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ORTHODONTIC BRACKETS
SELECTION, PLACEMENT AND DEBONDING

Dr. Haris Khan

B.D.S., F.C.P.S,F.F.D RCSI
Assistant Professor Orthodontics
The University Of Lahore
Pakistan
COPYRIGHT

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form
or by any means, including photocopying, recording, or other electronic or mechanical methods, without
the prior written permission of the publisher, except in the case of brief quotations embodied in critical
reviews and certain other noncommercial uses permitted by copyright law. For permission requests, write
to the publisher, or contact at drhariskhan@gmail.com

PUBLICATION DATA

ISBN-13: 978-1508936275
ISBN-10: 1508936277

Library of Congress Control Number: 2015905934

CreateSpace Independent Publishing Platform, North Charleston, SC

DEDICATION

This book is dedicated to my supervisors Dr. M. Waheed ul Hamid and Dr. Irfan ul Haq

ACKNOWLEDGEMENT
I highly acknowledge the efforts and inspiration made by Dr. Ateeq ul Reham to write this book. I am
thankful to Dr. Fayyaz Ahmad and Dr. Munawer Manzoor for providing me the technical guidance on
various aspects of brackets. I am also thankful to Dr. Erum Bashir for doing the proofreading, Dr. lubna
batool for provided used brackets from her clinical practice and Mr Jahanzeb for doing the composing
of this book.

CONTRIBUTOR, EDITOR AND AUTHOR

Dr. Haris Khan

B.D.S , F.C.P.S,F.F.D RCSI
Assistant Professor Orthodontics
UOL, Pakistan
 PREFACE
In this era of pre-adjusted brackets, the existing literature on orthodontics limits itself
to wire bending treatment practices. Since contemporary authors were not trained on the
pre-adjusted bracket mechanics, hence they were handicapped to broach on the subject at
the relevant point in time. In present day orthodontics, many orthodontists still resort to wire
bending methods to close extraction spaces or to correct three dimensional positions of the
teeth.

Chapters on orthodontic brackets in various books either focus on theoretical

perspective or are devoid of essential correlation of brackets,vis-a-vis their intended clinical
use. Some authors have depicted fancy graphics to demonstrate clinical use of brackets.

To address such obvious lacunae, I started working on orthodontic brackets in the

year 2012 by collecting the brackets which were debonded during my clinical practice.This
took me through the entire literature on orthodontic brackets as presented in various journals
and manufacturer catalogues. This provided me an access to real time pictures of brackets
using special micro lenses and portable microscopes.

This book was authored to cater for all aspects of orthodontic brackets. The focus
being to provide students with real time pictures of different brackets available in the market
and to determine their behaviour in oral cavity and their appearance after debonding. The
main emphasis being on three vital aspects viz; the selection, placement and debonding,this
book has accordingly been designed to comprise these three sections. Real times of new and
used brackets have been specifically included to provide the students a realistic insight of
brackets.Care has been taken to ensure correlation of clinical situation and various bracket
selection criterions.

This book has materialized after an enormous effort of two years in data collection
and a year further in arranging the data in a convenient book form.

I deeply acknowledge the help and encouragement provided my colleagues in

consummating this endeavor.

I earnestly hope that this effort would go a long way in providing ready help to
students.

Haris Khan
Table of Contents
Historical Perspective of Orthodontic Brackets 1

Material Perspective of Orthodontic Brackets 13

Selection of Bracket Base 41

Selection of Bracket Slot 61

Selection of Auxiliary and Convenience features 77

Selection of Bracket Prescription 83

Placement of Orthodontic Brackets 153

Bonding in Orthodontics 189

Debonding of Orthodontic Brackets 203

Adhesive Remnants Removal 239

Recycling of Orthodontic Brackets 255


Historical Perspective of Orthodontic Brackets
In this Chapter
History
Pierre Fauchard
Modifications of bandeau appliance
Development of edgewise appliance
E Arch
Pin and Tube Appliance
Ribbon Arch Appliance
Edgewise Appliance
Orthodontic brackets are important part of fixed
appliances which are temporarily attached to
the teeth during the course of orthodontic
treatment. They are used to deliver forces from
the wires or other power modules to the teeth.
Before going into the details of orthodontic
brackets a historic preview on the evolution of
brackets is given.
History
The origin of orthodontic brackets can well be
coined with the origin of orthodontics and the
human desire to align crooked teeth. The first
written record1 to correct crowded or protruded
teeth is found 3000 years ago. Orthodontic
appliances to correct maligned teeth have been
found in Greek, Etruscan and Egyptian artifacts
2
.These ranges from crude metal wire loupes to
metal bands wrapped around individual teeth in
ancient Egyptian mummies3. Pliny the Elder
1
CHAPTER
1
Begg Appliance
Other Appliances
Modification of Standard Edgewise Appliance
Self ligating brackets
Light wire Appliances
Lingual brackets
Customized labial brackets
(23-79 AD) was the first to mechanically align
elongated teeth4.
Pierre Fauchard
Pierre Fauchard (1678 –1761) a French dentist
was the first to make a scientific attempt to align
irregular teeth by an appliance named Bandeau
(Figure 1.1 & 1.2).This appliance was made of
precious metal and it was shaped like a horse
shoe to align teeth by arch expansion. Fauchard
also used to reposition irregular teeth with his
Pelican forceps and then ligate them with
neighboring teeth until healing took place.
Fauchard published his work in 1728 in his
landmark book entitled The Surgeon Dentist: A
Treatise on the Teeth.

Historical perspective of Orthodontic Brackets
Figure 1.1 Pierre Fauchard
Figure 1.2 Bandeau Appliance
Modifications of bandeau appliance
Fauchard's bandeau appliance was further
refined by another fellow French dentist
Etienne Bourdet (1722-1789) who was a dentist
to the King of France in his time. Etienne
Bourdet was also the pioneer of lingual
orthodontics by expanding the arch by metal
framework placed on the lingual side.
Christophe François Delabarre (1787-1862)
CHAPTER 1
another French dentist used swelling threads
and wooden wedges to separate crowded teeth.
Horace H. Hayden (1769-1844) invented bands
with soldered knobs to correct tooth rotation.
In 1803, Joseph Fox invented a modified
version of bandeau appliance that consisted of
silver or gold rim. Silk thread was used as mode
of attachment and force transfer between the
rim and teeth. These silk threads were adjusted
after every three weeks (Figure 1.3a). Blocks of
ivory were used to disocclude the occlusion and
to prevent interference with tooth movement. J.
M. A. Schange (1841) a French dentist wrote the
first book exclusively on orthodontics. He
modified bandeau appliance and took
anchorage by skeletal cribs attached to molars
(Figure 1.3 b). He also invented an appliance to
move malposed teeth within the arch (Figure
1.3 c).Harris in 1850 attached metal caps to
molar and took anchorage from palate in his
expansion appliance (Figure 1.3d)
Development of edgewise appliance
Norman W. Kingsley (1825-1896) and Calvin
S. Case (1847-1923) advocated extraction for
orthodontic purpose. Though Norman W.
Kingsley later abandoned his extraction
philosophy. This extraction philosophy later
influenced the basic design of orthodontics
braces.
Edward Hartley Angle5 (1855-1930) was the
most dominant and influential figure in
orthodontics and is regarded as the “Father of
Modern Orthodontics.” (Figure 1.4). Because
of Edward Angle, orthodontics was recognized
as a distant and separate science6 from general
dentistry. In his initial days of orthodontic
practice Angle advocated extraction in
orthodontics .But latter on the basis of Wolff's
law that “bone in a healthy person will adapt to
applied load” Angle abandoned extraction
treatment. Also another reason to abandon
extraction treatment was failure to get
satisfactory result after extracting 1st maxillary
2
 Historical perspective of Orthodontic Brackets
A B

C D
Figure 1.3 A. Joseph Fox modified bandeau appliance having ivory blocks to disocclude teeth. B . Schange modified
bandeau appliance having skeletal cribs attached to molars. C. Schange appliance to align malposed teeth .D. Harris
appliance having metal molar caps and utilizing palatal anchorage for dental expansion.

premolars of his wife, Anna Hopkins. It is

reported that Angle even after leaving
extraction therapy condoned it privately5 .In
July 1911 in a meeting of National Dental
Association after a heated debate between
orthodontist and on Angle recommendations
extraction was omitted from orthodontics.

Angle developed four major orthodontic

appliance systems which lays the basis of
contemporary fixed braces .These appliances
were

1. E Arch

The first device developed by Angle was E arch

in late 1890s but it was introduced in 1900
Figure 1.4 Dr. Edward Hartley Angle
(Figure 1.5) .This appliance was in fact a mix of
3

Historical perspective of Orthodontic Brackets
ideas from previous expansion appliance. In this
appliance a heavy labial arch extends around the
arch with the end of the wire threaded and
placed in the molar bands .The heavy labial wire
was directly ligated to the malposed teeth by a
thin metal wire. The E arch was expanded by
activating a small nut placed on the threaded
portion of the arch wire .This creates space in
the arch for the alignment of malposed teeth. As
E arch was only cable of tipping movements and
so it provided no axial control of tooth position.
Angle modified the heavy labial archwire into 4
different designs depending upon the treatment
type. These modifications were
1. Basic E arch was used in mandible with
Backer's anchorage (Class II elastics).
2. Ribbed E-Arch was used with expansion and
by tying brass ligatures around the teeth to the
arch.
3. Modified E-Arch was used with high pull
headgear and without threaded pins.
4. E-arch with hooks in upper canine region was
used with class II elastics.
Figure1.5. E Arch
CHAPTER 1
2. Pin and Tube Appliance
To have a better control over position of all the
teeth and to achieve their bodily movement
Angle banded the entire arch in his Pin and tube
appliance, which was introduced in
1910(Figure 1.6). In this appliance small pins
were soldered on the arch wire and these pins fit
in the vertical tubes of the bands. Changes in the
angulation of the pins, mesial or distal, labial or
lingual resulted in bodily movement of the
teeth. As a great degree of precision was needed
to insert pins into the tubes and also position of
these pins were needed to be changed at each
appointment this appliance became impractical
with time. It is said that Angle and one of his
student ever mastered the appliance.
Figure 1.6 Different parts of pin and tube appliance
3. Ribbon Arch Appliance
In 1916 Angle introduced his Ribbon arch
appliance which was a modified version of pin
and tube appliance (Figure 1.7). In this
appliance the tubes were modified to provide a
vertically positioned rectangular slot that was
4
 facing occlusally. A ribbon shaped gold arch
wire of 0.010x 0.020 inches was placed in the
slot and held in position by brass pins .This
appliance though having better spring qualities
than its predecessor appliances but it has poor
control on root position .
Figure 1.7 Different parts of Ribbon arch appliance
4. Edgewise Appliance
In ribbon arch appliances the span between the
first premolar and molar was too short to place
the stiff archwire and its friction sleeve nut into
the molar tube and the premolar slot. To
overcome these difficulties Angle developed
the edgewise appliance between 1923 to 1925
and that was introduced in orthodontics in 1928
(Figure 1.8). These brackets were attached to
bands and were made of soft gold .The edgewise
brackets (0.022” x 0.028”) had a horizontal slot
instead of vertical slot in which the rectangular
wire was rotated 90° to its previous orientation
in the ribbon arch appliance so the name
Edgewise was given which means sideway or
towards the edge. A 0.0215” x 0.0275” 7 gold
5
rectangular wire was inserted into the slot and
Historical perspective of Orthodontic Brackets
retained in the slot by ligature wires.
Edgewise brackets were also associated with
some limitations. There was deformation of soft
gold slot on insertion of heavy wire. Failure of
gold eyelets on the bands and decalcification of
enamel under the bands was common. Complex
wire bending was required to control tooth
position in all three planes (Figure 1.8). This
was time consuming process and needed
considerable skills from the orthodontist.
Even with these limitations the invention of
edgewise appliance was a turning point in
orthodontic fixed appliance therapy. Most of the
contemporary brackets are modification of this
edgewise appliance.
Figure 1.8 A. Edgewise bracket. B. Edgewise bracket with
eyelets . To have a better rotational control ligature wire were
passed through eyelets and then over the main arch wire. C.
Wire ligated with metal ligature in edgewise D. Complex
wire bending incorporating 1st, 2nd and 3rd order bends.
Begg Appliance
Paul Raymond Begg (1889-1983) was an
Australian who studied under Angle from
March 1924 to November 1925 on both Ribbon
arch and Edgewise Appliance (Figure 1.9). He
returned to Australia in 1927 and moved away
from Angle's non extraction philosophy. In
1933 he modified Angle's ribbon arch appliance

Historical perspective of Orthodontic Brackets
Figure 1.9 Paul Remend Begg
simply by turning the slot of the bracket upside
down. Begg appliance had gingival facing slot.
Begg also replaced the heavy 0.010 x 0.020 inch
rectangular gold wire of ribbon arch with 0.016
inch round stainless steel wire so the appliance
is also named as light wire appliance.
Begg published8 his appliance and mechanics in
1956 (Figure 1.10).To hold the wire within the
slot different types of pins were used(Figure
1.10). Begg light wire appliance used
differential anchorage during tooth movement.
As tooth movement in Begg philosophy was
done on light wire so the appliance had poor
control on root position so different auxiliary
springs were used with Begg appliance later in
the treatment to correct root position.
CHAPTER 1
Figure 1.10 A. Begg appliance in situ. Auxiliary springs
for torqueing and correcting root angulation. B. Begg
bracket with wire in place.C. Different types of pins used in
Begg Appliance.
Other Appliances
Joseph E. Johnson (1888-1969) developed his
light forces twin-wire appliance in 1929 and
published9 it in 1934(Figure 1.11).In this
appliance two light wires (0.010 inch) were
used simultaneously during treatment. Spencer
R. Atkinson (1886-1970) invented the
Universal brackets based on use of light forces
in 1929 but the appliance was introduced10 in
1937. The appliance was called Universal
brackets as it allowed all types of tooth
6

Figure 1.11 Twin wire appliance
movements. The brackets have two slots, a
smaller edgewise gingival slot and a larger
vertical incisor slot (Figure 1.12). The wires
were held in place by lock pins.
Charles H. Tweed, Jr (1895-1970) advocated
extractions in orthodontics and successfully
advocated extraction therapy by demonstrating
his cases in AAO meeting in 1940.
Modification of Standard Edgewise
Appliance
Brainerd F. Swain (1911-1999) attached two
Figure 1.12 Universal Brackets
7
Historical perspective of Orthodontic Brackets
Figure 1.13 A twin bracket with curved base
edgewise brackets separated by a gap to a single
base and called it the twin or “Siamese
brackets”. These brackets provided excellent
rotational control without the use of auxiliary
eyelets (Figure 1.13).Initially these brackets
were made for incisors and molars but later the
base of these twin brackets were carved and
adapted for canines and premolars. These
brackets were available in 4 different sizes.
These were extra wide, standard, intermediate
and junior sized.
Paul D. Lewis (1896-1992) modified 11
edgewise bracket for better rotational control by
soldering curved rotation arms to a single
bracket that contacted the inside of the arch
wire. Lewis brackets (Figure 1.14) were
available with regular and curved bases. Lewis
also made brackets with vertical slot. Howard
M. Lang12 (1914-94) modified Lewis brackets
by using straight arms or wings with holes for
ligature tying (Figure 1.15).
Glendon Terwilliger13 soldered brackets on
bands in such a way that they should express tip
and torque position. Holdaway 14 (1952)
suggested that lower buccal segment brackets
should be angulated over the band by an
amount proportional to the severity of the
malocclusion.Steiner15 in (1953) introduced
0.018 x0.022 inch bracket slot for better torque
control. Steiner also introduced brackets like
Lewis bracket which has single slot and
rotational arms.
 CHAPTER 1
Historical perspective of Orthodontic Brackets

closed vertical slot of 0.018” x 0.046” to

conventional edgewise brackets to accept
doubled 0.018 auxiliary wire(Figure 1.16). The
vertical slot is formed when bracket is welded to
a band.

Figure 1.16 Broussard brackets with vertical slot

Inspired from the work of Jaraback and James,

Figure 1.14 Straight and curved Lewis brackets. The
advantage of these brackets is that they provide good
rotational control without decreasing inter bracket
distance.
Figure 1.15 Lang brackets. A Lang bracket unlike lewis
bracket don't flatten the curvature of arch wire on canines.
and by analyzing study models of non-treated
ideal occlusion patients, Lawrence F. Andrew 18
advocated six keys to normal occlusion and
based his straight wire appliance (SWA) to
achieve these goals (Figure 1.17). Andrew
made many modifications19, 20, 21 in his
appliance with time. The preadjusted
edgewise brackets have tip, torque, in and out
bends built within the brackets (Figure1.18). It
was believed that these appliances don't
required wire bending hence the name Straight
wire appliance was given to them.

Buonocore 16 in 1955 introduced acid etching

which paved the path for attaching brackets
directly to the teeth. John J Stifter in 1958 made
edgewise brackets consisting of a male and
female part. The female part remained attached
to the tooth while there were many male parts to
choose, to provide tooth guidance in all three
planes of space. Ivan F. Lee in 1959 introduced
commercially viable anterior brackets with built
in torque while Jarabak and James A. Fizzell
demonstrated the first brackets with builtin
torque and tip in an annual meeting of AAO in
1960. Garford Broussard17 in 1964 added a Figure 1.17 Lawrence F. Andrew

8
 Alexander (1978) using 0.018” slot brackets

Historical perspective of Orthodontic Brackets

and 0.017x0.025” wire and MBT prescription
(1997) by Richard P. McLaughlin, John C.
Bennett and Hugo J. Trevisi.

Figure 1.18 Preadjusted edgewise brackets. Andrew

introduced these brackets in 1972.

The builtin tip, torque and in and out bends were

called prescription of brackets. Andrew
developed different brackets for different
skeletal patterns and for extraction and non-
extraction cases. Andrew believed that his
straight wire appliance will attain all the Six
Keys to Normal Occlusion. Almost all of the
modern orthodontic brackets in preadjusted
edgewise system are based on minor
modification of Andrew's work.

To overcome the difficulty to choose brackets

from Andrew's different bracket series,
22
Ronald H. Roth (1933-2005) (Figure 1.19)
refined Andrew’s SWA in 1976 by combining
extraction and nonextraction series of brackets
to make his own prescription called “Roth
setup.” 23
After Andrew and Roth work, a plethora of
bracket designs and prescription were made in
the name of SWA with very little modifications
to correct unknown problems or to suit
personally advocated mechanics. Many of these
appliances don't even fillful the basic
requirement of straight wire appliance. It
doesn't mean that all these prescriptions are
useless. Some modern bracket series have
very useful auxiliary and prescription features
too but they are not game changer as Angle
and Andrew work was.
Figure 1.19 Ronald H. Roth (1933-2005)
Self ligating brackets
The concept of self ligation in orthodontic
brackets came from Begg technique of using
brass pins to hold the wire within the brackets
.The first self ligating bracket was purposed by
Stolzenberg24 in 1935. The first commercially
produced self ligating bracket was named
Edgelok and manufactured by Ormco in 1972.
Self ligating brackets are divided into active and
passive ligating brackets depending upon the
mechanism of closure of ligating clip and
holding the wire in slot (Figure 1.20). Self
ligating brackets are available in almost all the
prescriptions in which conventional brackets
are available.

Some famous prescription of present day in Light wire Appliances

addition to Andrew and Roth prescription are Light wire appliance makes tooth movement on
Alexander's prescription by R.G. “Wick”
9

Historical perspective of Orthodontic Brackets
Figure 1.20 Active and passive self ligating brackets
light round wires using the concept of
differential anchorage, where differential
anchorage 25is pitting bodily movement of one
group of teeth (stationary anchorage units)
against tipping movement of another group of
teeth (simple anchorage units). In the light wire
appliances retraction of anterior teeth is done by
tipping movement .Begg brackets were true
differential force light wire appliance. These
were the most famous appliance in 1960s but
introduction of Andrew prescription and later
Roth prescription hasten their decline as Begg
brackets had poor three dimensional control
over tooth position and complex finishing
mechanics.
Peter Kesling26 in the late 1988 introduced his
Tip Edge brackets(Figure 1.21). These brackets
were modification of edgewise brackets which
used treatment mechanics of light wire and
differential anchorage of Begg system. Root
uprightning was done by side winder springs. A
modification of Tip Edge bracket was Tip Edge
plus27 by Parkhouse in 2007(Figure 1.21b). It
uses an auxiliary horizontal slot beneath the
main archwire slot. A round 0.14” super elastic
NiTi wire is passed in the final stages of
treatment instead of using side winders.
CHAPTER 1
B
Figure 1.21 A. Tip edge B. Tip edge plus brackets
Lingual Brackets
Lingual brackets (figure 1.21) have a long
history but they were first reported in 1978 by
Kinja Fujita28 in Japan, to avoid injury to lips
and cheeks by the brackets for patients who
practiced martial arts. Lingual brackets were
introduce in United States in1982 by Alexander
29
. Craven Kurz developed his lingual bracket
series, the seventh generation of which was
reported in 1990s.As lingual surface of tooth
has more variations than labial surface so use of
lingual bracket customized for individual
patients is on the rise (Figure 1.22).
Customized labial brackets
Customized labial bracket uses CAD/CAM
technology similar to customized lingual
brackets. Not only brackets, but wires are also
customized for each individual patient. As
increased cost is involved in these brackets
fabrication so these brackets have yet to gain
popularity.
10

A 14. Holdaway RA. Bracket angulation as applied to the edgewise
B 20. Andrews LF. The straight-wire appliance. Explained and compared.
Figure 1.22 A. Preadjusted lingual bracket B. Customize
brackets Incognito by 3M Unitek
References
1. Weinberger BW. Historical résumé of the evolution and growthof
orthodontia. J Am Dent Assoc 1934;21:2001-21.
2. Proffit WR, Fields HW, editors. Contemporary orthodontics. 3rd ed.
Saint Louis: Mosby; 2000.
3. Wahl N. Orthodontics in 3 millennia. Chapter 1: Antiquity to the mid-
19th century. Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):255-
9.
4. Asbell MB. A brief history of orthodontics. Am J Orthod Dentofacial
Orthop 1990;98:176-83.
5. Chapman H. Orthodontics: fifty years in retrospect. Am J Orthod
1955;41:421-42.
6. Weinberger BW. Dr Edward Hartley Angle: his influence on
orthodontics. Am J Orthod 1950;36:596-607.
7. Cross JJ. The Tweed philosophy: the Tweed years. Semin Orthod.
11
1996 Dec; 2(4):231-6.
Historical perspective of Orthodontic Brackets
8. Begg PR. Differential force in orthodontic treatment. Int J Orthod
1956;42:481-489.
9. Johnson JE. Twin wire alignment appliance. Int J Orthod
1934;20:946-963.
10. Atkinson SR. The strategy of orthodontic treatment. J Am Dent Assoc
1937;24:560-574.
11. Lewis PD. Space closure in extraction cases. Am J Orthod
1950;36:172-91.
12. Gottlieb EL, Wildman AJ, Lang HM, Lee IF, Strauch EC Jr. The
Edgelok bracket. J Clin Orthod 1972;6:613-23.
13. Dougherty HL Sr. The Curriculum II orthodontic program at the
University of California at San Francisco School of Dentistry from 1929
until 1969. Am J Orthod Dentofacial Orthop 1999; 115:595-7.
appliance. Angle Orthod 1952;22:227-36.
15. Steiner CC. Power storage and delivery in orthodontic appliances.
Am J Orthod 1953;39:859-80.
16. Buonocore MG. A simple method of increasing the adhesion of
acrylic filling materials to enamel surfaces. J Dent Res 1955;34:849-53.
17. Broussard JG, Broussard CJ,Buck HR. Clinical applications of the
Broussard auxiliary edgewise bracket Am J Orthod 1964;50:881-09.
18. Andrews LF. The six keys to normal occlusion. Am J Orthod
1972;62:296-309.
19. Andrews LF. The straight-wire appliance, origin, controversy,
commentary. Journal of Clinical Orthodontics 1976; 10:99–114.
Journal of Clinical Orthodontics 1976; 10:174–195.
21. Andrews LF. The straight-wire appliance. British Journal of
Orthodontics1979; 6:124–143.
22. Roth RH. The straight-wire appliance 17 years later. J Clin Orthod.
1987 Sep;21(9):632-42.
23. Roth RH. Treatment mechanics for the straight wire appliance. In:
Graber TM, Swain BF, eds. Orthodontics: Current principles and
techniques. St Louis: Mosby; 1985.
24. Stolzenberg J. The Russell attachment and its improved advantages.
Int J Orthod Dent Child. 1935;21:837–840.
25. Kesling CK. Differential anchorage and the Edgewise appliance. J
Clin Orthod. 1989 Jun;23(6):402-9.
26. Kesling PC. Dynamics of the Tip-Edge bracket. Am J Orthod
Dentofacial Orthop 1989; 96: 16–28.
27. Parkhouse R. Tip-Edge Orthodontics and the Plus Bracket. 2nd ed. :
Mosby; 2008.
28. Fujita K: Development of lingual bracket technique: esthetic and
hygiene approach to orthodontic treatment. J Jpn Res Soc Dent Mater
Appliances 46:81-86, 1978.
29. Alexander, C.M, Alexander, R.G, Gorman, J.C et al. Lingual
orthodontics: a status report. Part 1. J Clin Orthod. 1982; 16: 255–262.
 Historical perspective of Orthodontic Brackets
CHAPTER
1

12
 CHAPTER
Material Perspective of Orthodontic Brackets
2
In this Chapter

Introduction Plastic Brackets

Manufacturing Techniques Plastic Polyoxymethylene brackets
Casting Polyurethane brackets
Milling Composite plastic brackets
Sintering Ceramics Brackets
Metal injection molding (MIM) Aluminum oxide or Alumina (Al2O3) brackets
Ceramic injection molding (CIM) Monocrystalline brackets
Plastic injection molding (PIM) Polycrystalline brackets
Brazing Zirconia brackets
Cold working Calcium phosphate ceramic brackets
Metal Brackets
Stainless steel brackets
Cobalt chromium brackets
Titanium brackets
Precious metal brackets

Introduction stainless steel in edgewise appliances. Ernest

Contemporary orthodontic brackets are
modification of a standard edgewise brackets
developed by Edward H Angle. At the time of
edgewise brackets invention stainless steel
alloy although invented was in the phase of
evolution and orthodontic brackets soldered to
bands were largely made of 14 karat or 18 karat
gold. Rudolf Schwarz 1 was the first to use
13
Sheldon Friel (1888-1970) a pupil of the Angle
(Angle School, 1909) used stainless orthodontic
bands for the first time in 1935.Apart from
stainless steel different other materials have
also been introduced with time to meet the
orthodontists and patient's need. Modern
orthodontic brackets are made up of three
different types of materials which are as follow :
Material perspective of Orthodontic Brackets
1. Metal brackets (Stainless steel, titanium
and cobalt chromium)
2. Plastic brackets
3. Ceramic brackets (Monocrystalline and
Polycrystalline )
All these types of brackets materials are in use
for contemporary orthodontics with all of them
having their own benefits and limitations. An
ideal bracket in terms of material prospective
should have following qualities.
1. Biocompatible in oral environment.
2. Low cost.
3. High modulus of elasticity.
4. High corrosion resistance.
5. No magnetic properties.
6. No friction on bracket wire interaction.
7. Correct strength and hardness.
8. Resist staining and discoloration in oral
environment.
9. Resist plaque deposition.
10. Meet patient aesthetic demands.
Unfortunately none of the contemporary
materials used for bracket manufacturing meet
all the above mentioned qualities.
Before going into the details of different
materials a brief description of various
techniques used for brackets manufacturing are
given so that the orthodontists have a better
understanding of the brackets they select and
use.
Manufacturing Techniques
Most of the orthodontic metal brackets are
predominantly manufactured 2 by casting,
milling and metal injection molding 3, 4.
CHAPTER 2
Casting
In casting processes the ingredients of alloy are
melted and the liquid material is poured into a
mold of the desired shape and allowed to
solidify. Casting can be used to produce one
piece orthodontic brackets or individual bracket
components which are then brazed or welded
together. Casting procedure is usually reserved
for fabrication of complex parts like mesh and
wings of the brackets (Figure 2.1). The slot of
the bracket can also be produced by casting
procedure but many manufacturers prefer to
make slot by milling or machining process. In
terms of brackets fabrication casting is the most
expensive of all brackets manufacturing
techniques as 90% of metal is lost in runners and
sprues. In manufacturing orthodontic brackets
casting technique is reserved for metal brackets.
Casting can also produce single piece brackets
but casted brackets are softer5 than milled
brackets and usually stronger than metal
injection molded brackets made of the same
type of steel.
Clinical notes
Casted bracket parts which are brazed
together have potential side effects of
releasing cytotoxic agents, being separated
from each other on applying orthodontic
loading such as torqueing movements. It is a
common problem with two unit casted
brackets that slot/wings component become
detached on applying debonding forces
while the base of bracket remains attached
to the teeth (Figure 2.2).Removing only the
base component from teeth is cumbersome
and usually require grinding the base with a
diamond bur on a high speed handpiece .
The areas of the bracket where two parts are
joined together by brazing provide a
potential plaque accumulation area. If a cast
mesh is welded or brazed to a bracket base
the brazing or welding material may cover
14
 Material perspective of Orthodontic Brackets
some of the bracket mesh area and may
decrease the bond strength.
Casting error in slot manufacturing can
change prescription of the brackets
(Figure2.3).

Figure 2.3 Casting error in the slot of the bracket. Such

errors allow decrease dimension wires inserted within the
slot so increases the torque play.

Milling

Milling or machining is a process of giving

Figure2.1 A bracket mesh made by casting. This mesh will
certain shape by using a cutting instrument
be joined to the bracket base by welding or brazing. which is usually a nonabrasive rotatory cutting
instrument.

In case of orthodontic brackets a single piece

bracket can be produced by milling process but
manufacturer usually prefer to produce
individual parts by this process (Figure 2.4).
Milling or machining is good for economically
producing geometrically simple parts such as
hooks of brackets and slots. But milling of
orthodontic brackets is expensive as compared
to the metal injection molding process as 50% to
75% material becomes scrap while giving the
final shape. Milling is also prone to human
errors (Figure 2.5).

Contemporary orthodontic metal brackets are

manufactured by the computer numerated

Figure 2.2 Faulty casting procedures can lead to cracks on

bracket wings and slots and can lead to wing fracture during
clinical use. Such fractures are annoying for the orthodontist
as these brackets need to be changed. Figure 2.4 Hook of a bracket produced by milling process.

15
Material perspective of Orthodontic Brackets
CHAPTER 2
debunking or debinding procedure. In this
process heat or solvent or combination of both
are used to remove up to 90% of the binders
which are usually waxes or thermoplastic
resins from the green part. At the end of
debinding procedure the green part is converted
into same size porous structure called brown
part.

The brown part then undergo a sintering process

Figure 2.5 Milling errors in slot of the bracket with
irregular slot walls. Such manufacturing faults decrease
in which it is heated in a high temperature
torque expression and increases friction resistance. furnace up to 1400 C° under controlled or
vacuumed environment. Sintering process
controlled (CNC) milling processes in which causes removal of the residual binders from the
brackets are made by taking a single piece of brown part leading to its shrinkage by 17% to 22
metal which is cut and formed by a %. As the brown part was oversized, the final
computerized machine to create the bracket. product is about the same size as required. In
some cases final finishing touches are given by
Sintering secondary thermal procedure or surface
treatment. In case of MIM technique metal
Sintering is a process to create various objects
powder is stainless steel, titanium or cobalt
from powder, based on the principle of atomic
chromium. A description of MIM procedure is
diffusion. In this process the powdered material
given in figure 2.6.
is contained in a mold and heated to a
temperature below its melting point. The atoms
in the particles diffuse across the boundaries of
the particles thus uniting the various particles
and creating one solid single unit. Sintering is
used both for metal and ceramic brackets
manufacturing.

Metal injection molding (MIM)

Metal injection molding (MIM) is a powder

metallurgy process developed in early 1980s in
USA. The technique makes use of CAD/CAM
technology. In this process fine metal powder
called metal dust with particle size as small as
15 microns4 is combined with plasticizers, Figure 2.6 Flow chart of metal injection molding
organic binders, lubricants and dispersants to
form a homogenous mixture called feedstock. Advantages of metal injection molding
The feedstock is molded by injection molding 1. The bracket is made in a single piece with
machine into specific shapes .The new molded a high degree of precision.
product called the green body or green part is
fragile and is 17% to 22% larger than the final 2. In MIM brackets no brazing is involved
product3. Green body is processed through a so there are fewer chances of cytotoxicity.
16

3. MIM brackets wings don't separate from
brackets on clinical loading and debonding.
4. MIM brackets are inexpensive as little
material is wasted during the fabrication
process.
5. MIM brackets have increased corrosion
resistance. MIM brackets are free from the
corrosion risk associated with the galvanic
couple of brazing alloys with stainless steel
so MIM brackets are a good choice in nickel
allergic patients.
6. MIM brackets that have undergone
secondary thermal or surface treatment
during manufacturing have smooth surface,
offering decreased friction resistance.
Figure 2.7 A MIM bracket that has been debonded by
mechanical method using debonding pliers. The bracket is
broken in the middle and can't be recycled. In conventional
brackets base part are made of soft steel while slot part is
made from hardened steel. The soft base is easily peeled off
from the tooth on applying debonding force while the
harder slot part maintains its shape. The harder slot also
helps in greater expression of the built in torque. In
contrast a bracket fabricated from MIM has less hardness
than conventional brackets thus have less torque
expression than conventional brackets. As the base and
slot component are made of same grade material
mechanical debonding usually results in distortion of the
slot and the base of the bracket. This distortion can be
avoided by inserting a segment of full dimensions
rectangular wire5 within the slot at times of debonding.
17
Material perspective of Orthodontic Brackets
Limitations of metal injection molding
1. MIM brackets have surface porosity due
to shrinkage during sintering. This results in
decrease in mechanical strength and also
produces greater friction on sliding
mechanics if surface treatment is not done.
2. As wings and base of the brackets are
made from the same material and have the
same hardness so mechanical debonding of
brackets is technically more difficult by a
peel off force as compared to conventional
brackets (Figure 2.7).
3. Brackets manufactured by MIM have
lower Vickers hardness 3 than conventional
brackets of same material grade.
Comparison of brackets made by different
manufacturing techniques is given in figure 2.8.
Clinical Notes
Stainless steel metal injection molded
brackets made of conventional grades in
stainless steel were found to have equal
hardness3 to that of NiTi wires and less than
stainless steel wires. So MIM brackets will
distort if too much torque is introduced into
the wires or if the orthodontist jump to
higher dimensions wires without following
the proper sequence of wires during
treatment (Figure 2.9). So it is wise to
sequentially move from smaller to larger
dimensions stainless steel wires. Many
orthodontists prefer to use high torque value
brackets to compensate the torque loss by
slot distortion. Though NiTi wires are poor
in torque expression but full dimension NiTi
wires can be used with high torqued MIM
brackets for effective torque expression.
Material perspective of Orthodontic Brackets
CHAPTER 2

A B C

D E F

Figure 2.8 Comparison of brackets made by different manufacturing techniques. A. MIM bracket .The bracket surface is flat
and smooth .The bracket stem has a uniform blend with the bracket base. Such brackets offer little retention for plaque
accumulation. B. Slot wall of a MIM bracket .The slot surface is smooth but has long horizontal lines. Such horizontal lines can add
to friction resistance. C .A bracket fabricated from casting. The bracket has a smooth surface. The topography of the bracket is
irregular but not plaque retentive. D. The slot wall surface of casted bracket which is smooth and offer less friction than MIM. E. A
bracket fabricated from casting, parts joined by brazing and slot machined by milling. The junction between the stem and base area
is irregular and offer plaque retention area. F. The slot of the bracket made by milling processes. The slot wall is irregular and will
offer more friction resistance than MIM and casted slots.

