Temporar y Skeletal

Anchorage Devices
f o r Or t h o d o n t i c s
Bernard J. Costello, DMD, MD, FACSa,*,
Ramon L. Ruiz, DMD, MDb,c,
Joseph Petrone, DMD, MDS, MPHd,
Jacqueline Sohn, DMD, MDSe

KEYWORDS
 Miniscrews  Orthodontic mechanics
 Skeletal anchorage  Temporary anchorage devices

Orthodontists have always tried to develop ways Those patients who have more significant discrep-
to move teeth while minimizing the unwanted ancies, however, require additional techniques.
reciprocal movement of the teeth they pull or This is most evident to the oral and maxillofacial
push against. This constant battle is more easily surgeon when one examines patients with
won when ideal anchorage is in place to move moderate to severe skeletal discrepancies.
teeth in an efficient manner. Although dental Patients with occlusal discrepancies beyond
implants were used as absolute orthodontic what can be managed with standard orthodontic
anchorage in the past, they had not become therapy are usually treated with techniques that
popular for a number of reasons including cost; include growth modification or orthognathic
time of sequencing for osseointegration; and their surgery in combination with comprehensive ortho-
primary use for dental restoration purposes, not dontic therapy. Presently, patients with mild to
orthodontic mechanics. These concepts of skel- moderate discrepancies may benefit from skeletal
etal anchorage are not new, but have gained anchorage devices to compensate further for
more attention in the literature because of malocclusions that were not previously correct-
a number of innovations in design and technique. able using conventional orthodontic mechanics.
Even as this article is being written, advances in Additionally, a variety of problems encountered
materials and technique are poised to change by the orthodontist on a regular basis are now
how these procedures are planned and per- more efficiently treated with skeletal anchorage
formed. The reader is encouraged to review the as an adjunct to traditional mechanics.
literature regularly because the pace of change is This article discusses the recent advances and
rapid. basic concepts of skeletal anchorage devices of
The goals of orthodontic therapy include opti- various types and reviews the current literature
mizing occlusion, aesthetics, and facial balance. on their use. A primer on orthodontic mechanics
Traditional orthodontic mechanics are efficient at is required to treat patients with skeletal
accomplishing these goals for clinical scenarios anchorage devices adequately, and the reader is
that require mild to moderate compensation. encouraged to review principles of orthodontic
[Link]

a
Department of Oral and Maxillofacial Surgery, University of Pittsburgh School of Dental Medicine, 3471 5th
Avenue, Suite 1112, Pittsburgh, PA 15213, USA
b
Craniomaxillofacial Surgery, Pediatric Oral and Maxillofacial Surgery, Arnold Palmer Children’s Hospital,
Orlando, FL, USA
c
University of Central Florida College of Medicine, Orlando, FL, USA
d
Department of Orthodontics, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, USA
e
Private practice, Pittsburgh, PA, USA
* Corresponding author.
E-mail address: bjc1@[Link]

Oral Maxillofacial Surg Clin N Am 22 (2010) 91–105

doi:10.1016/[Link].2009.10.011
1042-3699/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
92 Costello et al

