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Refined begg /certified fixed orthodontic courses by Indian dental academy


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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.

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Refined begg /certified fixed orthodontic courses by Indian dental academy

  1. 1. REFINED BEGG STAGE II & PRE STAGE III INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. OBJECTIVES: Similar to conventional Begg – 1. To maintain all the corrections achieved during stage I 2. To close all the extraction spaces. This done by further retraction of the anterior teeth, by protraction of the posterior teeth, or a combination of both. The nature of initial malocclusion, or, the anchorage requirement determines which of the above 3 modes of space closure is indicated in a given case.
  3. 3. In addition, the stage II of the refined Begg aims at the following: 1. Controlled tipping of the incisors, when space closure is to be mainly achieved by the anterior retraction. 2. Preventing excess tipping of the anteriors (by using efficient brakes), when space closure is mainly achieved by protracting the posteriors. 3. If the molar relation is not fully corrected at the end of stage I, this correction is also achieved during the stage II. 4. In the 1st premolar extraction cases, crossbites and rotations of the 2nd premolars are corrected during this stage.
  4. 4. ARCHWIRES : Premolar extraction cases – 0.018” P or P+, or, 0.020” P wires, depending on the severity of initial malocclusion. If the stage I corrections involved extreme deep bite, badly distorted arch forms or severe rotations, new archwires are made for the 2nd stage in 0.020” size. Otherwise, 0.018” wires of the stage I can be continued during the stage II also. Heavy 0.020” archwires are extremely effective in: 1. Maintaining the rotational overcorrection, deep bite correction and arch form. 2. Resist disto-buccal rotational tendency of the molars due to class I elastics used during the space closure.
  5. 5. Since the bite opening requirement is fulfilled by the end of stage I, the anchor bends are reduced to a level that will maintain this correction. A reduction in the anchor bends is necessary, because a continued use of high degree of anchor bends will lead to excessive tipping of the molars, specially the upper ones. The degree of bend in 0.020” should be less than in 0.018” wire for the same bite opening effect. Other factors like the initial severity of the deep bite, mild bite deepening effect of the MAA, and the need to continue class II elastic for correcting the inter-arch relation, should be considered for deciding the amount of anchor bend.
  6. 6. The premolars are bypassed till the spaces close, except when they are in disto-buccal rotation. Such rotations require engagement of the archwire in the slot either for rotational correction using modules, or for holding the rotational correction using rotational springs. This is done towards the end of stage II and anchor curves are used instead of anchor bends.
  7. 7. CONTROLLED TIPPING OF THE INCISORS: MAA for lingual root torque is a must during the stage II for controlled lingual tipping of the incisors during their retraction. In some cases, the lower incisors would have received a MAA for labial root torque during stage I. even such teeth would need a MAA for lingual root torque, when they are to be significantly retracted during stage II in order to prevent their uncontrolled tipping.
  8. 8. If the canines appear to tip distally excessively, 0.010” uprighting springs on them minimizes their uncontrolled tipping. The adequacy of anterior retraction is judged clinically: The retracted incisors should appear upright or slightly retroclined, depending on whether they were moderately proclined or severely proclined respectively to begin with.
  9. 9. BRAKING MECHANICS FOR PROTRACTING THE POSTERIORS: The amount of protraction of the posterior teeth that is required for complete closure of the extraction spaces varies under different situations. In cases of 1st premolar extraction for correction of extreme anterior crowding, severe proclination or excess deep bite – only small amount of space may remain after these corrections are achieved. Hence minimal protraction is required in these cases.
  10. 10. 2nd premolars would be extracted in some other cases when these corrections are required to a lesser extent, and the patient has a good profile. More of the extraction space would remain at the end of stage I in such cases, and this will have to be closed by protracting the posteriors. There are also cases wherein the 2nd premolar extraction in one of the arches is undertaken mainly to mesialize the molars to correct the molar relation to a class I.
  11. 11. When space is to be closed mainly by protraction of the posteriors – it can be done by using efficient braking mechanics. The ‘brakes’ reverse the anchorage site from the posterior to the anterior segment by permitting only the bodily movement of the anterior teeth, instead of allowing them the freedom of tipping.
