibit their mesial movement. When extraction spaces are to be closed. Since the mesial movement would be along rather than against the cortical would be along rather than against the cortical plate of is doubtful that this techniques greatly augment anchorage (although is has the potential to create root resorption)

However, a layer of dense cortical bone that has formed within the alveolar process can certainly affects tooth movement.

Skeletal (Absolute) Anchorage Of has long been realized that of structure other than the teeth could be made to serve as anchorage, of would be possible to produce tooth movements or growth modification without unwanted side effects. Untill recently extra oral force (head gear) was the only way to obtain anchorage that was not from the teeth. Although headgear can be used to augment anchorage, there are two problem. 1.if is impossible for a patient to wear headgear all the time, and most wear of half the time at best and 2.When headgear is worn the force against the teeth is larger than optimal. The result is a force system that is for from ideal. Heavy intermittent force from headgear is simply not a good way to counter balance the effect of light continous force from the orthodontic appliances.

It is not surprising that head gear to the anchor segment of a dental arch usually does not control it movement very well with the development of successful bone implant techniques the potential existed for what could be desoribed as absolute anchorage, with no tooth movement except what was desired. Experiment in recent year showed that implants could be used as anchorage for orthodontic. Tooth movement and that they made of possible to do things that were previously impossible for example intrusion of maxillary posterior teeth in the treatment anterior openbite.

A number of option for absolute anchorage exist as present the principle one being titanium screw that penetrate through the gingiva into alveolar bone. At this point temporary skeletal anchorage is an exciting new aspect of clinical orthodontics.

Intrusion and skeletal anchorage Consideration for intrusion In adolescent and young adult (up to about age 18 in female and 20 in male) the choice between intrusion or extrusion to correct a deep over bite and level on excessive curve of spee often can be resolved in forever of extraction because vertical growth will compensate for of in adult the choice often must be intrusion which is much more effetives when skeletal anchorage in the from of mini plate or screw is available, and when segmented rather than continous arch wire are used.

The practical effect to make both skeletal anchorage and segmented arch treatment more important in adult than in younger patients. Are potential problem with intrusion in periodontally involved adult is the prospect that a deepening of periodontal pocket might to be poroduced by this treatment. The crown root ratio is a significant factor in the long term prognosis for a tooth that has suffcient periodontal bone loss.

Application of temporary skeletal anchorage In this new and potentially very important area rappid progress is continuing in the development of the necessary hardware and clinical technique which means that improvement in both areas un doubtdly will appear in the near future. The devices may charge but the principles in their use will not. There are now four major application & for skeletal anchorage in treatment of adult. 1. Intrusion of posterior teeth to close an anterior open bite. 2. Distal movement of maxillary molar and the entire maxillary arch if needed. 3. Retraction and intrusion of protruding upper incisor. 4. Positioning individual teeth when no other satisfactory anchorage is available (usually because other teeth have been lost of dental diseases)

Differential anchorage The density of the alveolar bone and the cross sectional area of the roots in the plane perpendicular to the direction of tooth movements are the primary consideration for assessing anchorage potential. The volume of osseaus tissue that must be resorbed for the tooth to move a given distance of its anchorage value. Of all the bone offered the some resistance to tooth movements, the anchorage potential of maxillary and mandibular molar would be about the same. However clinical expansion shows that

A common example is space closure in a class I four premolar extraction case, it often it necessary to use of head gear on the maxillary first molar to maintain the class I relationship. The relative resistance of mandibular molar to mesial movement is a well known principle of differential mechanism. Why are mandibular molar usually more difficult to move mesially than maxillary molars at least two physiological factors can be considered.

1. The thin conticy and trabecular bone of the maxilla offer less resistance to resorption than the thick contains and more course trabecular of the mandible. 2. The leading root of mandibular molar translated mesially from bone that as for more dense than the bone formed by translating maxillary molars mesially The reason mandibular molar from more dense bone than maxillary molars is unclear, However it may be that new bone famed in the maxilla is remodeled rapidly then those compared primary of cortical bone.

