Modified beggs /certified fixed orthodontic courses by Indian dental academy


Published on

The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit ,or call

  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Modified beggs /certified fixed orthodontic courses by Indian dental academy

  1. 1. SEMINAR ON MODIFIED INDIAN DENTAL ACADEMY BEGGS Leader in continuing dental education 1
  2. 2. Introduction The present Begg practice differs considerably from the traditional. Begg practice as under gone many changes over the time which have enhanced its efficiency and made it capable of meeting the contemporary treatment objectives. It must be noted that the basic tenants of Begg mechanotheropy have largely remained unaltered because they are relevant for ever. They can be summarized as follows; 1. Use of light orthodontic forces 2. Crown tipping movement followed by root movement for efficient ultimate bodily translation with the least taxation of anchorage. 2
  3. 3. 3. Use of brackets permitting free tipping movements in the initial stages due to minimum friction between wire and the bracket. 4. Use of differential force for movements of different group of teeth. 5. A definite sequence of treatment stages, eg. Bite correction proceeding other movements. Treatment is divided into three clear cut stages. 6. Use of light intraoral elastics. 3
  4. 4. 7. En mass movement of anterior and posterior teeth for objectives like overjet reduction and correction of posterior occlusion. 8. Overcorrection of all displacements. 9. Use of round high tensile wires. The changes introduced by various workers are on account of the following reasons; 1. Changes in the treatment philosophy : Not all Begg practitioners accept the alterational occlusion concept today as the basis for treatment planning. Attempts are being made to reconcile the Begg treatment with the Andrew’s six keys to normal occlusion. 4
  5. 5. 2. changes in the treatment approach: Advantages of mixed dentition treatment are realized. Profile consideration has assured greater importance reducing the number of extraction cases and seeking extraction choices other than the first bicuspids in many cases. 3. In order to overcome the deficiencies in the traditional Begg treatment such as its inability in achieving final finishing or in intruding the upper anteriors, the Begg mechanics is modified. 4. Several refinements have been introduced to take advantage of the newly developed materials, especially the wires. 5. Attempts have been made to combine the best in Beggs with the good aspects of other techniques. 5
  6. 6. What is conventional Begg, Modified Begg and refined Begg? Conventional Begg is the Begg treatment as outlined in the textbook authored by Begg & Kesling. The term modified Begg is applied to the treatment which follows the Begg principles to a large extent, but which uses brackets other than the ribbon arch bracket. Examples of some such brackets are the combination brackets (Chun-Hoon, Kessler, Fogel and Magill, four stage or C.A.T.), the edge wise brackets in Beddtiot approach and the tip edge brackets. 6
  7. 7. The refined Begg is the current Begg practice using the same Begg brackets, which is significantly deviated from the conventional Begg. It is still within the framework of basic Begg tenets. 7
  8. 8. THE MODULAR SELF LOCKING APPLIANCE SYSTEM 1 1976 Sep 653 – 660 The Modular Self-Locking Appliance System A Variation in the Combination Technique - MAXWELL S. FOGEL, DDS 2 1976 JACK M. MAGILL, DDS JCO Oct 728 - 741 The Modular Self-Locking Appliance System Part 2: A Variation in the Combination Technique – 3 1976 Dec 906 - 917 The Modular Self-Locking Appliance System Part 4: A Variation in the Combination Technique 4 1976 Nov 826 - 835 The Modular Self-Locking Appliance System Part 3: A Variation in the Combination Technique 5 1977 Jan 51 - 59 The Modular Self-Locking Appliance System Part 5: A Variation in the Combination Technique 8
  9. 9. THE MODULAR SELF LOCKING APPLIANCE SYSTEM This method, which is a light wire system using a single pivotal bracket or twin self-locking low frictional attachments, has clinically demonstrated simplified and securely controlled mechanics for individual and collective tooth movements to attain optimum end results. The insert bracket, become the cornerstone of a completely practical round wire technique by combining it with a twin selflocking modular attachment. 9
  10. 10. Both single and double insert brackets, with selflocking components, offer simple and practical time-saving feature by completely eliminating ligature tying and repeated pin placement. An added factor is the versatility of this unique method of directing tooth movement in all planes, in most instances without the use of time-consuming application of multiple spring auxiliaries 10
  11. 11. Insert Bracket The principal module is the Insert Bracket, which is made of a special soft stainless steel. The stainless steel insert bracket does not undergo electrolytic changes, although it possesses the desired quality of softness. Steel is stronger, generally lasting throughout treatment, and can be opened and closed as many times as necessary. The elements of the insert bracket are: Archwire chamber (.025"). For maximum performance in light wire therapy, the round archwires float freely in the .025 chamber. The chamber is strategically placed in relation to bracket wings, permitting adequate tipping of the archwire, setting in motion less restricted tooth movements. 11
  12. 12. Slot apex (.012"). Constricted portion of funnel, permits snapping in and retention of wire prior to closure of beaks Seat. Base of insert bracket which rests in the grooved wing of the receptacle for stability. Stem. Extension of insert bracket fits into the vertical slot and holds insert bracket in position when bent at right angle. General thickness (.018"). Bracket head (.070" X .070"). Overall length (.235" ). 12
  13. 13. Placement of Insert Bracket The stainless steel insert bracket is easily fitted into the vertical slot of the receptacle. The stem is cinched and bent laterally with a light wire plier or a dull ligature cutter, pressed snugly under the wing and against the side wall of the receptacle. Removal of the insert bracket is also a quick and easy procedure. The stem is straightened and cut; the head is grasped with the flat end of a dull ligature cutting plier; the insert bracket is removed, using the receptacle wing as a fulcrum. 13
  14. 14. There is adequate tipping movements and free flowing movement of the attachment along the archwire. In this technique, the constricting influences of the edgewise archwire is eliminated, and also the menial chore of wire ligation and the binding effects of ligation. 14
  15. 15. Receptacle The receptacle is made in three sizes — Small (.150"), Medium (.180"), Wide (.200") And is contoured for specific teeth in the anterior and posterior segments The three vertical slots accommodate insert brackets and auxiliaries. A single slot is used in the early stages and both mesial and distal slots are used in the finishing stages 15
  16. 16. It is suggested that the receptacle be placed toward the incisal edge of the band in order to provide sufficient metal backing for the insert bracket The receptacles are routinely spot welded to the bands in two strategic locations, namely the tabs and the body of the attachment 16
  17. 17. Receptacles are also available in either clear or tooth-colored plastic. It is our belief that bonding of either plastic or metal brackets is a unique innovation. 17
  18. 18. Molar Tube Attachment The oval or slightly flat molar tube with mesial hook is an important component of the Modified Combination Technique 18
  19. 19. The action of the tip-back bend in the light round wire as it behaves in the buccal tube and its effect on the positioning of the molars is directly related to the shape of the buccal tube. Garcia and Brandt have shown that there is less lingualization (rolling in) and unfavorable rotation of molars with the oval or flat tube than with round tubes 19
  20. 20. A tip-back bend, also known as a resistance or anchorage bend, when placed in a round wire becomes a modified toe-in, whereas the oval tube resists this action. Molar control and anchorage are definitely more favorable with the oval buccal tube. The oval tube has a vertical slot to assist in molar uprighting or increased molar resistance, when necessary. 20
  21. 21. Insertion of Light Wire Into Insert Bracket The .014, .016 or .018 round archwire is snapped into the insert bracket with mild finger pressure. In special situations involving major malpositions of certain teeth, a wire director may be used to guide the archwire into the insert slot, where it is quickly and easily snap-locked into the circular insert chamber. 21
  22. 22. Finally, closure of the insert bracket beaks is accomplished by gently using How pliers. Usually, the cuspid insert brackets are closed first, followed by the four incisor teeth, a remarkably simple and rapid procedure. 22
  23. 23. Removal of Archwire From Insert Bracket Removal is accomplished by opening the insert bracket with an insert spreader. The insert spreader, an .012 flat-bladed instrument, is carefully fitted into the insert slot and simply pushed forward, opening the slot to its original dimension and preparing the release of the wire. The archwire is snapped out of the slot, using a scaler which acts as a miniature crowbar, effectively and gently disengaging the archwire without distorting it. 23
  24. 24. STAGE 1 (TIPPING) Insert bracket can be placed in any of three positions in the first stage of light wire treatment, positions of choice are the mesial slot of the receptacle on the upper and lower four incisors and in the distal slot on the upper and lower cuspids. Centering the insert bracket in the first stage requires removing it to place the inserts in the mesial and distal slots for the next stage. Exceptions may be made for specific tooth malpositions and the initial insert brackets can be placed wherever they will be most effective. Where tooth malpositions are not too severe, it is strongly recommended that double insert brackets be considered from the start of the first stage 24
  25. 25. Special Consideration When the malocclusion is characterized by a deep overbite, the first stage usually includes the incisal coverage bite plate 1. accomplishes a preliminary bite opening, 2. eliminates occlusal interference and helps avoid anchorage loss, 3. prevents bracket shearing, band destruction, or bonding failure on lower incisors and cuspids, and 4. provides an opportunity for repositioning the mandible, when the tendency for this phenomenon exists. 25
