42 Orthodontics April 2015

Hywel J Naish Claire Dunbar, Nikki E Atack, Julie C Williams, Jonathan R Sandy and Anthony J Ireland

The Control of Unwanted

Tooth Movement − An
Overview of Orthodontic
A­nchorage
Abstract: The success of orthodontic treatment relies upon careful treatment planning, for both desired and unwanted tooth movement.
The theory behind anchorage reinforcement will be considered and the current means of anchorage support and creation will be
described. Methods by which the orthodontist can reduce anchorage demand and measure anchorage loss will also be discussed.
Clinical Relevance: To understand the clinical applications of the theory of unwanted orthodontic tooth movement and be able to give
examples of planned means of increasing anchorage and decreasing anchorage demands.
Ortho Update 2015; 8: 42­­­–54

In order for teeth to undergo planned
orthodontic movement it is necessary to
apply an appropriate force to the tooth or
teeth and for this force to be resisted, either
entirely or partially. An understanding of this
process is an essential part of orthodontic
diagnosis and treatment planning.
Before exploring anchorage
in orthodontics it is worth considering
the basic principle as to why resistance is
required for force application to be effective
in achieving the desired tooth movement.
Following Newton’s third law, it is well
known that for every action there is an
equal and opposite reaction. This means
that forces act not only on the teeth to be
moved, but also elsewhere to the same
extent, often reciprocally, upon other teeth
which are referred to as the anchor units.
It is when these reciprocal forces are not
managed adequately that unwanted tooth
movements may occur, leading to a poor
occlusal finish or insufficient orthodontic
correction of the initial problem, such as
increased overjet.
Anchorage is primarily
considered in the antero-posterior plane but
also needs to be planned in the vertical and
transverse spatial planes.
In order to understand
anchorage in orthodontics it is perhaps
worth describing current theories of
what happens during orthodontic tooth
movement.
Tooth movement
When an intermittent force is
applied to a tooth, such as during normal
masticatory function, the periodontal
ligament (PDL) is deformed slightly
for a short time and the surrounding
bone bends in response. If pressure is
maintained, the PDL loses its capacity
to spring back, as the tissue fluids are
squeezed out and bony remodelling occurs
adjacent to the periodontal ligament. On
the pressure side of the ligament, in the
direction of movement, resorption occurs
through the action of osteoclasts, whilst
on the tension side bone deposition
occurs through osteoblastic action. The
heavier the force, the greater the amount

Hywel J Naish, BSc, BDS, MFDS RCS(Ed), MOrth RCS(Ed), Specialist Practitioner, Cathedral Orthodontics, Cardiff, CF11 9LN, Claire Dunbar,
BDS, MJDF RCS(Eng), MSc, MOrth RCS(Ed), Senior Registrar, Dorset County Hospital, Dorchester and School of Oral and Dental Sciences,
University of Bristol, Nikki E Atack, BDS, MSc, MOrth RCS, FDS RCS, Consultant Orthodontist, Musgrove Park Hospital, Taunton and School
of Oral and Dental Sciences, University of Bristol, Julie C Williams, BDS, DDS, MOrth RCS, DPDS, MA (Ethics of Healthcare), Academic
Clinical Lecturer and Senior Registrar, School of Oral and Dental Sciences, University of Bristol and Royal United Hospitals, Bath, Jonathan
R Sandy, BDS, MSc, PhD(Lond), MOrth RCS, FDS RCS, FDS RCS(Ed), FFD RCS, Professor of Orthodontics and Dean of Health Sciences,
University of Bristol and Anthony J Ireland, BDS, MSc, PhD(Lond), MOrth RCS, FDS RCS, Professor of Orthodontics, School of Oral and
Dental Sciences, University of Bristol, UK.
April 2015 Orthodontics 43

