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

Those patients who have more significant discrepancies, however, require additional techniques.
This is most evident to the oral and maxillofacial
surgeon when one examines patients with
moderate to severe skeletal discrepancies.
Patients with occlusal discrepancies beyond
what can be managed with standard orthodontic
therapy are usually treated with techniques that
include growth modification or orthognathic
surgery in combination with comprehensive orthodontic therapy. Presently, patients with mild to
moderate discrepancies may benefit from skeletal
anchorage devices to compensate further for
malocclusions that were not previously correctable using conventional orthodontic mechanics.
Additionally, a variety of problems encountered
by the orthodontist on a regular basis are now
more efficiently treated with skeletal anchorage
as an adjunct to traditional mechanics.
This article discusses the recent advances and
basic concepts of skeletal anchorage devices of
various types and reviews the current literature
on their use. A primer on orthodontic mechanics
is required to treat patients with skeletal
anchorage devices adequately, and the reader is
encouraged to review principles of orthodontic

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 Childrens 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: [email protected]

Oral Maxillofacial Surg Clin N Am 22 (2010) 91105

doi:10.1016/j.coms.2009.10.011
1042-3699/10/$ see front matter 2010 Elsevier Inc. All rights reserved.

oralmaxsurgery.theclinics.com

Orthodontists have always tried to develop ways

to move teeth while minimizing the unwanted
reciprocal movement of the teeth they pull or
push against. This constant battle is more easily
won when ideal anchorage is in place to move
teeth in an efficient manner. Although dental
implants were used as absolute orthodontic
anchorage in the past, they had not become
popular for a number of reasons including cost;
time of sequencing for osseointegration; and their
primary use for dental restoration purposes, not
orthodontic mechanics. These concepts of skeletal anchorage are not new, but have gained
more attention in the literature because of
a number of innovations in design and technique.
Even as this article is being written, advances in
materials and technique are poised to change
how these procedures are planned and performed. The reader is encouraged to review the
literature regularly because the pace of change is
rapid.
The goals of orthodontic therapy include optimizing occlusion, aesthetics, and facial balance.
Traditional orthodontic mechanics are efficient at
accomplishing these goals for clinical scenarios
that require mild to moderate compensation.

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mechanics in conjunction with this article. Much
like the concepts introduced during the beginnings
of orthognathic dentofacial teams, treatment that
uses skeletal anchorage requires interdisciplinary
collaboration and planning with regular interaction,
continuing education, and a regular review of the
latest relevant literature. Additionally, frequent
communication between orthodontist and oral
and maxillofacial surgeon is necessary to achieve
superior results.

HISTORY OF SKELETAL ANCHORAGE

FOR ORTHODONTICS
Recent technical advances have resulted in an
increased level of interest in skeletal anchorage
for orthodontic treatment, although the concept
of using implantable devices for this purpose has
been present for more than a half century.15
Only recently have innovations in materials, new
outcome data, and improved techniques thrust
this concept forward as a more mainstream option
for treatment. In the 1940s, Gainsforth and Higley6
experimented with vitallium screws and wires in
the dog ramus used for skeletal anchorage. This
initial experiment was not considered a success.6
Linkow7 used blade-type implants in the posterior
mandible to apply class II elastics for retraction of
maxillary incisors. This cross-arch technique was
apparently successful, but had the disadvantage
of requiring the surgical placement of a blade
implant and then allowing adequate healing time
for its osseointegration before use as an anchor.
Sherman8 also used dental implants in dogs for
anchorage with limited success. In 1979, Smith9
noted that dental implants could act like ankylosed
teeth during orthodontic movement. In 1988, Shapiro and Kokich10 discussed how dental implants
could be used for orthodontic anchorage before
their prosthodontic use, and a number of practitioners used this technique from this point forward.
In 1995, Block and Hoffman11 used a hydroxyapatite-coated onplant placed in the midline palatal
tissues for use with an orthodontic anchor device.
This was moderately successful, but required the
orthodontist to rethink anchorage in terms of
palatal mechanics instead of what was typically
used with brackets and bands. Costa and
coworkers12 used titanium miniscrews borrowed
from plating fixation systems for orthodontic
anchorage with some success. In 1999, Umemori
and colleagues3 described techniques for using
a modified rigid fixation plate for use as orthodontic anchorage. This was a particularly important leap, because the plating system could be
easily placed and significant force could be used
without loosening of the device that was seen

rather frequently with individual screws. Loosening

of the screw mechanic had been a major drawback of screw systems. Sugawara and colleagues
and other authors3,4,1317 subsequently described
a number of interesting compensation techniques
for a variety of problems that traditionally would
have required orthognathic surgery to treat, such
as the anterior open bite and significant class III
deformity.

