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13
Chapter

Anchorage
Nigel Harradine
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Introduction
Many factors can make a treatment difficult. An incorrect treatment plan, poor patient motivation, and
markedly malaligned teeth can all cause difficulties and these topics are all discussed in relevant chapters
of this book. A frequent difficulty is that of obtaining sufficient anchorage - particularly if a “six keys”
occlusion is our goal and if we are not aiming to move the lower incisors labially to ease the anchorage
demands. Andrews' textbook documents the causes of failure to achieve a six keys' occlusion and many of
the cases would require additional posterior anchorage to be finished to his suggested goals. The
anchorage available within one arch is related to space in that arch and that space is usually obtained by
extractions. Anchorage other than from this source has, with most biomechanics, involved enlisting the co-
operation of the patient. This chapter chiefly addresses the means by which the need for this co-operation
can be minimised and how the patients' efforts can be put to best use. Reinforcing anterior anchorage - as
in Class 3 or hypodontia cases - is discussed in the chapter on Managing Class 3 Malocclusions.

Sources of anchorage
Anchorage can be obtained from intra-oral and extra-oral sources and we should not forget the possibility
of favourable growth and the question of our ability to enhance it. This latter aspect is discussed in the
chapter on Functional Appliances. It is sensible to firstly summarise the possibilities for maximising intra-
oral anchorage.

Sources of intra-oral anchorage

• root surface area
As discussed below, this is a fundamental source of anchorage
• ? bony cortex
In spite of widespread hope that this may prove source of anchorage, there seems little
evidence that this is indeed the case. It is clearly not difficult to move teeth labially right
through the cortex. Rebellato et al (1997) found that lingual arches did not prevent mesial
migration of molars even when no intra-arch traction was applied. A study by Ellen,
Schneider and Sellke (1998) found no enhancement of vertical or horizontal anchorage
when using utility arches to set up cortical anchorage. These papers would also suggest
that palatal arches would not be expected to add to posterior anchorage.
• mucosa and underlying bone
This is the source of anchorage which is sought with Nance buttons, removable appliances
and lingual flanges on functional appliances. It is hard to measure, but appliances which
cover a larger area of mucosa would be expected to provide additional anchorage.
• occlusal interferences
Some extraction patterns e.g. upper first and lower second premolars can create useful
interlocking of the dentition and increase the root surface area resisting a loss of upper arch
posterior anchorage. Conversely upper canines stuck mesial to lower canines can lose
upper arch anchorage as can attempted reduction of an overjet in the presence of a
complete overbite.
• implants/onplants
These are a powerful source of intra-oral anchorage and are discussed more fully in a
separate section later in this chapter.

Maximising root surface area

Although far from proven, there seems strong indirect evidence that the differential force theory has
substance ie: that within limits, the rate of tooth movement is related to the applied force per unit root
surface area. For example, the study by Saelens and De Smit (1998) showed a greater mesial movement
of molars and a lesser amount of anterior crowding resolved when second premolars rather than first
premolars were extracted. Other studies supporting this theory are discussed in the chapter on Diagnosis
and Treatment Planning in the section on planning extractions. Maximising root area in the anchorage unit
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is therefore sensible when anchorage is at a premium. In addition to choosing more anterior extractions,
root surface area in the anchorage unit can be increased relative to the root area of the teeth we wish to
move by:

• including second molars

• separate retraction of canines
• correcting centrelines one tooth at a time
• semi-transverse forces eg: pushing rather than pulling canines distally

Practical considerations may lessen the applicability and effectiveness of any of these in a given situation,
but they are all useful sources of anchorage.

Evidence for the differential force theory

A further complication is that the data on the relationship between force applied and tooth movement
achieved has yet to confirm a clear picture of the relationship between the two. A study by Pilon et al
(1996) in beagle dogs showed that the rate of tooth movement and the amount of anchorage loss were not
significantly different for forces ranging from 50 g to 200 g. Some dogs had teeth that moved quickly and
others moved slowly regardless of the force level. The rate of movement was highly correlated between
the left and right sides for any dog and this suggests that inherent metabolic factors may be much more
important than force level in determining the rate of movement of teeth - including those in an anchorage
unit. Anecdotal clinical observation certainly suggests that human patients show similar variation in
orthodontic response to applied force.

It might be concluded from a casual reading of this important paper that the differential force theory was in
serious doubt in its entirety. However, tooth movement was still related to the root surface area -
anchorage units moved less than the individual premolar teeth. The ratio of movement was not the same
as the ratio between the root surface areas. The anchorage unit averaged ten times the root surface area
of the premolar and yet moved an average of 25% of the premolar movement, not 10%. Root surface area
definitely seems to matter i.e. there is some scientific support for the differential force theory, but we don’t
yet know the exact extent of its influence and there are clearly other factors which are important.

Later work by this same team Von Bohl et al (2004), confirmed the poor correlation between force level and
tooth movement or the degree of histological hyalinisation. This paper used an implant to cleverly compare
different force level per unit root surface area with no complicating anchorage loss. The paper also has an
excellent summary bibliography of force and pressure levels in previous studies. Numbers are necessarily
small in studies using beagle dogs, but figure 4 in that paper does show data which suggest that for that
dog, lower force favoured premolar movement whereas higher force favoured molar movement. A meta
review by Ren et al (2003) referred to over 400 studies of relevance, but it is clear that the details of the
relationship between force applied and tooth movement remain insufficiently understood or documented.

Root surface area – summary

• force level is only part of the explanation of rate of tooth movement
• spreading the force over larger root area does reduce the rate of movement (and thus
preserve anchorage)

Retracting six teeth at once

In extraction cases where anchorage is not at a premium, clinicians traditionally retract the canines until
there is sufficient space to align the incisors and then the complete labial segment of six teeth is retracted
as a unit as opposed to fully retracting the canines to a class 1 relationship and then retracting the incisors.
On theoretical grounds, retracting all six teeth simultaneously would be expected to increase anchorage
demands and although this increase is not necessarily apparent clinically, there must be good reasons for
choosing this theoretically more anchorage demanding plan. These reasons fall into two categories,
namely, simplicity and not re-tracing steps of tooth movement.
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Sliding all six teeth as a unit along a stiff wire involves very simple archwire fabrication and activation when
compared with three sectional archwires and closing loops. Also, the chances of trauma to the lips, cheeks
and gingivae are very small and the obstacles to oral hygiene are minimised. This method also makes it
easy to keep all teeth under control and at the end of space closure, there is no need to align the teeth for
a second time before finishing. These advantages must be weighed against the possible increase in
anchorage required.

