Refined begg’s stage iii /certified fixed orthodontic courses by Indian dental academy


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Refined begg’s stage iii /certified fixed orthodontic courses by Indian dental academy

  1. 1. Refined Begg’s Stage III INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. Outline  Introduction  Objectives  Mechanics of stage III  Problems encountered in Stage III  Genesis of third stage Complications  How the third stage problems overcome  Start and finish of the third stage  Conclusion
  3. 3. Introduction  A Properly managed stage III is what distinguishes a well treated Begg case from a poorly treated one.  Correction of labio/ buccal – lingual and mesio- distal root positions of all teeth that is achieved during the third stage is mandatory for achieving, optimum aesthetics, function and stability of the treated occlusion.
  4. 4.  Traditionally, the begg stage III was considered the most demanding part of the begg treatment.  It not only taxed the operator’s skill in preparing the base wires and auxiliaries, but also extended over a long duration- often equal to the first and second stages put together.
  5. 5.  When not carefully monitored, the mechanics of the third stage used to create serious problems that were quite frustrating.  Fortunately now, with the many refinements introduced over the past two decades, most of the problems encountered are either eliminated or greatly minimised.
  6. 6. Objectives of Stage III  Conventional Begg.  To maintain the corrections achieved during the first two stages.  To achieve desired root positions viz. inclinations of the incisors and mesiodistal angulations of all the teeth.
  7. 7. Refined Begg  To carefully monitor the sagittal and vertical anchorage. Augment the anchorage if necessary.  To monitor and correct the inclinations of posterior teeth, especially molars.  To correct the positions of second molars, whenever required.  To monitor the treatment for undesirable sequels, like root resorption and para- functional habits due cuspal interference.
  8. 8. Mechanics of Stage III  In order to appreciate the nature of problems in the third stage, it is necessary to understand its mechanics.  This requires a delicate balance amongst the forces and moments generated by the arch wires, auxiliaries, springs and elastics.
  9. 9.  The torqueing auxiliary for labio- lingual root movements and the uprighting springs for the mesio- distal root movements generate reciprocal reactions in all the three planes of space which, when not properly controlled, results in complications.
  10. 10.  The lingual root torqueing auxiliary also tends to cause labial crown movements, extrusion of the posteriors, and buccal crown movement of the posteriors.  The labial root torqueing auxiliary will have effects in the opposite direction.
  11. 11.  The uprighting springs for distal root movement also have similar effects as the lingual root- torqueing auxiliary in all the three directions.  The vertical and sagittal reactions are easily appreciated.
  12. 12.  Reactions in the transverse direction arise because of the vertical forces acting away from the C.Res of the posterior teeth.
  13. 13.  The springs for the mesial root movements have the opposite effects of the above.  In a first premolar extraction case, the reciprocal effects from the springs on the 5s for mesial root movement neutralize those from the springs for distal root movement on the 3s.
  14. 14.  But the reciprocal forces from the springs on the incisors and also from the lingual torqueing auxiliary, tend to cause mesial crown movement of anterior segment, extrusion of the anteriors, intrusion of the posteriors and flaring of the molars.
  15. 15.  In 2nd premolar or 1st premolar extraction cases or a non- extraction cases, where all the springs face distally (for distal uprighting of the roots), the above effects become accentuated.
  16. 16.  The reciprocal mesial crown moving forces are commonly resisted by cinching the distal ends of the arch wires and, in the case of the upper arch, by the use of class II elastics,  However, use of heavy class II elastics can add problems of deepening the overbite and a mesial movement of the lower arch.
  17. 17.  When the mesial drag on the lower arch, on account of the uprighting springs and class II elastics, is more than can be resisted by cinching the wire ends or by the occlusion, a Reverse (labial) Root Torqueing Auxiliary should be used to counteract it.
  18. 18. Problems encountered in stage III  The problems are in the form of the reversal of corrections in the earlier stages as also some additional complications.  Further they could be both biological as well as mechanical in nature.
  19. 19.  Undesired sagittal movements. 1. In the treatment of class II malocclusion, the inter-arch relation reverts back (partially or fully) from the corrected class I to class II, when the upper arch moves mesially. 2. Mesial movement of both the arches causes a reversal of the bimaxillary protrusion correction.
