Stage i in refined begg /certified fixed orthodontic courses by Indian dental academy

GOOD MORNING
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


REFINEMENTS IN BEGG
TECHINQUE


CONTENTS
-INTRODUCTION
-OVER VIEW OF REFINED BEGG
-APPLIANCE COMPONENTS

-STAGE I
Stage 1 A
Sub stage 1B
-STAGE II and PRE STAGE III
-STAGE III
-TORQUING AUXILLARIES
-FINISHING AND DETAILING
-KAMEDANIZED BEGG
-CONCLUSION
-REFERENCES


INTRODUCTION
No treatment modality is ever perfect. With passage of time its
drawbacks become apparent . Unless the treatment evolves to
overcome those drawbacks, it is likely to become stagnant and then
die slowly. Refinements also become necessary to incorporate new
concepts and technological progress, the present day of Begg practice
has gradually refined from to overcome shortcomings of the
conventional Begg and to assimilate contemporary thinking and
material advances.


BEGG PRACTICE CAN BE GROUPED UNDER THREE BROAD
CATEGORIES
CONVENTIONAL (TRADITIONAL ) BEGG – Treatment philosophy as
Advocated by R P BEGG and P KESLING
Others – CADMAN, BARRER, RALEIGH WILLIAMS, FLETCHER, SAIN,
BRANDT.
MODIFIED BEGG – Follows Principles of Begg , but brackets other THAN
Ribbon arch brackets are used
Eg Combination Brackets- CHUN-HOON, KESSLER, FOGELL AND
MAGILL, C.A.T

REFINED BEGG- current Begg practice using Begg (Ribbon Arch)
brackets, BUT SIGNIFICANTLY deviates FROM CONVENTIONAL BEGG
and these can be elaborated under THREE headings
- CHANGE IN CONCEPTS
- IMPROVEMENTS IN HARDWARE
- MODIFICATION IN MECHANICS IN ALL THREE STAGES OF
TREATMENT

ADVANTAGES OF BEGG TREATMENT
-Light forces are used , physiologically more acceptable
-Anchorage control very efficient
-Quick correction of deep overbites

-Early resolution of malocclusion
- Roots are efficiently uprighted and torqued
-Demands on patient cooperation is minimized

- DIS-ADVANTAGES OF BEGG TREATMENT
-Round wire and bracket combination unable to give precise control for fine
finishing
-Posterior root torque was difficult to achieve

-Rotational control was poor
-True intrusion of upper incisors was minimal
-Ill efects of class ii elastics


Uncontrolled tipping of incisors
Long third stage of treatment
No failsafe mechanism to check tipping of tooth


1) CONCEPTUAL CHANGE ;
-Theory of attritional occlusion and differential force concept
-Treatment objectives
-Treatment planning

-Biomechanics
-Archform

2) CHANGES IN THE HARDWARE;
-A) ATTACHMENTS –
-Brackets
-Molar tubes
-B) ARCHWIRES-Premium, Premium plus, Supreme.
- Alpha titanium wires , combination wires

ELASTICS
Ultra light (road runner ) ormco
Light (yellow) tp labs
OTHERS
TPA , JASPER JUMPER


3) STAGE WISE MODIFICATIONS

STAGE I
-Ultra Fine Aust Archwires, CO-AX ,NITI
MAA
INCISOR INTRUSION

BYPASS ARCHWIRES, DISTALISING ARCHWIRES
0.018 WIRES

STAGE II
MAA
0.020 WIRE
APPLY EFFICIENT BRAKES

STAGE III
0.020 BASE ARCH WIRE

UPRIGHTING SPRINGS , TORQUING AUXILLARIES
BAND SECOND MOLARS
USE OF HEAD GEARS

FINSHING STAGE ;

RECTANGULAR WIRES
DIFFERENT ELASTIC CONFIGURATIONS


STAGE I in REFINED BEGG
The entire treatment is organized into Three Distinct Stages
which facilitated an orderly sequence of various corrections, in
the efficient conduct of treatment.
OBJECTIVES OF STAGE I
-ALIGNMENT
-CORRECTION OF ABNORMAL OVERBITE
-CORRECTION OF OVERJET
-ELIMINATION OF CROSSBITE
-CORRECTION OF ARCH FORM
-MATCHING OF MIDLINES
-ATTAINING CLASS I MOLAR AND CANINE RELATION
SUB STAGE IA

STAGE I
SUB STAGE IB

SUB STAGE I-A
 OBJECTIVES:
 To create space for CORRECTING CROWDING or to close









EXCESS SPACING if already present
Alignment of anterior teeth by CORRECTING LABIOLINGUAL
DISPLACEMENTS and or ROTATIONS or CROSSBITES
To IMPROVE UPPER INCISOR INCLINATION to within +/ - 10
degrees of normal
ROTATIONS AND BUCCOLINGUAL POSITIONS OF UPPER
MOLARS are CORRECTED so that TPA can be fitted
UPPER ARCH FORM IS BROADENED if narrow to permit
MANDIBULAR ADVANCEMENT for correcting class II relationship
Duration 1- 6 months
AIM – TO SHIFT TO 0.018 P/ P+ ARCH WIRE as soon as possible