A B C D

E F G H
Figure 2.9 Comparison of slot distortion between two different grades of MIM manufactured brackets on introduction of torque
in the wire. A. Low grade SS MIM bracket with straight 0.021”x0.025” wires inserted. B. Same bracket with 30° torque
introduced in the wire. C & D. Comparison between slots of brackets before wire insertion (0.021”x0.025”) and after torqued wire
(0.021”x0.025”) insertion. In bracket D the slot of the brackets has significantly been distorted due to introduction of torque in the
wire. In Figure E, F, G, H same setting was used with a higher grade of the SS MIM bracket. In a Figure H expansion of the slot is
evident but it is less than what was seen in brackets made of lower grade SS MIM.

Ceramic injection molding (CIM)
CIM is used for manufacturing of ceramic
brackets and is similar to metal injection
molding with the exception that ceramic
powder is used instead of metal powder and
sintering temperature is maintained at 2000 C°.
In case of ceramic brackets CIM technique is the
contemporary preferred method for
polycrystalline brackets manufacturing.
18

Plastic injection molding (PIM)
Plastic brackets are manufactured by plastic
injection molding. The manufacturing process
is similar to that used for metal or ceramic
brackets.
Brazing
In this process a metal filler alloy is used to join
two metals by heating the filler above its
melting point. The liquid filler is taken up by the
joined metals using capillary action. Brazing is
similar to soldering except the former uses a
higher temperature to melt the metal filler alloy.
In orthodontics, brazing process is used for
stainless steel brackets. Many orthodontic
companies traditionally produce individual
bracket parts (base, wings and mesh) from
different grades of stainless steel and then join
them together by brazing (Figure 2.10).
An ideal brazing alloy for orthodontic purpose
should have the following properties:
1. It should have a good compatibility in
terms of chemical nature and appearance
with stainless steel or any other bracket
material used.
2. It should have good mechanical strength
to hold the joined parts together under
masticatory and orthodontic loading.
3. The brazing cycle temperature should be
less than the sensitization temperature of
stainless steel.
4. A brazing alloy shouldn't contain or
causes the release of cytotoxic elements
like Ni, Cd, Cu, and Zn.
5. Brazing alloys should have galvanic
compatibility with saliva and with
stainless steel alloys. Galvanic corrosion
causes 7 progressive dissolution of brazing
filler metal thus weakening the joint
between two parts of the bracket. This can
19
Material perspective of Orthodontic Brackets
lead to detachment of the wings or mesh
from the bracket base during orthodontic
therapy or at the debonding stage.
Brazing alloys commonly used in orthodontics
are Ag, Ni, Cu, and Au. Unfortunately none of
these fulfill the ideal criteria of a brazing alloy
and always are associated with some
limitations.
Silver Ag based brazing alloy contains
cadmium8 which is added in this brazing alloy to
lower the melting temperature and improve
wetting6. Cadmium is shown to be cytotoxic.
Silver based brazing can also release cytotoxic9,
10, 11
copper and zinc ions by forming a galvanic
couple with stainless steel in water. Chromium
carbide precipitation also occurs by Ag based
brazing because of a higher sensitizing
temperature range.
Gold (Au) based brazing also forms a galvanic
couple with stainless steel and lead to
dissolution of stainless steel because gold is a
more noble metal than stainless steel.
Dissolution of stainless steel can cause a
decrease in its corrosion resistance and release
of nickel. Nickel is well known to cause nickel
allergy in presensitized nickel allergic patients.
Nickel based brazing may release Ni while Cu
Clinical Notes
Brackets joined by nickel based brazing
shouldn't be used in patients with nickel
sensitivity. Base method of debonding
should be used in mechanical debonding of
stainless steel brackets manufactured by the
brazing process because using the wing
method of debonding may result in
detachment of wings or mesh from the base.
Removing the base or mesh alone from the
tooth is a time consuming process. Flame
method of recycling should be avoided in
brazed brackets as there are greater chances
of corrosion of these brackets with this
method.
Material perspective of Orthodontic Brackets
CHAPTER 2
based brazing will release copper. Both have
known cytotoxic effects.

A B C

F D

Figure. 2.10 A. Bracket in which slot/wing component is joined with the base component using silver brazing. Such brackets are
known to release cytotoxic cadmium in the oral cavity .B .Copper brazing used to unite bracket parts. Copper brazing may release
Cu which can cause cytotoxic effects. C. Nickel brazing. Such brackets should be avoided in patients with nickel hypersensitivity
to avoid nickel allergy. D .A gauze mesh brazed manufactured separately and brazed to bracket base. Sometimes at debonding
these brackets meshe become separated from the main bracket body and remain attached to the tooth. Removal of the mesh alone
from the tooth is a cumbersome process and usually requires grinding the mesh with high speed handpiece. E. Magnified view of
the bracket mesh brazed to bracket base.The mesh is brazed at the corners of the bracket. Such corner areas provide poor retention
for bonding adhesives and so decrease the bond strength and providing potential areas for bacterial accumulation. F. A
bracket having silver brazing. Picture at time of debonding after two years of clinical use. Degradation of the brazing alloy is
evident with fissures, cracks and color change in the brazed area.

Cold working details and the type of manufacturing

Cold working is a process in which repeated
bending of the material is done while the
material is cold. This process is used to increase
hardness of the material. Cold working is used
in manufacturing of metal brackets. But a
stainless steel bracket in which cold work has
been done has greater chances of carbide
precipitation at a lower temperature so cold-
worked stainless steel brackets with low carbon
contents should be used12 to minimize carbide
precipitation.
Selection of brackets based on
manufacturing processes
Manufacturers usually don't provide the
processes until a personal query is raised.
With slightly limitations all types of brackets
manufactured by different techniques work
fine in most of the cases if the correct
manufacturing technique and standard have
been followed.
Some selection criteria's of brackets based on
manufacturing technique are given.
1.Casted brackets have well-polished
surfaces and are a good choice for sliding
mechanics and torque expression.
2.Many manufacturers don't have state of art
technology. If a milling process is used in
slots or other brackets parts manufacturing,
20

always select brackets in which computer
numerated controlled (CNC) milling
processes is used as this manufacturing
technique has less chances of errors in
bracket fabrication.
3.In case a brazing process is used in bracket
manufacturing always try to avoid bracket
based on nickel brazing. Avoid brazed
bracket recycled with flame or chemical
method.
4.MIM brackets are usually good for all types
of cases. If there are special torque
consideration in a case either use the proper
sequence of wires or use MIM brackets made
of higher grades of SS.
With the availability of on demand quality
products from china, many manufacturers
and distributers prefer cheap quality
products. This is a nightmare for young
orthodontists. All new brackets look good in
catalogs, all brackets shine in their packing's,
but it is after one to two years of clinical use
you came to know how they work. Keep in
mind all brackets degrade in oral cavity so
always seek an advice from seniors about
which product line of a specific company
degrade less? A comparison between new and
used brackets is given in figure 2.11.
Figure 2.11 A comparison of new and used, same
company bracket made by MIM SS.Don't select brackets on
their new look but how they behave in the oral cavity.
21
Material perspective of Orthodontic Brackets
Metal Brackets
There are four main types of metal brackets used
in modern orthodontics.These are:
1. Stainless steel brackets
2. Cobalt chromium brackets
3. Titanium brackets
4. Precious metal brackets
1. Stainless steel brackets
In metallurgy, stainless steel, also known as
inox steel is a steel alloy with a minimum of
10.5% chromium content by mass.
Stainless steel can be classified into
different types of crystalline structures and
each type of stainless steel has been given a
specific SAE (Society of Automotive
Engineers) or AISI (American Iron and
Steel Institute) number depending upon
composition of elements in the alloy. Low
numbers have little additional alloy metal
and are soft, while higher AISI numbers
have greater hardness and increased
corrosion resistance.
Orthodontic brackets13, 14 should have the
correct hardness and strength to withstand
and deliver the forces from the wires to the
teeth. Most of the orthodontic brackets are
made of stainless steel14, 15, 16, 17 because it
provides optimum properties required for
an orthodontic bracket. Before going into
the details of different types of stainless
steel used for manufacturing of orthodontic
brackets some important aspects related to
stainless steel brackets are discussed as they
affect the selection of these brackets.
Corrosion resistance
Corrosion is the gradual destruction of materials
by chemical reaction against their environment.
Corrosion of orthodontic brackets will degrade
their physical strength, color and increases
Material perspective of Orthodontic Brackets
CHAPTER 2
surface roughness by dissolution of the bracket
material.

This rough surface will act as a site for plaque

accumulation and bacterial growth so further
corroding and discoloring the brackets. In
stainless steel, corrosion resistance18 is provided
by self-healing passive surface layer of
chromium oxide which prevents surface A
corrosion by blocking the oxygen diffusion to
the steel surface. Breaking of the chromium
oxide layer will increase the permeability of
stainless steel for liquid and gases. This will
start a chain reaction resulting in degradation of
stainless steel and the release of its composite B
elements which in some cases are cytotoxic.
The pH of the environment in which
orthodontic brackets are used has a significant
effect on the integrity of the chromium oxide
layer. As most of the brackets have to remain for
long term in the oral cavity so there is increase
interaction of brackets with oral fluids which
C
lead to greater chances of brackets chromium
oxide layer breakup (Figure 2.12). Corrosion Figure 2.12 A. Labial surface of the tooth at time of
of orthodontic brackets can also occur due to debonding. Corrosion products and adhesive remnants of
on the enamel surface. These corrosion products cause s
Cl-ions in saliva, food, certain mouth washes release of cytotoxic elements in oral fluids and also causes
19
, acidic drinks, bacteria and their waste discoloration and decalcification of enamel .B. Corrosion of
brackets after 2.5 years of clinical use. There is a change in
products and selective interactions with gases color and texture of the bracket. Bracket corrosion affects its
such as oxygen and carbon dioxide. appearance and prescription. C. Bracket base of mesh
corrosion. Mesh Corrosion of bracket base will cause a
decrease in shear bond strength in case of reusing a bracket.

Clinical notes Nickel Allergy

At the time of bonding of orthodontic
One of the most annoying aspects of stainless
brackets all adhesive flash around the
steel brackets is that they can cause nickel
brackets should be removed. Any remained
allergy in nickel sensitive patients. Nickel
flash around the bracket base will act as a site
sensitivity is more common in females and
for bacterial accumulation thus leading to
more common due to cutaneous exposure than
increase chances of bracket corrosion. Good
subcutaneous exposure. Corrosion resistance of
oral hygiene measures by the patients and
steel brackets is more important 20 than its nickel
clinicians should be ensured. The patients
contents because if the corrosion resistance is
should be advised to limit his use of acidic
good then ions won't be released from the
and high sugar juices. Even if the same wire is
brackets. Nickle free brackets are brackets with
activated, removing and cleaning the wire good corrosion resistance should be used.
and slot with air and water spray is a good Higher grades SS has low nickel contents and
practice to limit corrosion of the brackets. better corrosion resistance. But it is difficult to
22

machine higher grade SS into orthodontic
brackets. A bar chart of different stainless steel,
showing their nickel contents is given in figure
2.13.
Figure 2.13 A bar chart on percentage of nickel in
different types of stainless steel
Vickers Hardness
The Vickers hardness test measures the
hardness of a material and was developed by
Robert L. Smith and George E. Sandland in
1921.Vickers hardness of orthodontic slots
should ideally be equal to orthodontic wires for
proper expression of the prescription built into
the brackets. The Vickers hardness of the
bracket base should ideally be less than that of
slots. This arrangement will help in easy
debonding of brackets. If the hardness of the
base is greater than optimum limits mechanical
debonding of brackets will become difficult as
peel off force cannot be applied to the brackets.
In conventional orthodontic brackets which are
made from casting and milling process the
slot/wings component is usually made of harder
steel which is usually 17-4 PH while the base
component is made of softer steel which is
usually 316 SS. This arrangement helps in easy
debonding of brackets but even with this
combination the Vickers hardness of slot /wings
component of a conventional bracket which is
400 VHN21 is less than stainless steel wires
which have a Vickers hardness of 600
VHN22.This decrease hardness of brackets slot
23
Material perspective of Orthodontic Brackets
is due to the reason that considerable strength of
the steel is lost during machining or casting of
the brackets. Also owing to complex shape of
the bracket parts, same degree of cold working
cannot be applied to the brackets as it is applied
to the wires. The Vickers hardness of a slot
/wings of conventional brackets was found to be
close to that of NiTi wire which has VHN of 300
to 43023.The Vickers hardness of some MIM
brackets3 was between 154 to 287 VHN which is
much lower than that of conventional brackets.
The effect of decrease Vickers hardness and
mismatch of Vickers hardness between slot and
wire is explained in figure 2.14 and 2.15.
A B
Figure 2.14 A. Slot wall of a new MIM bracket. B. The
slot of wall of a used bracket on which sliding mechanics
was done on 0.019x 0.025” SS wire. The slot walls have
lost their smoothness with clinical use. The increase
roughness has been contributed by ploughing effect of
harder SS wire on sliding mechanics and to a minor extent
by corrosion of the slot.
A
B
Figure 2.15 A. Rough area on front side of bracket base.
B. Rough bracket wings. Such areas are usually formed by
rough instrumentation during ligature insertion and
removal. Such areas are potential plaque retention areas.
The bracket should have optimum hardness to avoid the
creation of such areas.
Clinical Notes
Greater the mismatch of Vickers hardness
between the stainless steel wires and
Material perspective of Orthodontic Brackets
CHAPTER 2
comparison with other types of stainless
brackets greater would be the wear of softer
steels. The standard orthodontic twin brackets
material by ploughing effects and greater
are usually manufactured from austenitic type
friction would be offered on sliding
302 , 303SE ,303L ,304 ,304L,316 ,316L and
mechanics. Conventional brackets are more
318 7,24 with 304 L and 316 L mostly used
effective in sliding mechanics, torque
material12,25,26,27 . The L designation refers to
expression than MIM brackets. MIM
lower carbon contents of steel. The lower
brackets are peeled off from the tooth on
carbon contents in stainless steel eliminate
debonding but are usually distorted to the
harmful carbide precipitation thus decreasing
extent that they can't be recycled. the susceptibility to corrosion. But low carbon
NiTi wires though are poor in torque steel has decreased strength .
expression, can be used with high torque
prescriptions but problem of their increased 316 SS and 316-L SS are used where higher
corrosion resistance especially to chloride is
friction with sliding mechanics remains.
required.316 SS is used more commonly for
Types of stainless steel making base components and because of
increased corrosion resistance have shown28 to
Almost all manufacturers of orthodontic release less nickel. The composition of various
brackets only tell the type of brackets and don't austenitic stainless steel brackets is given in
reveal the exact composition of their brackets. table 2.1. A 316 L bracket is shown in figure
Different types of stainless steel based on their 2.16.
metallurgic structure are used for
manufacturing of orthodontic brackets. The
data is collected from different articles
published in orthodontic journals.

Austenitic Stainless steel (300 SERIES)

This is one of the most popular types of stainless

steel alloy24 used in orthodontics as a bracket
and wire material due to its good corrosion
resistance, excellent formability and low cost in Figure 2.16 316L SS bracket

Table 2.1. Composition of Austenitic stainless steel brackets

AISI Fe% C% Cr% Ni% Mn% Si% P% S% Others %

303 Balance 0.15 17-20 8-10 2.00 1.00 0.20 0.15 0.6 Mo

304 Balance 0.08 18-20 8-10 2.00 1.00 0.05 0.03

304L Balance 0.03 18-20 8-12 2.00 1.00 0.05 0.03

316 Balance 0.08 16-19 10-13 2.00 1.00 0.05 0.03 2-3 Mo
316L Balance 0.03 16-19 10-13 2.00 1.00 0.05 0.03 2-3 Mo

317 Balance 0.08 18-20 11-14 2.00 1.00 0.05 0.03 3-4 Mo

Fe=Iron. Iron balance means the rest is iron by % weight which is usually in the range of 69 to 72 %.In this table
C=Carbon, Cr= Chromium, Ni=Nickel, Mn=Manganese, Si=Silicon, P=Phosphorus, S=Sulfur and Mo
=Molybdenum. These values are for reference as many more elements are added in stainless brackets by the
manufacturer to improve their mechanical properties.

24

Super austenitic stainless steel
Super stainless steel is defined as SS with pitting
resistance equivalent value of 40. Super
stainless steel has higher molybdenum and
nitrogen content than conventionally used SS.
Super SS12 show good frictional properties,
higher resistance to chloride pitting and crevice
corrosion. Super SS had only been used in vitro
studies12. No information in any company
catalogue is present that they manufacture
brackets with supper stainless steel.
Precipitation-hardening (PH) martensitic
stainless steel (17-4 PH or S17400)
This form of stainless steel has corrosion
resistance equal to austenitic stainless 304 but
Table 2.2. Composition of Precipitation-hardening (PH) martensitic stainless steel
AISI Fe% C% Cr% Ni%
630/17-4 Balance 0.07 15.5-17 3-5
PH
631/17-7 Balance 0.09 16-18 6.5-7.5
PH
Where Nb is niobium Al=Aluminum , Cu = Copper
Figure 2.17 Brackets made from 17-4 PH SS
Ferritic Stainless steel
Ferritic stainless steel has main alloying
elements as chromium, titanium, molybdenum,
small amount of carbon and no nickel.
Generally corrosion resistance of this steel is
25
Material perspective of Orthodontic Brackets
has better strength than the latter. 17-4 PH or
S17400 precipitation– hardening alloy type has
lower nickel contents but have poor localized
corrosion resistance12.It has been shown28 that
more nickel is released from 17-4 PH than 316
SS as the former have less corrosion resistance
than 316 SS. So 17-4 PH is not a good choice
for patients with nickel sensitivity.
17-4 PH stainless steel is usually used for
manufacturing wing component of brackets or
for making mini brackets because of its higher
hardness and strength 14. Composition of
precipitation-hardening (PH) martensitic
stainless steel is given in table 2.2. A bracket
made from 17-4 PH stainless steel is shown in
figure 2.17.
Mn% Si% P% S% Others %
1.00 1.00 0.04 0.03 4Cu, 3Nb
1.00 1.00 0.04 0.04 0.08-
1.5AI
less than austenitic stainless steel but stabilized
ferritic stainless steel (AISI 441) has equal
corrosion resistance to that of 316 SS. Due to
decrease carbon contents , this form of steel
has less strength than austenitic stainless steel.
Some companies manufacture nickel free
brackets from super ferritic stainless steel but
their composition is not known (figure 2.18).
Figure 2.18 Super-Ferritic Stainless Steel BIOMIM
bracket

2205 Duplex stainless steel
Material perspective of Orthodontic Brackets
A duplex stainless steel is a combination of
austenite and delta ferrite stainless steel. A
duplex stainless steel is twice as strong as
austenitic stainless steel and also has improved
resistance to localized corrosion particularly
pitting, crevice corrosion and stress corrosion. It
is composed of high chromium contents (19-
32%), molybdenum (up to 5%) and lower nickel
contents than austenitic stainless steels. A
duplex stainless steel has been proposed25 as an
alternative to 316 L stainless steel brackets but
no such bracket material is mentioned in the
catalogs of orthodontic brackets manufacturers.
Martensitic Stainless steel
This forms of stainless steel though extremely
tough and strong is not used for orthodontic
brackets because of poor corrosion resistance.
A short description of different elements used in
stainless steel alloy is given so the orthodontist
must have a basic knowledge why each element
is added in the alloy.
Carbon
Carbon is added to stainless steel to give
hardness and strength. Increase carbon contents
may give increased hardness but there is also a
risk of increase chromium carbide formation
due to localized corrosion in the oral fluids.
Chromium
Chromium is added to steel to increase its
resistance to oxidation. Chromium forms thin
passive surface chromium oxide layer which
prevents surface corrosion by blocking the
oxygen diffusion to the steel surface.
Nickel
Nickel is used to stabilize austenitic phases of
stainless steel. So it improves resistance to
oxidation and corrosion. Since the nickel atoms
are not strongly bonded to form some
intermetallic compounds so there are greater
CHAPTER 2
chances of nickel ion release under the
influence of oral fluids. To minimize the risk of
hypersensitivity reactions to nickel, the
corrosion resistance of stainless steel should be
maximized to control the nickel ion release
from the alloy.
Manganese
Manganese, like nickel, is an austenite forming
element and has been used as a substitute for
nickel.
Nitrogen
Nitrogen has the effect of increasing the
austenitic stability of stainless steel. Like nickel
it is also an austenite forming element.
Molybdenum
Molybdenum is added to improve resistance of
SS to pitting corrosion especially by chlorides.
Titanium
Titanium is added for carbide stabilization and
to increase corrosion resistance.
Phosphorus
Phosphorus aids to increase strength and
corrosion resistance. It also lowers the
temperature for sintering.
Niobium (Columbium) and Tantalum
Niobium is added to steel in order to stabilize
carbon and to improve corrosion resistance.
Copper
Copper is added to stainless steel to produce
precipitation hardening properties.
Selenium and Sulfur
Selenium is added to steel to make it more
machinable and workable, but it also decreases
hardness and strength.
Cobalt chromium brackets
26
 Material perspective of Orthodontic Brackets
Selection of Stainless steel brackets Table 2.3 Cobalt-Base Wear-Resistant
Stainless steel brackets with good corrosion Alloys
resistance should be selected. Good corrosion
Cr 25-30%
resistance of a bracket is more important than
Mo 7% max
its nickel contents. Ideally SS brackets should W 2-15%
not be used for nickel sensitive patients. C 0.25-3.3%
Conventional SS brackets with softer base Fe 3% max
component and harder slot/wings component Ni 0.5%max
should be preffered.17-4 PH MIM brackets Si 2%
are a good choice for proper torque Mn 1%
expression. New bracket should always be Co Balanced
Where Cr=Chromium, Mo=Molybdenum, W =
the first choice by orthodontists to avoid
Tungsten, C =Carbon, Fe = Iron, Ni=Nickel, Si
corrosion.
= Silicon

Cobalt chromium brackets were introduced in Properties of Cobalt Chromium

mid 1990s as a low nickel alternative to stainless Brackets
steel. Cobalt chromium brackets are fabricated
Friction Resistance
from casting or metal injection molding.
In terms of friction resistance cobalt chromium
Type and Composition of Cobalt based alloys
brackets show comparable30, 31 but slightly less
Cobalt based alloys can be divided into three amount of friction than that of stainless steel
categories .These are: brackets when used with stainless steel wires.
But CoCr brackets offer more friction than
1. Cobalt based wear resistant alloys titanium brackets30 with both stainless steel and
beta titanium wires.
2. Cobalt based high temperature alloys
Corrosion Resistance
3. Cobalt based corrosion resistant alloys
Because of increase chromium contents there is
In these alloys cobalt based wear resistant alloys
less chance of corrosion32 of cobalt chromium
are used29 presently for orthodontic brackets
brackets.
manufacturing .In cobalt based wear resistant
alloys CoCr brackets are made from ASTM F-
75 CoCr where ASTM stands for American
Society for Testing and Materials. The amount
of nickel in this alloy is kept low 29and is up to
0.5 %. Composition of cobalt based wear
resistant alloys is given in table 2.3. A cobalt
chromium bracket is shown in figure 2.19.

Figure 2.19 Nu- Edge® Mini Cobalt Chromium Brackets

by TP orthodontics with 0.5 % nickel.
27
Material perspective of Orthodontic Brackets
Selection
Cobalt chromium alloys have good corrosion
resistance and have a highly polished surface.
But due to less favorable friction properties
with different types of wires, selection of
CoCr brackets over titanium and steel
brackets is a matter of personal choice than
logical basis.
Titanium Brackets
Titanium metal has excellent biocompatibility
and increased corrosion resistance18, 33, 34 so it has
wide ranging surgical application from artificial
heart valves and hip joints to dental implants.
In orthodontics to overcome the release of
nickel from stainless steel brackets which may
cause nickel allergy in some patients, titanium
brackets have been introduced35, 36 as nickel free
alternatives to stainless steel in mid 1990s.
Types of Titanium
From material science perspective titanium has
the following three types:
1. αTitanium
2. β titanium
3. α &β Titanium
Alpha titanium is commercially pure (CP)
unalloyed titanium while the other two types are
titanium alloys.β titanium include Ti-15V-3Cr-
3Sn-3Al alloy while α-β titanium included Ti-
6Al-4V alloy. Alloyed titanium has greater
strength than unalloyed titanium. Chemical
composition of various types of titanium is
given in table 2.4.
Commercially pure (CP) titanium is further
classified into four grades depending upon
degree of impurity, primary oxygen within the
unalloyed titanium. Grade 1CP titanium has the
lowest strength but highest purity, corrosion
resistance and formability as compared to grade
CHAPTER 2
4 CP titanium, which offers highest strength and
moderate formability. Composition of different
grades of CP titanium is given in table 2.5.
Contemporary titanium brackets21, 37 are either
manufactured from alpha titanium grade 2 and 4
or alpha-beta titanium (Ti-6Al-4V).Grade 2 CP
titanium is usually used to make base
component of brackets due to its decreased
strength while the wing component is made
from much harder titanium alloy, the alpha -beta
titanium Ti-6Al -4V.Both these components are
laser welded to make a single unit of bracket. As
explained before for stainless brackets
combination of harder slot/wings part and softer
base part has clinical importance. The softer
base part will allow easy mechanical debonding
while harder slot/wings part will allow
expression of torque.
Due to release of vanadium37from titanium alloy
Ti-6Al-4V which may have biological
hazardous effects some manufacturer make
single unit milled or metal injection molded
bracket from grade 4 CP titanium.
Characteristics of Titanium brackets
Corrosion Resistance
Titanium and titanium alloy brackets have
greater corrosion resistance than stainless steel
brackets. This is due to the presence of thin
passive protective layer of titanium dioxide
over the titanium. This layer of titanium dioxide
is more stable23 than its counterpart layer of
chromium oxide on stainless steel. The
composition of titanium dioxide layer which is
also called rutile is given in table 2.6.
Brackets in which two parts are joined together
by welding have greater chances of galvanic
corrosion than one piece milled or MIM
brackets. A titanium bracket is shown in figure
2.20.
28
 Material perspective of Orthodontic Brackets
Friction characteristics

All titanium alloys show galling and fretting on

Figure 2.20 Equilibrium Ti bracket by Dentaurum
Table 2.4. Chemical composition of various types of titanium
sliding but due to the presence of passive layer
of titanium dioxide, titanium brackets have
comparable38-40 or less30 friction resistance than
steel brackets when stainless steel arch wires are
used both in passive and active configuration.
Passive configuration is one in which there is
clearance in the slot and no binding from torque
or angulation is present whereas active
configuration has binding in the slot. Titanium
brackets also give least friction30 with beta
titanium wires as compared to other metal
brackets. The passive layer of titanium dioxide
remains stable39 during sliding mechanics. So

Crystal Structure Ti Al V Mo Sn Fe Cr Others

Unalloyed titanium (α) 100 - - - - - - -

Ti-6Al-4V(α + β) 90 6 4 - - - - -

Ti-4.5Al-3V-2Fe-2Mo(α+β) 88.5 4.5 3 2 - 2 - -

Ti-15V-3Cr-3Sn-3Al(β) 76 3 15 - 3 - 3 -

Ti-20V-4A1-1SN(β) 75 4 20 - 1 - - -

Ti-22V-4A1(β) 74 4 22 - - - - -

Ti-16 V-4 S n -3 Al-3Nb (β) 74 3 16 - 4 - - 3(Nb)

Table 2.5. Composition of different grades of CP titanium

Composition Grade 1 Grade 2 Grade 3 Grade 4

Nitrogen max. 0.03 0.03 0.05 0.05
Carbon max. 0.08 0.08 0.08 0.08
Hydrogen max. 0.015 0.015 0.015 0.015
Iron max. 0.20 0.30 0.30 0.50
Oxygen max. 0.18 0.25 0.35 0.40
Titanium Balance Balance Balance Balance

Table 2.6. Composition of titanium dioxide layer

Carbon Fluoride Hydrogen Iron Nitrogen Oxygen Titanium

42.0% 2.3% 0% 0% 1.5% 40.1% 14.1%

29
Material perspective of Orthodontic Brackets
Clinical notes
If greater torque is required it is better to use
titanium brackets whose slot /wings
components are made of titanium alloy than
using brackets made from commercially pure
titanium. For doing sliding mechanics in
nickel sensitive patients30 use titanium
brackets with beta titanium wires though loop
mechanics are better option than doing
sliding mechanics.
titanium brackets can effectively be used with
stainless steel wires for sliding mechanics just
like stainless brackets. Within titanium brackets
titanium alloys have less friction26 coefficient
than CP titanium.
Bond Strength
Titanum brackets has greater bond strength than
SS brackets (Figure 2.21)
Figure 2.21 Titanium has less contact angles with liquid
and adhesives than stainless steel. So theoretically titanium
brackets offer greater bond strength than SS brackets.
Limitations of titanium brackets
Following limitations can be associated with
titanium brackets.
1. Some titanium brackets can release
elements like vanadium which may have
undesirable biological effects43-45 under
certain conditions.
2. The laser welding used for joining
different components of titanium brackets
may leave gaps between these parts thus
decreasing the mechanical strength and
these areas act as plaque retentive areas thus
increasing chances of crevice corrosion37.
There are also greater chances of galvanic
corrosion in laser welded brackets.
CHAPTER 2
3. Titanium brackets have a rough surface as
compared to other metal brackets so there
are greater chances46 of plaque
Selection
Titanium brackets should ideally be selected
in patients with nickel allergy. As the surface
hardness of titanium is comparable to that of
teeth, titanium brackets cause less tooth
wear. So these brackets can also be selected
for deep bite cases and patients having
bruxism to avoid tooth wear.
accumulation and discoloration.
Titanium brackets may undergo crevices and
pitting corrosion47, 48 when used with fluoride
containing mouthwashes.
Precious metal brackets
Precious metal brackets are usually steel
brackets plated with precious metals18 like gold,
platinum and palladium (Figure 2.22). Of these
brackets 16, 18 and 24 karat gold plated
brackets are most commonly used especially in
lingual orthodontics. Gold is historically used
for different dental prosthesis because of its
property of non-reactivity. Traditional
edgewise brackets were made of gold but due to
the higher cost associated with it; gold has
universally been replaced by stainless steel
brackets and wires. No study was found in
literature on torque expression, hardness and
friction properties of these brackets. It is
Figure 2.22. A 22 karat plated gold bracket
30