Does the Straight-Wire Appliance use more anchorage?

Johnston et al (1998) reported that use of the Straight-Wire Appliance - probably involving the retraction of
the six front teeth simultaneously - cost 0.8 mm more anchorage (measured by his pitchfork analysis) in the
maxilla when compared to treatment with plain edgewise appliances. It must also be remembered in this
context that a fully programmed appliance makes it harder for the clinician to finish a case with inadequate
palatal root torque of the upper incisors and the slight extra anchorage requirement may be partly
explained by the achievement of more anchorage - demanding occlusal goals.

Self-ligating brackets and anchorage

The chapter Self-ligating brackets – theory and practice discuss in detail the potential benefits of using self-
ligating brackets such as SPEED, Opal, In-Ovation or Damon 2, 3 and MX. One such benefit is the ability
to slide a tooth along a wire with very low friction and with no loss of control. This previously unusual
combination reduces the potential disadvantages of separate retraction of canines. We would therefore
expect anchorage preservation to be enhanced if these mechanics are used with self-ligating brackets. It
has certainly been reported in a very interesting study by Rajcich and Sadowsky (1997), that retraction of
canines with sliding mechanics when the molar is prevented from tipping or sliding mesially incurs
impressively low anchorage loss. There are simpler ways of controlling molar tip and slide than the one
they suggest which uses an auxiliary arch. A crimped stop or hook is one of them. This combination of a
self-ligating bracket, a stopped archwire and separate canine retraction is worth close consideration for
anchorage enhancement.

Tipping and uprighting teeth versus bodily movement

Appliances such as Begg and Tip-Edge deliberately allow extensive distal tipping of anterior teeth followed
by a later phase in which the mesially tipped roots are moved distally. The differential force theory is
frequently quoted in this context in support of the idea that this two-stage movement will consume less
anchorage overall. This is another inadequately researched area. There is no doubt that tipping a tooth
requires less anchorage than bodily movement, because a given force is concentrated on only a small part
of the root area whereas in the anchorage unit where the teeth are held upright, the same force is spread
over the whole mesially-facing area of the roots and is thus much lower per unit area of root surface. What
has not been adequately explored is whether tipping and subsequently uprighting a tooth consumes less
anchorage than achieving the same result with more bodily movement. In that second phase, the force is
still resisted by the same root area in the anchorage unit, but is now also spread over the majority of the
root surface of teeth in which the apex is more mesially placed than at the start of treatment and must
therefore move distally through a large arc.

A study by Lotzof et al (1996) missed a potential opportunity to shed some light on this. Upper canine
retraction was compared within the same patient with a Tip-Edge bracket on one canine and a Straight-
Wire bracket on the other. The differences were not even close to being statistically significant, but
suggested that with much larger sample size, the Tip-Edge bracket might have shown that using the flawed
protocol chosen, 0.6 mm less anchorage loss over the approximately 11 week time required to retract the
canines. Apart from the small sample size (12 cases) the major reservation about the study is that the
tooth with the Tip-Edge bracket was, of course, allowed to tip distally but was not then uprighted. This
negates any sensible comparison of rate of retraction or anchorage loss. It is easy to be critical and this
study does reveal some of the practical difficulties in assessing the relative anchorage consumption of
differing mechanics. A very much better study reported by Bhavra at the British Orthodontic Conference in
2001 and as a poster at the BOC in 2003 and in a further presentation by O’Neill at the BOC 2004
compared treatment with Straight Wire and Tip Edge appliances in a randomised clinical trial. No
significant differences in the speed of treatment or nature of result were found. Although the relative
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amounts of headgear and class 2 traction are hard to quantify in anchorage terms, this excellent study
supports the view that tipping and then uprighting a tooth will consume the same anchorage as more bodily
movement to the same position.

Implants for anchorage

This source of intra-oral anchorage has been used and documented for many years, but has only recently
become available in forms which are sufficiently easy to place and have a good range of applicability.
Implants for orthodontic anchorage can be classified as follows:

• conventional implants in the line of the arch for later use as tooth-bearing implants.
Authors and speakers such as Vince Kokich (1996), have demonstrated the use of these for
many years. Their applicability is, however, severely limited by the small percentage of
anchorage-demanding occasions where a tooth-bearing implant is both feasible and
subsequently useful
• short, but otherwise conventional palatal implants. These are now a well-recognised
and documented source of anchorage, but are still relatively expensive and complex. They
need careful siting in the palatal vault to ensure sufficient bone depth and no contact with the
roots of adjacent teeth and are therefore relatively inconveniently situated for a palatal arch
to take advantage of them. Usual sizes are 3-4 mm in diameter and 6-10 mm in length.
Traditionally they have been left to osseointegrate before force application. The article by
Tinsley et al (2004) gives an excellent description of a typical current use of these implants
and further practical tips can be found in two articles by Cousley and Parberry (2005) and
Cousley (2005).
• onplants (osseointegrated to the surface of the bone) These are potentially much
simpler and more versatile but have yet to be available commercially from Nobel Biocare.
They are based on the very impressive research reported by Block and Hoffman (1995).
After a further decade, they have yet to emerge as an available, commercially marketed
product
• microscrews. There has been a consistent trend towards smaller implants for orthodontic
anchorage. This enables a wider range of sites for insertion and recognises the lesser
requirements for osseointegration and longevity in an implant used solely for orthodontic
anchorage. Kanomi described the use of mini fixation screws in 1997. The problem of
accommodating an implant in an intact arch is the subject of papers by authors such as
Ohmae et al (2001), Park H-S et al (2001) and Bae and Park H-S(2002) These implants
measure typically between 1.0 and 1.4 mm. in diameter and 4 to 6 mm of intra-osseous
length. Placement between molars is feasible and successful use as sources of anchorage
is reported when forces are applied either immediately or two weeks after insertion.
Conventional osseointegration does therefore not apply in such usage. The reports to date
are of very small series, but are encouraging. Many companies are now supplying such
screws
• miniplates These were reported by Umemori et al (1999) and Sherwood (2002), and have
been championed by Hugo de Clerk from Belgium amongst others. The advocated
advantages are twofold: that the fixing screws are above the root apices and therefore much
less of a risk to the tooth roots. Secondly, the force application can be brought down to the
occlusal plane and easily avoid unwanted intrusion. A minus point is that a flap needs to be
raised for insertion and removal. Also the extra space required may render impracticable
some applications nearer the front of the mouth