  12. 12. This conversion of tipping to bodily movement is either in a mesio-distal direction for the canines and lateral incisors, or in a labio-lingual direction for the incisors. The former is achieved by using braking springs or ‘T’ pins, while latter is achieved by using some torquing component on the incisor teeth.
  13. 13. The commonly used brakes are as follows: 1. BRAKING SPRINGS – These are passive uprighting springs made in 0.018” wire, which almost fill the bracket channel.
  14. 14. 2. ANGULATED ‘T’ PINS – These pins maintain the tipping already brought about, but prevent further tipping.
  15. 15. 3. COMBINATION WIRES – These are made either of stainless steel or alphatitanium alloy. The anterior segment is 0.022”× 0.018” (ribbon mode) and the posterior segment is in 0.018” round cross-section. The alpha-titanium wires being softer are easier to engage in the anterior bracket slots. However they are more prone to distort under occlusal forces in the posterior area, especially in the lower arch. When such distortion is anticipated, a stainless steel combination wire is preferred.
  16. 16. Torque in the anterior segment can be precisely built to the required degree, using a 0.022” torquing turret in which the wire is positioned in a ribbon mode. It must be remembered that greater the torque built in the anterior segment, more bite deepening effect it will have; besides the shearing force on the brackets, which tends to open the slots or dislodge the brackets.
  17. 17. Since combination wires are expensive, rectangular stainless 0.022”× 0.018” sectionals, suitably torqued in the same ribbon mode, can be used piggy back over a round 0.018” base wire, both held together using hook pins. 4. TORQUING AUXILLARIES: A two spur or four spur auxiliary, which is activated to the desired extent, or a MAA design in 0.010” or 0.011” size can be used as a braking mechanism along with a strong base wire (0.020” or atleast 0.018”)
  18. 18. DEROTATION OF PREMOLARS: A. Non-extraction treatment cases1a. First premolar having MB rotation and 5 and 6 normal. 1b. The first premolar and molar are normal but second premolar has a MB rotation
  19. 19. 2. The 4 and 5 both have MB rotations. 3. The 4 has DB rotation and the 5 has MB rotation.
  20. 20. 4. The 4 has DB rotation and the 5 has MB rotation. 5. The 4 or 5 has DB rotation but the other premolar is normal. a. If mild – bracket placed off centered. b. If severe – along with off centered bracket, flexible sectional wire such as NiTi c. If so severe that bracket cannot be placed off centered because of extreme tooth displacement, it is placed in center of the tooth and derotation carried by rotation springs
  21. 21. B. 1st Premolar extraction cases – 1. MB rotation of 5 can be corrected as described as for nonextraction treatment. A bracket is placed on 5 towards the end of stage II. 2. DB rotation of 5 can be corrected by placing a bracket towards the end of stage II and then derotating with the help of rotational module or a spring.
  22. 22. C. 2nd Premolar or 1st Molar extraction cases – Brackets are placed from the beginning in these cases to avoid extrusion of the premolars as the anteriors are retracted. However, they are bypassed by the archwire and only ligated till the bite opens. 1. MB rotation of 4 is corrected early from the palatal side 2. DB rotation can be corrected as mentioned earlier in A5
  23. 23. ELASTICS: Different configurations are employed during this stage as per the patient’s needs – 1. Upper and lower class I elastics are required in most cases.
  24. 24. 2. When the molar relation is not fully corrected during stage I, class II elastics along with lower class I elastics are used at the beginning of stage II till the molar relation is corrected. Thereafter, upper and lower class I elastics are continued.
  25. 25. 3. Class II elastics may be added to hold the corrected molar relation, thus making a Z Configuration. However, class II elastics should be used as sparingly as possible because of their bite deepening effect. In many cases, they are required only part time (for 8 hours during sleep, or for 12 hours during night).
