JC_REINFORCED_ANCHORAGE[1].pptxdvdsvsvdxdsvdv

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1. Aim- To study the anchorage from all aspects starting from the definition, sources, types, anchorage loss and methods to reinforce anchorage.

2. Anchorage According to Graber , “the nature and degree of resistance to displacement offered by an anatomic unit when used for the purpose of affecting tooth movement”. According to Gardiner et al., “the site of delivery from which a force is exerted”. While Lewis defined anchorage simply as “the resistance to unwanted tooth movement”.

3. Sources of orthodontic anchorage A. Intra-oral sources • Teeth • Alveolar bone • Cortical bone • Basal jaw bone • Musculature B. Extra-oral sources Cranium • Occipital bone • Parietal bone Facial bones • Frontal bone • Mandibular symphysis • Back of the neck (cervical bone)

4. Classification of anchorage I. According to the manner of force application 1. Simple 2. Stationary 3. Reciprocal II. According to the jaws involved: 1. Intra-maxillary anchorage 2. Inter-maxillary anchorage III. According to the site of anchorage: 1. Intra-oral anchorage 2. Extra-oral anchorage

5. IV. According to the number of anchorage units: 1. Single or primary anchorage 2. Compound anchorage 3. Reinforced or Multiple anchorage V. According to anchorage demands: 1. Maximum anchorage (Type A anchorage). 2. Moderate anchorage (Type B anchorage). 3. Minimum anchorage (Type C anchorage). 4. Absolute anchorage (direct and indirect anchorage).

6. Reinforced anchorage/multiple anchorage It frequently happens that the teeth available for simple anchorage are not sufficient in number or in size to resist the forces necessary for orthodontic treatment and that reciprocal anchorage is not appropriate to the type of treatment to be carried out. In such circumstance, it is necessary to reinforce the anchorage to avoid unwanted movements of the anchor teeth. Anchorage is said to be reinforced when more than one type of resistance units are utilized.

7. Methods to reinforce anchorage value with the fixed appliance Banding or bonding the second molars. Use of combined Nance button with trans-palatal arch in the upper and lingual arch in the lower. Utilizing dental implants or ankylosed teeth Mini-screws and mini-plates. Extra oral traction Lip bumper.

8. Methods to reinforce anchorage with removable appliances The palatal coverage increases anchorage. Colleting around the posterior teeth with acrylic. Using inclined bite-blocks, palatal bows or the use of incisor capping.

9. Anchorage loss It is the movement of the reaction unit or the anchor unit instead of the teeth to be moved . Signs of anchorage loss Mesial movement of molars. 2. Closure of extraction space by movement of posterior teeth. 3. Proclination of anterior teeth. 4. Spacing of teeth.

10. Means to detect anchorage loss 1. Relating the position of other teeth to the teeth in the same and opposite arch. 2. Increase in overjet. 3. Checking the fitness of the removable appliance in the mouth. 4. Measurements of the distance of anchor teeth from midline. 5. Measurements from palatal rugae and frenum. 6. Observation of the spacing mesial/distal to the anchor teeth. 7. Inclination of the anchor teeth. 8. Radiological examination (cephalometric radiograph).

11. Conclusion Before starting active treatment of any orthodontic case, anchorage must be planned well to get rid of the problems that might accompanied the treatment procedures.

12. Transpalatal arch Introduced by Robert A Goshgarian in 1972. Spans the palate between the upper first molars, with an omega loop in the midline Effective as an anchorage maintenance device as well as an active orthodontic appliance. Resist the mesial movement of the molars and the tendency of molars to rotate in a mesial direction around the palatal root.

13. Uses of TPA Stabilization and Anchorage Once the position of the molars has been corrected, the transpalatal arch serves as a stabilizing appliance by connecting the two first molars together with the palatal wire. An anchorage unit is formed that resists the mesial rotation of the molars. This type of anchorage is helpful when elastomeric chain is applied to a continuous arch wire. Maximum anchorage cases that utilize the TPA should be supported by extraoral traction.

14. Correction of Molar rotation In the majority of Class II patients, the maxillary first molars are rotated mesially around the palatal root. A gain of 1-2 mm of arch length per side may be achieved following correction of these rotations. The TPA is activated unilaterally by grasping the solder joint with the beaks of small Weingart pliers and pushing the palatal wire posteriorly with finger pressure.

15. Buccal Root Torque Another common observation is lateral flaring of the maxillary buccal segments . This type of torquing movement is accomplished through the three-dimensional activation of the transpalatal arch , by adding an additional bending movement at the solder joint Transpalatal wire is bent toward the tongue, so that buccal root torque is produced on the activated maxillary first molar after the TPA is cemented.

16. Intrusive Movements Prevent molar extrusion and can encourage molar intrusion . By enlarging the midline omega loop and directing the loop mesially, the force of the tongue may produce an intrusive force on the teeth. Intrusion TPA is given in high angle cases.

