CLINICIANS CORNER

Bracket positioning and resets: Five steps to

align crowns and roots consistently
Sean K. Carlson, DMD, MS,a and Earl Johnson, DDSb
Mill Valley, Calif
Orthodontists strive for accurate bracket positioning because it makes achieving a superior occlusion easier.
Whether one uses a direct or an indirect bonding technique, the initial appliance placement typically includes
some bracket-positioning errors. The clinician either corrects these errors during treatment or tediously
repeats archwire bends to compensate for the misplaced brackets. The clinician should assess bracket
positioning early in treatment by clinical and radiographic evaluations and then correct all positioning errors
during a single dedicated reset appointment. This article describes a 5-step protocol for assessing and
correcting bracket-positioning errors. (Am J Orthod Dentofacial Orthop 2001;119:76-80)

well-finished orthodontic case has the proper

alignment of crowns and roots and level marginal ridges. With preadjusted brackets
(straight-wire appliances), the position of the bracket on
the crown determines the tooths final tip, torque,
height, and rotation.1,2 Poorly positioned brackets result
in poorly positioned teeth and necessitate many more
archwire adjustments. This can lead to an increase in
treatment time or a final occlusion that is less than ideal.
Poor bracket positioning can render even the most
customized prescription ineffective. Consider the endless number of bracket prescriptions on the market.
Most differ by only a few degrees. Now, consider how
much one can change the prescription by misplacing
the bracket on the tooth.3
Orthodontists go to great lengths to ensure that each
bracket is positioned as ideally as possible. Unfortunately, even under the best of circumstances, ideal
bracket placement during initial bonding is often
impossible because of limitations brought on by the
existing malocclusion or operator error.4-6 Initial leveling often reveals bracket-positioning errors. The orthodontist should first recognize and then correct these
errors early in the treatment process so that wire adjustments can be minimized later.
The protocol below describes 5 steps for achieving
crown and root alignment. We recommended that
each step be performed on every patient undergoing
fully banded therapy. Once integrated into the treat-

aAssistant Professor of Orthodontics, University of the Pacific; and in private

practice.
bAssociate Clinical Professor of Orthodontics, University of California, San
Francisco; and in private practice.
Reprint requests to: Sean K. Carlson, 163 Miller Ave, Mill Valley, CA 94941.
Submitted and accepted, March 2000.
Copyright 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/111220
doi:10.1067/mod.2001.111220

76

ment protocol, it can decrease treatment time and

improve final results.
STEP 1: INITIAL BRACKET POSITIONING

Ideally positioning brackets during initial bonding

is challenging. Journal articles have described many
direct and indirect bonding techniques in an effort to
improve initial placement accuracy.7-14 Most of these
bonding techniques have in common 4 elements that
demand attention when positioning brackets: (1) base
adaptation, (2) rotational position, (3) vertical position,
and (4) slot angulation. Regardless of the bonding technique used, one should strive to optimize each bracket
placement relative to these 4 categories.
First, check to see that the contour of the bracket
base follows the contour of the tooths surface. The
bracket base may need to be modified to fit some teeth
either by flattening the base or by increasing its concavity. An ideal base contour helps to ensure an even
flow of adhesive during bracket seating. However,
even when the contour of the bracket base is ideal,
incomplete bracket seating can lead to unwanted rotations (Fig 1).
Second, evaluate the rotational position of each
bracket from the occlusal (Figs 2-5). Center the bracket
mesiodistally for incisors and in line with the labial
cusp tips for canines and premolars. Center the bracket
in the buccal groove for molars.
Third, determine the vertical position of each bracket
by using well-fitted molar bands as benchmarks for the
vertical position of the rest of the appliance. Position all
the posterior brackets so the distance from the archwire
slot to the marginal ridge is equal for all neighboring
teeth (Fig 6). This will result in even marginal ridges
when a straight wire is used. The distances from the slots
to the cusp tips may vary. The anterior brackets should
be positioned on the basis of the heights of the posterior

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Carlson and Johnson 77

Fig 1. Excess adhesive under mesial of left bracket will

lead to undesired rotation.

Fig 4. Ideal rotational bracket positioning for maxillary

posterior teeth as viewed from the occlusal.

Fig 2. Ideal rotational bracket positioning for maxillary

incisors as viewed from the occlusal.

Fig 5. Ideal rotational bracket positioning for mandibular

posterior teeth as viewed from the occlusal.

Fig 3. Ideal rotational bracket positioning for mandibular

incisors and canines as viewed from the occlusal angle.

in such a way that they can establish proper gingival and

incisal edge relationships (Fig 7).15 Position the lower
incisor brackets at equal distances from the incisal edges
and slightly more incisally than the neighboring canines
(Fig 8). Do not use fractured or worn incisal edges as
guides for bracket positioning.
Finally, determine the desired slot angulation of
each bracket by evaluating the position of the roots.
Use periapical radiographs as a guide during initial
bracket placement (Fig 9). If the root is well aligned on
the initial radiograph, be sure that the slot angulation is
neutral. If the root alignment needs correction, incorporate the needed adjustment into the slot angulation
during initial bracket placement (Fig 10).

brackets. The canine and adjacent premolar brackets

should be positioned equidistant from the cusp tip, or
with the canine cusp tip just slightly further from the
bracket slot. Upper incisor brackets should be positioned

STEP 2: PRIMARY EXPRESSION OF BRACKET

PRESCRIPTION AND POSITION

After initial bracket placement, the goal is to completely express the brackets prescription and position
through complete leveling and aligning. For example,

78 Carlson and Johnson

American Journal of Orthodontics and Dentofacial Orthopedics

January 2001

Fig 6. Ideal vertical positions of posterior brackets. Marginal ridges equidistant from wire slot.

