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Extra oral anchorage

H E A D G E A R S www.indiandentalacademy.com


Extra oral anchorage Principle use Forces derived from EOA Stabilize the position of the teeth Produce tooth movement Orthopedic changes

Extra oral anchorage

Extra oral traction www.indiandentalacademy.com


Extra oral anchorage Mild cases Cases with severe crowding and overjet Severe cases – additional space is required even after extraction

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Extra oral anchorage Application of EOF Face bow

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Extra oral anchorage Stops – inner bow

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Extra oral anchorage J hook head gear

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Extra oral anchorage Directional control Effects of EOF depends on

Duration Direction Magnitude 1 ounce – 28.35 gms www.indiandentalacademy.com


Extra oral anchorage Types of head gears

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Extra oral anchorage

Basic concept for types of head gears www.indiandentalacademy.com


Extra oral anchorage Relationship to the occlusal plane

Low pull High pull Medium pull

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Extra oral anchorage Low pull head gear

Extrusion of the molars www.indiandentalacademy.com


Extra oral anchorage

undesirable www.indiandentalacademy.com


Extra oral anchorage High pull head gear

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Extra oral anchorage

Intrusion of the molarswww.indiandentalacademy.com undesirable


Extra oral anchorage Medium pull head gear

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Extra oral anchorage

ď Ž

Protraction head gear

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Extra oral anchorage Orthopedic effects

Restrict forward and downward movement 350-450 gms/each side – 14hrs/day www.indiandentalacademy.com


Extra oral anchorage

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Extra oral anchorage Practical aspects

Good fitting bands

Inner bow – passive Should not contact any teeth Ant. Segment – between the lips Expansion – distalization www.indiandentalacademy.com


Extra oral anchorage Mandibular arch

Use of class III intermaxillary traction with head gear

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Mechanical aspect of anchorage Sliding mechanics Force is required for 2 purposes Bone remodeling Frictional resistance Controlling and minimizing friction is an imp. Aspect of anchorage control www.indiandentalacademy.com


Mechanical aspect of anchorage Friction ??? Frictional force

Nature of surface at the interface (rough or smooth, chemically reactive or passive, modified by lubricants) Independent of the apparent area of contact www.indiandentalacademy.com


Mechanical aspect of anchorage Real contact occurs only at a limited number of small spots: Asperities

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Mechanical aspect of anchorage Metal wire in a ceramic bracket

Stick slip phenomenon www.indiandentalacademy.com


Mechanical aspect of anchorage 2 other factors can affect the resistance to sliding Interlocking of surface irregularities Extent of plowing In clinical practice friction is largely determined by the shearing component

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Mechanical aspect of anchorage Surface quality of the wires NiTi > βTi > SS

Roughness

There is no correlation between surface roughness and coefficient of friction

β Ti has greatest frictional resistance www.indiandentalacademy.com


Mechanical aspect of anchorage Surface quality of the wires Changes in surface chemistry due to increased Ti content Cold weld effect

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Mechanical aspect of anchorage Possible solution to this problem

Alteration of the surface of Ti wires

Among all, SS/SS couple is most effective for sliding followed by CoCr/SS, NiTi/SS, βTi/SS www.indiandentalacademy.com


Mechanical aspect of anchorage Surface quality of the brackets SS brackets Ti brackets Ceramic brackets Ceramic brackets with metal slots Composite brackets Polycarbonate plastic brackets www.indiandentalacademy.com


Mechanical aspect of anchorage Flexibility of arch wire and width of the bracket

Force that pulls the wire into the bracket Self ligating brackets- reduced friction that allows more effective sliding- better anchorage control www.indiandentalacademy.com


Mechanical aspect of anchorage Magnitude of friction

Retraction springs Closing loops www.indiandentalacademy.com


Conventional Begg Differential force concept 1st premolar extraction 8 teeth extraction

Begg was applying the principles of differential forces www.indiandentalacademy.com


Conventional Begg Storey and Smith (1952) Statistical evidence confirmed the results of Begg’s clinical experience Edgewise app and springs

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Conventional Begg Storey and Smith (1952) Tooth with a greater root surface area needs greater force to be moved

canine: molar = 3:8 www.indiandentalacademy.com


Conventional Begg

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Conventional Begg Reason for different rates of movement of canines Storey and Smith presented the concept of undermining resorption Sandstedt (1904) Schwarz (1932)

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Conventional Begg Storey and Smith (1952) Teeth subjected to very high forces

Resorption of tooth investing tissues

Teeth are loosened within the sockets www.indiandentalacademy.com


Conventional Begg Use of differential forces Reduction of anterior overbite Use of anchor bends

