STAGE I AND STAGE II- BEGG’S APPLIANCESTAGE I AND STAGE II- BEGG’S APPLIANCE

PRESENTED BYPRESENTED BY

DR.B.VIJAYAGOPALDR.B.VIJAYAGOPAL

II YR PGII YR PG

INTRODUCTIONINTRODUCTION

The Begg technique has been divided into three stages.The Begg technique has been divided into three stages.

From a categorical standpoint the treatment is divided into the crown From a categorical standpoint the treatment is divided into the crown

tipping phase which includes the first two stages and the root tippingtipping phase which includes the first two stages and the root tipping

phase which covers the third phasephase which covers the third phase

From a clinical standpoint, the three phases are characterized by the From a clinical standpoint, the three phases are characterized by the

specific treatment objectives and tooth movementsspecific treatment objectives and tooth movements

Results will be better and problems fewer if the operator concentrates on Results will be better and problems fewer if the operator concentrates on

producing the required tooth movements for each stage, using the producing the required tooth movements for each stage, using the

prescribed wires and elastics for that stage and continuing until the prescribed wires and elastics for that stage and continuing until the

objectives of that stage are reached before proceeding to anotherobjectives of that stage are reached before proceeding to another

Stage I: (Usually 4 to 8 months)Objectives:

Closure of Anterior spaces

Correction of crowding

Overcorrection of rotation of anterior teeth

Overcorrection of Over jet to an edge to edge incisor relation

Overcorrection of Overbite to an edge to edge incisor relation

Correction of Cross bites

Correction of molar relation

Overcorrection of disto occlusion of the buccal segments

Correction of midline discrepancies

Correction of Axial inclination of mandibular incisors

Characteristic anterior tooth movements in stage ICharacteristic anterior tooth movements in stage I

Labiolingual movements as required for alignment on the Labiolingual movements as required for alignment on the anterior curve of the archwireanterior curve of the archwire

Over rotating - To positions that are reverse of the original Over rotating - To positions that are reverse of the original rotationrotation

Creating space for overlapped teeth or closing spaces as Creating space for overlapped teeth or closing spaces as required ,so that the incisors and cuspid of each dental arch required ,so that the incisors and cuspid of each dental arch are placed and maintained in a single segment of six are placed and maintained in a single segment of six anterior teethanterior teeth

Intruding the anterior teeth for correction of overbite,all 12 Intruding the anterior teeth for correction of overbite,all 12 teeth should be intruded evenlyteeth should be intruded evenly

Retracting anterior teeth for correction of overjet and for Retracting anterior teeth for correction of overjet and for placing them in a slightly lingual inclination.proper placing them in a slightly lingual inclination.proper retraction means that the central incisor crowns tip retraction means that the central incisor crowns tip lingually,lateral incisor crowns tip lingually and distally, and lingually,lateral incisor crowns tip lingually and distally, and cuspid crowns tip distallycuspid crowns tip distally

Characteristic posterior teeth movementCharacteristic posterior teeth movement

The anchor molars are maintained in upright positions The anchor molars are maintained in upright positions throughout treatment. Specifically, mesially inclined molars are throughout treatment. Specifically, mesially inclined molars are overcorrected to mild distal inclinations and distally inclined overcorrected to mild distal inclinations and distally inclined molars are maintained in mild distal inclinations. These positions molars are maintained in mild distal inclinations. These positions are most efficient for molar anchorage requirementsare most efficient for molar anchorage requirements

Molar rotations are corrected. Mesiolingual rotations are Molar rotations are corrected. Mesiolingual rotations are corrected to mild mesiobuccal rotation and mesiobuccal corrected to mild mesiobuccal rotation and mesiobuccal rotations are maintained as suchrotations are maintained as such

Cross bite relationships are overcorrected Cross bite relationships are overcorrected

Chracteristic archwires and elastics in the first stageChracteristic archwires and elastics in the first stage

Plain or looped archwires.looped archwires are replaced as soon Plain or looped archwires.looped archwires are replaced as soon as possibleas possible

In class I and class II cases,class II elastics are used. In class III, In class I and class II cases,class II elastics are used. In class III, class III elastics are usedclass III elastics are used

Bracket Placement:

Brackets are centered mesio distally on the labial or buccal surface with the base of the arch wire slot 4mm from the incisal edge of cusp tips. Only exception is maxillary lateral incisor where 3.5mm from the incisal edge is placed.