Whichever type of implant emerges as the most popular and useful will depend on the extent to which the
following requirements are met.

• quick and easy to insert in a variety of sites without damage to adjacent teeth
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• convenient for application of orthodontic forces by a variety of means and in a variety of

directions
• available for force application soon after insertion. Several studies of immediate loading with
a variety of implants have shown clinical stability and successful anchorage with no
histological osseointegration. Interplaced fibrous tissue also facilitates implant removal.
• easily removed following use
• no patient discomfort at insertion, during use and following removal

It is too early in this rapidly developing field to be confident which type of implant will be the most widely
successful in the terms of these criteria. It is possible that some types will find a specific niche (perhaps
mini plates for molar intrusion?). Microscrews are certainly the easiest and quickest to place and remove,
can be used immediately and can be put in a wide variety of sites.

Microscrews
We have started to use microscrews over the past two years, to meet a variety of anchorage demands
including posterior movement of upper teeth, intrusion of molars to correct anterior open bite and mesial
movement of molars in hypodontia cases.

We have been using both the Aarhus system, developed by Professor Birte Melsen and co-workers, and
the Dentos AbsoAnchor system developed by Professors Jae-Hyun Sung, Hee-Moon Kyung and Hyo-
Sang Park who have carried out foundation research in the placement and immediate loading of such
screws. We have used 9 mm screws, which is an average length in current practice and more recently, 12
mm screws. These screws have approximately 6 mm and 9 mm of intra-osseous length respectively.

Many microscrews are described as self-drilling or self-tapping. These terms do not have strictly
consistent definitions. Self-drilling usually have a sharp, pointed end and are designed to need no
preliminary lead hole, whereas self-tapping screws are designed to be screwed into a pre-drilled leading
hole and have a blunter tip. We initially used the self-tapping approach, believing this more likely to give
better control of direction. More recently, emboldened by some experience and influenced by the fact that
the bespoke drills cost more than the implants and are used for about 5 seconds per site, we have
sometimes pierced the cortex with a small rosehead bur and then used the self-drilling technique. Insertion
is quick and relatively easy and orthodontists are used to lining up attachments in all three planes of space.
To date our experience has been very encouraging, but as always in orthodontics, two or three years are
needed to give a good view of a technique

The literature has seen a rapid increase in papers on microscrews – many of them case reports. Typical
examples are the three contiguous papers in the August 2004 edition of the Angle Orthodontist by authors
from South Korea, Taiwan and Japan. The Far East has made much of the running in this field. The first
paper is another by Professor Park and co-workers (Park et al 2004) and focuses on distal movement.
The next article by Yao et al describes molar intrusion by a combination of microscrews and miniplates and
the third by Kuroda et al also describes molar intrusion – in this case by unusually long microscrews. A
paper by Park H-S et al (2005) describes mass distal movement of maxillary and mandibular teeth using
such screws. In this study of 13 patients, the implant success rate of the screws was 90%. Many
clinicians, including ourselves, have found the success rate to be lower than this – perhaps 75%. It is still
early for there to be a large body of experience and research data, but almost all large orthodontic
meetings have several talks on this type of implant.

Measuring anchorage
In all the discussion about anchorage and anchorage loss, the relative merits of the various means of
assessing anchorage are rarely discussed. Assessment means comparison over time of tooth position
relative to a non-tooth structure. The data is either cephalometric or from study models.
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Cephalometric measures of anchorage

• lower incisor anteroposterior position. This is probably the most common method in
clinical practice. A more labial position of the lower incisors at the end of tooth movement is
conventionally considered to represent anchorage loss. Similarly, except in the treatment of
bimaxillary proclination or in some class 3 cases, a more posterior position of lower incisors
following treatment is considered to be unused intraoral posterior anchorage. Cephalometric
measures such as Lower incisor to Nasion-Pogonion, or Lower incisor inclination to
mandibular plane are used to assess this aspect of anchorage consumption/loss. The
reference structures being used are the Nasion-Pogonion plane or the mandibular plane or -
in the Steiner analysis - the line Nasion-B point. This is a simple and very useful tool, but
does have its limitations. In particular, it gives no information about the quantity of
anchorage provided to move teeth distally, only about the anchorage consumed.
• Pitchfork analysis. This is a very well known form of superimposition on bony structures,
described and popularised by Lysle Johnston (1985, 1996). This reference structure is
essentially the maxilla and zygoma. Johnston developed a comprehensive set of measures
relative to a mean functional occlusal plane, which provide a measure of anteroposterior
movement of upper and lower incisors and molars and the contributions of mandibular and
maxillary growth. Whilst still not providing full quantification of the anchorage work done (no
measurement of changes in incisor inclination or canine angulation), it provides an extremely
useful summary of the contributors to anteroposterior achievements.
• superimposition on other cranial structures. There are other well-known reference
structures, for example, De Coster’s line in the cranial base and Bjork’s ‘stable’ structures in
the maxilla and mandible. Each structure has its merits. A paper by Mannchen (2001) has
pointed out some disadvantages in the pitchfork analysis. The criticisms are essentially
twofold: Firstly, that the maxilla is not the best structure on which to superimpose, because
rotational changes of the maxilla during treatment will effect the resolved anteroposterior
components. Secondly, that the mean functional occlusal plane can also change and effect
the measurements relative to it. Mannchen compared the results when the same cases
were assessed using the pitchfork analysis and Bjork’s structures. He found a tendency for
the pitchfork to estimate more skeletal and less dental change (approximately 1 mm.)
compared to using Bjork’s structures. All reference structures have disadvantages – both in
principle and in terms of the practicalities of reliable identification and measurement of
structures.