Fig 9. Periapical radiograph of maxillary posterior teeth.

Note mesial root inclination of second premolar.

Fig 7. Ideal vertical positions of maxillary anterior brackets.

Note differences in incisal edges and gingival margins.

Fig 10. Tip adjustment in bracket positioning for second

premolar with mesial root inclination.

Fig 8. Ideal vertical positions of mandibular anterior

brackets. Incisor brackets positioned slightly more
incisally than canines.

consider a patient who has a set of perfectly positioned

brackets with a bracket prescription that is ideal for the
shape of the teeth. In theory, treatment would require

only that the orthodontist level the bracket slots, finishing with a full-sized wire. The resulting tooth-to-tooth
relationships should be ideal without wire adjustments.
We do not encounter this situation often, but the lesson
it provides is an important onefilling the bracket slot
provides complete expression of bracket prescription
and position.
If, during the initial alignment stage, you find a
severe bracket-positioning error, reset the bracket
while still in the light initial wire (.014 or .016-in
nickel-titanium). This reduces the need to drop down
in wire size at the reset appointment. Minor bracketpositioning errors, on the other hand, are most efficiently corrected at the reset appointment after the
reset evaluation.
Completely seat a full-sized wire in each bracket
slot before moving on to the reset evaluation. A
smaller wire will only partially express the bracket
prescription and position. We recommend a .018
.018-in Sentalloy wire (GAC International, Islandia,
NY) for a 0.018 slot appliance. Allow sufficient time for

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Carlson and Johnson 79

Fig 11. Root-paralleling radiographic series. Note the mesial root inclination of the mandibular left
first premolar and maxillary left lateral incisor.

Fig 12. Bracket-positioning errors noted in a designated area of the patients chart. Abbreviations for
each tooth specify necessary reset instructions.

this wire to completely express the bracket prescription and position (4-8 weeks).
STEP 3: RESET EVALUATION

The reset evaluation involves both a clinical examination and a radiographic evaluation. For most
patients, the reset evaluation can take place within the
first 6 months of active treatment. Perform the clinical
examination at the appointment before the reset
appointment and prescribe a root-paralleling radiographic series (Fig 11).
Examine each tooth individually for bracketpositioning errors, paying close attention to base adaptation, marginal ridge height discrepancies, crown rotations, and nonparallel roots. We note the deficiencies in

each category in a specially designated area on the

patients chart (Fig 12).
Use abbreviations to specify the necessary reset
instructions for each bracket. Our recommended abbreviations are as follows: a check mark indicates poor
adaptation of the bracket base to the tooth. This might
be a bracket that was not fully seated or a band with a
distorted margin. An MO or DO indicates a rotational deficiency. An MO indicates that the mesial of
that tooth needs to be rotated out toward the labial, and
DO indicates that the distal needs to be rotated out.
I for intrude and X for extrude indicate the necessary vertical adjustments. Finally, a D indicates that
the root apex needs to be moved distally and an M
indicates that the apex needs to be moved mesially.

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American Journal of Orthodontics and Dentofacial Orthopedics

January 2001

STEP 4: RESET APPOINTMENT

SUMMARY

The information gathered during the reset evaluation are the instructions for the reset appointment.
Schedule the reset appointment with adequate time for
debonding, debanding, bracket preparation, tooth
preparation, rebonding, and rebanding. We recommend
at least an hour for this appointment.
It is easier to position brackets at the reset appointment than it is at the initial bonding. By the reset
appointment, the tooth-to-tooth relationships have
greatly improved, making it much easier to assess the
relative positions of brackets between neighboring
teeth. Also, visibility of each tooths facial surface is
greatly improved.
Remove the brackets and bands from teeth with
positioning errors. Clean each tooth of excess composite or cement. Remove excess composite or cement
from the bands and brackets by using a micro-etcher.
Refit each band before cementation. Refitting the band
is particularly important for rotational resets because
initial band fitting and burnishing creates a rotational
memory in the bands metal. This memory can be
removed by reshaping the band with bird-beak pliers
before refitting. Reposition the bands and brackets
according to the principles described in step 1. Use the
root-paralleling radiographs at chairside to determine
the amount of tip correction.
After cementation and bonding, fully engage the
same .018 .018-in Sentalloy wire (GAC International) that was used for primary expression of bracket
prescription and position. Use a lighter wire if the positional change of 1 or more brackets was severe.

We have presented a protocol that addresses errors

of initial bracket positioning and facilitates consistent
crown and root alignment. By implementing this protocol, the clinician can expect decreased treatment times
and superior results. We have found that although repositioning does not completely eliminate the need for
wire bends during finishing, it does significantly reduce
their number and complexity. This protocol can be
adapted to fit numerous treatment philosophies and can
be applied to an appliance of any slot size.

STEP 5: SECONDARY EXPRESSION AND

FINISHING

After the reset appointment, fully express the new

bracket positions by applying the same principles used in
step 2. Secondary expression is usually complete within 6
to 8 weeks. The amount of time depends on the severity of
the original positioning errors. After secondary expression, an adjustable wire can be inserted for finishing.
At this stage the orthodontist can be confident that
root alignment has been achieved and no further adjustments for root tip will be needed. Treatment can be
completed with your choice of finishing procedures.

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