Lingual Button:

Placed directly opposite to to the areas of engagement of the archwire on the opposite side of the teeth. This is to permit free mesio distal tipping or uprighting of the teeth.

If the lingual button is placed incisal or occlusal to the level of base of arch wire the steel ligature would loosen or tighten during mesio distal uprighting.

Buccal Tube:

Molar tubes should be parallel to the occlusal surface when viewed

from buccal and parallel with a line bisecting the occlusal surface

mesiodistally.

Arch wire:

Different diameters of wire are available but the most commonly used one is 0.016” wire

0.016” special plus - Looped arch wire in any case

0.016” special plus - Plain arch wire in extraction cases or in which 1st and 2nd premolars are extracted

0.018” - Plain arch wire in molar extraction cases

Initial Arch wire:

The basic shape of the initial archwire depends upon the shape of malocclusion and although it is similar it is seldom identical.

The archwire shape is proportional to the width, the form and symmetry of dental arch.

There may be localized modifications of archwire in the vertical and horizontal plane and these are called Offset bends.

Offset bends:

In Anterior segment

Vertical offset - To Intrude or Extrude

Horizontal offset - to Expand, contract and rotate

In posterior segment

Gingival offset - to avoid occlusal distortion and interference with

bicuspids

cuspid offset bend (canine curve) :cuspid offset bend (canine curve) :

The labiolingual width of the cuspid is greater than that of the The labiolingual width of the cuspid is greater than that of the

lateral when measured at bracket levellateral when measured at bracket level

To avoid lingual tipping of the cuspid and labial tipping of the To avoid lingual tipping of the cuspid and labial tipping of the

lateral a horizontal offset bend is given distal to the lateral a horizontal offset bend is given distal to the

intermaxillary hookintermaxillary hook

It is usually called the cuspid offset bend,however it provides It is usually called the cuspid offset bend,however it provides forfor

proper positioning of both lateral and canineproper positioning of both lateral and canine

Shape of Anterior segment:

The anterior curve of the initial arch wire is usually a compromise between the shape of the malocclusion and that of normal occlusion.

E.g.: If anterior segment is narrow and protrusive the arch wire is made slightly broader in the cuspid region and flatter opposite to central incisors.

Dental Arch Width And Archwire WidthDental Arch Width And Archwire Width

Since there is a tendency for the anchor molars to contract Since there is a tendency for the anchor molars to contract

and tip lingually during the first stage of treatment,hence theand tip lingually during the first stage of treatment,hence the

archwire should be made greater than the dental arch widtharchwire should be made greater than the dental arch width

this is called this is called expansion for preventionexpansion for prevention

In considering the initial archwire for a bicuspid extraction In considering the initial archwire for a bicuspid extraction

casecase

1.If the dental arch width is satisfactory,the wire should be made 1.If the dental arch width is satisfactory,the wire should be made 2-3mm wider at each cuspid and 8-10 mm at the molar region2-3mm wider at each cuspid and 8-10 mm at the molar region

2.If the dental arch requires expansion,the arch wire should be 2.If the dental arch requires expansion,the arch wire should be made 4-6mmwider at the cuspid and 15-25mm at the anchor made 4-6mmwider at the cuspid and 15-25mm at the anchor molarmolar

3.If a bilateral cross bite is present the archwire is made 25-40 3.If a bilateral cross bite is present the archwire is made 25-40 mm wider at the side where cross bite is presentmm wider at the side where cross bite is present

The widths given above are for first bicuspid extraction cases The widths given above are for first bicuspid extraction cases

and they should be decreased for second bicspid an molar and they should be decreased for second bicspid an molar

extraction cases.extraction cases.

