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Introduction: Force is an active ingredient of the appliance, the only drug in the practice of orthodontics. According to Newtons third law of motion, for every action there is an equal and opposite reaction. In accordance with this law, the forces used to move teeth may induce an equal and opposite force on the anchorage units tending to cause their movement which is not desirable. An orthodontic appliance consists of 1. Active member is the part which moves to the direction of applied force. 2. Reactive member functions as a secure hold to resist the pull and is called the Anchor unit.

DEFINITION: 1.White and Gardiner Anchorage is the site of delivery from which a force is exerted.
2. Graber The nature and degree of resistance to displacement offered by an anatomic unit for the purpose of effecting tooth movement .

3. Daskalogiannak Resistance to unwanted tooth movement.

SOURCES OF ANCHORAGE: These are anatomic units and / or regions which are used for the purpose of providing the resistance to movement . i.e. anchorage. Anchorage during orthodontic therapy is mainly obtained from two sources. I. Intra oral sources II. Extra oral sources. INTRA ORAL SOURCES OF ANCHORAGE The anchorage units lie within the oral cavity. They include: 1. The teeth 2. The alveolar bone 3. The basal jaw bone 4. The musculature

1. The teeth: whenever some teeth are moved orthodontically, the remaining teeth of the oral cavity can act as anchorage or resistance units. This is due to the fact that the teeth themselves can resist movement. The anchorage potential of teeth depend on 1. Root form Round roots as seen in bicuspids and palatal root of maxillary molar can resist horizontally directed force in any direction. Offer the least anchorage. Flat roots like mandibular incisors and molars and the buccal roots of maxillary molars, can resist mesiodistal movement better as compared to labiolingual movement. Triangular roots like canines and maxillary central and lateral incisors offer the maximum resistance to displacement .

2.Number of roots The greater the surface area the greater the periodontal support and hence, greater the anchorage potential . Multirooted teeth have a greater ability to withstand stress than single rooted teeth. 3.Root length The longer the root, the deeper it is embedded in bone and the greater is its resistance to displacement. 4.Axial inclination of tooth A greater resistance to displacement is offered when the force exerted to move teeth is opposite to that of their axial inclination. 5.Ankylosed teeth Orthodontic movement of such teeth is not possible and they can therefore serve as excellent anchors when ever possible.

6. Contact points teeth with intact contacts and / or broad contact provide greater anchorage. 7.Intercuspation Good intercuspation leads to greater anchorage potential. This is mainly because the teeth of one jaw are prevented from moving because of the contact with those of the opposing jaw.

2. Alveolar bone: The alveolar bone that surrounds a tooth offers resistance to tooth movement upto a certain amount of force. Once the forces generated exceed those that can be resisted by the alveolar bone it permits tooth movement by bone remodelling. 3.Basal bone: Areas like hard palate and lingual surfaces of mandible in the anterior region can be used to augment anchorage. Eg. Nance palatal button on hard palate, resist mesial movement of maxillary molars. 4.musculature: Dental anchorage may be increased by making use of hypertonic labial musculature as in the case of lip bumper.

EXTRAORAL SOURCES: They are mainly used when adequate resistance cannot be obtained from intraoral sources for the purpose of anchorage. 1. Cranium Can be obtained by using head gear that derives anchorage from the occipital and parietal regions of the cranium. Used along with a face bow to restrict maxillary growth or to move the dentition or maxillary bone distally.

2. Back of the neck obtained from neck or cervical region. Such a type of head gear is called cervical head gear.
3. Facial bones The frontal bone and the mandibular symphysis offer anchorage during face mask therapy in order to protract the maxilla.

TYPES OF INTRAORAL ANCHORAGE: 1.INTRA MAXILLARY ANCHORAGE When all the units offering resistance are situated within the same jaw the anchorage is described as intramaxillary.

In this type the teeth to be moved and the anchorage units are all situated in the maxillary or mandibular arches. Eg. When elastic chains are used to retract the anterior segment using the posterior teeth as anchorage units.