of compression of the blood vessels within teeth with higher forces. The optimum almost always be accompanied by some
the PDL. Since capillary blood pressure force to move a tooth is therefore one tipping and so, although theoretically
has been measured at 15−20mmHg per that maximizes desired tooth movement, higher forces would be possible,
1cm2, traditional theory suggested that whilst minimizing damage and anchorage maintaining similar forces to those required
the optimal force to move teeth would loss. The PDL response to the force is for tipping would be appropriate. Intrusion
be light enough to compress but not fully dependent on two main factors, namely creates a highly concentrated area of
occlude the capillaries.1 The osteoclasts the type of tooth movement required and force and so the lightest possible force of
would then be recruited from circulating the root surface area of the teeth. 10cN must be applied if intrusion is to be
monocytes within the PDL blood vessels successful. For a single-rooted tooth, the
and begin resorbing the alveolar bone Type of tooth movement optimal forces for different types of tooth
that is in direct contact with the PDL. This As already mentioned, the movements are shown in Table 1.5
resorption, known as frontal resorption, distribution of the force throughout the
would occur progressively and the tooth PDL will depend on the type of tooth Root surface area of the tooth
would gradually move. movement. During simple tipping of a When a force is applied to a
Using the same theory, if the single-rooted tooth, there will be two areas tooth, there is a threshold level that must be
applied force exceeds capillary blood of compression of the PDL (at the alveolar reached in order to overcome the intrinsic
pressure, then the blood vessels are crest and at the root apex) as the tooth is resistance of the periodontal ligament6 and
occluded and the PDL becomes avascular rotated about its centre of resistance. As the before tooth movement will occur.7 As the
or necrotic, seen microscopically as a force is concentrated at these two points, applied force increases above this threshold
glassy or hyalinized appearance. This is forces must be kept low at around 35cN. value, the amount of tooth movement
known as undermining resorption and Bodily movement of the same increases linearly until a plateau is reached,
results in a delay in tooth movement tooth would need uniform loading of the beyond which increasing the force no
whilst the osteoclasts begin resorbing PDL following the application of two forces longer increases the rate of tooth movement
the underside of the bone immediately to the crown of the tooth, thus doubling (Figure 1).8
adjacent to the necrotic area of the PDL. the force required for simple tipping. These optimum levels of
The delay is due to awaiting progenitor Rotational and extrusive movements will force described earlier are considered to
osteoclasts since the blood supply to the
area has been compromised. Therefore
the magnitude of force applied would
seem to determine the type of resorption Movement Forces (c/N)
that takes place.2 This is probably
somewhat simplistic as it is likely that
Extrusion 35
the application of force to a tooth will
always create at least some small areas of
avascularity within the PDL. Tipping 35
Testing this theory definitively
in a clinical setting is difficult owing Rotation 35
to the inherent ability of the PDL to
dissipate an applied force to other parts Intrusion 10
of the tooth, and also because the point
of application of a force varies during
Bodily movement 70
the process of tipping and uprighting
of the tooth. Indeed, a small scale study Table 1. The forces required for different tooth movements, adapted from Proffit (2013).5
testing the effect of a four-fold increase
in the force applied (200cN) to premolar
teeth in adolescents,3 found that teeth
moved 50% more in 7 weeks compared
with those receiving a low (50cN) force.
This is counter-intuitive in light of the
above theory, suggesting that the rate of
tooth movement may be related to other
factors rather than just the applied force.
Higher forces, which exceed
capillary blood pressure, are not only
associated with the possibility of delayed
tooth movement, but have also been
associated with an increased risk of
root resorption.4 Although the study
described above showed no difference
in the amount of root resorption of the
premolar teeth with higher forces,3 it could
be assumed that there was a greater risk Figure 1. Graph showing the theoretical relationship between increasing force and rate of tooth
of promoting movement of the anchor movement.8
44 Orthodontics
Figure 2. The average root surface areas (mm2) of
the permanent dentition.10
Figure 3. Comparing the effect of an optimal
(UR3) and a high (UL3) force on retraction of the
maxillary canine, where the second premolar
and first molar are the anchor teeth. The dotted
outline illustrates the amount of tooth movement
in each case.
be proportional to the root surface area
of the tooth9 being moved and Figure 2
illustrates the average root surface areas
in mm of the permanent maxillary and
mandibular teeth.10 The optimum force
for the movement of a block of teeth will
similarly be proportional to the sum of the
root surface areas of this block.
Although the forces being
applied to the teeth being actively moved
should be optimal, in the case of the
tooth or teeth not being moved, namely
the anchor teeth, the force should be
suboptimal or even below the threshold
level for tooth movement.
To illustrate this point, Figure
3 compares the effect of an optimal force
(70cN [70g]) and a high force (280cN
[280g]) for bodily retraction of a maxillary
canine against the resistance provided
by the second premolar and first molar
teeth. The average estimated root surface
area of a canine tooth is 273mm2.10
This compares to an average estimated
combined root surface area for the anchor
teeth on the same side, namely the first
molar and second premolar, of 653mm2
and equates to a ratio of root surface areas
for the canine and the two anchor teeth of
1:2.39. If 70cN (70g) of force is applied to
the single-rooted canine, then the equal
and opposite force, over the larger root
surface area of the two anchor teeth, will
be 17.5cN (17.5g) per root (assuming three
roots on the molar and one on the second
premolar). This will result in optimal bodily
movement of the canine, with only a small
amount of mesial bodily movement of the
anchor teeth, ie anchorage gain.
If the force applied to the canine
was increased to 280cN (280g), then the
reciprocal force on the anchor teeth would
be 70cN (70g) per root, which would be
optimal for promoting movement of the
anchor teeth. At the same time, the 280cN
(280g) force will lead to hyalinization within
the canine PDL, resulting in undermining
resorption and slower movement of the
canine. The result of this will be that the
anchor teeth move mesially more than the
canine retracts, ie anchorage loss.
This example refers to the level
of root surface encased within bone in a
healthy periodontium. Any bone loss will
alter the response of the PDL and reduce
the threshold required to move the tooth.
The location of the bone loss will also alter
the tooth’s natural ability to resist the force
in this area, eg furcation involvement on a
molar tooth, and this must be taken into
account during treatment planning.11
Factors affecting anchorage
requirement
Type of planned tooth movement
As part of the diagnosis and
treatment planning process, one of the
skills required of an orthodontist is the
assessment of the anchorage requirements
for each individual case. The explanation
of anchorage management so far has been
simplistic in order to help describe the
principles, but other factors will also have
important effects.
Anchorage is most often
considered in the antero-posterior plane