Although archwire variations are essential for correcting crossAlthough archwire variations are essential for correcting cross

bite,they cannot do so without cross bite elastics that exert six bite,they cannot do so without cross bite elastics that exert six

to eight times more force than archwireto eight times more force than archwire

Intermaxillary Hooks:

Routinely bent into the arch wire for both the upper and lower arches and are positioned 1mm mesial to the cuspid brackets.

The coil Pattern is usually a small helical loop 2 to 2.5mm of outside diameter.

The helical Intermaxillary hook two primary and two secondary advantages

Archwire is stiffer and aids in overbite correction

Wire is stiffer in horizontal plane and aids in correction of arch form, width and symmetry

Helical loops can be formed quickly

Helical hook is seldom distorted or broken

If Boot shaped loops are used they are angulated buccaly away the vertical in order to avoid any possibility if wedging of distal arm of loop into slot.

variation in the location of intermaxillary hooksThe location of the intermaxillary hook varies with the type of archwire being used (looped or plain) and the malocclusion

when plain archwires are used :-with anteriors in good alignment the hooks are 1-2mm mesial to the cuspid bracket

If slight space is required for the alignment of the anteriors, the hooks If slight space is required for the alignment of the anteriors, the hooks

are placed against the mesial side of the cuspid bracket.After the are placed against the mesial side of the cuspid bracket.After the

anteriors have been aligned the hooks will be 2-3 mm mesial to the anteriors have been aligned the hooks will be 2-3 mm mesial to the

bracket on either sidebracket on either side

If anterior spacing is present the hooks should be placed in such a way If anterior spacing is present the hooks should be placed in such a way

that after the spaces are closed the hooks are 1-2 mm mesial to the that after the spaces are closed the hooks are 1-2 mm mesial to the

cuspid bracketcuspid bracket

when looped archwires are placed the hooks are placed right at the when looped archwires are placed the hooks are placed right at the

mesial surface of the cuspid bracketmesial surface of the cuspid bracket

Vertical Loops:Used to supply local increased arch flexibility or used for space

opening or closing, stops, rotation or root torque.

The most vertical loops to align six anterior teeth are five, one in each interproximal area.

Generally loops are made 6 to 8mm long but greater the length of the loop, the more gentle the force on the tooth .

The Loop between the maxillary central incisors should be avoided, when indicated the loop is made shorter because

1) Avoid irritation to the labial frenum

2) Loop in midline causes arch wire to assume “V” shape when contracted by placement in the molar tube

Horizontal bracket area for severly lingually placed tooth is bent 1mm further gingivally than plane of arch wire to prevent elongation of tooth as it tips labially

Contraction Loop in midline with incisor stops to tip crowns of upper centrals

Vertical loops bent in case of high frenum attachment

MOLAR STOPSMOLAR STOPS

Molar stops are placed on the archwire in order to limit the Molar stops are placed on the archwire in order to limit the

extent to which the wire can slide into the molar tube.they areextent to which the wire can slide into the molar tube.they are

not used expect when it is necessary to preserve spacenot used expect when it is necessary to preserve space

Molar stops may be bent into the archwire or may consist of Molar stops may be bent into the archwire or may consist of

removable lock placed on itremovable lock placed on it

Double back archwireDouble back archwire

Flat oval molar tubes and double back archwires are used Flat oval molar tubes and double back archwires are used whenwhen

second permanent molars are the anchor teeth; second second permanent molars are the anchor teeth; second

permanent molars require more arch wire support than first permanent molars require more arch wire support than first

molarsmolars

Archwires with double back ends and flat molar oval tubes are Archwires with double back ends and flat molar oval tubes are

also used on mandibular dental arch when lower second also used on mandibular dental arch when lower second

premolars are absent because archwire spanning the space premolars are absent because archwire spanning the space

between the first premolars and first molars are likely to be between the first premolars and first molars are likely to be bentbent

by patients when they are masticating foodby patients when they are masticating food

flat oval tubes are better for double back archwire,because flat oval tubes are better for double back archwire,because

double back round archwires fit more accurately into flat oval double back round archwires fit more accurately into flat oval

tubes tubes

Molar anchorage bends:

Placed immediately posterior to the 2nd premolar bracket

Bent opposite so that when inserted into the buccal tubes the anterior section of the archwire lies in the buccal sulci

Amount of bend varies from case to case

Greater force tend to eventually cause lingual rolling and distal tilting of molars

Increase of excessive leverage the mesial marginal ridge of the molars are is seen to raise above the occlusal level

the purpose of anchor bend in upper arch is to prevent mesial migration of the molars; In lower is to supply bodily control of the lower molars as these are moved forward by action of Class II elastics

The anchorage bend,formerly called the tip back bend is a bend whoseThe anchorage bend,formerly called the tip back bend is a bend whose

vertex faces occlusallyvertex faces occlusally

Anchorage bend opposite to molar premolar contact point

Labial portion lying in buccal sulci

The degree of anchor bend is influenced by the The degree of anchor bend is influenced by the

following factorsfollowing factors

The stage of treatment-The stage of treatment- the anchor bend is usually greater the anchor bend is usually greater intheinthe

first stage than for second stage and little if any for the third first stage than for second stage and little if any for the third

stagestage

The depth of overbite-The depth of overbite- the degree of anchor bend in the initial the degree of anchor bend in the initial

archwire should be such that the archwire lies passively archwire should be such that the archwire lies passively

at the mucobuccal fold when the wire is inserted into the at the mucobuccal fold when the wire is inserted into the buccalbuccal

tubestubes

The location of extraction space-The location of extraction space- greater for 2 greater for 2ndnd bicuspid than bicuspid than

for first bicuspidfor first bicuspid

Inclination of the anchor molar-Inclination of the anchor molar- if one or both the molars are if one or both the molars are

inclined then the anchor bend should be reduced so that theinclined then the anchor bend should be reduced so that the

wire will rest evenly and passively in the mucobuccal foldwire will rest evenly and passively in the mucobuccal fold

The hazard of occlusal impingementThe hazard of occlusal impingement

The type of archwire used –The type of archwire used –in looped archwire it is placed far in looped archwire it is placed far enough forward so that ythe bend does not slide back into enough forward so that ythe bend does not slide back into the buccal tube before the looped archwire is discardedthe buccal tube before the looped archwire is discarded

Bayonet bends:

Commonly used passively to retain overrotation brought about via previously looped arch.

It is inadvisable to use bayonet bends for active correction, because of the tendency for round archwire to rotate within bracket slots causing the bayonet bend to become ineffective or supply movement in wrong plane

They should be small and offset section is 5 degrees to the line of main arch.

Use of Lock pins and ligation on arch wires:

The pins used in the opening stages of treatment should be super safety lock design and safety lock pin in the second stage. which will automatically obviate friction between pinhead and archwire.

In the StageI of treatment of ClassII all the teeth are pinned except

The second premolars

Teeth initially so far displaced

Upper laterals which are lingual to centrals

Rotated Buccal teeth.

CANINE TIECANINE TIE

They are steel ligature ties (0.008-0.009 inch) from the inter maxillary hook to They are steel ligature ties (0.008-0.009 inch) from the inter maxillary hook to

the canine bracketthe canine bracket

If there are no restraints between the intermaxillary hook and the cuspid If there are no restraints between the intermaxillary hook and the cuspid

bracket the cuspid will continue to tip distally away from the lateral.In order tobracket the cuspid will continue to tip distally away from the lateral.In order to

prevent this and to maintain and move the six anterior teeth as a unit the prevent this and to maintain and move the six anterior teeth as a unit the canine canine

ties are giventies are given

Improper method of engaging canine tieImproper method of engaging canine tie

ELASTICSELASTICS

Elastics are used to effect changes in the length,depth and Elastics are used to effect changes in the length,depth and

breadth of the dental archesbreadth of the dental arches

All anteroposterior tooth movements, including anterior All anteroposterior tooth movements, including anterior

retraction ,mesial molar movements,correction of class II or retraction ,mesial molar movements,correction of class II or

class III occlusion and closure of spaces are entirely due to class III occlusion and closure of spaces are entirely due to

