CLINICIAN’S 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)

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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 tooth’s 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-

ment protocol, it can decrease treatment time and improve final results.
STEP 1: INITIAL BRACKET POSITIONING

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

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 tooth’s 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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the goal is to completely express the bracket’s prescription and position through complete leveling and aligning. Finally. in such a way that they can establish proper gingival and incisal edge relationships (Fig 7). Ideal rotational bracket positioning for mandibular posterior teeth as viewed from the occlusal. If the root is well aligned on the initial radiograph. determine the desired slot angulation of each bracket by evaluating the position of the roots. The canine and adjacent premolar brackets should be positioned equidistant from the cusp tip. Do not use fractured or worn incisal edges as guides for bracket positioning. Upper incisor brackets should be positioned After initial bracket placement. Fig 5.15 Position the lower incisor brackets at equal distances from the incisal edges and slightly more incisally than the neighboring canines (Fig 8). Fig 2. If the root alignment needs correction. Excess adhesive under mesial of left bracket will lead to undesired rotation. or with the canine cusp tip just slightly further from the bracket slot. incorporate the needed adjustment into the slot angulation during initial bracket placement (Fig 10). Number 1 Carlson and Johnson 77 Fig 1.American Journal of Orthodontics and Dentofacial Orthopedics Volume 119. Ideal rotational bracket positioning for maxillary incisors as viewed from the occlusal. Fig 4. Use periapical radiographs as a guide during initial bracket placement (Fig 9). Ideal rotational bracket positioning for maxillary posterior teeth as viewed from the occlusal. Fig 3. For example. Ideal rotational bracket positioning for mandibular incisors and canines as viewed from the occlusal angle. . be sure that the slot angulation is neutral. STEP 2: PRIMARY EXPRESSION OF BRACKET PRESCRIPTION AND POSITION brackets.

are most efficiently corrected at the reset appointment after the reset evaluation. finishing with a full-sized wire. In theory. Periapical radiograph of maxillary posterior teeth. Ideal vertical positions of mandibular anterior brackets. Minor bracketpositioning errors. The resulting tooth-to-tooth relationships should be ideal without wire adjustments. This reduces the need to drop down in wire size at the reset appointment. Completely seat a full-sized wire in each bracket slot before moving on to the reset evaluation.018 × . We do not encounter this situation often. Fig 10. If.016-in nickel-titanium). Fig 7. but the lesson it provides is an important one—filling the bracket slot provides complete expression of bracket prescription and position. on the other hand. consider a patient who has a set of perfectly positioned brackets with a bracket prescription that is ideal for the shape of the teeth. We recommend a . A smaller wire will only partially express the bracket prescription and position.014 or . Fig 8.78 Carlson and Johnson American Journal of Orthodontics and Dentofacial Orthopedics January 2001 Fig 6. NY) for a 0. Fig 9. Note mesial root inclination of second premolar. Incisor brackets positioned slightly more incisally than canines. Marginal ridges equidistant from wire slot. Allow sufficient time for .018-in Sentalloy wire (GAC International. Ideal vertical positions of maxillary anterior brackets. Tip adjustment in bracket positioning for second premolar with mesial root inclination. reset the bracket while still in the light initial wire (. Islandia. you find a severe bracket-positioning error. Note differences in incisal edges and gingival margins. during the initial alignment stage.018 slot appliance. Ideal vertical positions of posterior brackets. treatment would require only that the orthodontist level the bracket slots.

“I” for intrude and “X” for extrude indicate the necessary vertical adjustments. Root-paralleling radiographic series. This might be a bracket that was not fully seated or a band with a distorted margin. For most patients. Note the mesial root inclination of the mandibular left first premolar and maxillary left lateral incisor. An “MO” or “DO” indicates a rotational deficiency. paying close attention to base adaptation. We note the deficiencies in each category in a specially designated area on the patient’s chart (Fig 12). marginal ridge height discrepancies. Our recommended abbreviations are as follows: a check mark indicates poor adaptation of the bracket base to the tooth. this wire to completely express the bracket prescription and position (4-8 weeks). Perform the clinical examination at the appointment before the reset appointment and prescribe a root-paralleling radiographic series (Fig 11).American Journal of Orthodontics and Dentofacial Orthopedics Volume 119. Abbreviations for each tooth specify necessary reset instructions. and “DO” indicates that the distal needs to be rotated out. crown rotations. and nonparallel roots. . Finally. the reset evaluation can take place within the first 6 months of active treatment. Fig 12. STEP 3: RESET EVALUATION The reset evaluation involves both a clinical examination and a radiographic evaluation. Use abbreviations to specify the necessary reset instructions for each bracket. Number 1 Carlson and Johnson 79 Fig 11. An “MO” indicates that the mesial of that tooth needs to be rotated out toward the labial. a “D” indicates that the root apex needs to be moved distally and an “M” indicates that the apex needs to be moved mesially. Bracket-positioning errors noted in a designated area of the patient’s chart. Examine each tooth individually for bracketpositioning errors.