Study model measurement

Over many years, there have been investigations of the suitability of the palatal rugae for superimposition
of changes in maxillary teeth. There has been a recent resurgence of interest in this method, prompted by
the developments in digital imaging which assist the recording, enhancing and measuring of the upper
study models. Hoggan and Sadowsky (2001) reviewed some of the previous papers and carried out a
study which concluded that palatal rugae landmarks are as reliable as cephalometric structures for
superimposition. However, it should be noted that the standard deviation of repeated measurements was
0.8 mm. or more for several of the measures. This would mean that a real difference of 1.6 mm. is
unlikely to be shown to be statistically significant. Indeed in the study, a difference of 1 mm. between the
cephalometric and study model measurements of the same parameter was not statistically significant. Of
course, this also reflects on the relative unreliability of cephalometric measures of molar position. Ashmore
et al (2002) have utilised different digitising techniques to measure molar movement in the vertical and
anteroposterior directions and concluded that superimposition on the palatal rugae was sufficiently reliable
to pursue as a method.

There is no ideal method of measuring anchorage loss and anchorage achieved, but cephalometrics
provides information of great value for both scientific and clinical purposes. The use of palatal rugae needs
further investigation, but with newer digital techniques and the advantage of good identification of tooth
landmarks, it may prove to have a useful place.
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'Fixed' class 2 traction

Intermaxillary traction - Class 2 in the context of this chapter - is a traditional way of transferring anchorage
from one arch to another. Such traction is frequently required in extraction cases where retroclination of
the lower incisors is not required and methods which reduce or eliminate the need for patient co-operation
in relation to Class 2 elastics are surely worth considering. Many appliances have been produced to try to
meet this aim. Most have not proved popular for a variety of reasons. Most commonly the problems are:

• excessive breakage rates of the class 2 device

• excessive breakage of the archwires or loss of adjacent bonded attachments
• difficult to place
o quickly
o with the correct activation
o in a position where occlusal forces do not lead to breakage or distortion and where
trauma to the cheeks is unlikely
• special attachments are required (e.g. oval upper molar tubes with the Klapper spring)

Devices, which are rapidly placed, comfortable, robust and effective, are clearly a big technical challenge,
but a form of class 2 traction which is effective and requires no active patient participation remains a very
worthwhile objective.

Types of fixed class 2 traction

• Saif spring
• Alpern interarch coil spring
• Jasper Jumpers
• Eureka piston spring
• Bite fixer
• Klapper superspring
• Forsus flat spring
• Forsus FRD spring
• TwinForce bite corrector
• Sabbagh spring
• (Fixed functionals- e.g. Fliplock Herbst)
Nickel-titanium springs which can withstand being tied in as class 2 'elastics' for several months were
disappointing as a product because of breakage problems. Such springs were available under the name
‘Saif springs’ The Alpern spring is a sheathed coil spring. All other fixed forms of intermaxillary traction
employ compression of an elastic device rather than extension.

Curving pusher springs

Several of the fixed calls 2 traction devices can be grouped together under this heading. When the patient
closes in a retruded mandibular position, the spring is compressed and curves buccally into the sulcus.
We tried Jasper Jumpers in the past on a significant number of cases and found their effectiveness
severely compromised by a very high breakage rate. A more recent version involves a snapaway
capability which is claimed to preserve the ‘Jumper’ for reassembly, but this perhaps just saves on
‘Jumpers’ rather than enhances treatment efficacy. A study by Stucki and Ingervall (1998) reports a 9%
breakage rate. Clinicians do report success however and this concept may prove its worth with more
robust springs. Weiland et al (1997) have reported cephalometric changes with the Jasper Jumper which
are typical of a tooth-borne functional-type appliance and overjet reduction in an average of six months, but
no mention of breakages or other technical problems. A more recent development of this idea is the ‘Bite
Fixer’. This has a coil spring which surrounds a flexible core rather than a central spring surrounded by a
flexible cover (the Jasper Jumper design). We have tried these and met with success but they, or the
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archwires to which they are attached, are not immune from breakage. One challenge with this type of
device is the need to build in a good range of action as the mouth opens by providing travelling space
along a wire. Forsus flat springs are leaf-like nickel-titanium springs. Other companies sell the same
spring under different names.

Tips when using Bite Fixers or other ‘curving pushers’

• if you have lower molar bands with double tubes, use them to place an auxiliary mandibular
wire from the lower molar to the main archwire just distal to the lower canine. This increases
the range of possible mandibular movement and prevents the need to remove a lower
premolar bracket. The auxiliary wires are easy to fabricate. The additional investment in
time, complexity and double tubes is reported to greatly increase patient comfort and
certainly reduces breakage
• if you use upper molar tubes with headgear stops, grind these off before cementing the
upper molar bands. Alternatively, it is possible (but more fiddly) to grind these off intra-orally
or remove and re-cement these bands at a later stage prior to fitting the Fixers. If you use
Nitom facebows, you will not use molar tubes with headgear stops anyway
• do not overactivate, especially at the first visit. This increases patient comfort. If the overjet
is large, the Bite Fixers will be passive when the mandible is postured forward as far as the
patient can achieve

Piston-type pusher springs

Eureka springs are compressed nickel-titanium springs in a piston arrangement. They are designed by
John De Vincenzo and manufactured in San Luis Obispo, California. An excellent study by Stromeyer,
Caruso and De Vincenzo (2002), measured the cephalometric effects in 50 consecutive cases which had
failed to cooperate with conventional elastic class 2 traction. The appliance was successful in achieving
class 1 canine and molar relationships in all cases in an average of 4 months (range 2 to 14 months). This
compares with an average of 27 months of treatment prior to starting the Eureka springs because of non-
compliance. The cephalometric changes were almost entirely dentoalveolar and of equal extent in upper
and lower arches. The average age at the start of the Eureka spring stage was 16.0 years, reflecting the
long previous treatment with no compliance. They are fairly technique-sensitive in terms of placement with
correct activation and positioning, requiring a tieback ligature to be accurately placed.