Anchorage planning Anchorage planning is a atmost importance for the source of orthodontic treatment. Prior to innitation of orthodontic therapy, it is essential to carefully asses the anchorage demand of an individual cases so that appropriate treatment modaleties can be executed. The anchorage requirement depends on a number of factors which are listed below 1. Number of teeth being used : Greater the number of teeth being moved greater the demand of on the anchorage 2. Type of teeth being moved : The movements of selender anterior teeth offers lesser strain on the anchorage than robust multirooted teeth.

3.
4. 5.

6.

Types of tooth movement : When every bodily tooth movements is required there is a greater strain on the anchorage in comfort tipping tooth movement offer a relatively lesser strain on the anchorage unity. Duration of tooth movement : Treatment of a prolonged duration place on under strain on the anchorage. Skeletal pattern : It is noted that patient & who exhibit increased vertical skeletal growth pattern shown more tendency for mesial tooth movement and anchorage loss. Patients who exhibit a horizontal skeletal growth pattern. Show lesser tendency for the mesial movement of the anchorage tooth. Occlusal interlock : A good buccal occlusal may act as to resist tooth movement . Cases that have a high anchorage requirement need reinforcement of the anchorage by once more various mean.

Anchorage loss

In spite of the precaution taken in planing anchorage a certain amount of unwanted movement of the anchorage teeth invariably occurs during orthodontics treatment such unwanted movement of anchor teeth is called "Anchorage loss" Based on the anchorage loss that is permissble The anchorage demand of an extraction cases can be three types. 1. Maximum anchorage cases : In cases when the anchorage demand is very high, not more than of the extraction space should be last by forward movement of the anchor teeth. The anchorage in these patient should be augmented to avoid unwanted movement of the anchor teeth.

2. 3.

Moderate anchorage cases : In cases when the anchorage teeth can be permited to move forward into to of the extraction space. Minimum anchorage cases : In these cases the anchorage demand is very low more half the extraction space can be lost by the anchor teeth moving mesially.

Anchorage control The principle factors determining the success of treatment is anchorage control. Essential anchorage control invalues the ability to achieve different tooth movement of the anterior and posterior teeth. Maximum posterior anchorage : Involve retrachen of the incisor and canine without mesial movement of premolars and molars. Reciprocal anchorage : is equal movement of posterior teeth mesially and anterior teeth is distally. Maximum anterior anchorage : require protraction of the posterior teeth menally without retraction of the incisor & canine.

Anchorage control is established in a variety of ways. Extraoral appliance Such as headgear are frequently presented for anchorage control head gear is used to an attempt to secure the posterior teeth to extra oral structure additionaly the forces is delivered from most headgear should exceed the mesiodistal force level of elastic or spring used for retraction of the anterior segments. Intermaxillary elasticy Pit the upper teeth to lower teeth and are another common mean of gaining differential tooth movement. The direction of the elastic defines its force vector and the terminology used to describe it.

Class II elastic attach to the anterior maxillary teeth and the posterior mandibular teeth. Thus a class II elastic act to correct a class II relationship by providing a retraction force to the upper anterior teeth and simulations protraction force to the lower molars. Alternatively a class III Elastic hook from the lower anterior to upper posterior teeth, creating a force for lower anterior retraction and upper posterior practration for the resolution of a class III occlusion. The major limitation in the use of either headgear or elastic as on anchorage techniques is their dependence on patient compliance without patient cooperation these method are incapable of influencing the treatment results.

REFERENCES

1.

Contemporary orthodontics

(4th

edition) William R. Proffit Henery W fields David M. Sarver

2. Orthodontic the art and science 3. The text book of orthodontics

(4th

edition) S.I. Bhalajhi Samir E. Bishara

4. Orthodontics current principles & techniques

(4th

edition) Graber Vanarsdall Vig