mechanics in conjunction with this article. Much rather frequently with individual screws. Loosening
like the concepts introduced during the beginnings of the screw mechanic had been a major draw-
of orthognathic dentofacial teams, treatment that back of screw systems. Sugawara and colleagues
uses skeletal anchorage requires interdisciplinary and other authors3,4,13–17 subsequently described
collaboration and planning with regular interaction, a number of interesting compensation techniques
continuing education, and a regular review of the for a variety of problems that traditionally would
latest relevant literature. Additionally, frequent have required orthognathic surgery to treat, such
communication between orthodontist and oral as the anterior open bite and significant class III
and maxillofacial surgeon is necessary to achieve deformity.
superior results.
BASIC ORTHODONTIC MECHANICS
HISTORY OF SKELETAL ANCHORAGE AND SKELETAL ANCHORAGE
FOR ORTHODONTICS
To understand the indications for skeletal
Recent technical advances have resulted in an anchorage, the practitioner placing the devices
increased level of interest in skeletal anchorage must have a baseline understanding of orthodontic
for orthodontic treatment, although the concept mechanics to ensure superior results. Planning for
of using implantable devices for this purpose has a team approach to a skeletal anchorage case is in
been present for more than a half century.1–5 many ways similar to planning for orthognathic
Only recently have innovations in materials, new surgery. Issues that arise in the preoperative, intra-
outcome data, and improved techniques thrust operative, and postoperative phases of treatment
this concept forward as a more mainstream option concern both the orthodontist and surgeon. As
for treatment. In the 1940s, Gainsforth and Higley6 such, frequent communication must occur to
experimented with vitallium screws and wires in ensure the best outcome.
the dog ramus used for skeletal anchorage. This The term ‘‘anchorage,’’ within the context of
initial experiment was not considered a success.6 orthodontic treatment, is defined as the resistance
Linkow7 used blade-type implants in the posterior to unwanted tooth movement. The forces involved
mandible to apply class II elastics for retraction of in orthodontic tooth movement obey Newton’s
maxillary incisors. This cross-arch technique was third law, which states that for every action, there
apparently successful, but had the disadvantage is an equal and opposite reaction. For every move-
of requiring the surgical placement of a blade ment of a tooth in the desired direction, the force is
implant and then allowing adequate healing time distributed to the anchorage segment, potentially
for its osseointegration before use as an anchor. affecting the position of those teeth within the
Sherman8 also used dental implants in dogs for anchorage segment. If an orthodontist wishes to
anchorage with limited success. In 1979, Smith9 move a canine posterior (distally), but only one
noted that dental implants could act like ankylosed molar is present, then the molar has a tendency
teeth during orthodontic movement. In 1988, Sha- to drift toward the mesial if the molar is used as
piro and Kokich10 discussed how dental implants an anchor for that movement. If more anchorage
could be used for orthodontic anchorage before is provided to that area, however, then the move-
their prosthodontic use, and a number of practi- ment can occur with less of the unwanted mesial
tioners used this technique from this point forward. movement of the molar.
In 1995, Block and Hoffman11 used a hydroxyapa- Using conventional mechanics, anchorage can
tite-coated onplant placed in the midline palatal be increased by using intraoral or extraoral tech-
tissues for use with an orthodontic anchor device. niques. Intraoral techniques commonly use
This was moderately successful, but required the tooth-borne appliances to improve anchorage.
orthodontist to rethink anchorage in terms of This can be achieved by increasing the number
palatal mechanics instead of what was typically of teeth in the anchorage unit. For example, teeth
used with brackets and bands. Costa and can be tied together with ligature wire to resist
coworkers12 used titanium miniscrews borrowed unwanted tooth movement in another area.
from plating fixation systems for orthodontic Another way of increasing teeth in the anchorage
anchorage with some success. In 1999, Umemori segment is to use a transpalatal arch. A transpala-
and colleagues3 described techniques for using tal arch can be fabricated to distribute force to
a modified rigid fixation plate for use as ortho- another segment of teeth across the arch. Alterna-
dontic anchorage. This was a particularly impor- tively, elastic bands can be used between the
tant leap, because the plating system could be opposing arches to provide additional anchorage.
easily placed and significant force could be used This technique is commonly used to close space
without loosening of the device that was seen after maxillary premolar extraction by retracting
 Skeletal Anchorage Devices for Orthodontics 93

the anterior dentition of the maxilla with elastic require mechanical stability instead of
bands bilaterally and attaching the elastic to the osseointegration
mandibular posterior teeth. These class II elastics  Devices are easily removed.
also help to minimize the unwanted mesial move-
ment of the maxillary posterior anchorage The anchorage applied may be considered
segments. This technique is based on compliance, direct or indirect. Direct techniques are those
and can be ineffective if the patient does not regu- that apply force directly from the anchor to the
larly wear the elastics. segment or tooth that is to be moved (Fig. 1). For
Another way to provide maximum anchorage to example, maxillary plates placed at the zygomatic
the posterior teeth is to use a Nance button appli- buttresses may be designed to provide intrusion
ance that holds the posterior molars in position force to the maxillary molars with the intent of
with an acrylic button on the anterior palate. Force closing an anterior open bite. This is a direct tech-
can then be applied to the posterior teeth to close nique because the force is applied from the anchor
premolar space, and the tendency for the molar directly to the molar teeth. Indirect techniques tie
teeth to move mesial is resisted by the acrylic the anchor device to the segment of teeth that
button on the palate near the incisive foramen. requires additional anchorage such that more
These appliances may irritate the tissue and traditional mechanics can be used in the area
become uncomfortable. Extraoral appliances, (Fig. 2). Rather than an active, elastic connection
such as a headgear, can also be used to provide between the anchor and the archwire, indirect
additional anchorage, but are often subject to anchorage involves an inelastic or even rigid
compliance issues and rarely offer more than 6 connection between the anchor and the ortho-
to 10 hours of force per day. They are also not dontic appliances. For example, if a maxillary
readily accepted by some patients, particularly anchor is tied by a steel ligature to the anterior
adults. teeth to provide more anchorage to that segment,
Skeletal appliances (specialized bone screws or then a coil spring could be used on the archwire to
plates) provide anchorage that is not tooth-borne distalize the molar teeth. This represents an indi-
because they are attached to the surrounding rect technique because the force used is along
bone. As a result, unwanted reciprocal tooth the archwire by the coil spring, and represents
movements involving the surrounding teeth are a traditional type of mechanic in orthodontics.
totally avoided. Other advantages of these devices The advantage to the indirect technique is that
include the following: most orthodontists already design their move-
ments of teeth based on traditional mechanics.
 No or minimal reliance on existing dentition Providing additional anchorage by a skeletal
 Less dependent on patient compliance device simply increases efficiency without neces-
 Continuous rather than intermittent force sitating a new appliance design or vectors and
may be applied movements difficult to achieve in commonly used
 Surgical procedures are necessary, but orthodontic techniques. Either a direct or indirect
they are simple in most instances technique can be used in most situations, and
 May be significantly less expensive than each case requires careful planning to ensure ideal
other surgical options, such as orthognathic placement of the anchor for these purposes.
surgery Skeletal anchorage devices allow orthodontic
 Force may be applied very soon or immedi- movements to be designed that were previously
ately after placement of the device; devices thought to be difficult, if not impossible.