BASIC ORTHODONTIC MECHANICS

AND SKELETAL ANCHORAGE
To understand the indications for skeletal
anchorage, the practitioner placing the devices
must have a baseline understanding of orthodontic
mechanics to ensure superior results. Planning for
a team approach to a skeletal anchorage case is in
many ways similar to planning for orthognathic
surgery. Issues that arise in the preoperative, intraoperative, and postoperative phases of treatment
concern both the orthodontist and surgeon. As
such, frequent communication must occur to
ensure the best outcome.
The term anchorage, within the context of
orthodontic treatment, is defined as the resistance
to unwanted tooth movement. The forces involved
in orthodontic tooth movement obey Newtons
third law, which states that for every action, there
is an equal and opposite reaction. For every movement of a tooth in the desired direction, the force is
distributed to the anchorage segment, potentially
affecting the position of those teeth within the
anchorage segment. If an orthodontist wishes to
move a canine posterior (distally), but only one
molar is present, then the molar has a tendency
to drift toward the mesial if the molar is used as
an anchor for that movement. If more anchorage
is provided to that area, however, then the movement can occur with less of the unwanted mesial
movement of the molar.
Using conventional mechanics, anchorage can
be increased by using intraoral or extraoral techniques. Intraoral techniques commonly use
tooth-borne appliances to improve anchorage.
This can be achieved by increasing the number
of teeth in the anchorage unit. For example, teeth
can be tied together with ligature wire to resist
unwanted tooth movement in another area.
Another way of increasing teeth in the anchorage
segment is to use a transpalatal arch. A transpalatal arch can be fabricated to distribute force to
another segment of teeth across the arch. Alternatively, elastic bands can be used between the
opposing arches to provide additional anchorage.
This technique is commonly used to close space
after maxillary premolar extraction by retracting

Skeletal Anchorage Devices for Orthodontics

the anterior dentition of the maxilla with elastic
bands bilaterally and attaching the elastic to the
mandibular posterior teeth. These class II elastics
also help to minimize the unwanted mesial movement of the maxillary posterior anchorage
segments. This technique is based on compliance,
and can be ineffective if the patient does not regularly wear the elastics.
Another way to provide maximum anchorage to
the posterior teeth is to use a Nance button appliance that holds the posterior molars in position
with an acrylic button on the anterior palate. Force
can then be applied to the posterior teeth to close
premolar space, and the tendency for the molar
teeth to move mesial is resisted by the acrylic
button on the palate near the incisive foramen.
These appliances may irritate the tissue and
become uncomfortable. Extraoral appliances,
such as a headgear, can also be used to provide
additional anchorage, but are often subject to
compliance issues and rarely offer more than 6
to 10 hours of force per day. They are also not
readily accepted by some patients, particularly
adults.
Skeletal appliances (specialized bone screws or
plates) provide anchorage that is not tooth-borne
because they are attached to the surrounding
bone. As a result, unwanted reciprocal tooth
movements involving the surrounding teeth are
totally avoided. Other advantages of these devices
include the following:
 No or minimal reliance on existing dentition
 Less dependent on patient compliance
 Continuous rather than intermittent force
may be applied
 Surgical procedures are necessary, but
they are simple in most instances
 May be significantly less expensive than
other surgical options, such as orthognathic
surgery
 Force may be applied very soon or immediately after placement of the device; devices

