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

Refined Begg’s Stage III
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

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

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
mesiodistal 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.

 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.

 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.

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.


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.

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.


 The torqueing auxiliary for labio- lingual

root movements and the uprighting
springs for the mesiodistal root
movements generate reciprocal
reactions in all the three planes of
space which, when not properly
controlled, results in complications.


 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.


 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.


 Reactions in the transverse direction

arise because of the vertical forces
acting away from the C.Res of the
posterior teeth.


 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.


 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.


 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.


 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.

 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.

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.


 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.

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.

 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.

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.


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.

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.

 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.

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.

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.

 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.

 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

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.


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.

 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.




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.


 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:


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.


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.

 An occlusal film can be taken to assess

the labio- lingual alignment of the lower
incisor roots.


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.

 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 toein) or expansion in the lower
arch wire is much less as compared to
the previous once.

Upper arch wire

Lower arch wire


 The molar segments of the upper arch

wire is given slight toein 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.

 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.

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.

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 thirdwww.indiandentalacademy.com
stage.

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.

TORQUING AUXILLARIES


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.


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.


 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


.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.


 Mollenhauer can be used for

controlling
the mesiodistal root position.
This application is called MAA- tip


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.


 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.


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.


 2. Inclination of the spurs to the horizontal(occlusal) plane

is kept 0.in 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.


 . 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.


 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

 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


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


 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”

 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

 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.


 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


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.

 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.

 100% activation; the stem and active

arm are in one line ie making an angle
of 180 compared to the earlier 135
angulation


 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.


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.






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.

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

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