Fig. 1. Direct anchorage is achieved by

adding a force from an elastic chain or
thread to the loop in an existing ortho-
dontic mechanical system to achieve
retraction of the entire anterior segment
of teeth. (Data from Nanda R. In: Nanda
R, editor. Temporary anchorage devices
in orthodontics. St Louis: Elsevier; 2008.
p. 157.)
94 Costello et al

Various dental implants including miniature

dental implants were used in a similar fashion
and placed in the retromolar region for anchorage
purposes.8,18 These also required osseointegra-
tion before use and surgical removal, and had
the same types of drawbacks. Similar devices
continue to be used in the palate, either in the
midline or parasagittal to the midline. The anatomy
in this region does not support full bony integration
of an implant in most instances. Midline insertion
into the septum may provide initial stability, but
may also create problems, such as septal perfora-
tion either at the time of placement or at the time of
Fig. 2. An example of indirect anchorage using some-
removal. If the implants are placed parasagittal,
what complicated palatal mechanics. The left first
molar is tied with a ligature wire to a temporary anchor
then a fistula may result when the implant is
screw providing absolute anchorage. The right removed because of the thin bone in this region
segment is planned to move distally, so an elastic chain of the nasal floor and hard palate.
is threaded from the hook behind the first bicuspid on The onplant system, with attachments that
the transpalatal bar. The final result is distalization of penetrate through the palatal tissues for ortho-
the entire right segment, a vector of force that is tradi- dontic anchorage, is an attempt to get around
tionally difficult or impossible to achieve with standard these inadequacies of the endosseous implant
mechanics. (Data from Anka G. In: Nanda R, editor. approach. These onplants are coated with tita-
Temporary anchorage devices in orthodontics. St Louis: nium or hydroxyapatite in the hopes of osseointe-
Elsevier; 2008. p. 199.)
gration after a small palatal incision is made for
a subperiosteal placement. Long-term outcomes
Compensation beyond the typical envelope of of this technique have not been reported, and it
discrepancy is possible for many clinical indica- has mostly been supplanted by single screws or
tions. Skeletal anchorage devices do not allow plates at other locations. As with any palatal
faster movement of teeth, or the ability to over- implant, the additional drawback of redesigning
come exceptionally large discrepancies; the orthodontic mechanics around a device posi-
devices have limitations. They provide absolute tioned on the palate requires significant planning
anchorage for orthodontic movement, however, by the orthodontist in a manner that is not
and do so in a number of novel ways. They allow conventional.
for more efficient movement of teeth and address Placement of a bone screw for orthodontic
a number of anchorage problem areas that previ- mechanics has been described using a number
ously were difficult or impossible to resolve with of different screw devices.10,14,19,20 Recently,
traditional orthodontic mechanics alone. there has been an explosion of these screws
commercially available for use. Originally, fixation
DEVICES FOR SKELETAL ANCHORAGE screws used for craniomaxillofacial surgery were
placed and then attached to the orthodontic appli-
A number of devices have been used to provide ance for use as additional anchorage. Other screw
additional anchorage for orthodontic purposes. systems used for alternative purposes, such as
The early attempts that were successful used maxillomandibular fixation, were modified for use
dental implants placed with the intention of using as skeletal anchorage. Eventually, screws specifi-
them for total skeletal anchorage. These had the cally designed for use in orthodontic skeletal
significant drawbacks of requiring osteointegra- anchorage were manufactured with versatile
tion before use and the high cost. They also orthodontic attachments to optimize their use
required aggressive surgery for removal. Although (Fig. 3). Both self-tapping and self-drilling systems
some could be kept in place for prosthetic use, are currently available.
often it was difficult to determine the exact position Screws are typically manufactured in multiple
required at the end of orthodontic treatment when lengths for a number of indications. Short screws
placing them for anchorage purposes before treat- can be used, but fail more often because of
ing the malocclusion. Consequently, the implants minimal bone-to-screw interface. Screws that
were often not in ideal position for the final crown engage cortical bone across the alveolus tend to
or prosthesis, rendering them either useless or have more stability, and this technique requires
requiring specialized prosthodontic techniques to longer screws (8–12 mm). The thread pitch should
compensate for poor position. also be ideal for the type of bone in this area, and
 Skeletal Anchorage Devices for Orthodontics 95