2.INTER MAXILLARY ANCHORAGE: Resistance units situated in one jaw are used to effect tooth movement in the opposing jaw is called inter maxillary anchorage. It is also called Bakers anchorage.

Class II elastic traction applied between the lower molar and the upper anterior as well as Class III elastic traction applied between the upper molar and the lower anterior are types of intermaxillary anchorage.

3.SIMPLE ANCHORAGE: The manner and application of force is such that it tends to change the axial inclination of the tooth or teeth that form the anchorage unit in the plane of space in which the force is being applied. Thus, resistance of the anchorage unit to tipping is utilized to move another tooth or teeth.

Simple anchorage is obtained by engaging a greater number of teeth than are to be moved within the same dental arch.
The combined root surface area of the teeth forming the anchorage unit must be double that of the teeth to be moved. Eg.anterior retraction with Hawleys appliance. Movement of a single tooth using a screw appliance.

4.STATIONARY ANCHORAGE: The manner and application of force tends to displace the anchorage unit bodily in the plane of space in which the force is being applied.

The anchorage provided by a tooth resisting bodily movement is considerably greater that one resisting tipping.
It refers to the advantage that can be obtained by pitting bodily movement of one group of teeth against tipping of another . In simple words, RESISTANCE TO BODILY MOVEMENT IS CALLED STATIONARY ANCHORAGE. For this to be achieved differential light force has to be used.

Eg. In stage II of the Begg technique, a combination of anchor bends and Class II elastics pits the mandibular molars against the maxillary anterior segament, the resistance to bodily movement of the madibular molars helps in retracting the maxillary anterior by tipping them.

5.RECIPROCAL ANCHORAGE: Is said to exist when two teeth or two sets of teeth move to an equal extent in an opposite direction.

Here the root surface of the so called anchorage units is equal to that of the teeth to be moved. The effect of forces exerted is equal, i.e. the two sets of teeth are displaced in the opposing direction but by the same amount.
Eg: cross elastics to correct molar cross bite, arch expansion using midline screw, closure of a midline diastema by moving the two central incisors towards eachother.

6.SINGLE OR PRIMARY ANCHORAGE: Cases where in the resistance provided by a single tooth with greater alveolar support is used to move another tooth with lesser support is refered to as single or primary anchorage.

7. COMPOUND ANCHORAGE: This type of anchorage provides for the use of more teeth with greater anchorage potential to move tooth or group of teeth with lesser support. Eg: retracting incisors using loop mechanics in the fixed orthodontic appliance.

8.REINFORCED ANCHORAGE: Here the anchorage units are reinforced by the use of more than one type of resistance units. Eg: use of head gear with fixed mechanotherapy, use of transpalatal arch,or simply banding the second molar for retraction of permanent canine, use of inclined planes. TADs

Upper anterior inclined plane removable appliance incorporating an upper anterior inclined plane results in forward movement of the mandible during closure of the jaw. This results in stretching of the retractor muscles of mandible and contracts and forces the mandible against the upper inclined plane. Thus a distal force is applied on the maxillary teeth there by reinforcing the maxillary anchorage.

A modification of the inclined plane is the Sved applinace that has an additional upper incisal capping.

Transpalatal arch: Introduced by Robert A Goshgarian. It spans the palate between the upper 1st molars, with an omega loop in the midline and is effective as an anchorage maintenance device as well as an active orthodontic appliance. TPAs can be used for molar stabilization and anchorage, correction of molar rotation, molar distalization and also for torquing the molars. They resist the mesial movement of molars and particularly the tendency of molars to rotate in a mesial direction around the palatal root. The midline omega loop is usually oriented distally with 11.5mm clearance in the palatal area.

Intrusion TPA in high angle cases: It can provide vertical control by intrusion of molars. By placing omega loop in a mesial direction and increasing the clearance in the palatal area, tongue pressure places an intrusive force on TPA. Translingual arch: Used in mandible and functions as an anchorage device. Extends along the lingual contour of the mandibular dentition one side of first molar to the other side of first molar. An adjustment loop can be placed in the region of second deciduous molar or second premolar.