elasticselastics

In extraction cases,the class II,horizontal,vertical and crossbite In extraction cases,the class II,horizontal,vertical and crossbite

elastics average 2-4 ounces (57-113 ) gmelastics average 2-4 ounces (57-113 ) gm

In non extraction cases the class II and horizontal elastics average 1 ½ -2 ½ In non extraction cases the class II and horizontal elastics average 1 ½ -2 ½

ounces (42-71) gramsounces (42-71) grams

Larger diameter elastics exert lighter force and smaller diameter exert heavierLarger diameter elastics exert lighter force and smaller diameter exert heavier

forceforce

Reactivation cycleReactivation cycleThe natural rubber Begg elastics used in the early 1960’s exerted 5-8 ounces The natural rubber Begg elastics used in the early 1960’s exerted 5-8 ounces

(142-227) gms and the elastic force was reactvated in four day cycle.(142-227) gms and the elastic force was reactvated in four day cycle.

Currently, latex elastics are preferred that exert much lower force initially but Currently, latex elastics are preferred that exert much lower force initially but

show less drop off over a 24 hour spanshow less drop off over a 24 hour span

Placement of Elastics:

It is impossible for the arch wire to function properly without the proper elastics.

In order to determine the size of the elastics the tension gauge is used.

The Class II elastics are engaged around the distal ends of the molar tubes or molar hooks and stretched anteriorly to engage the maxillary Intermaxillary hook mesial to the maxillary cuspid.

In Class III elastics are worn from the maxillary molars to the intermaxillary hook mesial to the mandibular cuspid bracket.

No horizontal (intramaxillary) elastics are applied during stage I

Class II elastics pulling 2 to 3 ounce at the beginning

Class III elastics

Horizontal (intramaxillay) elastic

Check list for stage I:

Check for desired movementsOverbite and over jet improvement

Anterior alignment progressingDental arch width particularly the molar width

Dental arch form being maintained Antero - posterior relation of cuspids and molars being maintained Individual molar positions being maintained

Check for undesired movements or manifestationsFailure to wear elastics at all times

Poor hygieneVertical loops impinging on

tooth or tissues Arch wire distortioncontraction or expansion of arch width

STAGE MODELS.STAGE MODELS.THE IMPORTANCE OF STAGE MODELS AS TOLD BY DR.A ROCKE,:

1. TO CHECK THE ARCH CONTOUR AND WIDTH.

2. TO CHECK THE INCLINATION OF UPPER AND LOWER ANTERIOR TEETH.

3. SELF-DISCIPLINE TO TO COMPLETE EACH STAGE BEFORE PROCEEDING TO THE NEXT.

4. TO DETERMINE THE TEETH MOVEMENT.

5. TO GAIN INSIGHT INTO ANCHORAGE MAINTAINED IN THE TREATMENT.

6. VISUAL AID FOR PATIENTS AND PARENTS.

7. VISUAL AID FOR REFERRING DENTISTS THE POSSIBILITY OF ANTERIOR TORQUING..

Stage II: ( usually 1 to 4 months)

Maintenance of all anterior and posterior overcorrection achieved in stage I

Completion of extraction space closure1. By continuing retraction of anterior

teeth 2. Correction of premolar rotations

Completion of correction of midline discrepancies

Continued correction of Open Bite

Arch wire:

The Archwire pattern is basically that of Stage I treatment

0.016” gauge of wire is used

0.018” is used when there is frequent arch wire distortions or unilateral space closure

Anchor bend is made 1mm mesial to the molar, premolar contact point.

