Extraction patterns for begg treatment in orthodontics /certified fixed orthodontic courses by Indian dental academy


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Extraction patterns for begg treatment in orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. Extraction patterns for Begg Treatment www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 3. Introduction Since the beginning of orthodontics, mechanical therapy has been used to create space for crowded teeth. Space - created in three ways: expansion of the dental arch, lengthening of the dental arch, and extraction of teeth or any combination of the three. www.indiandentalacademy.com
  4. 4. ‘to extract or not to extract’ – key qn.- planning ortho trt. 2 major reasons for extraction:  Severe crowding – provide space – remaining teeth.  protrusion or camouflage Sk Cl II or Cl III. www.indiandentalacademy.com
  5. 5. Historical Background Great Extraction controversy – 1920’s. Occlusal concepts  def. of normal occlusion. Potential complications: Facial esthetics. Stability of results. Angle influenced by: Philosophy of Rousseau & biologic concepts of his time. Rousseau  perfectibility of man www.indiandentalacademy.com
  6. 6. Extn. for ortho trt. – inappropriate. Inherent capability – perfect dentition. Ideal relation of 32 natural teeth.  Angle impressed by discovery Bone architecture  stresses placed. 1900’s – German Physiologist – Wolff “Wolff’s law of bone” – bone trabeculae arranged in response to stress lines on the bone. www.indiandentalacademy.com
  7. 7. Two Key Concepts. Skeletal growth – infl. by external pressures. Class II or Class III  problem – abnormal stress on jaws. Difft. pressure patterns – with trt – change growth  overcome problem. www.indiandentalacademy.com
  8. 8. Proper fn.  Key – maintain teeth in correct position. teeth in proper occl. – force transmitted to teeth – stimulate bone growth – stabilize teeth in new position. Edgewise appl. – “Bone growing appliance” – capable of controlling root posn. – bodily movement. www.indiandentalacademy.com
  9. 9. Dentofacial Esthetics: Professor Wuerpel – tremendous variety – impossible to specify – ideal. Angle’s insight: Reln. of dentition to face & VARY esthetics of lower face Ideal esthetics for each individual – teeth in ideal occlusion www.indiandentalacademy.com
  10. 10. Calvin Case’s challenge: arches expanded – teeth aligned – neither esthetics nor stability satisfactory – long term. Re-introduction of extraction. 1930’s – relapse observed. Charles Tweed – retreated with extrn. – four 1st PM’s  stable results. Reintroduction – 1940’s. Raymond Begg, Australia – Non extn – unstable  Extn. Trt. with Begg appliance. www.indiandentalacademy.com
  11. 11. Stockards breeding experiments – crossbreeding dogs Malocclusion – inherited. Begg’s – Attritional occlusion studies.  Extraction – necessary. Recent Trends. decline in extraction rates. PM extn – no guarantee of stability. Public preference – more prominent lips. “Neo – Angle” school of Treatment planning. www.indiandentalacademy.com
  12. 12. Rational contemporary view: majority – trtd without removal of teeth. some require extn. – compensate for: Crowding, incisor protrusion  facial esthetics or jaw discrepancy. Contemporary Extn. Guidelines. – Cl I crowding & protrusion. <4mm discepancy –extn. Indicated.  5- 9mm – extn.or non. extn. >10mm – Extn. Almost always. www.indiandentalacademy.com
  13. 13. Extraction trt. & Begg technique. Dr. Begg’s studies – Stone Age Man’s dentitionAttritional occlusion. Natural wearing away of tooth – not seen in modern man – dietary refinements. Evolutionary progress – Smaller jaw bones.  Primary cause of Malocclusion. Reduction in tooth str. – extn. & stripping  modern substitute for attrition. www.indiandentalacademy.com
  14. 14. Five factors – considered – case requiring extn. Arch length problems: tooth size to jaw discrepancy – civ. Man. tooth extn.- in tooth sub. – fnly. stable occlsn. Anchorage values. rate of tooth movement α total root surface area. force kept constant. Growth tendencies. assess adult size of tooth bearing parts of the jaws. Relative to – total M-D width – full complement of teeth. www.indiandentalacademy.com