Swain BF. 15. After cementation and bonding. Indirect bonding of orthodontic attachments.72:261-75. fully engage the same . Remove the brackets and bands from teeth with positioning errors. 2. 5. Secondary expression is usually complete within 6 to 8 weeks. the tooth-to-tooth relationships have greatly improved. By the reset appointment. Salama MA. Gianelley AA. By implementing this protocol.22:509-11. Hickham JH. Refitting the band is particularly important for rotational resets because initial band fitting and burnishing creates a “rotational memory” in the band’s metal. 13. 4. J Clin Orthod 1978. 9.11:18-28 After the reset appointment.116:346-51. Periodontol 2000 1996. essence of the science. Also. Garber DA. making it much easier to assess the relative positions of brackets between neighboring teeth. an adjustable wire can be inserted for finishing. Moin K. Use a lighter wire if the positional change of 1 or more brackets was severe. STEP 5: SECONDARY EXPRESSION AND FINISHING We have presented a protocol that addresses errors of initial bracket positioning and facilitates consistent crown and root alignment. Bowman N. visibility of each tooth’s facial surface is greatly improved. J Clin Orthod 1993.12:300-2.30:277-81. Waldron JM. Koo BC. Timmins H.82:269-76. The amount of time depends on the severity of the original positioning errors. Esmay T. King JG.018 × . the clinician can expect decreased treatment times and superior results. 1986. Sheridan JJ. Sandrik J. Clinical comparison of direct versus indirect bonding with different bracket types and adhesives. and rebanding. Indirect bonding with a diagnostic setup. St Louis: CV Mosby. Variations in bracket placement in the preadjusted orthodontics appliance. Am J Orthod 1978. Am J Orthod 1972. Indirect bonding: simplicity in action. Vanarsdale RL.13:93-105. This memory can be removed by reshaping the band with bird-beak pliers before refitting. We have found that although repositioning does not completely eliminate the need for wire bends during finishing. Shen A. J Clin Orthod 1996. fully express the new bracket positions by applying the same principles used in step 2. Brobakken BO. 14. J Clin Orthod 1988. Tovilo K. Am J Orthod 1977. Dogon IL. tooth preparation. 3. Clean each tooth of excess composite or cement. Zachrisson BU. Klapper L. Simmons M.74:62-78. Reposition the bands and brackets according to the principles described in step 1. it does significantly reduce their number and complexity. p. Cohen M. The aesthetic smile: diagnosis and treatment. 279-98.102:62-7. Am J Orthod Dentofacial Orthop 1992. 7. Am J Orthod 1982.018-in Sentalloy wire (GAC International) that was used for primary expression of bracket prescription and position. After secondary expression. rebonding. Chung C-H. Hoffman BD. Knight LD. J Clin Orthod 1979. Creekmore TD.80 Carlson and Johnson 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. Am J Orthod Dentofacial Orthop 1999. Treatment can be completed with your choice of finishing procedures. Use the root-paralleling radiographs at chairside to determine the amount of tip correction. Am J Orthod Dentofacial Orthop 1993. 8. Moskowitz EM. Refit each band before cementation. . Thomas R.111:652-6. Assessment of bracket placement and bond strength when comparing direct bonding to indirect bonding techniques. Aguirre MJ. In: Orthodontics: state of the art. Silverman E. bracket preparation.27:215-17.62:236-44. 6. A universal direct bonding system for both metal and plastic brackets. Schedule the reset appointment with adequate time for debonding. Dietz VS. 10. This protocol can be adapted to fit numerous treatment philosophies and can be applied to an appliance of any slot size.104:8-20. debanding. Kunik RL. Predictable indirect bonding. Kasrovi PM. It is easier to position brackets at the reset appointment than it is at the initial bonding. Straight wire design strategies: five-year evaluation of the Roth modification of the Andrews straight wire appliance. A new look at indirect bonding. 12. REFERENCES 1. We recommend at least an hour for this appointment. Improved laboratory procedure for indirect bonding of attachments. Am J Orthod Dentofacial Orthop 1997. Balnut N. At this stage the orthodontist can be confident that root alignment has been achieved and no further adjustments for root tip will be needed. Remove excess composite or cement from the bands and brackets by using a micro-etcher. A new approach to indirect bonding using light-cure composites. Straight wire: the next generation. Comparison of the accuracy of bracket placement between direct and indirect bonding techniques. 11.

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