Anchorage for fixed appliance

1. Anchorage for fixed appliance
By Prof. Dr.Maher Fouda
Orthodontic department- Faculty
of dentistry- Mansoura University

2. Anchorage is the term
used by orthodontists to describe the process of ensuring that desirable tooth
movements occur and undesirable tooth movements, in all three dimensions,
are prevented. In brief, it is the control of unwanted tooth movement.

3. Action and reaction to orthodontic forcePower chain elastic
retracting canine
Power chain elastic retracting canine
Closing arch to retract upper incisors

4. Bodily canine retraction with a rectangular
sectional archwire. 65| have moved forward
as a reaction to distal movement of 3|. The
arrows illustrate a distal force applied to 6|6
using E.O.T.
Activation of a
canine retraction
sectional (active).

5. Canine retraction with power chain
elastics from canine bracket to the first
molar

6. Retraction of maxillary incisors by looped arch wire

7. The Nance appliance or Nance palatal arch (NPA) was
one of the earliest modifications of the TPA, first
described in 1947. The palatal wire is welded/soldered to
the molar bands and is connected anteriorly by an acrylic
button positioned in the
highest part of the palatal vault resting on
non‐compressible mucosa. The button is made of
heat-cured, cold-cured or light cured acrylic. Light-
cured composite has also been used. Modifications
of the wire design and minor alterations in the
position of the button can also be made
Anchorage is conserved in the fixed appliance by: 1-Nance button

8. 1-Nance button
Anchorage is conserved in the fixed appliance by:
2-Modified Nance button on the
premolars to distalize the molars
Modified Nance button
with adjustable loops

9. A, A lingual sheath holds the palatal bar (8-degre
medial offset). B, The lingual
sheath is welded to the maxillary first molar band;
a gingival hook is used. C, A close-up distal
view of the lingual sheath. D, A maxillary left molar
with a palatal bar held in place with an elastic
attached to gingival hooks.
A transpalatal bar with a
U-loop positioned
generally
toward the mesial
This appliance can be bonded on the molars or
soldered to the molar bands (fixed anchorage) or
inserted in sheath boxes attached to the molars
(removable anchorage)

10. 1. This anchorage leans on the hard palate in order to resist mesial molar migration during the
anterior retraction phase.
Advantages OF Nance button
2. Cheap and easy to make. 3. Can be used in the mixed dentition in cases of premature
tooth loss to preserve leeway space, as in the permanent dentition as anchorage maintaining
the space of the extraction site. (29) 4. Maintains dental arch length.
Anchorage is conserved in the fixed appliance by :1-Nance button

11. 2. The appliance can dislodge if it is removable. 3. Laboratory time consuming. 4.
Not always well tolerated by the patient because of the food entrapment under the
acrylic dab. 5. The bigger the dab, the greater the anchorage, but there will also be
more food entrapment. 6. In cases where the button is directly bonded to the
molars, it can loosen due to the force of the occlusion.
Disadvantages
1. Can ulcer the hard palate due to the fact that the acrylic dab can retain food
particles or to the excessive anterior retraction force that may impinge it against the
palate
Anchorage is conserved in the fixed appliance by : 1-Nance button

12. Recommendations regarding Nance button
1. Short use periods in order to avoid ulcers. 2. Polish well both sides of the
acrylic dab at the moment of fabrication. This will lessen food retention. 3. Not
recommended for patients with bad oral hygiene. In this case it is best to apply
other anchorage appliances. 4. Leave the dab borders as rounded as possible so
it will not impinge itself in the palate. 5. The bonded Nance button helps
maintain periodontal integrity, more so in patients with periodontal problems.
Anchorage is conserved in the fixed appliance by :

13. 6. Remove the Nance button in a monthly basis if it is removable, this will
enhance hygiene in the patient. 7. In case it is fixed, instruct the patients to use
a syringe with a solution of water and Clorhexidine Gluconate under pressure to
avoid gum irritation or ulcer formation. 8. It may be placed at premolar level
while upper molar distalization is taking place with NiTi open coils.
Recommendations regarding Nance button
Anchorage is conserved in the fixed appliance by : 1-Nance button
premolar Nance for upper molar distalization with NiTi open coils.
Nance button on upper
premolar - molar