require mechanical stability instead of

osseointegration
 Devices are easily removed.
The anchorage applied may be considered
direct or indirect. Direct techniques are those
that apply force directly from the anchor to the
segment or tooth that is to be moved (Fig. 1). For
example, maxillary plates placed at the zygomatic
buttresses may be designed to provide intrusion
force to the maxillary molars with the intent of
closing an anterior open bite. This is a direct technique because the force is applied from the anchor
directly to the molar teeth. Indirect techniques tie
the anchor device to the segment of teeth that
requires additional anchorage such that more
traditional mechanics can be used in the area
(Fig. 2). Rather than an active, elastic connection
between the anchor and the archwire, indirect
anchorage involves an inelastic or even rigid
connection between the anchor and the orthodontic appliances. For example, if a maxillary
anchor is tied by a steel ligature to the anterior
teeth to provide more anchorage to that segment,
then a coil spring could be used on the archwire to
distalize the molar teeth. This represents an indirect technique because the force used is along
the archwire by the coil spring, and represents
a traditional type of mechanic in orthodontics.
The advantage to the indirect technique is that
most orthodontists already design their movements of teeth based on traditional mechanics.
Providing additional anchorage by a skeletal
device simply increases efficiency without necessitating a new appliance design or vectors and
movements difficult to achieve in commonly used
orthodontic techniques. Either a direct or indirect
technique can be used in most situations, and
each case requires careful planning to ensure ideal
placement of the anchor for these purposes.
Skeletal anchorage devices allow orthodontic
movements to be designed that were previously
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 orthodontic 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.)

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Fig. 2. An example of indirect anchorage using somewhat complicated palatal mechanics. The left first
molar is tied with a ligature wire to a temporary anchor
screw providing absolute anchorage. The right
segment is planned to move distally, so an elastic chain
is threaded from the hook behind the first bicuspid on
the transpalatal bar. The final result is distalization of
the entire right segment, a vector of force that is traditionally difficult or impossible to achieve with standard
mechanics. (Data from Anka G. In: Nanda R, editor.
Temporary anchorage devices in orthodontics. St Louis:
Elsevier; 2008. p. 199.)

Compensation beyond the typical envelope of

discrepancy is possible for many clinical indications. Skeletal anchorage devices do not allow
faster movement of teeth, or the ability to overcome exceptionally large discrepancies; the
devices have limitations. They provide absolute
anchorage for orthodontic movement, however,
and do so in a number of novel ways. They allow
for more efficient movement of teeth and address
a number of anchorage problem areas that previously were difficult or impossible to resolve with
traditional orthodontic mechanics alone.

DEVICES FOR SKELETAL ANCHORAGE

A number of devices have been used to provide
additional anchorage for orthodontic purposes.
The early attempts that were successful used
dental implants placed with the intention of using
them for total skeletal anchorage. These had the
significant drawbacks of requiring osteointegration before use and the high cost. They also
required aggressive surgery for removal. Although
some could be kept in place for prosthetic use,
often it was difficult to determine the exact position
required at the end of orthodontic treatment when
placing them for anchorage purposes before treating the malocclusion. Consequently, the implants
were often not in ideal position for the final crown
or prosthesis, rendering them either useless or
requiring specialized prosthodontic techniques to
compensate for poor position.

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 osseointegration 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 perforation either at the time of placement or at the time of
removal. If the implants are placed parasagittal,
then a fistula may result when the implant is
removed because of the thin bone in this region
of the nasal floor and hard palate.
The onplant system, with attachments that
penetrate through the palatal tissues for orthodontic anchorage, is an attempt to get around
these inadequacies of the endosseous implant
approach. These onplants are coated with titanium or hydroxyapatite in the hopes of osseointegration after a small palatal incision is made for
a subperiosteal placement. Long-term outcomes
of this technique have not been reported, and it
has mostly been supplanted by single screws or
plates at other locations. As with any palatal
implant, the additional drawback of redesigning
orthodontic mechanics around a device positioned on the palate requires significant planning
by the orthodontist in a manner that is not
conventional.
Placement of a bone screw for orthodontic
mechanics has been described using a number
of different screw devices.10,14,19,20 Recently,
there has been an explosion of these screws
commercially available for use. Originally, fixation
screws used for craniomaxillofacial surgery were
placed and then attached to the orthodontic appliance for use as additional anchorage. Other screw
systems used for alternative purposes, such as
maxillomandibular fixation, were modified for use
as skeletal anchorage. Eventually, screws specifically designed for use in orthodontic skeletal
anchorage were manufactured with versatile
orthodontic attachments to optimize their use
(Fig. 3). Both self-tapping and self-drilling systems
are currently available.
Screws are typically manufactured in multiple
lengths for a number of indications. Short screws
can be used, but fail more often because of
minimal bone-to-screw interface. Screws that
engage cortical bone across the alveolus tend to
have more stability, and this technique requires
longer screws (812 mm). The thread pitch should
also be ideal for the type of bone in this area, and