and requirements are usually classified
as low, medium or high. For example, in
deciding whether or not to extract teeth
to correct a malocclusion, the amount of
space required to correct the malocclusion
informs this judgement of the anchorage
requirements. Clinical experience suggests
that, if <30% of the space created by the
extraction is required to complete the
treatment, it may be considered a low
anchorage case, if 30−60% it is medium,
and if >60% it would be considered to be
a high anchorage case. There are, however,
a number of factors that should also be
considered when making this judgement,
in particular the type of tooth movement
required and therefore the angulations and
inclinations of both the teeth to be moved
and any anchor teeth.
April 2015
As previously described, tipping
teeth around the centroid of the root
requires less force (35−60cN, depending on
the number of roots) and is achieved much
more readily than either bodily movement
(70−120cN), or root movement centred
on the crown (50−100cN), ie torquing
movements. Many orthodontic cases
require retraction of canines following the
removal of first premolar units. Favourable
mesially angulated canines can be tipped
easily into the desired position with little
strain on anchorage. This is because the
estimated 45cN of force required to tip the
canine can be dissipated across the roots
of the anchor teeth, principally the second
premolar and first molar, and will be well
below the optimal level for their movement.
In the case of a distally angulated canine,
the force required to move the root distally
will be much greater, around 50−100cN.
This in turn will lead to a greater reciprocal
force on to the anchor teeth and this is
also likely to be for an extended period of
time. The resultant reciprocal force may
more closely approach the optimal level for
movement of the anchor teeth, particularly
if the anchor teeth are themselves able to
tip mesially. This model can also be applied
in the case of proclined incisors, which
require simple tipping to reduce an overjet,
versus retroclined incisors that require
palatal root movement.
Anchorage is not exclusively
about preserving space. Good anchorage
management will aim to leave the
patient with no spaces to close at the
end of treatment. This may entail actively
encouraging anchor teeth to move as part
of the planned mechanics, often called
planned anchorage loss.
Choice of planned extractions
The most common teeth to
be chosen for extraction are the premolar
teeth owing to their location close to the
site of anterior crowding. First and second
premolars, although similar in mesio-distal
width, will yield different amounts of space
for orthodontic treatment. This is related to
the different contributions they will make to
anchorage creation.
When the first premolar is
extracted, the posterior anchorage block
will include the second premolar and
molar so that the canine can be retracted
directly into the extraction space. If the
second premolar is extracted, then an
extra unit is added to the anterior teeth
block, increasing its anchorage value and,
furthermore, the first molar can more easily
move mesially into the extraction space.
Therefore more space is created to align
the labial segment from the extraction
46 Orthodontics
of a first premolar compared to a second
premolar and more anchorage is ‘created’
for correction of the malocclusion.
If only small amounts of
space are required for correction of a
malocclusion and the anchorage need
is considered to be low, interproximal
reduction may be considered for space
creation rather than extraction of teeth.
Approximately 0.25mm of enamel can be
removed from each tooth at each contact
point and up to 6.4mm of space can be
gained across the molar and premolar
contact points, depending on the shape
and size of the teeth.12
Sometimes other factors, such
as caries and abnormal tooth position, will
dictate which teeth need to be extracted
as part of the orthodontic treatment. This
can transform an averagely demanding
case into one that has high and complex
anchorage demands, depending on the
resultant anchorage balance.
Methods of supporting
anchorage
Anchorage can be divided
into two principal types, extra-oral and
intra-oral and within the latter it can be
classified as being within one arch or
intra-maxillary, or across two arches, inter-
maxillary. The source of any tissue-borne
anchorage can be used in the description,
namely teeth, soft tissues or bone. We will
consider each in turn along with any sub-
classification.
Figure 4. Simple anchorage between the first
molar and first premolar.
b
Figure 5. Compound anchorage to retract the
canine against a three tooth anchor block.
Intra-oral anchorage
Intra-maxillary from teeth
Intra-maxillary anchorage from
the teeth within the same arch can be
sub–classified according to the treatment
mechanics used:
 Simple anchorage. This is where the
movement of one tooth is pitted against
another and the relative movement of each
is proportional to their root surface areas.
Usually this will be a multi-rooted molar tooth,
with its large root surface area acting as the
anchor tooth for the movement of a single-
rooted tooth. There will be proportionately
greater movement of the single-rooted tooth
and lesser movement of the anchor tooth
(Figure 4).
 Compound anchorage. This is when more
than one tooth is used in the anchorage
unit. The sum of the root surface areas of the
anchor teeth is again greater than the root
surface area(s) of the tooth or teeth to be
moved. It is therefore anticipated that there
will be less movement of the anchor teeth
and greater movement of the active tooth or
teeth than in simple anchorage. An example
of this is when a canine is retracted into a
first premolar extraction site (Figure 5). By
adding the second permanent molars to the
anchor block, the anchorage value becomes
even higher and, by moving just one tooth
at a time against this anchorage, inadvertent
space or anchorage loss will be minimized.
 Reciprocal anchorage. This is when an equal
force is applied to equivalent teeth, in order
to achieve equal movement of the two blocks
of teeth. This type of anchorage is used for
the central incisors when closing space such
Figure 6. (a). Reciprocal anchorage to close a median diastema.
Figure 6. (b) Reciprocal anchorage for maxillary expansion.
April 2015
as a median diastema (Figure 6a) or for blocks
of posterior teeth when making transverse
corrections, such as bilateral maxillary
expansion (Figure 6b).
 Stationary anchorage. As previously
described, different types of tooth movement
require different amounts of force, eg tipping
requires less force than bodily movement and
this difference can be utilized in anchorage
management. Therefore if the anchor teeth
can only move bodily, whilst the other
tooth or teeth to be moved can be tipped
into position, then anchorage loss will be
minimized. This would classically be the case
when retracting proclined upper incisors
into extraction spaces (Figure 7). This is called
stationary anchorage and, although used in
all fixed appliance techniques, it is particularly
used in Begg and Tip-Edge therapy. Here,
bends in the wire, known as anchor bends, are
used to prevent mesial tipping of the crowns
of the molars, whilst simultaneously retracting
the upper incisor teeth by tipping the crowns
palatally.
Inter-maxillary from teeth
So far we have described tooth-
borne intra-maxillary anchorage. It should be
remembered that the same classification of
simple, compound, reciprocal and stationary
could also be applied to inter-maxillary
anchorage, where the teeth in one arch
provide anchorage for those in the opposing
arch. This can be as obvious as good
interdigitation resisting mesial movement of
the opposing buccal segment teeth. More
commonly specific treatment mechanics are
employed to this effect.
April 2015 Orthodontics 47