Nance palatal arch: Used in upper arch as anchorage device. In molar distalization cases and as a space maintainer. Has wire connecting upper 1st molars and an anterior loop portion covered by acrylic which rests on the slope of the anterior palate. Can provide sagittal anchorage reinforcement and is used as anchorage saver during leveling and alignment and during canine retraction.

Vertical holding appliance: Is a modification of the TPA, with a acrylic pad Is banded to permanent maxillary 1st molar with a dime size acrylic button at the sagittal and vertical level of the gingival margin of the molar bands. Four helices are incorporated into the wire for flexibility. The VHA uses tongue pressure to reduce vertical dentoalveolar development of the molars. Acrylic button enhances the intrusion force of the tongue.

TYPES OF EXTRAORAL ANCHORAGE: 1.Head gear 2.Face mask 3.Chin cup. 1. HEAD GEAR: They are generally used during the growth period to intercept or correct certain skeletal malocclusion. Head gear can accomplish the following kinds of anchorage control - Retraction of posterior teeth or all teeth in the arch - Restriction of mesial drift associated with growth or with premature loss of deciduos teeth - Increase of the vertical anchorage during the treatment of deep overbites or open bites. - Restraints of the upper jaw when the lower jaw is retracted, as in the use of class III elastics.

Head gear consists of head strap and face bow Head strap: Appliance takes anchorage from the rigid bones of the skull or from the back of the neck by means of a head strap . Face bow: 1. inner outer bow type 2. J-hook type Inner outer bow type:- inner bow is 0.045 or 0.051 inch. Made of stinless steel and contoured around the dental arch . Available in 5 assorted sizes. Is inserted into the head gear tube on the first molar brackets. Outer bow is 0.072 inch. Contoured to fit around the face. The outer bow can be short , medium, long.

J-hook type:- consists of 0.072 inch wire contoured so as to fit over a small soldered stop on the arch wire, usually between the upper lateral incisor and canine. Force system: Determined by point of attachment of the strap of the head gear in relation to the center of resistance of the tooth, the segment, or the entire jaw. This can be altered by 1. Changing the orientation of the outer bow i.e bending it up or down. 2. Changing the length of the outer bow. Force values used range from 200g per side in mixed dentition to about 500g per side in permanent dentition.

Principles in the use of head gear: Head gear can move the dentition and maxilla in all three planes of space. The following factors should be considered when planning head gear use. Center of resistance of the dentition:- inner bow is attached to maxillary first molar. Thus force acting on the molar displaces them. The center of resistance of molar is at the mid root region. Center of resistance of maxilla:- is at the posterosuperior aspect of zygomatico maxillary suture. Under clinical conditions the center of resistance of the dental arch as a whole should be considered. It is located between the roots of the premolars.

Point of origin of the force:- occipital or cervical Occipital head gear produce a superior and distal force on teeth and maxilla Cervical head gears produce an inferior and distal force. Point of attachment of force:- refers to hook present on distal aspect of outer bow to which the force is attached. Alterations can be made by altering the length of the outer bow or by altering the angle between the outer and inner bow.

Types of head gears: 1. Cervical head gears 2. Occipital head gears 3. Combination head gears
CERVICAL HEAD GEARS: Obtain anchorage from the nap of the neck Cause extrusion of maxillary molars leading to increased lower facial height. Move maxillary dentition and maxilla in a distal direction. Generally indicated in low mandibular angle cases.

High cervical head gear:- fits back of the head with an occipitocervical type or harness. Forces come from the level of the neck and are below the center of resistance .

OCCIPITAL HEAD GEAR:Derives anchorage from the back of the head. Fits over the occiput. Produces a distal and superiorly directed force on the maxillary teeth and the maxilla.

COMBINATION HEAD GEARS: Occipital and cervical anchorage are combined. Forces exerted by both are equal, a distal and slight upward force is exerted on the Maxillary dentition and the maxilla. Interlandi type:- harness arrangement consists of an occipitocerviacal combination strap along with a small c shaped plastic ring into which are parallel notches for the elastics. Force level is determined by which of the notches is used to connect the elastic to the outer bow.