Selection of Precious metal brackets
These brackets can be used in nickel sensitive
patients. As these brackets are usually
expensive so it is an aesthetic preference by
the patient over titanium brackets in nickel
sensitive patients. These brackets are still a
popular choice for manufacturers in lingual
orthodontics because of easy machinability
with gold metal.
generally assumed that these brackets behave in
the same way as steel brackets as the core of
these brackets is made of stainless steel.
Plastic Brackets
The first commercially available plastic
brackets were introduced49 in 1963 by Morton
Cohen and Elliott Silverman. Plastic brackets
are either translucent or transparent to fulfill
aesthetic demand during treatment and to make
the treatment less visible. Plastic brackets are
usually manufactured from plastic injection
molding and are good alternative of metal
brackets for patients having nickel allergy.
Conventional plastic brackets were made of
unfilled polycarbonate. These brackets were
associated with certain drawbacks. Some of
these drawbacks are given below:
1. They undergo water absorption in the
oral cavity. Water absorption has
plasticizing effects on the brackets with
resultant decrease in mechanical properties
of the brackets. Staining, increase bacterial
growth over the brackets and foul odor
from the mouth are also reported
disadvantages of unfilled polycarbonate
plastic brackets.
2. The unfilled polycarbonate plastic
bracket has a stiffness which is 60 times 50
less than that of stainless steel brackets.
This decreased strength problem is further
aggravated by plasticizing effect of water
absorption. Giving torque to the teeth on
31
Material perspective of Orthodontic Brackets
rectangular wires engaged in plastic
brackets is extremely difficult if not
impossible because deformation or creep51,
52
of the bracket slot occurs.
3. Wings fracture of plastic brackets is also
common because of decreased strength and
wear resistance.
4. Plastic brackets offer greater friction to
wires on sliding mechanics as compared to
stainless steel brackets because of rough
surfaces of bracket slot. Also the slot of the
bracket is softer than SS wires so there are
greater ploughing effects on sliding steel
wires.
5. Some conventional unfilled plastic
brackets need application of special
primer53 for bonding.
6. Plastic brackets have been reported52, 54
to have lower shear bond strength as
compared to conventional brackets.
7. Polycarbonate plastic brackets are
produced by the reaction of Bisphenol A
and phosgene CoCl2. There are
biocompatibility issues 55 with
polycarbonate brackets due to Bisphenol A
release.
Advancement in plastic brackets
To overcome the problems of conventional
plastic brackets, different materials were used
for manufacturing of plastic brackets. These
materials include polyoxymethylene, filled
polycarbonate, polyurethane brackets and
hybrid polymers.
Plastic Polyoxymethylene Brackets
In 1997 plastic polyoxymethylene brackets
were introduced 56 (Figure 2.23). The
manufacturer claims that these brackets have
better color stability, physical properties, low
friction resistance and safe debonding
Material perspective of Orthodontic Brackets
characteristics. Researchers have voiced
concern50 over the use of these brackets for
orthodontic purpose as it was shown that these
brackets release toxic formaldehyde in the oral
cavity on degradation.
Figure 2.23 Polyoxymethylene bracket by Forestadent
Simple or medical grade polyurethane is used to
manufacture modern plastic brackets (Figure
2.24). Unfilled polyurethane57 is usually used
for bracket manufacturing. These brackets don't
need a special primer for bonding and usually
has a mechanical retentive base. These brackets
don't use plasticizer and have shown to have
increased strength, good color stability, less
friction resistance. These brackets are either
tooth colored or transparent.
Figure 2.24 Orthoflex by Ortho Technologies (Medical
grade polyurethane)
CHAPTER 2
Composite plastic brackets
To overcome the problems of unfilled
polycarbonate brackets, fillers were added to
polycarbonate brackets so the term composite
brackets was originated. Later fiber glass
reinforced, ceramic reinforced and hybrid
copolymer brackets were included under the
name of composite brackets (Figure 2.25).
To solve friction and to some extent slot
creep problems, the slot of plastic brackets
was replaced57 by austenitic stainless steel,
niobium, silver and Ag-Cu alloy. It is
claimed51 that these composite plastic brackets
overcome all the disadvantages related to
conventional unfilled polycarbonate brackets,
however, controversy exist58 about this claim.
Jia and colleagues59 showed that modern
plastic brackets perform better with certain
bonding cements and have acceptable 57 bond
strength.
Conventional plastic brackets were superseded
by ceramic brackets but advancement in
composite brackets and drawbacks of ceramic
brackets has given renewed clinician interest in
plastic brackets as they are safer for enamel
integrity59 both during treatment and at
debonding.
Figure 2.25 Composite bracket
Selection of plastic brackets.
In plastic brackets ideally composite or
polyurethane plastic brackets should be
32

selected. Plastic or composite brackets are
good choice for patients with aesthetic
concerns requiring minor tooth movement
usually in adult patients. A patient having
nickel allergy is also a good candidate for
plastic brackets but plastic brackets with
stainless steel slot should be avoided .In cases
requiring sliding mechanics metal lined slots
in plastic brackets or a combination of plastic
and metal brackets is also used. Canine to
canine plastic brackets are given to fulfill
patient's aesthetic concern and posterior
metal brackets are used for efficient sliding
mechanics. This method is effective in cases
where no considerable torque on anterior
dentition is needed. Owing to decrease wear
resistance of plastic brackets and safe
debonding characteristics plastic brackets are
also used in patients with esthetic concerns
and where ceramic brackets are
contraindicated. Those cases are deep bite
cases, enamel hypoplasia, enamel cracks and
root canal treated teeth.
Ceramic Brackets
Ceramics are broad class of inorganic materials
which are neither metallic nor polymer.
Ceramics includes glasses, clays, precious
stones and metal oxides. Ceramic is 3rd known
hardest material and is harder60 than stainless
steel and enamel.
Ceramic brackets were introduced in the early
1980s and extensively marketed in the mid-
1980s to make patients braces less visible. As
ceramic brackets are transparent or translucent
they mask the appearance of fix orthodontic
appliances.
Advantages of ceramic brackets
Ceramic brackets provide high bond strength,
superior aesthetic, high wear resistance and
better color stability over the plastic brackets.
Because of shortcoming of plastic brackets
33
Material perspective of Orthodontic Brackets
ceramic brackets have gained increased interest
especially in adults. Ceramic brackets are inert
and can safely be bonded in patients with nickel
and chromium allergy.
Disadvantages
High bond strength, extra hardness and brittle
nature of ceramics are the causes of different
disadvantages associated with ceramic
brackets. Some of the disadvantages are as
follows.
1. Due to increase hardness there is
difficulty in debonding, more chances of
enamel damage and bracket fracture on
debonding and tooth attrition61.
Clinical notes
Heavy forces can cause fracture of ceramic
brackets. Heavy forces are usually applied
during accidental impact or during debonding
of ceramic brackets. Such scenario can be
avoided by practicing recommended
debonding techniques and avoiding bonding
ceramic brackets in patient involved in sports
where chances of accidental impact is greater
such as footballers ,boxers etc.
Enamel wear or tooth attrition occurs from
ceramic brackets in clinical practice
especially on upper incisor edges or their
lingual aspects in deep bite cases or if lower
brackets were bonded too incisal. Attrition of
upper canine tips can also occur if upper
canines come in contact with the lower canine
ceramic bracket during canine retractions in
class 2 cases.
Proper placement of ceramic brackets is
always mandatory as for all other types of
brackets. If the patient has some
parafunctional habit, ideally ceramic
brackets in lower arch shouldn't be placed.
Deep bites should be opened up before
placing ceramic brackets on lower dentition.
Material perspective of Orthodontic Brackets
Deep bites can be opened by the intrusion of
upper incisors, proclining upper incisors,
placing bite blocks or using bite turbos.
Placing metal or plastic brackets on lower
dentition is also a viable option in deep bite
cases. The same is true to avoid canine
attrition during canine retractions.
2. Discoloration of ceramic brackets also
occurs in cases with longer treatment time
and due to stress corrosion 62, 63.
Clinical Notes
In clinical practice many times the main
reason for selecting ceramic brackets are
aesthetic concerns of the patients. But
unfortunately the aesthetic results of ceramic
brackets are not absolute. Some
polycrystalline brackets discolor with time if
used with some specific diet. It is reported
that caffeine containing diet, lipstick and
mouth washes discolor64 the polycrystalline
ceramic brackets. No mix adhesives have
been contraindicated with ceramic brackets
by Swartz60 because they discolors with time.
So while using polycrystalline brackets no
mix adhesives should be avoided and the
patient should be advised regarding the
potential chances of bracket discoloration
from diet or life style factors.
3. Ceramic, being the 3rd hardest material is
harder than stainless steel wires.
Clinical Notes
Ceramic brackets are harder than stainless
steel wires so they offer greater friction in
closing extraction spaces on sliding
mechanics. So loop mechanics are preferred
with ceramic brackets on closing spaces. For
sliding mechanics ceramic brackets with metal
slots should be used or combination of anterior
ceramic and posterior metal brackets can also
be used.
CHAPTER 2
To avoid posterior anchorage loss while
retracting anterior dentition on sliding
mechanics, anchorage should be reinforced
with implants, headgear, and TPA Nance
appliance. A safe way for enmass retractions of
anterior dentition is to use implant in posterior
part of the arch for anchorage reinforcement.
Canines can also be retracted ahead of incisors
to decrease anchorage demands.
Some clinicians use round wires to decrease
friction during tooth movement which results
in roller coaster effect resulting in increase in
overbite and enamel wear of upper incisors by
lower ceramic brackets. It is better to use
ceramic brackets with metal slots on
rectangular wires than retracting teeth on
round wires.
4. Due to brittle nature of ceramics there is
always danger of ceramic bracket fracture
on engaging heavier wire in brackets slots or
if there is torsion in the wire. Torque
expression characteristics of ceramics are
poor.
Clinical Notes
Using tight steel ligatures increases the surface
roughness of bracket wings and so decreases
their fracture strength. Always avoid too much
tightening of the steel ligatures on ceramic
brackets. Extra care should also be exercised
while cutting these ligatures as the sharp cutter
may leave scratch marks on the bracket surface
or may accidentally cut the bracket wings.
Giving increase torque on a rectangular wire
can also lead to bracket slot fracture. Engaging
full dimensions rectangular wires in the slot
sometimes also lead to bracket fracture.
Progressive torque should always be given in
ceramic brackets. Using same dimension NiTi
or TMA wires are a better option before moving
to steel wires. In cases involving full
engagement on steel wires like orthognathic
surgeries, or fixed functional appliances
ceramic brackets should not be used.
34

5. Ceramic brackets are radiolucent and so
can't be detected by x rays if accidentally
aspired or swallowed during debonding.
6. Ceramic brackets have increased bond
strength as compared to other brackets. So
these are contraindicated 65 in patients with
enamel cracks, restorations or devitalized
teeth, hypoplastic teeth and hypocalcified
teeth.
7. Ceramic brackets are made bulkier to
resist fracture. Bulkier brackets are more
conspicuous and may cause soft tissue
injury.
8. Ceramic is bonded with directional ionic
and covalent bonds66. These brackets cannot
be debonded like metal brackets
Clinical notes
To avoid ceramic brackets fracture semi twin
design is used instead of true twin design.
Tying elastic ligature in semi twin brackets
require a heavier force of insertion and
different wrist movement than used in tying a
ligature in conventional brackets.
There are three types of ceramic brackets used
for orthodontic purpose which are made of
aluminum oxide, Zirconia or calcium
phosphate.
1. Aluminum oxide or Alumina (Al2O3)
Brackets
Alumina is formed when aluminum is added
to steel to remove dissolved oxygen from the
steel. For orthodontic purpose alumina may
be used in two ways60, 67.
1. S i n g l e c r y s t a l m a t e r i a l o r
Monocrystalline brackets
2. Multiple crystals or Polycrystalline
brackets
35
Material perspective of Orthodontic Brackets
Monocrystalline Brackets
Monocrystalline brackets are also called clear
sapphire or monocrystalline sapphire brackets
(Figure 2.26). Monocrystalline brackets were
initially manufactured from naturally
occurring sapphire but contemporary
monocrystalline brackets are manufactured
from synthetic sapphire. Monocrystalline
brackets have a clear transparent appearance.
Monocrystalline brackets are manufactured by
melting pure aluminum oxide particles on
temperature above 2100 °C and then allow it to
cool slowly thus permitting complete
crystallization. This results in a single large
crystal rod or bar of aluminum oxide from
which brackets are milled by using various
cutting tools (ultrasonic cutting techniques,
diamond cutting or Nd:YAG lasers). As a result
of milling, stresses are introduced into the
crystal which is relieved by heat treatment 60, 68.
Figure 2.26 Monocystalline bracket
Polycrystalline Brackets
As polycrystalline brackets contain multiple
crystals of alumina hence are called
polycrystalline (Figure 2.27).
These brackets are manufactured by sintering
of aluminum oxide. The process involves
blending of micron size (average particle size
0.3 μm) aluminum oxide particles using a
Material perspective of Orthodontic Brackets
binder and molding the mixture into desired
shape.
The molded part is then heated at temperature
which is in excess of 1800 °C but below the
melting point of aluminum oxide, to burn out
the binder particles and the molded mixture is
fused together. Magnesia69 is used in sintering
process of the manufacturing of polycrystalline
brackets to facilitate growth of grain
boundaries of crystals.
Diamond cutting tools are then used to machine
the slot of brackets. Heat treatment is also done
to reduce stress and imperfections. Heat
treatment after machining must be carefully
controlled to prevent further grain fusion which
could detract the physical properties of the
brackets. The particle size of final ceramic
bracket is between 20 to 30 μm.
Molding of polycrystalline brackets can also be
done by ceramic injection molding which does
not require the parts to be machined and so
eliminate structural imperfection caused by the
cutting process. The injection molded brackets
have shown to have increased fracture
resistance68.
The larger the crystal size of a polycrystalline
bracket less would be grain boundaries, clearer
would be the bracket, however bracket become
weaker when the grain size reaches 30
micron60.
Figure 2.27 Polycrystalline Bracket
CHAPTER 2
Zirconia Brackets
Zirconia (ZrO2) is material extracted from the
beach sand of Australia .Partially stabilized
Zirconia brackets were introduced as an
alternative to polycrystalline alumina brackets
to have better fracture resistance(Figure 2.28).
Polycrystalline Zirconia brackets are
manufactured by mixing ultrafine Zirconia
powder with 5% by weight yttrium oxide. By
the impression molding technique specific
bracket shape is given and sintering is done.
Hot isostatic pressing is employed to remove
residual porosity from brackets.
Stabilized polycrystalline Zirconia brackets are
cheaper and have greater fracture resistance
because of the phase transformation toughness
among all ceramic brackets while
controversy76, 77 exist whether they have
equivalent or better friction properties over
other ceramic brackets. As polycrystalline
zirconium oxide brackets are opaque and have
a yellowish tint as compared to polycrystalline
brackets, so these brackets failed to gain much
popularity as an aesthetic appliance.
Figure 2.28 Coby Zirconia ceramic brackets by YDM
Cooperation
Calcium phosphate ceramics
A new type of orthodontic brackets has been
introduced by Tomy international Japan which
36

Table 7.Comparison between Monocrystalline and Polycrystalline Bracket
Monocrystalline brackets
1. Monocrystalline brackets are transparent as
they contain a single crystal of aluminum
oxide.
2. Monocrystalline brackets resist staining.
3. Monocrystalline brackets are expensive70
because shaping single crystal into bracket by
cutting tools is a delicate process.
4. Monocrystalline brackets have greater71 tensile
strength .The tensile strength of
monocrystalline brackets is 1800 MPa.
5. Monocrystalline fracture strength decreases 66
with time.
6. Monocrystalline brackets though having
greater tensile strength fracture easily 66, 72 than
polycrystalline brackets. Monocrystalline
brackets being made from a single crystals
fracture at once due to lack of grain boundaries
and so are more brittle.
7. Monocrystalline brackets have more smooth
surfaces than polycrystalline brackets but have
equivalent friction resistance73.
8. Bond strength values of monocrystalline versus
polycrystalline brackets are controversial in
literature 72, 74.
is made of calcium phosphate ceramics .The
manufacturer of this bracket claims that these
brackets have excellent biocompatibility, low
friction properties and hardness equivalent to
the enamel surface, which eliminates fears of
dental abrasion due to contact with tooth
surface even when the patient has deep-bite. No
37
Material perspective of Orthodontic Brackets
Polycrystalline brackets
Polycrystalline brackets have decreased optical
clarity and are translucent. In polycrystalline
brackets as the binder is involved in manufacturing
process to fuse multiple particles so there are
greater chances of impurities in bracket as
compared to monocrystalline brackets. Also
multiple crystals in polycrystalline bracket mean
increases in the number of grain boundaries and so
decreases in optical clarity.
Polycrystalline brackets discolor with time if used
with some specific diet.
Polycrystalline brackets are inexpensive because
the molding process is simple and large quantities
of brackets can be manufactured.
The tensile strength of polycrystalline brackets is
380 MPa which is less than monocrystalline
brackets.
Polycrystalline bracket strength remains unchanged
with time.
Polycrystalline brackets have multiple grain
boundaries which resist crack propogation.
Polycrystalline brackets have a rough surface as
compared to monocrystalline brackets.
information is available by the manufacturer
about the exact composition and
manufacturing technique of this bracket.
Calcium phosphate is usually used in dentistry
for bone prosthesis. It has been reported78 that
calcium phosphate ceramic brackets have
lower but clinical acceptable bond strength
Material perspective of Orthodontic Brackets
than conventional ceramic brackets and these
brackets don't cause enamel damage.
Selection of ceramic brackets
Ceramic brackets are usually selected for
patients who have aesthetic concerns. Due to
iatrogenic damages associated with ceramic
brackets they should only be selected when
clinicians have proper knowledge of
mechanics and proper instrumentation for
debonding is available.
Monocrystalline brackets give better
aesthetic than polycrystalline brackets but are
more expensive and fracture easily and more
with time. Zirconia brackets are rarely used in
contemporary orthodontics. Calcium
phosphate ceramics is manufactured by only
one company and not much is known about
these brackets so selection of these brackets is
a personal preference.
References
1. Hotz RP. The changing pattern of European orthodontics. Br J Orthod
1973; 1:4-8.
2. Matasa C. Characterization of used orthodontic brackets. In: Eliades
G, Eliades T, Brantley WA, Watts DC, eds. Dental Materials in Vivo:
Aging and Related Phenomena. New York, NY: Quintessence;
2003:141–156.
3. Zinelis S, Annousaki O, Makou M, Eliades T. Metallurgical
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33. Eliades T. Passive film growth on titanium alloys: physicochemical
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44. Martyn CN. The epidemiology of Alzheimer's disease in relation to
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46. Harzer W, Schröter A, Gedrange T, Muschter F. Sensitivity of
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toothpaste and tea. Angle Orthod. 2001 Aug;71(4):318-23.
47. Reclaru L, Meyer JM. Effects of fluorides on titanium and other
dental alloys in dentistry. Biomaterials. 1998;19:85–92.
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49. Brandt S. JCO interviews Dr Elliott Silverman, Dr Morton Cohen,
and Dr A. J. Gwinnett on bonding. J Clin Orthod 1979 ; 13:236-51.
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deformation characteristics of orthodontic polycarbonate brackets. Am
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52. Aird JC, Durning P. Fracture of polycarbonate edgewise brackets: a
clinical and SEM study. Br J Orthod. 1987;14:191–195.
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55. Suzuki K, Ishikawa K, Sugiyama K, Furuta H, Nishimura F 2000
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56. Foerster R. Plastic orthodontic bracket for retaining wire bridge
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of modern plastic brackets. Eur J Orthod. 2012 Oct;34(5):595-602.
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Strengths of Plastic Brackets With a Mechanical Base, Angle
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brackets bonded to enamel. Am J Orthod Dentofacial Orthop.
1993;104:21–26.
60. Swartz ML. Ceramic brackets. J Clin Orthod. 1988 Feb;22(2):82-8.
61. Douglass JB. Enamel wear caused by ceramic brackets. Am J
Orthod Dentofacial Orthop. 1989 Feb;95(2):96-8.
62. Michalske TA, Bunker BC, Freiman SW. Stress corrosion of ionic
and mixed ionic/covalent solids. J Am Ceram Soc. 1986;69:721–724.
63. Salem J, Powers L, Allen R, Calomino A. Slow crack growth and
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64. Ghafari J. Problems associated with ceramic brackets suggest

limiting use to selected teeth.Angle Orthod. 1992 Summer ;62 (2) :145-
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65. Bishara SE, Trulove TS. Comparisons of different debonding

techniques for ceramic brackets: an in vitro study. Part I. Background
and methods. Am J Orthod Dentofacial Orthop. 1990 Aug;98(2):145-
53.

66. Flores DA, Caruso JM, Scott GE, Jeiroudi MT. The fracture strength
of ceramic brackets: a comparative study. Angle Orthod. 1990
Winter;60(4):269-76.

67. Birnie, D. Ceramic brackets. Br. J. Orthod., 17:71-5, 1990.

68. Bordeaux JM, Moore RN, Bagby MD. Comparative evaluation of

ceramic bracket base designs. Am J Ortho Dentofacial Orthop. 1994. 1
O5:552-560.

69. Soni K, Thompson A, Harmer M, Williams D, Chabala J, Levi-Setti

R. Solute segregation to grain bondaries in MgO doped alumina. Appl
Phys Lett. 1995;66:2795–2797.

70. Scott GE Jr. Fracture toughness and surface cracks—the key to

understanding ceramic brackets. Angle Orthod. 1988; 58:5–8.

71. Johnson G, Walker MP, Kula K. Fracture strength of ceramic

bracket tie wings subjected to tension. Angle Orthod. 2005
Jan;75(1):95-100.

72. Viazis AD, Cavanaugh G, Bevis RR. Bond strength of ceramic

brackets under shear stress: an in vitro report. Am J Orthod Dentofacial
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73. Cacciafesta V, Sfondrini MF, Scribante A, Klersy C, Auricchio F.

Evaluation of friction of conventional and metalinsert ceramic brackets
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74. Klocke A, Korbmacher HM, Huck LG, Ghosh J, Kahl-Nieke B.

Plasma arc curing of ceramic brackets: an evaluation of shear bond
strength and debonding characteristics. Am J Orthod Dentofacial
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contemporary ceramic brackets, master's thesis,University of Detroit,
1990.

76. Springate SD, Winchester LJ. An evaluation of zirconium oxide

brackets: a preliminary laboratory and clinical report. Br J Orthod
1991; 18: 203–9.

77. Keith O, Kusy RP, Whitley JQ. Ziconia brackets: an evaluation of

morphology and coefficient of friction. Am J Orthod Dentofac Orthop
1994; 106: 605–14.).

78. Meguro D, Hayakawa T, Kawasaki M, Kasai K. Shear bond strength

of calcium phosphate ceramic brackets to human enamel. Angle Orthod.
2006 Mar;76(2):301-5.

40
 CHAPTER
Selection of Bracket Base
3
In this Chapter

Bracket Base Retention Design Precious metal Brackets

Stainless steel Brackets Plastic Brackets
Chemical Retention
Mechanical Retention
Mechanical Retention
Perforated bases
Combination of chemical and mechanical
Mesh type bases
retention
Integral bases
Ceramic Brackets
Photoetched bases
Chemical Retention
Microetced bases
Mechanical Retention
Metal sintered bases
Micromechanical retention
Laser structured bases
Ceramic brackets with prestressed base
Plasma coated brackets
Combination of different retention designs
Chemical Retention
Bracket base surface area
Stainless steel brackets and Cross
infection Bracket base shape

Titanium Brackets Bracket identification marks

Cobalt Chromium Brackets Torque in the Base

The base component of orthodontic brackets Bracket Base Retention Design

makes possible the attachment of a bracket to
the tooth. This attachment must be strong
enough to transfer orthodontic forces from the
wires to the teeth, withstand masticatory loads
and should easily be removed at the end of
treatment.
Orthodontic brackets are attached to teeth or
other supporting structures of porcelain, metal,
composite and acrylic through various
commercially available adhesives. To increase
retention of bracket bases to adhesives various
chemical, mechanical or combination of both
retention designs have been added to the bracket
base. Though the exact manufacturing details

41
Selection of Bracket Base
are not provided from the manufacturer some
basic informations are available.
1) Stainless steel Brackets
Most orthodontic brackets used in
contemporary orthodontics are made of
stainless steel which mostly uses mechanical
retention because stainless steel doesn't form
any chemical union with adhesives. Stainless
steel bracket base is either integral part of the
bracket or is made separately and then joined
to the main body of the bracket by brazing or
welding (Figure 3.1).Different types of
stainless steel bracket bases are given in the
following text.
1. Perforated bases
Brackets with perforated bases are one of
the oldest bracket designs for mechanical
retention1 (Figure 3.2). The original metal
pad consists of one row of peripheral
perforation. The basic idea was to allow
greater penetration and free flow of
adhesive cement through the bracket base
to increase the bond strength. But
unfortunately excessive adhesive coming
out of the holes of bracket base was
potential plaque retention area which get
discolored with time so raised esthetic
concerns by the patients and don't provide
superior retention as compared to other
designs2,3,4,5,6. Because of these
disadvantages perforated bracket bases
went into disuse.
2. Mesh type bases
Mesh type bases have replaced perforated
bases and are most popular type used in
contemporary orthodontics. Following
different terms are used for mesh based
bases in literature and by manufacturer
owing to slight variation in mesh design.
CHAPTER 3
a) Foil mesh base
b) Gauze or woven mesh base
c) Mini mesh base
d) Micro mesh base
e) Optimesh base
f) Ormesh base
g) Laminated mesh base
h) Single mesh base
I) Double mesh base
j) Supermesh base
Description of some important mesh
designs is as follows.
a) Foil mesh base
In orthodontic literature the term foil
mesh base is used interchangeably with
gauze or woven mesh base. But there are
slight differences in the manufacturing
design between foil mesh and woven
mesh base (Figure 3.3) .Foil mesh bases
are more esthetic and hygienic than
perforated bases because of their smooth
covered surface 2, 3, 7, 8 . Foil and woven
mesh bases provide superior retention
than perforated bases and many other
bracket base designs used in
contemporary orthodontics 4, 7, 9. Foil mesh
bases can be simple or microetched,
photoetched or plasma coated by the
manufacturer. The foil mesh is either
brazed or welded on to the bracket base.
The spot welding of foil mesh to bracket
base results in decreased base surface
areas and so bond strength 2, 4, 10 therefore
spot welding have been taken over by
silver based laser welding 11.
Foil mesh bases can be single mesh or
double mesh.
42
 Selection of Bracket Base
Figure 3.1 Bracket bases can either be integral part of the bracket made by casting or MIM procedure or these bases can be
made separately and then joined to the main body of bracket by brazing or welding process. A. Bracket base made separately by
casting and joined by brazing to base of the main bracket body. This design of base usually adds to the height of the bracket making
the brackets more conspicuous. Increase height of the bracket also effects its torque expression. B.A gauze mesh made separately
and brazed to the bracket base. Brazing in this part of the bracket decrease the flow of adhesive in the mesh and decreases the bond
strength. C. A bracket mesh which is integral part of the bracket made by MIM.

Figure 3.2 A perforated base. Due to discoloration of
the bonding adhesive coming out of the perforated bases
these brackets raised esthetic concerns by the patients.
Brackets with perforated bases have been abandoned from
mainstream orthodontics.
43
Figure 3.3 Difference between foil mesh base and
woven mesh base. A. Woven or gauze mesh base. In woven
mesh or gauze mesh base two separate wires of same
diameter are woven over each other B. Foil mesh base. In
foil mesh base a single wire is used to make the mesh base.
Selection of Bracket Base
a) Single mesh base
Single mesh base also known as
monolayer base has a single layer of
mesh attached to the bracket base (Figure
3.4). Single mesh base is the most
popular design used in orthodontic
brackets.
b) Double mesh base
Double mesh is also known as bilayer or
dual mesh (Figure 3.5). Superficial layer
of double mesh is coarse mesh (80gauge)
while deep layer is fine mesh (150 gauge)
12
. In terms of effectiveness Bishara13
found comparable bond strength of
single and double mesh brackets.
Figure 3.4 A single mesh base. Single mesh base is one of
the most popular designs in orthodontic brackets.
Figure 3.5 Double mesh base of woven type. The
diameter of wire in outer mesh is increased while the inner
mesh has decreased mesh diameter.
CHAPTER 3
c) Super mesh
Super mesh base is a type of double mesh
base that consist of superficial or outer
mesh of 100 gauge over a deep or inner
mesh of 200 gauge.
Clinical Notes
Single mesh can be easily recycled and
reused. In double mesh recycling by thermal
or sandblasting method can leave adhesive in
deep layer thus decreasing the bond strength
of recycled brackets.
Following characteristics of a mesh base should
be kept in mind while selecting mesh based
bracket bases14.
1. Mesh Number or size or Mesh gauge
Defined as number of openings of a mesh
per linear inch from center of the wire to
center of the wire 3, 13. Mesh size reported in
orthodontic literature ranges from 40 to 100
gauge (40, 60, 70, 80,100 gauge). So a 40
gauge mesh has 40 openings per linear inch
.More is the gauge number finer would be
the mesh. 100 gauge is a fine mesh while 40
gauge is coarse mesh. In literature up to 80
gauges mesh is taken as coarse mesh 1, 12.
Literature about selecting proper mesh
number is controversial and support
increase bond strength for coarse mesh
11,15,16,17
, fine mesh 4,9, 60 gauge 3,18,19, 60 to 70
gauge 16, 100 gauge mesh 20.Cucu21found
no clinically significant difference between
80 gauge and 100 gauge mesh. A personal
view of this author after going through
many manufacturers' websites is that single
80 gauge mesh was most manufactured base
design.
2. Wire diameter of the mesh
Though the manufacturer never reveals the
exact diameter of the wire used for making
44
 Selection of Bracket Base
of mesh shouldn't be confused with mesh
diameters of brackets. Wire diameter of
mesh should be optimum as increased
diameter will hinder adhesive flow while
the decrease in wire diameter will increase
the risk of wire breakage and faulty mesh
design.

3. Aperture diameter or mesh diameter

It is the diameter of a single mesh opening.

It's usually given in microns or micrometer
(µm) .In literature 13, 16 it ranges from 75 to
700 µm. Mesh diameter may be equal to
wire diameters of the mesh in case of a fine
mesh or greater than its wire diameter in
case of coarse mesh. Increasing wire
diameter will decrease the aperture
diameter (Figure 3.7).

Figure 3.6 A.60 gauge mesh. B. 80 gauge mesh. C. 100

gauge mesh. Greater the number of opening per linear inch
greater would be the mesh number.

mesh of bracket bases but studies have

shown various diameters. Usually more the
mesh number less is the wire diameter. The
wire diameter is usually given in inches or
micrometer (µm) and ranges in literature
Figure 3.7 Both brackets have 80 gauge mesh. Bracket A
from 0.0021 to 0.0080 inch. Wire diameter has increase aperture diameter while bracket B has
increased wire diameter.
45
Selection of Bracket Base
4. Open area %
It's the total amount of open area on a
bracket base available for adhesive
penetration and depends upon the aperture
diameter. Greater the aperture diameter
greater is the open area percentage.
Sandblasting and microetching also
increases the open area percentage. A
greater open area % helps better penetration
and more room for adhesive thus increases
the bond strength of the bracket (Figure
3.8). In literature 13,16 the open area
percentage ranges from 21.2 % to 55.5% of
the bracket base surface area.
Figure 3.8 Two debonded brackets. Bracket A has more
open area %, so the adhesive is still retained in the mesh of
the bracket due to better penetration. Bracket B has less
penetration of the adhesive due to decreased open area %.
CHAPTER 3
Clinical Notes
The choice of adhesive is correlated with the
choice of the bracket mesh. Greater the mesh
number lesser would be the aperture
diameter, so a less viscous or less filled
adhesive would be required to flow into the
opening of the mesh. If the mesh number of
the bracket is increased a point will be
reached at which the contact angle of
adhesive with metal will prevent the flow of
adhesive in a single aperture. Decreasing the
filler contents of adhesive to increase its
viscosity will decrease its strength and also
increase correct bracket position difficult
because increased flow of adhesive will slide
the bracket downward in time interval
between bracket placement and adhesive
curing.
Decreasing the mesh number will many
times decrease the wire diameter of the mesh.
Such brackets are poor choices for recycling
as mesh wire will break during debonding or
during recycling especially with
sandblasting (Figure 3.9).
Also the increased open areas have its
limitation. An excessively increased open
area will decrease mechanical retention of
the adhesive and so the bond strength.
Figure 3.9 60 gauges woven mesh on recycling with 90
micron aluminum oxide. As the diameter of the wire in
mesh decreased there are greater chances of wire damage on
recycling. A damaged mesh will provide poor mechanical
retention to brackets and so decreases their bond strength.
46
 Selection of Bracket Base
e) Sandblasted foil mesh

Some clinician use chair side sandblasting

units to roughen the mesh and increase its
mechanical retention (Figure 3.10).
Sandblasting is usually done with 50 µm
aluminum oxide particles for 5 seconds
maintaining a distance of 10 mm from the
handpiece tip to bracket base. The line
pressure is maintained at 90 psi 22.
Sandblasting the bracket for more than 9
seconds can damage the foil mesh. Most
clinician uses sandblasting on deboned
brackets to recycle them rather than doing it
on new brackets.

Figure 3.11 A. An integral base with pits in the base.

Figure 3.10 A foil mesh base sandblasted to increase the
bond strength by giving macro and micro retention to the
adhesive. Macro retention is provided by openings of
bracket mesh and microretention is produced by
sandblasting.
3. Integral bases
Integral bases are fabricated in one unit with
the brackets. They are manufactured by
casting (cast integral base), milling
(machined integral base) or metal injection
molding (MIM) procedure. Integral bases
have furrows, pits and undercut channels for
retention 23(Figure 3.11). There is conflict in
literature 9, 18, 22, 23, 24, 25 regarding bond strength
of integral bases.
4. Photoetch bases
Such smaller pits provide greater open areas in the bracket
base but this open area is too large to provide good
mechanical retention to the bracket. The bracket base is
sandblasted to increase the bond strength by
microretention. B. A integral base made by casting of 304
SS. Open area of the bracket is optimum for providing good
adhesive flow and mechanical retention.
process that removes metal using a chemical
reaction and thus creating small indentation
in the bracket base. In this process parts of
bracket base that are to be etched are exposed
to chemical while the other parts are covered
with a photo etching resistant material. The
whole process is done using the computer
generated templates for etching in a clean
controlled environment. The photo etched
processes can also be applied to foil mesh
bases to increase their mechanical retention
(Figure 3.12). Photoetched bases have
reported4,7,25 less bond strength than foil mesh
bases .

Photoetching or photochemical etching is a

47
Selection of Bracket Base
Figure 3.12 Photoetch foil mesh to increase bond
strength.
5. Microetced bases
Microetching of brackets is done by the
manufacturer by a grit blasting procedure
(Figure 3.13). Microetching of brackets in
dental office can be done by sandblasting
.Microetching does a more uniform etching
than the photoetching.
Figure 3.13 A bracket by GAC with microethed bases.
These types of brackets only provide microretention for
adhesives.
6. Metal sintered bases
In this type of bases a porous structure is
created on the bracket base by fusion of metal
powder or ceramic particles to increase
mechanical retention of the base.
CHAPTER 3
7. Laser structured bases
These bracket bases are treated with a laser
beam (Nd:YAG) to create retentive holes by
burning out the metal (Figure 3.14).The laser
structured bases have increased bond
strength than mesh type bases 26.
Figure 3.14 The laser structured bases of discovery
brackets by Dentaurum. A. A new laser structured base. B.
A recycled base after sandblasting. New laser structured
base has better bond strength than mesh type bases but laser
structured bases recycled by sandblasting or flame method
has poor bond strength.
8. Plasma coated brackets
In this process finely grounded metallic and
non-metallic materials are deposited on a
bracket base in a molten or semi molten state
thus increasing roughness and surface area of
bracket base. Plasma coating can be done on
mesh foil bases or on a smooth base. Even a
 Selection of Bracket Base
A

D E

F G
Figure 3.15 A&B .These sticky packings should be avoided. C. Properly packed brackets. D, E, F show insects or their
body parts in sticky bracket packings. G. Corrosion product of the bracket bases .As bracket bases continuously remain in
touch with liquid solution so their corrosion occur. These pictures are from some well reputed companie's products. The
situation is much worse with other companies.