Plate systems were originally used by Sugawara

and others to provide additional three-dimensional
stability and increase the success rates over the
long-term. Originally these were modified fixation
plates used for Le Fort osteotomies and facial
trauma repair.3,4 Eventually, custom-designed
plating systems specifically indicated for skeletal
orthodontic anchorage were developed.4,13,21–25
Skeletal anchorage plates have the advantage of
increased stability, allowing the use of greater
forces. They do not require osseointegration and
can be loaded immediately. The plates typically
allow for placement of multiple small screws away
from the tooth roots, avoiding injury (Fig. 4). Skel-
Fig. 3. A maxillary anchor screw is used to provide
etal anchorage plates are also easy to remove,
anchorage to the anterior dentition because of
a lack of anchorage in the right posterior maxilla. but require an additional incision and dissection.
This allows the orthodontist to distalize the premolars
and canine to treat the crowding of the anterior Clinical Indications
dentition while preserving the dental midline.
Skeletal anchorage devices may be used in many
different applications to provide absolute
anchorage and optimize the efficiency of tooth
typically is approximately 0.6 mm. The attach- movement. The authors prefer plates over screws
ments come in a variety of designs. The authors to provide anchorage using indirect mechanics
prefer an attachment that allows for placement of when possible. Direct anchorage techniques may
a ligature, elastomer chain, or wire. Although also be helpful for some indications. Some case
a number of entities manufacture screws, it is examples illustrating the use of skeletal anchorage
important to consider the quality of the titanium follow, and new applications are being investigated.
alloy used and the highly engineered aspects of
the screw. Poorly made devices are prone to frac- MESIAL OR DISTAL MOVEMENT OF TEETH
ture, and as such it is recommended that surgeons WITH MAXIMUM ANCHORAGE
use devices with proved use in these indications.
Devices should The need to move posterior teeth in the mesial
direction is difficult because of a lack of anchorage
 Be designed for the purpose of skeletal
orthodontic anchorage
 Have a very high quality of manufacturing
with standardized quality control
 Have an appropriate pitch thread to ideally
engage bone
 Have the appropriate core and external
diameter to withstand orthodontic forces
in maxillary and mandibular bone
 Be designed well at the runout and shaft-
head interface to avoid fracture.

Screws that are smaller than 1.5 mm tend to fail

much more often, and are not recommended for
indications that require significant force. Addition-
ally, screws with bracket-like head designs offer
little advantage to more simple attachments,
which tend to be more versatile. Bracket-like
attachments require specialized custom bending
Fig. 4. A maxillary anchor plate is placed along the
of the orthodontic wire, and often fail with minimal left maxillary buttress. This allows placement of three
torque or a force that rotates the screw in the or four monocortical screws away from the tooth
counterclockwise direction, loosening it. The indi- roots and placement of the orthodontic attachment
cations, success rates, and limitations of screws in an ideal position for intrusion of the maxillary
used for skeletal anchorage are discussed later. molars.
96 Costello et al