  26. 26. Placing Bands and Archwires When preliminary bite opening has been established sufficiently, banding and placement of archwires constitutes the first stage of treatment. Uncrowding through action of vertical loops flows easily and quickly. The multiple-loop archwire is changed for a plain twolooped archwire as soon as possible, while continuing Class II mechanics until a Class 1 molar and cuspid relation is achieved. 26
  27. 27. The two-looped archwires can be preformed and easily adjusted for cuspid-to-cuspid contact, to avoid recrowding. The loops can also continue to move the cuspids distally, if necessary. Class III Mechanics The rationale for Class III mechanics includes: 1. Improved movement of lower incisors over basal bone. 2. Avoiding stress on lower molars and preventing excessive forward movement into extraction space. 27
  28. 28. 3. Less lingualization of lower incisors than with the use of lower horizontal elastics. 4. Compensation for tipping of occlusal plane caused by Class II mechanics. The tipped occlusal plane returning to its original position after Class 111 mechanics. 5. It is often desirable to overcorrect lingual positions of lower incisors, to compensate for the forward movement of the lower dentition as a result of leveling and uprighting. 28
  29. 29. Transpalatal Bar The transpalatal bar is a maxillary resistance unit which is made of a single .036 semi-soft round wire, which fits into lingual .036 horizontal tubes on the maxillary molars. The appliance is bent back behind the tubes, cinching slightly, creating a fixed/removable resistance appliance. This appliance can be made in the mouth quickly and easily. 29
  30. 30. With this additional anchorage reinforcement providing bracing support to resist forward movement in the upper arch during Class III mechanics, One can use intramaxillary elastics in the upper arch in addition to the intermaxillary elastics. In this manner, maxillary incisors move lingually and distally at the same time as the mandibular teeth are being retracted. This strategy proves most rewarding in the attainment of optimum incisor position and subsequent improved facial esthetics. 30
  31. 31. End of First Stage The first stage of treatment generally brings about a compelling biologic response in which reduction of protrusion, bite opening, uncrowding, and correction of jaw relationships take place simultaneously and without excessive tipping. 31
  32. 32. STAGE II (LEVELING) The objectives of the second stage are: 1. Leveling (alignment). 2. Preliminary uprighting of cuspids and bicuspids. 3. Correction of rotations and labiolingual malpositions. 4. Continued bite opening. 5. Improved arch relations. 6. Improved arch form. 7. Closure of all remaining extraction spaces . 32
  33. 33. The second stage of treatment sets forth the modular aspect of the Modified Combination Technique in the conversion to a double bracket insert. The second bracket insert is placed in the unoccupied mesial or distal vertical slot of the receptacle, opposite to the insert bracket used in the first stage, creating a double bracket These bracket inserts are widely spaced for more effective tooth movement during the leveling and finishing stages. 33
  34. 34. By placing another insert bracket at the other extremity of the receptacle, the twin inserts offer a synergistic action with one effort complementing another. This arrangement is precisely what we have in mind with the Modified Combination Technique, where two or more low frictional components are used to blend for the production of physiologic tooth movement. The upper and lower second bicuspids are banded at this time, using mesial and distal bracket inserts. With severely irregular tooth positions, an .012 or .014 highly tempered round steel archwire can be used to start the task of tooth alignment and changed to an .016 archwire after a few visits 34
  35. 35. Leveling and Space-Closing Appliance This appliance is made of .014 or .016 wire, having a spaceclosing helical loop. This imparts flexibility to engage tipped teeth, and begins uprighting teeth adjacent to the extraction spaces. All conventional adjustments can be incorporated into this appliance. Once snapped and locked into position, it will translate most gentle forces to the teeth, arranging the dentition according to plan. 35
  36. 36. Auxiliary springs for uprighting and rotating may be applied while main archwire is fully engaged in the insert brackets . A cardinal requirement of this technique is to permit the archwires to function for long periods without interference or unnecessary adjustments. It is definitely a mistake to change archwires too frequently. A good high grade, fully tempered steel wire is recommended. 36
  37. 37. When Stage II is completed, the accomplishments should include a generalized alignment of all teeth, with rotations and overbite corrected, and all anterior and extraction spaces closed. The teeth adjacent to the extraction sites should demonstrate improved axial positions, with final movements taking place during the next stage. 37
  38. 38. STAGE III (FINISHING) This final step in treatment deals with correction of axial inclinations of anterior and posterior teeth, with special emphasis on lingual root torque and labial crown torque of maxillary incisors. Closure of small spaces, maintenance of overbite correction, and ideal arch form are vital functions of this stage. Final movements occur by means of an .016 or .018 dual helical spring archwire, 38
  39. 39. This has proven to be exceedingly effective for uprighting and aligning teeth. These archwires, plus a superimposed torquing appliance, impart a gentle though positive action to complete correction of axial inclinations of cuspids and bicuspids in the extraction area, as well as satisfactory axial inclinations of upper incisor teeth Torquing appliance for central incisors. 39
  40. 40. Toward the end of the third stage of treatment. Final appliance embodies the ideal modifications which have always been routine requirements such as: upper lateral incisor and molar offsets, ideal arch form, gable bends and molar tipback adjustments. It is imperative that cuspids and bicuspids be tied together to prevent reopening of extraction spaces. Very fine ligature wire (.006) can be snapped into the cuspid and bicuspid insert brackets and tied. 40
  41. 41. Further progress Optional use of receptacle as a regular edgewise bracket. The Low Profile Receptacle has recently been created to offer less bulk in height and width 41
  42. 42. SUMMARY OF THE MODIFIED COMBINATION TECHNIQUE FEATURES • No special skills required to insert archwires. • No special ties. • Reduced number of chairside assistants needed. • Lessened chair time. • Minimal unwanted tooth movements. • Easy, rapid, uncomplicated torque for incisor teeth. • No unpredictable reactions to torque. 42
  43. 43. • Low frictional relation between wire and bracket chamber makes elastic cord more applicable for rotations, uprighting, and space closing. This procedure is simplified because no wire disengagement is necessary and teeth flow along wire into correct positions. • Fewer archwire changes. • Treatment time moderately reduced. • A lesser number of auxiliary springs in the third stage of treatment. • Smaller gauge wires and larger archwire chamber permit greater flexibility and increased biologic response, via natural forces of occlusion. 43
  44. 44. • Archwires designed and tempered for long range of action, making frequent visits unnecessary. • No heavy base wires required for special tooth movements. • The modularity of the system enables the operator to "plug into treatment". • The self-locking system is a natural for bonding, because of less pressure and tension on bonded attachment. Plastic brackets are more compatible with self-locking inserts, since ligature stresses are eliminated. 44
  45. 45. 45
  46. 46. Beddtiot (Begg-edgewise diagnosis-determined totally individualized orthodontic technique – Hocevar AJO-DO, Volume 1985 Jul (31 - 46): ) The appliance system known as the Begg-edgewise diagnosis-determined totally individualized orthodontic technique (BEDDTIOT) offers the capacity to employ selected principles and features of Begg and edgewise mechanisms in specific situations in which they are most advantageous. The intent was to incorporate the important advantages, features, and capabilities of many fixed appliances and minimize deficiencies, making the most of current understanding of orthodontic biomechanics and technology. 46
  47. 47. The control and precision of edgewise appliances (having full torque and angulation built in) is combined with the capabilities for anchorage conservation and rapid tooth movement (of the ''light-wire differential force" approach to biomechanics) by means of attachments that are versatile, simple, economical, and small. Treatment is individualized. Begg principles are employed in some cases; various edgewise techniques in others. A wide variety of combinations may be employed easily. 47
  48. 48. FOUNDATIONS Light wire •Gentle, long-range force systems may be employed for fast, efficacious alignment and major movements of crowns and/or roots. • Minimal bracket size yields maximum interbracket arch wire spans. •Light, undersized wires have ample free play in the brackets. •These factors, together with extensive use of elastomeric ligatures and elastics, combine to produce an appliance that can provide low force levels over great elastic ranges •Alignment may be achieved instead with extremely light auxiliary wires. 48
  49. 49. Brackets The brackets are narrow, single-width (0.050 inch or 1.3 mm) edgewise brackets with 0.022 inch (height) ´ 0.028 inch (faciolingual depth) horizontal arch wire slots. On the lingual side of the bracket (that is, against the band or bonding pad) is a 0.020 X 0.020 inch vertical slot. 49
  50. 50. The arch wire slots are ''torqued" (cut at such angles to the brackets that they will be oriented parallel to the plane of the arch when the teeth are positioned properly) Except for torque, the brackets are all identical. Therefore, they are interchangeable; any bracket may be used on any tooth. Placed with its torqueindicator groove gingival, a bracket provides lingual root torque; with the groove occlusal, it provides lingual crown torque. The standard torques make up a set with a smooth progression— 0°, 5°, 10°, 15°, and 20 ° 50
  51. 51. Brackets can be prewelded on bonding pads and indirect bonding provides superbly accurate positioning. Each of the five brackets prewelded on both flat and curved universal bonding pads provides maximum versatility. The pads are of minimal size, and their shape facilitates the placement of the brackets with either end toward the gingiva. So that each may be used for either lingual crown or root torque. The brackets are small in all dimensions to ensure optimal appearance and minimal lip and cheek irritation. 51