49
Selection of Bracket Base
smooth plasma coated brackets have shown
accepted bond strength 27.
Chemical Retention
Although stainless steel brackets predominantly
use mechanical retention some clinicians have
also reported salinated mesh on grooved bases
25
. Commercially available silane coupling
agents can also be applied to silanized metal
brackets to give chemical retention to the
brackets. Silica plus silane coating of stainless
steel brackets is usually done with brackets
recycled by sandblasting or flame method to
increase their bond strength.
Stainless steel brackets and Cross infection
Usually orthodontists use the bracket in the as
received state and don't go for sterilization of
the brackets as this may affect bracket
properties. It is thought that these brackets have
been kept and packed by the manufacturer in an
aseptic environment. Unfortunately that's not
the case with many of the brackets we get from
renowned manufacturers. Packing of the
brackets is very important and in some
packings it's usually the base part of the
bracket which is attached to the packing base,
is involved in cross infection (Figure 3.15.)
Selection of Stainless steel bracket bases
In stainless steel brackets, foil or woven
mesh type bases are universally used. The
mesh number of the bracket should be
selected in accordance with bonding
adhesive the orthodontist uses. As filled
adhesive is used mostly in contemporary
orthodontics it's my personal experience
that 80 gauge mesh is suitable for most of
the luting adhesives.
Double mesh and super mesh bases are poor
in recycling so are laser structured bases. The
new laser structured mesh has the highest
bond strength but has poor strength after
recycling so it is good for single use only.
CHAPTER 3
Rest of the base designs should be selected on
personal experience.
Mechanical retention is best suited with
stainless steel brackets. Chemical retention
should be avoided both with new and
recycled brackets.
Packing using sticky substances for
attaching the brackets to packing should be
avoided.
Titanium Brackets
Titanium brackets like stainless steel brackets
uses mechanical retention in the form of mesh
or laser structured bases. The only difference
between SS brackets and titanium brackets is
the presence of titanium oxide layer in titanium
brackets which form a chemical bond with the
adhesive. So chemical retention is also
provided because of material properties of the
brackets. The same selection principles of
stainless steel brackets base applies to the
titanium brackets.
Cobalt Chromium Brackets
Cobalt chromium brackets base can provide
both mechanical and chemical retention (Figure
3.16). Mechanical retention is provided with
mesh base type similar to stainless steel
Figure 3.16 NV ® Hybrid Bracket with poly mesh base
from TP orthodontics.
50
 Selection of Bracket Base
brackets. Chemical retention is provided with
covering the bracket base with a chemical layer
(PrimeKote® polymer by TP orthodontics).
The polymer mesh base provides better
penetration of curing light so it also increases
the bond strength of brackets (Figure 3.16).
Selection of CoCr bracket is similar to SS bases.

Precious metal brackets

Precious metal bases have main body of

stainless steel that is coated with precious
metals so these brackets use the same form of A
bracket base design as SS brackets. Mostly
precious metal bracket bases uses mesh type
retention design (Figure 3.17).

B
Figure 3.18 A . Single unit plastic brackets with
mechanical retention base. B. A two unit plastic bracket with
mechanical retention base.Both units are joined together by a
strong adhesive .

Types of Plastic brackets base

Chemical retention

Chemical retention is added to some plastic

Figure 3.17 80 gauge mesh base of 22 karat gold plated
bracket
Plastic Brackets
Plastic bracket base can either be integral part of
the bracket in a single unit bracket made by
plastic injection molding or individual parts of
the plastic brackets are made by casting of
plastic material (Figure 3.18). These individual
parts are than joined together by a strong plastic
adhesive. For retention of adhesive cements
plastic brackets uses either chemical,
mechanical retention or combination of both.
51
brackets by application of special primer 19.
However some researchers have disputed that
chemical retention is provided with application
of this primer. They claimed28 that application of
plastic primer which is methyl methacrylate
polymer causes swelling of plastic bracket base
and so increase the penetration of adhesives in
the base of bracket.
Clinical Notes
Plastic brackets have decreased bond
strength than ceramic and metal brackets. As
recycled plastic brackets have mostly lower
bond strength than new brackets so to
increase their bond strength silane coupling
agents can be added to the bracket base.
Selection of Bracket Base
Some experimental studies29 have also used
silica coatings and silane coupling agent to
plastic brackets to increase their bond strength.
Mechanical retention
Contemporary plastic or composite brackets
usually use mechanical retention for bonding.
Mechanical retention is provided in the form of
grooves, undercut channels, round-angled
square protrusions or mesh (Figure 3.19).
Micromechanical retention can also be added
by sandblasting the bracket base30.
Figure 3.19 Different retention base design of plastic
brackets.
CHAPTER 3
Combination of chemical and mechanical
retention
Some contemporary plastic brackets use
combination of mechanical and chemical
retention. Chemical retention is provided with
application of plastic bracket primer on bracket
bases before bonding and mechanical retention
is provided by mean of undercuts channels.
Selection of plastic brackets base
Plastic brackets with only chemical retention
are usually not available in contemporary
orthodontics. Mechanical retention base or a
combination of mechanical and chemical
retention base can be selected as no
difference in terms of bond strength have
been reported between different bracket base
designs .
Ceramic Brackets
Ceramic bracket base is usually manufactured
in one unit with the main bracket body. In
ceramic brackets, bases are available in four
different designs to aid retention of adhesive.
These are:
1) Chemical retention
2) Mechanical Retention
3) Micromechanical retention
4) Bracket using the combination of above
designs
1) Chemical retention
Ceramic is an inorganic inert material so it
doesn't form any union with organic
adhesives used for bonding of orthodontic
brackets. To aid retention of adhesives on
ceramics, coupling agents are used.
Coupling agents are used to provide a stable
bond between two otherwise nonbonding
and incompatible surfaces. Orthodontic
52

ceramic bracket bases are coated with silane
coupling agents to provide chemical
retention for the bonding adhesives. Prior
to application of silane coupling agents
ceramic bracket bases are also silica coated 31.
Silanes are silicone compounds which are
bifunctional molecules that contain both
organic and inorganic reactives in the same
molecule.
There are many types of silane coupling
agents, but for ceramic brackets trialoxy
silanes are used with following formula.
Where R group is a nonhydrolyzable organic
radical X is a hydrolyzable group typically
alkoxy, halogen,chlorine or amine. The most
common alkoxy groups are methoxy, ethoxy
or acetoxy, which reacts with water to form
silanol (Si-OH) and ultimately form an
oxane (Si-0-M) bond between the inorganic
substrate.
To make things simple this is the R group of
one end of the molecule that unites with the
luting adhesive and X group at the other end
of molecule that unites with silica coated
ceramic bracket bases (Figure 3.20).
Figure 3.20
53
Selection of Bracket Base
Ceramic brackets using chemical retention
by addition of silane coupling agents have a
smooth shinny surface and are usually
marketed by the manufacturer.
Chemical retention by silane coupling
agents to ceramic brackets was given in
early days to offer strong retention for
successful marketing of brackets(Figure
3.21). However it was not without
disadvantages. The biggest disadvantage
was enamel fracture during accidental
impact or debonding .This was due to high
bond strength, brittle nature and hardness
of ceramic brackets.
Clinical Notes
Silane coupling agents can also to be applied
in dental office by commercially available
preactivated silanes. They are available
either in one bottle solution in the form of
prehydrolyzed silane by 1-5 vol% in a
solution to ethanol and water. To increase
shelf life of silane coupling agent two bottle
solutions is also available. This system
consists of unhydrolzed silane with ethanol
in one bottle and acid solution (acetic acid or
carboxylic acid ) in the other bottle. The two
solutions are mixed to allow activation of
silanes.
Silane coupling agents can also be applied to
metal and plastic brackets to increase their
bond strength.
Figure 3.21 A ceramic bracket with chemical retention
base. Ceramic brackets with chemical retention base alone
are no longer manufactured and marketed.
Selection of Bracket Base
CHAPTER 3
Modification of Chemical retention base retention designs have been introduced into
contemporary ceramic brackets. Mechanical
Smooth surfaces of chemical retention base lead retention of ceramic brackets is provided with
to even stress distribution of debonding and dovetail grooves, undercut channels, round-
thus offer higher bond strength32. To angled square protrusions, protruded buttons or
counteract this problem chemical retentive laser structured bases (Figure 3.23).
base was made rough by protruding ceramic
crystals in polycrystalline brackets. Silane
coupling agents are applied to only the
protruding surfaces and not on the whole
bracket surface area thus decreasing the bond
strength and facilitating easy debonding.

Another modification to chemical retention

base was to add a thin polycarbonate laminate
usually an epoxy resin or polymer layer over the
chemically treated bracket bases so the union of
adhesive is with plastic bases rather than with
saline coupling agents (Figure 3.22). It has been
reported33 that with this base design bracket is
easily debonded in a peel off fashion like
metal brackets and so no enamel damage
occurs. This type of bracket design34 has lower
and clinically acceptable bond strength. Bond
failure of these brackets occurs at bracket
adhesive interference. Figure 3.23 Different mechanical retention base design of
ceramic brackets.

Mechanical retention using grooves have edge

angles at 90o and have crosscuts to prevent
sliding of brackets along the undercuts.
Because of this assembly35 in mechanical
retention by grooves, stress of debonding is
concentrated at localized area resulting in
bond failure at bracket adhesive interference.

As mechanical retention of ceramic brackets

Figure 3.22 InVu® brackets by TP orthodontics with
polymer mesh base. These brackets are debonded similar to
metal brackets.
Mechanical Retention
Chemical retention base of ceramic brackets is
associated with increased chances of enamel
damage due to increased bond strength. To
avoid iatrogenic enamel damage that is related
with chemical retention bases, mechanical
provides lower bond strength32 than chemical
retention bases so it doesn't cause any iatrogenic
effects on enamel during accidental impact or
debonding. Bond strength of mechanically
retained ceramic brackets depends upon its
design and is usually higher36 than metal
brackets.
Micromechanical retention
Micromechanical retention is given in the form
54
 Selection of Bracket Base
of randomly arrange crystals or spherical glass
particles emerging out of the bracket base in
polycrystalline brackets and in the case of
monocrystalline brackets a thin coat of crystals
is added to brackets base (Figure 3.24).

Figure 3.25 Ceramic bracket micro mechanical with

stress concentrator for easy debonding.

Combination of different retention designs

Mechanical retention can be combined with

chemical retention to decrease bond strength of
ceremic brackets. Mechanical and
micromechanical retention can also be
combined to give better retention of adhesives
on bracket base.

Figure 3.24 A bracket with micromechanical retention .A.

Monocrystalline bracket. B Polycrystalline bracket.

Ceramic brackets with prestressed base Figure 3.26 A Bracket using mechanical retention
grooves with silane coating to increase the bond strength.
Some polycrystalline bracket using
micromechanical retention has prestressed Clinical Notes
bracket bases (Figure 3.25).So when debonding Chemical retention of ceramic brackets
force is applied these brackets collapse at these
alone is usually not used in orthodontics.
prestressed areas and bond failure occur at
Apart from using various modified bracket
bracket adhesive interference or cohesive
base designs with ceramic brackets,
failure occur within the adhesive thus
orthodontist can decrease the bond strength
preventing enamel damage 37. These brackets
of these brackets by using low filled
have shown debonding properties similar to
adhesives 39, 40. Low filled adhesives have
metal brackets 38.
55
Selection of Bracket Base
CHAPTER 3
lower bond strength than high filled
adhesives.
Another alternative is to use glass ionomer or
resin modified glass ionomer41 cements
(RMGIC) with ceramic brackets as glass
ionomer cements have shown to have
decreased 42,43 but clinically acceptable bond
strength32, 44, 46 than composite resins . Though
bond failure of glass ionomer cement is
present at enamel adhesive interference but
no enamel damage is reported 44, 45 with this
adhesive cement because RMGIC has lower
Figure 3.27 Greater the retentive bracket base surface
bond strength. area greater would be the bond strength.If the base surface
area is not retentive then no matter how much wider is the
Glass ionomer cement also has the added bracket the bond strength will remain minimum or
advantage of fluoride release and so it bracket will fail to bond. The above brackets have
manufacturing faults which have increased the surface
prevents enamel decalcification and area but area is not retentive. So instead of favoring bond
formation of white spot lesions during strength the area can act as plaque reservoir and may lead
to development of white spot lesion under the bracket
orthodontic treatment. base.
of increasing or decreasing the bracket base
Selection of ceramic bracket base surface area. Proffit 48 purposed that width of
Ceramic bracket base using only chemical the bracket shouldn't be more than half of the
retention is neither marketed nowadays nor width of the tooth while MacColl49
should be used due to risk associated with recommended that bracket base surface area
enamel damage. All other commercially should be around 6.82 mm2. Usually the
available ceramic brackets are acceptable for manufacturer of brackets keep a larger base
orthodontic purpose as long as suitable or area to give better bond strength and rotational
recommended debonded techniques are control .
used. My personal recommendation after Clinical implication of Bracket base
going through all the available literature and surface area
personal experience is that ceramic brackets
with plastic base or prestressed base should Increase Bracket base surface area
be used as it debond safer than other base
Advantages
types.
This has the following advantages:
Bracket base surface area
1. Increased bond strength. This is helpful
An important technical specification that affects
especially in case of plastic brackets which
the bond strength of orthodontic bracket is its
offer less bond strength than other type of
base surface area. Most orthodontists presently
brackets. Clinically acceptable bond
use twin brackets. The surface area 26,47 of these
strength50 is around 5.9 to 7.8 Mpa but bond
brackets range from 12.5mm2 to 28.5 mm2.
strength shouldn't exceed 51 than 13.5Mpa to
Greater the retentive bracket base area greater
avoid enamel damage.
would be the bond strength and vice versa
(Figure 3.27). But there is practical limitations
56

2. Brackets with large bracket base areas can
cover the underside of wings so protecting
the tooth from plaque which usually
accumulates under the wings as this area is
most difficult to clean.
3. Larger bases also give better rotational
control and better tip expression.
Disadvantages
1. A large bracket base area will result in a
bulkier and more conspicuous bracket thus
rendering poor aesthetics.
2. Larger bracket base area is especially
damaging in ceramic brackets having
chemical retention as bond strength is
already much higher than recommended.
3. More adhesive needs to be placed on the
bracket base so more would be the cost of
bonding brackets.
4. A larger bracket base can interfere with
occlusion at one end and gingiva at the other
end.
Decreased Bracket base surface area
Decrease bracket base surface area means
smaller and more esthetic brackets which have
fewer chances to cause soft tissue and occlusal
trauma. But these brackets have less bond
strength, are difficult to fabricate, need a
stronger material for manufacturing and give
less coverage under the wings so lead to greater
chances of white spot lesion.
Note
Demineralization or development of white spot
lesion and its relation to bracket base surface
area is controversial topic. A larger bracket base
area means there are greater chances of leakage
and more chances of adhesive voids under the
bracket so greater chances of development of
white spot lesions. In turn smaller brackets don't
efficiently cover the wings of brackets. Under
57
Selection of Bracket Base
areas of wings are difficult to brush. So it has
greater chances of plaque accumulation and
development of white spot lesion. Both these
situations can be managed by optimum bracket
placement and adhesive curing by the
orthodontist and proper brushing by the patient.
Bracket base shape
Bracket base shape can be rectangular, round,
circular, rhomboid, oval and triangular (Figure
3.28). This difference is usually due to patent
issues. But whatever the overall shape of the
bracket the base of a bracket should be
compound contoured. A compound contoured
base mean that the base should have a shape that
matches with shape of tooth for which it is
made. For example as the labial surface of the
incisor is a flat the base of incisor brackets
should also be flat and that a canine bracket
base should be convex as the of canine labial
surface is convex. Another aspect of the bracket
base is its landing on the tooth (Figure 3.29). It
can be 3 point landings or 4 point landing. I
think again this is a patent issue and there is no
difference in bracket landing as long as bracket
bases are compound contoured.
Figure 3.28 Different bracket base designs in posterior
dentition. Many manufacturer claims self-purposed
advantages of these designs but this is basically more
related with patent of design than theoretical basis. All
designs are good as long as the bracket is compound
contoured and seats good on the tooth.
Selection of Bracket Base
Figure 3.29 3 point bracket base landing on the tooth
versus 4 point landing. This is a patent issue between
companies and don't hold clinical significance as long as
base is compound contoured
Bracket identification marks
Some manufacturers for ease of identification
places tooth notation systems on the base of
brackets (Figure 3.30).With these types of base
designs sandblasting to increase the bond
strength on new or recycled brackets should be
avoided as it will erase these identification
marks.
Figure 3.30 A lower right canine bracket.
Torque in the Base
A true characteristic of straight wire appliance is
that it should have torque in the base52-54. Torque
in base is built by the manufacturer by adjusting
the size of triangle in the base of the bracket
(Figure 3.31).
CHAPTER 3
Figure 3.31 Torque in base is built in by adjusting the size
of triangle in the base of bracket.
Andrew proposed that for proper bracket
placement the slot point (center of arch wire slot
) of bracket, the base point ( center of bracket
base ) of bracket and center of clinical crown
(FA point) should be in one line (Fig3.32).
Figure 3.32 In the ideal placed brackets the slot point the
base point and FA point should be in one line .This is only
possible when the torque is built in the base of the bracket.
In brackets in which torque is built in face of the
bracket the base point and FA point are in one
line but slot point don't coincide with them
(Figure 3.33). So when heavy wires are placed
such arrangements lead to vertical bracket
positioning errors though torque expression is
normal. These vertical position errors can range
0.7 mm in lower and 0.5 mm in upper arch. It is
usually claimed that these vertical positioning
errors will lead to different expression of torque
due to morphology difference of tooth surface.
The clinical significance of torque in the base
versus torque in the face is controversial 55.
58

Selection of bases on important variables
Ideally a bracket with torque in the base
should be selected to avoid vertical position
errors. The bracket should have a compound
contoured base (contoured both horizontally
and vertically). In selecting mini-series of
brackets the bracket base surface area
shouldn't be less than 6 mm2. In cases of
ceramic brackets less bracket base surfaces
are beneficial to bond strength, but the
potential benefit should not compromise the
overall strength of brackets.
Figure 3.33 Comparison of torque in the base versus
torque in the face. The torque in the face can cause the
vertical positioning errors.
59
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CHAPTER 3
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Orthod Dentofacial Orthop. 1992 Feb;101(2):138-44.
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resin-modified glass ionomer bonding systems in relation to ceramic
bracket debond. J Orthod. 2000 Dec;27(4):329-32.
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strength of three bonding agents with metal and ceramic brackets. Angle
Orthod. 1999 Oct;69(5): 457-62.
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orthodontic bases. Am J Orthod. 1980 Dec;78(6):630-9.
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in orthodontic force control . In: Proffi t W R (ed.). Contemporary
orthodontics. Mosby , St Louis , pp. 326 -362.
49. MacColl GA, Rossouw PE, Titley KC, Yamin C. The relationship
between bond strength and orthodontic bracket base surface area with
conventional and microetched foil-mesh bases. Am J Orthod
Dentofacial Orthop. 1998 Mar;113(3):276-81.
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1975;2:171-8.
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60

Selection of Bracket Slot
In this Chapter
Introduction
Type of bends for 3 dimensional tooth
movements
Dimensions of Edgewise slot
Accessary slots
Tip edge brackets
Advantages of 0.018” slot
Advantages of 0.022” slot
Introduction
Slot is part of the bracket in which the wire is
engaged to express the builtin prescription of
the bracket. The slot of the bracket has seen
much evolution with time. It started from
occlusal opening slot in Angle ribbon arch
appliance to gingival opening slot in Begg
appliance and front opening slot in Angle
edgewise system. In contemporary orthodontics
edgewise slot is universally accepted .Vertical
slots are still used in some bracket series but
usually as an accessary slot.
When bracket slot was first introduced they
were simple openings in which a bended wire
incorporating all the necessary tooth
movements was inserted. The brackets having
such passive slots were called standard
brackets. With time 1st, 2nd and 3rd order bends
61
CHAPTER
4
Bidemensional mechanics
Morphology of the brackets
Gingival offset brackets
Slot modifications to reduce friction
Ligation: The fourth wall of Bracket slot
Tie Wings of the brackets
were incorporated in brackets to produce
respective tooth movements 1. Before going into
the details of slot a brief description of these
bends and associated movements are given.
Type of bends for 3 dimensional tooth
movements
First order bends (In or out bends)
First order bends are given to accomplish first
order tooth movements which are in a
labiolingual or buccopalatal direction. 1st order
bends can be made in horizontal direction in the
wires such as the step bends, or are
accommodated in the brackets (Figure 4.1). As
different teeth in the arch have different width
these bends made in the wire or built into the
bracket are used to accommodate different tooth
width. Vertical step bends that don't change the
Selection of Bracket Slot
CHAPTER 4
angulation of the teeth are also considered as 1st
order bends. First order bends in brackets are
incorporated by increasing the prominence of
the bracket.

A B

C
Figure 4.1 A. A line showing different prominence of the teeth in natural dentition due to difference in width of the teeth. B.
Wire bending done to compensate 1st order tooth movement. This type of wire bending is usually done in conventional edgewise
system. C. First order bends built within the bracket. This is evident with different prominence of the brackets in upper arch.

Clinical Notes Second Order Bends (Tip or Angulation

The clinician should always use same
companie's brackets. If a bracket is
debonded either the bracket should be
recycled and reused or a new bracket of
same company should be used. Different
companies have different prominence of
the brackets(Figure 4.2). So using different
companie's brackets will result in first
order tooth position problems in a finished
case.
Figure 4.2 Maxillary lateral incisor brackets from two
different manufacturers having same builtin prescription.
The height or prominence of these brackets is different.
bends)
These bends are made in vertical plane in the
wire to accommodate tooth angulation and root
parallelism. Second order bends can also be
incorporated in the brackets by placing the slot
at an angle to the base (Figure 4.3).
Clinical Notes
Different bracket prescription have
different builtin tip. An experienced
clinician can use combination of brackets
from different prescription provided that
they have the same prominence. It is a good
practice to use brackets of single
manufacturer while altering the
prescription.
62
 Selection of Bracket Slot
fully be expressed on engagement of full
dimensional wire within the slot. If
clinician are keen on using light wires then
torque can be expressed by giving twist in
the wires or by using torqueing springs.

A B

C
A
Figure 4.3 A. 2nd order bends are for crown or root
movement in mesiodistal direction and can be incooperated
in the bracket (B) or can be made in the wire (C).

Third order bends (Torque)

B
Third order bends are used to position the roots
labial or lingual. Third order bends are placed in
the wire by twisting it in a clockwise or
counterclockwise direction. In case of brackets
3rd order bends are either placed in base or in
slot of the brackets but placing the torque in the
base is a preferred method (Figure 4.4).

Clinical Notes
Bracket prominence of different brackets
should be kept in mind when altering
bracket prescription for using customized
torque values.
C
Figure 4.4 A. 3rd order bends are for root movement in
labiolingual or buccopalatal direction .It can be achieved by
placing a twist in the wire (B) or building torque in the base
of the brackets (C ).

If a smaller dimension wire is engaged

within the bracket there would be play
between the wire and the bracket and all
torque within the bracket won't be
expressed. Torque built into the bracket can
63
Brackets with torque built in the face or slot of
the bracket can result in vertical position errors.
The brackets having no builtin in/out, tip and
torque are called standard edgewise brackets
introduced by Angle while brackets having all
Selection of Bracket Slot
these features builtin are called preadjusted
brackets introduced by Andrew.
A term usually confused by the students is
difference between tip and tipping movement.
Tip is the angulation of the tooth in the
mesiodistal direction while tipping is a type of
tooth movement. A tipping tooth movement can
result in decrease or increase of tip and torque of
a tooth.
Dimensions of Edgewise slot
The edgewise slot purposed by Angle and
carried forward by Andrew in preadjusted
brackets have two dimensions 2, vertical and
horizontal. In original edgewise slot the vertical
height which is height of base of slot or opening
of the face is 0.022 inch and horizontal length of
walls is 0.028 inch (Figure 4.5).
0.028”
0.022”
Figure 4.5 Slot dimension of a conventional edgewise
bracket. This slot dimension is still the most popular choice
in preadjusted edgewise appliance. The 0.022” dimension
is called base of the bracket while 0.028” is walls of the
bracket.
Modification of slot dimension
The original 0.022” slot was modified3 with
time into 0.018 x0.025 inch slot (Figure
4.6).The reason behind this modification was
that when edgewise appliance was introduced
by Angle, gold wires were used with 0.022” slot.
With the introduction of stainless steel in
orthodontics in 1930s orthodontist were
troubled with the use of full dimension stainless
steel wires in the slot which were 50 % more
stiffer than gold. As gold became very
expansive option with time the slot size of the
bracket was reduced to 0.018 inch. In this slot
CHAPTER 4
smaller dimension and so more flexible
stainless steel wires can fill the slot much more
early and easily. But introduction of stainless
steel also turned out to be a blessing in disguise
for the 0.022 “ slot . As the original edgewise
appliance introduced by Angle was meant for
only nonextraction cases and so filling the slot
was mandatory for expression of torque built
within the wires. As modern orthodontist
became more liberal and started doing
extractions where ever it deemed necessary so
the need to close the extraction space arises.
One popular way of doing it was sliding the
teeth on the wire which was more time efficient
than making loops on wires to close extraction
spaces.
Sliding mechanics plus the introduction of more
elastic wires which helps in initial leveling
and alignment has again turned the tide in
favor of 0.022” slot.
0.025”
0.018”
Figure 4.6 A bracket with 0.018x 0.025 inch slot.
Variations in 0.022” and 0.018” slot
Both 0.022” and 0.018” slots have variation in
the horizontal dimension. Theses variations are
basically for ease of mechanics. These are:
0.022”x0.030” slot and 0.018”x0.028” slot
The horizontal dimension in these variations is
increased so that the wire is fully seated in the
slot and express all the torque built within the
bracket .It is also useful when accessary wire is
needed to be passed along with main archwire
64
 in cases requiring piggy back mechanics and brackets and light round super elastic wires in

Selection of Bracket Slot

utility arches . case of tip edge plus brackets are used to move
the main archwire from open to closed
Accessary slots dimensions.
Accessory slots are available for ease of
mechanics in edgewise brackets (Figure 4.7).
Vertical slots are mainly available for use with
torqueing or tipping springs. Accessary
horizontal slot beneath the main slot is integral
component of tip edge plus brackets. Some
experimental brackets 6 also feature both 0.022”
and 0.018” slot in a single bracket but addition
of another slot in the bracket make the bracket
bulkier.
A

B
A
Figure 4.8 A tip edge and a tip edge plus bracket.Tip
edge plus bracket has a acessory slot in which a 0.014” or
0.016” superelastic NiTi wire is passed in final stages of
treatment.

Advantages of 0.018” slot

Using 0.018” slot has following advantages:

B 1. In 0.018” slot as smaller dimension wires
are used which have more flexibility than
Figure 4.7 A. A accessary horizontal slot attached to larger wires used in 0.022” slot so filling the
main horizontal slot. Such slots are used for piggyback
mechanics and intrusion arches. B. vertical slot are used slot is more early and easily achieved.
with auxiliary springs.
2. Smaller dimension of the 0.018” slot
Tip edge bracket mean that these brackets can be made
smaller than 0.022” slot brackets. Narrower
A variation of 0.022”x0.028” slot is found in tip
the brackets more would be the inter bracket
edge or tip edge plus brackets (Figure 4.8) . The
distance and increased would be the
bracket has open dimensions of 0.028”x0.028”
flexibility of the wires used. Increase
to accommodate tipping of teeth and close
flexibility of wire is essential in alignment
dimensions of 0.022”x0.028” to express final
and leveling. With advent of superelastic
torque. Auxiliary springs in case of tip edge
NiTi wires which apply light continuous
65
Selection of Bracket Slot
force this advantage of smaller dimension of
0.018 slot has turned clinically
insignificant.
3. Due to increased flexibility and gaps
between the brackets, wire loops or wire
bending can easily be incorporated between
the brackets 7. Also due to filling of slots
friction increase between the slots and the
wires. That's why 0.018” slot are more
favored by orthodontists who are good in
wire bending and prefer loop mechanics for
space closure. This doesn't mean that sliding
mechanics cannot be done on 0.018” slot.
Sliding mechanics can be done on these
brackets too but it is more efficient to do it
on 0.022” slot.
4. Using maximum engagement wire results
in more torque expression by 0.018” slot 8, 9.
This greater torque expression is important
in anterior dentition where torque loss occur
during retraction of these teeth. Detterline 10
reported that 0.018” slot is more time
efficient in surgical cases than 0.022” slot
because decompensation is easily done by
efficient torque expression.
5. It is reported10, 11, 12 that cases treated with
0.018” slot take less time than 0.022” slot
but the results are not clinically significant.
Advantages of 0.022” slot
The 0.022” slot has the following advantages.
1) The 0.022”slot due to its wider
dimensions offers more options in wire
selection.
2) The larger slot allows more easy insertion
of wires at the initial visits 13.
3) As undersized wires are used there is
more clearance between the slot and the wire
.So there is less binding of wire to slot 14.
Because of this reason 0.022” slot is
preferred by orthodontists who opt sliding of
CHAPTER 4
teeth on wires for space closure. Loop
mechanics for space closure can also be done
on 0.022” slot but these are more efficiently
done on 0.018” slot.
4) As larger dimension wires are used that
have higher stiffness .These wires keep teeth
upright during sliding mechanics.
5) 0.022” slot brackets are usually wider
than 0.018” slot though it not always the case
as in case of mini brackets. Wide brackets
have less contact angle between the wire and
the bracket slot. So less friction is offered by
the bracket (Figure 4.9). Also due to
increased width the moment arm of bracket
which is half the width of the bracket is
increased so these brackets offer better
rotational and root position control. Wide
brackets also provide greater bracket base
surface area and so increased bond strength.
A
B
Figure 4.9 A. Wider brackets have less contact angle
so offer less friction. B. Greater moment arm provided by a
wide bracket results in better control of root position during
tooth movement.
Bidemensional mechanics
Some clinicians 15, 16 favor to use advantages of
both 0.018” and 0.022” slots by combining both
in a single appliance. Incisor brackets with
0.018” slot and canine and posterior brackets
with 0.022” slots are used. With this technique
torque control is maintained 2 on incisors during
66
 anterior retraction or posterior protraction while
sliding mechanics on posterior teeth are easily
done. Bidimensional mechanics are more
popular in lingual than labial orthodontics.
In cases requiring extraction space closure with
sliding mechanics on ceramic brackets the
buccal segment is bonded with metal brackets
and labial segment with ceramic brackets. This
combination is also sometimes termed as
bidimensional mechanics. In this combination
anterior ceramic brackets preserve aesthetic
while posterior metal brackets help to reduce
friction during sliding mechanics. Also posterior
metal brackets help to reduce cost of treatment
as ceramic brackets are more expensive than
metal brackets.
Selection of slot
The selection of slot is more a matter of
personal choice. Usually clinician who
favor loop mechanics for space closure
prefer 0.018” slot while clinician who
choose sliding mechanics for space closure
favor 0.022” slot. But an experienced
clinician with wise choice of wires can do
both mechanics on both these slots. As
0.018” slot is more efficient in torque
expression, cases requiring greater torque
expression are usually treated with 0.0.18”
slot brackets. Such case included Class II
div 2, surgical cases requiring
decompensation and growth modification
cases.
According to a survey 1 7 54% of
orthodontists prefer 0.022 inch slot size,
40.5% used 0.018 inch slot and 5% used a
combination of above slots(bidimensional
mechanics) or some other bracket style.
To decrease confusion in selection of slot
size there are increased efforts by some
orthodontists to bring uniformity in slot size
and give it a standard measuring unit3,4,5,18.
67
Selection of Bracket Slot
Till this consensus is not reached the
clinician should select slot according to
space closing mechanics they prefer.
Brackets with vertical slot are good option
for clinicians who prefer to use light wires
during treatment and correct tip and torque
with auxiliary springs.
For selection of tip edge plus brackets the
clinician must have good knowledge of
mechanics used with that system. Tip Edge
plus brackets employ differential tooth
movement based on Begg's philosophy
which is far different than concept of bodily
movement used in preadjusted
orthodontics.
Bidemsional slot philosophy is usually used
in lingual orthodontics.
Morphology of the brackets
The brackets can be classified according to their
morphology into
1. Single slot brackets
When edgewise brackets were first made
available they had only one slot. So they were
called single brackets (Figure 4.10). Due to
single slot interbracket distance was
increased and these brackets were good for
the initial leveling, alignment and closing
spaces with loop mechanics. But these
brackets have poor rotational and tip control.
A B
Figure 4.10 A. Attract bracket by Ormco for pedo
patients. B. A single slot bracket in Alexander prescription.
Selection of Bracket Slot
2. Twin or Siamese bracket
This design of bracket has two slots. Most of
the contemporary brackets are available in
this design. Twin brackets are further divided
into true twin or semi twin brackets.
a) True twin brackets
In these brackets there are separate mesial
and distal tie wings. Twin brackets are
usually available in metal but can be made
in plastic or ceramic material (Figure 4.11).
b) Semi twin brackets
Figure 4.11 True twin Siamese (A) Metal bracket (B)
Polycrystalline ceramic bracket
CHAPTER 4
In these brackets a connecting arm is
present between mesial and distal tie wings
(Figure 4.12). Semi twin brackets are
usually ceramic or plastic brackets. Some
mini-series of metal brackets are also
available in semi twin design. The mesial
and distal tie wings are joined together to
give increased strength to the brackets.
Figure 4.12 Semi twin bracket in (A) Metal (B)
Polycrystalline Ceramic and (C) Composite plastic bracket
68