  20. 20. 3. Individual crown movements in a mesial direction can crowd the incisors and affect the rotational correction. 4. Mesial and distal crown moving tendencies in the teeth adjacent to the extraction sites can open the extraction spacing, closed earlier at the end of second stage.
  21. 21.  Undesired vertical movements cause the anterior deep bite to return partially or fully. In the 2nd or 1st premolar extraction cases, an open bite may develop in the molar area.  Undesired transverse movements cause the molars to roll out buccally and rotate.  Root resorption possibilities.
  22. 22. Genesis of the Third Stage Complication  Amount of lingual root torque needed for the incisors and the amount of distal root movements needed in other teeth.  Amount of forces generated by the auxiliaries and the springs.  Use of weak base wires.
  23. 23. How the third stage problems are overcome  Keys to successful third stage are: 1. To minimize the need for root 2. 3. 4. 5. movements in the third stage. Use of heavy base wires. Lighter auxiliaries and Uprighting springs. Light class II elastics. Reinforcement of the Anchorage.
  24. 24. How to minimize the need for root movements in the third stage  By diagnosing the case correctly and by carefully planning the extraction decision. 1. Over ratraction of the incisors is avoided.  By using Efficient Brakes. 1. The molars can be efficiently protracted in some cases.
  25. 25.  By Using Improved Mechanics. The mechanics for controlled tipping in the first two stages involves: 1. A careful balance b/n the intrusive force of the arch wire and the retractive force of the class II elastics. 2. Use of MAA for controlled lingual crown tipping. 3. Use of light uprighting springs for controlled distal crown tipping.
  26. 26. Use of heavy base wires  0.020 inch Premium grade wire.  Very effective in resisting the vertical (the bite deepening) and transverse ( molar rolling and rotation) reactions of the torqueing auxiliaries.  Almost three times stiffer than the previously used 0.020 inch special plus wires.
  27. 27. Lighter auxiliaries and uprighting springs  Because of reduced need to torque the incisor roots, the troqueing auxiliary used is a two spur auxiliary.  The “ Spur design having 2, 4, or 6 spurs are made in 0.020 inch wire”.  Even lighter wires than 0.020 inch wire can be used for other types of auxiliaries. Ex: 0.010 inch wire for ‘Mouse Trap’ auxiliary.
  28. 28.  The uprighting springs are also made in lighter wires. The ‘Mini Springs’ made of 0.009 inch wire, springs with slightly bigger coils in 0.020 inch for canines and premolars, and with 0.010 inch for the incisors.  These auxiliaries made from lighter wires equally effective to that of the previous once used.
  29. 29.  The forces generated by them are much lighter (and hence more physiological).  The forces are more constant.  On account of their low load deflection rate, they tax the anchorage in all the three directions much less, and are less likely to cause root resorption.  Thus, A much stiffer base wire combined with very light auxiliaries have reduced the stage three
  30. 30. Light class II elastics  Because of the lighter reciprocal actions generated, only light class II elastics (eg: yellow) are required in most of the cases.  Thus, problems associated with the use heavy class II elastics is overcome.
  31. 31. Reinforcement of the anchorage  In the treatment of the extreme malocclusions such as very large overjet, very deep over bite, severe bimaxillary protrusion, anchorage needs to be reinforced in the third stage, 1. By using Reverse Torqueing Auxiliary. 2. Headgear or a TPA may be added to the upper molars. 3. Lip bumper to the lower molars.
  32. 32.  For Vertical augmentation of the anchorage, 1. A high pull head gear or 2. A TPA or Posterior Bite Blocks may be used. Molar uprighting springs reinforce the anchorage in the sagittal and vertical directions in the 2nd premolar and 1st molar extraction cases. 
  33. 33. Start and finish of the third stage  At the start of the third stage, the teeth must be well aligned and well leveled and all the spaces should be completely closed.  Upper molar distal tipping, if caused during the bite opening, should be eliminated before the start of the third stage.