from the anterior segment.4,24,25 For example, skeletal anchorage, this may be difficult to achieve
when an overretained primary first molar is ex- because the posterior teeth have a tendency to
tracted and the succedaneous permanent first move toward the mesial when using traditional
bicuspid is missing, the orthodontist may choose mechanics (Fig. 8).
to move the remaining posterior tooth or teeth to It follows that these techniques can be helpful
the mesial to close the space of the primary first after extraction of bicuspids if the orthodontist
molar (Fig. 5). This is often difficult because the wishes to close the space with maximum
anterior segment of teeth have a tendency to anchorage in either segment. Although this is
move to the posterior (distal), causing the incisors easily done with traditional orthodontic
to upright and changing the canine position to mechanics, in certain instances when anchorage
class II. To maintain the position of the anterior is lacking, or maximum anchorage is desired,
teeth including the class I canine, a skeletal anchor then skeletal anchorage appliances can be used
may be placed to provide either indirect to maximize efficiency.
anchorage with a rigid attachment to the anterior
segment or direct anchorage with and active UPRIGHTING OR INTRUDING MOLAR TEETH
attachment to the molar segment. This allows for
more efficient movement of the posterior molars One of the more difficult movements in orthodontic
to close the space, without loosing the position treatment is uprighting a molar tooth that has
of the canine or disrupting the overbite-overjet moved mesially into an edentulous space. Most
relationship of the incisors. To improve a class II often this occurs in the adult patient who has lost
relationship, a variety of tooth movements are their first molar to caries and the second molar
possible including distalizing the maxillary teeth. tips to the mesial over a period of time. Subse-
By moving the maxillary molars distally, space quent to this event, if a patient presents for ortho-
can be created to reduce the overjet and to dontic treatment, it may be very difficult to upright
achieve a class I canine relationship (Figs. 6 and the second molar without extruding the tooth and
7).14,25 opening the patient’s bite.14,15,22 With the use of
Alternatively, if a patient presents with a class III a skeletal anchor, the tooth may be uprighted
discrepancy, then the orthodontist may choose to without the untoward extrusion that often results
compensate by providing maximum anchorage to with conventional orthodontic techniques.
the mandibular posterior teeth or to distalize Another difficult problem to remedy is the over-
mandibular molar teeth.26 This allows the mandib- erupted maxillary or mandibular tooth that is in
ular anterior dentition to be retracted and to close poor position because of an edentulous space in
the space while providing maximum anchorage to the opposite arch. Intruding teeth in this situation
the distal (posterior) segment of teeth. Without is exceptionally difficult using traditional ortho-
dontic mechanics. The use of a skeletal anchorage
device makes intrusion a relatively easy ortho-
dontic movement.22 This technique may be used
in the anterior or posterior dentition. Patients
who have a deep class II relationship with exces-
sive overbite can have their anterior maxillary
dentition intruded and retropositioned to improve
the overbite-overjet relationship. Typically, this is
done with an intrusion arch or other traditional
mechanics, such as headgear. With skeletal
anchorage devices, this is made much more effi-
cient and also requires very little compliance
from the patient.

Fig. 5. A patient who has lost their lower primary first CLOSURE OF ANTERIOR OPEN BITE
molars has good position of the canines (class I), and
There has been a great degree of excitement
lacks enough anchorage posteriorly to close the space
generated by the initial reports of anterior open
without the unwanted distal movement of the
canines. This is a frequent problem for orthodontists bite closure with orthodontic anchorage appli-
who need to close space with maximum anchorage. ances.3,4,13,16,22,27–29 Typically, this is performed
Anchorage plates or screws can provide absolute by placing orthodontic plates or screws in the
anchorage to close the space efficiently without posterior maxilla, apical to the dentition. Force is
unwanted tooth movements. then generated to intrude the posterior molars
 Skeletal Anchorage Devices for Orthodontics 97

Fig. 6. A patient with a significant class II relationship who is unwilling to undergo orthognathic surgery has
upper first premolar extractions, and lower second premolar extractions in preparation for orthodontic therapy.
The space in the maxilla is closed with the aid of anchor screws, which allow for closure of the space by bodily
moving the anterior centrals, laterals, and canines en mass. (A–C) Preoperative occlusion photos. (D) Preoperative
lateral cephalometric radiograph. (E, F) Postoperative occlusion photos after 6 months of orthodontic therapy
with closure of the space and improvement of the class II relationship. The force is generated at the optimized
vector to allow for efficient movement.

and premolars (as necessary) to close the anterior closure of their open bites may be good candi-
open bite. A number of case reports have shown dates for this procedure, but retreatment does
this to be successful. Excitement has grown in come with additional risk, such as root resorption.
this area because of the difficulty typically encoun- Orthodontists should be careful to not extrude the
tered with orthodontic-only closure of the anterior anterior maxillary teeth, which likely decreases
open bite, and the subsequent relapse that often long-term stability of the correction. Intrusion of
occurs. The alternative is orthognathic reposition- the posterior maxillary dentition is preferred and
ing with the presumed improvement in stability. has been shown to be effective. Patients should
Although the use of skeletal anchorage to close be cautioned regarding the expectations of
anterior open bite is reported to be stable in case outcome over the long-term. It is expected that
reports and a few case series publications, there more data will become available to assess the
are no long-term data on stability of these proce- safety, efficacy, and long-term stability of this
dures as there has been for orthognathic surgery. treatment option.
For this reason, the authors prefer to use this
technique for those patients who cannot or will ORTHOPEDIC GROWTH MODIFICATION
not undergo orthognathic surgery, and for those
patients who have minimal open bites. Patients An area of considerable interest is the use of skel-
who have already failed orthodontic treatment for etal anchorage to provide forces for orthopedic
98 Costello et al