A more recent version of this concept is the Sabbagh spring which is of more robust dimensions and can
be used as a fixed functional or as a fixed class 2 traction device. The Forsus FRD is similar. The
Twinforce bite corrector is also a linear piston device. As the name suggests, these have two pistons
containing two springs which give a longer range of action and therefore, it is hoped, a lower breakage
rate. Another innovation is the use of a grub screw to attach the device to the archwire at the mandibular
end or at both ends. This latter attachment avoids the need for a molar headgear tube. These appliances
are easier to place and give a longer range of action without an auxiliary wire. Early versions suffered from
insufficient hardness of the grub screw, which could remove the hexagonal corners of the screw head and
render the screw impossible to tighten. This has now been modified. Longer experience will tell whether
they are sufficiently robust, comfortable and effective.

One factor shared by all the curving pusher springs and many of the piston-type springs is the need for a
headgear tube for the distal (maxillary) attachment. This has several disadvantages:

• one suspects that this would severely tax the bond strength of a molar bond and placing
molar bands is an additional chore.
• adjusting the attachment to ensure that the pusher-type (in particular) easily bypass the
archwire tube can be tricky – especially if the headgear tube is gingival to the archwire tube.

Fixed functional appliances

These differ from fixed forms of class 2 traction in that the force is stored in the muscles and ligaments
rather than in the elasticity of a metal spring.
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Types of fixed functional appliance:

• Herbst appliance
• Fixed twin-block
• Sabbagh appliance with spring element locked
• MARA appliance

The Mara appliance, popularised by James Eckhart, consists of two buccally placed wire ‘wedges’
attached to molar bands which interlock in a postured bite as do twin-blocks or the Dynamax. We have no
personal experience of these. We have not used fixed functional appliances until relatively recently but use
many removable functionals. More recently we have employed fliplock Herbst appliances (made by TP
Orthodontics) direct to rectangular tubing slid over the archwires. This promising approach is very similar
in its practicalities to the piston-type class 2 traction devices, but attachment is significantly easier - see the
chapter on Functional Appliances.

It is probable that one or two designs of fixed class 2 traction will emerge as robust, easy to attach,
comfortable and effective and these will steadily grow in popularity. Our impression is that the linear
piston-type devices or a non-elastic Herbst-type attachment will prove more robust and more comfortable
than the devices which compress into a curve towards the cheek. A large factor in the robustness of this
linear piston-type of device may come form the inherent extendibility and the lack of need for the end of the
device to travel along an archwire or auxiliary wire.

Headgear
Decline in our personal use of headgear
We have steadily used less headgear in recent years. Several reasons contribute to this trend. Some
relate to a slight shift in average treatment goals and others to availability of better technology for class 2
correction and anchorage control.

• functional appliances which have better compliance

• fixed functionals
• more class 2 elastics
• self-ligating brackets seem to reduce anchorage demands
• more lower incisor proclination accepted
• more arch expansion accepted

Direction of pull
We favour a direction of pull that is significantly above the occlusal plane in order to avoid a backwards
rotation of the mandible and the need to chase the retreating target of the lower incisors to obtain overjet
reduction.

The excellent review by Bowden (1978) of the effects of altering headgear geometry has more recently
been supported and amplified by Yoshida et al (1995) who investigated the initial direction of movement
within the periodontal membrane of upper first molars with headgear using magnetic sensors. These
authors support the view that a short outer bow ending opposite the centre of resistance of the molar offers
the best options. They highlight the disadvantages of too flexible an outer bow in inadvertently altering the
intended direction of force and they again point out the drawbacks of a cervical pull. It is however worth
noting that the comparative vertical effects of occipital and cervical headgear may not be entirely clear-cut
in clinical practice. For example, the paper by Burke and Jakobson (1992) revealed, as expected,
substantial differences in upper molar extrusion, but no clear short or long term differences in measures of
face height. O’Reilly et al (1993) show definite mandibular rotation from cervical headgear when compared
to occipital pull. It would still seem sensible to avoid upper molar extrusion since this is only desirable in a
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class 3 case where autorotation of the mandible is being deliberately sought. Of course, the skeletal
effects of headgear (see chapter on Functional Appliances) are not desirable in a class 3 case.

Clinical Tip:
• Always pull from above the occlusal plane

Force level
No single study of which we are aware has thoroughly investigated in a controlled manner the effects of
differing force levels. Many different papers have however shown very similar effects from widely varying
force levels. One irritation is that many papers do not make clear whether the forces quoted are total or
per side. It seems probable that force level is less important than force duration in a situation where force
application is inherently intermittent.

Clinical tip: We use forces of approximately 900 g total, which is roughly a medium level force in terms of
the intermittent wear and the root surfaces involved. (It has incidentally been shown that high forces if
required are tolerated much better if delivered by occipital rather than by cervical traction – O’Reilly 1993).

Hours of wear
Most of our small number of headgear patients only wear headgear in bed at nights. Most, but not all,
patients will co-operate sufficiently with headgear if asked only to wear it at night and several manoeuvres
can be employed to lessen the problem of non-compliance. One of the simpler measures has emerged
from a study by Cureton et al (1993a) who used concealed timers in the headgear of two groups of patients
to show that the use of headgear calendars increased the wear by an average of 2.6 hours per day and
also greatly increased the accuracy of the patients’ estimates of their hours of wear.