a b

Figure 7. Stationary anchorage from the first

molar, restricted to bodily movement, to tip and
c d
retrocline the upper incisors.

 Intra-oral elastics. One of the simplest

forms of inter-maxillary anchorage is
the use of intra-oral elastics. They are
commonly worn from attachments on the
molars to more anteriorly positioned teeth
in the opposing arch. The attachments may
be directly on the archwire or associated
Figure 8. (a, b) Class II elastics (c, d) Class III elastics.
with specific teeth, typically the canines.
The direction of the elastic is prescribed to
bring about the desired tooth movements.
Class II elastics, from the lower molars to
the upper anterior teeth (Figure 8a, b), are
used to reduce an overjet. Class III elastics,
from the upper molars to the lower anterior
teeth (Figure 8c, d), are used to increase or
gain a positive overjet.
In order to work effectively,
elastics are usually required to be worn
24 hours a day. Patients must be relied
upon to replace their elastics every day
and also additionally when they break. Not
all patients comply with this13 and fixed
variants have been developed to eliminate
the requirement for patient co-operation.
They are divided into two broad subtypes, Figure 9. The activation of a curved spring pusher on closure. Attachment of the spring is placed directly
springs and pistons. onto the archwire in the mandibular arch and then attached to a distal arm from the maxillary molar
 Springs. These are auxiliaries that are tube.
essentially Nickel Titanium (NiTi) coil
springs that have attachments on either
end to connect to the fixed appliances and
act as pushers. For correction of Class II these types of fixed corrector are prone to the Twin Block appliance,15 originally
malocclusions, the spring is attached in the fatigue and fracture during use.14 This is described by Clark.16 Fixed functional
maxillary molar region and in the canine costly, both in terms of time and money, appliances, such as the Herbst appliance,
region in the mandible. When the patient’s as it delays treatment and repair requires are also available with a reduced reliance
mouth is open, the spring is straight, but unscheduled extra appointments. Despite on patient compliance. However, they
as the patient closes the mouth, the spring improvements in design to mitigate are more prone to appliance failure.17
becomes compressed and may flex (Figure against this failure, this is still seen as a Most of the treatment changes seen
9). This activates the spring and generates a problem and goes some way to explaining with functional appliances are dento-
force to move the teeth. their limited adoption into widespread alveolar in nature with a small amount
 Pistons. These auxiliaries are connected clinical practice. of skeletal change contributing to the
in similar places to the curved spring  Functional appliances. Functional correction.18 These dento-alveolar effects
pushers, but they encase the NiTi spring appliances can either be used alone in the correction of a Class II malocclusion,
inside a piston instead of just allowing it to to treat a malocclusion or used to gain namely palatal tipping of the upper
curve. When patients close their mouths, anchorage prior to completing treatment incisors, labial tipping of the lower incisors,
the spring compresses within the piston with fixed appliances. They are most often distal movement of the upper molars and
providing the force to move the teeth. used for treating Class II malocclusions and mesial movement of the lower molars, are
However, as a result of constant activation there are many different designs available. largely a result of reciprocal anchorage,
and de-activation throughout the day, both In the UK, the most commonly used is with roughly equal effects in both arches.
48 Orthodontics April 2015

Other tissues a b
Soft tissue can be utilized
directly as a source of anchorage whilst
bone can be utilized either directly or
indirectly.