Fig. 7. A patient with Noonan’s syndrome who has a skeletal class II relationship. His behavioral issues and
bleeding disorder (both associated with this syndrome) make him a poor candidate for orthognathic or other
craniofacial procedures. His class II is compensated by distalizing the entire maxillary dentition with two skeletal
anchors placed in the posterior maxilla. Over time he develops a class I relationship. At the time of the anchor
placement, a genioplasty is performed to balance his facial profile. (A, B) Preoperative facial photographs. (C)
Cephalometric tracing showing a significant class II relationship that would typically be treated with orthog-
nathic surgery. (D, E) Photographs of the anchors in place after several weeks with minimal inflammation.
(F–H) Photographs of the progression of treatment over 9 months as the class II discrepancy improves. (I, J) Post-
treatment facial photographs.
 Skeletal Anchorage Devices for Orthodontics 99

Fig. 8. A 21-year-old woman is shown with an asymmetric class III relationship, but without significant transverse
discrepancy. She was unwilling to consider an orthognathic surgery treatment option, so one skeletal anchor
plate was placed in the posterior right mandible to bring the entire mandibular dentition to her right. This al-
lowed for distal movement of most of the mandibular arch of teeth, and establishment of a class I canine rela-
tionship. (A–E) Pretreatment photographs. (F) Mandibular anchor plate in place with orthodontic anchorage
activated. (G–K) Posttreatment photographs.

growth modification in a manner similar to the use class I relationship.30 The vector of force is similar
of headgear appliances. This has been used by to reverse-pull headgear without the need for an
some practioners for children during phase I ortho- external appliance. The mechanics involved are
dontic therapy. For patients with a class III skeletal more favorable because of the constant force
pattern (midface hypoplasia or mandibular prog- provided rather than relying on the patient to
nathism), skeletal anchors can be placed in the wear the appliance only for a prescribed time.
mandible and maxilla to provide forward ortho- Although the concept has been reported in the
pedic force to the maxilla and encourage a more literature, there is little evidence of its efficacy or
100 Costello et al

safety. Practitioners must be careful to avoid anchor placement. A periosteal elevator is used to
developing tooth structures, and minimize surgical develop a full-thickness mucoperiosteal flap
procedures in this growing population so as not to exposing the underlying skeletal buttress. The
hamper tooth or bone growth. More literature is anchor device is then carefully adapted so that
necessary before the widespread use of this the plate and connecting bar closely follow the
technique. contour of the underlying cortical bone of the zy-
gomaticomaxillary or piriform buttress region.
Surgical Procedures Care should be taken to avoid any dead-space
The application of temporary anchorage devices or gaps between the bone and the implanted
for orthodontic treatment usually requires only portion of the device. Another critical technical
a minor surgical procedure. The exact type of consideration is the location of the connecting
anchor (miniscrew or specialized anchor plate), bar as it exits the subperiosteal pocket and enters
location, and angle of the device are determined into the oral cavity. The transmucosal position of
by the orthodontic treatment plan. Preoperative the connecting bar should be located at approxi-
planning requires a careful clinical examination; mately the mucogingival junction. Nonkeratinized
at least a panoramic radiograph; and clear mucosal tissues should be avoided. When the
communication between the orthodontist and transmucosal location of the connecting bar is
surgeon regarding positioning, activation, and within the unattached tissues of the maxillary
removal. vestibule, increased irritation, inflammation, infec-
tion, and soft tissue overgrowth may result. Once
PLACEMENT OF SKELETAL the anchor has been appropriately contoured
ANCHORAGE PLATES and positioned, it is secured using self-drilling or
self-tapping monocortical screws. The incision is
Bone plates used for anchorage during ortho- irrigated and soft tissue closure is carried out using
dontic treatment can be placed in a variety of resorbable suture material.
anatomic locations within the maxillary and In contrast with the maxilla, the facial cortex of
mandibular arches. These devices typically the mandible is composed of dense bone that
consist of a bone plate with holes for screw place- allows for stable placement of skeletal anchorage
ment and a transmucosal connecting arm that devices. Despite the favorable cortical nature of
extends from the plate to a specialized working the mandible, however, specific, key anatomic
end. The working end of the appliance allows for structures including the mental foramen and
the attachment of wire, springs, elastics, and other nerve, and the mandibular canal must be avoided
orthodontic constructs. during placement. Placement of anchors in the
Within the maxillary arch, the anchor plate is mandible is most frequently carried out within the
typically placed within one of the vertical symphysis, posterior body, and ramus. In cases
buttresses of the midface (eg, zygomaticomaxil- where the bone plate is positioned directly over
lary buttress or piriform buttress) where the the mandibular canal, monocortical screws should
bone thickness allows for adequate mechanical be used to avoid injury to the inferior alveolar neu-
stability using monocortical screws. Monocortical rovascular bundle.
screws are preferred for fixation of the plate. The When skeletal anchorage plates are used, the
mid-anterior maxillary wall is avoided because of bone plate portion of the device is positioned
the thin cortical bone that is present directly over away from the tooth roots. Even in certain cases,
the maxillary sinuses and the proximity of the in- where the bone plate must be placed in closer
fraorbital neurovascular bundle. These consider- proximity to the adjacent teeth, the risk of damage
ations are reminiscent of the rationale applied to the underlying root structure remains very low.
when placing maxillary bone plates within the The use of short bone screws that engage only
piriform and zygomatic buttresses during orthog- the outer (facial) cortex avoids damage to dental
nathic surgery and the repair of mid-face structures and allows for the orthodontic move-
fractures. ment of teeth with minimal risk of hardware-related
The procedure is easy to perform for most impingement on the roots.
patients (Figs. 9 and 10). First, a vertical incision, The placement of a skeletal anchorage plate
approximately 8 to 10 mm in length, is created is usually carried out using local anesthesia.
from the mucogingival junction superiorly into the The use of local anesthesia in combination
maxillary vestibule. A small horizontal releasing with light conscious sedation may be preferable
incision is usually added along the mucogingival depending on the specific surgical plan, the
line to improve direct visualization and minimize number of anchors being placed, and patient
retraction-related trauma to the soft tissues during preference.
 Skeletal Anchorage Devices for Orthodontics 101