Skeletal Anchorage Devices for Orthodontics

Fig. 3. A maxillary anchor screw is used to provide

anchorage to the anterior dentition because of
a lack of anchorage in the right posterior maxilla.
This allows the orthodontist to distalize the premolars
and canine to treat the crowding of the anterior
dentition while preserving the dental midline.

typically is approximately 0.6 mm. The attachments come in a variety of designs. The authors
prefer an attachment that allows for placement of
a ligature, elastomer chain, or wire. Although
a number of entities manufacture screws, it is
important to consider the quality of the titanium
alloy used and the highly engineered aspects of
the screw. Poorly made devices are prone to fracture, and as such it is recommended that surgeons
use devices with proved use in these indications.
Devices should
 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 shafthead 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. Additionally, 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
of the orthodontic wire, and often fail with minimal
torque or a force that rotates the screw in the
counterclockwise direction, loosening it. The indications, success rates, and limitations of screws
used for skeletal anchorage are discussed later.

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.4,13,2125
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). Skeletal anchorage plates are also easy to remove,
but require an additional incision and dissection.

Clinical Indications
Skeletal anchorage devices may be used in many
different applications to provide absolute
anchorage and optimize the efficiency of tooth
movement. The authors prefer plates over screws
to provide anchorage using indirect mechanics
when possible. Direct anchorage techniques may
also be helpful for some indications. Some case
examples illustrating the use of skeletal anchorage
follow, and new applications are being investigated.

MESIAL OR DISTAL MOVEMENT OF TEETH

WITH MAXIMUM ANCHORAGE
The need to move posterior teeth in the mesial
direction is difficult because of a lack of anchorage

Fig. 4. A maxillary anchor plate is placed along the

left maxillary buttress. This allows placement of three
or four monocortical screws away from the tooth
roots and placement of the orthodontic attachment
in an ideal position for intrusion of the maxillary
molars.

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Costello et al
from the anterior segment.4,24,25 For example,
when an overretained primary first molar is extracted and the succedaneous permanent first
bicuspid is missing, the orthodontist may choose
to move the remaining posterior tooth or teeth to
the mesial to close the space of the primary first
molar (Fig. 5). This is often difficult because the
anterior segment of teeth have a tendency to
move to the posterior (distal), causing the incisors
to upright and changing the canine position to
class II. To maintain the position of the anterior
teeth including the class I canine, a skeletal anchor
may be placed to provide either indirect
anchorage with a rigid attachment to the anterior
segment or direct anchorage with and active
attachment to the molar segment. This allows for
more efficient movement of the posterior molars
to close the space, without loosing the position
of the canine or disrupting the overbite-overjet
relationship of the incisors. To improve a class II
relationship, a variety of tooth movements are
possible including distalizing the maxillary teeth.
By moving the maxillary molars distally, space
can be created to reduce the overjet and to
achieve a class I canine relationship (Figs. 6 and
7).14,25
Alternatively, if a patient presents with a class III
discrepancy, then the orthodontist may choose to
compensate by providing maximum anchorage to
the mandibular posterior teeth or to distalize
mandibular molar teeth.26 This allows the mandibular anterior dentition to be retracted and to close
the space while providing maximum anchorage to
the distal (posterior) segment of teeth. Without

Fig. 5. A patient who has lost their lower primary first

molars has good position of the canines (class I), and
lacks enough anchorage posteriorly to close the space
without the unwanted distal movement of the
canines. This is a frequent problem for orthodontists
who need to close space with maximum anchorage.
Anchorage plates or screws can provide absolute
anchorage to close the space efficiently without
unwanted tooth movements.

skeletal anchorage, this may be difficult to achieve

because the posterior teeth have a tendency to
move toward the mesial when using traditional
mechanics (Fig. 8).
It follows that these techniques can be helpful
after extraction of bicuspids if the orthodontist
wishes to close the space with maximum
anchorage in either segment. Although this is
easily
done
with
traditional
orthodontic
mechanics, in certain instances when anchorage
is lacking, or maximum anchorage is desired,
then skeletal anchorage appliances can be used
to maximize efficiency.