Light wires Heavy wires www.indiandentalacademy.com


Conventional Begg Use of differential forces  Strang (1954) – Treatment problems, their origin

and elimination  Edgewise app  Closing extraction space requires more force  Use of head gears - recommended

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Conventional Begg Use of differential forces Space closure

Premolars bypassed Extra oral anchorage is not required www.indiandentalacademy.com


Conventional Begg Means of preventing anchorage failure

Use of thin round steel wires Anchor bends Stationary anchorage Premolars not bracketed Light torquing forces in 3rd stage Use of reverse torquing auxillaries www.indiandentalacademy.com


Refined Begg ( Dr. V P Jayade ) Differential force concept was misunderstood Excessive retraction Prevented in refined begg by applying efficient brakes along with heavy differential forces

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Refined Begg ( Dr. V P Jayade ) Perfect example of stationary anchorage Saggital Vertical transverse

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Refined Begg ( Dr. V P Jayade ) Stage I

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Refined Begg ( Dr. V P Jayade ) Active components in stage I Light or ultra light class II elastics

Lower class I elastics www.indiandentalacademy.com


Refined Begg ( Dr. V P Jayade ) Active components in stage I Upper palatal elastics / elastics from power arm (Jyotindra Kumar)

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Refined Begg ( Dr. V P Jayade ) Active components in stage I Upper Class I are seldom used

Uneven class I ,class II for midline correction www.indiandentalacademy.com


Refined Begg ( Dr. V P Jayade ) Anchorage considerations in stage I Palatal elastics or elastics from power arm Upper molars to be supported with TPA

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Refined Begg ( Dr. V P Jayade ) Anchorage considerations in stage I Conserving lower molar anchorage Stiffer wires Light or ultra light elastics Molar stops

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Refined Begg ( Dr. V P Jayade ) Anchorage considerations in stage I High angle cases Light anchor bends Light elastics TPA – away from the palate High pull head gear

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Refined Begg ( Dr. V P Jayade ) Anchorage considerations in stage I Transverse plane Stiffer arch wires Expansion in arch wires TPA Sufficiently expanded face bow or lip bumper

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Refined Begg ( Dr. V P Jayade ) Stage II – easiest Objectives

Maintain all the corrections of stage I Closure of extraction spaces Controlled tipping of anteriors Protraction of posteriors Correction of molar relation Correction of premolar crossbites and rotation www.indiandentalacademy.com


Refined Begg ( Dr. V P Jayade ) Stage II Archwires used Reduction in the anchor bend

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Refined Begg ( Dr. V P Jayade ) Braking mechanics Reversal of anchorage Def – the brakes reverses the anchorage site from posterior to anterior segment by permitting only bodily movement of the anterior teeth, instead of allowing them freedom to tip Braking springs/ T pins Torquing components www.indiandentalacademy.com


Refined Begg ( Dr. V P Jayade ) Braking springs

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Refined Begg ( Dr. V P Jayade ) Angulated T pins

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Refined Begg ( Dr. V P Jayade ) Combination wires

Material Ant. Seg – rectangular (022 x 018) Post. Seg – round 018

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Refined Begg ( Dr. V P Jayade ) Torquing auxiliaries 2 spur or 4 spur MAA – 010 / 011 Strong base wires

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Refined Begg ( Dr. V P Jayade ) Active components in stage II

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Refined Begg ( Dr. V P Jayade ) Active components in stage II

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Refined Begg ( Dr. V P Jayade ) Active components in stage II

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Refined Begg ( Dr. V P Jayade ) Stage III – most complicated and anchorage consuming Objectives of stage III Maintain all the corrections

Distal root uprighting auxilliary

Palatal root torquing auxilliary

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Refined Begg ( Dr. V P Jayade ) Stage III - objectives To achieve desired root movements Monitor anchorage in all 3 planes To correct the position of 2nd molars To monitor undesirable effects

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Refined Begg ( Dr. V P Jayade ) Stage III Reciprocal mesial crown moving forces Upper arch Lower arch

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Refined Begg ( Dr. V P Jayade ) How to overcome stage III problems??? Proper diagnosis and treatment planning Using efficient brakes Controlled tipping of incisors Use of heavy base arch wires Lighter auxiliaries and uprighting springs Light cl II elastics Reinforcement of anchorage Contraction and toe in built into the wires www.indiandentalacademy.com


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Tweed’s anchorage preparation Tweed Merrifield appliance Level Anchorage System Vari Simplex Discipline Rickett’s Bioprogressive Therapy MBT appliance

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Tweed’s anchorage preparation Tipping the posterior segment distally Lower posterior segment