Fig. 9. (A–C) Maxillary anchor plate procedure. A small L-shaped incision is used at the mucogingival junction to
allow for placement of an anchor plate. Three screws or more are placed with appropriate positioning for the
indicated orthodontic mechanics. Closure is achieved with resorbable suture.

PLACEMENT OF MINISCREWS FOR SKELETAL depth or thick fibrous tissue is encountered,

ANCHORAGE a small tissue punch or surgical blade may be
used to create a small puncture site for introduc-
Skeletal anchorage miniscrews are placed near or tion. A number of self-drilling screws are available
at the mucogingival junction and engage that allow for placement of the anchor screw
the cortical and cancellous bone layers. Because without the creation of a pilot hole within the outer
the entire anchorage device is dependent on the cortex of the maxilla. When anchor screw place-
stability of the single screw, the longest length ment is undertaken within the mandibular arch,
possible is usually placed. In the maxillary arch, the use of self-drilling screws is generally avoided.
placement can be undertaken at the buttresses The density and thickness of the mandibular
(ie, zygomatic or piriform); the hard palate; or cortical plate may cause fracture of the screw
within the alveolar process in-between tooth roots. when a self-drilling anchor is used. Instead, a pilot
Within the mandible, placement can be under- hole is made using the surgical handpiece and
taken along the alveolar process at the mucogingi- a self-tapping anchorage screw is placed.
val junction, the symphysis, and within the
retromolar pad region. Because the screws extend
Postoperative Regimen
into the trabecullar bone, the subsequent ortho-
dontic movement of tooth roots must be Postoperative radiographs may be obtained to
anticipated. confirm the position of the skeletal anchorage
The surgical procedure for placement of minis- devices relative to the surrounding anatomic
crews is minimally invasive and does not typically structures. A panoramic radiograph is usually
require the elevation of a soft tissue flap. Local adequate. In cases where miniscrews are placed
anesthesia is used and a simple infiltration is in between teeth, periapical radiographs may be
usually adequate for placement of a single bone useful in examining the proximity of adjacent tooth
screw. In areas where a more pronounced tissue roots.
102 Costello et al

Fig. 10. (A–D) Mandibular anchor plate procedure. A small linear or L-shaped incision is used to position the plate
in a manner ideal for orthodontic mechanics of the specific case. The incision is placed at or near the mucogin-
gival junction if possible to avoid inflammation. Closure is achieved with resorbable suture.