UPRIGHTING OR INTRUDING MOLAR TEETH

One of the more difficult movements in orthodontic
treatment is uprighting a molar tooth that has
moved mesially into an edentulous space. Most
often this occurs in the adult patient who has lost
their first molar to caries and the second molar
tips to the mesial over a period of time. Subsequent to this event, if a patient presents for orthodontic treatment, it may be very difficult to upright
the second molar without extruding the tooth and
opening the patients bite.14,15,22 With the use of
a skeletal anchor, the tooth may be uprighted
without the untoward extrusion that often results
with conventional orthodontic techniques.
Another difficult problem to remedy is the overerupted maxillary or mandibular tooth that is in
poor position because of an edentulous space in
the opposite arch. Intruding teeth in this situation
is exceptionally difficult using traditional orthodontic mechanics. The use of a skeletal anchorage
device makes intrusion a relatively easy orthodontic movement.22 This technique may be used
in the anterior or posterior dentition. Patients
who have a deep class II relationship with excessive 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 efficient and also requires very little compliance
from the patient.

CLOSURE OF ANTERIOR OPEN BITE

There has been a great degree of excitement
generated by the initial reports of anterior open
bite closure with orthodontic anchorage appliances.3,4,13,16,22,2729 Typically, this is performed
by placing orthodontic plates or screws in the
posterior maxilla, apical to the dentition. Force is
then generated to intrude the posterior molars

Skeletal Anchorage Devices for Orthodontics

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. (AC) 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

open bite. A number of case reports have shown
this to be successful. Excitement has grown in
this area because of the difficulty typically encountered with orthodontic-only closure of the anterior
open bite, and the subsequent relapse that often
occurs. The alternative is orthognathic repositioning with the presumed improvement in stability.
Although the use of skeletal anchorage to close
anterior open bite is reported to be stable in case
reports and a few case series publications, there
are no long-term data on stability of these procedures as there has been for orthognathic surgery.
For this reason, the authors prefer to use this
technique for those patients who cannot or will
not undergo orthognathic surgery, and for those
patients who have minimal open bites. Patients
who have already failed orthodontic treatment for

closure of their open bites may be good candidates for this procedure, but retreatment does
come with additional risk, such as root resorption.
Orthodontists should be careful to not extrude the
anterior maxillary teeth, which likely decreases
long-term stability of the correction. Intrusion of
the posterior maxillary dentition is preferred and
has been shown to be effective. Patients should
be cautioned regarding the expectations of
outcome over the long-term. It is expected that
more data will become available to assess the
safety, efficacy, and long-term stability of this
treatment option.

ORTHOPEDIC GROWTH MODIFICATION

An area of considerable interest is the use of skeletal anchorage to provide forces for orthopedic

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Fig. 7. A patient with Noonans 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 orthognathic surgery. (D, E) Photographs of the anchors in place after several weeks with minimal inflammation.
(FH) Photographs of the progression of treatment over 9 months as the class II discrepancy improves. (I, J) Posttreatment facial photographs.

Skeletal Anchorage Devices for Orthodontics

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 allowed for distal movement of most of the mandibular arch of teeth, and establishment of a class I canine relationship. (AE) Pretreatment photographs. (F) Mandibular anchor plate in place with orthodontic anchorage
activated. (GK) Posttreatment photographs.

growth modification in a manner similar to the use

of headgear appliances. This has been used by
some practioners for children during phase I orthodontic therapy. For patients with a class III skeletal
pattern (midface hypoplasia or mandibular prognathism), skeletal anchors can be placed in the
mandible and maxilla to provide forward orthopedic force to the maxilla and encourage a more

class I relationship.30 The vector of force is similar

to reverse-pull headgear without the need for an
external appliance. The mechanics involved are
more favorable because of the constant force
provided rather than relying on the patient to
wear the appliance only for a prescribed time.
Although the concept has been reported in the
literature, there is little evidence of its efficacy or

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Costello et al
safety. Practitioners must be careful to avoid
developing tooth structures, and minimize surgical
procedures in this growing population so as not to
hamper tooth or bone growth. More literature is
necessary before the widespread use of this
technique.

Surgical Procedures
The application of temporary anchorage devices
for orthodontic treatment usually requires only
a minor surgical procedure. The exact type of
anchor (miniscrew or specialized anchor plate),
location, and angle of the device are determined
by the orthodontic treatment plan. Preoperative
planning requires a careful clinical examination;
at least a panoramic radiograph; and clear
communication between the orthodontist and
surgeon regarding positioning, activation, and
removal.