  52. 52. This also lessens Occlusal interference Enamel surface involved in bonding And problems with gingival proximity and oral hygiene. Narrow brackets have long, resilient spans of arch wire between them 52
  53. 53. The dimensions of the arch wire slot allow considerable (but limited) mesiodistal tipping on undersized wires (10° distal crown tip on 0.016 inch, the usual working wire), as well as limited uprighting (5° mesial crown tip on 0.018-inch arch wire) Thus, if the arch wire slots are oriented perpendicular to the long axes of the canines, they allow optimal limited tipping on the lighter wire during retraction and optimal limited uprighting by auxiliaries on the heavier wire. 53
  54. 54. Uprighting springs are not needed for ''braking" (to prevent overtipping) and need not be removed before treatment is truly completed (they cannot go too far). In cases that do not warrant sequential tipping and uprighting, brackets may be angulated on the teeth as necessary to achieve and maintain desired inclinations. 54
  55. 55. Uprighting springs may be inserted in the 0.020 ´X 0.020 inch vertical slot. The original springs are only slightly different from those used in the Begg technique; as the helix is farther from the arch wire, the hook arm is slightly longer and the helix winds out away from the tooth from the pin leg, the hook arm does not require the extra offset bend usually used in Begg springs 55
  56. 56. A new spring design offers rotation control and less bulk. It is more hygienic, less likely to impinge upon or irritate the gingiva, and less conspicuous in appearance 56
  57. 57. The vertical slot has many potential uses. It can accommodate ligatures, elastic hooks, rotation devices, and various other auxiliaries. Turned 90° (so it is horizontal), it can serve as a miniature buccal tube. An example of its function as a buccal tube would be to gain control of partially erupted or impacted second molars that require uprighting or crossbite correction 57
  58. 58. The basic buccal tubes are conventional 4.5 mm long, 0.022 ´X 0.028 inch "edgewise" tubes with 25° lingual crown torque for lower and 10° for upper first molars. The distal end of the maxillary tube is angulated outward 10° from the welding flanges to maintain the proper rotation ("toein"). In cases that require headgear to maxillary molars, a tube assembly like that just described, with the addition of a 0.051inch round tube, is used. The headgear tube is located occlusal and slightly buccal to the main tube and is not angulated. 58
  59. 59. In cases with deep overbites or moderate-to-severe anchorage requirements, an additional rectangular tube is carried diagonally across the buccal surface of the basic tube, its mesial end pointing gingivally. Headgear tubes may or may not be used The additional tube is (like the basic tube) 4.5 mm long and the inside dimensions are 0.022 ´x 0.028 inch 59
  60. 60. The additional tube will be referred to as the outer tube and the basic tube as the inner tube. The outer tube crosses the inner tube at an angle of approximately 15° and is somewhat gingival to the inner tube. It carries the main (working) arch wires during the bite-opening and retraction phases of treatment, while rectangular sectional wires in the inner tubes and second premolar brackets lock molar and premolar teeth together so neither can tip independently; as a unit they provide tremendous anchorage for bite opening and retraction 60
  61. 61. The gingivally positioned and angulated outer tubes direct the arch wires away from the danger of distortion from mastication. They provide effective built-in "anchor bend" while the actual bends can be slight (usually about 25°) and still provide sufficient force to intrude the anterior teeth and hold the posterior teeth upright. Considerable force for incisor intrusion can be derived from the arch wires because the molars cannot tip distally without extruding the premolars. 61
  62. 62. The center of resistance (CR) of a molar is at or near the furcation. The CR of the unit made by locking a molar and premolar together with a sectional wire is a few millimeters further mesial. The distal tipping moment created upon the posterior anchorage by an arch wire activated to intrude incisors equals the product of the magnitude of the force upon the incisors and the distance from the incisors to CR (M = F x d). 62
  63. 63. The mesial tipping moment of a Class II elastic on the posterior anchor unit is the product of the elastic's force magnitude and the distance of its line of action from the CR. Thus, if the CR of the anchor unit is further mesial, the distal tipping moment upon it is smaller and the mesial tipping moment greater. Therefore, more intrusive force (approximately 40% more in this illustration) can be applied to the incisors without a tendency to tip the anchor unit distally. 63
  64. 64. Rotations It is preferable on a round tooth (premolar or canine) to offset the bracket slightly toward the side of the tooth that is displaced lingually. Simple engagement of the bracket on the arch wire with a small elastomeric ligature will correct the rotation. If the bracket is so far from the arch wire that this would be too forceful, a larger, more gentle ligature may be used or the bracket may be tied to the arch wire with elastomeric thread 64
  65. 65. Torque control with brackets and arch wires One of the reasons the smaller (0.018 X 0.025 inch) edgewise bracket slot gained some favor was the fact that the edgewise wires required for precise control in the larger (0.022 X 0.028 inch) brackets were too rigid. In fact, there is no need for the heavy edgewise wires ever to be used in the large brackets. Similarly precise control can be attained with lighter forces by using more resilient rectangular wires bent as ribbon arches— 0.020X0.016 inch, 0.021 X 0.016 inch, 0.022X 0.016 inch, or square 0.019 X 0.019 inch, 0.020 X 0.020 inch, 0.021 X 0.021 inch or 0.022 X 0.022 inch wires. 65
  66. 66. These wires are easier for the operator to work with than the heavier edgewise wires. A 0.022 X 0.016 inch ribbon arch has just over half the cross-sectional area of an 0.022 X 0.028 inch edgewise arch and is only one third as stiff; yet it fits the bracket just as precisely A 0.022 X 0.016 inch ribbon arch is only one third as forceful as a 0.022 X 0.028 inch edgewise wire; yet it can provide the same precise control in the same "edgewise" bracket. 66
  67. 67. In most instances the lighter ribbon wires are preferable to square ones. Heavy rectangular arch wires should not be used to deliver active torquing forces because force levels would be too high and the range too limited. If and when arch wires of new nonsteel alloys become available in appropriate sizes for precise bracket engagement, these extremely resilient gentle wires could effect all torquing and uprighting; the need for any auxiliaries would then be virtually eliminated. 67
  68. 68. How it is different In the Begg technique, the anterior teeth are tipped continuously until all of the spaces are closed and the overjet eliminated. There is then an abrupt transition to the mechanics required for root positioning. A virtually total reversal of the biologic processes involved in tooth movement must occur throughout the supporting structures of the anterior teeth. Apices that either were not moving or were moving anteriorly while crowns were being tipped posteriorly are suddenly forced to move posteriorly. This requires change to resorptive tissue response along the posterior surfaces of the roots near their apices where, until that moment, there has been either no activity or deposition. 68
  69. 69. In BEDDTIOT, on the other hand, tipping appears to be ended abruptly by mechanical means when the play between bracket and wire is exhausted. However, because the wire is flexible, there must be a transition period while the wire is deformed enough to create a moment equal and opposite to that created by the retracting elastic. The tooth is still being retracted while the total moment affecting it is being reduced to zero and, as the moment decreases, the proportion of translation relative to tipping increases. 69
  70. 70. One of the most important advantages of the BEDDTIOT appliance is its facility for both three dimensional control and limited tipping with light forces using a simple bracket. 70
  71. 71. The four stage light wire appliance 71
  72. 72. The four stage light wire appliance This appliance enables the orthodontist to combine both the tipping and bodily movement principles of mechanics. The system permits the use of pure Begg mechanics in that part of the treatment and in those cases in which it is most effective. It also permits the use of a straight wire appliances in the same cases or in any cases in which a rigid, preangular-pretorqued finishing procedure is required. 72
  73. 73. Brackets and tubes This appliance system has a combination bracket design in which the lower third of the bracket is a type 256 Begg bracket and the upper two thirds of the bracket is a 0.018 by 0.025 inch straight wire slot with in-and-out positioning, preangulated and pretourqued. 73
  74. 74. The begg slot will accept all auxiliaries and arch wires used in Begg treatment and it performs a typical Begg bracket in relation to tipping, bite opening, incisor and molar positioning, and torque. The appliance is set up in the standard manner with the 0.036 inch Begg tube placed gingivally on the first molars. All Begg slot heights, other than the molars, are dictated by the edgewise slot and, as such, are 1 to 1.5 mm. more gingival than in a routine Begg banding. It is essential to set up the straight wire slot so that on the straight wire series the wire is level from the molar tube to all other brackets. 74
  75. 75. In clinical preparation, it is desirable to band the molars first. Slight variations in the dimension from molar tube to cusp tip will exist because of anatomic differences, but a cusp-tip-to-tube distance of 3.5 mm. is a desirable starting point. If 3.5 mm. is acceptable, then all other edgewise slots must also be at 3.5 mm. except those on the canines and lateral incisors. Upper and lower canine brackets are placed gingivally 0.5 to 1 mm. more, depending on tooth size and shape. Such a position promotes canine-protected occlusion. 75
  76. 76. The upper lateral incisors are placed 0.5 mm. more incisally to free them from interferences on the working occlusal movements. Each tooth must receive the specific brackets designed for it so that angulation, torque, and the in/out compensation are correct. The 1 to 1.5 mm. increased gingival positioning of the Begg slot does not seem to affect the bite-opening or tipping characteristics of Begg treatment. Free tipping is made very effective by means of a specially tapered bracket slot. 76
