BONDING ORTHODONTIC BRACKETS

I. Introduction:
Palmer notation used in Orthodontics
Right

2n
d

1st
M

2nd
B

1st
B

C
u

LI

CI

CI

LI

C
u

1st
B

2nd
B

1st
M

2nd
M

Left

Upper

Upper

Tooth
#

10

11

12

13

14

15

Tooth 31
#

3
0

29

28

27

26

25

24

23

22

21

20

19

18

Lower

Lower

The bracket height chart is written in Palmer Notation (Figure 1A). This notation
numbers the teeth starting with the central incisors as 1. The laterals are then 2.
The canines are 3. The 1st and 2nd premolars are 4 and 5 respectively, the 1st molars
are 6 and the 2nd molars are 7.
Figure 1A. Bracket Heights from Cusp tip or Incisal Edge

Right

2n
d

Upper
Bracke
t
height
Occ
plane
Bracke
t

3.
5

1st
M

2n

3.
5

3.
5

1st
B

C
u

LI

CI

CI

LI

C
u

1st
B

2nd
B

1st
M

2nd
M

Left

Upper

4.
5

3.
5

3.
5

4.
5

In
mm

3.
5

3.
5

3.
5

In
mm

height
Lower

4.
5
7

4.
5
2

Lower

II. Laboratory Exercise:

Step 1: Place Columbia typodont with complete dentition on pole to simulate a
clinical situation.

Step 2: Pick up a bracket with the cotton pliers as shown in above figure. It is
advisable to begin with the maxillary central incisor, for this exercise.

Step 3: Place a small dab of white rope wax on back of bracket as shown in above
figure. The wax is being used as a substitute for the composite bonding material that
would be used for an actual patient.
Step 4: Place the bracket in center of the facial surface of the appropriate tooth and
press firmly to express the excess wax.
Step 5: Using a perio probe or a boone gauge (if your instructor has one) measure the
height of the bracket from the incisal edge of the tooth to the center of the bracket.
For example, horizontal slot of the bracket for the maxillary central incisor should be
4mm from its incisal edge.
Step 6: Idealize the bracket position mesio-distally and occluso-gingivally (refer to
appropriate figure in following pages for tooth specific instructions).

Step 7: Continue with remaining brackets until all have been placed on the
appropriate teeth. Evaluate vertical position of each bracket in relation to the incisal
edge of the tooth where it is placed, then evaluate the vertical position of each bracket
in relation to the adjacent brackets. Evaluate the mesiodistal position of each
bracket. Ask your GTA or faculty to evaluate your bracket positioning.

Bracket Positioning: General Instructions

Dimple or paint dot identifies disto-gingival

Center each bracket on the crown long-axis

Vertical slot between the bracket wings parallel to the CROWN
LONG AXIS!!!
Posterior teeth the center of the bracket slot at the height of
convexity
Bicuspids - the archwire slot is lined up parallel to a line connecting
the mesial and distal crest of convexity (proximal contact pts.). This
corresponds to the (occluso-gingival) center of a normally fully erupted clinical
crown.
There are many different systems for bracketing teeth. Recommended bracket
height will vary depending on manufacturer and system.
Mesio-distal positioning is often best viewed in a mirror similar to checking a
crown prep for parallelism.

Maxillary Teeth
Upper Central Incisors

Distance from the slot to the incisal edge = 4mm

From the occlusal, the bracket is centered mesiodistally.
The bracket position usually appears somewhat
incisal.

As a guide, approximate the incisal edge of the tooth with the base of the bracket,
perpendicular to the clinical crown long axis.

Upper Lateral Incisor

Distance from the slot to the incisal edge = 3.5mm
The incisal edges of the maxillary laterals will line up on the
same level or slightly gingival to the central incisors. This is
one-half to one millimeter shorter than the maxillary cuspid
tip.
3.
From the occlusal, the bracket is centered mesio-distally.
5
On a fully erupted lateral, the correct vertical position for
the bracket is usually slightly more incisal relative to the
center of the clinical crown
Future restorative plan for malformed laterals should be factored into bracket
placement
As a guide, approximate the incisal edge with the slot to align the archwire slot
perpendicular to the clinical crown long axis.