PLACEMENT OF SKELETAL
ANCHORAGE PLATES
Bone plates used for anchorage during orthodontic treatment can be placed in a variety of
anatomic locations within the maxillary and
mandibular arches. These devices typically
consist of a bone plate with holes for screw placement and a transmucosal connecting arm that
extends from the plate to a specialized working
end. The working end of the appliance allows for
the attachment of wire, springs, elastics, and other
orthodontic constructs.
Within the maxillary arch, the anchor plate is
typically placed within one of the vertical
buttresses of the midface (eg, zygomaticomaxillary buttress or piriform buttress) where the
bone thickness allows for adequate mechanical
stability using monocortical screws. Monocortical
screws are preferred for fixation of the plate. The
mid-anterior maxillary wall is avoided because of
the thin cortical bone that is present directly over
the maxillary sinuses and the proximity of the infraorbital neurovascular bundle. These considerations are reminiscent of the rationale applied
when placing maxillary bone plates within the
piriform and zygomatic buttresses during orthognathic surgery and the repair of mid-face
fractures.
The procedure is easy to perform for most
patients (Figs. 9 and 10). First, a vertical incision,
approximately 8 to 10 mm in length, is created
from the mucogingival junction superiorly into the
maxillary vestibule. A small horizontal releasing
incision is usually added along the mucogingival
line to improve direct visualization and minimize
retraction-related trauma to the soft tissues during

anchor placement. A periosteal elevator is used to

develop a full-thickness mucoperiosteal flap
exposing the underlying skeletal buttress. The
anchor device is then carefully adapted so that
the plate and connecting bar closely follow the
contour of the underlying cortical bone of the zygomaticomaxillary or piriform buttress region.
Care should be taken to avoid any dead-space
or gaps between the bone and the implanted
portion of the device. Another critical technical
consideration is the location of the connecting
bar as it exits the subperiosteal pocket and enters
into the oral cavity. The transmucosal position of
the connecting bar should be located at approximately the mucogingival junction. Nonkeratinized
mucosal tissues should be avoided. When the
transmucosal location of the connecting bar is
within the unattached tissues of the maxillary
vestibule, increased irritation, inflammation, infection, and soft tissue overgrowth may result. Once
the anchor has been appropriately contoured
and positioned, it is secured using self-drilling or
self-tapping monocortical screws. The incision is
irrigated and soft tissue closure is carried out using
resorbable suture material.
In contrast with the maxilla, the facial cortex of
the mandible is composed of dense bone that
allows for stable placement of skeletal anchorage
devices. Despite the favorable cortical nature of
the mandible, however, specific, key anatomic
structures including the mental foramen and
nerve, and the mandibular canal must be avoided
during placement. Placement of anchors in the
mandible is most frequently carried out within the
symphysis, posterior body, and ramus. In cases
where the bone plate is positioned directly over
the mandibular canal, monocortical screws should
be used to avoid injury to the inferior alveolar neurovascular bundle.
When skeletal anchorage plates are used, the
bone plate portion of the device is positioned
away from the tooth roots. Even in certain cases,
where the bone plate must be placed in closer
proximity to the adjacent teeth, the risk of damage
to the underlying root structure remains very low.
The use of short bone screws that engage only
the outer (facial) cortex avoids damage to dental
structures and allows for the orthodontic movement of teeth with minimal risk of hardware-related
impingement on the roots.
The placement of a skeletal anchorage plate
is usually carried out using local anesthesia.
The use of local anesthesia in combination
with light conscious sedation may be preferable
depending on the specific surgical plan, the
number of anchors being placed, and patient
preference.