14. . A conventional Nance palatal arch in a
patient with a broad palate providing
anteroposterior anchorage for retraction
of the canine in space-opening treatment
for a missing upper lateral incisor
Nance palatal arch being used to maintain the
position of the second molars where the first molars
have been extracted. (Note: the button has been
positioned too vertical in the palate and this has
reduced the anchorage support of the appliance.)
Anchorage is conserved in the fixed appliance by:
2-Nance button in the upper arch

15. 2-upper transpalatine Arch (TPA)
Dr. Robert A. Goshgarian introduced this arch in
1972. It crosses the palate joining as one unit both
first molars; it is effective appliance forming an
anchorage unit that resists mesial molar movement .
The central loop is oriented either mesially or distally
Anchorage is conserved in the fixed appliance by

17. Or the transpalatal arch
It is constructed from 0.9 or 1.25 mm stainless
steel wire and crosses the palate to connect
one molar or premolar to a contralateral tooth.
This connection can be fixed by
welding/soldering or be
removable by insertion into a lingual sheath
on the molar bands. These molar band
sheaths are known as Wilson tubes or
Mershon attachments. A modification of the
attachment involves bonding the palatal wire
directly to the lingual surface of the molars
Anchorage is conserved in the fixed appliance by
2-upper transpalatine Arch (TPA)

18. Although the TPA does not provide absolute
anchorage, it is used as an adjunctive appliance
during orthodontic treatment to control anchorage
in the vertical, transverse and sagittal (antero-
posterior) dimensions. The extent of anchorage it
provides depends on the design and the
anatomical/morphological features of the palate.
Where the TPA is modified
by the addition of acrylic for the palatal vault , the depth and width of the palate
contribute to the potential increase in anchorage. Logically, a shallow and wide
palate has less anchorage potential than that of a deep-vaulted palate.
Anchorage is conserved in the fixed appliance by :
2-upper transpalatine Arch (TPA)

19. Addition of cyanoacrylate to temporarily
stabilize the resting arms on molars.
Fabrication of a TPA using 0.040”
Stainless Steel wire
BONDED TPA

20. Incision of the wax on the tissue surface with a sharp knife to
facilitate the removal of the appliance after bonding
Gentle injection of molten wax from the heated gun
on the entire wire length and around the TPA,
followed by cooling down

21. Pumicing then etching of the palatal surface
of first molars for 30 seconds. Rinsing and
drying until chalky white appearance is
observed and a layer of bond is added to the
etched surfaces, followed by air thinning
Application of digital pressure over the appliance
using a single finger. The appliance rests precisely
over the palatal surfaces of first molars

22. Packing of composite with the other hand
over the sandblasted arm and over the
palatal surface, followed by light curing
Removal of the wax tray around the TPA using a sharp probe
A final photograph showing
the bonded appliance
transferred precisely in the
designated position
BONDED TPA

23. It is best to fit the appliance before extractions
are undertaken or active orthodontic
treatment is commenced to avoid tooth
movement which can make fitting of the
appliance difficult, with the potential loss of
vital space. The traditional clinical steps
include prior placement of separators for 5−7
days in order for molar bands to fit well.
When selecting bands, it is a common
practice to choose bands one size bigger since
the lumen of the band can reduce during the
laboratory welding and soldering procedures.
Anchorage is conserved in the fixed appliance by
2-Transpalatine Arch (TPA) in the upper arch

24. The central loop is oriented either mesially
2-upper transpalatine ArchAnchorage is conserved in the fixed appliance by
Rationale When permanent maxillary molars move anteriorly, they rotate mesiolingually around
the large lingual root. The space between the buccal and lingual cortical plates becomes narrow
anterior to the first molar roots, preventing the molar from advancing directly and limiting its
movement to a rotation
The large lingual root contacts the lingual plate and acts as a pivot, allowing the 2 buccal
roots to rotate mesiolingually. The TPA reduces anterior molar movement by coupling
the right and left permanent molars together and, thus, preventing any possibility of
rotations.