SUB STAGE I-B
OBJECTIVES:
-BITE OPENING
-RETRACTON OF ANTERIORS TO ELIMINATE
CROWDING
-CONTROL OF MANDIBULAR PLANE ANGLE
-MATCHING UPPER AND LOWER MIDLINES
-CORRECTING INTER ARCH RELATIONSHIP TO
CLASS I
-DURATION 4 -6 MONTHS
ENTIRE FIRST STAGE – 6- 10 MONTHS

ARCHWIRES IN STAGE I
CORRECTION OF MALALIGNMENT
PRODUCE LIGHT CONSTANT FORCE OVER LONG
DEFLECTIONS AND LONG TIME
NI TI , MULTISTRANDED WIRES
GENERALLY USED AS SECTIONALS

CONSIDERATION OF ANTERIOR OVERBITE
VERTICAL COMPONENT OF CLASS II HAS
UNDESIRED EFFECT
( EXTRUSION) ON INCISORS AND MAND MOLARS .
PREFERRED ARCHWIRE .018 P+ /P.
OPEN BITE CASES .014 P/P+ IN MAXILLARY ARCH
PREFFERED ARCHWIRE IN SUB STAGE I-B IS .018


SUB STAGE 1 A
1) ALIGNMENT of the CROWDED TEETH
The archwire chosen should have –
Stiffness – to resist undesired effect of class II elastics
Flexbility - to facilitate application of continuous forces
-DECLINE

IN THE USE OF MULTILOOPED ARCHWIRES
ILL EFECTS OF MULTILOOPED ARCH WIRES (SIMS)

Inadequate or uneven bite opening
Labial flaring of incisor teeth and canines
Loss of control on molars
Failure to maintain anchorage
Difficult and time consuming
Loop orientation may change during unravelling of crowding
Difficult to maintain arch form
Difficult to maintain oral hygiene


ALIGNMENT OF TEETH WITHOUT THE USE OF
MULTILOOPED ARCHWIRES
BASE WIRES MUST BE STIFF PREFERABLY
0.016SS WITH ANCHOR BENDS BUT NOT WITH
CUSPID CIRCLES
NITI ARCHWIRE IS INSERTED INTO ALL THE
BRACKETS AND TIED TO SS BASE ARCH
WIRES AT 3 PLACES ie AT MIDLINE,
BETWEEN LATERALS AND CANINES
ELASTICS ARE HOOKED TO THE HIGH HAT PINS
IN THE CANINE BRACKETS FOR DISALIZATION
TWO SITUATIONS WHERE FULL LENGTH NITI
WIRES ARE USED
-MAXILLARY CANINES HIGHLY PLACED
-CLASS III CASE WITH POOR INCISOR VISIBILITY


AMOUNT OF CANINE DISTALIZATION NEEDED TO RELIEVE
CROWDING

MINIMAL CROWDING
CUSPID CIRCLES FORMED .5MM
DISTAL TO CANINES
MORE AMOUNT OF CROWDING
DISTALIZE CANINE ALONG SS
BASE ARCH WIRE , CUSPID
CIRCLES ARE OMITTED . USE
CLASS I ELASTICS IN
MANDIBULAR ARCH

PRECAUTIONS
IF EXCESS TIPPING – USE
UPRIGHTING SPRINGS TO GET
CONTROLLED TIPPING
MOLAR STOPS IN MANDIBULAR
ARCH
DISTAL ENDS ARE LIGHTLY BENT

Class I elastics are not used in the upper arch as it can tax anchorage
When sufficient space is created 0.016 S S wire with cuspid circle is used .
AMOUNT OF ARCH WIRE DEFLECTION NEEDED
A) If minimal crowding of 1-2mm use 0.016 or 0.014 S S with offset bends or
v bends to correct malalignment .there after shift to 0.018 ss for bite
opening
B) if crowding is more than 2mm 0.0165 coax or 0.009 supreme ,0.016 niti
wires are used
AMOUNT OF ROTATIONAL CORRECTION REQUIRED
- Archwire should fill the bracket slot as much as possible for rotational
correction
Supreme wires------ labiolingual correction
Niti or coax------ correction of rotations


Niti, coax, supreme wires for correcting incisor
irregularity are usually used as sectionals from
canine to canine. In combination of stiff SS wires
Two imp points to be noted while using sectional
wires are -Started after canines have been distalized
sufficiently for aligning the malposed incisors
-Base wire will require offsets so that they do not
impede action of flexible wires
ANTERIOR OPEN BITE

0.014 SS WIRE is used when extrusion of anteriors
are required
OVER CORRECTIONS OF ROTATIONS
Rotated teeth should be over corrected at each visit
on the lesser dimension wire using rotation
modules.