  77. 77. Special bypass pins and safety lock pins are used to reduce binding. The pins used are of a special length, since the width of some of the combination brackets is larger than a routine 256 bracket. The pin length is slightly greater in order to clear the tie wings of the edgewise part of the bracket, especially on the maxillary incisors. 77
  78. 78. Begg molar tubes are kept gingivally and can be obtained with convertible straight wire tubes on the lower molar. The convertible tubes provide for desired Class II elastic hooks during Stages I, II, and III. They can be adapted to function as a routine straight wire type of bracket when the straight wire system is continued with first and second molars. It is not recommended that second molars be incorporated into the Begg system initially. All Begg treatment should be built around the first molar as the anchor unit, since experience shows that this is the most effective differential anchorage position and the most desirable for bite-opening mechanics of the Begg philosophy. 78
  79. 79. After the bite is opened and retraction of incisors has been completed, the second molars can be banded without altering the anchorage or bite-opening potential of the system. When the appliance is properly and accurately constructed, the system is set up so that all edgewise slots are positioned for accepting a straight arch wire. The angulation, tip, and torque are comparable to current straight wire systems. 79
  80. 80. Ligation of the wire can be done routinely with ligature wire or elastic modules. The lower molar combination tube permits ease of passing from first to second molars. Headgear tubes are available if desired. Use of the edgewise portion of the bracket is not begun in most instances until late in Stage III. 80
  81. 81. Clinical experience with the combination bracket indicates that the Begg portion of the bracket is highly successful and fulfills all the essentials of a true 256 type slot. The treatment procedures necessitate the use of pure Begg type principles when the Begg slot is being used. All arch wire forms, anchor bands, bypass bends, and elastic forces are similar to a routine Begg treatment approach. Because of the difference in the physical characteristics of the bracket parts, any attempt to alter the Begg treatment principles by switching slots or forces is prone to problems and anchorage difficulty. 81
  82. 82. All Stage I, II, and III objectives should be followed, and this can be done effectively only if free tipping is exercised within the Begg slot. It is recommended that treatment be initiated with routine 0.016 inch round Australian wire (orange special plus) using 40- to 45-degree anchor bends and 2½ to 3 ounce Class II elastics. Vertical loop arches are suggested as the initial wire if gross irregularity exists and bite opening is desired immediately. A free-tipping appliance is essential, and all recorded problems which can affect tipping and bite opening must be controlled. 82
  83. 83. For the best physiologic response to the appliance, the Begg procedures should be carried completely through Stage I and Stage II and at least partly through Stage III. Routine 0.016, 0.018, and 0.020 inch round wires, toe in or out, anchor bends, and intra- and interarch elastics are used as recommended in Begg therapy. At the end of Stage II, the occlusion should show the typical Stage II characteristics: spaces closed, bite opened to an edge-to-edge relationship, molars Class I or better, incisors retracted and tipped lingually, all rotations and ectopically repositioned teeth overcorrected. 83
  84. 84. Stage III is essential, the combination bracket is not intended as a substitute for this phase of treatment. When the occlusal relationship and treatment objectives are ready for Stage III, the severe tipping of the buccal segments and incisors, which is typical and characteristic of Begg therapy, produces a very irregular pattern to the angulated rectangular slots. Short interbracket distance between the edgewise slots increases force values and leveling forces. Stage III should be carried out with 0.020 inch base wires, constricted in the maxillary arch, and having reduced anchor bends in a typical Begg program. 84
  85. 85. All Begg uprighting springs and torquing auxiliaries can be placed in the Begg slot with no difficulty. The Stage III mechanics should be continued until the occlusion approaches a fairly level plane and the edgewise slots are almost parallel. When the alignment has reached this degree of leveling and uprighting, the Begg portion of treatment has ceased. The Begg wires and springs are removed and the remaining treatment is done in the rectangular slot with a straight arch wire. The new wires may be braided round, braided rectangular, nitinol, routine round, or edgewise wires up to 0.018 by 0.025 inch. 85
  86. 86. Banding of second molar Banding of second molars is, however, often essential for proper marginal ridge control, to improve the buccolingual position of the second molars, and to act in functional balance. These movements are best accomplished in late Stage III and with the rectangular straight wire mechanics. The second molars can be banded or bonded during Stage IV, and sectional 0.014, 0.016, or 0.018 inch wires can be used to begin leveling without interfering with Stage III. 86
  87. 87. The second molars can be bonded or banded with routine straight wire tubes placed at the same occlusogingival positions as the first molar rectangular tube. Since the Stage III arches are in the round tube, the sectional auxiliary wires to level the second molars can be placed in the rectangular tubes. When the Stage III is removed and straight wire treatment initiated, the second molars are level and ready for incorporation into the finishing mechanics. 87
  88. 88. 88
  89. 89. 89
  90. 90. TIP EDGE It was Dr Peter Kesling who modified a single straight wire bracket, to create the tip edge. The technique was first introduced at the Kesling-Rocke orthodontic center, Westville, Indiana, USA, in 1986. Although the modification is essentially simile and confined largely to removing two diagonally opposed corners from the rectangular slot. Dr Peter Kesling 90
  91. 91. Dynamics of tip edge The proto type tip edge bracket is derived from a single . 022inch slot straight wire bracket merely by cutting away two diametrically opposed corners from the arch wire slot, thereby allowing differential movement. 91
  92. 92. Each bracket is thus enabled to tip in the predetermined direction, whereas with the full thickness archwire in place, it will resist tipping in the reverse direction. The desired direction of tipping, in the routine orthodontic cases, is easy to predict; in general, distal crown tipping is he way the bracketed teeth will naturally want to incline, the exception being the second premolar in the 1st premolar extraction case, which will require to tip mesially. 92
  93. 93. The Tip-Edge bracket also contains many features already familiar to the edgewise or straight wire operator including conventional tie wings, which accept standard elastomeric ligatures. Bracket identification is by small circular markers at the disto gingival tie wings of the maxillary anterior brackets, and similarly placed triangular markings for the mandibular anteriors. 93
  94. 94. In common with some straight wire brackets, a vertical slot is incorporated lingual to the main archwire slot, which accommodates a range of possible auxiliaries. The dimension of the vertical slot is .020 inch square. With a round funnel shaped entry to facilitate insertion. 94
  95. 95. The strangely shaped inner surface to the main archwire slot, due to the lateral extension is some times referred to as ‘propeller slot’. This preserves rotational control throughout the range of tip permitted by the bracket, without determinant to aesthetics, since it is concealed by the archwire itself. The ‘cut out surfaces’ of the archwire slot form the ‘tip limiting surfaces’, which restricts the degree of tipping. The intact surfaces are therefore ‘finishing surfaces’, containing the individualized finishing prescription for each tooth. The point at which the tip limiting and finishing surfaces meet constitutes the central ridge , the opposing central ridge provide vertical control until final finishing and also the points at which torque is imported, under the influence of auxiliary springs, during the final rectangular wire phase. 95
  96. 96. The basic sequence of the Tip-Edge treatment Maxillary right canine at the start of treatment Following retraction the crown will tip distally, at the end of stage II A rectangular wire in stage three with the side winder will commence root uprighting Because the archwire is rectangular, torque will be achieved automatically with tip correction, until the bracket prescription is expressed 96
  97. 97. The pre adjusted finishing prescription contained within the Rx-1 bracket system is identical in principle to today’s straight wire systems, with the tip in the face, torqe in the base. The values are particular to Tip-Edge, but alongside various prescription in common use today, they compare most closely to Roth specification 97
  98. 98. TP orthodontics also manufactures the twin version of the Tip-Edge bracket in both .018 and .022 inch formats, sometimes known as the freedom brackets. A dynamic slot The unique feature of the Tip-Edge, is that the arch wire slot increases its vertical dimension as the tooth tips. Tipping of the tooth crown, during initial translation, alters the axial inclination between the vertical space available for the archwire from .022 to a maximum .028 inches. The explanation lies in the geometry of the bracket 98
  99. 99. This feature has considerable clinical significance. Levelling and aligning is greatly assisted, so much so that it is possible to setup from a .016 to a .022 inches stainless steel archwire in a single move. The inter bracket distance is far greater than with any other conventional twin type bracket as, with Tip-Edge, the inter bracket span is effectively the distance between the central ridges. The dynamic slot makes possible an entirely new means of torque delivery, when the vertical slot dimension is closed by an auxiliary spring, against a rectangular archwire, to produce a tree-dimensional precision finish. 99
  100. 100. Vertical reactions during retraction 100