Clinical Notes
A clinical problem with use of semi twin
bracket is placement of ligatures. As most
orthodontists use standard twin brackets so
they have good reflexes to place the ligature
on these brackets. But placing ligature on
semi twin bracket need different rotation of
the wrist as the saddle area is covered by
arms connecting the wings. In true twin
brackets the initial direction of ligature
placement is vertical usually from gingival
to incisal wing but in semi twin brackets
because of saddle area obstruction it is
horizontal. As the horizontal distance in
most standard twin bracket is greater than
vertical distance so there is greater stretch
of the ligature in semi twin bracket during
its placement. This may lead to bracket
deboning on ligature tying. This is more
common with newly bonded plastic
brackets.
Both true twin and semi twin brackets can be
divided into standard size and miniature type.
Miniature or mini twin bracket as the name
indicates is smaller in size than the standard twin
bracket. The miniature size of metal bracket is
more common with semi twin brackets .Mini
twin brackets though are more aesthetic and less
conspicuous but has the disadvantages of
narrow brackets explained before. Mini twin
brackets are available in both 0.018” and 0.022”
slots.
Selection of bracket according to
morphology
In case of metal brackets true twin brackets
are strong enough to withstand orthodontic
loading and debonding forces. Mini
brackets have poor rotational and axial
control due to decreased moment arm and
would offer more friction on sliding
mechanics due to greater contact angle
69
Selection of Bracket Slot
between wire and bracket on sliding
mechanics. Mini brackets should ideally be
selected in only nonextraction cases.
True mini twin bracket made of metal is a
good choice in 0.018” slot but my personal
opinion is that it's not a good choice in
0.022” slot if someone is aiming for sliding
mechanics until all the clinical crowns are
small .
Mini brackets are added advantage in
ceramic brackets because decrease surface
area mean decrease bond strength but not a
good choice in plastic brackets because they
have already decreased bond strength.
Using semi twin bracket is a good option in
ceramic and plastic brackets.
Single bracket is really used because of
poor angulation and rotational control until
it's a part of a specific prescription.
Gingival offset brackets
Usually the slot of the bracket is universally
placed on the middle of the bracket base.
Many a time especially in young patients,
lower premolar clinical crown is short. Placing
the standard brackets in such scenario results
in interference of the bracket with occlusion
and also the base of bracket irritates the
gingiva (Figure 4.13). In such circumstances
slot of bracket is modified by placing it more
gingival on the base so that the gingival tie
wings are hardly covered by the base. This
modification prevents occlusal interference
and gingival irritation, while the bracket
maintains it optimum surface area to give good
bond strength 19. A randomized control clinical
trial 20 concluded that gingival offset
mandibular premolar brackets have lower bond
failure rate than standard brackets.
Many manufacturers make gingival offset
brackets for lower premolars but these brackets
Selection of Bracket Slot
A B
Figure 4.13 Comparison between normal and gingival
offset bracket. A . Gingival offset premolar bracket in which
the slot is placed more gingival on the base. B. Normal
premolar bracket .Slot is placed in the middle of the bracket.
are also a good choice in upper premolars
where optimum placement of bracket is
hindered by gingiva due to short clinical
crown.
Slot modifications to reduce friction
Friction in orthodontics is especially a problem
during tooth movement. Friction is offered from
the slot, wires and oral environment. Friction
from the slot is especially a problem in case of
ceramic and plastic brackets. To reduce friction
some manufacturers have replaced the slot with
metal usually stainless steel, titanium, gold and
niobium (Figure 4.14).
A B
Figure 4.14 A .Plastic bracket with stainless steel metal
slot. B. Polycrystalline ceramic bracket with metal lined SS
slot.
CHAPTER 4
Clinical Notes
Stainless steel slot aesthetic brackets should
not be used in nickel allergic patients.
Metal slot ceramic brackets shouldn't be
recycled with flame method because it will
discolor the slot thus jeopardizing the
esthetic value of brackets.
Limitation of metal slots in aesthetic brackets
Metal slot used in aesthetic brackets are usually
placed after the bracket is manufactured and
held within the slot of bracket by unknown
material. The hardness of this material is usually
not known and can affect the torque expression
of brackets. In many ceramic brackets it is
noticed that material flow in the slot thus
decreasing slot dimension and increasing
friction resistance. Usually there are void
between the slot and bracket that act as plaque
retention area thus obliterating the esthetic
advantage of the brackets. The finishing of slot
is also poor as compared to much cheaper metal
brackets (Figure 4.15).
In plastic brackets the metal slot is effective in
sliding mechanics but not in torque expression
and creep or expansion of the slot occur on
giving torque in the wire (Figure 4.16 ).
Apart from metal lined slots some ceramic
bracket slots are silica lined 21 to give better
aesthetics and decrease friction. Some
manufacturer make bumps in the floor to
decrease friction resistance on sliding
mechanics but effectiveness of such slots is just
a manufacturer claim and not evidence based 22
(Figure 4.17).
Chamfered Slot Walls
Slot walls of the bracket are chamfered or
rounded for easy insertion of wires, increase
inter-bracket distance and decrease friction
(Figure 4.18). Rounding of slot walls and floors
70
 Selection of Bracket Slot
A B C
Figure 4.15 A. A ceramic bracket with metal attached to the bracket by unknown material. Also base of the bracket is irregular
offering greater friction. B. A new ceramic bracket with foreign material on slot base and walls. Also slot design is not elegant as
there is some part of ceramic on both mesial and distal sides of the slot base .If this ceramic is at the level of slot it will increase
friction resistance and if it slightly below the level it will act as a plaque retention area. C. Gaps between metal slot wall and
bracket slot wall. These gaps will act as a potential plaque retention area and will also affect the torque characteristics of the
brackets.

A Figure 4.17 A bracket with bump or hump in base of

bracket. Such design does not decrease friction resistance
but make full insertion of the wire in the slot difficult thus
effecting the torque characteristics of the brackets.

more expansive than metal brackets but

B inspection of brackets slots should be done.
Figure 4.16 A. Corrosion in base of the slot in just 4
months of clinical use of a plastic bracket. In metal lined
aesthetic brackets both clinician and manufacturer are more
focused on the plastic or ceramic part and less on metal part
which led to embracement in clinical cases. B. A slot wall
distorted by introduction of 15° torque in 0.019”x0.025”
wire .Even a metal slot in plastic bracket is usually not
enough to withstand extra torque application because thin
walls of metal slot are not supported well by plastic behind
it.
Selection of modified slots
In cases requiring sliding mechanics on
aesthetic brackets metal slot is always an
advantage. Though aesthetic brackets are
their metal slot has not the level of
perfection found in metal brackets. While
selecting these brackets a careful physical
Stainless steel slot should be avoided in
nickel sensitive patients. Plastic brackets
with metal slot are good in sliding
mechanics but poor in torque expression.
So cases in which extra torque is required
such as class II div 2, palatally or buccally
displaced teeth and impacted teeth plastic
brackets should be avoided even they are
with metal slot.
Slight chamfering of the slot is
advantageous but too much chamfering will
increase the dimensions of the slot and so
increases the wire play. Rounding of the slot

71
Selection of Bracket Slot
base or humps to decrease friction
resistance is not evidence based so selection
of these brackets is only a personal choice.
A teeth, piggy back mechanics and surgical
B
Figure 4.18 A. Chamfered slot walls of a ceramic bracket
.B. A composite bracket with rounded slot base. This type of
slot base is made so that the wire only touches the walls of
the brackets and a minimum base area. Decrease friction
offered by these slot bases is not evidence based but these
bases are known to increase wire play in the slot.
increases torque play and result in decrease in
effective torque expressed from the brackets.
Ligation: The fourth wall of Bracket slot
Wires once inserted into the slot should remain
within the slot till next appointment. As the
edgewise bracket slot has three fixed walls, so
there is a fair chances that the wire will come out
of the slot opening until or unless a mechanism is
present that make up the fourth wall of the slot
and prevent the wire from coming out. This
fourth wall is traditionally been provided by
ligatures.
Traditional wire ligatures were used to keep the
wire within the slot. For many decades thin
stainless steel wires were used as ligatures
which provide durable, cheap and effective
ligation. Though stainless steel ligature are still
used but due to increased chair side time which
is on the average23 11 minutes to tie these
ligature, steel ligatures are taken over by elastic
ligatures.
CHAPTER 4
Clinical notes
Steel ligatures though largely have been
taken over by elastic ligatures are still used
in cases where there is a need to express
more torque i-e lower arch in growth
modification cases , impacted canines and
cases in which teeth are palatally or
buccally displaced. Steel ligature are also a
reliable mechanism of ligation in rotated
cases. Steel ligatures are also used on teeth
undergoing translation because if wisely
ligated they offer less friction as compared
to elastic ligatures.
Elastic ligatures are mostly used in
contemporary orthodontics for ligation of wire
within the slot. Elastic ligatures though
provide very good ligation at the time of
insertion have a rapid force decay rate and
almost half of the force is lost in the first 24
hours 24. They also get discolor with time so
increases esthetic concern of the patients. To
overcome these problems associated with steel
and elastic ligatures self-ligating brackets were
introduced. Though the history of self-ligating
bracket is very old starting back to 1935 but
they have only gained much popularity in the
last decade 25.
Self-ligating brackets are available in all type of
materials in which conventional brackets are
available. Self-ligating brackets are of two types
depending upon the type of ligation they
provide. (Figure 4.19)
1. Active self-ligating brackets
2. Passive self-ligating brackets
Active self-ligating brackets are one in which
ligating clip is occupying some of the slot space.
This clip is flexible and caries some energy.
While the passive self-ligating clip doesn't cover
the slot space and is usually hard. So an active
clip will push a rectangular wire into the slot and
in some grossly displaced teeth round wire is
72

A Archambault found that active stainless steel
B Advantages over conventional brackets
Figure 4.19 A . Forestadent active self ligating bracket.
B. A passive self-ligating bracket.
also pushed in, while a passive clip will simply
prevent the wire whether round or rectangular
from coming out of the slot.
Too much have been written on self-ligating
brackets and its proposed benefits in different
orthodontic books. In following text only
evidence based findings would be given.
Oral hygiene
A systematic review by Nascimento 26 found no
evidence of self-ligating brackets related to less
formation of streptococcus mutans colonies as
compared to conventional brackets. So claims
by manufacturers that these brackets are more
hygienic are not evidence based.
Treatment time and initial pain
A systematic review by Celar 27 found no
evidence that self-ligating brackets are related
with less initial pain, less number of visits and
less treatment time than conventional brackets.
Friction resistance
Ehsani 28 in a systematic review concluded that
self-ligating brackets show less friction
resistance on round wires if used on well aligned
arches but there is no evidence of decrease
73
friction resistance on rectangular wires. A low
Selection of Bracket Slot
29
level of evidence suggested that there is no
clinically significant difference in terms of
friction resistance between active and passive
self-ligating brackets on SS wires.
Torque Expression
30
self-ligating brackets show less wire play than
passive self-ligating brackets. So there would
be more torque expression from active self-
ligating brackets than passive self-ligating
brackets.
Fleming 31 after a systematic review concluded
that there is insufficient evidence for use of self-
ligating fixed orthodontic appliances over
conventional appliance systems or vice versa.
Chen et al 32 in a systematic review found that
current evidence only support that with use of
self-ligating bracket there is shortened chair
time and slightly less incisor proclination over
conventional systems.
Tie Wings of the brackets
The tie wings of the bracket act as a retention
area to hold the ligatures. Ideal tie wings should
Selection of self-ligating brackets
Evidence mentioned above make it clear
that selection of self-ligating bracket is a
matter of personal choice. Self-ligating
brackets are expensive than conventional
brackets so the Orthodontists must evaluate
cost versus benefit before selecting self-
ligating brackets. From the present
evidence self-ligating brackets seem to be a
better choice in growth modification cases
and nonextraction cases having lower arch
crowding or increased lower incisor
inclination. Active self-ligating brackets
should be preferred over passive self-
ligating brackets.
Selection of Bracket Slot
have following characteristics.
1) Tie wings should have ample under wings
area to hold the ligature .Down draft under tie
wings provide more safe and easy ligation
(Figure 4.20).
A
B
Figure 4.20 A. A metal bracket with down draft tie wing.
B. A ceramic bracket with straight tie wing .Such tie wings
provides poor retention for ligature.
Clinical Notes
Placing ligatures is especially a problem in
mandibular incisors where the brackets are
small to match the smaller teeth (Figure
4.21). The problem is further aggravated
when the lower incisor also needed to be
lace-backed. So brackets with ample under
tie wings area should be selected especially
in lower incisors.
Figure 4.21 A lower incisor bracket with smaller tie
wings .Placing ligature on these tie wings is extremely
difficult especially when laceback wire is also passed
through these brackets to make units of teeth
CHAPTER 4
2) Tie wings should be rounded or chamfered
to avoid soft tissue injury.
3) Tie wings should be strong enough to with
stand force of ligation.
Clinical Notes
Many clinicians make gingival tie wings longer
to facilitate easy ligation (Figure 4.22). But
using longer tie wings will increase play of the
wire. Brackets with longer tie wings should be
avoided in cases requiring special torque
requirement.
Figure 4.22 Bracket with longer gingival tie wings
References
1. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972;
62:296-309.
2. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th ed.
St Louis, Mo: Mosby Elsevier; 2007:376–377.
3. Peck S. Orthodontic slot size: it's time to retool. Angle Orthod. 2001
Oct;71(5): 329-30.
4. Kusy RP, Whitley JQ. Assessment of second-order clearances between
orthodontic archwires and bracket slots via the critical contact angle for
binding. Angle Orthod 1999;69:71-80.
5. Kusy RP. "Two" much of a good thing? Then let's pick one slot size and
make it metric. Am J Orthod Dentofacial Orthop. 2002 Apr;121(4):337-8.
6. Shen G, Chen RJ, Hu Z, Qian YF. The effects of a newly designed twin-
slot bracket on severely malpositioned teeth--a typodont experimental
study. Eur J Orthod. 2008 Aug;30(4):401-6.
7. Swartz ML. Comprehensive fixed appliance therapy. In: McNamara JA,
Brudon WL, eds. Orthodontics and Dentofacial Orthopedics. Ann Arbor,
Mich: Needham Press; 2001:149–151.
8. Epstein MB. Benefits and rationale of differential bracket slot sizes: the
use of 0.018-inch and 0.022-inch slot sizes within a single bracket system.
Angle Orthod. 2002;72:1–2.
74
 9. Sifakakis et al . Torque expression of 0.018 and 0.022 inch conventional time. J Orofac Orthop. 2013 Jan;74(1):40-51.

Selection of Bracket Slot

brackets. Eur J Orthod. 2013 Oct;35(5):610-4.
28. Ehsani S, Mandich MA, El-Bialy TH, Flores-Mir C. Frictional
10. Detterline DA, Isikbay SC, Brizendine EJ, Kula KS. Clinical outcomes resistance in self-ligating orthodontic brackets and conventionally ligated
of 0.018-inch and 0.022-inch bracket slot using the ABO objective grading brackets. A systematic review. Angle Orthod. 2009 May;79(3):592-601.
system. Angle Orthod. 2010 May;80(3):528-32.
29. Krishnan M, Kalathil S, Abraham KM. Comparative evaluation of
11. Vu C, Roberts WE, Hartsfield JK, Ofner S. Treatment complexity index frictional forces in active and passive self-ligating brackets with various
for assessing the relationship of treatment duration and outcomes in a archwire alloys. Am J Orthod Dentofacial Orthop. 2009 Nov;136(5):675-
graduate orthodontics clinic. Am J Orthod Dentofacial Orthop. 82.
2008;133:9.e1–e13.
30. Archambault A et al Torque expression in stainless steel orthodontic
12. Amditis C, Smith LF. The duration of fixed orthodontictreatment: a brackets. A systematic review. Angle Orthod. 2010 Jan;80(1):201-10.
comparison of two groups of patients treated using edgewise brackets with
31. Fleming PS, Johal A. Self-ligating brackets in orthodontics. A
0.0180 and 0.0220 slots. Aust Orthod J. 2000; 16:34–39.
systematic review. Angle Orthod. 2010 May;80(3):575-84.
13. Frantz RC. Achieving excellence in orthodontics with a selfligating
32. Chen SS et al .Systematic review of self-ligating brackets. Am J Orthod
appliance system. In: Graber TM, Vanarsdall RL, Vig KW, eds.
Dentofacial Orthop. 2010 Jun;137(6):726.e1-726.e18; discussion 726-7.
Orthodontics: Current Principles and Techniques. 4th ed. St Louis, Mo:
Mosby; 2005:834–836.

14. Mclaughlin RP, Bennett JC, Trevesi HJ, systemized orthodontic

treatment mechanics , mosby 2001.

15. Schudy FF, Schudy GF. The bimetric system. Am J Orthod. 1975;
67:57–91.

16. Gianelly AA, Bednar JR, Dietz VS. A dimensional edgewise technique. J
Clin Orthod. 1985; 19:418–421.

17. Keim RG, Gottlieb EL, Nelson AH, Vogel DS. 2002 JCO study of
orthodontic diagnosis and treatment procedures: part 1: results and
trends. J Clin Orthod. 2002; 36:553–568.

18. Rubin RM. A plea for agreement. Angle Orthod 2001; 71.

19. Thind BS, Larmour CJ, Stirrups DR, Lloyd CH.An ex vivo assessment
of gingivally offset lower premolar brackets. J Orthod. 2004
Mar;31(1):34-40.

20. Thind BS, Stirrups DR, Hewage S. Bond failure of gingivally offset
mandibular premolar brackets: a randomized controlled clinical trial. Am
J Orthod Dentofacial Orthop. 2009 Jan;135(1):49-53.

21. Russell JS. Aesthetic orthodontic brackets. J Orthod. 2005 Jun;

32(2):146-63.

22. Thorstenson JA, Kusy RP. Resistance to sliding of orthodontic brackets

with bumps in slot floors and walls: effects of second-order angulation.
Dent Mater 2004; 20: 881–892.

23. Shivapuja PK, Berger J. A comparative study of conventional ligation

and self-ligation bracket systems. Am J Orthod Dentofac Orthop.
1994;106:472–480.

24. Taloumis LJ, et al. Force decay and deformation of orthodontic

elastomeric ligatures. Am J Orthod Dentofac Orthop. 1997;111:1–11.

25. Graber LW, Vanarsdall RL & Vig KW Orthodontics: Current Principles

and Techniques. 5th ed. E: Elsevier; 2011.

26. do Nascimento LE, de Souza MM, Azevedo AR, Maia LC. Are self-
ligating brackets related to less formation of Streptococcus mutans
colonies? A systematic review. Dental Press J Orthod. 2014 Jan-
Feb;19(1):60-8.

27. Čelar A, Schedlberger M, Dörfler P, Bertl M. Systematic review on self-

ligating vs. conventional brackets: initial pain, number of visits, treatment

75
 Selection of Bracket Slot
CHAPTER
4

76

Selection of Auxiliary and convenience features
In this Chapter
Auxiliary features
Power arms
Accessary slots
Convenience features
Vertical Mid Scribe line
Shape of brackets
Bracket identification
Many auxiliary and convenience features are
added to the brackets and tubes to make
treatment mechanics easier and convenient.
Auxiliary features
Power arms
Power arms are added to the brackets on its
gingival side to control root position during
translation of the teeth. The reason for making
power arms on gingival side is to bring the force
application closer to the center of resistance of
the teeth. Andrew1 proposed that for effective
control of root position during translation, the
mesiodistal length of bracket plus height of
power arm should be equal to distance from the
slot point to tooth center of resistance (Figure
5.1). As root of canine is longer than other teeth
so power arm of canine tooth would also be
77
CHAPTER
5
longer than other teeth. But there are practical
limitations in increasing the width of bracket
and height of power arm. A wider bracket will
decrease interbracket distance so increasing the
wire stiffness and thus greater time would be
needed in alignment and leveling. Also a wider
bracket will be more noticeable, thus increasing
aesthetic concerns of the patients. The height of
power arm is limited by soft tissue present
around the tooth as long power arm will
impinge on the gingiva either making ideal
bracket placement difficult or leading to
gingival hyperplasia due to soft tissue
impingement.
Advantages of power arm
1. Power arm makes the application of force
delivery system such as springs, power
chains, and elastics much easier and close to

Selection of Auxiliary and convenience features
the center of resistance of the tooth.
2. Power arm also gives a better retention
area for the ligatures and settling elastics
during finishing stage of treatment (Figure
5.2). So power arm is helpful even the tooth
doesn't need translation.
3. Power arms are also helpful in
orthognathic surgery in tying of surgical
splints to the main archwire and the brackets.
Figure .5.1 Where
A = Distance between the middle of bracket or slot point to
center of resistance of the tooth
B= Mesiodistal length of the bracket
C= Height of the power arm
An ideal bracket on a tooth needing translation should follow
the following rule: A=B+C. This is very important
mechanical consideration while selecting brackets. If a
wider bracket is selected than B is increased in equation so C
should be decreased to accommodate B. If this is not done
and contemporary mechanics are followed where some play
is present between wires and brackets then extra tip would be
expressed by the brackets. Greater the play of the wire in the
brackets greater would be the extra tip expressed. The
opposite is true in smaller or miniseries brackets where B is
small and C needs to be large to accommodate B. If this is not
done, there would be loss of tip during tooth translation.
CHAPTER 5
Figure 5.2 A case with settling elastics .The upper
premolar bracket has a kobayashi hook attached to help
better retention of settling elastics. On canine bracket
elastics can easily be attached as it got an integral bracket
hook.
Clinical Notes
The direction of translation is the key in
selecting power arm. The power arm should
always be present in direction of translation.
If a tooth needs protraction during treatment
as in case of upper 1st premolars extraction
with moderate anchorage, the upper second
premolar is moved forward so power arm
should be present on mesiogingival side of
the 2nd premolar bracket. In same
extraction case canine needs to be retracted
in the extraction space so power arm
should be on distogingival aspect of canine
bracket (Figure 5.3).
In distalization of molars, both canines and
premolars are moved backward or retracted,
so power arms should be present on
distogingival side of the brackets on both
premolars and canines.
In situation where canines and premolars are
moved forward as in case of generalized
spacing the canine's bracket should ideally
have a hook on it's mesial. Unfortunately
most cases in contemporary orthodontics
need canine's retraction so manufacturers
make canine's brackets with distal power
arms and orthodontists have no other
choice to use these brackets. In case power
arm is not present on the ideal side of the
bracket then there are greater chances of
tooth rotation while translation.
78

A B
Figure 5.3 A. Right lower 2nd premolar bracket with
power arm on mesial side .This bracket is useful in lower 1st
premolar extraction with moderate anchorage, where 2nd
premolar needs mesialization. B. Left lower 1st premolar
with distal power arm. This type of bracket is useful in lower
2nd premolar extraction where power modules can be added
from molars to 1st premolars on distal power arm.
The shape of the power arm can be rounded,
mushroom shaped or in the form of a hook
(Figure 5.4). Hook design power arm allows
easy engagement of power modules but takes
more time in placement of ligatures and are
usually less acceptable by the patients. To
address this problem most manufacturers
make ball end power arms.
A B
Figure 5.4 A left
upper canine with (A)
rounded (B) mushroom
C shaped (C) hook shaped
power arm.
79
Selection of Auxiliary and convenience features
Selection of power arm on brackets
The power arm should be on gingival side of
the bracket and in the direction of
translation. For teeth with long roots the
power arm should also be long though
mostly this criterion is not fissible for the
orthodontists to fulfill.
Miniseries brackets available in the market
shouldn't be selected in extraction cases
where space after extraction is closed by
translation of teeth. Mini brackets having
small mesiodistal length should have long
power arms, which is usually not the case
with commercially available mini brackets.
These brackets are more effective for cases
requiring minimum or no translation of teeth
during treatment.
Accessary slots
Accessary slots can be horizontal and vertical.
Horizontal accessary slot can be used to pass
accessary wires and is very important part in tip
edge plus brackets but are also present on
conventional preadjusted brackets to help
intrusion of teeth, extrusion of teeth and piggy
back mechanics. Vertical accessary slot can be
used to pass torqueing springs, uprighting
springs, rotation springs and auxiliary power
pins (Figure 5.5). In some cases vertical slot is
used for indirect anchorage by engaging a wire
from implant to vertical slot of bracket. Vertical
slot is added in designs of some ceramic
brackets to facilitate easy debonding (Figure 5.5
D).
Convenience features
Vertical Mid Scribe line
A mid scribe line help in easy placement of
brackets (Figure 5.6). The mid scribe line
should follow long axis of the tooth for ideal
bracket placement. The vertical mid scribe line
also act as an instrument channel during bracket
positioning. A continuous vertical scribe line is
 CHAPTER 5
Selection of Auxiliary and convenience features

preferred. Scribe line is usually not found in

ceramic and semi twin metal brackets.

A B

Figure 5.6 A. Metal bracket with continuous scribe line. B.

Interrupted scribe line. C. A ceramic bracket with no scribe
line. Such brackets give poor guidance in axial bracket
positioning

Shape of brackets

The shape of the bracket can be rhomboidal,

rectangular or triangular. These different
shapes are more related with patent issues than
clinical importance. Whatever the shape of the
bracket, an ideal bracket shouldn't interfere
with occlusion, soft tissues, provide good
rotational control and keep optimum
interbracket distance.
C
Bracket identification

Manufacturers engrave different marks on

brackets to make identification of the brackets
easy. A dimple or bracket number is usually
added on the disto-gingival tie wing of the
D bracket. Some manufacturers also color code
that dimples for easy identification of the
Figure 5.5 A. Accessory horizontal slot in Damon Q bracket while others put bracket number on
bracket Ormco. B. Vertical slot in an American orthodontics
brackets. C. Various accessories used with vertical slot back of the bracket (Figure 5.7).
brackets. D. A polycrystalline ceramic bracket with vertical
slot to aid easy debonding. Auxillary springs can also be used
in this vertical slot.
80
 Selection of Auxiliary and convenience features
A B C

E F G

Figure 5.7 A. Plus sign on distogingival tie wing of a gold bracket. B.A plastic dimple on 1st premolar. C. A right lower 1st
premolar with number engraved by lasers on distogingival wing. An arrow on the scribe line of the bracket is point in gingival
direction to help the clinician recognize the different sides of bracket. D. Different color coding on wings of commercially
available brackets. Different manufacturers use different color coding for their bracket series. E&F .In ceramic material the
marks are usually made from unknown colors which usually erode in a couple of hour in the oral cavity. In some bracket both
gingival wings are color code. This is usually the case where power arm is present on distogingival wing. In case power arm is not
present than distogingival tie wing have an extra ring build within the main ring. G.A identification mark on bracket base of a left
upper 1st premolar.

Clinical notes and are usually swallowed by the patient.

Many identification marks used on metal
brackets are made of plastic material. The
composition of these plastic materials is
usually not known. Many of these
identification marks are removed from the
brackets in the first few hours of bonding
81
Other that remains on the brackets gets
discolored with time and raise aesthetic
concerns of the patient. A personal
recommendation is to use identification
marks that are made of metal or some laser
markings.
 CHAPTER 5
Selection of Auxiliary and convenience features

Reference
In some cheap ceramic brackets the marks
were made from even women's nail polish! 1. Andrews LF. Straight-Wire-The Concept and
(Figure 5.8). Appliance; L. A. WellsCo., San Diego, California.
92107: 1989.

B C

Figure 5.8 A .Ceramic bracket with marking made by

ladies nail polish. B. Plastic dimple tear on instrumentation.
C. Plastic dimple discolored in clinical used

Many other convenience features are also

added to the brackets such as access bevels on
the slots for steel ligature cutters, De-ligation
saddles for easy removal of elastic ligatures etc.
(Figure 5.9). Other convenient features like
accessary tube, headgear tubes are also added to
brackets especially to molar brackets.

Figure 5.9 Bracket having acess bevel and deligation

saddle
82

Selection of Bracket Prescription
In this Chapter
Introduction
Andrew Prescription
Key I: Interarch Relationship
Key II: Crown Angulation or
Mesiodistal Crown tip
Key III: Crown inclination or Torque
Key IV: Absence of Rotations
Key V: Tight Contact points
Key VI: Flat Occlusal plane or Curve
of Spee
Limitations of Andrew prescription
Introduction
Angle introduced edgewise brackets to have a
better control on three dimensional positions of
the teeth. But the problem in these brackets was
that complex wire bending was required to
control the tooth position. Andrew 1,2 modified
the standard edgewise brackets developed by
Angle by introducing tip, torque and in& outs in
his preadjusted edgewise brackets .The amount
of tip torque and in & outs built within
preadjusted brackets were called prescription of
the brackets. After Andrew a lot of orthodontists
introduced their versions of bracket prescription
sometimes based on studies and many times
based on clinical experience. Each clinician
83
CHAPTER
6
Different Bracket prescriptions
Roth Prescription
Limitations of Roth Prescription
MBT Prescription
Alteration of prescription
who advocated a specific prescription also
advocated specific mechanics during the course
of treatment for expression of the prescription.
In medicine to treat a disease properly, the right
diagnosis should be made. That helps the
physician to advise the right prescription of
drug .Same is true in orthodontics. After making
a right diagnosis and treatment planning of a
malocclusion the right prescription should be
used. Using the right prescription, simplify the
treatment mechanics which will save
considerable chairside time. In most cases there
would be minimal or no need of wire bending
during the course of orthodontic treatment.

Selection of Bracket Prescription
A detailed description on evolution of different
types of orthodontic prescriptions is given in
this chapter. Main focus is given to the
development of Andrew prescription because
all other prescriptions are either variations or
based on Andrew's data.
Andrew Prescription
Lawrence F. Andrew1 introduced the first
preadjusted brackets where all the bending's
needed in archwire in standard edgewise
bracket system were built within the brackets. It
was proposed that this appliance does not
require wire bending during treatment hence the
name Straight wire appliance (SWA) was given
to it.
Andrew after a study on 120 non-orthodontic
ideal occlusion dental casts concluded that in
order to attain ideal occlusion some
characteristics must be present within the
occlusion. These characteristics were divided
into six keys. Based on these 6 keys Andrew
developed his prescription of brackets, so that
using this bracket prescription no wire bending
would be required during treatment and at the
end of treatment, all the six keys to normal
occlusion would be attained.
Andrew apart from studying these non-
orthodontic ideal occlusion dental casts also
studied 1150 orthodontic treated cases so that
his prescription could also address some of the
problems not found in ideal occlusion e.g.
Extraction cases where molar relation may
deviate from class I relationship.
Most of the modern preadjusted brackets are
minor modification of Andrew straight wire
appliance. To give a better understanding of
prescription so that clinician can make an easy
selection of brackets a complete description of
Andrew six keys to normal occlusion and how
prescription components evolve from each key
is given. Details on how a prescription in
bracket is transferred to a tooth are also given
CHAPTER 6
with each key so that the readers can have a clear
knowledge of effects and limitations of a
prescription.
Key I: Interarch Relationship
Key I as originally proposed by Andrew 1 was
molar relationship. But in 1989 Andrew2
changed the key from molar relationship to
interarch relationship. Interarch relationship is
broader and more definite description of
occlusal relationship than relying on molar
relations only. Interarch relationship as key 1 is
considered in this text because it will clear the
reader's mind about the basis and need of
prescription.
Key I have seven parts 2 which are given below:
Part 1
The mesiobuccal cusp of the maxillary first
permanent molar fits in the groove between the
mesial and middle buccal cusps of the
mandibular first permanent molar.
Part 2
The distal marginal ridge of maxillary 1st molar
occludes with mesial marginal ridge of the
mandibular 2nd molar.
Previously1 this relation was. "The distal
surface of the distobuccal cusp of maxillary 1st
molar made contact and occluded with the
mesial surface of the mesiobuccal cusp of the
mandibular second molar." The closer these
two surfaces of maxillary 1st and mandibular
2nd molar contact and occlude , the better
would be the opportunity for normal
occlusion.
Part 3
The mesiolingual cusp of the maxillary 1st
permanent molar occludes in the central fossa of
mandibular 1st permanent molar.
84

Part 4
The buccal cusp of the maxillary premolars
have cusp embrasure relationship with
mandibular premolars. The maxillary 2nd
premolar buccal cusp lies between embrasure of
mandibular 1st molar and mandibular 2nd
premolar. Buccal cusp of maxillary 1st premolar
lies in the embrasure between mandibular 1st
and 2nd premolars.
Clinical Notes
To check if a case has attained Key I,
always judge from buccal aspect clinically
and both from buccal and lingual aspects on
the dental cast.
Part 5
The lingual cusp of the maxillary premolars has
a cusp fossa relationship with mandibular
premolars.
Part 6
The maxillary canine tip lies slight mesial to the
embrasure between mandibular canine and 1st
premolar.
Part 7
The maxillary incisors overlap the mandibular
incisor with their dental midlines coinciding.
A description of key I is given in figure 6.1.
A B
Figure 6.1 An ideal occlusion case meeting all the criteria of key I . A .Buccal aspects . B. Lingual aspects
85
Selection of Bracket Prescription
Incorporating key I into bracket
prescription
Key I is interrelated with next 5 keys to normal
occlusion. Key I will only be achieved when the
rest of the keys have been achieved too.
To attain key I, a preadjusted bracket should
have built in 1st, 2nd and 3rd order bends and
brackets should be optimally placed on the
tooth. Only description of 1st order bends and
how and why they are included in the
prescription would be given here. The rest
would be discussed in their respective keys.
To incorporate the right amount of 1st order
bends with in his prescription Andrew 2
measured the facial prominence of each tooth
within the arch of an ideal occlusion
case .This was done by measuring the distance
from the embrasure line to most prominent
facial point of each tooth, where embrasure
line is imaginary line at crown mid transverse
plane that connects the facial portion of
contact areas of a single crown or all the
crowns in an arch when the crowns are
optimally placed. Figure 6.2 and table 6.1.
From the figure 6.2 and table 6.1 it is clear that in
maxillary arch lateral incisors have least facial
prominence while in mandibular arch both
central and lateral incisors have least facial
prominence. These values were built within the
base or stem of the brackets so that at the end of
leveling and alignment all the brackets slots
 CHAPTER 6
Selection of Bracket Prescription

have same level of prominence while all the

teeth have the prominence value found in table
6.1.