25. .
Direct adhesion TPA used as anchorage at premolar
level while distalizing upper molars
It can be used as anchorage at
premolar level in conjunction with
Class II elastics while molar
distalization with NiTi open coils
takes place.
2-Upper transpalatine Arch (TPA)
Anchorage is conserved in the
fixed appliance by A Modified Transpalatal
Arch for Correction of
Bucally Placed Maxillary
2nd Molars

26. 3-Upper Chromosome Arch
1. Wire bending with the hollow chopped plier in the middle of the wire. 2.
After the bend is done the wire is adapted to the palatal vault. 3. Once
adapted to the palatine vault the center of resistance of the molars is
marked and distal bends are made.
The distal bends are made and the end of the wire is adapted to the palatal
aspect of the second molars.
Anchorage is conserved in the fixed appliance by

27. A second wire is bent in the middle and the ends are adapted to the palatal
aspects of upper first molars. These two wires are placed together and
soldered.
Soldered chromosome arch on working model. (chromosome arch can be
either bonded or soldered to the molar bands)
Anchorage is conserved in the fixed appliance by
3-Chromosome Arch

28. Anchorage is conserved in the fixed appliance
by
3-UPPERChromosome
Arch

29. Anchorage is conserved in the fixed appliance by 4- Upper double
transpalatal arch :
Anchorage is conserved in the fixed appliance by 5-Uppercombined Nance
and transpalatal arch

30. The lingual arch was used extensively by Nance in the mid-
1940s. The same 0.9 mm diameter wire is used for
construction as with the palatal arch . Again the stainless
steel wire can be either welded/soldered to molar bands,
inserted into molar sheaths (removable), or bonded directly
to the lingual surfaces of lower molars. The wire diameter
can be increased where greater rigidity is required.
However, Owais et al showed that, when using 1.25 mm
wire compared with 0.9 mm
wire, the increased wire stiffness results in increased
forces on the lower incisors and first molars.
Anchorage is conserved in the fixed appliance by:
3-Lingual arch in the lower arch

31. Modifications in wire construction allow direct attachments of exposed teeth
to the arch to improve patient comfort and allow initial traction.
Modified lingual arch as auxiliary in the mechanics
for lower molar verticalization.

34. An impression is taken over the bands; these are
repositioned in the impression, which is
decontaminated before transporting to the laboratory.
When the anchor molars are rotated, this makes band
placement difficult and so four options are available: 1.
Position the band in an offset position so that a rigid
stainless steel wire can be easily passed passively
through the molar tube bilaterally. This requires the
bands to be repositioned to the correct axial position
after molar derotation
2. Use an initial sectional fixed appliance to
derotate the molars before construction of
thetranspalatal or lingual arch
3-Lingual arch in the lower archAnchorage is conserved in the fixed
appliance by:

35. 3. Place the molar bands in the conventional
(correct) position with adjustment and
activation of the appliance at the
cementation stage to aid molar derotation; 4.
Use molar bands with convertible tubes
allowing sliding of the non-fully seated
archwire through molar tubes and aiding
molar derotation
Anchorage is conserved in the fixed appliance by:
3-Lingual arch in the lower arch

36. Extraoral anchorage
 Anchorage in which the
resistance units are situated
outside the oral cavity is
termed extraoral anchorage.
Various extraoral anatomic
units used as sites of
resistance are occiput, back
of the neck, cranium and
face. Examples of extraoral
anchorage include the use of
head gears that derive
anchorage from the cervical
or cranial regions and face
mask that derives anchorage
from the facial bones.

37. Anchorage is conserved in the fixed appliance by 4- extraoral appliance

38. EXTRA-ORAL ANCHORAGE AND TRACTION
General principles
 In practice, the distinction between extra-oral anchorage (EOA)
and extra-oral traction (EOT) is a matter of degree, although
confusingly the terms are often used interchangeably.

39.  Extra-oral anchorage is a method of
increasing anchorage and therefore is
designed to prevent forward
movement of the anchor teeth.
Extra-oral traction is a method of
achieving tooth movement, most
commonly in a distal direction.
 It is also sometimes used to try to
move the maxilla distally and/or
vertically, although in reality the net
result is rather a restraint of maxillary
growth.