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Tweed’s anchorage preparation When teeth are tipped distally as they are in anchorage preparation, osteoid tissue appears to be laid down adjacent to the mesial surface of the tooth being moved distally.�

- Kaare Reitan

Such conclusions do not make the necessity of anchorage preparation obselete www.indiandentalacademy.com


Tweed’s anchorage preparation

Clinical orthodontist who routinely create excellent facial changes are those who recognize the importance of and prepare anchorage in their practice

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Tweed’s anchorage preparation Concept Upright the mesially inclined lower posterior segment Terminal molar to be tipped distally Angle formed between the class II elastic and long axis of terminal molar

Mandible will be much more stable and will resist forward displacement www.indiandentalacademy.com


Tweed’s anchorage preparation After anchorage preparation, if movement does occur

Slow mesial bodily movement Anchorage not prepared Uprooting and elevation of the molars www.indiandentalacademy.com


Tweed’s anchorage preparation Tweed classified anchorage preparation First degree Second degree Third degree

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Tweed’s anchorage preparation First degree / minimal anchorage preparation ANB 0º- 4º, facial esthetics are good Discrepancy < 10 mm Mandibular terminal molars must be uprighted Direction of intermaxillary elastic pull should not exceed 90º www.indiandentalacademy.com


Tweedâ&#x20AC;&#x2122;s anchorage preparation Second degree ANB exceeds 4.5

Class II

Mandibular second molars should always be banded Must be tipped distally so that their distal marginal ridges are at gum level Direction of pull of intermaxillary elastics should always be > 90Âş www.indiandentalacademy.com


Tweed’s anchorage preparation Third Degree or Total Anchorage Preparation ANB does not exceed 5º Discrepancy – 14 -20 mm All posterior teeth (second premolar to terminal molars) are tipped distally Distal marginal ridges of terminal molars are below gum level www.indiandentalacademy.com


Tweedâ&#x20AC;&#x2122;s anchorage preparation Severe cases â&#x20AC;&#x201C; anchorage prepared in both the arches How to tip lower posterior segment ???

Sliding jig

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Tweedâ&#x20AC;&#x2122;s anchorage preparation

Lower anchorage preparation completed Lower canines and incisors retracted Upper extractions Class II elastics â&#x20AC;&#x201C; distal tipping of upper posterior segment www.indiandentalacademy.com


Tweed Merrifield appliance

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Tweed Merrifield appliance Attachments

022 edgewise slot Permits variety of archwire use

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Tweed Merrifield appliance Highlighting points â&#x20AC;&#x201C; Anchorage preparation

Sequential banding and bonding Sequential tooth movement Sequential anchorage preparation Directional force system

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Tweed Merrifield appliance Sequential banding and bonding

Less traumatic Longer interbracket span Heavy wires

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Tweed Merrifield appliance Sequential tooth movement

Enmasse retraction Placing all bends at a time Not followed

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Tweed Merrifield appliance Sequential anchorage preparation

High pull head gear Vertical spurs soldered Distal to Mb. Lateral incisor 10 â&#x20AC;&#x201C; 2 anchorage system www.indiandentalacademy.com


Tweed Merrifield appliance Sequential anchorage preparation

Distal tip achieved Read out 15ยบ www.indiandentalacademy.com


Tweed Merrifield appliance Sequential anchorage preparation

Before tipping premolars Read out to be performed

Distal tip achieved www.indiandentalacademy.com


Tweed Merrifield appliance During the course of treatment, various hooks are soldered

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Tweed Merrifield appliance Directional force system Defined as controlled forces which place the teeth in most harmonious relation with their environment

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Tweed Merrifield appliance

Favorable

Unfavorable www.indiandentalacademy.com


Level anchorage system Terrell L. Root Aim â&#x20AC;&#x201C; quantify the anchorage requirement 018 edgewise slot Mandibular molars â&#x20AC;&#x201C; 2 choices of distal crown tip

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Level anchorage system Anchorage â&#x20AC;&#x201C; Resistance to movement Distance to move Anchorage savers Those orthodontic adjunctive procedures that reduce the amount of tooth anchorage necessary to correct the malocclusion

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Level anchorage system High pull headgear to maxillary 1st molars or J hook headgear to anteriors: reduction in ANB by 1 degree every 6 months Palatal bar: decreases vertical descent due to tongue pressure. Delaying upper first premolar extraction by one year: reduces mandibular anchorage space by 1mm Class III elastics worn 24 hrs: flatten the curve of Spee and upright buccal segments at the rate of 1mm / month www.indiandentalacademy.com


Level anchorage system

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Level anchorage system

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Vari-simplex discipline-Alexander Vari – variety of bracket used Simplex – KISS principle fewer archwire changes

1. 2. 3.