OTHER CORRECTION OF SUBSTAGE 1 A
CLOSING ANTERIOR SPACING
Decide the position of incisors first- determine whether they need to be
retracted or they are in proper inclination.
a) retract the proclined incisors on 0.016 S S wire with cuspid circles
2mm mesial to the canine brackets and elastic cuspid ties. Class 1 or II
elastics are used to retract the teeth
b) When spacing is to closed without retracting the anteriors spaces are
closed by tying anterior teeth with a figure of 8 elastomeric tie.

Since intrusion of teeth requires some amount of space active apace
closure should not be done till intrusion is accomplished if existing space
is less than 2mm.


IMPROVING THE INCLINATION OF INCISORS
Excessively proclined incisors are retracted by using class II elastics
Retroclined incisors are corrected by placing loops mesial to molar tubes
MOLAR POSITION CORECTION
Toe in or out bends are used to correct molar rotations

Mild bucco lingual corrections are carried out using
expanded arch forms
Severe discrepancies are corrected using TPA ,Quad helix, Nitipalatal expander.
ARCH FORM CORRECTIONS

Arch form in most of the cases can be broadened in canine to canine region by
shaping 0.016 ss arch wires
PINS USED IN SUB STAGE 1 A
1) well positioned incisors receive stage 1 pins

2) Cuspid retractions - high hat pins – facilitate engagement of elastics
3) Brackets that engage both the base wire a well as the sectional wires
--hook pins or ligature wires are used

SUBSTAGE 1 B
Major part of stage 1 treatment
Archwires used are standard 0.018 P, P+ . Elastics employed are class II light or
ultra light elastics
BITE OPENING
Unless other wise indicated preference during bite opening is for incisor intrusion
and for avoiding molar extrusion ,
-incisor intrusion reduces gummy smile
-Intruded incisors are placed in thicker zone of palatal bone and symphyseal bone

-This facilitates root movements
--molar extrusion in adult patients are not stable and increases the class II profile
-Whether to intrude uppers or lowers are determined by esthetic requirements
Refinements in Begg has over come many shortcomings of conventional Begg in
bite opening
Round wires used Begg technique have no capability of their own to counter the
labial flaring of upper incisors www.indiandentalacademy.com

Labial flaring of incisors are resisted by class II elastics
VARIED STRATEGY FOR CONTROLLING THE
MAGNITUDE AND DIRECTION OF THE NET
INTRUSIVE FORCE ACTING ON UPPER INCISORS
1)Initially (in substage 1a) intrusive force applied is 45
gm while class II force is 60 gm. This mainly reduces
the proclination of teeth but causes very little intrusion
2) As the inclination improves the intrusive force is
gradually increased to about 60 gm while classII force is
reduced to 30 gm on each side , bringing about further
correction of inclination of teeth
3) As the incisors become more upright the elastic
direction is changed to an oblique direction ( anteriorly
pointing downwards) it not only reduces inclination but
also brings about active intrusion of incisors
A gradual increase in the intrusive force is brought
about by increasing the anchor bend from about 30 to
50 degrees and elastic usage is for longer duration (35days) instead of changing them frequently

The directional change is effected by changing class II
orientation to class I orientation

1) Applying elastics from TPA to attachment on lingual side
2) Use power arms on upper molars made from
0.018X0.025 WIRE WHICH IS BENT IN FORM OF
HOOK and soldered to buccal aspect of upper molars
( Dr Jyothindra K)
LOCATION OF BITE OPENING BENDS
Many authors have proposed different sites for bite
opening bends
Any bite opening bend in archwire divides it into segments
that no longer remain parallel to the occlusal plane
They exert reciprocal intrusive and extrusive force on
different teeth to a variable effect

1) The conventional bite opening bend placed 3mm
mesial to the molar tube tend to cause more intrusion of
the upper canines and progressively less intrusion of
the lateral and central incisors due to bowing effect

2) Gable bends placed distal to canines tend to cause a
relative extrusion of canines while there is progressively
more intrusion of the lateral and central incisors.
3) With Hocever modification the centrals are subjected
to intrusion while the canine and lateral incisor are both
extruded

4) Bite opening curve (or Kameda design the canines (and
premolars if engaged) are extruded while the laterals and
centrals experiences progressively more intrusive effect.
Modifications for uniform intrusion of incisors
A mild gingival curve is incorporated in the anterior
segment from mesial of one cuspid circle to corresponding
point on the other side (swain)
If further augmentation of intrusive effect is needed
gingival curve is augmented with a vertical step up bend
4-5 mm in height and placed 2-3 mm mesial to molar tube.
Uniform intrusion of 6 anterior teeth