  34. 34.  It should be remembered that it is better to do over corrections by about 15% at the end of the second stage, in order to compensate for the loss during the third stage.  Such corrections which to be done are indicated/listed in the following table:
  35. 35. Malocclusion Overcorrected at the end of stage II 1. Class II molar and canine relation 1. Super Class I 2. Bimaxillary dental protrusion 2. Mild retroclination of upper and lower inclination. 3. Edge to Edge incisors 4. Edge to Edge incisors 5. Positive Over bite 3. Large Overjet 4. Deep Overbite 5. Anterior open bite 6. Midline Deviations 7. U. Molar rotations. 6. Over corrected to the opposite side 7. Molars mildly derotated.
  36. 36. How to judge the completion of the third stage  The degree of uprighting and torqueing is assessed by a visual inspection of appearance of the teeth.  By palpating the teeth roots, and from radiographs.  Pre- finishing panoramic radiograph and lateral cephalogram are routinely taken.
  37. 37.  An occlusal film can be taken to assess the labio- lingual alignment of the lower incisor roots.
  38. 38. Archwires  Made with cuspid circles tightly touching the cuspid brackets as suggested by Raleigh Williams.  If this is not done, the mesial crown moving component of uprighting springs on the canines and laterals can cause crowding and malalignment of the incisors, this is more likely to happen in the lower arch.
  39. 39.  The posterior segments of the arch wires are kept gingivally in relation to the anterior segments.  This helps in avoiding excess of extrusion of the canines on account gable bends in the arch wires.  Amount of contraction in the upper (as also toe- in) or expansion in the lower arch wire is much less as compared to the previous once.
  40. 40. Upper arch wire Lower arch wire
  41. 41.  The molar segments of the upper arch wire is given slight toe- in so that they are slightly converging.  Lower arch wire ends are in line with posterior posterior section of the arch wire.  Amount of gable bend in the upper and the gable and anchor bends in the lower wires is decided according to the degree of overbite in the original malocclusion.
  42. 42.  The wire ends are annealed and tightly cinched.  Needless to say that, the upper and the lower arch wires must be properly coordinated.  Their arch form, the amount of contraction or expansion and molar toein all decided by looking at the original study models.
  43. 43. Elastics  Very light class II elastics are used such as TP yellow, which are adequate for maintaining the inter- arch relationship.  Blue or red elastics in distal vertical or box configuration may be used to prevent tipping of the upper and the lower molars.  Heavier green or blue inter- arch elastics may be used, when the extraction spaces tend to open.
  44. 44. Banding the second molars  When the second molars are malaligned, they are banded in the middle of the third stage.  A sectional wire,0.012 or 0.014 inch wire is used in the tubes of first and the second molars to align them buccolingually or vertically.  After they are aligned, a continuous wire 0.016 inch along with 0.020 inch base wire is employed towards the end of the stage.
  45. 45. Conclusion  Third stage in the Refined Begg still involves the same amount of wire bending as was in the conventional.  However, the mechanics has become much more predictable and easily manageable.  Hence there is no excuse now for not attempting the third stage.
  47. 47. MOLLENHAUR ALIGNING AUXILLARY  The MAA attempts root control from the very beginning, without significantly affecting the anchorage and over bite correction.  The MAA is made from the 0.009” Supreme grade wire.
  48. 48. Requirements for use of the MAA  It must generate very light moving forces.  The adjacent rectangles must not diverge by more than 45  The auxillary must be able to resist deformation- Supreme grade wire is used.  The base wire should be able to resist the reciprocal forces.
  49. 49.  Advantages 1. Efficient in intrusion and simulataneous retraction of the anterior teeth. 2.rapidly bodily alignment of the anterior teeth. 3. Stable results. 4. Reciprocability of torquing forces on the in standing laterals or palatally placed canines. 5. periodontal advantages
  50. 50. .Various applications of the MAA  By bending more positive torque, it can be used after the stage I as a braking mechanism.  Applying labial root torque on the lower incisors in growing brachyfacial cases to prevent their roots from lingualizing.
  51. 51.  Mollenhauer can be used for controlling the mesio- distal root position. This application is called MAA- tip
  52. 52. Modified application of the MAA  The holding down the boxes for lingual root torque with the tail end of the lock pins was difficult.  In this modification, the torque is directly applied on the gingival surface of teeth.  It is made with the boxes inside the circle.