Because the implants used for skeletal Pain and discomfort following miniscrew place-
anchorage are transmucosal and involve a portion ment is generally minimal. Patients undergoing
of hardware that remains exposed to the oral anchor plate placement may require a short
cavity, antibiotic coverage is used during the post- course of analgesic coverage because the proce-
operative phase. Patients are given a 5-day course dure involves the creation of an incision and
of oral antibiotics following surgical placement. greater soft tissue dissection. Patients may also
The most commonly used agents include peni- report cheek irritation, which tends to peak at
cillin, amoxicillin, and clindamycin. In addition, approximately 10 days following surgery before
meticulous oral hygiene and chlorhexidine oral resolving.
rinses during the first week postsurgery dramati- Because temporary anchorage devices require
cally reduce the amount of soft tissue inflammation primary mechanical stability, and not osseointe-
and risk of infection. gration, they may be used for orthodontic
 Skeletal Anchorage Devices for Orthodontics 103

treatment immediately following surgical place- Complications related to the device itself can
ment. Miniscrews may be activated immediately occur because of device failure (fracture); loos-
after surgical placement. Manipulation of full ening associated with a design flaw; or infection.
orthodontic force using a skeletal anchorage plate Most devices are made of titanium alloy that is of
is usually delayed for 7 to 10 days following place- a sufficient quality to avoid deformation of the
ment. This allows for adequate healing at the site threads, breakage of the screw head or shaft, or
of the mucoperiosteal flap and at the soft tissue fragmentation of the metal during placement with
of the mucogingival junction where the connecting the driver. Manufacturers with experience
bar is located. manufacturing plates and screws rarely encounter
issues with material failure because of the exten-
OUTCOMES AND COMPLICATIONS sive experience with materials used in rigid internal
fixation. If the titanium is not sufficiently strong or
Although in general the procedures described the manufacturing process for producing the
previously are reported as being very successful, screw or instrumentation has flaws, then the screw
the overall success rate of screw and plate or plate may be more likely to break or fatigue
systems warrants a special discussion. There is quickly. This can lead to device failure. Screws
considerable variation in the reported success of that are designed with an appropriate pitch thread
these techniques, and a number of opinions for the soft bone of the maxilla may also fail
regarding the exact indications for the choice of because of a lack of contact with cortical bone.
plates over screws in a given clinical situation. This is also true if the run-out of the screw is partic-
Placement of a screw or plate system is associ- ularly long because the screw threads do not inter-
ated with few complications, but the surgeon face with adequate cortical bone for stability. The
must be aware of those rare occurrences that screw prematurely loosens in this setting.
can create issues for patients. Problems related Although infection is rare in this area, it does occur,
to skeletal orthodontic anchorage appliances are and the devices should be sterilized before
typically screw, patient, or operator related. insertion.
The overall success rates vary between devices Operator-related complications can also occur
rather dramatically. A number of reports have listed for a variety of reasons. Small screw systems
loosening or outright failure of orthodontic anchorage require very careful placement, and a fine tactile
screws to be above 15%.12,14,19,20,23,31–34 In some sense is necessary to avoid stripping the bone-
indications and anatomic locations, the rate of loos- screw interface during placement. Overworking
ening of the screw is higher than 30%. As might be the screw material can also lead to failure. Poor
expected, the rate of failure of plates is considerably stability can also occur because of a poor choice
lower with failure rates below 5%.4,23,24,27 It is impor- of placement, such as in the mid-maxillary antral
tant to recognize that most of the data published are sinus wall. Bone is not adequate in this area to
reported by the individuals who placed and used the support fixation in most patients, and individual
devices, and as such the definition of failure may vary. screws or plates are prone to failure. Most screws
There is an inherent self-reporting bias with such liter- and the working attachments of plates should
ature. Plate systems offer a greater degree of three- enter the oral cavity within attached mucosa if
dimensional stability, and a higher integration with possible. Significant inflammation, pain, and even
the bone structure because of the multiple screws infection may result if moveable mucosa
used for fixation. Consequently, the authors tend to surrounds the screw head or working end of an
use bone plates more often than screws for cases anchor plate system.
that require longer treatment times or greater forces. The device must be placed in a location that is
Many surgeons and orthodontists believe plates to helpful for the orthodontic mechanics required by
be more stable, but they often are concerned the orthodontist. This should be the case
regarding the additional incision and dissection throughout the entire treatment period. For
required for placement despite the minor nature of example, if a screw is placed within alveolar
the procedure.35 Additionally, although reports of bone to allow for distal movement of teeth just
improved outcomes using these techniques appear anterior to that screw, then the eventual location
in the literature, not many prospective studies in the of those teeth should be anticipated after they
level I evidence category exist.36 Most studies have are moved. Will the device be in the way of moving
significant reporting bias, disparate patient popula- teeth? Will it need to be replaced? Is it far enough
tions, and data analysis flaws.36,37 Although the avail- away from the point of attachment to allow for all of
able literature is encouraging, any innovation requires the movement necessary throughout the case? All
scrutiny and comparative study to ultimately deter- of these questions should be addressed at the
mine its use in the treatment armamentarium. treatment planning stage before surgical
104 Costello et al

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