  15. 15. Soft tissue analysis. extn – influence – relative posn. of upper lip, lower lip; nasolabial angle & prominence of chin. Organized occlusion. impt. role in selection of teeth for extn Esp. in cases with missing laterals & mandibular 2nd PM’s. www.indiandentalacademy.com
  16. 16. Choice of Extraction. essential to discard – automatic or routine decision – which teeth to extract. Refinement in diagnostic aids, Changes in Sophistication in mechanotherapy, Understanding of growth & Dev. objectives of trt. ability of the orthodontist to move teeth  variety of choices other than Ist bicuspids. www.indiandentalacademy.com
  17. 17. Four first Premolars. Dr. Begg  when indicated, all 4 1st PM’s – teeth chosen. Reasons: 1st PM’s – closer to ant. region – crowding seen. Ease of appl. Therapy – teeth close to the crowding region. www.indiandentalacademy.com
  18. 18. Smallest occlusal surface – masticatory fn. not hampered. Cuspids – good proximal contact – 2nd PM. maintain – normal physiologic fns. Esthetic appearance – not ruined – when extd. Approx.7.5 mm space gained on each side. www.indiandentalacademy.com
  19. 19. Study – Raliegh Williams & Fred Hoslla ( AJO 1976). Amount of incisor retraction – difft. extns. 4 1st PM extn. – 66.5% of extn space – ant. retraction. Mean distal movement – ant. 10.3mm. Post. Anchor unit – 5.2mm 1st PM, 34.50% 1st PM, 66.50% www.indiandentalacademy.com ant. retraction post . Movmt.
  20. 20. Controversial issues: Etiologic factor in TMJ disorders – over retraction – displ. of condyle post.  vertical dimension of occlusion.  Julie Ann Staggers ( 1994 AJO )– proved wrong. Changes in V.D – Not difft. – occuring in nonextn. cases. www.indiandentalacademy.com
  21. 21. Four Second Premolars Orthodontic trt. with Begg – border line cases – good facial profile & mild crowding – challenge. In 1965, Henry gave two basic criteria for extraction of second bicuspids: 1. A mild degree of crowding and a good profile. 2. No crowding and a fullness of the lips. www.indiandentalacademy.com
  22. 22. De Castro - mammalian dentition arrangement of three independent segments— an anterior segment ending at the canines & two posterior segments. Second premolar extracted – middle of the posterior segment, - this segment is shortened. first premolars extracted, posterior segments & transitional areas are disturbed www.indiandentalacademy.com
  23. 23. www.indiandentalacademy.com
  24. 24. The indications for second premolar extraction are:  Good profile + mild crowding.  Flat profile + moderate crowding.  Class II division 1 arch relation on Skeletal I base with mild mandibular crowding .  Mild Class III arch relationship with mild crowding in maxillary arch. www.indiandentalacademy.com
  25. 25. The advantages of this approach : Original facial contours - maintained, without reduction of lip profile. Maxillary first premolar - esthetic tooth alongside a canine. less tendency for extraction spaces to reopen in the mandibular arch. www.indiandentalacademy.com
  26. 26.  buccal or lingual bone furrows in the extraction area,  rapid space closure. Maintain – correct mand. canine width. Proper axial position of canines. Canine protection – better – canine 1st PM combination. www.indiandentalacademy.com
  27. 27. Begg – 2nd PM extn - likelihood of relapse. Extract – when carious or faulty – formation. De Castro (1974 AJO). – findings: Deliberate molar movement - > 2.5 mm on each side, requd. Average extn case – no change in facial profile. > 5mm disc.- good profile at start of trt. Post. Crowding – 2nd or 3rd molars / impactions . www.indiandentalacademy.com
  28. 28. Upper first & lower second PM’s Indications: Lower cuspids & ant. well placed. To correct MO – protract molars. Eg; Class II reln. Pathology ( Caries , malformed etc. ) Advantages: Contact b/w cuspid & 1st PM – lower arch undisturbed. Good occlsn. Upper 2nd PM & lower 1st PM & Molar. www.indiandentalacademy.com
  29. 29. Disadvantages: Mechanotherapy – difficult[ distalization of 1st PM – lower arch.] Narrow distal surface of 1st PM. – Contact not as desirable as with 2nd PM. www.indiandentalacademy.com
  30. 30. Willliams & Hoslla ( ’76 AJO) –  Mean forward movmnt. – 43.70% 56.30% anchor unit  7.2mm.  Actual mean rtrcn.  9.3 mm. Space utilized for retrcn. – 56.3% www.indiandentalacademy.com ant. post.