Vertical step up bends are effective in
anterior intrusion, but tend to tip the anchor
molar distally to a greater extent
Excess molar tipping is avoided by the use
of distal vertical elastics
If second molars are present ,wire is passed
through the molar tubes on both the molars
Use of elastics from TPA
TPA carries hooks that are bent in the TPA
or are soldered which lie in line with the
lateral incisors. an additional oval shaped
wire is soldered in the center kept slightly
away from the palate ,this helps in
generating constant intrusive effect from the
tongue
Brackets are bonded lingually with slots
facing incisally

ELIMINATION OF OVERJET
With the combination higher intrusive force and lighter elastic force
that is used now for incisor intrusion the chances for obtaining a
proper M/F ratio for controlled tipping are much better
Further augmentation with MAA auxiliary is also needed
PREVENTING UNCONTROLLED TIPPING OF LOWER INCISORS

1) Lower incisor brackets are bonded as gingivally as possible,
anchor bends are reduced
2) MAA with labial root torque is used on the lower incisors
3) the ends of lower incisors are cinched back

4) Lingual root movement of canines having marked prominence is
corrected using Jenners auxillary
5) If adjacent incisors need reciprocal torque a spec auxillary is
used
CONTROLLING MANDIBULAR PLANE ANGLE
More likely to happen with high angle cases with weak masseteric
sling

Adjuncts like TPA , high pull head gear, bite blocks can be used

CORRECTION OF MIDLINE DISCREPANCY

UPPER MIDLINE CORRECTION IS DONE USING SLIGHLTY UNEVEN CLASS II
elastics
If both midlines are shifted a diagonal elastics is utilized along with class II elastics
In lower arch if deviation is severe classI elastics with an uprighting springs added
on the opposite side for correction
CORRECTION OF INTER ARCH RELATIONSHIP
A) IN GROWING CHILD CORRECTION of molar relation from class II to class I is
MOSTLY ACHIEVED by encouraging mandibular growth. Functional appliances
like EVAA appliance is used
b) Mesialisation of lower molars is brought about by the use of class II elastics in
adult patients
c) In selected cases class II molar relation is corrected using distalizing appliances


Lock pins used in stage I -B

Stage III lock pins for engaging the archwire into
the slots as soon as Aligament is completed
Use of high hat pins on palatal brackets are
recommended for ease in attachment of elastics
CHECK LIST AT THE END OF STAGE I
-incisors are in edge to edge relation
-midlines are matching –
Upper and lower archforms are matching
-molar rotations and buccolingual displacements
are corrected
-good control of root positions and mandibular
plane angle are maintained
Molar relation is usually improved to class I , the
rest of molar correction can also be carried out in
stage II

ANCHORAGE CONSIDERATIONS IN STAGE I
The causes for anchor loss during stage I is summarized as follows
-Insufficient resistance from the anchor bends either because bends are inadequate
-Excessively heavy elastic pull
-Increased resistance from anterior teeth due to
-Incisor and canine roots touching labial cortical plates
-Abnormal tongue or lip posture
-Overjet reduction before overbite correction

-High mandibular plane angle reflecting weak musculature


INCORPORATION OF
CONTEMPORARY TREATMENT
CONCEPTS IN REFINED BEGG
Four refinements;
1) UPPER MOLAR DISTALIZATION in Begg treatment

Wilsons Bimetric Arch Principle
Movement causd by Modified begg archwire mostly
causes distal tipping of upper molars
Upper molars are distalised in growing child to gain a
permanent increase in the archlength of about 2mm
Case selection
Normal Mandibular plane angle
Late mixed or early permanent dentition

Upper molars should be normally placed
Profile considerations
Absence of third molar is helpful www.indiandentalacademy.com

Upper arch wire made of 0.016 premium wires
One teardrop shaped loop to be made mesial to molar
Loops have legs that are 6-7 mm in height 4mm wide , about 45 degree bite
opening bend is placed
Activation is by opening the loops by 2mm
class II elastics are used
ELASSTIC LOAD REDUCTION PRINCIPLE
Sequential use of class ii elastics
Tp green elastics for first week
Tp pink elastics for second week
Tp yellow elastics for following 2-3 weeks


MOLLENHAUER ALIGNING AUXILLARY (MAA)
MAA attempts root control from the very beginning without
significantly affecting the anchorage and overbite
correction . This has become possible by using a
combination of a stiff base archwire made from 0.009
supreme grade wires.
Development of MAA
MOLLENHAUER first experimented with rectangles made
of 0.010 wires for reciprocal torque on adjacent incisors
(SPECS)
0.009 wire was manufactured at Mollenhauers request
He made Boxed Auxllary “ an Aligning Auxillary for Ribbon
arch Brackets “