  101. 101. Bite opening Early bite opening is one of the key reasons why differential tooth movement so frequently demonstrates a decrease in treatment time, particularly in deep bite cases. Edgewise bracket used with full archwires are unable to intrude the incisor segments until the canine root angulations are corrected, which in turn delays overjet reduction. A straight wire bracket exacerbates this problem by prescribing a greater distal root inclination, which requires to be achieved clinically before the curve of spee can be leveled. A segmental arch approach can overcome this problem, but at the expense of added complexity. Segmental arches are never required with Tip-Edge, overbite reduction can take place from the outset irrespective of canine angulation. 101
  102. 102. 102
  103. 103. Molar tubes In the interest of combining the advantages of both straight wire and Begg mode of treatment, Tip-Edge employs double buccal tubes. These comprises a normally sited preadjusted straight wire rectangular tube of .022X.028 inches, which is convertible and a gingivally placed round tube of .036inch internal diameter. The rectangular tubes are the easy out design, with the posterior inner lumen slightly flared towards the occlusal. This facilitates archwire removal when cinch back has been used. 103
  104. 104. Use of round tube is confined to bite opening in the initial stages of treatment in deep bite cases. All space closure and root uprighting is carried out in the rectangular tubes. The round tube offers significant advantages when deriving molar anchorage and bite opening from anchor bends during which their more gingiva position gives better protection from occlusal trauma. In addition the increased length of the molar tubes makes more efficient use of the anchor bend in terms of bite opening. As well as the friction arising from it. 104
  105. 105. Auxiliaries Many of these are begg derived and designed for orthodontists unfamiliar with rectangulart wire. The Side Winder It is the everyday workhorse among the Tip-Edge auxiliaries. It generates mesiodistal root movement and used when conjunction with rectangular archwires, produce torque correction as well. It is made in .014 inch high tensile stainless steel. So called because it carries its coils alongside the archwire, over the bracket face, withy a significant improvement over the former Begg type uprighting spring, which carried its coils gingivally 105
  106. 106. It has undergone considerable variation. Original versions were retained in the vertical slots by bending the protruding gingival tails 90degrees, which made them fiddlesome to remove. It was subsequently realized that the spring pressure of the activated arm reciprocally keeps the tail of the spring securely seated up the vertical slot, so that loner tails wee deleted. 106
  107. 107. For the most significant improvement has come with the ‘invisible side winder’. This is not strictly invisible, although aesthetics are improved by the fact that the wire of the spring overlays the bracket and archwire. It has several functional advantages. It s retained in position by the elastomeric modules, in addition to its own spring pressure. This also enables the modules to be changed if necessary. 107
  108. 108. Because of the bulky hook as been eliminated, the spring arm has the wider range of activation than as the previously possible. While the extra power of the spring is an advantage, particularly on the incisors, when delivering the final torque prescription. Some reduction of activation on canines and premolars may frequently be indicated, therefore in order not to strain anchorage during uprighting phase. 108
  109. 109. Side-winders come in clockwise and anti clockwise formats, the one a mirror image of the other. Selection of correct spring for each tooth is according to the direction of second order correction required as seen from the labial. Hence an upper right canine requiring distal root correction will need a counterclockwise rotation and so froth 109
  110. 110. Side winder springs should always be inserted from the occlusal and never gingivally. If the spring is inserted upside down, form the gingival, the occlusal forces will impact beneath the coils and distort them labially, away from the bracket. This spoils the action of the spring as well as causing discomfort 110
  111. 111. Power pins This is a traction hook that can be fitted in the vertical slot. Made of soft stainless steel, it will normally inserted from the gingival, and is retained in the slot by bending the occlusally projecting tail 90degrees. Strictly this bend should be made in the opposite direction to the elastic pull, since this avoids the possibility of a slackly turned pin doing a U turn and being pulled out of the slot by the elastic. 111
  112. 112. 112
  113. 113. Rotating spring The rotation spring is seldom required for correcting initial rotations. It is because the rotations of the anterior teeth are dealt with by full bracket engagement with light nickel titanium wires. Premolar rotations are sometimes corrected with traction elastomerics, if bonded later in the treatment. However rotation spring prove very useful for recapturing a rotation that has recurred in treatment, particularly if the patient is in a heavy archwire. 113
  114. 114. Like the side winder rotation spring comes in clockwise and counter clockwise version and is made in .014inch high tensile stainless steel. Selection is simply a matter of viewing the tooth from the occlusal and determining in which direction derotation is required. To avoid occlusal interferences rotation springs should always be inserted gingivally, passed up the vertical slot with a light wire plier. Holding the spring arm directly to the labial, at 90 degrees to the tooth surface, the long leg can be bent along the labial face of the tooth, to the same side as the hook will be engaged, the surplus end then tucking gingivally under the archwire. This contact of the leg against the crown ensures that when the spring arm is hooked over the archwire, the coils will be wound up to activate the spring. Finally the hook should be squeezed. 114
  115. 115. 115
  116. 116. Bonding and setting up Since the Tip Edge appliance is preadjusted. With a torque and tip prescription incorporated in each attachment, it should be set up like any other straight wire appliance. Bracket placement A mid crown position is recommended for routine bonding. Each bracket should be aligned with its vertical axis parallel with the long axis of the tooth, and at the midpoint of the crown mesio distally. The height of the bracket should be at the vertical midpoint of the fully erupted clinical crown 116
  117. 117. Tip Edge brackets are considerably smaller than a Siamese twin type bracket, which is an aesthetic advantage, but also makes the accurate placement of Tip Edge bracket rather more difficult, particularly on large clinical crowns. For this reason, Tip-Edge brackets are supplied with the option of colored plastic jigs, they provide the ready sight line for the correct angulation of each bracket, but they also make the brackets much easier to handle in conventional bonding tweezers 117
  118. 118. The mid crown height can be gauged by eye. On a normally shaped incisor, correct angulation up the long axis will result in the incisal wing being parallel to the incisal edge of the crown. The rationale behind a mid crown bonding position is that the middle point of the crown is generally the point of the labial surface. It therefore follows that placing a pre torqued bracket further gingivally will decrease the torque prescription, while placing it too incisally will increase the torque. 118
  119. 119. Bonding position incisally is contraindicated because 1. The prescribed torque value in the bracket base is effectively altered 2. For any given overjet reduction, the amount of retroclination produced during the initial tipping stage will be increased . in turn this will require an increase in the amount of root uprighting during stage III 3. When the side winder spring uprights the root, in both tip and torque planes, during the third stage, it is placed at greater mechanical disadvantage if the distance between the point of rotation and the root apex is increased. This results in loss of efficiency 119
  120. 120. Premolar brackets Where as the anterior Tip-Edge brackets are designed to allow distal crown tipping during translation during the first stage of treatment, premolar may require to tip either mesially or distally, according to the extraction pattern. The Tip-Edge brackets have identical torque and tip value in the upper 1st and 2nd premolars, similarly in the lower also. Upper premolar brackets are identified by circular markings in the gingival tie wing, lowers by triangular markings, in the usual way. The occlusal tie wing carries an arrow, which will indicate the direction of rotation. 120
  121. 121. Premolar jigs are modified by the addition of a 90 degree angle at the tip of the jig, which indicates the direction of rotation. (Queen’s university, Belfast –‘Irish jig’). 121
  122. 122. Correct selection of premolar brackets for different extraction configuration 1st premolar extractions 2nd premolar extractions 1st molar extraction or non extraction 122
  123. 123. Molar tubes Bonded first molar tubes are contraindicated in Tip-Edge. The rectangular buccal tubes should be aligned to the brackets, at mid crown height, just as with a straight wire appliance. The round wire will therefore sit towards the gingival margin. In the mandibular arch, the tubes should be parallel to the occlusal cusps, in the maxillary arch, seating the band fractionally higher toward the distal may be helpful in obtaining final seating of the disto buccal cusp. It should be noted that round tubes can be omitted altogether in class III malocclusion and reduced overbites. 123
  124. 124. Second molars are unnecessary to reinforce bite opening, contrary to straight wire practice and their inclusion in early stages, particularly in extraction cases, merely add friction. However, final alignment of the second molars during the finishing phase I frequently necessary. Second molar tubes are also available, although not specifically for Tip Edge, with minus 14 degrees of torque and 10 degrees of distal offset (maxillary) and minus 10 degrees of torque and zero offset (mandibular). 124
  125. 125. Stage I Objectives 1. Alignment of upper and lower anterior segments 2. Closure of anterior spaces 3. Correction of increased overjet or reverse overjet 4. Correction of increased overbite or anterior open bite 5. Work toward buccal segment crossbite correction 125
  126. 126. Anchorage mode Since the Tip Edge appliance has the capability of combining the treatment advantages of both Begg and straight wire concepts, it has the flexibility to proceed in the either mode, while exploiting the advantages of differential tooth movement. Anchorage may therefore be derived from a number of possible sources. Setting up stage I The base archwire .016 inch round high tensile wire is ideal for stage I. This has the necessary resilience to withstand forces of occlusion, combined with the flexibility required to align mild tooth to tooth irregularities. It is particularly suitable for bite opening, offering a good range of action without excessive forces. 126