  53. 53.  When reciprocal root torque is required, the box meant for labial root torque rides over the main wire and presses against the incisal portion of the crown.  MAA is not used for unravelling crowding. It is fitted only after enough space is created by distalizing the canines.
  54. 54. The torquing auxillary with spurs  The auxillary is made from 0.012” premium Plus wire.  Modifications:  1. Length of the spur- the length of the spur should be kept at least 5mm, leaving it about 1mm short of the gum to facilitate proper hygeine.
  55. 55.  2. Inclination of the spurs to the horizontal(occlusal) plane is kept other words the activation is 100%.  3. The angle of the spur from the inter spur span opens up and the legs of the spur tend to converge.  This is remedied by slightly over angulating the spur and by keeping it less divergent.  The distal leg of every spur is kept slightly shorter by about 0.5mm so that it does not project incisally to the main archwire.
  56. 56.  . The inter spur span is curved as recommended by Kesling.a straight or angulated inter-spur span cannot assume a perfect curvature.  Correctly made auxillary having curved inter-spur span.
  57. 57.  Modifications of torquing auxillary  A. Reverse (labial) torque on one or both the lateral incisors: Boxes at right angle to the plane of the spurs are made that lie at the incisal area of lat incisors  Crossover bends are made on either side of the lateral incisor bracket to permit the auxillary to pass over the base wire
  58. 58.  B. torquing boxes on the canines for lingual root torque: Boxes can be provided  The ends of the auxillary need not extend beyond the canine area
  59. 59. Some other torquing auxillary  1. Single root torquing auxillary : It is useful design for any teeth except molars. It is particularly indicated on upper premolar
  60. 60.  2.Reciprocal torquing auxillary (SPEC) design.  It is employed when teeth require torque in opposite directions.  It is made in lighter 0.009” or 0.010” size wire if uded in stage I & II  If needed for the stage III it should be made in 0.012”
  61. 61.  3. Reverse torquing auxillary for cntrolling the roots of canine or premolars.  Designed by Franciskus Tan in 1987  It is used for labial root movement of palatally impacted canine.  For lingual root torque it is inverted.  It is made from 0.012”P wire in conjunction with 0.018” or 0.020” base wire
  62. 62.  4. Buccal root torque on the molars.  An additional auxillary made in 0.014” size wire is fitted in a round molar tubes.  It has boot design occlusal extensions on the molars.
  63. 63.  5. Labial root torque only on the lateral incisors: It is used for reducing the prominence of the canine roots  It is made from0.012” size arch wire
  64. 64. Uprighting springs  The 0.014” size wire was used earlier but now 0.009” supreme grade wire is used.  Advantages Very light continious forces.  Less taxation on the anchorage  Ease in maintaining mouth hygeine and better esthetics.
  65. 65.  The new springs differ from the older springs in the following respects The coil of the spring is only twice the size of the wire; in contrast to the size of the former springs that was 4 times the wire diameter.  The stem of the spring runs tangential to the coil, unlike the previous springs in which the stem was radial to the coil.
  66. 66.  100% activation; the stem and active arm are in one line ie making an angle of 180 compared to the earlier 135 angulation
  67. 67.  Securing the springs  The ligature wire is passed through the bracket in front of the archwire and then passed behind the archwire outside the bracket and the two ends are twisted together.  The ligature tied in this fashion will leave just enough space for insertion of the spring stem, thus ensuring a snug fit.
  68. 68. Size of the coil- Mini Maxi or midi Newer springs- mini springs Conventional springs- maxi spring The coil of the spring is very small. The coils can be made bigger by winding it around the0.9mm spring winder tip.- midi spring.  These are generally made in 0.010” for incisors.  0.012” canines and premolars.    
  69. 69. How to prepare a Spring winder?  2 pieces of wires are embeded in a cylindrical acrylic handle  One wire is kept at axial centre.  The other is kept at the side of the main arch wire.  Both are seperated by a distance of about 1mm.
  70. 70. Conclusion  Third stage in the Refined Begg still involves the same amount of wire bending as was in the conventional.  However, the mechanics has become much more predictable and easily manageable.  Hence there is no excuse now for not attempting the third stage.
  71. 71.