How it works?

To build the right amount of prominence within

the brackets, Andrew incooperated a simple rule
that the distance between most prominent facial
point of the crown and the embrasure line is
inversely proportional to the distance between
slot point and most prominent facial point of
crown in mid transverse plane.(Figure 6.3A) .
This means that if a tooth has less facial
prominence of crown it would have increased
A
bracket prominence (Figure 6.3B&C). The slot
point is the mid of the bracket slot in all three
planes of space. For the ease of simplicity
since we are viewing the tooth from lateral
side so base of the slot instead of slot point
would be used in this text.

So in maxillary arch lateral incisor bracket

B found to be less prominent than central incisors
Figure 6.2 Facial prominence of teeth in the arch
.The distance between embrasure line and most prominent
facial point of each tooth is the prominence of the tooth. A.
Average maxillary arch crown prominence. B. Average
mandibular arch crown prominence. These prominence
values are incorporated into the brackets by varying the
distance from base of slot to base of brackets.
would be the most prominent bracket in mid
transverse plane. When such a bracket is placed
on the tooth a palatal force is expressed by the
flexible wire on this tooth as compared to
neighboring teeth which absorb reactionary
labial or buccal force because less prominent
brackets are placed on them . So eventually on
heavy wires maxillary lateral incisor crowns are
and canine crowns while all the brackets slot
point or slot bases are at same level of
prominence .
In Andrew's prescription (table 6.2) of fully
programmed standard brackets, maxillary

Table 6.1.Crown prominence in maxillary and mandibular arch

Teeth Central Lateral Canine 1stpremolar 2ndpremolar 1st Molar 2nd Molar
incisors incisors
Maxillary Arch 2.1mm 1.65mm 2.5mm 2.4mm 2.4mm 2.9mm 2.9mm
Mandibular arch 1.2mm 1.2mm 1.9mm 2.35mm 2.35mm 2.5mm 2.5mm

86

central incisor bracket has prominence of 1.8
mm; maxillary lateral incisor bracket has
prominence of 2.25mm). The difference
between maxillary central and lateral incisor
bracket prominence is 0.45 mm (2.25mm -
1.8mm =0.45mm). So lateral incisor bracket
slot base would be 0.45 mm more inward after
Selection of Bracket Prescription
leveling. This difference in bracket prominence
is same as difference in teeth prominence as
measured from embrasure line (2.1mm -
1.65mm =0.45 mm). The same rule is true for all
other brackets in both maxillary and mandibular
arch.

Table 6.2.Bracket prominence in maxillary and mandibular arch in Andrew prescription

Teeth Central Lateral Canine 1stpremolar 2ndpremolar 1st Molar 2nd Molar
incisors incisors
Maxillary Arch 1.8mm 2.25mm 1.4mm 1.5mm 1.5mm 1mm 1mm
Mandibular arch 2.3mm 2.3mm 1.6mm 1.15mm 1.15mm 1mm 1mm

C
Figure 6.3 A. In this figure A= embrasure line, B= most prominent facial point of crown, C= Slot
base. Slot base is taken instead of slot point for ease of simplicity. Distance A to B ∝1 ∕Distance B to C.
So if distance between A to B is smaller as in the case of maxillary lateral incisor crown, distance B to C
should be larger. B. Upper incisor brackets. In maxillary arch the prominence of lateral incisor is least
in the arch so its bracket slot base is highest in prominence. After subsequent leveling of the slot base
with other brackets in maxillary arch lateral incisors will move palatally equal to the amount of its
bracket prominence as compared to the other brackets. C. Mandibular brackets. Mandibular central and
lateral brackets are greater in prominence than other brackets in the arch. This is because these teeth
have least prominence in the arch in term of first order position. In the figure some brackets like
mandibular canine have different prominence than recommended values .This is because of
A manufacturer error of placing the right amount of prominence in the brackets

Clinical notes
Clinicians usually change brackets for altering bracket prescriptions. But using brackets from
different series of brackets may result in first order difference between brackets (Figure 6.4). It
is better to select brackets from same manufacturer while altering the prescription.

Figure 6. 4 Lateral
incisor brackets from three
different manufacturers.
First two brackets are in
MBT prescription. Bracket
C is in Roth prescription.

87

Selection of Bracket Prescription
Molars offsets
Maxillary molars
Another important consideration is molar offset
bends. Part 1 of key I state that mesiobuccal
cusp of the maxillary first permanent molar
occlude in the groove between the mesial and
middle buccal cusps of the mandibular first
permanent molar. To achieve this part as a
treatment goal one must have clear
understanding of tooth morphology. The
mesiobuccal groove of the mandibular first
molar is more facially prominent than its
distobuccal groove relative to the embrasure
line. To occlude with mesiobuccal groove of
mandibular first molar the mesiobuccal cusp of
maxillary 1st molar should have more facial
prominence or in orthodontic terms should have
an offset or mesial buccal orientation. Andrew
measured this maxillary molar offset by
measuring the angle between embrasure line
and a line connecting the buccal cusps of the
molars. The offset was found to be 10° in normal
occlusion where molar relation was class I
(Figure 6.5).
The mandibular 2nd molar also have a prominent
buccal groove, though distobuccal groove is not
Figure 6.5 Molar offset. The angle between the
embrasure line and the line connecting the buccal cusps of
the teeth is 10° for both the maxillary 1st and 2nd molars.
CHAPTER 6
present within 2nd mandibular molar. The
maxillary 2nd molar should also have an offset of
10° so that its mesiobuccal cusp should be
properly occluded in buccal grove of
mandibular 2nd molar.
How it works?
The rule of thumb used in bracket
manufacturing is that plane of bracket or base
should always be parallel to the facial plane of
crown. Further, tube of the bracket should also
be straight when tooth is in its ideal position. In
case of maxillary 1st molar in Class I molar
relationship the distobuccal half of the tooth is
slightly palatal to mesiobuccal half. Placing a
tube base with parallel slot having a 0°angle or
offset between tube base and slot on the buccal
surface of tooth will result in opening of slot
more buccal on mesial side and more palatal on
distal side. This will cause molar to rotate
mesiopalatal and distobuccal on subsequent
leveling on orthodontic wires. At the end of
leveling when the slot is straight to other
neighboring bracket slots the mesiobuccal and
distobuccal cusps of the molars have the same
level of prominence. To avoid this problem
more tube material is added under the slot on its
distal half giving the tube distal offset on its base
so the that the tube make an angle of 10° with its
base. When such a tube is aligned and its
opening become straight, the distal half of tube
base and so the molar is more inward or palatal
as compared to the mesial half (Figure 6.6). The
same rule is true for maxillary 2nd molars
brackets and tubes.
Mandibular molars
A zero degree angle was measured in
mandibular molars between embrasure line and
buccal line joining middle and mesial buccal
cusp. So no offset was incorporated in
mandibular molar tubes in normal occlusion
(Figure 6.7 A&C). In mandibular molars the
plane of bracket tube is parallel to bracket base
and to the facial plane of crown (Figure 6.7 B).
88
 Selection of Bracket Prescription
A B

C D

E F

Figure 6.6 A&B Mesial and distal opening of a 0° offset double molar tube .The distance of tubes slots from their base is
same on both mesial and distal side C& D Mesial and distal opening of a 10° distal offset single molar tube. The distance of tube
slot from its base is less on mesial side as compared to distal side .As the distal side of tube slot is more outward buccaly so these
molar tubes are called distal offset tubes. E. A 0° offset tube as base of the molar tube and its slot are parallel to each other. F. A 10°
distal offset molar tube as slot of the tube makes an angle of 10° with its base.(continued....)

89
 CHAPTER 6
Selection of Bracket Prescription

I J

Figure 6.6 G. A 0° offset molar tube placed on maxillary 1st molar .As the slot of the tube is angular to the facial surficial of
the tooth so on subsequent alignment both mesial and distal cusps of the molar would have equal facial prominence resulting in
0° offset molar. H. A 10° distal offset bracket placed on the maxillary 1st molar. A distal offset tube is used to bring mesial offset in
the molar. The slot of the tube makes an angle of 10° with the embrasure line and is parallel to the facial surface of the tooth so on
subsequent alignment the mesial cusp of the molar would be more facially prominent than the distal cusp. I.A 0° offset tube placed
on a well aligned maxillary 1st molar. As the distal surface of the molar is less facially prominent so the slot is more inward distally
though there is no offset in the tube. J. A 10° molar offset tube placed on maxillary 1st molar in a well aligned arch .Even there is a
distal offset, the slot is straight because decrease prominence of the distal cusp of the molar is compensated by the offset in the
tube.

B
A
Figure 6.7. A. A mandibular 1st molar having 0° offset. B. A 0° offset molar
tube place on the molar. As the embrasure line, facial surface of the tooth and
slot of the tube make an angle of 0° so the mesial and middle cusp have the
same level of prominence after leveling and alignment. C. A 0° offset molar
tube placed on a well aligned molar. As mesial and middle cusps have equal
level of facial prominence so the tube has a straight opening.
C
90

Molar offset in dental class II&III
In an ideal occlusion non orthodontic patients,
posterior dentition having Class II or Class III
relations and anterior dentition having Class 1
relations is not technically possible as all the
teeth are present. But such relations are a
frequent finding in orthodontically treated cases
in which extraction of premolars have been
done. In case of such relations only part 6 &7 of
key I is applicable. For better understanding of
molar relations a classification of class I, II and
III molar is given in figure 6.8.
A Characteristics of class II molars are given in
B 1st molar and 2nd molar.
Figure 6.8 A. Zones of Class I, II& III molar relationship
on the mandibular cast in accordance with ABO standards.
The mesiobuccal cusp of the maxillary 1st molar occluding
in these zones will decide the molar relations. B.
Mesiobuccal cusp of the maxillary 1st molar.
91
Selection of Bracket Prescription
Andrew from his study of 1150 orthodontic
treated cases proposed that a class II molar
relation should have following characteristics.
Characteristics of Class II molar
relationship
Part 1
The mesiobuccal cusp of maxillary 1st molar
lies in the embrasure between mandibular 1st
molar and 2nd premolar.
Part 2
The distobuccal cusp of maxillary 1st molar
occludes in the mesiobuccal groove of
mandibular first molar.
Part 3
The mesiolingual cusp of maxillary 1st molar
occludes with the mesial marginal ridge of
mandibular 1st molar.
Part 4
The canine and incisor relation should follow
key I part 6&7.
figure 6.9.
Characteristics of Class III molar
relationship
No occlusal relation was proposed for class III
molar relationship by Andrew. But from my
understanding, a class III molar relation should
have following characteristics.
Part 1
The mesiobuccal cusp of maxillary 1st molar
should lie in the embrasure between mandibular
Part 2
The distobuccal cusp of maxillary 1st molar
should occlude in the buccal groove of
 CHAPTER 6
Selection of Bracket Prescription

A B

Figure 6.9 Buccal and lingual view of class II molar relationship

mandibular 2nd molar. the corresponding embrasure which is less

prominent facially than the mesiobuccal groove
Part 3 of the mandibular 1st molar (Figure 6.11). To
The mesiolingual cusp of maxillary 1st molar have a proper relationship of the maxillary 1st
occludes with the marginal ridge of mandibular molar with corresponding embrasure, there
2nd molar. shouldn't be any offset on maxillary 1st or 2nd
molar in class II or III molar relationships.
Part 4
Key II: Crown Angulation or Mesiodistal
nd
The buccal cusp of maxillary 2 premolar Crown tip
should occlude with the mesiobuccal groove of
the mandibular 1st molar. Crown angulation as the name indicates, is the
angulation of long axis of the clinical crown
Part 5 (LACC) or facial axis of clinical crown
(FACC).Crown angulation is measured by the
The canine and incisor relation should follow angle formed between LACC or FACC and line
key I part 6&7. perpendicular to the occlusal plane. The long
Characteristics of class III molars are given in axis of the crown of all the teeth, except molars
figure 6.10. is judged from the mid developmental ridge,
where mid developmental ridge is the most
Both in class II and III molar relationship, the prominent and centermost vertical portion of
mesiobuccal cusp of 1st molar have relation with the labial or buccal surface of the crown (Figure

A B
Figure 6.10 Buccal and lingual view of class III molar relationship
92
 Selection of Bracket Prescription
A B C
Figure 6.11 Molar relations in Class I, II & III. 10° maxillary 1st molar offset is present on all three figures. A. Placing an offset
in class I molar relation will result in proper occlusion .B&C. Placing an offset in Class in II or III molar relations will result in
increased transverse overjet in mesial half of the molar.

6.12 A&B) .In case of molars the long axis of the
clinical crown is judged from dominant vertical
groove on buccal surface of the molars (Figure
6.12 C&D).
For measuring tip or angulation values, Andrew
1
initially used long axis of clinical crown and
later2 advocated facial axis of clinical crown
(FACC).Though Andrew believed that there is
difference between long axis and facial axis of
clinical crown but he used mid developmental
ridged or vertical buccal groove in case of molar
to define these long axis positions.
Andrew recommended that the gingival portion
of the long axis of the crown should be distal to
the incisor portion. Crown tip is expressed in
degrees with positive (+ve) or negative (-ve)
sign. Positive sign indicate that gingival portion
of the long axis of the crown is more distal to the
incisor portion while negative sign indicates the
opposite. Crown angulation is best judged from
buccal or labial perspective depending upon the
type of teeth viewed. Both maxillary and
mandibular dentitions have positive crown
angulations in ideal occlusion.

Occlusal Plane

Occlusal Plane
FACC or LACC
perpendicular Occlusal Plane
Occlusal Plane
perpendicular
Occlusal Dominent
Plane Vertical
perpend. Groove

FACC or LACC
A B C D
Occlusal Plane

Figure 6.12 Crown tip or angulation of different teeth. A & B. Upper and lower central incisors. The crown angulation of
upper and lower incisors is measured from mid developmental ridge. C & D. Upper and lower 1st molars. Crown tip or angulations
of upper and lower molars are measured from dominant vertical buccal groove.

93

Incorporating key II into Bracket
Selection of Bracket Prescription
prescription
Proper crown angulation is necessary to get a
good occlusal and esthetic results. More the
angulation of the teeth more the space they will
occupy in the arch (Figure 6.13). Over angulating
A B
Figure 6.13 A. Ideal angulation of upper central and
lateral incisors. B. increased angulation of upper central and
lateral incisor. Because of increased angulation these
incisors are occupying more space than ideally angulated
incisors.
the teeth will disturb the embrasures /connectors
relations and will result in development of black
triangles. If the teeth are under angulated, spaces
would be present within the arch which would be
difficult to close without altering the occlusal
relations or giving proper tip/angulation. To
incorporate the right amount of tip within his
bracket prescription, Andrew measured average
angulation of teeth from his study of 120 ideal
nonorthodontic treatment casts. The average
value of tooth angulation are given in table 6.3.
How it works?
In Straight wire appliance tip or angulation is
incorporated in the face or slot of the bracket by
placing the slot at an angle in the mesiodistal
Table 6.3.Tooth angulation in ideal occlusion in non-orthodontic patients
Teeth Central Lateral Canine
incisors incisors
Maxillary Arch +5° +9° +11°
Mandibular arch +2° +2° +5°
CHAPTER 6
plane over the bracket base so that one side of
the slot is vertically high than the other. This will
cause a straight wire to rotate the bracket on
subsequent leveling of slots. The required angle
of rotation of the slot was taken from Andrew's
measurements and incorporated in his standard
series brackets. Mechanism of tip expression is
explained in figure 6.14.
Tip compensation in Andrew Translation
series brackets
Tip expression is not a problem when the teeth
are not translated. But it is a common finding
that when a tooth is translated mesial there is
increase in its angulation and when a tooth is
moved distal there is decreased in its angulation.
This rule is not applicable to incisor teeth
because of their position in the arch. Andrew 2
proposed that for effective tip expression, the
mesiodistal length of slot should equal to
distance from the slot point to the tooth center of
resistance (Figure 6.15).
Such brackets length is technically not possible.
So power arms were added to bracket to cover
up rest of the length. The length of power arm
plus mesiodistal length of the bracket should be
equal to the distance between slot points to the
tooth center of resistance. For complete
expression of tip the power arm and bracket
should be activated collectively during
translation and full dimension wires should be
used. Since engaging full dimensional wire is
technically not possible, especially during
sliding mechanics and also there are soft tissue
limitation on increasing the length of power
arm, some loss of tip during sliding is inevitable.
To maintain control over three dimensional
1stpremolar 2ndpremolar 1st Molar 2nd Molar
+2° +2° +5° +5°
+2° +2° +2° +2°
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 Selection of Bracket Prescription
Figure 6.14 Maxillary left side brackets .Archwire slot on mesial side of the bracket is downward directed while on the distal
side it is upward directed.On engagement of flexible wire after ideal bracket placement the mesial and distal slot of bracket will
rotate in the clockwise direction and so will the teeth. Due to clockwise rotation of the teeth in left side of the arch the incisal
portion of teeth would be more mesial than the gingival portion. In this way tip is expressed. There is anticlockwise rotation of
brackets for expression of tip on right side of the maxillary arch. In maxillary arch for positive tip the mesial part of slot is directed
downward as compared to distal part and for negative tip mesial part would be directed upward. In mandibular arch for positive tip
expression, the mesial part of the slot should be directed upward/occlusal and vice versa.

positions during tooth translation in extraction

or spacing cases, Andrew developed the
translation series brackets. These translation
series brackets were of three types :

1. Minimum translation series brackets for

0.1 to 2mm translation

2. Medium Translation series brackets for 2.1

to 4mm translation

3. Maximum Translation series brackets for

greater than 4mm translation

To compensate the change in tooth angulation

Figure 6.15 For effective control of root position during
translation the mesiodistal length of bracket plus height of
power arm should be equal to distance from the slot point
to tooth center of resistance.
during mesial or distal translation, Andrew
introduced counter mesiodistal tip in his
translation series brackets. A 2° tip was added to
the slots of standard brackets in case of intended

Table 6.4.Angulation /Tip for Minimum Translation series brackets for 0.1 to 2mm Translation
Maxilla Mandible
Tooth Distal Translation Mesial Translation Distal Translation Mesial Translation
Canine 13° 9° 7° 3°
st
1 Premolar 4° 0° 4° 0°
2nd Premolar 4° 0° 4° 0°
1st Molar 7° 3° 4° 0°
nd
2 Molar 7° 3° 4° 0°
95
 CHAPTER 6
Selection of Bracket Prescription

Table 6.5.Angulation /Tip for Medium Translation series brackets for 2.1 to 4mm Translation
Maxilla Mandible
Tooth Distal Translation Mesial Translation Distal Translation Mesial Translation
Canine 14° 8° 8° 2°
st
1 Premolar 5° -1° 5° -1°
2nd Premolar 5° -1° 5° -1°
1st Molar 8° 2° 5° -1°
nd
2 Molar 8° 2° 5° -1°
Table 6.6.Angulation/Tip for Maximum Translation series brackets for greater than 4mm
Translation
Maxilla Mandible
Tooth Distal Translation Mesial Translation Distal Translation Mesial Translation
Canine 15° 7° 9° 1°
1st Premolar 6° -2° 6° -2°
2nd Premolar 6° -2° 6° -2°
st
1 Molar 9° 1° 6° -2°
2nd Molar 9° 1° 6° -2°

distal movement in minimum translation series

brackets and in cases of intended mesial
movement, 2° was subtracted from the slot. 3°
was added or subtracted from standard series
brackets for distal or mesial translation in
medium translation series brackets. 4° was
added or subtracted from standard series
brackets for distal or mesial translation in
maximum translation series brackets.
Tip/angulation values for minimum, medium
and maximum translation series brackets are
given in table 6.4-6.6.
Note: Usually distal translation of the molars
and mesial translation of canines is not done in
orthodontic practice so there are few cases
which benefit from these angulation values.
Some of the angulations values are given for
clarity of concept as actuals brackets having
such tip values are not manufactured.
Take the example of a mandibular canine with
+5° tip in standard bracket. Suppose it's an
extraction case of 1st premolar. If it is planned to
retract this canine into the premolar space a
translation series bracket would be required. If
intended distal movement of the canine is less
than 2.1 mm ,a minimum translation series
bracket would be used that will have an
effective bracket slot angulation of 7° , 5° of
standard tip and 2° of countermesiodistal tip
added to the slot . If the intended retraction of
mandibular canine is between 2.1 to 4mm a
medium translation series bracket is selected
which have a 5°+3°=8° tip built within the slot.
For maximum translation series, bracket having
9° tip would be used on canine when retraction
is greater than 4mm.
In cases of spacing in lower arch and mesial
movement of mandibular canine is intended
following tip/angulation values were
introduced in translation series brackets.
Minimum translation series bracket of
mandibular canine for mesial translation (0.1-
2mm translation) =+3°
Medium Translation series brackets of
mandibular canine for mesial translation (2.1 -
4mm translation) =+2°
Maximum translation series brackets of
mandibular canine for mesial translation
(˃4mm translation) =+1°
Molar Class II & III Relationship
As explained before, in ideal occlusion cases in
96

which the molar relation is class I the angulation
or tip of both 1st and 2nd maxillary molars should
be +5°. But keeping a 5° tip in class II or Class
III molar relations will result in poor occlusion
due to hanging or more downward position of
distal surface of the molars (Figure 6.16).
In a finished case a zero degree angulation of
maxillary molars should be present in both class
Selection of Bracket Prescription
II & III molar relationship. But what angulation
brackets, tubes or bands should be used if molar
is translated to that position? To the best of my
knowledge Andrew didn't propose molar
angulation changes for class II &III relationship
for translation series brackets. But my
understanding is that the same principles of
angulation should be applied considering zero
degree as ideal angulation. So if final relation of

A B C

D E F
Figure 6.16 A. Molar Class I relationship. For molar Class I relation Andrew proposed that FACC of maxillary molar which is
dominant vertical buccal groove should be 5° to a line 90° to the occlusal plane. B. In case of class II molar relation keeping 5°
positive tip in the molars will result in hanging of distal cusps of maxillary 1st molar and poor interdigitation of its mesiobuccal
cusp.C. Giving a 0° to the maxillary 1st molar will result in proper interdigitation. D. Class I molar relationship on the dental cast. E.
Class II molar relationship on the dental cast. F . Mandibular 1st molar showing the transition from class I to class II position . In
class I position the distobuccal cusp of the maxillary 1st molar was occluding at point A on the mandibular 2nd molar while the
mesibuccal cusp was occluding at point B on mandibular 1st molar. In the Class II molar relations, the distobuccal cusp will
jump to point B on mandibular 1st molar while the mesiobuccal cusp will occlude at point C on mandibular 2nd premolar . So
distobuccal cusp of maxillary 1st molar has jumped from a lower position to a higher position while mesiobuccal cusp of
maxillary 1st has fallen from a higher position to a lower position. Keeping the same amount of tip won't allow the maxillary
1st molar to rotate for an ideal occlusion resulting in premature contacts of distobuccal cusp of maxillary 1st molar with buccal
groove of manidulbar 1st molar while the mesiobuccal cusp of maxillary 1st molar will remain out of occolusion . To avoid
these improper occlusal results in an orthodontic treated case, tip of maxillary molars is decreased from 5° to 0°.
97
 CHAPTER 6
Selection of Bracket Prescription

G H I

J K L
Figure 6.16 G&H.Class I and III molar relationship with 5° tip in maxillary 1st molar . Note the poor occlusal contact of
mesiobuccal cusp of the maxillary 1st molar in class III relationship . These relations can be improved by rotating molar
couterclockwise so that angulation of molar become 0° with occlusal plane perpendicular. I . A molar with 0° angulation with
occlusal plane perpendicular having proper relationship with lower molar.J,K,L show transition of molar relation from class I to
III. Since there is similarity in change in relationship to that of class II molars so same rules of teeth angulation will apply here.
Giving a 0° tip to maxillary molars will result in proper occlusal relationship.

molar is planned full cusp class II and 1.5mm
maxillary molar mesialization is intended, -2°
countermesiodistal tip should be present. For
3mm molar mesialization -3°
countermesiodistal tip and for 5 mm
mesialization -4° countermesiodistal tip should
be present. For 2.5mm molar distalization for
attaining a class II molar relationship +2° of
countermesiodistal tip should be used though it
doesn't usually happen that one distalize molar
to attain class II molar relations.
molar offset. If a 0° offset is present on molar
there would be a mesiobuccal rotation of the
molar and it is well know that a rotated teeth
occupy more space. So how this extra space is
acquired in class II & III molar relationship
where a 0° maxillary molar offset is
recommended for 1st and 2nd molar? This extra
space is provided by placing the maxillary
molars in class II& III position at their right
angulation which is a 0° instead of 5° of class I
molar.

Relation between Tip and molar offset
An important aspect which must be well
understood is relation of molar offset and
angulation of molars in class II & III molar
relationship. In class I molar relationship
maxillary 1st and 2nd molar should have 10°
Some orthodontic literature and manufacturer
catalogs claim 10° molar offset as antirotation
in molar. This is a misconception as 10° offset in
a molar in class I position is its natural position
and not rotated position. Instead, 0° offset in a
molar in Class II &III relations is a rotated
position of molar, intentionally created to give a
98

better occlusion.
Factors effecting Expression of Tip
1. Play of the wire
2. Manufacturer tolerance of the wire and slot
3. Mesiodistal length of the bracket
4. Height of power arm
5. Force applied during translation
6. Type of bracket ligation
7. Direction of tooth movement
8. Position of neighboring brackets
Play of the wire effect torque more than tip.
Almost the entire tip is expressed in a
0.018”wire on 0.018”x0.025” slot. Most of the
tip in a 0.022” slot is expressed on a 0.020” wire.
Manufacturer tolerance of the wire and slot also
increases the play of wire leading to loss of tip.
Greater the force applied to translate the teeth in
extraction cases and weaker the ligation of wire
in brackets, greater would be the chances of tip
loss. Position of neighboring teeth and their
brackets can cause increase or decrease of tip in
cases where wire play is present. Rests of the
factors have been explained before.
Key III: Crown inclination (labiolingual or
buccolingual inclination)
It is inclination of long axis of clinical crown
(LACC). Crown inclination is measured by
angle formed by a line tangent to the middle of
the labial or buccal long axis or facial axis of the
clinical crown (LACC or FACC) and a line that
is 90° to the occlusal plane (Figure 6.17).
Crown inclination is measured in degrees with
positive or negative sign. A positive sign is
given when gingival portion of the tangent line
or gingival portion of crown is lingual or palatal
to the incisor portion. A minus or negative sign
is given when gingival portion of the tangent
99
Selection of Bracket Prescription
Figure 6.17 Normal inclination of upper incisor crown
as measured with reference to occlusal plane perpendicular.
line or gingival portion of crown is buccal or
labial to the incisor portion.
In maxillary incisors the gingival portion of
crown is lingual or palatal to the incisor portion.
The incisor portion is more labial for central
incisor than lateral incisor. So there is a positive
torque in maxillary incisors.
In maxillary canines to premolars, cusp or
occlusal portion of clinical crown is more
palatal than gingival portion of the clinical
crown. The same trend is seen in molar teeth
but it is more pronounced.So there is negative
torque in maxillary posterior segment and
canines.
In lower teeth a negative crown inclination is
found from incisors to second molars. This
negative torque increases progressively from
incisors to molars.
Proper torque is for proper occlusion. An
increased positive torque will cause arch
expansion and space opening within the arch
while increased negative torque will collapse
the arch and there would be lack of space
within the arch. Increased positive or negative
torque can result in root damage and
periodontal recession by bringing the roots
 CHAPTER 6
close to or out of the cortical bone.
Selection of Bracket Prescription

placing the slot at an angle over the stem but

Incorporating key II into Bracket
prescription
Torque is incorporated in straight wire
appliance by varying the thickness of base or
stem under the slot so that the slot comes at an
angle to the base in vertical plane (Figure 6.18).
Some manufacturers also introduce torque by
torque in base is favored.
In measuring the average inclinations, most of
the variations were found in incisors torque.
This is because of the fact that apart from
skeletal class I ,mild skeletal class II & III
pattern can also exhibit class I occlusal
relationship. Andrew standard brackets are
effective for ANB differential of up to 5°.As the

A B

Figure 6.18 A .Bracket with slot placed at an angle over the bracket. Thickness of the base and height of bracket stem is
modified to introduce torque within the bracket. B. Bracket with zero degree torque as base of bracket is parallel with base of slot
and is at right angle to slot walls.

Table 6.7.Inclination values for Andrews’ Standard bracket prescription (Class I molar and
skeletal relationship)
Tooth Maxilla Mandible
Central incisor +7° -1°
Lateral incisor +3° -1°
Canine -7° -11°
st
1 Premolar -7° -17°
2nd Premolar -7° -22°
1st Molar -9° -30°
nd
2 Molar -9° -35°

distance between upper and lower alveolar
processes vary with different skeletal relations
of the jaws, it is technically not possible to keep
the same amount of torque in the incisors for all
the three skeletal relations. Doing so will results
in bringing root closer or out of the alveolar
cortex in case of moderate to severe skeletal
discrepancy. To avoid such technical limitations
and iatrogenic damages, Andrew proposed
different torque values for upper and lower
incisors in skeletal class I,II and III relations.
For class II skeletal relations (ANB greater than
5°) 2° maxillary central incisor and -2 °
maxillary lateral incisor torque was proposed
(Table 6.8). For skeletal class III (ANB less than
0°) 12° maxillary central incisor and 8°
maxillary lateral incisor torque was proposed
(Table 6.9).
The above mentioned values of incisors torque
were also confirmed by an unpublished
cephalometric study of 100 cases by Andrew.
An important finding in that study was that the
maxillary lateral incisor torque is always 4° less
than maxillary central incisor torque while
mandibular central and lateral incisor have
same amount of inclination.
100
 Selection of Bracket Prescription
Table 6.8.Incisor Torque in Skeletal Class II
Tooth Maxilla Mandible
Central incisor 2° 4°
Lateral incisor -2° 4°
Table 6.9.Incisor Torque in Skeletal Class III
Tooth Maxilla Mandible
Central incisor 12° -6°
Lateral incisor 8° -6°
is introduced in the bracket by directing the slot
Positive torque is incooperated in the brackets
downward (Figure 6.19).
in maxillary arch by directing the slot
downward and negative torque is incooperated Another problem is torque loss in maxillary
by directing the slot upward. In mandibular molars during translation in extraction cases .As
arch the opposite rule hold true and positive maxillary molars are three rooted teeth with
torque is introduced within the brackets by dominant palatal root. So when a maxillary
directing the slot upward while negative torque molar is translated especially mesial, the palatal

B
Figure 6.19 Builtin torque in upper and lower arch brackets with slots walls at an angle with bracket base. A. Maxillary
brackets from incisors to 2nd premolar. The maxillary central and lateral incisor brackets slots are directed downward towards
incisor edge so they have builtin positive torque. Central incisor bracket have more positive torque than lateral incisor bracket.
Maxillary canine and premolars bracket slots are directed upward so they have builtin negative torque. In the figure maxillary
canine bracket have less negative torque than premolars brackets. This is because the brackets don't have builtin Andrew
nd
prescription and diagram is given for the ease of understanding. B. Mandibular brackets from central incisor to 2 premolar. All the
bracket slots have a downward directed opening except canine. So all the brackets have negative torque while canine has zero
torque. Again mandibular arch brackets are not in Andrew prescription and are only given for ease of understanding of torque.

root lag behind and causes the tooth to tip

buccally. At the end of translation buccal cusps
are more gingival and palatal cusps are more
occlusal. This clinical problem is resolved by
counterbuccolingual tip feature built within the
tube or band which adds more negative torque in
band or tube .This negative torque is builtin by
rotating the base of the tube upward around its Figure 6.20 A molar with hanging palatal cusps
vertical axis, so when slot is aligned by rotating which is usually the result of translation or expansion. To
correct this problem more negative torque is added to molar
in a clockwise direction more negative torque band or tube .In figure the tube with negative torque is
would be expressed (Figure 6.20). attached to the molar. As slot of the tube is clockwise rotated
a straight rectangular wire passing through the slot will
cause counterclockwise rotation of the molar. To counter
More the tooth is translated greater would be the palatal cusps hanging during translation
amount of overcorrection needed for maxillary counterbuccolingual tip feature is built within the tube slot.
101
 CHAPTER 6
Selection of Bracket Prescription

molars. Following counter buccolingual tip
values are added on maxillary molars.-4° of
torque is added to maxillary molars in standard
brackets for minimum translation series
brackets.-5° torque is added in medium
translation series brackets and -6° torque or
counterbuccolingual tip is added in case of
maximum translation series brackets. So
following torque values are found in maxillary
molars in translation series bracket.
Minimum Translation series bracket for
maxillary 1st and 2nd molars (0.1-2mm
translation) =-9°+-4°=-13°
Medium Translation series brackets for
maxillary 1st and 2nd molars (2.1 -4mm
translation) =-9°+-5°=-14°
Maximum Translation series brackets for
maxillary 1st and 2nd molars (˃4mm
translation) =-9°+-6° = -15°
How torque is expressed?
A common question mostly asked is how torque
is expressed from the bracket and how tooth
would have proper inclination at the end of
treatment?
In case of brackets, torque is expressed by
interaction of brackets and the wires. Torque is
always expressed when wire engages the slot of
the bracket at an angle and wire is passing
through multiple teeth. As round wire can't
engage the bracket at an angle and will simply
rotate within the slot, so torque expression is not
possible by round wires. A rectangular or square
wire can engage the bracket at an angle if the
slot of the bracket is not straight on insertion of
these wires. This can occur if there is builtin
torque within the wire or bracket. Morphology
of the teeth can affect the position of the slot,
while builtin torque in the neighboring brackets
can effect orientation of the wires. The amount
of torque expressed by the brackets wires
interaction depends upon amount of force
delivered from the wires to the brackets over a
period of time, but force levels should be in
optimum limits for torque expression. A higher
dimension wire will deliver heavier forces on
smaller contact angle than small dimension

A B

C D
E

Figure 6.21 A. Straight rectangular wire. Straight rectangular wires are used in preadjusted edgewise system also called
straight wire appliance. Straight wires are used because all the features for control of three dimensional tooth positions are built
within the brackets. B. Twisted or torqued rectangular wire. A torqued rectangular wire is usually used in standard edgewise system
but can also be used in straight wire appliance if there is need for extra torque application. C. A rectangular wire passing passively
through a bracket slot .If the wire don't contact the slot at an angle no torque would be expressed by the bracket no matter how much
torque is built within the bracket and how larger is the wires dimensions. Even if torque is introduced in the wire but if it don't
contact the slot at an angle no torque would be expressed. D. A rectangular wire twisted in a counterclockwise direction in the
bracket. A wire contacting the slot at an angle and twisting in a counterclockwise direction will express positive torque in maxillary
arch and negative torque in mandibular arch. E. A wire contacting the slot in a clockwise direction. Such contact will express
negative torque in maxillary arch and positive torque in mandibular arch. (continued....)
102
 Selection of Bracket Prescription
F G
Figure 6.21 F.A round wire in a bracket slot. Whatever their dimensions, round wires will never express torque because they
will simply rotate within the slot. G. Torqued wire inserted into the bracket contacting the slot at an angle.