Upper Cuspids

4.5

Distance from cusp tip to bracket slot = 4.5 mm

The severe angulation and prominent anatomy of cuspids
(10o) can make placement difficult
From the occlusal view, the bracket is centered mesio-distally
on the prominent buccal developmental ridge. This also
corresponds to the clinical crown long axis. This will usually
be mesial to the center of the contacts
Sharp cusp tips on newly erupted canines may need to be
modified

Upper Bicuspids

Distance from cusp tip to bracket slot = 4 mm

Upper bicuspid bracket placement is the most difficult
due to individual variability in tooth morphology. Often

the brackets are not placed gingivally enough, especially on smaller sized or
partially erupted teeth, resulting in a vertical step between the 1st molar and the
2nd bicuspid.
From the occlusal view, the bracket is centered mesio-distally on the prominent
buccal developmental ridge. This also corresponds to the clinical crown long axis.
Thus, the archwire slot is lined up with the maximum convexities mesio-distally
and occlusogingivally on the crown.

Mandibular Teeth
Lower Incisors

Distance from incisal edge = 4mm

From the occlusal, the brackets are centered mesio-distally.
Position the archwire slots so that the incisal edges of the
incisors will be one half to one millimeter shorter gingivally
than the cuspid tip after initial alignment.
With the incisal edge and the base of the bracket as a
guide, align bracket wings parallel to the clinical crown long
axis and the base of the bracket perpendicular to the crown
long axis.

Lower cuspid
Distance from cusp tip = 4.5 mm
From an occlusal view, the bracket is centered mesiodistally on the prominent buccal developmental ridge.
This corresponds also to the clinical crown long axis.
Like the upper cuspid this is mesial to the center of the
contacts
The archwire slot is lined up parallel to an imaginary
line passing through the mesial and distal proximal
contact points. This bracket height will vary depending
on the size of the other teeth, and the size and shape of
the cuspid and its cusp tip.
Press firmly, checking carefully that a vertical line through the bracket wings is
parallel with the clinical crown long axis.

Lower bicuspids

Distance from cusp tip to bracket slot = 4 mm

Centered mesio-distally

Bracket slot parallels the marginal ridges and contacts

If a partially erupted 2nd bicuspid is bracketed too far occlusally the marginal
ridges will be inferior to adjacent teeth after leveling
Direct vision of the facial surface is important to properly positioning the bracket
relative to the marginal ridges

Positioning Errors
The most important factor in aligning teeth using contemporary orthodontic
techniques is precise bracket positioning. Proper bracket position is critical if our
treatment objectives are to be achieved with the preadjusted bracket (straight wire
appliance).
Correct initial placement of the preadjusted brackets should minimize iatrogenic
complications. The correction of bracket placement errors tends to be extrusive.
Since orthodontic extrusion of teeth is the easiest movement, one can assume that
the lowest bracket (tooth ) will come up to the level of the highest adjacent bracket.
Each subsequent re-bracketing may tend to raise the entire occlusal plane.

III. Clinical Procedure

A. Band Positioning: General Instructions
Maxillary first molar bands
A)

POSITION

B)

ADAPTING BAND AFTER SEATING

a) Select a size by using the diagnostic model

b) If the initial band is not the right size then choose a
band 3 sizes larger or smaller and then work toward the
correct size
c) Seat the distal of the band first, firmly using a band
seater or bite stick to utilize biting force.
d) Seat the band in the patient's mouth until the archwire
slot is located in the middle of the clinical crown
occluso-gingivally
e) Excessive seating of the band will cause extrusion
f) A small band insufficiently seated will position the buccal tube too far occlusally
g) Uneven seating on the buccal relative to the lingual will lead to torque
errors, height of the cusps above the band should be equivalent
h) Uneven seating on the mesial relative to the distal will lead to tip errors, the
band should fit just below the marginal ridges
i) From the occlusal view, the entrance of the mesial of the buccal tube should
line up with the mesio-buccal cusp tip. As the band is seated, the slot is to
be horizontal and level in relation to the crown. Mesial and distal marginal
ridges indicate height and level.

a) Once the appropriate band size has been selected, adapt the metal margins
of the band with a plugger or Hauk file.
b) Both right and left bands should be checked to make sure they are in the
same vertical position on the crowns.

Mandibular first molar bands

A)

POSITION

ridges.

B)

a) From the occlusal, the mesial of the buccal tube

lines up with the mesio-buccal cusp tip.
b) Seat the lingual first with most of the seating
done on the buccal and the mesio-buccal.
c) Seat until the archwire slot is located in the
middle of the clinical crown occluso-gingivally.
d) The slot is approximately horizontal and level in
relation to the crown. The buccal cusps can
be used as a guide as well as the marginal

ADAPTATION
Adapt well with a band pusher, especially between the distal and the distobuccal cusps. Bend over any excess band material above the occlusal and
marginal ridges and trim excess away with a stone. A fully seated band should
fit just below the marginal ridges with no excess to trim off.