Skeletal Anchorage Devices for Orthodontics

Fig. 9. (AC) 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

ANCHORAGE
Skeletal anchorage miniscrews are placed near or
at the mucogingival junction and engage
the cortical and cancellous bone layers. Because
the entire anchorage device is dependent on the
stability of the single screw, the longest length
possible is usually placed. In the maxillary arch,
placement can be undertaken at the buttresses
(ie, zygomatic or piriform); the hard palate; or
within the alveolar process in-between tooth roots.
Within the mandible, placement can be undertaken along the alveolar process at the mucogingival junction, the symphysis, and within the
retromolar pad region. Because the screws extend
into the trabecullar bone, the subsequent orthodontic movement of tooth roots must be
anticipated.
The surgical procedure for placement of miniscrews is minimally invasive and does not typically
require the elevation of a soft tissue flap. Local
anesthesia is used and a simple infiltration is
usually adequate for placement of a single bone
screw. In areas where a more pronounced tissue

depth or thick fibrous tissue is encountered,

a small tissue punch or surgical blade may be
used to create a small puncture site for introduction. A number of self-drilling screws are available
that allow for placement of the anchor screw
without the creation of a pilot hole within the outer
cortex of the maxilla. When anchor screw placement is undertaken within the mandibular arch,
the use of self-drilling screws is generally avoided.
The density and thickness of the mandibular
cortical plate may cause fracture of the screw
when a self-drilling anchor is used. Instead, a pilot
hole is made using the surgical handpiece and
a self-tapping anchorage screw is placed.

Postoperative Regimen
Postoperative radiographs may be obtained to
confirm the position of the skeletal anchorage
devices relative to the surrounding anatomic
structures. A panoramic radiograph is usually
adequate. In cases where miniscrews are placed
in between teeth, periapical radiographs may be
useful in examining the proximity of adjacent tooth
roots.

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Costello et al

Fig. 10. (AD) 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 mucogingival junction if possible to avoid inflammation. Closure is achieved with resorbable suture.

Because the implants used for skeletal

anchorage are transmucosal and involve a portion
of hardware that remains exposed to the oral
cavity, antibiotic coverage is used during the postoperative phase. Patients are given a 5-day course
of oral antibiotics following surgical placement.
The most commonly used agents include penicillin, amoxicillin, and clindamycin. In addition,
meticulous oral hygiene and chlorhexidine oral
rinses during the first week postsurgery dramatically reduce the amount of soft tissue inflammation
and risk of infection.

Pain and discomfort following miniscrew placement is generally minimal. Patients undergoing
anchor plate placement may require a short
course of analgesic coverage because the procedure involves the creation of an incision and
greater soft tissue dissection. Patients may also
report cheek irritation, which tends to peak at
approximately 10 days following surgery before
resolving.
Because temporary anchorage devices require
primary mechanical stability, and not osseointegration, they may be used for orthodontic

Skeletal Anchorage Devices for Orthodontics

treatment immediately following surgical placement. Miniscrews may be activated immediately
after surgical placement. Manipulation of full
orthodontic force using a skeletal anchorage plate
is usually delayed for 7 to 10 days following placement. This allows for adequate healing at the site
of the mucoperiosteal flap and at the soft tissue
of the mucogingival junction where the connecting
bar is located.

OUTCOMES AND COMPLICATIONS

Although in general the procedures described
previously are reported as being very successful,
the overall success rate of screw and plate
systems warrants a special discussion. There is
considerable variation in the reported success of
these techniques, and a number of opinions
regarding the exact indications for the choice of
plates over screws in a given clinical situation.
Placement of a screw or plate system is associated with few complications, but the surgeon
must be aware of those rare occurrences that
can create issues for patients. Problems related
to skeletal orthodontic anchorage appliances are
typically screw, patient, or operator related.
The overall success rates vary between devices
rather dramatically. A number of reports have listed
loosening or outright failure of orthodontic anchorage
screws to be above 15%.12,14,19,20,23,3134 In some
indications and anatomic locations, the rate of loosening of the screw is higher than 30%. As might be
expected, the rate of failure of plates is considerably
lower with failure rates below 5%.4,23,24,27 It is important to recognize that most of the data published are
reported by the individuals who placed and used the
devices, and as such the definition of failure may vary.
There is an inherent self-reporting bias with such literature. Plate systems offer a greater degree of threedimensional stability, and a higher integration with
the bone structure because of the multiple screws
used for fixation. Consequently, the authors tend to
use bone plates more often than screws for cases
that require longer treatment times or greater forces.
Many surgeons and orthodontists believe plates to
be more stable, but they often are concerned
regarding the additional incision and dissection
required for placement despite the minor nature of
the procedure.35 Additionally, although reports of
improved outcomes using these techniques appear
in the literature, not many prospective studies in the
level I evidence category exist.36 Most studies have
significant reporting bias, disparate patient populations, and data analysis flaws.36,37 Although the available literature is encouraging, any innovation requires
scrutiny and comparative study to ultimately determine its use in the treatment armamentarium.