Soft tissues
Anchorage can be gained from
the soft tissues and one example of where
this is the case is the lip bumper, which
can be used to resist mesial movement of
Figure 11. Anchorage from the palate. A shallow, inclined palate (a) gives less anchorage than a deep,
the lower molars (Figure 10). Using a lip
steep one (b).
bumper will also remove the lower lip’s
influence on the lower incisors, which in
turn may result in their proclination as a
be secured to the TAD. The force of the developed. They are usually 3−4 mm in
result of tongue pressure.19
wanted tooth movement is, in this case, diameter and 6 mm in length and are not
Indirect bony anchorage applied to the anchor tooth (or teeth) itself placed in the dental arch, but in the midline
The simplest indirect method supported by the TAD. of the hard palate. After a period of 13
is to use the vault of the palate to weeks for osseointegration, the implant
Endosseous dental implants is uncovered and the healing abutment
supplement anchorage and to resist mesial
Endosseous dental implants is replaced with a treatment abutment.
movement of the buccal teeth. This effect
are widely used in restorative dentistry Usually a transpalatal arch is constructed
can be harnessed through removable
for the replacement of missing teeth and to connect the implant abutment and
appliances or fixed transpalatal arches with
as abutments for bridgework. They are the buccal segment teeth; often the first
an acrylic ‘Nance’ button resting against the
typically constructed from titanium and, molars. The anterior dentition is then
palatal mucosa.20 The depth and inclination
once placed, osseointegrate with the retracted against the anchored buccal
of the palate will affect the anchorage that
patient’s alveolar or jaw bone. Placement is segment teeth (Figure 13a). Alternatively,
can be gained, with a deep vertical anterior
a complicated surgical procedure requiring the transpalatal arch can connect the
palate providing the maximum anchorage
preparation of the implant site and a canines to the implant abutment and
(Figure 11a, b).
period of healing of 4−6 months before the buccal segment teeth can be moved
The horizontal part of the
the implant can be used as an anchor for anteriorly against them (Figure 13b). As
palate is also excellent at providing vertical
tooth movements.21 Specific orthodontic these implants osseointegrate, removal can
anchorage when using an upper removable
abutments have been produced but often be difficult. A trephine is usually needed
appliance to extrude an unerupted ectopic
a temporary crown with an appropriate to remove the implant in a second surgical
maxillary tooth (Figure 12).
attachment is used, later to be replaced by procedure, possibly necessitating a general
Direct bony anchorage a definitive restoration after completion anaesthetic.
Direct bony anchorage can be of the orthodontic treatment. Using
gained from a series of devices collectively endosseous implants in this way requires
known as temporary anchorage devices that the final restorative position for the
(TADs), although they are not always implant is known and can be accessed, a
temporary. These include: as these are not temporary and will form
 Endosseous dental implants; part of the patient’s overall orthodontic/
 Onplants; restorative treatment plan.
 Miniplates; and Specific orthodontic
 Mini-screw implants. endosseous dental implants have been
TADs can be used either as an
anchor against which the force to move a
tooth or teeth is itself directly applied, or
alternatively an anchor tooth or teeth can
b

Figure 12. An upper removable appliance (URA)