B. Direct Bonding:

Bonding of Brackets Directly on the Facial Surface of

the Teeth

Direct bonding technique can yield

good bracket placement with
minimum chair time and no
laboratory time.
1. All of the teeth are cleaned using
a prophy angle with a mixture of fine
flour of pumice and water.
2. The teeth are then isolated with a
cheek retractor and good saliva
evacuation is performed. The teeth
are washed and dried with air water
spray. Maintain a dry field and keep
the tongue out of the way.
3. To prepare the teeth for bonding, the
facial surface of each tooth is etched with
phosphoric acid for 30 seconds. Wash and
dry all teeth thoroughly as for restorative
procedures.
4. The teeth are desicated to expose
a chalky or frosted appearance,
indicating an adequate etch has been
achieved.
5. The facial surface of each tooth is sealed with an unfilled resin (or sealant) and
light cured for 5 10 seconds.
6. It is advisable to begin bonding in the mandibular arch, as it is the most susceptible to saliva
contamination. Bonding material is mixed (if
necessary) and applied to each individual
bracket by the assistant
7. Cotton pliers or special bracket placing instruments are used to transfer the
bracket from the bracket set up to the tooth. The doctor places the bracket carefully
using firm pressure to express excess material, removes the excess material and
idealizes mesio-distal and inciso-gingival bracket placement.
8. The recommended sequence is: lower left and then right bicuspids, cuspids and
incisors, working from side to side to insure that the heights are even on both sides of
the mouth. Then the upper bicuspids, cuspids and finally the incisors again working
from side to side (e.g. left second bicuspid, right second bicuspid, left first bicuspid,
right first bicuspid and so on).

Bracket adjustment is done with an

instrument that will fit into the archwire slot
of the bracket and allow manipulation of the
bracket.

IV. Supplemental information on the direct bonding

technique
Introduction:
In 1955 Buonocore wrote a paper entitled, A Simple Method of Increasing the
Adhesion of Acrylic filling Materials to Enamel Surfaces. He is quoted as saying, " In
an attempt to obtain bonding between filling material and tooth structure, the
alteration of the tooth surface by chemical treatment to produce a new surface to
which acrylic filling material might adhere must be explored." This very statement
laid the foundation for contemporary bonding techniques. Interestingly enough, this
concept was borrowed from the use of preparations containing phosphoric acid in
industry to prepare metal surfaces for better adhesion of paint and resin coatings.
Buonocore researched the preceding technique by using phosphoric acid ( 85%! ) to
etch the surface to help acrylic adhere to human teeth for considerable lengths of
time ( avg. 1070 hrs.). His study brought to light these important factors concerning
etched tooth enamel:
a) the acid etching action creates a tremendous increase in surface area
available for bonding
b) the exposure of the organic framework of the enamel serves as a network,
in and about which the acrylic can adhere
c) old fully reacted and inert enamel surface is removed
d) a fresh, reactive surface more favorable for adhesion is exposed.
However, his clinical methods and observations did not take into account the importance of
removing the accumulated organic plaque on the surfaces of the teeth before etching.
Theoretical Considerations:
With the advent of better materials (i.e. orthodontic brackets, isolation devices,
bonding systems etc.), the contemporary techniques of orthodontic bonding have
greatly improved. Certain principles must be clearly understood regardless of the
new materials and techniques.
1)

Prophylaxis:
A thorough prophylaxis with wet pumice or oil-free
and non-fluoridated prophy paste of the tooth surface
to be bonded is imperative. Plaque removal from the
enamel surface increases the wettability of the surface
(Figure 1). The greater the wettability the greater the

tendency for a fluid to spread over the enamel surface and the lesser the
tendency for a fluid to bead on the surface. Care is taken not to agitate gingival
tissue during the cleaning procedure to prevent bleeding on the enamel surface
to be bonded. After cleaning the enamel surface it is thoroughly rinsed with
water (Figure 2), isolated if needed, and dried (moisture and oil free air). The
success of the next phase of orthodontic bonding technique is totally
dependent on proper prophylaxis to increase the wettability of the surface.

