<\/p>\n
Skeletal vs. Conventional Anchorage in Dentofacial Orthopedics: A Delphi Consensus Study<\/strong><\/p>\n Introduction:<\/strong> The Debate Over Anchorage in Orthodontics<\/p>\n Anchorage control has long been a cornerstone of orthodontic treatment, particularly in cases of dentofacial orthopedic correction. Over the last 40 years, skeletal anchorage using temporary anchorage devices (TADs) such as miniscrews and miniplates\u00e2\u20ac\u201dhas emerged as a means to enhance skeletal changes while minimizing unwanted dental side effects. However, despite widespread adoption, the comparative effectiveness of skeletal versus conventional anchorage remains a topic of debate.<\/p>\n The study by Franchi et al. (2025) attempts to bridge this gap by employing a modified Delphi consensus method to gather expert opinions on the use of skeletal anchorage in three key clinical scenarios:<\/p>\n 1. Maxillary transverse deficiency in growing and adult patients<\/strong><\/p>\n 2. Class II skeletal disharmony due to mandibular retrusion in growing patients<\/strong><\/p>\n 3. Class III skeletal disharmony in growing patients.<\/strong><\/p>\n While expert consensus can provide valuable guidance, it must be viewed as an adjunct to empirical clinical evidence. Let\u2019s take a closer look at the methodology and key findings of this consensus study.<\/p>\n <\/p>\n Study Design: A Structured Expert Consensus<\/strong><\/p>\n The study utilized a four-round modified Delphi method, a structured process that gathers expert opinions iteratively to develop consensus. A steering committee composed of experienced orthodontic researchers first conducted a literature review and formulated 33 key statements regarding skeletal versus conventional anchorage. These statements were then reviewed by 25 international experts, each providing their level of agreement on a 5-point Likert scale. Statements that failed to reach consensus were revised or rejected.<\/p>\n After four rounds, 24 statements achieved consensus, while 9 were rejected, highlighting areas of both agreement and continued uncertainty.<\/p>\n <\/p>\n Key Findings: Where Experts Agree (and Disagree)<\/strong><\/p>\n 1. Maxillary Transverse Deficiency: Skeletal vs. Conventional Expansion<\/p>\n \u2022 Bone-borne expanders reduce unwanted dental effects: Experts agreed that skeletal expanders reduce the buccal tipping of posterior teeth compared to conventional tooth-borne expanders.<\/p>\n \u2022 Success decreases with age: Skeletal expanders were deemed effective in late adolescents and adults, but with reduced success rates after age 25 – 30.<\/p>\n \u2022Unpredictability in older patients: While effective, experts noted that skeletal expanders cannot reliably predict midpalatal suture opening in patients over 30.<\/p>\n Lack of Consensus:<\/strong> Experts did not agree on whether bone-anchored expanders provide more stable long-term outcomes or significantly reduce gingival recession risk.<\/p>\n Clinical Takeaway:<\/strong> For young patients, skeletal anchorage can improve expansion without adverse dental effects. However, in adults, results are less predictable, necessitating individualized treatment planning.<\/p>\n 2. Class II Skeletal Disharmony: Does Skeletal Anchorage Improve Mandibular Advancement?<\/strong><\/p>\n \u2022 Greater skeletal effects, but limited evidence: Panelists agreed that fixed functional appliances (FFAs) anchored to the lower jaw provide greater sagittal skeletal correction and better control of lower incisor proclination compared to conventional FFAs.<\/p>\n \u2022 No superior mandibular rotation control: Contrary to some expectations, skeletal anchorage did not offer superior control of mandibular clockwise rotation.<\/p>\n \u2022 Miniscrews vs. Miniplates: Given their less invasive nature, miniscrews were preferred over miniplates for skeletal anchorage in Class II correction.<\/p>\n \u2022 Patient acceptance: Skeletal anchorage devices were noted to have lower patient acceptance due to their invasive nature.<\/p>\n Lack of Consensus:<\/strong> No agreement was reached on whether skeletal FFAs offer superior effects compared to removable functional appliances, reflecting ongoing debate.<\/p>\n Clinical Takeaway:<\/strong> Skeletal anchorage may enhance mandibular growth effects, particularly for controlling incisor inclination. However, its clinical impact remains debated, and patient comfort should be a key consideration.<\/p>\n 3. Class III Skeletal Disharmony: Is Skeletal Protraction Superior?<\/strong><\/p>\n \u2022 Better dentoalveolar control: Skeletal anchorage significantly reduces undesirable dental movements compared to conventional facemask therapy.<\/p>\n \u2022 Greater maxillary protraction, but limited clinical impact: Bone-anchored devices produce larger sagittal skeletal changes, though the magnitude of these changes may not be clinically relevant.<\/p>\n \u2022 Alt-RAMEC protocol gains support: Skeletally-anchored maxillary expansion using Alt-RAMEC (Alternating Rapid Maxillary Expansion and Constriction) was considered more effective, particularly in pubertal patients.<\/p>\n \u2022 Surgical considerations: The invasiveness and economic cost of skeletal anchorage were justified only in pubertal patients, not in younger children.<\/p>\n \u2022 Infection risk: When miniplates emerge through non-keratinized tissue, the risk of inflammation and failure increases.<\/p>\n Lack of Consensus:<\/strong> Experts disagreed on whether Bone-Anchored Maxillary Protraction (BAMP), a fully intraoral alternative to facemask therapy, justifies its invasive surgical approach.<\/p>\n Clinical Takeaway:<\/strong> Skeletal anchorage enhances maxillary protraction, particularly in pubertal patients, but its additional invasiveness should be weighed carefully.<\/p>\n Critical Evaluation: Strengths and Limitations<\/strong><\/p>\n Strengths<\/strong><\/p>\n \u2022 High-level expert participation: The study included 25 globally recognized orthodontists, ensuring a broad and authoritative consensus.<\/p>\n \u2022 Well-structured methodology: The Delphi method systematically refined statements, leading to well-considered conclusions.<\/p>\n \u2022 Clinical relevance: The study provides pragmatic guidance for orthodontists facing real-world treatment decisions.<\/p>\n Limitations<\/strong><\/p>\n \u2022 Consensus is not clinical proof: The Delphi method reflects expert opinion, not direct clinical evidence. While valuable, these findings require further validation through randomized controlled trials (RCTs).<\/p>\n \u2022 Limited long-term data: The study does not resolve the question of long-term stability for skeletal anchorage techniques.<\/p>\n \u2022 Patient factors not fully addressed: While patient acceptance was acknowledged, more research is needed to assess patient-reported outcomes, including comfort and compliance.<\/p>\n Final Thoughts: Where Do We Go from Here?<\/strong><\/p>\n This Delphi consensus study provides an insightful look into expert opinions on skeletal anchorage in orthodontics.<\/p>\n While skeletal anchorage clearly reduces undesirable dentoalveolar effects, its superiority over conventional anchorage in producing skeletal changes remains uncertain. Moreover, invasiveness, cost, and patient acceptance remain crucial limiting factors.<\/p><\/blockquote>\n Ultimately, the decision to use skeletal anchorage should be patient-specific, taking into account age, malocclusion severity, compliance, and willingness to undergo minor surgical procedures. Future high-quality RCTs will be essential to confirm these findings and refine treatment protocols.<\/p>\n <\/p>\n Reference:<\/strong><\/p>\n Franchi L, et al. Skeletal versus Conventional Anchorage in Dentofacial Orthopedics: An International Modified Delphi Consensus Study. Progress in Orthodontics (2025) 26:9.<\/p>\n