  31. 31. Maxillary & Mandibular first molars Indication: Any form of pathology – necessitating – extn. Endodontically treated teeth / multifilled teeth. Missing molars ( premature extn.) Disadv: Site of extn. – far from site of crowding. necessary to move 10 teeth in each arch. Mechanics – complicated. Relapse – mesial migration of 10 teeth – greater amt. of ant. translation. www.indiandentalacademy.com
  32. 32. Williams & Hoslla:Forward movement of post. teeth – 13.9 mm. Ant segment – 6.3mm. Space used for retraction – 31% www.indiandentalacademy.com
  33. 33. Maxillary & Mandibular 2nd molars. Extd. very rarely for orthodontic purposes. Indications:  Severely carious, ectopically erupted or severely rotated.  Mild discrepancies, good facial profiles.  To facilitate molar distal movt.  Class II Sk.cases – mild mandibular crowding. Prerequisites: Third molars present – normal size & shape. No congenitally missing teeth. Third molar inclination – 15 – 30° - long axis of 1st molar. www.indiandentalacademy.com
  34. 34. Advantages  amount and duration of appliance therapy  Disimpaction & Faster eruption of third molars  Prevention of "dished-in'' appearance of the face  Prevention of "late" incisor imbrication  1st molar distal movement www.indiandentalacademy.com
  35. 35. Distal movement of the dentition only as needed to correct the overjet "residual" spaces – less - end of orthodontic treatment  relapse Good functional occlusion Good mandibular arch form  incisal overbite www.indiandentalacademy.com
  36. 36. Disadvantages. Extraction site - far - in moderate-to-severe anterior crowding  patient cooperation - wearing appliances moving the dentition to the distal ''en mass" Possible impaction of third molars even with second molar extraction  Frequently unacceptable positions of erupted third molars second, late stage of fixed-appliance therapy. www.indiandentalacademy.com
  37. 37. Staggers (1990 AJO): compared results – 1st PM & 2nd Molar extn. Not much diff. in findings. Amount of ant. retraction Protraction of first molars in PM gp. Retraction of lower lip Facial profile change - in 2nd molar gp. Not statistically sig. Third molar angulation – OPG – not stat. sig. www.indiandentalacademy.com
  38. 38. Eight tooth Extraction Incidence – 0.5% of cases – Lyman Wagers ( JCO 1977) Rationale. Goals in trt. – mand incisor - + 2° AP Line. interincisal angle - 130°. 1 – Sn =100° In severe discrepancy cases – to achieve – goals. High mand. plane angle – no room – post. roots – moved back. www.indiandentalacademy.com
  39. 39. Problems: Lack of proper molar control – tipping mesiolingually. Biting archwire – unwanted bends. Williams & Hoslla: Mean forward movement – 18.6 mm. Ant. retraction - 18.3 mm. 50% space utilized for retraction of ant. segments. www.indiandentalacademy.com
  40. 40. Single Arch Extractions Indications: Class II div I- perfect lower arch alignment & incisor position. Growth expectations – inadequate – non extraction. Non – extn. – tried. Class II div I with mild openbite. www.indiandentalacademy.com
  41. 41. Upper first premolars Choice of extn. – amount of space requd. – region. Good molar interdigitation, Space requirement – 15 mm ant to 2nd PM’s. Profile improved. Esthetics improved. Masticatory fn. optimum. www.indiandentalacademy.com
  42. 42. Problems encountered: Molar reln. Still in class II. Reopening – space behind canine. Partial relapse of upper incisor protrusion. Mesial tipping of upper 1st molar – lingual cusp plunging b/w lower first molar & 2nd PM. www.indiandentalacademy.com