2)

Etching:
After prophylaxis the tooth surfaces are ready for etching. The principle of
etching is to simply remove microscopic amounts of enamel leaving porosities.
This creates an increase in surface area and an architecture favorable for
microretention. There are two types of etching media, liquid and gel. Liquid is
applied by saturating a small sponge pellet with acid and carrying it to the
enamel surface (Figure 3). The time for the etching solution (35% to 65%
phosphoric acid) to remain on the enamel, is approximately 30 seconds.
Etching gel is applied to the tooth with a syringe and remains on the surface
for 20 30 seconds. The surface is rinsed with water for approximately one
minute and thoroughly dried. The final etched surface will have a white chalky
appearance (Figure 4). Etching should be done carefully (avoid contact with
the gingiva and oral mucosa) and in accordance with the manufacturer's
instructions. This step is one of the most critical factors in successful bonding.
Improper etching and moisture control are probably the major causes of failure
in bonding.
There are a few precautions to consider during etching. Rubbing the etchant
on the surface of the enamel must be avoided since pressure will break newly
exposed enamel rods. The liquid etchant solution should be replenished every
10 to 15 seconds to avoid partial evaporation and a more viscous solution, this
is not required with the gel. Salivary contamination of the newly etched
enamel will greatly reduce the eventual bond strength. Isolation and
maintenance of a dry uncontaminated field is critical. Operator induced
complications include oil and water contamination from the air hose to the air
syringe. Check the air hose tubing routinely by blowing air on a gauze pad or
paper tissue which will reveal oil and water particles. Minimizing the
previously mentioned complications, is the KEY to successful orthodontic
bonding.

3)

Use of adhesives:
The bonding adhesives used to adhere orthodontic bracket to enamel have
improved tremendously over the years. During the middle 1970's different
brands of bonding adhesives strong enough for routine clinical use became
commercially available to the orthodontist. Clinical research led to
contemporary bonding adhesives that exhibit these qualities:
a) a coefficient of expansion relative to enamel with minimal water
absorption
b) development of full adhesive strength in a relatively short period of
time so arch wire placement can be accomplished in the same visit

c) long enough working time to allow the orthodontist to properly

position the bracket
d) no toxic effects
e) stain resistant
It is important to prevent the bonding system (i.e. etching solution, sealants, and pastes) from
touching the marginal gingiva during application to the tooth surface. The etchant may
chemically burn the gingiva and cured adhesive near the gingiva will encourage plaque
accumulation. Running an explorer along the gingiva after bonding will detect the thin
transparent sealant that tends to form there.
The bonding systems for placement of orthodontic brackets, are of two types:
chemical cure or light cure. The chemical cure can be either; a) one step (no
mix) or b) two steps. The one step involves no mixing of the bonding
adhesives. The polymerization catalyst (liquid) is painted on the back (mesh)
side of the bracket pad and the etched enamel surface. The bonding adhesive
or paste is placed on the back (mesh) side of the bracket pad in an
unpolymerized form. When the bracket is placed on the tooth surface; the
paste polymerizes. The unpolymerized paste around the margins can be easily
cleaned away. The two step system is the most common and consists of
polymers and catalysts. It usually requires the mixing of a sealant and paste to
accomplish adherence of the bracket to the tooth. The sealant is mixed (two
liquids) and applied to the etched enamel surface to prevent microleakage and
to wet the surface. (Figure 5). The paste is mixed (usually two components)
vigorously for approximately 20 seconds and applied to the back of the bracket
pad (Figure 6). The bracket is placed in the proper position on the prepared
tooth (Figure 7). Once the paste on the mixing pad begins to polymerize, do
not move or reposition the bracket. At that moment, start a new mix for the
next bracket placement. Arch wires can usually be inserted approximately five
minutes after the placement of the final bracket. The light cure adhesive is
placed similar to restorative composites. The etched surface is coated with a
light cured sealant. Then the adhesive is dispensed directly on to the bracket
base and pressed to place. After positioning the bracket is tacked into place
with a quick 5-second cure that prevents drifting while the other brackets are
placed. After all brackets are positioned the full cure of 40 seconds is applied
to each tooth. The advantage of the light cure system is nearly unlimited
positioning time

References:

Buonocore, M. A simple method of increasing the adhesion of acrylic filling materials

to enamel surfaces. J. Dent. Res. 34: 849, 1955
Sheykholeslam, Z. and Brandt, S. Some factors affecting the bonding of orthodontic
attachments to tooth surfaces. J. Clin. Orthod. 11: 734, 1977
Brandt, S. Servoss, J. and Wolfson, J. Practical methods of bonding direct and
indirect. J. Clin. Orthod. 9: 610, 1975
Profitt, W. Contemporary Orthodontics, The C.V. Mosby Company, 1986