  127. 127. The horseshoe shaped archform, as used in the early straight wire techniques, is not appropriate for the early stages of Tip Edge, since use of an anchorage bend requires a straight posterior leg. Combining a buccal archwire curvature with a vertical anchor bend will cause the wire to wiggle and rotate with in the buccal tube, which will invite a molar rotation. The Intermaxillary circles should not be more than 2mm in front of the canine bracket after alignment. If bending an archwire up by hand, each circle should be formed so that the posterior section loops to the labial of the anterior segment and not vice versa. 127
  128. 128. Repositioning cuspid circles To roll circle distally, will require a counter clockwise rotation. First unravel the anterior segment the desired amount using the light wire plier, then winding up the posterior segment to restore the horizontal segment. 128
  129. 129. Preformed archwires are also available which are made of .016 inch Bow-Flex wire. These are size graded according to the distance in millimeters between the cuspid circles, which can be ascertained in the mouth by a flexible plastic ruler, between the mesial surfaces of both canine brackets. Co-ordination of the archform 129
  130. 130. Anchorage bends The correct position of the anchor bends should be 2mm infront of the molar tube. Placing the anchor bend further forward than this will cause them to protrude occlusally and slightly lessen the amount of overbite reduction imparted in the anterior segment. The maximum vertical deflection permitted in the anterior segment can be till to the depth of labial sulcus. The intrusive force distributed between the six anterior teeth amounts only 2 ounces in the upper and rather less in the lower. The auxiliary arch .014 NiTi under arch can be used for aligning the anterior segment, and can usually discarded at the 1st or 2nd adjustment visits. 130
  131. 131. Anterior spacing. Elastomeric chains can be used, but its force values are less easily controlled than the E-links, which comes in the variety of lengths. Generally a size E-9 is appropriate for closing anterior spacing. Intermaxillary elastics These require to wear full time from the upper cuspid circles to the distal ends of the lower archwire. 131
  132. 132. It is absolutely essential to keep the elastic forces light at all times. 50gms or 2 ounces each side may be as little as 1/6th of that recommended for straight wire, and is one major reason why TipEdge escapes the unwanted side effects of intermaxillary elastics. Using forces in excess of 50grams with Tip-Edge increases the risk of elongating the upper incisors, by overcoming the intrusive effects of the upper anchor bends, as well as provoking problems in the lower molar control. 132
  133. 133. The routine adjustment visits throughout the stage I is 6 weeks. At each adjustment visit, the following checks will be necessary 1. Measuring the overjet. 2. Observing the overbite 3. Molar widths. 4. Checking the intermaxillary circles. 5. Siting of anchor bends. 6. Distal arch ends. 7. Distortion of the archwire. 8. Reassessing the elastic tension. 133
  134. 134. Stage II Objectives Closure of residual spaces Correction of centerlines Derotation of 1st molars Levelling of 1st molars Continuing crossbite correction Maintaining the stage I corrections 134
  135. 135. If premolars are not bonded in the stage I. it will required to be picked up and aligned at a pre stage II visit. The procedure for a deep bite cases at the pre stage II visit is • Remove the 0.016 archire • Bond the premolars • Using the same archwires, remove the anchorage bends and replace them with the vertical bite sweeps, to retain the overbite reduction previously gained. In the upper arch, this will be an increased curve of Spee, and in the lower arch an inverted curve of Spee. Much as in the straight wire techniques. • Reinsert the archwires, but in the rectangular molar tubes. 135
  136. 136. Stage II archwires An intermediary wire between the flexible 0.016 inch stainless steel stage I and the rigid but passive .0215X.028 inch stainless steel stage III is the preferable. The choice is .020 inch high tensile stainless archwires. Space closure Cuspid circles serve as the traction hooks Buccal segment spacing can be closed very easily by applying elastomeric E-links from the cuspid circles yo the molarhooks Free sliding mechanics are greatly facilitated throughout the stage II by the design of Tip-Edge brackets, as the friction with conventional bracket is eliminated due to the opening of the vertical slot dimension during tooth translation. 136
  137. 137. Appling the breaks A gently active Side-winder can be placed on a canine to induce a distal root movement, anterior to the space to be closed, in each quadrant to be braked. This will significantly increases the anterior anchorage, hence resistance to retraction, and so favor the protraction of posterior teeth. 1 st molars corrections A limited amount of molar rotation can be expected as a result of space closure with free sliding mechanics. If the molars are mesially rotated after the space closure, a simple adjustment to the archwire at the end of the stage II, keeping a 1 mm buccal offset and 10 degree of lingual toe in opposite the interspace between the 1st molar and premolar will derotate the molar. 137
  138. 138. The vertical adjustment in the archwire can be combined with the molar derotation adjustment, opposite the molar to premolar contact points. It consist of an ‘anti tip’ bend of more than 10 degrees, aimed at the sating the molar cusps into occlusion. Stage II checks 1. Observing the space closure 2. The distal arch ends 3. Molar widths 4. Labial segment position and inclination 5. Attention to centerlines 6. Derotation of 1st molars 138
  139. 139. 7. ‘un-tip’ the molars 8. Avoid over compression of the gingival cinchback of the archwire 9. Interarch relationship Stage III Objectives 1. Correction of torque and tip angles for each tooth individually 2. Attainment of optimum facial profile compatible with stability 3. Maintenance of class I occlusion 4. Final detailing 139
  140. 140. 140
  141. 141. Choice of archwire Only one size of rectangular wire is ever used in stage III. This is . 0215X.028 inch ‘Shiny Bright’ stainless, the lateral dimension is . 027 inch to facilitates the insertion into molar tube. Comes in 2 formats- plane or pretorqued Archform •Approximately 5 degrees of lingual toe-in should be placed opposite the mesial molar contacts. This ensures that the archwire enters the preangulated molar tubes at an equivalent angle to straight wire archform. •2mm expansion in the molar region 141
  142. 142. Traction hooks Crimped on the midway between lateral incisor and canine Always point gingivally Accept elastics or elastomerics from either direction Preparation of archwire ends Correlated stage III archwires 142
  143. 143. Testing Molar Torque 143
  144. 144. Cinch back 144
  145. 145. Stage III checks 1. Progress of tip and torque 2. Available space in the arch 3. Unwanted space 4. Condition of sidewinder 5. Activation of sidewinder 145
  146. 146. 6. Interarch relationship 7. The vertical relationship 8. Molar width 9. Second molars 10. Profile consideration 146
  147. 147. Precision finishing Picking up second molars Occlusal seating Braided rectangular arches Titanium–niobium archwire Sectioning the main archwire Positioners 147
  148. 148. 148
  149. 149. The separate arch system (SAS) The new concept in the begg technique- The separate arch system Yoshinari Ashikari The separate arch system is a system of conducting orthodontic treatment by partitioning the dental arch into an anterior segment and a posterior segment. The movement period is normally divided into three stages sometimes after stage III is also required. 149
  150. 150. Stage I 1. Improvement of the overbite of the anterior teeth. 2. Elimination of crowding in the anterior teeth Stage II 1. Elimination of displacement of the posterior teeth 2. Establishment of occlusal relationship of the posterior teeth Stage III 1. Harmonizing of maxillary and mandibular dental arches 2. Uprighting of all teeth 150
  151. 151. Brackets The brackets are reversed, that is attached upside down with the bracket slot opening incisally. Their positions are calculated from the incisal edges of the relevant teeth, normally upper central incisors 4.0 mm; upper lateral incisors, 3.5 mm; canines, 4.5 mm; premolars 4 mm. Mesiodistally they are positioned centred, except for the lower canines, which can be positioned 0.5mm mesially. High profile brackets are used for the upper laterals, and normal brackets for the rest. 151
  152. 152. Brackets are set upside down for the following reasons 1. Even under biting pressure, the wire will be held firmly in place by the brackets 2. The brackets and wires can be tightly ligated and locked 3. The operations of setting and removing wires, mounting auxiliaries are made easier. Buccal tubes For the 1st molars 5mm long flat oval tubes with hooks are ued For the 2nd molars round or rectangular tubes are used They are positioned 4mm from the cusp tips. 152
  153. 153. Wires Anteriors wires -0.012, 0.014, & 0.016 inch Australian wire of atleast special plus hardness Posterior wires -0.016 inch Australian wire of atleast extra special plus Anterior k-type wires (shape) –0.016 inch Australian wire of atleast extra special plus hardness Plain archwires -0.012, 0.014, & 0.016 inch NiTi wires and 0.014 inch Australian wire of atleast extra special plus hardness From 1-4 wires are used in each segment in each stage. Basic wire combinations are identified as I, II, and III, each with a ‘plus x’ factor to allow for additional wires. 153
  154. 154. I is one wire, II is two wires, III is three wires: ‘plus x’ is +1 154
  155. 155. Coil springs Used to connect anterior and posterior wires, open or closed coil springs are chosen, depending on the diameters that results when anterior and posterior wires placed one on top of the other. Pliers used for wire bending Ohno-type arch forming pliers, arch contouring pliers, tweed arch bending pliers, light pliers Wire bending 1.Anterior wires The distance between the distal ends of the canine brackets is measured, and that is added to 24mm, this is taken as the retentive length of the wire. When crowding is present, length is determined by estimating what the length will be after the crowding has been 155 eliminated.