Figure 10. A prefabricated lip bumper in situ.
with a buccal arm, constructed from 0.8mm
stainless steel and soldered to the molar crib, to
extrude the ectopic canine. Note the occlusal rest
on the UL4 to help resist the intrusive ‘reciprocal’
forces.
Figure 13. (a, b) A mid-palatal implant is used to
anchor teeth indirectly, against which the desired
movements can then be achieved.
50 Orthodontics
Onplants
Onplants are hydroxyapatite-
coated titanium discs, 8−10mm in
diameter, placed sub-periosteally on the
surface of the palatal bone, once again
in the midline22 (Figure 14). The onplant
osseointegrates with the bone surface and,
after a healing period of 10−12 weeks, it is
uncovered and an appropriate abutment
is screwed into the central implant thread
and impressions are taken for a transpalatal
arch. A transpalatal arch is then used in a
similar fashion to the conventional mid-
palatal implant. When the onplant is no
longer required, it can easily be removed
via soft tissue exposure and direct force
application with a chisel, usually under local
anaesthesia. Onplants offer an advantage
over the conventional mid-palatal implant
in that they are easier and less invasive to
place and remove and are also cheaper.
However, they have not been fully adopted
into common orthodontic use due to
higher reported failure rates than with
other TADs23 and are largely historical now.
Miniplates
Miniplates are either I-, T-, L- or
Y-shaped bone plates that are fixed to
the bone with fixation screws.24 They are
constructed from titanium and broadly
divided into three elements, namely the
body, the connecting arm and the head
(Figure 15). They are placed as part of a
minor surgical procedure, usually under
local anaesthesia. A flap is raised and
the body of the plate is screwed to the
bone using fixation screws. The screws
are usually sited apical to the roots of the
teeth and the flap is then repositioned.
The connecting arm is passed through the
attached gingivae to leave the head of the
miniplate exposed near to the dental arch.
Like other implants, the miniplate head can
be used to support direct force application
Figure 14. An onplant, separated into its two
component parts.
Figure 15. Miniplates of different shapes with a variety of heads.
to a tooth or teeth, or it can be used to
support the anchor teeth against unwanted
movement. The position of the head can
be optimized to enable force vectors to
be applied for good tooth movement. The
miniplate is easily removed with a small
surgical procedure at the end of treatment
under local anaesthesia. The placement
of the fixation screws away from the roots
of the teeth confers several advantages
(Figure 16) including elimination of the
risk of root damage during placement and
removing any potential interference with
planned tooth movement. Miniplates are
versatile since they can be placed in many
sites across both jaws to provide direct or
indirect anchorage where needed. The sub-
apical bone is of a better quality for implant
placement than inter-radicular bone and
the success rates for miniplates has been
reported to be as high as 91.4−100%.25
The temporary anchorage
Figure 16. Miniplate placement in the maxillary
molar region. The position of the screws away
from the roots of the teeth can be seen to
minimize the risk of damage but the head can
still be placed in an ideal location for anchorage
requirements.
April 2015
devices discussed so far all require surgical
procedures for placement and removal so
are often placed by surgeons rather than
orthodontists.
Mini-screw implants
Mini-screw implants are much
more straightforward to place and can be
placed using only topical anaesthesia or
a small amount of local anaesthesia. They
are subsequently removed, often with no
anaesthesia at all. Mini-screw implants
are made from either titanium alloy or
stainless steel, and they are surgical grade
screws that have modified heads to allow
attachment of orthodontic auxiliaries.
The screw has three components − the
intraosseous threaded screw, the smooth
transmucosal collar and the head (Figure
17). The intraosseous screw component
varies between 1−2mm in diameter and
6−11mm in length.26 Many different
companies supply mini-screws and
there are many variations in design of
the elements that make up the mini-
screw. Some screws require a pilot hole
to be drilled prior to placement, whilst
others are self-drilling, requiring no pilot
hole. The latter simplifies the process of
insertion and these mini-screws have been
shown to give better primary stability.26
In addition to their ease of
placement and removal, mini-screws
have several advantages over the other
available TADs, namely they are more
economical, they can be placed in a
variety of intra-oral sites and they can be
loaded immediately after placement. They
do, however, have some disadvantages.
Firstly, mini-screw fracture has been
reported and as a result it is recommended
that screws with a diameter of greater
than 1.3mm be used to minimize this
risk.27 Secondly, although mini-screws can
be placed into the intra-radicular bone,
which helps to provide anchorage with a
April 2015
vector as close to the plane of the teeth as
possible, it is clearly not possible to move
teeth through the site of the screw. Thirdly,
mini-screws are often placed near to the
roots of the teeth and care must be taken
not to place the screw into the periodontal
ligament or into the roots themselves.
A recent Cochrane review by
Jambi and colleagues28 concluded that
surgical anchorage is more effective than
conventional anchorage, with mini-screw
implants appearing particularly promising.
However, a recent multicentre randomized
clinical trial,29 comparing TADs, headgear
and Nance button palatal arches, found no
difference between the three techniques
for anchorage support, although better
quality orthodontic results were achieved
when using TADs.
A naturally occurring bony
anchorage device is an ankylosed tooth.
This arises when replacement resorption
causes the tooth to become fused
directly to the bone, often as a sequela
of trauma to the tooth.30 Teeth that have
become ankylosed are not amenable to
orthodontic alignment but can be used
for absolute anchorage, against which the
rest of the dentition may be moved. The
ankylosed tooth may be retained following
orthodontic treatment if in a favourable
position, or surgically removed once it has