Clinical tip:
• We should all consider using headgear charts routinely

A further study by Cureton (1993b) using the same covert timers revealed that even experienced clinicians
are very inaccurate at assessing the actual hours of wear that their patients are achieving, although with
greater experience, orthodontists become more sanguine about the hours achieved (rightly) and lower their
estimates. These covert timers were not sufficiently cheap or robust for routine use, but a much more
modern inexpensive electronic device - the Affirm headgear traction module -has recently become
commercially available. We have assessed this device and the associated software in a study involving
random allocation to two groups, only one of which was aware that their hours of wear were being
recorded. The modules are inexpensive and effective at both tooth movement and at compliance
monitoring. The preliminary results of our study were presented as a prize-winning poster at the 2000
British Orthodontic Conference (Clark et al 2003). A clear finding is that patients wear their headgear much
less than the wear charts indicate. Subjects who were aware they were being monitored wore their
headgear an average of 1.5 hours longer per 24 hours. It may be worth investing in these monitoring
devices in order to know the truth about headgear compliance for an individual patient. A similar paper by
Cole (2002), in a small number of patients (16) over a short period (8 weeks) also showed some marked
lack of reliability in the recorded hours in a significant percentage of patients. Whist 69% wore headgear
for >84% of the time recorded on their chart, 31% were at 58% or less. However, the recent RCT
comparing palatal implants and headgear reported by Sandler at national meetings in 2005 reported very
good levels of headgear compliance and success.

Safety and headgear

Although reports of injuries from headgear continue to be rare in the literature (eg: Booth-Mason and Birnie
1988, Chaushu, Chaushu and Weinberger 1997), this is a topic which demands our continued close
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interest. Samuels (1996) and Samuels et al (1996b) have published surveys of the reported injuries in
many countries and have classified the reported incidents as follows:

• accidental disengagement when the child was playing whilst wearing the headgear
• incorrect handling by the child during the fitting or removal of the headgear
• deliberate disengagement of the headgear caused by another child
• unintentional disengagement or detachment of the headgear whilst the child was asleep

Efforts to reduce the chance of injury from the facebow continue to follow one of three strategies.

• prevention of release of the facebow from the molar tube

• limiting the force required to release the traction force from the facebow and thus preventing
elastic recoil injuries – catapult or slingshot injuries
• limiting the potential for damage by blunting or shielding all the ends of an inadvertently
released facebow.

Examples of the first strategy are the plastic safety straps (e.g. Masel type) and the customised facebow
locks developed by Samuels et al (2000). Safety straps have to try to square the circle of being tight
enough to allow insufficient movement for the bow to leave the tube whilst still being capable of insertion
and comfortable wear. In practice, this is usually achievable or at the worst, the facebow can be
inadvertently removed from the tubes with the strap still attached, but the inner bow will remain in the
mouth where the scope for serious, irreversible damage is extremely small and the range of possible labial
movement of the bow in response to traction is too small to permit a ‘slingshot/catapult’ type of injury.
Such safety straps are inexpensive, quick and easy to fix and to wear.

The customised facebow locks recommended by Samuels et al (2000) have become commercially
available as Nitom headgears or they can be made ‘in-house’ by a laboratory adding to a chosen facebow.
They are usually fairly easy to adjust and insert although with significantly rotated molars they can be
awkward to place. Adjustments to the length of the inner bow also require adjustments to the safety lock
wire. In many ways these represent the most logical and potentially effective method to date. A paper
describes the successful experience of a group of clinicians with these facebows (Samuels et al 2000).
One comment is that even the short outer bows are inconveniently long unless used with a snapaway
traction module.

Examples of the second strategy are the many snap-release headgears available of which some have
better mechanical performance than others (Postlethwaite 1989, Stafford et al 1998), but all possibly suffer
from the limits of their ambition which is solely to prevent one type of potential injury - the slingshot/catapult
type.

Examples of the third approach are the previous Guardian facebow from Lancer, which is still available
from GAC and the partially plastic bows made by Odontec. These are a sensible idea but significantly
more demanding to insert than an orthodox bow or a Nitom bow (especially if the molars are rotated or
instanding). We do not recommend this approach.

There is of course, no reason why more than one of these categories of safety measure cannot be
simultaneously adopted. In addition, it is essential that suitable verbal and written instruction is always
given about placing and removing the headgear and behaving appropriately when wearing headgear. The
British Orthodontic Society has published guidelines on headgear safety and Samuels and Brezniak
(2002), have published a review of this topic.
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Distalising molars/assisting headgear

Several devices have been described as means of assisting or replacing headgear in the distalising of
molars. Most of these are described as non-compliance devices

• repelling magnets
• compressed coilspring distaliser of various types, both buccal and lingual.
• Hilger’s Pendulum/Pendex appliance
• 'nudgers'

Repelling magnets
• Several authors e.g. Gianelly (1989) , Bondemark et al (1994) and Bondemark (2000) have
described this use of magnets for distalising molars. We have not tried them for several
reasons: other strategies work well, the force is inherently high initially with an exponential
(which is the opposite of the required pattern (obeying Coulomb’s Law)) and attaching
headgear simultaneously is not easy which leaves the problems of reciprocal forces and
anchorage loss.
• Bondemark et al (1994) elegantly showed that superelastic coils are more effective than
magnets in distalising molars and that this may well be associated with the much more
constant forces applied by the superelastic coils. The appliances were reactivated every
four weeks and the anchorage loss (no headgear was worn) was 50% of the 3 mm average
distal movement in 6 months. This anchorage loss is a serious drawback to these methods
of distalising molars without anchorage reinforcement and it must be assumed that in many
such cases, the upper incisors will finish further forward than at the start of treatment or - if
extractions are used - that the scope for upper incisor retraction is substantially reduced.
• Everdi et al (1997) also reported on a comparison between nickel-titanium coilsprings and
repelling magnets. Again, the coilsprings produced greater distalisation, in spite of the
magnets being reactivated at weekly intervals (!) to overcome the exponential decay of
magnetic force. The molar distalisation was accompanied by significant tipping
(approximately 9 degrees) in both methods. Anchorage loss was not even measured, but
the photographs in the article show that the first premolar has moved mesially as much as
the molar has moved distally from the second premolar. This suggests that the anchorage
loss was large.