17. FABRICATION OF TRANSPALATAL ARCHES Removable Transpalatal Arch A sheath must be attached to the lingual aspect of each molar band at the same occluso -gingival height and the same mesiodistal position as the buccal tube on the opposite side of the band. These sheaths receive the doubled-over .036" terminals of the transpalatal arch. Easier to adjust because it can be removed from the sheaths and adjusted outside of the mouth. The routine adjustment is less accurate than is that of the soldered TPA.

18. FIXED (SOLDERED) TRANSPALATAL ARCH Made from .036" stainless steel wire Features the soldering of the palatal wire to the lingual surfaces of the molar bands

19. Conclusion The transpalatal arch has become an integral part of both mixed-dentition and permanent-dentition treatment. The author strongly prefer the soldered transpalatal arch rather than the removable transpalatal arch. The author found that the routine use of the soldered transpalatal arch to be an important adjunct to our fixed appliance treatment. If used after existing transverse problem has been corrected, the sequential activation of the TPA allows for the proper positioning of the maxillary first molars within a few appointments, so that the rest of the patient's fixed appliance treatment can proceed smoothly and efficiently.

20. AJODO ,2006 This cephalometric study aimed to perform a detailed comparison between two groups of patients. The study sought to quantify the anchorage capabilities provided by the TPA.

21. MATERIALS AND METHOD Sample Collection - Cephalometric records gathered from patients treated either with or without a TPA. Inclusion Criteria - 4 first premolar extractions. Class I molar malocclusion. Exclusion Criteria Incomplete records, poor film quality, magnification issues. Missing or ankylosed teeth anterior to the third molars. Use of headgear or other auxiliary anchorage devices during treatment. Banded or bonded maxillary second molars. TPA removed before space closure or more than a few months before appliance removal. Extraction patterns other than 4 first premolars. Non-Class I molar malocclusion.

22. No-TPA Group Matching Matched for age at treatment start, treatment duration, and cervical vertebral maturation stage at pretreatment (T1) and posttreatment (T2). Means and standard deviations were calculated for age, duration of treatment, and all cephalometric measures at T1 and T2 and for the changes between T1 and T2. The data were analyzed

23. RESULTS The TPA group had slightly longer maxillae and mandibles at T1 compared to the no-TPA group. The sagittal positions of the maxilla and mandible in the TPA group, were optimal, whereas the no-TPA group showed slight retrusion of both

24. Mesial movement of the maxillary first molar relative to the maxilla was 0.4 mm greater in the no-TPA group, indicating it moved more forward compared to the TPA group. Vertical movement of the maxillary first molar was also 0.4 mm greater in the no-TPA group, indicating more downward movement compared to the TPA group.

25. Conclusion Study Investigated TPA's additional role as an anchoring device in extraction cases where maxillary first molars were splinted. TPA did not significantly prevent forward movement of maxillary first molars during anterior teeth retraction compared to cases without TPA. While TPA remains valuable for various orthodontic functions, it does not provide significant anchorage control in extraction treatments. Implants or miniscrew implants might be more suitable for cases requiring absolute anchorage.

26. 2018,Acta Odontologica Scandinavica Aim : The aim of this review was to systematically review the effectiveness of miniscrews in reinforcing anchorage during en-masse retraction of anterior teeth in comparison to conventional anchorage appliances.

27. Method Comprehensive searching of the electronic databases was undertaken up to March 2018 in the Cochrane Database of Systematic review, Cochrane Central Register of Controlled Trials, MEDLINE via PubMed and Scopus databases. Additional searching for on-going and unpublished data and hand search of relevant journals were also undertaken, authors were contacted, and reference lists screened.

28. Eligibility criteria Only randomized clinical trials (RCTs), which compared anchorage reinforcement using mechanically-retained miniscrews (diameter of 2 mm or less) to conventional anchorage appliances during en-masse retraction of anterior teeth Participants of any age treated with fixed appliances combined with extraction of maxillary premolar

29. Data collection and analysis Blind and induplicate data Data extraction and risk of bias assessment was under taken. Primary outcome was amount of mesial movement of the upper first permanent molar. Secondary outcomes included treatment duration, number of visits, adverse effects and patient-centered outcomes. The risk of bias was assessed using Cochrane risk of bias tool.

30. Result Seven RCTs met the inclusion criteria The standardized mean difference (SMD) of the anchorage loss between the two intervention groups was 2.07 mm in favour of miniscrews, which was also preserved after excluding the high risk of bias studies. Information on overall treatment duration, space closure duration, quality of treatment, patient-reported outcomes, adverse effects and number of visit were limited.

31. Conclusion Meta-analysis suggested that there is moderate quality of evidence that miniscrews are clinically and statistically more effective in preserving orthodontic anchorage than conventional appliances. High-quality RCTs would give a better understanding of miniscrews effectiveness in providing orthodontic anchorage.