40.  In order to achieve true
(orthopaedic) maxillary
movement, prolonged wear
with forces in excess of 500 g
over the years of active growth
is required, followed by
prolonged retention to reduce
any rebound growth. Perhaps
not surprisingly, most patients
are unable to sustain this level
of cooperation.

41. Extra-oral traction and anchorage
EOA EOT
Purpose Reinforcement of
anchorage
Tooth movement
Force 200-250 g 400 – 500 g
Wear required 10-12 hours 14 - 16+ hours

42. In addition to magnitude and duration, the direction of the
headgear force also needs to be considered, although this is of
more consequence with extra-oral traction.
A direction of force below the level of the occlusal plane
(cervical-pull headgear) will tend to extrude the upper molar
teeth and thus cause an increase in the vertical dimension of
the lower face.
Safety face-bow.

43.  Whilethis may be an advantage in
a patient with a reduced lower
facial height, it is contraindicated
in a patient with increased
vertical proportions.
 In the latter case, a direction of
pull above the occlusal plane
(high-pull headgear) is usually
preferable, as this will have the
effect of intruding the upper
buccal segment teeth and will
also tend to restrain vertical
maxillary development.
Cervical-pull
headgear with the
force produced by
an elastic strap. The
headgear is attached
to a face-bow and
the patient is also
wearing a rigid
safety strap.
High-pull
headgear attached
to a face-bow.
Safety face-bow

44.  To achieve distal movement of the
upper first permanent molars, a
force directed slightly above the
occlusal plane, through the centre
of resistance of those teeth, is
desirable.
 It is important to monitor the
direction in which the teeth are
being translated. For example, if it
can be seen that the crowns of the
teeth are being tilted distally, the
direction of pull needs to be raised
to counteract this.

45. Class II elastics

46. Anchorage is defined as the resistance to unwanted tooth
movement . Control of anchorage is one of the most
important aspects of orthodontics. Conventional methods of
reinforcing orthodontic anchorage like 1- Transpalatal arch
,2- Double Transpalatal arch,3- Nance button,4-
chromosome arch ,5-combined transpalatal and Nance
arch,6- Intraoral intermaxillary elastics ,7- lingual arch and 8-
Headgears etc, have certain practical limitations, including
complicated appliance design, produce unwanted reciprocal
effects, and neccessitates exceptional patient cooperation..
Newer anchorage devices like
microimplants though provide excellent
sites of force delivery without taxing
anchorage, have the disadvantages of
invasiveness and is expensive

47. Anchorage control is an important factor in the success of orthodontic treatment. There
have been many attempts to devise suitable anchorage methods, including intra-oral and
extra-oral appliances. These conventional methods do not provide reliable anchorage
without patient compliance and anchor loss.
Anchorage is conserved in the fixed appliance by 5-micro screws

48. When using skeletal anchorage such as osseous dental implants, miniplates, or micro
screws, the clinician can expect reliable anchorage without patient compliance. Among
these anchorage devices, microscrew implants have been increasingly used in orthodontic
anchorage because of their absolute anchorage, low cost, easy placement, and removal.
Anchorage is conserved in the fixed appliance by 5-micro screws

49. Anchorage is conserved in the fixed appliance by 5-micro screws

50. The small size of microscrew implants allow them to be placed in the bone between the
teeth, thus expanding their clinical application
Anchorage is conserved in the fixed appliance by 5-micro screws

51. Anchorage is conserved in the fixed appliance by
5-micro screws

52. Anchorage is conserved in the fixed appliance by 5-micro screws

53. Micro screw anchorage to retract canine and
enmasse retraction of anterior teeth
Anchorage is conserved in the fixed appliance by 5-microscrew

54. Nance arch is soldered to micro implant
Anchorage is conserved in the fixed appliance by 5- micro implant

55. Anchorage is conserved in the fixed appliance by5-microimplant

56. Anchorage is conserved in the fixed appliance by 5- micro implant