  26. 26. 4. If the upper and lower teeth do not retract at the same rate, only class II elastics are given when the overjet increases (because the lower anteriors are retracting faster than the upper)
  27. 27. On the other hand, only lower class I elastics are given when the upper anteriors tend to go in a crossbite relation (because the upper retraction is faster than lower). When such abnormal relations are corrected, the elastic pattern is reverted back for retracting both the upper and lower anteriors together.
  28. 28. Strength of the elastics is also varied according to the clinical requirement. Light (yellow) class I or class II elastics are employed for anterior retraction. For posterior protraction, stronger (green) class I elastics are employed. Very heavy- blue or red elastics are seldom required, only when green elastics are found ineffective as, for example, in a low mandibular plane angle case.
  29. 29. PINS USED IN STAGE II: Hook pins are used when the anterior retraction is attempted in a controlled manner using MAA along with a base wire. While these pins permit full freedom of lingual tipping of incisors, they limit the distal tipping of the canines. The rectangular sectional along with the round base wire, or the rectangular component of the combination wires for protracting the posteriors, are also engaged using hook pins.
  30. 30. DURATION OF STAGE II: The durations of stage I and stage II have an inverse relationship in the extraction cases. Longer the stage I, (i.e., more the utilization of extraction space for relieving anterior crowding, retracting the anterior teeth and intruding the anteriors) lesser will be the need to close the space in stage II, hence shorter its duration and vice versa. The 2 stages together take approximately 1 yr to complete in most cases, and should not take more than 1 yr 3 months even in very difficult cases.
  31. 31. CHECK LIST AT THE END OF STAGE II: 1. All spaces are closed completely 2. All teeth are well aligned 3. The anteriors are in edge to edge bite 4. The incisors are either are upright or slightly retroclined 5. The canines and premolars are in mild to moderate mesio-distal angulations 6. The canine and molar relations are class I
  32. 32. PRE STAGE III : Most of the cases require the pre stage III adjustments before going from stage II to stage III. This is so because the premolars are usually not engaged in the archwire till the extraction spaces are completely or almost completely closed. Hence the premolars are at a different vertical level than the molars at the end of stage II.
  33. 33. Also, engagement of the archwire in premolar bracket and the molar tube and the molar tube requires a horizontal offset between the two, in order to compensate for the greater buccal bulge due to bigger dimension of molars
  34. 34. Coordinated upper and lower prestage III wires
  35. 35. If the vertical and /or horizontal discrepancy is such that the 0.018” wire of stage II cannot be engaged in the premolar brackets at end of stage II, a slightly undersized 0.016” archwire can be used for one visit in order to get the archwire engagement in the premolar brackets. The horizontal offset between the canines and the premolar brackets of the earlier stage I and stage II is eliminated (unless required for holding the overcorrected position of a canine that was initially buccally placed or distobuccally rotated).
  36. 36. The offset is now made between the premolar and the molar. A vertical adjustment is also made at the same sight so as to engage the premolar brackets. These adjustment should be semi passive so that they bring about the required correction without creating excessive forces. Then the heavier wires are employed for the stage III.
  37. 37. The upper arch wire is given a gable bend distal to the canine, while the anchor bend in the archwire is eliminated. This helps in holding the deep bite correction and simultaneous uprighting the molars, which had tipped distally during earlier stages. The lower wire is given both the a mild anchor bend as well as mild gable bend. The position of anterior and posterior segments of the wires are inverted to avoid excessive extrusive effects on the canines on account of the gable bends.
  38. 38. The archwires ends are bent to prevent opening of the extraction spaces. Light class II elastics are used, as required, for maintaining the corrected relationships of the anterior and posterior teeth. Occasionally, class I elastics may be required for holding the closure of extraction spaces. The pre stage III adjustments are usually completed within 1 month. If the discrepancy between the premolar and molar positions is excessive, it may require two months to go from the 0.016” archwire through the 0.018” intermediate archwire to the 0.020 third stage archwire.
  39. 39. New impressions are taken at the beginning of pre stage III. A lateral cephalogram and a panoramic radiograph are also taken, which help in assessing the degree of root movement needed during the stage III.