Requirements of MAA
-It must generate very light forces
-When reciprocal torque is needed the adjacent rectangles
shoud not diverge more than 45 degree
-Auxillary must resist deformation
-Base wire should be able to resist vertical and transverse
forces from MAA hence 0.018 wire is used
- MAA is first engaged and then main archwire engaged
piggyback

Advantages of MAA
-EFFICACY IN INTRUSION AND SIMULTANEOUS RETRACTION OF ANTERIOR
TEETH
-Efficiency in rapidly bodily alignment of anterior teeth
-Stable results
-Reciprocability of torquing forces on the instanding incisors
-Periodontal advantages in such cases because prolonged root torquing forces are
not required during stage III
-Possibility of remodelling point A and B

APPLICATIONS OF MAA AUXILLARY
-Bodily alignment of anterior teeth
-Can be used as braking mechanism
-Labial root torque in brachyfacial individuals to prevent ligualising of the roots
-Labial root torque in class III cases
-Can be used for controlling mesiodistal root tip

MODIFICATION IN APPLICATION OF MAA
-Holding down the boxes for lingual root torque with
the tail end of the lock pins was difficult with the
available pins
--hence applying the torquing action of the MAA
directly on the gingival surface of the teeth there by
eliminating the need for pins to hold down the
boxes.
-CONSTRUCTION OF MAA
- Tweed plies

-Rectangles with uniform height of 4mm
-The width of the rectangles could be varied
depending on the widthof the teeth
-The wire ends are wound around the mesial of the
terminal boxes
-Blank is then activated by shaping it into open
ended circle

INDICATIONS

-In Achieving Controlled Lingual Tipping Of The Upper And Lower Incisors
-When root apices are very close to labial or lingual cortical plates at the start
-instanding laterals or lingually placed canines
-preventing uncontrolled labial tipping of the lower incisors in stage I
-As a braking mechanism
RECENT INTRODUCTION OF RECTANGULAR WIRES
Rectangular wire bent in the form of an arc in edgewise mode but engaged in
Begg brackets in ribbon mode acts like a torquing auxillary
-0.0175 x0.025 braided rectangular Niti wire TURBO (Ormco) ( By Dr Tejashri)


OTHER BOXED AUXILLARY

-Mini versions of MAA
-Made from 0.009 – 0.012
-A) Two boxed auxillary on central incisors for
classII div2

-B) Two boxed for instanding incisors
-C)Jenner auxillary- two boxes on upper or
lower canines with very prominent roots
--made of 0.012 wire

--Lingual root torque exerted from these boxes
reduces the prominence to facilitate anterior
retraction
-D) SPEC Auxillary
-Used for reciprocal torquing of the adjacent
teeth a cross over bend is placed between the
two boxes if it is fitted piggy back

Functional appliances in conjuction with Refined Begg
When a JASPER jumper or Churro jumper is to be used
upper molar band are provided with double round tubes

The lower molar tubes combination tubes
EVAA Appliance
-Van der Schuerrin and De Smit ( JCO 1994)
--Simple Design, inexpensive ,

-Well tolerated by patients
-Additional attachment required is round buccal tubes
occlusal to conventional Begg in upper molars
--the appliance is made after both arches are well
aligned
--Instanding incisor in maxilla is positioned properly so
that mandible is easily anteriorly positioned
-Widening of upper arch in canine premolar region
required
--construction bite is taken with 5-6www.indiandentalacademy.com
mm of sagittal
advancement and 3-4mm of vertical clearance

The appliance consists of right and left occlusal blocks joined by lower plate. It
is anchored to occlusal tubes of the upper molars with the help of U loop wire
elements
The flanges touch the lower alveolar mucosa but can be kept free from of
contact with lower incisors
Bite blocks negate the extrusive effect of class II elastics
In low angle cases lower surface of the occlusal block can be trimmed for
erupting the lower molars
Appliance worn full time except while brushing
Duration of wear is 5-6 months full time extended by 3-4 months during night


MIXED DENTITION TREATMENT
Mulligans 2X4 appliance can be adapted to Beg set up
Distal tipping or uprighting of the molar can be done
Correction of mild crowding in lower incisor region
Begg appliance in combination with other appliance like RME


STAGE II AND PRE STAGE III
OBJECTIVES
-to maintain all corrections achieved during stage I
-To close all extraction spaces- by retraction of incisors or protraction of molars

AIMS
-CONTRLEED TIPPING OF INCISORS
-PREVENTING EXCESS TIPPING OF INCISORS BY USING BRAKES
-CORRECTION OF MOLAR RELATIONSHIP
-CORRECTION OF CROSSBITE AND SECOND PREMOLAR ROTATIONS