  156. 156. The arch form is bent to mach the ideal arch form desired at the completion of orthodontic treatment. 2. Posterior wires Light wire pliers are applied about 3cm from the distal end of a straight 11.5cm wire, the wire is bent back, then another bend is made 6mm from the first so that the wire crosses over it is wound one turn round, to produce a hook, and cut. At the mesial end wire is cut 7cm from the double back end. One wire is wound clockwise, the other counterclockwise. They are adjust to the buccal tube in such a way that, as much as possible, play is eliminated. The double back wire end section is given horizontal curve with ohno arch forming plier to give it toe in 156
  157. 157. 3. Anterior k type wires with AK hooks. Use is made of 0.016 inch extra special plus wire that has been bent in conformity to an arch symmetry chart. After the distal end of the canine and mesial end of the buccal tube of the 1st molars are measured, a wire size chart is made, and the wire bent in accordance with this chart, a wire bender can be used at this time. 157
  158. 158. Arch symmetry chart Wire size chart 158
  159. 159. Formation of anterior k- type wire with hooks 159
  160. 160. The advantage of using AK hooks are They can be matched up accurately with the distal end of the brackets at the time they are being made. It is easy to hang elastics onto them and to mount and remove the archwires from the brackets. Elastics do not slip off, hence can be left even on eating 160
  161. 161. Wire retention a. Lock pins b. High hat o rings- high hat safety pins are inserted into the brackets in reverse direction, and the wire is held in place with O ring c. Super high hat ligature cross- retention is offered by the 0.011 inch ligature in place of O rings 161
  162. 162. d. T pin uprighting- involves use of a T pin in conjunction with an uprighting spring, a hook pin is also used instead of a T pin e. Twist- torque- used for torque on individual teeth f. High hat rotation T pins- involves use of T pin in conjunction with a high hat pin. Easy to attach intermaxillary elastics and vertical elastics 162
  163. 163. g. Bypass ligature- used to retaining type II wire h. T pin ligature- used for retaining type II wire 163
  164. 164. i. Retention of posterior wires- a double back end is inserted into an oval tube with a hook and held in place by an O ring 164
  165. 165. Elastics A variety of elastics can be used including class II, class III, check elastics, and vertical elastics 165
  166. 166. Stage I Commence by using a type III wire or III + I wire. Brackets are attached to incisors and canines. For anterior wires 0.014inch Australian wire special plus or higher grade is used. Sometimes 0.012inch NiTi wire is added. For the posterior wires 0.016 inch Australian wire extra special plus or higher is used. The double back ends of the posterior wires are inserted into the buccal tubes on the first molars, and adjusted so that the hooks end up in the buccal side, with the round loops of the hooks close to the cervices, and tips of the hooks pointing crownwards. 166
  167. 167. The posterior and anterior wire are joined with 0.030 inch diameter closed coil springs. Two closed coil springs of 1 mm length are use for each connection (8 there fore for the whole mouth). The distal end of the anterior wire and the mesial end of the posterior wires are bent into round loops, using light wire plier. The finished type three wire is placed into the mouth, lining the posterior wires up with the canines and 1st molars, and the anterior wire with the incisor and canines, and then fastened. The distal end of the anterior wires are rolled into circles and cut (roll up cut). A length of 3 – 5 mm of posterior wire is left at the mesial ends of the canines, and bent inwards. When crowding is severe, the wires are doubled by adding 0.012 inch NiTi wire to the anterior wires 167
  168. 168. In non extraction cases, the mesial end of the posterior wires are cut longer, after estimating how much length will be needed once crowding is relived. In the beginning ordinary lock pins are used, but it is good to gradually replace the incisor lock pins with high hat O rings, and canine lock pins with high hat ligature or rotation T pin. The rollup cuts and M cuts are adjusted at every visit of the patient. Intermaxillary elastics are attached to the circle hooks at the distal ends of the anterior wires and to buccal tube hooks on the first molars. This is followed until there is improvement in the overbite and overjet. 168
  169. 169. Stage II Stage II is alignment of posterior teeth begins after the alignment of anterior teeth is completed. Type II wire is used Normally a 0.016 inch anterior k type wire of extra special plus grade or higher is used, together with a plain arch wire of NiTi wire, normally 0.016 inch which can be activated with a tip back bend and a molar offset as required. Special plus or higher grade 0.014 inch Australian wire can also be used When displacement in the posterior teeth is severe, treatment can begin with 0.012 wire for both anterior k-type wire and plane arch 169 wire.
  170. 170. Both wires are checked against the wire size chart, the lengths are measured, and then they are mounted and fastened with lockpins. The lock pins used are; Canines - rotation T pins or high hat ligature Incisors - rotation T pins or high hat O rings Premolar section – T pin at 900 In nonextraction cases, differential orthodontic force is used to advantage. When it is desired to move the posterior teeth forward, the canines are connected to the 2nd premolars by means of elastomeric modules and the teeth are moved one at a time. When it is desired to move the anterior teeth distally, the second premolar and the first molar are made to provide the anchorage. 170
  171. 171. Slightly stronger elastics than those used in stage I are used in this stage. Method of closing extraction spaces. Pulling is achieved through elastomeric modules. Method of using intermaxillary elastics in stage II 171
  172. 172. Stage II ends when the extraction spaces close up, displacement in the posterior teeth is eliminated, and the occlusal relationship is firmly established. One activates the anterior k-type wire by the addition of an anchorage arc, which is made at the distal end if the AK hook 172
  173. 173. Stage III This stage begins with the use of type II wire. By the end of stage II, overjet, overbite, and the occlusal relationship have been corrected. When a greater torque to the NiTi wire is desired, a twist torque technique is used. Molar offset are incorporated. Lockpins can be changed from 900 T pins to 100 T pins in order to achieve over uprighting, and individual teeth can be adjusted. 173
  174. 174. After stage III Type I wire either round or rectangular is used and the conventional Begg method is followed. The anchorage bend is increased by 150. Annealed wire can, if desired, be cut and passed through the first molar oval tube and fastened, so as to reduce the size of the lumen to that of a single tube. 174
  175. 175. 175
  176. 176. Lingual Beggs In 1982, Paige introduced a lingual lightwire technique with a horizontally slotted unipoint combination bracket and both round and ribbon wires. It was the Fujita, Kurz, Kelly, Paige in the late 1970’s worked on lingual orthodontics. Fujita confirmed that orthodontic treatment with brackets placed on the lingual is possible, and that there was an obvious improvement in esthetics and increased patient acceptance for this form of treatment. 176
  177. 177. Bracket Design Criteria The first important factor to be considered in designing lingual attachments is that interbracket distance is reduced on the lingual Therefore, the bracket must be designed to be as narrow as possible mesiodistally. Keeping the buccolingual distance minimal would also have advantages, since a small buccolingual dimension will increase interbracket distance. In crowded situations, more brackets could be placed at the initial appointment if the bracket profile is small 177
  178. 178. Secondly, as a consequence of decreased bracket width, mesiodistal root control becomes more difficult. Cuspid and bicuspid uprighting after closure of extraction spaces requires efficient mechanisms for uprighting. A possible solution to this problem is the use of vertical slots for arch auxiliaries. The third factor to consider is the topography of the lingual surfaces of the maxillary and mandibular anterior teeth. The lingual contours of the anterior teeth seem to vary a great deal Because of the concave and convex surfaces, the amount of torque supplied to the tooth by the bracket will be very sensitive to its occlusal-gingival placement. 178
  179. 179. A very small change in the occlusal-gingival placement can produce a large change in root torque. It has been argued that this problem could be solved by indirect bonding procedures. 179
  180. 180. A fourth factor for consideration would be ease of insertion, ligation, and removal of the archwires. A very satisfactory solution in the technique is the incisal/occlusal placement of the archwire. The use of vertical slots could permit the use of pins to increase ease of ligation. Archwire Design Because of the reduced interbracket distance, consideration of archwire selection is very important. The general shape of the archwires resembles the mushroom shape as proposed by Fujita When use of elastics to the archwire is required a horizontal loop distal to the cuspids have added 180
  181. 181. Mushroom arches with horizontal loops for elastics. Formation of this loop in Nitinol or other very resilient archwire may be difficult and, therefore, placed only when needed or when ready for elastic wear in the stainless steel archwires 181
  182. 182. The amount of constriction or expansion, or toe-in or toe-out of the archwire will be dictated by the proposed treatment mechanics. The distal ends of the archwire should always be annealed. This allows easy removal of the wire from the molar tube and allows easy shaping distal to the tube for the necessary patient comfort. Cutting the distal ends of the archwire flush with the tube has proven to be unsatisfactory because it invariably produces patient discomfort. Molar Tube Design Conventional oval tube with a mesiogingival hook 182
  183. 183. Initially, the reasoning behind the oval tube was to allow for doubleback bends to prevent irritation to the tongue. However, the discovery that the distal end could be bent in a buccal direction negated the need for a double-back bend. The squashed oval tube has some advantages in that it increases patient comfort, allows molar control, and will accept a ribbon arch. Securing of Archwires Various methods of securing the archwire are available and will be dictated by the position of the bracket relative to the archwire. A common one, proposed by Fujita,4 is with doubled-over O-ring elastics . Pins and steel ligatures are also used when the situation warrants it. Regardless of the method of securing archwires, the operator will 183 discover that it will be more time-consuming from the lingual initially.