A B C D

Figure 6.22 A. An upper central incisor bracket placed at ideal height over the labial surface of the tooth. As the slot opening is
directed downward so insertion of a straight rectangular or square wire will rotate the slot and so the tooth in clock wise direction
resulting in expression of positive torque. B. Central incisor bracket inverted and placed over the same tooth. Inverting the bracket
slot, rotate the slot and make it upward direction. Straightening of the slot on passing straight rectangular wire will result
counterclockwise rotation of the slot and tooth and so expression of negative torque. C&D. The opposite rule hold true in
mandibular arch. If the slot opening is upward directed in mandibular arch than positive torque would be expressed on
straightening of the slot and vice versa.

rectangular or square wires of the same
material. A complete description of torque
expression is given in figure 6.21.
Another aspect of torque expression is how
positive or negative torque is expressed from
the brackets? In preadjusted brackets the torque
is already built within the brackets by
angulating the slot over the base or varying the
thickness of the base so that the slot opening is
upward or downward directed. As explained
before for positive torque expression in
103
maxillary arch the slot opening should be
angulated downward and for negative torque
slot opening should be angulated upward (fig
6.22 A&B). The opposite rule hold true in
mandibular arch (6.22 C&D). When a straight
rectangular or square wire is passed through the
slot it would engage the slot at an angle and will
straighten the slot with time. Straightening of an
angulated slot will cause rotation of long axis of
the teeth and so expression of bracket torque.
Description of different types of torque
expression is given in figure 6.23.

Selection of Bracket Prescription
A The answer to this question is that in standard
B bracket base if there is builtin torque within the
Figure 6.23 A. upward twist is given in the wire for
positive torque in maxillary arch and negative torque in
mandibular arch. The twist is given by modified torqueing
pliers. The outer plier is moved upward as shown by the
arrow to torque the wire. B. Outer plier moved downward to
give downward twist to wire. This downward twist in wire
will result in negative torque to corresponding teeth if the
wire is inserted in upper arch and positive torque to
corresponding teeth if wire is inserted in lower arch.
Clinical Notes
Sometimes clinician wants to add extra
torque to the teeth like in case of class II div
2, impacted canines and palatally placed
incisors. The extra torque is given by giving
twist in rectangular wires. As opposed to
brackets, torsion in wires is given in the
direction of movement. An upward
directed twist is given in the wire for
positive torque in maxillary arch and
negative torque in mandibular arch
(Figure 6.23 A). A downward directed
twist is given in wire for negative torque
expression in maxillary arch and positive
torque in mandibular arch (Figure 6.23
B).Torque given in the wire will increase
CHAPTER 6
or decrease the torque present within the
brackets. A positive torque given in wire
will augment positive torque present
within brackets and vice versa.
An important question asked by young
graduates is that how certain amount of torque is
expressed by a prescription?
edgewise appliance amount of torque given by
wire bending was more of guesswork. In
Andrew prescription torque is built within the
brackets. As the brackets have a compound
contoured bases so their bases lies parallel to
labial surface of teeth on which it is attached.
Bracket base can rightly be said as an extended
labial portion of the teeth. In brackets as
explained before slot is always at an angle to the
brackets. So when the bracket base is straight
the slot is at an angle to the base that is
equivalent to the builtin torque. In mathematical
sense the opposite is also true that when the slot
is straightened the base is at an angle to the slot
with the amount of angulation equivalent to the
builtin torque. As bracket base is attached to
teeth so the surface of the teeth will achieve the
same level of angulation as that of bracket base
when the slot is straighten by straight
rectangular wire. The description is given in
figure 6.24.
Theoretically a slot can fully be straightened
when a full dimension wire is passed through it.
That wire in Andrew prescription using
0.022x0.028 inch slot would be 0.021.5x0.028
inch wire. The bracket should always be bonded
at a position that was used as a reference for
measuring crown torque. Andrew used middle
of labial surface of clinical crown in vertical
plane for measuring torque. So bracket base
should be placed at middle of labial surface of
clinical crown if required amount of torque is
needed to be introduced within the teeth.
104
 Selection of Bracket Prescription
A B C

Figure 6.24 A.Maxillary central incisor bracket with slot at +7° to the bracket base. The slot of the bracket is facing downward.
In a zero torque bracket the slot walls are at right angle to the base and slot base parallel to bracket base. But in this bracket the slot
walls make an angle of 97° with the bracket base as bracket has +7° builtin torque. B. Straightening of slot. The straightening of
the slot occurs when full dimension rectangular wires are passed through the slot after required alignment and leveling. In a
straight slot the walls of the slot are parallel to occlusal plane while the base of the slot is parallel to occlusal plane perpendicular.
When the slot becomes straight, the base of bracket becomes angular equal to the amount of builtin torque. C. A maxillary central
incisor bracket with +7° builtin torque bonded at middle of labial portion of central incisor. As the slot of the bracket is straight so
the base has turned angular equal to the amount of builtin torque. Base of the bracket being attached to labial surface of the crown
will also make the crown angular or inclined equal to the amount of builtin bracket torque. Note that when the slot is straight the
base of bracket and middle of the LACC or FACC is making an angle of 7° with occlusal plane perpendicular.

Another important aspect about amount of
torque expression is pretreatment inclination of
the teeth. A simple a rule of thumb should be
remembered “When the slots of the brackets are
straight no further torque is expressed on
insertion of a straight wire”. Now take the
example of maxillary central incisor. The
middle of labial surface of this incisor should
have 7° inclination to occlusal plane
perpendicular in ideal occlusion .If a maxillary
central incisor bracket with +7° builtin torque is
bonded to central incisor which already has an
ideal inclination of 7° to occlusal plane
perpendicular than no torque would be
expressed on passing a full dimensional wire.
But if the same incisor has an inclination of -7°
to occlusal plane perpendicular as happen in
class II div 2; +14° torque would be expressed
on engagement of full dimensional wire to make
incisor inclination to +7°. In case of class 2 div1
the middle of LACC of central incisor
105
inclination can be at +20° to occlusal plane
perpendicular. In this case central incisor
bracket having +7° torque will deliver -13°
torque to the central incisor on engagement of a
full dimension wire so that the inclination of
incisor will become +7° to occlusal plane
perpendicular (Figure 6.25).
From the above discussion it is clear that if the
entire torque built within the bracket is
expressed on engagement of full dimension
wires, the final inclination of incisors would be
same no matter from where one started. Andrew
advocated using full dimension rectangular
wires for final expression of torque. But there
are some practical limitations of using full
dimension wires in the slot. Engaging a full
dimension wire in slot is practically not possible
because a full dimensional wire will generate
extra friction making sliding mechanics
difficult if not impossible. Full dimensional
 CHAPTER 6
Selection of Bracket Prescription

A B C

Figure 6.25. Pretreatment inclination of teeth effect the amount of torque expressed by the brackets. A. A maxillary incisor with
ideal inclination. Bonding a bracket to an incisor having the same amount of inclination as bracket builtin torque will not result in
expression of any torque i-e the bracket will act as a zero torque bracket. B. A positive +7° bracket placed on a maxillary central
incisor having increased inclination .In maxillary incisors the opening of bracket should be downward directed if it has to express
positive torque. In case of class II div 1 the inclination of maxillary incisors is already increased. Placing a positive torque bracket
of +7° on an incisor already having an inclination of 20° with occlusal plane perpendicular will result in orientation of bracket
opening in upward direction .On insertion of full dimensional rectangular wire; this bracket will express negative torque
instead of positive torque. In ideal scenario a change of -13° in maxillary incisor inclination on full torque expression would
occur so that the final inclination of incisor would be +7°. C .A retroclined maxillary central incisor with -7° inclination with
occlusal plane perpendicular. A +7° torque bracket placed on this incisor will make the slot opening downward directed, so
positive torque would be expressed on engagement of full dimensional rectangular wire. On expression of entire torque built
within the bracket the inclination of tooth will become +7° resulting in an overall change of +14° in incisor inclination.

wire also would be too stiff and so good fitted 3) Stiffness of the wires
that it cannot easily be inserted and removed
from the brackets by hand and also will generate 4) Diminution of force
heavy forces which would be painful for the 5) Material of brackets
patient and might debond the bracket on
insertion. So in clinical orthodontics smaller 6) Vertical position of brackets on teeth
dimensional wires are used.
7) Inclination of neighboring teeth
On insertion of smaller dimensional wires,
expression of torque from a bracket depend 8) Direction of tooth movement
upon the following factors: 9) Prominence of the slot
1) Play of the wire within the slot 1) Play of the wire within the slot
2) Interbracket distance When a smaller dimension wire is used in a

A B C
Figure 6.26 Play of wire in the slot on insertion of smaller dimension wires. A. 0.016x0.022 inch wire. B. 0.019x0.025 inch
wire. C. 0.021x0.025 inch wire .The bracket dimension is 0.022x0.028 inch. Smaller the dimension of the wire, greater is the gap
between the slot walls and the wire. The play in vertical dimension or width of slot affect torque more than play in prominence or
length of the slot.
106

slot there would be a gap between the slot
walls and the wire. This gap will cause
certain rotation or free play of the wire in the
slot (Figure 6.26). Because of this play or
free space, not all the torque built within the
bracket is expressed on passing the wire .To
express the required amount of torque either
we have to introduce torque or torsion in the
wire by pliers or have to use a bracket with
extra torque built within to accommodate the
amount of play of the wire. The amount of
torsion in the wire or extra torque built within
the bracket should be equal to the amount of
play of the wire with in the slot.
To measure free play of wire in the slot
different mathematical formulas and
techniques are used. Without going into the
details of these, theoretical torque play and
effective torque of wires in bracket slot as
measured by Sernetz4 is given Table
6.10&6.11. These values were given with
assumption that their minimal edge rounding
up to 0.03 mm of slot and slot width is 0.46
mm (slot 0.018x0.025 inch) or 0.56 mm (slot
0.022x0.028inch).
Take the example of 0.018x0.025 inch wire
in a 0.018” and 0.022” slot from the tables
6.10&6.11. There is 1° of free play of this
wire in 0.018” slot and 11.4° play in 0.022”
slot. Using this wire on a maxillary central
incisor having +7° torque bracket will result
in expression of +6° torque in 0.018” and 0°
in 0.022” slot. In 0.018” slot introducing a 1°
torque in the wire by torqueing it will make
the inclination of incisor to +7° but in case of
0.022” slot 11.4 ° torque in the wire would be
required to express all the bracket torque. An
alternative approach is to use customize
central incisor bracket having 8° torque in
0.018” slot and 18.4° torque in 0.022” slot to
express +7° torque on 0.018x0.025 inch
wire.
The formula and tables presented by Sernetz
107
Selection of Bracket Prescription
are mostly quoted in orthodontic literature
but they also have some flaws. They didn't
take into consideration of many other factors
that also affect torque play like type of
ligation, wire tolerance etc. A systematic
review by Archambault5 showed that greater
torque play than Sernetz calculated values.
However, these tables are still valid for rough
calculation of torque play and the effective
torque expressed by brackets wires
interaction.
Torque or wire play is affected by following
factors.
a) Manufacture tolerance of slot and wire
b) Edge bevel of slot and wire
c) Mechanotherapy
d) Type of ligation
e) Defects in brackets slot
f) Aging of brackets
a) Manufacture tolerance of slot and wire
Dimensions of bracket slots are usually not
as accurate 6 - 1 2 as claimed by the
manufacturer. Many manufacturers also
intentionally keep slot dimension larger so
that the clinician could pass full dimension
wire with ease in the bracket slot. Usually
the manufacture tolerance13 in 0.018” slot
ranges from 0.0182” to 0.0192” while in a
0.022” slot it ranges from 0.023” to 0.030”.
Larger the bracket slot than prescribed
value greater would be the play of the wire
within the slot and greater would be the
torque loss.
Like dimensions of the bracket slot,
dimensions of the wire are also not accurate
6, 7, 12, 14
as claimed by the manufacturers and
there is more variation in dimensions of the
wire than dimensions of the slot. In
archwires the dimensions are kept smaller

Selection of Bracket Prescription
by manufacturer to aid easy insertion of
wire within slot but this arrangement results
in torque loss. The manufacturer tolerance
in archwires ranges from 0.0178” for 0.018”
wire and 0.0215” for 0.022” wire. The
physical properties like stiffness of the
wires and bracket vary between
manufacturer products as properties of the
material is affected by the manufacturing
process and additional elements added to
enhance the material properties. This can
also result in change in torque expression.
Because of difference 6 in different
measurement units there is difference in slot
and wire size of European and American
wires and brackets. The 0.022-inch slots in
European made brackets are oversized by
4.22% even if no other manufacturing
variability is present. Also European wires
are oversized than American wires. Using
Table 6.10
Table 6.11
CHAPTER 6
European made brackets with American
made wires can result in increased torque
play.
a) Edge bevel of slot and wire
Edge bevel of slot and wire or edge
rounding is done by the manufacturer so
that the wires are easily inserted into the slot
(Figure 6.27). Edge bevel in the slot can be
present as rounding of slot floor or walls
edges. Both slot15 and wire bevel6, 16, 17
results in decreased wire dimension and so
increase in play of the wire in the slot
resulting in increase in torque loss.
Different manufacturers keep different edge
bevel of wires and slots. So torque play
varies between manufacturers even in same
continent. Edge bevel of the wires effect
torque play more than edge bevel of slots.
108

A usually prefers to use soft elastic ligature by
B slot (Figure 6.30).
C B
Figure 6.27 A .Beveling of slot walls. B. A wire with
beveled edges, so decreasing the dimension of the wire. C. A
beveled wire inserted into a bracket. There is increase wire
play because of beveling of the wire.
c) Mechanotherapy
Wires used in sliding mechanics shouldn't
be used for torque application as there is
considerable loss of surface layer6, 18 .
Torqueing pliers may deform the archwire 19
giving less torque values so it is better to add
some extra torque while using torqueing
pliers (Fig 6.28). If greater torque is
required it's better to use a high torque
prescription brackets because high torque
prescription brackets express more torque
than low torque prescription brackets 21.
Giving repeated torque on the wires will
cause plastic deformation 20 of the bracket
(Fig 6.29) and will diminish torque
expression from brackets.
109
Selection of Bracket Prescription
d) Type of ligation
Tighter the ligation better would be the wire
seated within the bracket slot and more
would be the torque expressed. Elastic
ligature has a rapid force decay rate so they
are less effective in torque expression as
compared to steel ligatures. Clinician
stretching the ligature with the help of
dental probe at initial leveling and
alignment and use tight elastic ligature at
heavy wires for expression of torque. Active
self-ligating bracket5, 22 shows less play and
so more torque expression than passive self-
ligating brackets. The design of bracket also
affects ligation of wire and its play in the
Figure 6.28 A. The edges of the wires are roughened and
rounded by torqueing pliers. Loss of edges of a rectangular
wire will lead to increase wire play in the slot. B. A wire used
for 7 months in sliding mechanics. Due to friction between
wire and brackets the surface layer of the wire is lost
decreasing the dimension of the wire. It's a common clinical
practice to use the same wire for torque expression after
sliding mechanics. But it is better to use a new wire for torque
application after sliding mechanics.
Figure 6.29. Comparison between new bracket and bracket
after torque application by torsion in wire. If greater torque is
required it is better to use a high torque brackets than using
low torque brackets and introducing torque in the wire.
Insertion of heavy pretorqued wire will always causes some
plastic deformation of brackets as Vickers hardness of SS
wires is usually greater than SS brackets. Many a time the
clinician doesn't have choice to change the bracket
 CHAPTER 6
Selection of Bracket Prescription

prescription and torque in wire is needed. But if first torque

introduction in wire don't provide the required inclination
change then it is better to use a new bracket with added torque
on the wire. On heavy wires the new bracket can be placed
passively on wire guidance. A clinical tip is that while placing
bracket on wire guidance using a straight wire to place the
bracket instead of existing torqued wire. Doing this will also
help to produce torque on insertion of previously used A
torqued wire.

Figure 6.30 A maxillary premolar bracket with negative

builtin torque as opening of slot is facing upward. Slot
dimensions in this bracket are 0.022x0.030 inch. The height
of the underarm of gingival tie wing is greater than occlusal
tie wing so ligature will exert lighter force on gingival edge of
the wire than occlusal .This is usually a problem on lighter C
rectangular wires such as 0.016x0.016 inch or 0.016x0.022
inch. Unfortunately these are the wires which are usually Figure 6.31 Defects in bracket slot. A. Crack in the middle
used for torque application by twisting the wire as heavier of bracket slot base due to manufacturing defect. With this
torqued wires are too stiff to be inserted in the slot. Another defect the slot would be expanded on insertion of heavy
aspect of this type of bracket design is that the gingival edge wires. B. A manufacturing innovation for easy debonding of
of the wire is facing upward if negative torque is given in wire ceramic brackets. Such design prevents insertion of heavy
and it is the part of the wire where ligature will affect less wire in the slot so increasing the wire play. C. Bracket
force. So effective torque is decreased .Such a bracket design material extending from the slot wall thus preventing
cannot be avoided as we all engage ligature from gingival insertion of heavy wire in the slot.
side to prevent soft tissue injury on instrument slip. So some
torque loss on these brackets on smaller dimension wires is
inevitable.

e) Defects in brackets slots

Defects in brackets slot can cause increase

torque play. These defects are due to poor
manufacturing or ill design of slot (Figure
6.31). More defects in brackets slots are
found when using recycled brackets than A
new brackets (Figure 6.32). Recycled
brackets should be avoided in teeth
requiring extra torque.

f) Aging of brackets
Bracket left in the oral cavity undergo aging
in the form of corrosion and plaque
accumulation (Figure 6.33). Corrosion will
B
Figure 6.32 Bracket debonded by technique not favorable
for reusing brackets. Recycling and reusing such brackets
will result in increased torque play due to decrease dimension
of the wire that can be inserted within the slot.
110

A stainless steel wire will express more torque
B wires. This sequence also prevents bracket
C slot due to builtin torque, the wires tend to
Figure 6.33 Aging changes in brackets. With time
corrosion resistance of bracket decreases resulting in
increase in bracket roughness. This increase roughness offers
more plaque retention and calculus formation. Calculus in
bracket slot initially prevents the insertion of heavier wires
but latter under the load of torqueing forces the calculus
breaks thus increasing the wire play.
increase the dimension of the slot while
calculus accumulation will prevent
insertion of heavier wire. Unfortunately
these aging changes are found more at the
time of treatment when torque application is
required.
1) Interbracket distance
As the interbracket distance increases,
stiffness of wire decreases. So less torque 23
would be expressed on increasing the
interbracket distance. In lingual brackets as
there is decreased interbracket distance
greater torque is expressed as compared to
labial brackets using same dimensional
wires.
111
Selection of Bracket Prescription
2) Stiffness of wires
Stiffer the wire more the torque would be
expressed by bracket wire interaction. A
24, 25, 26
than a same dimension TMA or NiTi
wire. But the problem with stiffer wires is
that they are difficult to insert and generate
heavy forces. It's a good practice to use
flexible wires initially and later use same
dimension stiffer wires when torqueing
movement is required at larger dimension
fracture in case of ceramic brackets.
3) Diminution of force
A minimum threshold of force is always
required to cause tooth movement. When
torsion is given in the wire within its elastic
limit or the wire is twisted within the bracket
returns to its original shape with time. As the
wire returns to its shape there is gradual
reduction of force so that a point comes when
the forces transmitted from the wire to
brackets are beyond the level of torqueing
movement of teeth. Force loss in archwire
was found in following sequence27 SS
>NiTi>TMA.
4) Material of brackets
Plastic and ceramic brackets are less
effective in torque expression than stainless
steel brackets. Titanium brackets are more
effective28 in torque expression than stainless
steel brackets.
5) Vertical position of brackets on teeth
Andrew used the center of long axis of
clinical crown to measure torque values of
individual teeth. These torque values were
then incooperated in his bracket
prescription. As teeth don't have uniform
morphology throughout their clinical crown
length29 so location of brackets will affect

their torque expression13, 30-32.
Selection of Bracket Prescription
In fact bracket will only express it's builtin
torque and incline the surface of the tooth
where it is bonded to an inclination
equivalent to the amount of builtin torque
(Figure 6.34). Due to uneven morphology
of crown if the bracket is not placed at the
middle of clinical crown, the middle of
clinical crown won't have an inclination
found in an ideal occlusion, leading to poor
occlusal results.
Zone 1
Increase Positive
torque zone
Zone 2
Ideal Positive
torque zone
Zone 3
Negative
torque zone
Figure 6.34 The morphology of the labial surface of the
tooth can be divided into three zones. Zone 2 is the middle of
the clinical crown. This is the zone where inclination of the
tooth was measured by Andrew and the amount of inclination
measured was incooperated into the bracket. Andrew
advocated placing the bracket in this middle zone. Zone 1 is
gingival to the middle zone. This zone has increased
positive torque than zone 2. If bracket is needed to be
placed in this zone it must have increased torque. Suppose
this zone have +12° torque when the middle zone have +7°
torque. Placing the +7° torque bracket in this gingival zone
and expressing all the torque of the bracket will result in
orientation of zone 1 +7° to occlusal plane perpendicular.
This 5° decrease in inclination of zone 1 will automatically
decreases the inclination of zone 2 and make it 2° to
occlusal plane perpendicular. So the overall picture we get
is that placing the bracket gingival to require position will
result in expression of more negative torque because we
are taking middle of clinical crown as reference to measure
inclination. Zone 3 is incisal to the middle of clinical
crown and has negative torque. If someone wishes to place
bracket in this zone the bracket must have negative torque
to keep other parts of the labial surface of crown at their
optimum inclination. Placing a bracket meant for middle of
the clinical crown which have positive torque in zone 3
will result in positive inclination of this part of the tooth
thus increasing positive inclination of other parts of the
crown too. Suppose +7° torque bracket is placed in zone 3
having a negative inclination of -5° to occlusal plane
perpendicular .On expression of full torque, zone 3
inclination will become +7° while zone 2 inclination will
become +19°.
CHAPTER 6
The morphology of teeth apart from
mandibular incisors 33 is such that when the
bracket is placed gingival to middle of
clinical crown negative inclination of the
middle of clinical crown is increased 32. The
opposite is also true that when bracket is
placed incisor to the middle of clinical
crown positive inclination of middle of
clinical crown increases. A description of
brackets placed at different clinical heights
is given in figure 6.35.
Mestriner 33 in a study on mandibular
dentition found that 1mm of height change
of the brackets from occlusal to cervical will
effect torque expression of approximately
2° in central and lateral incisors, 3° in
canines and 8° in premolars and molars.
While other studies reports 34-36 that a height
change of 1 to 3 mm can affect torque up to
10° to 15°.
The difference in torque variation between
these different studies is related to the type
of tooth measured. Incisors have less sharp
changes in surface topography than canine
and premolars. Middle zone of the incisor is
larger while that of canine and premolars is
smaller (Figure 6.36).
7) Inclination of neighboring teeth
Torque in a bracket is expressed when
wire is passed through multiple brackets
bonded to teeth. If full dimension wires
are used then the entire builtin bracket
torque would be expressed. But as we
don't use full dimension wires for ease of
mechanics so inclination of neighboring
teeth and bracket torque of neighboring
teeth effect torque expression of brackets.
For example an increased negative torque
on canine will increase positive torque on
lateral incisor due to reactionary forces, if
there is wire play present during torque
application.
8) Direction of tooth movement
112

A B
C D
E increase the transverse distance between
Figure 6.35 The same zone of torque exists in
mandibular arch. Zone 2 the middle zone have negative
inclination which should usually be found in ideal occlusion
cases. Zone 1, the gingival zone has less negative inclination
than zone 2 while zone 3 the incisal zone has more negative
inclination than zone 2.Placing a bracket which is meant for
middle zone on zone 1 will increase negative inclination of
zone1thus also increasing the negative inclination of zone 2
& 3.Placing the same bracket on zone 3 will decrease its
negative inclination thus decreasing the negative inclination
of whole crown or it will increase the positive inclination of
the crown.
113
Selection of Bracket Prescription
Bracket placed at different heights of canine crown is shown.
Straightening the bracket slot and superimposition of
different bracket heights is done. Gingival the bracket is
placed more would be the negative inclination of the tooth
and more the bracket is placed incisal more would be its
positive inclination.
A variation in morphology is usually found in mandibular
incisors because they have flat labial surface of crowns. So
incisal zone of mandibular incisors, many a time have same
inclination as middle zone.
A B
Figure 6.36 A. An upper central incisor labial surface. B.
Upper canine labial surface. The surface of the incisor is less
convex than canine so bracket position variation on canine
has more sharp effect on change in inclination as compared to
incisors. The variation is greater if the bracket is placed
gingival as there is sharp steep in inclination in the
gingival area.
Direction of tooth movement also effect
torque expression if there is play in the wire.
Mesial movement and intrusion of incisor
produce lingual root torque while distal
movement and extrusion produces labial
root torque 13.
9) Prominence of slot
Prominence of bracket slot effects its torque
expression. As the bracket prominence
slot and center of resistance increase so
decreasing the torque expression of the
bracket.
Clinical Notes
While selecting brackets prominence of
brackets should be kept in mind. Brackets
with less prominence which are strong
enough to withstand orthodontic loading
should be selected (Figure 6.37).
 CHAPTER 6
Selection of Bracket Prescription

Figure 6.37 Maxillary arch bracket sets from three different manufacturers. Set A has the least prominence so it would be most
effective in torque expression.

Interaction between tip and torque the

wagon wheel effects

Andrew pointed out the interaction between
angulation and inclination of the teeth in
anterior part of the maxilla. On increasing the
maxillary incisors inclination or torque, the
roots of incisor come close to each other. As
maxillary incisors have a positive tooth
angulation or mesial crown tip so increase in
torque will result in decrease in tip or angulation
of tooth. It was found1 that increase in torque of
4° will decrease tooth angulation by 1° in
maxillary incisors.
The interaction between tip and torque was
verified on a rectangular wire containing
vertical wire spurs. On giving palatal root
torque to these vertical wire spurs which were
supposed to behave like maxillary incisors, the
spurs ends come closer to each other and the
whole assembly of rectangular wire and vertical
spurs look like a wagon wheel so the
phenomenon is called wagon wheel effects
(Figure 6.38).
Clinical implication of wagon wheel
effects
The lost tip or angulation due to increase in
torque must be accommodated in the
brackets prescription. If maxillary central
incisor torque is increased from 7° to12° as
in the case of class III incisor relationship
than 1.25 ° of maxillary central incisor tip
should also be increased. Proper occlusal
and esthetic results cannot be obtained if tip
is missing in the maxillary incisors.
Clinical notes
Clinician often encounter with problem of
root approximation in incisor area at the
final stages of treatment. Many a time it is
because of poor axial placement of brackets
but sometimes the axial position of brackets
both clinically and on x ray seems fine. To
correct the problem of root approximation
either give proper torque or if ideal torque

114
 Selection of Bracket Prescription
A B

C
Figure 6.38. To see wagon wheel effect Andrew attached four vertical spurs on a rectangular wire. The vertical wires represent
four maxillary incisors. When the positive torque or palatal root torque is given on this wire distal to laterals at both ends, the
ends of the vertical spurs will move towards each other thus decreasing their mesiodistal inclination. It was found that a
positive torque of 4° will decrease the angulation or tip by 1°. A. Vertical spurs attached to a 0.021x0.025 inch wire
considering it a wire for upper arch. B. Positive torque given to same wire, which results in decrease in angulation of vertical
spurs. C. Negative torque given in same wire which results in increase in inclination of spurs. The same ratio of 4:1 was
applicable to increase in tip .Though wagon wheel effects were proposed for maxillary incisors but my personal understanding
is that it is also true for mandibular incisors because mandibular incisors like maxillary incisors are also present on a
semicircular area though smaller in size .

cannot be given as in camouflage cases, correction of rotation will give space within the
brackets should be debonded and rebonded in arch .Only ovoid shaped premolars will need
overcorrect position . space for correction of rotation.

Incorporating key IV into prescription

Key IV: Absence of Rotations
There are three types of tooth rotation that are
The fourth key to normal occlusion is that no
encountered in orthodontic cases:
teeth should be rotated within the arch.
1. Natural rotation present before start of
If teeth are rotated with in the arch, space
treatment.
management would be difficult and proper
occlusion won't be established. Incisors teeth 2. Tooth rotation because of faulty bracket
both maxillary and mandibular have very small placement.
labiolingual width as compared to mesiodistal
width so derotation of incisors will need space 3. Tooth rotation because of orthodontic
within the arch .In contrast canines and molars mechanics and treatment plan.
teeth will give space on correction of rotation .
Natural rotation and faulty brackets placement
Only a complete 90° rotation of canines and
can be corrected by placing brackets with
molars will need space for correction of
compound contoured base at mesiodistal center
rotation. In premolars most of the time
of the tooth at optimal height (Figure 6.39).
115

Selection of Bracket Prescription
Rotation should be corrected early in the
treatment at round wires and correction
maintained throughout the treatment.
A buccaly or labial out and slot base is away from
B
Figure 6.39 A. Bracket placed at mesiodistal center of
maxillary central incisors. To avoid rotation of tooth the
brackets should be placed at mesiodistal center of the tooth.
B. A bracket bonded on a rotated premolar at mesiodistal
center.
Figure 6.40 For rotation control during tooth translation
the mesiodistal length of bracket (A) should be equal to the
distance from the slot point to the tooth vertical axis (B). This
is not technically possible in posterior dentition so counter
rotation is added to the brackets.
Rotation control is very easy in nonextraction
case where bracket is placed at ideal location. In
extraction cases rotational control of the teeth is
CHAPTER 6
poor. The teeth are usually rotated in the
direction of rotation. For effective rotation
control Andrew proposed that the mesiodistal
bracket length should be equal to distance from
the slot point to the tooth vertical axis (Figure
6.40).
As this distance is usually greater than bracket
length, Andrew added counter rotation in slot
component of brackets. This was done by
rotating the slot so that the slot base is closer to
the bracket base on the side which need to be
the bracket base which needed to moved palatal
B Distal
Meisal
Figure 6.41. A. Bracket with equal prominence of mesial
and distal tie wings and so the slot. A mandibular left
canine bracket with mesial wing slightly more prominent
and so is its slot than distal wing. As builtin counter
rotation in the bracket is only 2° so it is barely noticeable.
or lingual (Figure 6.41) . The greater the
distance the tooth is translated greater would be
the counter rotation. For translation series
brackets Andrew recommended 2° slot rotation
for minimum series brackets, 4° slot rotation for
medium series brackets and 6° slot rotation for
maximum series brackets.
This antirotation feature would be present in all
116

teeth undergoing translation excluding incisors.
How it works?
For counter rotation the slot is rotated at an
angle over the base of bracket. Suppose a
maxillary canine has to be translated distally
in a premolar extraction space. So when distal
translation of canine or any other teeth is done
the direction of translation will cause the canine
to rotate mesial out. To counter this problem,
A
Distal
Meisal
B case if the contact points are not tight and
Figure 6.42 A canine bracket with builtin counter
rotation for distal movement. On initial alignment because of
design of bracket slot the tooth would be rotated
mesiopalatal. This is to counter the distopalatal rotation of
canine that occur during retraction of canine in extraction or
distalization cases. Greater the amount of translation the
greater would be the builtin counter rotation.
depth of the distal slot base in a twin canine
bracket would be closer to its bracket base than
the mesial slot base. On leveling the distal
portion of tooth will move out or buccally and
mesial portion of tooth will move palatally. So
at the end of leveling the canine would be
rotated mesial in on translation,distal out
117
Selection of Bracket Prescription
rotation of canine occur,so at end of
translation tooth would have zero rotation. A
description of above example is given in
figure 6.42.
Factors effecting rotation of a tooth during
translation are
1. Play of wire within the slot
2. Using small mesiodistal length of bracket
3. Poor ligation or low quality ligatures
4. Heavy forces during translation
5. Distorted slots
6. Low stiffness of the wire
Key V: Tight Contact points
The 5th key state that contacts point should be
tight and there should be no spaces between the
teeth.
Tight contact point can be achieved by attaining
rest of the keys of normal occlusion and careful
treatment planning (Figure 6.43). Nothing
special is built within straight wire appliance
(SWA) to give tight contact points.
This key should be achieved for proper space
management, good gingival health, aesthetic
and good final occlusal outcome. In a finished
there is no genuine tooth size discrepancy it is
usually because less than required tip or
torque is given to the teeth. But genuine tooth
size discrepancies pose special problems. In
those cases if size of the teeth is small a
composite build up or prosthetic crowns
should be given and if size of the teeth is large
tooth size reduction or extraction should be
done. Case example of importance of tight
contact points and their relation with Andrew's
other keys is given in figure 6.43.
Key VI: Flat Occlusal plane or Curve of Spee
Curve of spee should be flat or slightly
 CHAPTER 6
Selection of Bracket Prescription

B
Figure 6.43. A. Improper tip of central incisors and lack of torque in lateral incisors. To compensate it canine was moved
forward leaving poor contact point between canine and premolar. B. A case with good occlusal results and proper contact points
due to proper tip, torque, prominence and lack of rotation characteristics.