ARCH WIRES IN Stage II

Arch wires made of 0.018 P,P+ OR 0.020 P
ANCHOR BENDS ARE REDUCED TO MAINTAIN achieved correction
The premolars are bypassed till the spaces close except when premolars are disto
buccaly rotated
A MAA auxillary for lingual root torque is is a must during second stage
If canines appear to tip distally excessively 0.010 uprighting springs are added
The adequacy of anterior retraction is judged clinically
BRAKING MECHANICS FOR PROTRACTING POSTERIORS

The brakes reverse the anchorage site from the posterior to anterior segment by
permitting only bodily movement of anterior teeth
COMMONLY USED BRAKES IS AS FOLLOWS
1) Braking springs uprighting springs made of 0.018 wire angulation between the
stem is reduced
2) angulated T pins prevent for the tipping
3) Combination wires: SS OR Alpha titanium – ant segment 0.022 x0.018 ribbon
mode and post segment 0.018

Torque in anterior segment can be built by using torquing turret
4) Torquing auxillary ; Two or Four spur auxillary which is activated to the
desired or MAA in 0.010 , 0.011 Can be used along with a strong
base arch wire
ELASTICS
Upper and lower class I elastics

If molar relation correction is needed class II elastics are added till the
molar relation gets corrected
Class II should be used as sparingly as possible
Because of bite deepening effect part time wear for 8- 10 hours is
recommended
Only class I elastic is given in lower arch if Cross Bite seems to develop
Light (yellow) elastics are preferred
Stronger (green) elastics are used for posterior protraction

PINS
Hook pins are commonly used.


If only base archwire is used then Stage III pins are used

CHECK LIST at the End of SECOND STAGE
-All spaces are closed

Teeth well aligned
Anteriors are in edge to edge bite
Incisors are upright or mildly retroclined
Canines or premolars are in mild or moderate mesio distal
angulation
Molars are in class I OR super class I
PRE STAGE III
In the premolar brackets at the end of stage I 0.016 wire
is used for one visit to pick up the pre molars
Offsets can be used to engage pre molars
the upper arch wire is given a gable bend distal to canine
to maintain overbite
Lower wire is give a mild anchor bend and a gable bend
Distal ends are cinched to prevent opening of the
extraction spaces

0.018 wire is switched over to 0.020 wire

STAGE III
A PROPERLY MANAGED stage III is what differentiates a well treated
Begg case from a poorly treated one
Correction of Labio lingual and Mesiodistal root positions of all the teeth
that is achieved during the third stage is mandatory for achieving optimum
esthetics

OBJECTIVES
-TO MAINTAIN CORRECTION ACHIEVED DURING STAGE I AND II

- TO ACHIEVE DESIRED ROOT POSITIONS ,INCLINATION OF ALL THE
TEETH
- –AUGMENT ANCHORAGE
-TO MONITOR CORRECT INCLINATION OF POSTERIOR TEETH
-TO CORRECT POSITONS OF SECOND MOLARS
-TO MONITOR UNDESIRED SEQUELS LIKE ROOT RESORPTION AND
PARAFUCTIONAL HABITS

MECHANICS OF STAGE III
Auxillaries used generate reciprocal reactions in all the planes
of space which when not properly controlled result in
complications
a) Lingual root torquing auxillary – labial crown movement,
extrusion of anteriors, intrusion of posteriors, buccal crown
movement of posteriors
b) Labial root Torque auxillary- effects in opposite direction
c) Uprighting springs for distal root movement- similar effects
as that of lingual root torquing auxillary
d) Uprighting springs for mesial root movement- opposite
effect

In first pre molar extraction cases 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 .
But reciprocal forces from the springs on the incisors as
also lingual root torquing auxillary tend to cause mesial
crown movement of the anterior segment , extrusion of
anteriors, intrusion of posteriors www.indiandentalacademy.com
, flaring of the molars

In second premolar extraction or first molar extraction cases or in the non
extraction cases where all the springs face distally , the above said effects
become accentuated
Mesial crown moving forces are commonly resisted by cinching the distal ends
of the arch wires and use of class II elastics

PROBLEMS ENCOUNTERED IN STAGE III

UNDESIRED SAGITAL MOVEMENTS

-REVERSION OF CLASS II INTERARCH RELATION DUE TO
MESIALISATION OF UPPER ARCH
--MESIAL MOVEMENT OF BOTH THE ARCHES CAUSES REVERSION OF
BIMAXILLARY PROTRUSION
--INDIVIDUAL CROWN MOVEMENTS CAUSING CROWDING
--MESIAL AND DISTAL CROWN MOVING TENDENCIES IN THE TEETH
ADJACENT TO EXTRACTION SPACES CAUSES OPENING OF THE
EXTRACTION SPACES