served its purpose for anchorage.
Methods of minimizing
anchorage demand
So far we have discussed the
principles of anchorage management and
some of the intra-oral devices that can
be used to preserve anchorage utilizing
the teeth, soft tissues and bone. There
are, however, other means by which the
orthodontist can help to manage the
anchorage.
Push-pull mechanics
By using ‘push-pull’ mechanics it
is sometimes possible to move two teeth in
opposite directions to create space between
them, whilst simultaneously helping to
preserve anchorage. One example would
be where space is to be created for a
palatally excluded upper lateral incisor and
the central incisor and canine are in close
approximation. By simultaneously using
push coil between the central incisor and
canine and retracting the canine against the
buccal segment teeth, the upper centreline
can be corrected and the canine retracted
to a Class I relationship, whilst reducing the
strain on the buccal segment anchor block
on both sides of the arch (Figures 18 and 19).
Figure 17. A mini-screw and its component parts.
Figure 18. The top image shows a palatally
placed upper right lateral incisor and shift of
the upper centreline to the right. By using push-
pull mechanics (bottom left image) the space
for the lateral incisor is created by simultaneous
retraction of the canine and correction of the
centreline. If pull only mechanics are used it may
be more difficult to correct the centreline (bottom
right image).
Figure 19. Push-pull mechanics being used to
open space for the upper left second premolar.
Controlling tooth movement
As discussed previously, the
rate of tooth movement will be affected
by several factors, including the density of
the surrounding bone. Since mandibular
Orthodontics 51
bone is more dense than the maxillary
bone, especially in the molar regions,31
and maxillary teeth have been shown to
move significantly more than mandibular
teeth in animal models,32 it would be
expected that more anchorage is to be
gained from the mandibular molars than
the maxillary molars. Similarly, cortical bone
is more dense than cancellous bone and
manoeuvring the roots of anchor teeth into
the cortical plate is thought to slow their
movement and therefore increase their
anchorage value.33 Active management of
anchorage demanding tooth movement
can be achieved using the following
methods.
Tip back and toe in bends
We have already discussed
tipping versus bodily movement in
anchorage preservation. By actively
tipping teeth in the opposite direction to
their preferred movement, it is possible
to reinforce the anchorage further,
although it is not always as effective and
straightforward as it may seem. Second
order ‘tip back’ bends can be placed into
stainless steel archwires, usually between
the second premolar and first permanent
molar (Figure 20) with the aim of limiting
the molar to bodily movement. However,
they may often end up tipping the molar
too far distally, which then has to be
corrected towards the end of treatment
with an increased risk of anchorage loss at
this late stage.
‘Toe in’ bends are likewise
placed for molars in stainless steel
archwires, but are first order bends. They
are placed to rotate the molars distally
(Figure 21) and thereby counteract the
buccal flaring and rotation of the molars
that might otherwise occur as a result
of the buccally applied forces during
retraction, again ideally restricting the
teeth to bodily movement and limiting the
rotation. This utilizes the higher anchorage
value of bodily movement compared with
rotational movements.
Transpalatal and lingual arches
Transpalatal and lingual arches
come in a number of forms and are either
commercially available or can be custom-
made. They are usually fabricated from
0.9mm diameter hard stainless steel wire
soldered to bands on the first molars
(Figure 22) and, by maintaining the inter-
molar width, they have three theoretical
modes of action. Firstly, as the anchor teeth
try to move mesially into the narrower
anterior part of the arch, the roots of the
52 Orthodontics
Figure 20. A ‘tip back’ bend to the maxillary first
molar.
Figure 21. A ‘toe in’ bend to the maxillary first
molar.
Figure 22. A transpalatal arch.
Figure 23. A Nance button.
first molars will end up hitting the buccal
cortical plate, increasing the amount of
anchorage present. Secondly, any mesio-
lingual/mesio-palatal rotation of the
molars will be prevented and, thirdly, for
either molar to tip mesially, the other
molar cemented to the palatal arch on the
opposite side will have to tip by exactly the
same amount, which may not be possible.
Although the theory sounds plausible, in
practice it has been shown that transpalatal
arches have little effect in reducing
anchorage loss,34 and may even contribute
to it,35 possibly by lulling the orthodontist
into a false sense of security. However, as
discussed previously, a transpalatal arch
April 2015
may be used in conjunction with other
elements, such as a mid-palatal implant,
to good effect. They may also be helpful
at increasing vertical anchorage, such as
required during mechanical eruption of
an ectopic canine where they are used
to support the extrusive force from a
sectional rectangular NiTi wire.36
Similar to the simple palatal
arch, lingual arches are not very effective
in reducing anchorage loss as an Figure 24. The marked depression in palatal
unwanted effect can be proclination of mucosa made by a Nance button that had
the lower incisors.37 They are, however, become embedded into the palate and has just
effective in maintaining arch length been removed.
whilst awaiting tooth eruption. Nance, in
1947, described a modified palatal arch
where the arch is extended forward to mandible for anchorage and can be used
the anterior palate and where an acrylic to mesialize the upper arch teeth in a Class
button rests against the most vertical III malocclusion. In this case, elastics are
aspect of the palatal mucosa20 (Figure connected directly between the intra-
23). The intention of this appliance is to oral appliance and the cross member
gain antero-posterior anchorage from the of the facemask, without the need for
vertical component of the vault of the an intervening facebow. The challenge
palate in a similar manner to a removable with the use of the facemask is patient
appliance. However, Nance buttons can compliance with wear.