Clinical tip:
• In the light of these papers, we remain disinclined to try magnets or to recommend them as a
means of distalising teeth.

Distalising coilsprings
Gianelly (1998) and Gulati et al(1998) have separately reported on the use of compressed coilsprings to
distalise molars with either fixed or removable Nance appliances to reinforce anchorage. Gianelly did not
measure anchorage loss. Gulati found approximately 1 mm. of mesial movement of all ten anterior teeth
for every 2.8 mm. of distal molar movement. The Wilson coilspring system also undoubtedly produces
effective molar movement but the reciprocal forces have to be opposed by class 2 traction and the remarks
above therefore apply.

The paper by Muse et al (1993) clearly shows that the class 2 traction to this appliance causes almost as
much mesial lower molar movement as distalisation of the upper molar and the upper incisors are extruded
by the class 2. If the co-operation with wearing the class 2 is not good then the upper incisors move
labially instead. It is interesting to compare the changes obtained by Muse in four months with those
described by Firouz et al (1992) using unassisted high-pull headgear instructed to be worn for 12 hours
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Author Method Anchorage loss in per day for six months. The rate of
mm. (usually the
premolar) per mm.
distalisation with headgear was 0.1
gain mm less per month than with the
Gulati Coilsprings 0.4 distalizing coils, but there was, of
Muse Wilson coilsprings 0.8 course, no anchorage loss with
Ghosh Pendulum 0.75 headgear alone and there was no
Byloff Pendex (tipping) 0.48
distal tipping of the upper molars as
with the coils.
Bussick Pendulum 0.32
Byloff Pendex (bodily) 0.53
Kinzinger et al Pendulum 0.69 / 0.48 / 0.41
Jones jig and distal jet
Gianelli Magnets 0.25
There are several named versions of
Itoh Magnets 0.5
compressed coilspring devices
including the distal jet (placed on the
Everdi Magnets and coils Not measured
palatal), Keles slider (also on the
Bondemark Magnets and coils 0.35
palatal) Keles and Sayinsu (2000),
Bondemark (2000) Magnets and lingual coils 0.6
Keles (2002) and Jones jig (buccally
Keles Coils 0.53
placed). They vary slightly in their
Ngantung et al Distal jet 1.2 (!) ease of use and in the usual force
Gianelli Coils and compressed Not measured levels. Jones jigs use an average of
loops
75 gm. force (Brickman et al 2000)
Runge Jones jig 1.00 (!)
and distal jets 240 gm. (Ngantung et
Haydar and Uner Jones jig 1.2 (!!) al 2001). However, the results are
Hoggan and Sadowsky Jones jig 0.8 similar. Data on anchorage loss for
Papadopoulos et al Jones jig 1.85(!) most of these appliances is shown in
Mavropoulos et al Jones jig 1.17(!) Table 13.1. The paper by Brickman
Fortini et al Screws 0.4 et al has some confusing apparent
Ferro et al Nudger + headgear 0.19 inconsistencies between the two main
tables and concludes that the results
Table 13.1: Anchorage loss with molar distalising appliances
are very similar overall for a Jones jig
and for headgear. Importantly, no
measurements involving the lower arch are included in this paper. Also the average overjet reduction in
this group was only 1.6 mm. A further paper by Papadopoulos et al (2004), measured anchorage loss with
a modified Jones jig. They too found it to be very expensive for anchorage. The overjet increased by 64%
and the premolars moved mesially by 185% of the molar distal movement! The paper by Chiu et al (2005),
comparing the distal jet and pendulum appliances (see below) found more distal movement and less
anchorage loss in the distalisation phase with the pendulum.

Clinical conclusion:
• Coilsprings used in this way do not therefore seem to confer benefit unless the labial movement of
the lower incisors is part of the plan and class 2 elastics are worn to enable harnessing of the
anchorage in the lower arch.

Pendulum appliance
This was described by Hilgers in 1992 and is analogous to a fixed ‘nudger’. The TMA distalizing finger
springs are inserted into palatal sheaths on the molar bands. A relatively high force of 230 g per side is
reported by Ghosh and Nanda (1996). As with the majority of these appliances, the anchorage loss is
resisted by a Nance button bonded to the first premolars. The advantage of the design is that patient
compliance with wearing the removable appliance is not required. In six months, an average of 3.4 mm
distal movement was achieved, with substantial variability and distal molar tipping of 8 degrees. The
anchorage loss was an average of 2.6 mm or 0.75 mm for every 1 mm of distal movement of the molars.
This is greater than the 0.25 mm and 0.35 mm anchorage loss per mm distal movement reported by
Giannelly and by Bondemark using magnets. A pendulum appliance is clearly a technique which loses a
great deal of anchorage and this may be related to the relatively high forces which are opposed by a
relatively small anchorage unit. The oral hygiene consequences of a Nance button in place for six months
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should also be considered. The paper by Kinzinger et al (2005) showed that less anchorage was provided
by deciduous molars than by premolars.

The Pendex appliance

This is a pendulum appliance with a midline expansion screw. Two papers by Byloff and Darendeliler
(1997) and Byloff et al (1997) have further quantified the effects with smaller (45 degree) activations
producing a reported initial force of 200-250 g. In the first paper, anchorage loss of the premolars was 0.5
mm for every 1 mm distal movement with a high average distal tipping of 14.5 degrees for the first molar.
The second paper describes a pendulum appliance with uprighting bends in the springs which were used
to upright the distally tipped molars in a second phase of activation. The overall rate of distal molar
movement was slower , but the distal tipping was reduced to an average of 6 degrees. The penalty was a
slightly higher percentage of anchorage loss - 0.54 mm for every 1 mm distal movement - and more
transmission of this anchorage loss through from the premolars to the incisors. A paper by Bussick and
McNamara (2000) with a large sample of 101 patients found an average mesial movement of the
premolars which was 32% of the distal molar movement.

A variation on this theme is the distaliser described by Fortini et al (2004), which uses bilateral screws with
a Nance button as the anchorage. This requires the compliance of the patient to turn the screws, but is
cemented to molar and premolar bands. The average anchorage loss per mm of distal molar movement is
shown in Table 13.1.