UNDESIRED VERTICAL MOVEMENTS

-Causes deep bite to redevelop
- in second premolar and first molar extraction cases open bite may develop in
molar region
-UNDESIRED TRANSVERSE MOVEMENT
-Causes molar to roll out buccally and rotate
-ROOTRESORPTION POSSIBILITIES
-GENESIS OF THIRD STAGE COMPLICATIONS
-- More amount of lingual root torque more is the reciprocal effect

-Forces generated by uprighting springs
-Use of weak base arch wire


OVERCOMING THIRD STAGE PROBLEMS
1) MINIMIZE THE NEDD FOR ROOT MOVEMENT
-

Plan from the beginning

-

Diagnose the case correctly , the amount of reduction in proclamation

-

Use efficient braking mechanism to protract molars

-

Tip the incisor in controlled manner , use of MMA , LIGHT UPRIGHTING
springs

-

2) USE OF HEAVY BASE WIRES

0.020 premium grade wires
These resist the vertical and transverse reactions
3) LIGHTER AUXILLARIES AND UPRIGHTING SPRINGS
Spurs made of 0.012 wire is the choice
Mini uprighting springs 0.012 and 0.010 wires


4) LIGHT CLASS II ELASTICS
Yellow elastics (TP ORTHO)

5) REINFORCEMENT OF ANCHORAGE

In severe proclination
Head gear or TPA is added in the upper arch
Lip bumper in the lower arch
Bite blocks for vertical augmentation

Molar uprighting in reinforcing the anchorage


Start and finish of third stage
At the start
Teeth must be well aligned and leveled
Spaces closed, Correct distal tipping of upper molar
Some percentage of correction achieved is always lost during third stage
Overdo corrections by 15% at the end of second stage

COMPLETION Of THIRD STAGE

Visual inspection
Palpate the roots
Radiographs- lateral ceph ,OPG.
Teeth should be mildly overtorqued and over uprighted


ELASTICS

LIGHT CLASSII ELASTICS FOR MAINTAINING INTER ARCH
RELATIONSHIP
BLUE OR RED ELASTICS IN DISTAL VERTICAL OR BOX CONFIGURATION
IF SPACES REOPEN GREEN OR BLUE ELASTICS MAY BE USED

BANDING SECOND MOLARS
WHEN MALALIGNED, BANDED MIDWAY DURING THIRD STAGE
SECTIONAL WIRE 0.012 OR 0.014 IS USED

AFTER ALIGNMENT CONTINUOUS WIRE 0.016 IS USED


TORQUING AUXILLARIES AND
UPRIGHTING SPRINGS
Torquing auxillaries with spurs
The lingual torquing effect is on account of two factors-

-the vertical plane in which the torquing auxillary orients
when fitted on the two central incisors, is changed to the
horizontal plane of the arch wire when fully tied to it
-when torquing auxillary is opened to the larger arc of
the anterior region it rolls inwards

Both these effects force the tips of the spurs to press in
a lingual direction against the gingival portion of the
crown
Auxillary is made from 0.012 P + PULSE
STRAIGHTENED
On an average length of the spur should be 5mm
can be varied according to the length of the crown

Inclination of the spur should be kept 0 0 ,hence activation is 100%
Slightly overregulate the spur and keep the legs of the spur divergent
Distal leg of the spur is kept 0.5mm short
Inter spur span is curved as recommended by KESLING

Recommended size of the circle is an old 50 paise coin
Forces increase with the decrease in the diameter of the circle


Single root torquing auxillary (KESLING)
Used on any tooth other than molars
Upper premolars for buccal root torque
Long arm should extend three to four adjacent teeth when engaged in the
brackets
Convexity facing upwards exerts buccal root torque
Made 0.012 wire

RECIPROCAL TORQUING AUXILLARY (SPEC)
EMPLOYED WHEN TWO ADJACENT TEETH REQUIRE ROOT TORQUE IN
OPPOSITE DIRECTIONS
Made of 0.010 wire

REVERSE TORQUING AUXILLARY FOR
CONTROLLING THE ROOTS OF CANINES
OR PREMOLARS
-FRANCICUS TAN
-For labial root movement of the palatally
impacted canines
MADE of 0.012 P+ Wire, inserted into the
molar from the distal end
Activation is by rotating the auxillary 90 o

BUCCAL ROOT TORQUE ON THE MOLARS
Boot designed occlusal extensions on the
molars
Made of 0.014 wire


Lingual root torque only on the lateral incisors
Made of 0.012 wire
Convexity of the auxillary facing gingivally


UPRIGHTING SPRINGS
Made from 0.009 supreme grade wire (MOLLEHAUER)
Minisprings differ from the older springs in two ways
-coil of the spring is only twice the size of the wire
-Stem of the spiring runs tangential to the coil
Activation 100% Angulation 180, previously 135
MAXI – Coil diameter 4 TIMES THAT of wire
Mini- Coil diameter 2 times that of wire