Treatment philosophy – Tweeds fundamentals Anchorage preparation Positioning Mb incisors over basal bone Orthopedic alteration using head gear www.indiandentalacademy.com


Vari-simplex discipline-Alexander Key objective Non extraction therapy as far as possible Interproximal enamel reduction Control of Mb incisor position with â&#x20AC;&#x201C;ve torque

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Vari-simplex discipline-Alexander Bracket selection Twin brackets Lang brackets Lewis brackets

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Vari-simplex discipline-Alexander Anchorage considerations

Tip values

Gain in the arch length Promotes leveling 0° angulation in Mb 2nd molarâ&#x20AC;&#x201C; Need not to be uprighted excessively www.indiandentalacademy.com


Vari-simplex discipline-Alexander -5째of labial root torque Holds the Mb incisors to their original position

Major change

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Vari-simplex discipline-Alexander Head gears / Retractors Retractorsâ&#x20AC;&#x2122; ( Dr. Fred Schudy) Cervical, combination or high pull depending on growth pattern and control needed

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Vari-simplex discipline-Alexander Other intra oral appliances to control anchorage:

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Vari-simplex discipline-Alexander Other intra oral appliances to control anchorage: Mandibular lingual arch: sagittal and transverse control Lip bumper: - uprighting of mandibular first molars - distal force on lower molars - muscular anchorage www.indiandentalacademy.com


Rickettâ&#x20AC;&#x2122;s Bioprogressive Therapy Muscular anchorage Cortical anchorage

Nance button Quad helix Headgears: cervical, combination and high pull www.indiandentalacademy.com


Anchorage control in MBT 2nd principle of orthodontic anchorage Anchorage loss â&#x20AC;&#x201C; maximum in the first stage Def â&#x20AC;&#x201C; Tooth movement needed to achieve passive engagement of steel 19 x 25 wire of suitable arch form into a correctly placed 022 preadjusted bracket system

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Anchorage control in MBT Major reason for anchorage loss ??? Mesial tip built into the bracket system Anchorage control The maneuvers used to restrict undesirable changes during the opening phase of treatment, so that leveling and aligning is achieved without key features of the malocclusion becoming worse.â&#x20AC;&#x2122; www.indiandentalacademy.com


Anchorage control in MBT 1st step in anchorage control

Recognize the anchorage needs of the case

Diagnosis and treatment planning stage

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Anchorage control in MBT Eg â&#x20AC;&#x201C; class II div 1 Goal is set for incisor position - PIP

Class III www.indiandentalacademy.com


Anchorage control in MBT Mistakes in tooth leveling and aligning during early years

Roller coaster effect

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Anchorage control in MBT Roller coaster effect has been eliminated from the present day practice Reduced tip in bracket system Light arch wire forces Use of lacebacks instead of elastic forces

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Anchorage control in MBT Lacebacks for A/P canine control

Restrict canine crown from tipping forward www.indiandentalacademy.com


Anchorage control in MBT Lacebacks for A/P canine control Robinson â&#x20AC;&#x201C; 57 PM extn cases

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Anchorage control in MBT Restrict canine crown from tipping forward Distalizing canines without causing unwanted tipping

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Anchorage control in MBT Continued till rectangular SS wire stage Discontinued if space appears betn lateral & canine

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Anchorage control in MBT Bendbacks for A/P incisor control

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Anchorage control in MBT Bendbacks for A/P incisor control

Bend is placed 1-2 mm distal to molar tube www.indiandentalacademy.com


Anchorage control in MBT A/P anchorage control of lower molars â&#x20AC;&#x201C; the lingual arch

Class III elastics & headgear www.indiandentalacademy.com


Anchorage control in MBT A/P anchorage support & control for upper molars –  The upper molars move mesially more easily than lower molars  Upp ant segment has larger teeth than low ant  Upp ant brackets have more tip built  Upp incisors require more torque control & bodily movement  More Class II type malocclusions than Class III www.indiandentalacademy.com


Anchorage control in MBT A/P anchorage support & control for upper molars â&#x20AC;&#x201C;

Head gears www.indiandentalacademy.com

TPA


Anchorage control in MBT Vertical anchorage control of incisors

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Anchorage control in MBT Vertical control of canines

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Anchorage control in MBT Vertical control of molars in high angle cases Palatal bar

Upp 2nd molars not initially banded

Headgear â&#x20AC;&#x201C; high pull www.indiandentalacademy.com


Anchorage control in MBT Anchorage control in Transverse plane

Intercanine width Molar crossbites

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