32. AIM: The aim of this systemic review is to evaluate whether the Transpalatal arch and Nance appliance can effectively reinforce anchorage during fixed orthodontic treatment. Cereus, 2024

33. The Nance palatal arch (NPA) is a modified version of TPA, composed of a stainless steel wire that incorporates an acrylic button. This acrylic button is strategically placed to enhance anchorage, thereby reinforcing the appliance's stability. NANCE PALATAL ARCH

34. A split-mouth clinical trial was conducted, including 14 subjects, to compare anchorage loss with NPA using both tipping and bodily mechanics . The findings showed anchorage loss of 1.2 ± 0.3 mm and 1.4 ± 0.5 mm for tipping and bodily mechanics, respectively, indicating limited efficacy of NPA in providing absolute anchorage, accounting for 17% to 20% of total extraction space.

35. The challenge with NPA may arise from the Nance acrylic button resting on the firm anterior palatal tissues, which could contribute to patient’s discomfort. The design and placement of the acrylic button are critical, as improper fitting can lead to irritation or ulceration of the palatal tissues.

36. TRANSPALATAL ARCH A comparative analysis study found that TPA did not effectively minimize anchorage loss in continuous arch mechanics during canine retraction, noting an anchorage loss of 4.5 mm. TPAs did not significantly improve molar anchorage in either the anteroposterior or vertical directions. Vertical anchorage loss was noted in the form of molar extrusion during en -masse or two-stage retraction, and a decrease in inter-molar distance was reported after incisor retraction using TPA.

37. It was found that TPA alone resulted in significant mesial molar movement ranging from 27% to 54%. However, combining TPA with other anchorage methods reduced this movement from 20% to 40%. This indicates that TPA alone does not provide maximum anchorage , particularly during en -masse or two-step retraction. Comparative analysis: The study found negligible differences between the two arch types in preventing mesial drift and distal tipping, highlighting a similar performance in anchorage control.

38. CONCLUSION: The Nance appliance does not achieve absolute anchorage. The transpalatal arch alone is insufficient when a maximum anteroposterior anchorage is required, whether for en -masse or two-stage retraction. For patients with critical anchorage demand, mini-screws may be the method of choice, either solely or in combination with Nance or transpalatal arch, though they carry a risk of failure. Therefore the selection between the NPA and TPA should consider individual patient needs like comfort and adaptability of the appliance.

39. JOCPD,2024

40. Children at mixed dentition stage need selective serial extraction and anchorage control to correct the dentition. Face-bow anchorage is commonly used in clinical cases, but it lacks stability and has large wounds. Mini-implant anchorage is a temporary anchorage with small size and wide applications.

41. RESULTS COMPARISON OF THE UPPER CENTRAL INCISOR CONVEX DISTANCE DIFFERENCE, INCLINATION ANGLE OF THE UPPER CENTRAL INCISOR AND DISPLACEMENT OF THE MOLAR After one year of treatment the two groups were compared using CBCT and the difference was statistically significant

42. COMPARISON OF GINGIVAL HEALTH To compare the gingival health the following parameters were taken into consideration: . Plaque index (PLI) : a probe was wiped along the gingival margin to detect the quantity and thickness of plaque. The scores ranged from 0 to 3. More points indicated more plaque. Bleeding index (BI) : a periodontal probe with blunt end was used to detect bleeding state. The scores ranged from 0 to 5. More points indicated more bleeding. Gingival index (GI) : the scores ranged from 0 to 3. More points indicated worse gingival status. Scores of PLI, BI and GI that children in the observation group got were all lower than those in the control group, and the differences were statistically significant (p < 0.05)

43. MASTICATORY FUNCTION Biting force : A biting test piece was put at the first molar of the lower jaw and children were asked to bite the piece 10 times continuously. 3 times of the maximum biting force were selected to calculate the average value. Masticatory efficiency : it was calculated with peanuts. The children were given 2 g of peanuts to chew for 20 times on each side. And then they rinsed their mouth. Masticatory efficiency = the weight difference of peanuts before and after chewing/the weight of peanuts before chewing. The biting force and masticatory efficiency of children in the observation group were higher than the control group, and the differences were statistically significant (p < 0.05).

44. ADVERSE REACTIONS : oral infection, oral discomfort, edema of soft tissues were accounted for The adverse reaction rate of children in the observation group was lower than the control group, and the difference was statistically significant (p < 0.05)

45. EFFECT EVALUATION : Effective meant the physiological and anatomical relationship between the teeth was normal, and the dentition was orderly; Improved meant the relationship between the teeth was obviously improved, and the dentition was generally orderly; Ineffective meant that the above standards were not met. The treatment effect of the observation group was better than that of the control group, and the difference was statistically significant (p < 0.05)

46. CONCLUSION A stable and effective anchorage is vital to a successful orthodontic treatment Mini-implant anchorage is more stable and has stronger directive forces. The small size of the mini-implant anchorage is also convenient for oral cleaning, reducing adverse reactions caused by poor oral hygiene.