Anchorage loss with ‘non-compliance’ molar distalisers

This review of these appliances has focused on the high level of anchorage loss. It should also be
remembered that they only distalise two teeth (or four if the second molars are counted) whereas at least
eight of the anterior teeth will have moved mesially by approximately the amounts indicated in the table
above. Enthusiasts for these appliances refer to the benefit of palatal arches or Nance buttons in
preventing subsequent mesial movement of the molars when intra-traction is subsequently applied to
distalise the anterior teeth. This overlooks the fact that Nance buttons (or similar) failed to prevent
anchorage loss in the initial molar distalisation phase. The paper by Chiu et al (2005), comparing the distal
jet and pendulum appliances is unusual in looking at the outcomes, including anchorage loss, through the
entire treatment and not just the initial distalisation phase. Jasper jumpers, Nance buttons and in some
cases, headgear were used to support anchorage during the postdistalisation phase. In spite of this, the
upper molars ended the treatment more mesially positioned than at the start and there was “significant
flaring” of the incisors. It seems reasonable to contend that anchorage must be sought from outside the
upper arch at some stage if a significant overall net gain in distal tooth movement is to be achieved. The
long-standing theories of anchorage and the results from all the papers in Table 13.1 are still sufficient for
us not to have included these devices in our practice to any significant extent. More recently, specific
molar distalizing devices to use with palatal implants have been described (eg: Karaman et al 2002 with a
distal jet). This is a different scenario and the earlier remarks about implant-reinforced anchorage apply.

Nudgers
These are removable appliances with finger springs to aid distalisation of molars. They are intended to
assist headgear by holding on during the day to the progress obtained at night. A study by NH, mentioned
in the lecture on this chapter, has shown that this is indeed achieved to a clinically worthwhile extent. Used
without headgear, the remarks above on non-compliance molar distaliser apply equally to nudgers.
Several well-known clinicians such as Ten Hoeve and Cetlin (1983) have advocated such appliances. This
appliance can lessen the required hours of headgear wear and it is also a very useful way to get differential
movement in one quadrant when required. When we used more headgear, we found these appliances
very valuable. As always, there are potential pitfalls. These are:

Potential problems with nudgers

• excessive molar tipping which then needs uprighting
• excessive anchorage loss with an increase in overjet
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• a false sense of security which is dispelled when the nudger is discarded and the headgear
is insufficient on its own

Avoiding problems with nudgers

These problems can be very largely avoided if the following points are noted:

• only activate the spring by 2 mm and make them out of wire no thicker than 0.7 mm and
preferably 0.6 mm. If the headgear is not worn, then there should be virtually no detectable
distal movement. Headgear is the motive force and the springs should very largely only hold
on to what the headgear achieves. This is a significantly different situation from the use of
coils, finger springs or magnets described above.
• overcorrect the molar relationship
• if the molars look undesirably tipped, leave the nudger passive and raise the outer bow to
upright the molars before discarding the nudger
• use gentle initial aligning wires so that the headgear does not have to combat a sudden
heavy uprighting force if any tipping has occurred
• if concerned at the time of stopping the nudger, increase the headgear hours for one visit

These are all applications of the usual principals behind anchorage conservation. Ferro et al (2000)
published a study of 110 patients treated with a nudger and cervical headgear. They advocated gentle
activation (2-3 mm.) of the finger springs and found an average of 3.6 mm. distal movement of the molars
compared to untreated controls with an average of 0.7 mm. increase in overjet. The anchorage loss was
therefore 19% of the distal movement. This anchorage loss is not negligible but is lower than any of the
figures in the table above for non-compliance appliances and, of course, the headgear offers a plausible
means of maintaining the distal position of the molars once retraction of the anterior teeth starts.

Nudgers without headgear

Lewis and Fox (1996) published on their use of nudgers without headgear support, describing good
anchorage conservation in a majority of cases and advocating headgear via J hooks to the removable
appliance if anchorage loss occurs. They particularly favoured this technique in cases where the upper
molars are mesially rotated and the class 2 appearance viewed from the buccal is chiefly due to this
rotation rather than to a class 2 skeletal pattern with unrotated molars. When anticipating space gain from
molar derotation, the work of Braun et al (1997) should be borne in mind. These authors showed that
derotation of 22 degrees around the molar centre of resistance produces 0.7 mm of space mesial to the
first molar and impinges 0.2 mm on second molar space. Lewis and Fox (1996) reported the distal tipping
of the molar which would be anticipated without headgear to provide an uprighting moment. They also
advise consideration of second molar extraction if progress is slow and third molars are present. This
technique is probably more appropriate where the second molars have yet to erupt. If lower premolars are
extracted the anterior bite plane will also assist molar relationship correction by disengaging the occlusion.
Careful case selection and gentle activation are clearly important if the potential for anchorage loss is to be
minimised when headgear at night is not added.

Indications for using a nudger with headgear added at nights

• class 1 cases with class 2 molars
• class 2 division i with very irregular teeth
• class 2 division ii cases where distal molar movement is required
• adults needing distal movement
• asymmetrical molar relationships
These are all situations where the more powerful anchorage enhancing effects of functional appliances are
less suitable. We use few of these appliances but value having them at our disposal for some of the types
of cases on this list
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Skeletal anchorage system for open-bite correction
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Initial effects of treatment of class II malocclusion with Herren activator, activator-headgear combination, and
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Intrusion of the overerupted upper left first and second molars by mini-implants with partial-fixed orthodontic
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Yoshida N, Jost-Brinkmann PG, and Yamada Y. (1995)
Initial tooth movement under extraoral force and considerations for controlled molar movement
Angle Orthodontist 65: 199-208

Useful related references not referred to in this chapter

Carano A, Testa M and Siciliana G (1996)
The lingual distaliser system
European Journal of Orthodontics 18: 445-448
McSherry PF and Bradley H (2000)
Class II correction - Reducing patient compliance: A review of the available techniques
Journal of Orthodontics 27: 219-227
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