  184. 184. Double-back O-loops for ligation. Steel ligatures and pins for ligation. 184
  185. 185. Use of Auxiliaries There is an advantage to the use of auxiliaries for precise root control, because the arch-wire does not need to be removed to place the auxiliaries. Uprighting springs are necessary for proper mesiodistal control during uprighting and esthetic positioning of anterior teeth. The safety-hold uprighting spring works adequately in most circumstances. A special consideration is needed for uprighting of cuspids and bicuspids at the extraction spaces, because of the inset distal to the cuspids. Uprighting springs with longer arms are recommend. 185
  186. 186. The uprighting spring is still placed from the gingival direction. Because the arch-wire is placed from the incisal-gingival direction the archwire should be secured by a ligature or elastic module. The use of a power arm of .016"×.022 " Elgiloy (Rocky Mountain/Orthodontics) is also effective in cuspid retraction and uprighting 186
  187. 187. Rotations can be controlled by the use of thick .030" elastic thread wedged between the archwire and the bracket base and then tied on the opposite side of the bracket. This has an advantage of not requiring archwire removal to effect the necessary rotation. Torquing of maxillary and mandibular anterior teeth requires special consideration. Begg mechanotherapy traditionally requires torquing of maxillary and mandibular anterior teeth during Stage III of treatment. the application of force on the tooth is at the incisal edge 187
  188. 188. Use of Elastics The size and strength of the elastics are the same as for conventional light-wire orthodontic therapy. Class II elastics from the lingual of the first molars to the archwire loop lingual to the maxillary cuspids, appears to restricted the movement of the tongue during speech. In order to provide more tongue space these elastics may be placed on the buccal of the mandibular first molars. Anterior attachment of the elastic may be buccal or lingual to the cuspid, as it does not seem to affect speech or tongue function. No difficulty was experienced with Class I intra-arch elastic placement on the palatal or lingual areas. 188
  189. 189. All maxillary and mandibular teeth may be bracketed with little interference from occlusion. Although the maxillary and mandibular molars were banded on our patients, direct bonding is definitely feasible. Headgear tubes should be welded to the buccal of the molar bands, if necessary, for extraoral treatment procedures. Although our patients received direct bonding procedures, indirect bonding techniques may be practical and may improve placement of the brackets. For isolation, a Hygroformic saliva ejector or the Unitek lingual saliva ejector is used to keep the tongue retracted and to control moisture. 189
  190. 190. Placement of the bracket is based on the work of Fujita. He has recommended that the molar tube be placed approximately 3mm from the lingual cusp tip and the slot of the brackets on the anterior teeth approximately 4mm from the incisal edge. Deep bite situations present the most challenging mechanics for bracketing. In extraction cases, the goal is to move the maxillary cuspids to a position where the lingual surface is not in occlusion so that these teeth may be bracketed. This may require the maxillary or mandibular cuspid to be tipped distally separately as necessary, which may be accomplished with the lingual cleat placed on the buccal of the cuspid in a distogingival position. 190
  191. 191. Once the cuspids are bracketed, Class II elastics can be initiated to the lingual archwire to begin opening the bite. When the bite is open, placement of additional brackets can continue as normal. Rotation of the cuspid is an undesirable side effect of the elastic action on the cleat, but can be corrected later by continuing retraction from the lingual side. 191
  192. 192. TP 256-500 mini-mesh lower incisor labial brackets, which have narrow bonding bases, are used for both upper and lower incisors. The brackets are adapted to the study models to conform to the lingual surfaces of each tooth. The mini-mesh may be ground to make it narrower. Upper lateral incisor labial brackets are adapted to the cuspids, and the curved upper cuspid labial brackets to the bicuspids. Usually little reshaping is required. The slot of the 256-500 bracket allows up to 60° of tipping action with its wide mesiodistal bracket channel 192
  193. 193. A bracket height of 3.5mm from bracket slot to incisal edge is recommended for the upper central incisors, lower incisors, and cuspids. For bicuspids and upper lateral incisors, 3.0mm from slot to lingual cusp is sufficient. To provide proper interbracket distance in Stage I , the vertical slots of the brackets should be directed incisally for incisors and cuspids and occlusally for bicuspids. Stage I bracket placement with vertical slots directed incisally/occlusally to receive archwire with vertical loops. Note horizontal circles distal to cuspid brackets. 193
  194. 194. For Stage II and Stage III , a new set of brackets must be bonded with the vertical slots directed gingivally. Space closure with Stage II mechanics. High-hat pins act as hooks on cuspid brackets, and both buccal and lingual elastics are in use. Stage III bracket placement with vertical slots directed gingivally, torquing auxiliaries for incisors, and uprighting springs for bicuspids. 194
  195. 195. A bracket seater made of .019" × .025" wire, will fit into the TP bracket slots to hold the brackets at the correct heights during direct bonding. All brackets can be bonded in about 30 minutes Bracket seaters made of . 019"´.025" wire: A for anterior brackets and B for bicuspids. 195
  196. 196. The mushroom-shaped archwire should have horizontal loops for elastics distal to the cuspids. Offset bends are usually necessary at the bicuspids and molars. A toe-out bend is generally used in the lower arch and a toe-in bend in the upper, depending on the amount of constriction or expansion needed. The distal ends of the archwire can be annealed to permit easy bending into the embrasures and prevent tongue irritation 196
  197. 197. Final adjustment of cuspid position in Stage III is best accomplished by using a labial arch with open vertical loops. This wire is supported by buccal tubes and by brackets bonded to the distolabial surfaces of the bicuspids. The ends of the wire are annealed and cinched to facilitate the effect of the loops on the cuspids. Cuspid prominence can usually be reduced within five weeks. 197
  198. 198. K B Horizontal brackets KB technique is called revised Begg technique. It become completed by rearranging the treatment goals of stage I, stage II, stage III of original Begg technique from a biological standpoint to meet the social needs of the patient at that time. I II III Original Begg III II I KB technique Therefore the operations and patients become feel to ease in reducing the no of things to be done as stage goes by just like a reverse triangle 198
  199. 199. The new type of buccal tube and torquing brackets In order to solve the problems of round buccal tubes, here uses the ribbon arch type which is easy to direct force and which brings littie loss of distribution of force. The dimensions of the buccal tube Inside margin of the buccal tube is rounded to reduce friction. In addition to a vertical slot, a 6degree distal offset is incorporated to prevent molars from distobuccally rotating in the mesial movement of the molars. 199
  200. 200. The brackets are modified by carrying out torque and reverse torque by combining a ribbon archwire with angulated bases of the bracket. KB Horizontal brackets The original tip edge brackets have a 26 degree tipping cut. If the canine tips by 26 degree it takes 10 months to upright since the speed of uprighting by using the uprighting springs is 2.5 degree per month. Here the tipping cut was made to 6 degrees to applying the idea of KB technique top the tip edge brackets and these brackets are called KB Horizontal brackets. 200
  201. 201. 201
  202. 202. Thank you For more details please visit 202