  43. 43. www.indiandentalacademy.com
  44. 44. Upper first molars Adv. over 1st PM extn: ( Raliegh Williams AJO 1979) Space behind canine – does not reappear. Buccal interdigitation normal – U 2 PM’s x L 2 PM’s 2nd molar – Class I reln. with lower 1st molar. cusp fossa reln. normal. Upper 3rd molars – can erupt succesfully. www.indiandentalacademy.com
  45. 45. Other Adv. Tuberosity – not crowded – distal movmnt. of molars. Min. patient co-operation. results stable in A-P dimension. No retention in lower arch. Post trt. profile excellent – upper and lower lips balanced. Ultimate appearance – no extns. www.indiandentalacademy.com
  46. 46. Precautions: Strap lower arch alsoLevel the lower arch. Minor interarch adjustments – Class II or Class III elastics Not even slightest crowding in lower arch. Curve of spee – should not be significant Upper 3rd molars – present. www.indiandentalacademy.com
  47. 47. Upper 2nd molars. Recommended by Graber ( AJO 1969). In class II div I (1) there is excessive labial inclination of the maxillary incisors, with no spacing; (2) overbite is minimal; and (3) third molars are present in the maxilla, in good position and of proper size and shape. www.indiandentalacademy.com
  48. 48. 3rd molar erupting www.indiandentalacademy.com
  49. 49. Advantages:  in trt. time and appl. use. Molar distalization easier. Bite opening effective. Less adverse effect on profile. Disadv. More loss of tooth subs.  dist form site of crowding. Overeruption of L 2nd molars. Uncertainty of third molar eruption www.indiandentalacademy.com
  50. 50. Lower first molars or 1st PM’s. Trt. Of Class III MO – Problem – large lower arch & jaw. Space analysis – if extn. Requd – L 1st Molars or L 1st PM’s. Teeth ant to extn site retracted. www.indiandentalacademy.com
  51. 51. Unilateral Extractions. Very seldom. Single lower incisor extn. – in this category Well formed arches, major midline shift, Class II on one side, Class III on other. Extn. ltd. to – class II side. Lower arch, Class II side – protracted. Class III side – retracted www.indiandentalacademy.com Class I
  52. 52. Single lower incisor. Indications: Periodontally involved incisor. Widening of mand. Intercanine width – prevented. narrow arch forms, severe crowding non extn – incisors finish forwards – “prow of a boat” – ( Riedel ) www.indiandentalacademy.com
  53. 53. Advantages: Maintains or  intercanine width. retention period. Ant. segments - retracted readily. Anchorage loss  overbite – readily accommplished. Co-op.- wearing of elastics Mechanotherapy simplified. www.indiandentalacademy.com
  54. 54. Disadvantages: Tendency – space opening. Danger of tooth size disc. eg. In extn of mand incisors with max. PM’s. Color diff. b/w – lateral & canine. Incising impaired. www.indiandentalacademy.com
  55. 55. Conclusion A particular malocclusion can be treated with more than one approach. The astute and the learned clinician will treat each individual patient with the approach that provides him with the best results. The success or failure of of orthodontic treatment is not often the result of the teeth extracted. It is dependent on the ability of the clinician to properly diagnose the malocclusion and skillfully use the appropriate appliance to provide optimal functional and esthetic results www.indiandentalacademy.com
  56. 56. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com