The pressure supplied by the anchor bends to the molars and incisors is slightly reduced from that employed during Stage I

Because Intermaxillary elastics tend to rotate molars slight toe in bends are made in the molar areas to prevent molar rotation

Intermaxillary hooks are incorporated in both archwire immediately mesial to the cuspid brackets and in contact or very near contact with them

The hooks in upper arch has to bear two elastics which is somewhat difficult for ring pattern. A ‘Z’ shaped hook makes it easier for the patient to apply two rubbers to the hook

The 2nd premolar is bypassed from pinning as in Stage I, The wire is held in position by bypass clamp or steel ligature

The bypass clamp in position of the bracket in premolar

Slight horizontal offsets are formed distal to canines to maintain correct buccolingual position of the premolars and canines-they are the premolar offsets

TOE IN AND TOE OUT BENDSTOE IN AND TOE OUT BENDS

they are horizontal offset bends that are often combined withthey are horizontal offset bends that are often combined with

the anchor bendsthe anchor bends

If the wire is bent lingually it is a toe in bend and if it is bent If the wire is bent lingually it is a toe in bend and if it is bent

buccally it is a toe out bendbuccally it is a toe out bend

FunctionsFunctions

Corrective- for rotation of molars when required.After Corrective- for rotation of molars when required.After insertion,the toe-in or toe-out bend exerts light force so insertion,the toe-in or toe-out bend exerts light force so that the molar tends to rotate and the wire and the tube that the molar tends to rotate and the wire and the tube gradually become parallelgradually become parallel

Preventive- preventing the rotation of molars due to elastic Preventive- preventing the rotation of molars due to elastic forceforce

Passive- to prevent the rotation of anchor molars already in Passive- to prevent the rotation of anchor molars already in normal alignmentnormal alignment

Inter & Intramaxillary elastics:

Lateral Cephalogram is taken and from cephalometric evaluation it is determined whether the anteriors are to be retracted or posteriors are moved for closure of space.

The Space – closing elastic ( esp. the maxillary) stretching from the Intermaxillary hook to the molar hook against molar lies against the gingiva and irritates the gingiva, to overcome this elastic is twisted one half turn when it is placed

Wearing of horizontal elastics try to rotate the molars distobuccaly and this should be counteracted by the toe – in bends of the arch wire. If rotation aggravates after giving toe in bends the elastics can be engaged on the lingual hooks. Care should be taken of the second premolar so it doesn’t tip when elastic crosses it occlusally.

Correction of Midline discrepancy:

Midline must be determined by reference to the center of face, whether the discrepancy is confined to one arch or in both

If one arch is involved shifts more than 2mm is major; less than 2mm is a minor problem.

The application of intramaxillary elastic will complete closure on the side to which midline is shifted; The intramaxillary elastic on the side which closes first can be discontinued

Minor discrepancies are self correcting

Diagonal elastics for correction of midline in both the arches

Correction by movement of individual units or small group after distal tipping of canine

Auxiliaries in stage II:

The auxiliaries used are passive mesio distal root uprighting springs on the mandibular canines and the lower anterior braking arches.

The function of of these types of auxiliaries is to establish two point contact between teeth and archwire and prevent free tipping movement of the anteriors.

Lower braking auxiliary on the four Anteriors

All extraction spaces are closedAll extraction spaces are closed The crowns of the upper and lower anterirs are tipped back The crowns of the upper and lower anterirs are tipped back

further than the first stagefurther than the first stage The anteroposterior occlusal relations attained in the first The anteroposterior occlusal relations attained in the first

stage are maintainedstage are maintained The overcorrections of rotations done in the first stage are The overcorrections of rotations done in the first stage are

maintainedmaintained

Changes observed at the end of stage IIChanges observed at the end of stage II

Check list for stage II:

Check the teeth and appliances berfore treatment progress for Loosened bands

Loosened bracketsPatient co-operation in

elastic wearing

Compare the positions of the teeth on the second stage model with those in mouth

Check for desired movements

Check for undesired movements or manifestations such as

Failure to wear elastics at all times

Poor oral hygiene

Arch wire projecting out and causing impingement,Contraction or expansion of the arch

Asymmetry of dental arch

Molars rotating mesiolingually due to use of single elastic on the buccal

Anterior class III relation developing

Excessive anterior open bite

Anchorage bend coming into close proximity

References:

The Begg orthodontic theory and technique – Kesling 3rd edition

Begg appliance and technique – Fletcher

Current orthodontic concepts and technique – Graber and Swain

AJO 1975 may volume 67 – George R Cadman

AJO 1973 Jan volume 63 – Doyle W Baldbridge

AJO 1963 oct volume 49 – George V Newman