become embedded into the palatal
mucosa (Figure 24) with some anchorage
loss.38
Methods of anchorage creation
So far we have discussed
methods of anchorage preservation
Extra-oral anchorage and management. In cases of very high
The bones of the cranium anchorage demand it may be desirable
and facial skeleton can also be used to create additional anchorage and this is
to provide anchorage via the use of a usually achieved by distalizing the maxillary
headgear or a face mask in conjunction buccal segments, in addition to any
with either fixed or removable appliances. planned extractions.
Headgear is connected to the teeth
via a facebow and the force is usually Extra-oral traction
primarily directed to distalize the teeth. The use of headgear for
The vertical component of force can be maintaining anchorage has already been
altered by varying the direction of pull discussed but, by increasing the force to
− occipital, cervical or combination pull 400−500g per side and increasing the
(Figure 25).
The duration and the
magnitude of force required for
anchorage is 250−300cN of force per side
for 8−10 hours a day.
There are rare reports of
injuries as a result of wearing headgear
and a number of safety features have
been incorporated into the appliance
to help prevent this occurring. 39 They
aim to prevent release of the facebow
from the molar tube, limit the elastic
recoil if the facebow is inappropriately
pulled away from the teeth, or to blunt
the ends of the facebow to minimize
the risk of penetration injuries. The
British Orthodontic Society guidelines
recommend at least two separate safety Figure 25. Headgear can be applied occipitally
features must be in place whenever a (blue), cervically (red) or a combination (green)
patient is wearing headgear. 40 of both. The circles represent the points of force
A reverse pull headgear or application and the arrows the resultant force
facemask uses the frontal bone and the vectors.
April 2015
hours of wear to a minimum of 12−14
hours per day, distalization of the buccal
segments can be achieved. This can be
optimized through the additional use of
a ‘nudger’ appliance.41 Figure 26 shows a
simple ‘nudger’ design that could be used
in conjunction with molar bands with head-
gear tubes. The use of the ‘nudger’ means
that additional anchorage is incorporated
using the vertical component of the palate.
However, patient satisfaction with headgear
is low and non-compliance can be an
issue.42 If the headgear is not worn whilst
using a ‘nudger’ appliance, this may result
in the overjet increasing as antero-posterior
anchorage is lost. This is particularly difficult
to detect if a lower fixed appliance has
been placed at the same time and some
lower incisor proclination has taken place.
Fixed molar correctors are also
available to achieve molar distalization and
create anchorage. Commonly used molar
correctors include the pendulum, Distal
jet (Figure 27) and Jones jig appliances.
They are similar in principle to the ‘nudger’
appliance, but instead are fixed to the
teeth. They are designed to utilize the
vault of the palate to act against the
active components distalizing the buccal
segments. Despite this, anchorage can
be lost and can be seen as unwanted
proclination of the upper incisors with an
increase in the overjet along with mesial
tipping of the premolars.43 In a recent
Cochrane review it was concluded that
greater molar distalization is achieved with
Figure 26. A simple ‘nudger’ appliance design
where forced extraction of second premolars has
left a high anchorage demand.
Figure 27. Distal jet appliance.
intra-oral appliances than with headgear,
but that it comes with a greater loss of
anterior anchorage.44
Skeletal anchorage, obtained
through using TADs, can also be used to
distalize teeth and create anchorage. Force
can be applied directly from the TAD to
distalize teeth, or indirectly from teeth that
are anchored to the TAD, against which the
buccal teeth are distalized.
Assessment of anchorage loss
The ability to assess anchorage
loss is an important part of clinical
orthodontics. Regularly assessing the
anchorage requirements during treatment
is good practice as it allows judicious
changes to be made to treatment
mechanics, where necessary. Clinically,
the simplest assessment of anchorage is
to check that planned tooth movements
are occurring. Regularly reviewing the
remaining space within the arch, checking
the molar and canine relationships,
position of the centrelines and any overjet
correction all contribute to this ongoing
assessment.
This clinical impression may
also be supplemented with radiographic
assessments, most often using two or
more lateral cephalometric views taken at
different time points during treatment. The
changes in tooth position can be assessed
against stable reference points, such as
those described by Björk.45 Commonly,
lower incisor inclination relative to the
mandibular plane and the change in
molar position are used as indicators
of anchorage loss. The disadvantage of
using cephalometric radiographs to assess
anchorage loss is that features such as the
molar relationship can be difficult to judge
due to superimpositions in addition to the
increased radiation exposure risk to the
patient.
Study models, either plaster or
3D, can also be used to monitor anchorage.
They are used routinely in the clinic to
assess changes in tooth relationships and
arch form. It is also possible to measure
changes against supposedly stable
structures such as the palatal rugae.46
These have not always been found to be
completely stable, especially during periods
of facial growth.47 In addition, identifying
the medial aspect of the most stable third
palatal rugae, in itself, can be difficult. As a
result, this method of assessing anchorage
loss is usually only used for research
purposes. With the increasing use and
reliability of digitally scanned models48
and further development in scanning
technology, this may however change.
Orthodontics 53
Conclusions
It can be seen that anchorage
is a complex subject and there will
always be challenging cases that test the
orthodontist’s understanding of anchorage
demands and means. However, careful
pre-treatment assessment of anchorage
requirements with regular in-treatment
monitoring and management of anchorage
is key to obtaining excellent orthodontic
results.
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