Complications related to the device itself can

occur because of device failure (fracture); loosening associated with a design flaw; or infection.
Most devices are made of titanium alloy that is of
a sufficient quality to avoid deformation of the
threads, breakage of the screw head or shaft, or
fragmentation of the metal during placement with
the driver. Manufacturers with experience
manufacturing plates and screws rarely encounter
issues with material failure because of the extensive experience with materials used in rigid internal
fixation. If the titanium is not sufficiently strong or
the manufacturing process for producing the
screw or instrumentation has flaws, then the screw
or plate may be more likely to break or fatigue
quickly. This can lead to device failure. Screws
that are designed with an appropriate pitch thread
for the soft bone of the maxilla may also fail
because of a lack of contact with cortical bone.
This is also true if the run-out of the screw is particularly long because the screw threads do not interface with adequate cortical bone for stability. The
screw prematurely loosens in this setting.
Although infection is rare in this area, it does occur,
and the devices should be sterilized before
insertion.
Operator-related complications can also occur
for a variety of reasons. Small screw systems
require very careful placement, and a fine tactile
sense is necessary to avoid stripping the bonescrew interface during placement. Overworking
the screw material can also lead to failure. Poor
stability can also occur because of a poor choice
of placement, such as in the mid-maxillary antral
sinus wall. Bone is not adequate in this area to
support fixation in most patients, and individual
screws or plates are prone to failure. Most screws
and the working attachments of plates should
enter the oral cavity within attached mucosa if
possible. Significant inflammation, pain, and even
infection may result if moveable mucosa
surrounds the screw head or working end of an
anchor plate system.
The device must be placed in a location that is
helpful for the orthodontic mechanics required by
the orthodontist. This should be the case
throughout the entire treatment period. For
example, if a screw is placed within alveolar
bone to allow for distal movement of teeth just
anterior to that screw, then the eventual location
of those teeth should be anticipated after they
are moved. Will the device be in the way of moving
teeth? Will it need to be replaced? Is it far enough
away from the point of attachment to allow for all of
the movement necessary throughout the case? All
of these questions should be addressed at the
treatment planning stage before surgical

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Costello et al
placement of the device to avoid the need for additional surgery.
One area requiring special attention is that of
root damage from either placement of a screw or
the drilling process. Surgeons who are comfortable with the anatomy of these regions typically
do not have issues with root damage, but this
may still occur because of anatomic variation or
other causes. Thankfully, roots have excellent
recuperative power that allows for recuperation if
a minimal insult occurs. If a device has been
placed and the screw is in contact with the root
of a viable tooth, then the patient typically experiences discomfort during mastication. Moving the
root away from the implant typically relieves this
discomfort, or the device can be replaced in
a new location.
A number of patient-related complications also
can occur. Patients must have good-quality bone
to accept the devices and have reasonable
hygiene. Quality cortical bone is a necessity for
long-term stability of the anchors. Patients who
have systemic disorders that affect bone or
mucosal healing are not good candidates for these
procedures. Likewise, those patients who have
undergone radiation therapy in the region or are
taking bisphosphonate medications are not good
candidates. Those patients who smoke are also
prone to mucosal breakdown, infection, and failure
of the devices.

SUMMARY
Skeletal anchorage devices allow orthodontic
movements that were previously thought to be
difficult if not impossible. The devices do not
accelerate tooth movement, but do provide the
greatest amount of anchorage in a manner that is
bone-borne, creating more efficient mechanics
for moving teeth while avoiding unwanted (reciprocal) tooth movement in a number of challenging
clinical situations. Additionally, unwanted reciprocal tooth movements are minimized or avoided
altogether. An additional advantage is the use of
mechanics for which the success is not based on
compliance factors, such as with headgear or
elastic band therapy that requires patient placement and removal. Multiple applications, devices,
and technique innovations are evolving. Caution is
warranted for some applications because longterm data are not available at this time. It is hoped
that additional data will become prevalent and
help decide how skeletal anchorage fits in best
with the armamentarium of treatment choices for
significant skeletal and dental discrepancies.

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