Combee type:- have both occipital and cervical traction springs. Perhaps the most versatile type because the pull can readily be controlled by selecting the force level of the springs and by controlling the length of the outer bow.

FACE MASK: Hickham (1972) claims he was the first to use a reverse headgear. However, this modality was made popular by Delaire around the same time.

A reverse pull headgear consists of a rigid extra oral framework which takes anchorage from the chin or forehead or both for the anterior traction of the maxilla using extra oral elastics.
Indications:- in a growing patient having a prognathic mandible and a retrusive maxilla. For bending the condylar neck for stimulating temporomandibular joint adaptations to posterior displacement of the chin For selective rearrangement of the palatal shelves in cleft patients. In correction of post surgical relapse after osteotomies.

Anchorage: Uses anchorage from both the forehead and chin. No excessive force is exerted on to growth cartilage. Disadvantage with this appliance is difficulty in speech and compromise in aesthetics and comfort due to its size. Biomechanical considerations: Amount of force:- force required to bring about skeletal changes is about 450g per side. Direction of force:- most authors recommend a 15-20 degrees downward pull to the occlusal plane to produce a pure forward translatory motion of the maxilla. If the line of force is paralle to the occlusal plane, a forward translation as well as an upward rotation takes place.

Duration of force:- time taken to achieve desired results is proportional to the amount of force utilized. Low forces (250gm/side) take 13months. However high force like 16003000gm reduced treatment time to 4-21 days.

Frequency of use:- 12-14 hours of wear a day.

DELAIRE TYPE OF FACE MASK

PETIT TYPE OF FACE MASK

CHIN CUP: Is used to restrict the forward and downward growth of the mandible. The chin cup-face bow assembly consist of a chin cup that covers the chin, a head cap and an adjustable elastic strap that connects the chin cup and the head cap. Occipital pull chin cup:Derives anchorage from the occipital region of the head. Used in class III malocclusions associated with mild to moderate mandibular prognathism. They are successful in patients who can bring their incisors close to an edge to edge position in centric relation. They are also indicated in patients with slightly protrusive lower incisors as they invariably produce lingual tipping of the lower incisors.

Vertical pull chin cup:Derives anchorage from parietal region of the head. Indicated in patients with steep mandibular plane angle and excessive anterior facial height. These patients usually exhibit an anterior open bite. Force and duration of wear:- at the time of appliance delivery a force of 150-300gm per side is used. Over the next two months the force is gradually increased to 450-700gm/side. Appliance is worn for 12-14 hours a day to achieve the desired results.

ANCHORAGE PLANNING Is of utmost importance for the success of orthodontic treatment. Anchorage requirements depends on a number of factors:

1. Number of teeth being moved :- the greater the number of teeth being moved the greater the demand on the anchorage. 2. Type of teeth being moved:- the movement of slender anterior teeth offers lesser strain on the anchorage than robust multirooted teeth. 3. Type of tooth movement:- bodily tooth movement has a greater strain on the anchorage. Tipping tooth movement offer a relatively lesser strain on the anchorage units.

4. Duration of tooth movement:- treatment of a prolonged duration places an undue strain on the anchorage. In spite of the precaution taken in planning anchorage, a certain amount of unwanted movement of the anchor teeth invariably occurs during orthodontic treatment. Such unwanted movements of the anchor teeth is called Anchorage loss

Based on the anchorage loss that is permissible, the anchorage demand of an extraction space can be of three types:

Maximum anchorage: In cases where the anchorage demand is very high, not more than 1/4th of the extraction space should be lost by forward movement of the anchor teeth. The anchorage in these patients should be augmented to avoid unwanted movement of the anchor teeth.

Moderate anchorage: In these cases, the anchor teeth can be permitted to move forward into 1/4th to 1/2 of the extraction space. Minimum anchorage: In these cases, the anchorage demand is very low. More than half of the extraction space can be lost by the anchor teeth moving mesially.