Midi – In between, made of 0.010 or 0.012


FINISHING AND DETAILING
OBJECTIVES

1) INTRA ARCH OBJECTIVES
Good inter dental contacts, proper inclinations, rotations over corrected, complete
space closure, flat curve of spee, maintainence of lower inter canine arch
width, proper archforms
2) INTER ARCH OBJECTIVES
Normal overjet ,overbite, class I molar, canine, interdigitation of posterior cusps
3) FUNCTINAL REQUIREMENTS
MATCHING CO-CR , NORMAL CUSPID ,INCISOR GUIDANCE, HEALTHY TMJ
ARTICULATION
4) CONTROL OF THE ETIOLOGIC FACTORS

5) SOFT TISSUE FACTOR – FRENECTOMY, CSF

ROUND FINISHING ARCHWIRES –

0.020 WIRE IS USED
CONTINUE USE OF TORQUING AND UPRIGHTINNG AUXILLARY
FIRST ORDER ADJUSTMENTS
-PROPER LABIOLINGUAL POSITIONNING OF UPPER LATERAL INCISOR
-UPPER CANINE PROMINENCE
-OFFSET BETWEEN MOLARS AND PREMOLARS
-TOE IN FOR UPPER MOLARS

-SECOND ORDER ADJUSTMENTS
-VERTICAL ARCHWIRE STEPS
-A SLIGHT MESIAL ANGULATION OF MOLARS

-A DISTAL TIP OF LOWER MOLARS


TIP AND TORQUE CORRECTIONS
OVER TORQUE AND OVER TIP ALL THE TEETH BY 10 -15 %
RECTANGULAR FINISHING WIRES
RECTANGULAR MOLAR TUBES ARE REQUIRED

0.022 X0.018 ALPHA TITANIUM ARCHWIRE IS USED
TORQUING TURRET IS USED
T PINS ARE USED IN CONJUNCTION


KAMEDANIZED BEGG
STAGE I
-CONTROL UNNECESARY TIPPING OF TOOTH
USE SECTIONAL NiTi OVER BASE ARCH WIRES AND T PINS

BITE OPENING BENDS DISTAL TO CANINES AND MESIAL TO MOLARS
USE OF ELASTICS ;


STAGE II
RIBBON ARCH TYPE BUCCAL TUBE 6 0 OFFSET IN MAXILLA
TORQUING BRACKETS
200 FOR MAXILLA

100 REVERSE TORQUE IN MANDIBLE

COMBINATION WIRE
BYPASS LOOP FOR PREMOLARS
E- LINKS AND POWER CHAINS USED BUCCALLY AND LINGUALLY


STAGE III
ONLY UPRIGHTING IS CARRIED OUT


CONCLUSION:
KNOWLEDGE ABOUT VARIOUS APPLIANCE PHILOSOPHIES ,
TECHNIQUES IS A REQUIREMENT FOR THE ORTHODONTIST.

USING THE ACQUIRED KNOWLEDGE, SUITABLE TREATMENT STRATEGY
SHOULD BE PERFORMED ON THE PATIENTS.
THE MARKETING DICTUM “ ONE SIZE FITS ALL “ SHOULD NOT BE
FOLLOWED.
INDIVIDUALISATION OF THE TREATMENT PLAN AND CHOICE OF
APPLIANCE SHOULD BE GIVEN PRIME IMPORTANCE.
PROS AND CONS ARE A PART AND PARCEL OF EACH APPLIANCE
SYSTEM, HENCE ORTHODONTIST SHOULD CONCENTRATE MORE ON
OVERCOMING THE SHORTCOMINGS AND IMPROVISE THE APPLIANCE
SYSTEM FURTHER.


REFERENCES

Mollenhauer B. New approaches to the Begg technique . Aust orthod j :10;4 ,
1987.
Mollenhauer B. An aligning auxillary for ribbon arch brackets . Aust orthod j :11;
1990.
Kameda A. Begg technique and practice. J ind orthod soc.23:51;1992.
Vijay P Jayade. Refined Begg for modern times. I ed :2001.
Sims MR . Looped system: A contemporary approach . Am j orthod :61; 278 ,
1972.
Swain B F. Current orthodontic concepts and technique. Vol 11, 2 ed , Saunders,
1975.
Barrer : Current concepts in Begg philosophy. Jol Clin Orthod ,16: 2 , 1982.
Mamutil. Begg rotation module. J Clin Orthod.21, 1987.
Divakar HS , Jayade VP. JIOS interviews . JIOS 1997.
Wagers L . Pre orthodontic guidance and corrective mixed dentition treatment
concept . Am J Orthod 69:1976.

THANK YOU


Stage i in refined begg /certified fixed orthodontic courses by Indian dental academy

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