A B
Figure 6.44 A. increased curve of spee. If curve of spee is increased or deep, there would be less space for upper incisor.
Occlusion would be disturbed both anteriorly and posteriorly. B. Reverse curve of spee. If the curve of spee is decreased or reversed
in lower arch than there would be excessive space in the upper arch.

increased at the end of treatment.
Clinical implication of Key VI
Nothing is built within bracket prescription to
accommodate key VI because it is more related
with position of the brackets on the teeth.
Accomplishing this key is very important for a
good occlusal outcome. Andrew found that
nonorthodontic dentition has flat to slight curve
of spee and preposition of flat curve of spee was
given to accommodate natural tendency of
curve of spee to increase with age due to growth
of lower jaw and its growth rotation. Banding or
bonding the second molars also help in leveling
of curve of spee .Usually leveling 1mm of curve
of spee 37 require less than 1mm of space. A
description of curve of spee is given in the
figure 6.44.
Limitations of Andrew prescription
Large inventory
In Andrew system to deal with different types of
arch discrepancies there are 12 maxillary and 11
mandibular sets, which are combination of five
different types of brackets .These are
118

S – Standard Brackets
T1 – Minimum Translation Brackets
T2 – Medium Translation Brackets
T3 – Maximum Translation Brackets
T4 – Maxillary Molar tubes or bands for Class
II&III
Andrew gave such a big inventory to make the
treatment more individualized. But
unfortunately this became one of the biggest
limitations of his prescription. Making so many
different types of brackets means that there is
need for more machinery, more space, more
work force and so more finances needed for the
manufacturer. Also when there are so many
different types of brackets, more time and
education is needed for the orthodontist to get a
better understanding for making the right choice
in each case. So when there is no Magic formula
available, orthodontics will remain only for
professional orthodontists. This means loss of
valuable clientage for the manufacturers.
Unfortunately the problem in orthodontics is
that if the orthodontist is customizing treatment
Table 6.12
answers. Do we need to accommodate wagon
wheel effect in class I incisor torque as it is
natural position of the incisors within the arch?
If wagon wheel effects occur due to anatomy of
area and our treatment mechanics, why not the
tip is decreased in the prescription in case of
class II incisor torque and increased in case of
class III incisor torque?
119
Selection of Bracket Prescription
by bracket prescription or by wire bending he is
wasting his time but if the manufacturer is
customizing brackets it's an innovation and you
have to pay for that innovation.
For the orthodontist keeping a large inventory at
orthodontic office means there is need for more
financial resources and more office space. This
is obviously against the core rules of good office
financial management. So unfortunately the
very benefit of Andrew prescription to provide
individualized treatment to some extent became
the most limiting factor of its wide acceptance.
Tip and Torque
Both tip and torque values placed in Andrew
prescription are slight different from Andrew
original findings of normal occlusion 2.
Tip in Andrew Straight wire appliance and
actual tip from his study are given in table 6.12.
There is overall increased in tip in SWA as
compared to Andrew original findings. For
change in tip values it is generally presumed that
Andrew made the changes to accommodate
wagon wheel effects. There are some questions
in this regard that for the time being have no
Torque values were also changed by Andrew to
some extent than original norms (table
6.13).Overall there is decrease in torque values
in SWA as compared to original findings. After
going through Andrew work my understanding
is that Andrew changed the upper incisor torque
values to incorporate finding of his unpublished
100 cases cephalometric study. For example in

Selection of Bracket Prescription
Table 6.13
original Andrew's norms the maxillary central
incisor class I torque was 6.11° while the lateral
incisor torque was 4.42°.In cephalometric study
Andrew found that there is always 4° difference
between maxillary central and lateral incisor
torque. So I presume that he changed the torque
of central to 7° and lateral to 3° to make that
study count. Other values were changed either
to incorporate clinical experience or to round off
values for ease of standardization.
Apart from this, Andrew also didn't take in
consideration various factors that affect the
expression of tip and torque especially the play
of the wire. This is because Andrew advocated
full dimension wires at the end of treatment for
expression of entire builtin tip and torque.
Because of their increased stiffness use of full
dimension wires have been abandoned and so
the problem started with expression of the
prescription.
Counter-rotation
Andrew incorporation of counter rotation into
the slot was also not appreciated by many.
Though effective during space closure but if the
orthodontist remain on a heavier wire for long
time using effective ligation of wire to
consolidate tooth position or torque correction
after space closure the teeth having counter
rotation brackets will become rotated due to
expression of prescription .
So Andrew prescription presents a dilemma for
clinician in extraction cases. Moving to heavier
CHAPTER 6
wire for better tip and torque expression as
Andrew didn't accommodated wire play in his
prescription but such wire will cause counter
rotation expression. Many clinicians who
favors counter rotation in brackets for
extraction cases and also have included counter
rotation in their own prescription advocate that
as relapse is inevitable so the rotation is part of
over correction and it will eventually be
relapsed during the settling phase. But the
practical problem a young orthodontist face
today is that he has to display his finished case
in exam and complete the settling phase with
elastics or wire bending than going on natural
settling with retainers. It is difficult to settle
teeth into occlusion when they are rotated.
Correction of rotation will leave space in the
arch and there are many different retainers of
modern day such as fix retainers and vacuum
formed retainers that don't allow settling to the
extent as Hawley retainers do.
So orthodontists are left with two choices when
using counter rotation brackets at the end of
treatment. Replace bracket with standard
brackets or resort to wire bending.
Limitations in Mechanics
As expression of bracket prescription depend
upon what mechanics one uses, many clinicians
who later made their own prescription pointed
out some mechanics flaws present in Andrew
philosophy for case treatment. These were
1) Anchorage loss
120

As tip built into Andrew appliance was more
than what Andrew found in his original
research so this increased tip put strain on
posterior anchorage and also cause anterior
anchorage loss at the initial stages of
treatment. Anchorage control was also
difficult in extraction case.
2) Leveling Curve of Spee
Many clinicians also didn't agree with
Andrew philosophy of leveling curve of spee
with compensatory curves in wires in
maxillary arch and reverse curves in wire in
mandibular arch.
3) Roller coaster effects
In early years of SWA class II elastics were
used for sliding mechanics. In order to
overcome friction heavy forces were used.
Increased anterior tip, vertical component of
elastics and heavy forces resulted in
deepening of anterior bite and opening of
lateral bite. This effect was called Roller
Coaster Effect (Figure 6.45).
Figure 6.45 Roller coaster effects and anterior deep bite
and lateral open bite.
4) Root parallelism
Andrew measured tip values by using long
axis or facial axis of clinical crown and not
the whole tooth. There is always some degree
121
Selection of Bracket Prescription
of variation32 between long axis of clinical
crown and long axis of the tooth. Placing the
bracket just by keeping in mind the long axis
of clinical crown will result in poor root
parallelism in many cases. Also due to
increase tip built into Andrew prescription
there are chance of root approximation of
teeth especially between maxillary canines
and premolars.
5) Bracket Height
Andrew advocated bracket placement at mid
of long axis or facial axis of clinical crown
also called LA point(long axis point) or FA
point(facial axis point). Judging the FA point
or LA point on a tooth was a matter of clinical
experience. Some clinicians3, 38 didn't agree
with validity of placing bracket at the FA
point to get an ideal occlusion while others39, 40
advocated that there are greater chances of
error in placing bracket on FA point and gave
fixed distance from incisor edge and
suggested using special gauges for bracket
placement. Effects of change in height on
bracket prescription have been discussed
before.
Because of these limitations different types of
bracket prescription were put forward with
time. Whether these new bracket prescriptions
solved any practical limitation of Andrew
prescription is still debatable but there is a
general consensus that they solved the problem
of manufacturers and general dentists in the
form of “A Single Fairytale Bracket Set for All
Types of Malocclusion”.
Different Bracket prescriptions
With time so many clinicians put forward their
own prescriptions of brackets .For effective use
of these prescriptions many of them also
advocated their own treatment mechanics and
bracket position on teeth. Even some clinician
went to the extent to recommend certain
commercial brands of wires for effective
 CHAPTER 6
Selection of Bracket Prescription

expression of their prescription. Some of these
prescriptions were also even disowned after
copyright of the patent was expired. Other
prescriptions were changed with time after hit
and trials reveals the flaws within them. In
many cases same prescription vary between
different bracket manufacturers. It is because,
to avoid copyright and patent violation many
manufacturers produce the same prescription
with minor changes in tip and torque values.
Even different values in 0.018” and 0.022” slots
of same prescription are sold by the
manufacturers. This is due to more clearance
between wire and slot in 0.022” slot so 0.022”
slots are sometimes made in higher torque
values41 than 0.018 “ slot. Many text books of
orthodontics show charts containing only tip
and torque and no importance is given to
counter rotation and mesial offset. Some
bracket sold in the markets has prescriptions
which are never endorsed by any clinician,
meaning manufacturers also make their own
prescriptions!
So it's not possible to give details of each
prescription and each variation. Some
prescriptions are given in tables 6.14&15.
Though every effort is made to give the original
prescription as purposed by the inventor but
readers may find some values of tip or torque
different from what they use to know for the
reasons explained before.
Roth Prescription
Ronald H. Roth (1933-2005) put forward his
modified version of Andrew prescription in
1976 which he called3 Roth Prescription of the
Andrew Appliance.
Roth based his prescription on following
principles:
I. Small inventory .A single bracket set for all
types of malocclusion.
II. Overcorrection, especially in torque of
brackets to accommodate relapse and

Table 6.14 Maxillary arch values of different prescriptions

Maxillary Central Lateral Canine 1 st 2 nd 1 st Molar 2 nd M olar

Arch incisor incisor Premolar Premolar

Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Offset° Torque° Tip ° offset

Alexander +15 +5 +9 +9 –3 +10 –6 0 –8 4 –10 0 13 – 10 0 10

Begg 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 6

Burstone +7 +5 +3 +8 –7 +10 –7 0 –7 0 –10 –5 10 –10 0 6

Damon +15 +5 +6 +9 +7 +5 -11 +2 -11 +2 -18 0 12 -27 0 6

(standard
torque)

Hasund +20 +3 +14 +9 –2 +6 –10 +2 – 10 +2 – 20 +3 10 – 25 +5 6

Hilgers +22 +5 +14 +8 +7 +10 –7 0 –7 0 –10 0 14 –10 0 10

Ricketts®– +22 0 +14 +8 +7 +5 0 0 0 0 0 0 15 –10 0 12
IV.
Dimension

Ricketts® +22 0 +14 +8 +7 +5 0 0 0 0 0 0 0 0 0 0

Standard
Standard 0 0 0 0 0° 0 0 0 0 0 0 0 0 0 0 0
Edgewise
Tweed 0 0 0 0 0 0 0 0 0 0 0 0 0/6 0 0 0/6
122
 Selection of Bracket Prescription
Table 6.15 Mandibular arch values of different prescriptions

Mandibular Central Lateral Canine 1 st 2 nd 1 st Molar 2 nd M olar

Arch incisor incisor Premolar Premolar

Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Torque° Tip° Offset° Torque° Tip ° offset

Alexander -5 +2 +5 +6 –7 +6 –7 0 –9 0 –10 0 0 0 0 5

Begg 0 0 0 0 0 0 0 0 0 0 0 0 6 0 0 6

Burstone –1 0 –1 0 – 11 +6 –17 0 –22 0 – 27 0 5 –27 +2 6

Damon -3 2 -3 +4 +7 +5 -12 +4 -17 +4 -28 +2 2 -10 0 5

(standard
torque)

Hasund 0 0 0 +5 0 +5 –10 +2 –15 +2 -22 +4 0 – 25 +2 6

Hilgers –1 0 –1 0 +7 +6 –11 0 –17 0 –25 0 7 –25 0 6

Ricketts®– 0 0 0 0 +7 +5 -7ex 0° -7 ex 0 –22° –5 12 –27 0 16

0 n- -14 n-
IV. ex ex
Dimension
Ricketts® 0 0 0 0 +7 +5 0 0 0 0 0 0 0 0 0 0
Standard
Standard 0 0 0 0 0° 0 0 0 0 0 0 0 0 0 0 0
Edgewise
Tweed 0 0 0 0 0 0 0 0 0 0 0 0 0/6 0 0 0/6

diminution of force. brackets such as double and triple tubes,

addition of hooks for ease of mechanics.
III. Leveling of curve of spee to some extent by
placing anterior brackets more incisal. How Roth Made this Prescription?

IV. More torque in anterior brackets to
accommodate torque loss by wire play.
V. Super torque brackets for rapid correction of
torque in class II div2 cases.
VI. Roth proposed a new archform called Tru-
Arch to be used with his prescription. Roth
advocated selection of archwire is important
as it effects the rotational position of teeth.
Wider the archform more positive torque
would be expressed and vice versa. Roth
archform was most prominent and wide at
mesiobuccal cusp of the first molars.
VII. Different translation philosophy.
According to Roth tipping of the teeth to some
extent is accepted on round wires.
VIII. Many auxiliary features were added to
123
Dr. Andrew in one of his articles42 commented
on origin of Roth prescription. According to
Andrew, Dr. Roth found that a high percentage
of his cases can be treated by using Andrews'
class III incisor torque brackets for maxillary
arch and class I incisor torque brackets for
mandibular arch. For buccal segment Roth used
Series 1-C and Series II-Classic. Where series
1-C was given in all 1st premolar extraction
cases where both maxillary and mandibular
canines are given maximum translation series
brackets and both arches 2nd premolars are given
minimum translation series brackets while
molars are given standard SWA. Series II-
Classic brackets were used in case of extraction
of maxillary 1st and mandibular 2nd premolars
because of class II molar relationship. In this
series maxillary canines and lower posterior
 CHAPTER 6
Selection of Bracket Prescription

Table 6.16. Roth Prescription

Teeth Central Lateral Canine 1st & 2nd Premolar 1st &2nd Molar
incisors incisors

Torque Tip Torque Tip Torque Tip° Rotatio Torque Tip Rotation Tip Torq Rotation°
° ° ° ° ° n° ° ° ° ° ue°

Maxillary +12 +5 +8 +9 -2 +13 2MR -7 0 2 MR 0 -14 14DR/0°

Arch
Class II

Mandibul -1 +2 -1 +2 -11 +7 2 DR -17 -1 4DR -1 -30 4DR

ar arch P1&

-22
P2

Where MR=Mesial Rotation to counter distal translation. DR= Distal rotation to counter mesial
translation. P1 = 1st Premolar P2 =2nd Premolar , Class II= Molar Class II in cases where
only upper 1st or 2nd premolars are extracted .Reference for above Table 3, 40.

are given maximum translation series brackets Canines

and lower canine and upper posterior are given
minimum translation series brackets.
Roth prescription is given in table 6.16.
These comments by Andrew about Roth
prescription were made in 1976 and in the same
year Roth43 wrote an article about his 5 year
practice changing experience with Andrew
prescription. Unfortunately he didn't reveal
anything about his specific selection of brackets
from Andrew's work. It was in 1987, that Roth3
published his prescription and given
justification for it. That prescription is far
different from Andrew's comments. The only
comment true is about maxillary and
mandibular incisor tip and torque. A personal
review of literature by this author couldn't find a
prescription by name of Roth that matches
Andrew's comments. The first published Roth
prescription is given in table 6.16.
An evaluation of origin of this prescription is
given.
Maxillary Arch.
The maxillary canine tip is taken from
minimum translation series brackets made for
distal translation. Canine torque was Roth
personal calculation of torque to accommodate
wire play. Canine counter rotation feature was
also taken from Andrew distal translation group
in minimum translation series brackets.
Premolars
Both 1st and 2nd premolar tip was taken from
minimum translation series brackets requiring
mesial translation. Premolar torque was taken
from Andrew standard SWA. Counter rotation
feature was taken from minimum translation
series brackets for distal translation.
Molars
Both 1st and 2nd maxillary tip was selected from
Andrew Class II molar tip. Torque of molars
was selected from Andrew medium translation
series brackets. Counter rotation values for
molars were taken from medium translation
series for mesial translation.
124

Controversy
In maxillary arch both canine and premolars
brackets have minimum translation features
builtin. If one tooth need to be minimally
translated in extraction space in most of the
cases than the other tooth need to be maximally
translated to close the extraction space.
Premolars have counter rotation feature for
distal translation. It's a common finding that in
most of our cases premolars needed to be
translated mesially than distally. Also premolar
counter rotation feature don't correlate well
with molar except in 2nd premolar extraction
cases where molar need mesial translation and
1st premolar need distal traction.
The molar tip is meant for class II relationship
while offset is meant for class I molar
relationship.
Mandibular Arch
Canines
Canine tip is taken from minimum translation
series brackets for mesial translation while
torque is taken from Andrew standard SWA.
Counter rotation feature for canine is taken
from minimum translation series for mesial
translation.
Premolars
Premolars tip correlate with Andrew medium
translation series brackets. Torque values
remain similar to standard SWA while counter
rotation feature values are from medium
translation series for mesial translation.
Molars
Molars have tip of medium translation series
for mesial translation. 1st mandibular molar
torque remain same as that of standard SWA
while 2nd molar torque was made equal to 1st
molar. Counter rotation feature were also taken
from medium translation series brackets for
125
Selection of Bracket Prescription
mesial translation.
Controversy
In mandibular arch canine is given minimum
translation series counter rotation feature and
tip values while molars and premolars have
medium translation series values. Second
molar torque was made equal to 1st molar.
Giving less torque on second molar increase
their chances of coming in cross bite as it's a
common finding that 2nd molars are usually
present slightly buccally as compared to 1st
molar in finished cases using Roth prescription.
Roth Justification for his prescription
Roth3 while giving his prescription gave some
justification for the specific selection.
Maxillary Arch
Roth3 justified his prescription by explaining
that 5° extra torque was added to maxillary
incisors keeping is line with his treatment
philosophy of overcorrection and
accommodating torque loss by wire play. So
without moving to full dimension wires the
clinician can attain natural inclination of
incisors.
For canines, Roth used -2° torque which was -
5° less than Andrew prescription. This was
done to avoid reactionary effect of building
more positive torque into the incisors brackets.
This is explained in the figure 6.46. The final
torque of canine would be -7° due to
reactionary forces from the wire and because of
wire play. If no wire play is present the final
torque of the canine would be -2°.
Also canine tip was increased by +2° to
accommodate tip loss in extraction cases as
distal translation of canine take place and it is
also helpful to get better canine guidance.
Canines was also given 2° rotation to mesial
so that when it is translated distal, mesial
builtin rotation compensate the effect of distal
 CHAPTER 6
Selection of Bracket Prescription

B C

Figure 6.46 A .A rectangular wire passed through maxillary incisors and canine brackets. The slots opening of the maxillary
incisors is facing downward causing the wire to rotate clockwise on exiting the lateral incisor bracket. This clockwise rotated wire
when passes through canine bracket whose slot opening is facing upward will cause the canine bracket to rotate clockwise while
canine bracket slot will cause the wire and so the incisor brackets to rotate counterclockwise. So positive torque would be
expressed on incisors and negative torque would be expressed on canine. If the incisors have more positive torque, than reactionary
forces of wire leaving from incisors will cause more negative torque on canine. This only happen when wire play is present. If no
wire play is present all the torque built within the bracket would be expressed. B. Wire exiting lateral incisor in a clockwise fashion.
C. Wire engaging canine bracket clockwise at an angle thus negative torque expression in canine.

rotation that occur during distal translation of canine.

Premolar torque was kept the same while the tip

was decreased. Though there was no
justification given for using minimum
translation angulation in both premolars nor
does there is any logical basis of decreasing tip
after giving 2° mesial offset for counter A
rotation. This decreased tip can accommodate
increased tip on canine but the roots of these
teeth come close to each other at end of
treatment. Also 2° mesial rotation was added to
premolar brackets. The justification was that
this was done to counter the of effect distal
traction of these teeth. As Roth favored
headgears in his mechanotherapy this addition B
seems logical.
Figure 6.47 According to Roth -14° torque should be
On 1st and 2nd molars buccal root torque was given to maxillary molar to counter the effect of palatal cusp
hanging during translation. A. Palatal cusp hanging in
increased from -9° to -14°.The increased torque maxillary molar after translation. B. No cusp hanging.
126
 can counter the effect of hanging of
mesiolingual cusp on translation (Figure 6.47).
Roth gave no rational explanation for
increasing molar offset or distal rotation from
10° of Andrew's value to 14°. This can be due to
get an ideal molar relationship after the
mandibular molar offset was also increased
by 4°, otherwise Roth Class II elastics or
headgear mechanics don't favor increased
maxillary molar offset.
The angulation of molar was decreased to 0°
from Andrew's value of 5°.As Roth places
bands at different angulation than Andrew's
bands. So 0°tip was in fact 5° tip of Class I
A have increased negative inclination in class II
B where final relation is full cusp class II molars.
C
Figure 6.48 A. The mesiobuccal cusp of the molar is
more vertically prominent than distobuccal cusp and the
dominant buccal groove is slightly aiming backward at an
angle of 5° to occlusal plane perpendicular. B. Tube with
builtin 5° tip in Andrew prescription are placed more
gingival on mesial. This make the vertical axis of the tube
parallel to dominant buccal groove but base of the tube is not
parallel to the buccal cusps. The tube will express 5° tip. C. If
tube with 5° is placed parallel to buccal cusps as
recommended in Roth and MBT system, the mesial slot of the
127
Selection of Bracket Prescription
tube would be facing downward. So a 5° tube will act as a 10°
tube. But if the tube with 0° tip is placed parallel to buccal
cusps than the final outcome would be 5° of molar
angulation.
molar (Figure 6.48). Otherwise actually giving
a 0° tip to molars in class I position will result in
poor angulation of molars.
For Class II div 2 Roth proposed super torque
for maxillary anterior brackets. Prescription
values of super torque brackets are found in
many manufacturers catalogs. The values given
in table 6.17 are taken from a manufacturer
catalog ( DENTSPLY GAC ).
This super torque prescription will correct
decrease inclination of incisors in class II div 2
more efficiently. Use of different canine tip
depends upon clinical scenario (Figure 6.49).
In super torque prescription positive torque is
present on both upper and lower canines. This is
because both upper and lower canines usually
div 2. Another reason for choosing positive
torque on canines is to counteract the
reactionary effect of increasing positive torque
on incisors for reasons explained before.
Roth also proposed 0° offset for molars in cases
Such are the case where only upper premolars
are extracted. In such cases Roth also
recommended that his super torque incisor
prescription should be used. It was reasoned
that as half the molar width is smaller than the
mesiodistal width of bicuspid so that extra
space would be utilized by the anterior torque.
Super torque Prescription
The super torque prescription of Roth was
indeed genius innovation and it will help to
correct upper incisor inclination in less time but
full torque expression built within the brackets
should be avoided.
 CHAPTER 6
Selection of Bracket Prescription

Table 6.17.Roth prescription (Super or Extra torque)

Teeth Central Lateral incisor Canine 1st and 2nd Premolar

incisor

Torque Tip Torque Tip Torque Tip Rotation Torque Tip Rotation
° ° ° ° ° ° ° ° ° °

Maxillary +17 +5 +10 +9 +3 +9 +4MR // // //

arch
and
+13

Mandibula // // // // +3 +5 0 // // //
r Arch

Note. Mandibular dentition

Super torque values were taken from a catalog Roth justification

and may or may not be endorsed by Roth .Some
Not much was changed from Andrew's in Roth
of the justifications in favor of Roth work was
prescription in lower dentition. Canine
also this author logical reasoning.
angulation was increased 2° in an effort to give
canine guidance and give better canine class I
relationship. Distal tip and distal rotation was
introduced in lower prescription because Roth
believe that lower teeth settle more mesial than
upper and also rotate while settling so using
modifications will counter the relapse factor.
Both the lower molars have same torque.
Decreasing the tip in lower arch would also
decrease the anchorage demands. Roth
proposed that as his appliance rest on
A mesiobuccal cusp rather than buccal groove so
same torque on molars is justified.

In super torque prescription only the lower

B case usually the lower canine root is more labial
Figure 6.49 A. If tip of the canine is decreased at start of
treatment then standard tip of 13° should be used. B. If tip of
canine is increased at the start of treatment which is usually
the case in some types of class II div 2 cases where canine is
overlapping the incisors; decrease tip of 9° should be used.
canine's brackets are present. Tip was
maintained at norms while positive root torque
was added to canine. This prescription values is
only suited when the upper laterals and canines
have pushed the lower canine inward. In that
and crown is lingual.
Conclusion of above discussion
Roth work was not an innovation rather it was a
128

wise selection of brackets from Andrews' work
that favors mechanics used by Roth on most of
the patients he treated at his office. Roth
humbly named his prescription as Roth
prescription of Andrew appliance.
Difference from Andrew Prescription
The question which is usually asked is which
prescription is better, Andrew prescription or
Roth prescription?
The simple answer is that both works if you
follow the treatment philosophy of what their
inventor said. There is a saying about
contemporary prescriptions.
“They don't have a brain you have to use your
own.”
When using Andrew prescription you have to
use your brain to choose the best brackets that
suits your case. Many times the selection is
composed of brackets from all 5 types of
Andrew series. In Andrew prescription you
need to express all the tip and torque present
within the bracket by simply going to heavy
wires. The main disadvantage of Andrew
prescription is that one needs wire bending to
level curve of spee and the finishing wires are
usually curved wires.
While in Roth prescription you simply get the
bracket set but after bonding brackets to teeth
till end of treatment some variation in bracket
position and wire bending is necessary. In Roth
philosophy instead of resorting to wire bending
as Andrew did, curve of spee is leveled by
virtue of bracket positioning.
In Roth prescription you don't need to go to full
dimension wires. When Andrew place 7° torque
in his maxillary central incisor brackets he
means that your incisor should be at 7°
inclination with occlusal plane perpendicular at
the end of treatment. But when Roth place 12°
or 17°torque in his upper incisors brackets he
doesn't aim to attain all the torque built within
129
Selection of Bracket Prescription
the bracket. Doing so will bring the roots out of
lingual cortex. So one needs to be extra vigilant
while using Roth prescription. In Roth
treatment mechanics tipping of teeth is allowed
so is using smaller dimension wires for closing
spaces. Tipping plus smaller dimension wires
means that not all the torque would be
expressed from the brackets. So in Roth terms
while using a 12° or 17° brackets one need to
express only 8 to 10 ° torque. The 1° to 3° extra
torque from norms attained during treatment
would eventually be lost in relapse during the
settling. So a finish case has a 7° incisor torque.
But it's always difficult to tell that the teeth have
attained the required torque and the assessment
is more of a guesswork based on final
occlusion.
So both Andrew and Roth aim at similar final
occlusal results, but the pathway is different.
One cannot use Andrew treatment philosophy
with Roth prescription to get the required
results and vice versa.
Limitations of Roth Prescription
Inventory
Roth prescription like Andrew has a multiple
inventory. Roth prescription started as a single
bracket set but with time having hit and trials
multiple options were available. The present
day Roth prescription are available as Roth
standard prescription available in option of
upper premolar in mesial rotation or distal
rotation, Roth super or extra torque for class II
div 2 and Roth surgical for surgical cases.
So person of Roth statue also reached the
conclusion that it's not possible to treat all types
of malocclusion with a single bracket set.
Lack of variability
Cotemporary Roth prescription contain
multiple bracket sets. But the level variability
found in Andrew prescription is missing in
Roth. In Roth prescription standard brackets are

Selection of Bracket Prescription
meant to treat most types of malocclusion. So
we have one single bracket set for extraction
and nonextraction cases. We are bound to use
brackets with increased tip and counter rotation
in nonextraction case where teeth are not
supposed to translate. In translation or
extraction case we use same brackets for every
type of extraction and so translation of teeth. It
is well understood that, greater the amount of
translation needed greater tip, torque and
counter rotation would be required. Using
standard Roth series brackets in cases requiring
greater translation of teeth would be lead to less
over corrections present at the end of treatment.
So by using Roth prescription and reaching the
same dimensions of archwire we do most
overcorrection of teeth position in cases where
we required least i-e the nonextraction case and
we do least over correction in case where we
required most i-e extraction cases requiring
more than 4.1 mm of translation.
Mechanotherapy
Today's orthodontists want their cases to be
well settled down when they deboned it. But
Roth prescription is based on the assumption of
overcorrection to accommodate relapse. By
using Roth brackets we presume that same
amount of relapse will occur in all type of cases.
Present day evidence 44-47 on relapse doesn't
support this assumption. As relapse is
unpredictable, so if Roth philosophy of
overcorrection in finished cases is followed
then some cases may relapse more than is
required to achieve ideal results while in other
cases there may be no relapse at all and
orthodontists are left with no other option but to
cause a force relapse to correct over correction.
Unlike Andrew prescription where full
dimensional archwires are used in both
extraction and nonextraction cases in Roth
prescription, arch wire selection need to vary
between extraction and nonextraction cases to
get the desired results.
CHAPTER 6
Root Parallelism
Like Andrew prescription Roth prescription
also has problem with root parallelism
especially in maxillary canines. The canine root
comes very close to the premolar root after
expression of tip. Though it is claimed that not
all the tip would be expressed because of wire
play, yet wire play is less a problem with tip
than torque. So if someone wants to attain +7°
center incisor torque in Roth standard
prescription having +12° build in torque, the
minimum wire he would need is 0.021”x0.025”
on 0.022”x0.028” slot. Such wire will
theoretically express +7.9° of torque on incisor
but more than 12° of tip on canine as the play of
the wire is 0.001” in vertical dimension.
Contemporary Roth prescription
Roth prescription available commercially
today is different from what originated in 1970s
and justified and advertised in 1980s.The
difference is more evident in counter rotation. I
have no idea whether the present day Roth
prescription found in different catalogs and
books is also endorsed by its founder.
Different Roth Prescription values are given in
table 6.18&6.19.
Roth Surgical Prescription
All the values are same of standard series
prescription except upper canine. The upper
canine has -2° torque, 9° tip and 4° mesial
rotation. This prescription values seem to be
effective for class III surgical cases but not for
class II.
Standard Roth prescription
Standard Roth prescription taken from two
different sources is given. Table 6.18 values are
from a reputed manufacturer 48 catalog while
table 6.19 values are from a widely recognized
under and postgraduate text book 49.
130
 Selection of Bracket Prescription
Table 6.18

In table 6.18 there are some much required
modifications. Mesial rotation of maxillary
canine is increased to accommodate greater
translation of this tooth in extraction cases. Also
counter rotation in mandibular canine is
reversed from distal rotation to mesial rotation.
This surely will help translation of canine in
premolar extraction cases. In both first and
second maxillary premolars counter rotation is
reversed to distal rotation. Distal rotation will
favor planned anchorage loss as we required in
many of the 1st premolar extraction cases.
In the table 6.19, canine angulation is taken
from Roth extra torque prescription. No counter
rotation value is given for canines and
premolars. So it is generally presumed by
students that no counter rotation exists in both
maxillary and mandibular canines and
premolars. Zero tip and torque is present in
mandibular incisor which don't have any
precedent in Roth work. 9° tip is used for

Table 6.19 Roth Prescription

Teeth Central Lateral Canine 1stPremola 2ndPremola 1st Molar 2nd Molar
incisors incisors r r

Tip Tor Tip Torq Tip° Torq Tip° Tor Ti Torq Ti Torq Rotati Ti Torq Rotati
° que ue° ue° que p° ue° p° ue° on° p° ue° on°
° °

Maxillar 5 12 9 8 9 -2 0 -7 0 -7 0 -14 14 0 -14 14

y Arch

Mandib 0 0 0 0 7 -11 0 - -1 -22 1 -30 4 0 -30 4

ular 17
arch

maxillary canine which is usually a part of advocated by these orthodontists. The

super torque series and not a part of standard
Roth prescription.
MBT Prescription
MBT is an abbreviation for Richard
McLaughlin, John Bennett and Hugo Trevisi.
These three orthodontists from three different
parts of the world worked together to introduce
their own prescription of brackets called MBT
prescription in 199750. The bracket prescription
was made to accommodate specific mechanics
131
prescription was based on following principles:
1. Light continuous force.
2. Lacebacks, bendbacks and elastic module
assisted retractions.
3. Sliding mechanics on a 0.019”x0.025” SS
wire in 0.022”x0.028” slot bracket.
4. Use of specific arch form close to patient
natural arch form. Three different arch forms
were advocated. These were tapered, ovoid
 CHAPTER 6
Selection of Bracket Prescription

Table 6.20 MBT Prescription

Teeth Central Lateral Canine 1stPremol 2ndPremola 1st Molar 2nd Molar
incisors incisors ar r

Tip Tor Tip Torq Tip Torque Tip Tor Ti Torq Ti Torq Rotati Ti Torq Rotati
° que ue° ° ° ° que p° ue° p° ue° on° p° ue° on°
° °

Maxillar 4 17, 8 10 8 +7,0, 0 -7 0 -7 0 -14 10 0 -14 10

y Arch
22 -7

Mandib 0 -6 0 -6 3 -6,0 2 - 2 -17 0 -20 0 0 -10 0

ular ,+6 12
arch

and square archform. Incisors angulation or tip in both maxillary

5. Selection of brackets in specific
malocclusions and alteration of prescription
in some specific clinical problems.
6. Bracket positioning at specific height on
the teeth taking guidance from bracket
positioning charts and using specific bracket
positioning gauges.
7. Using curves in the wire to level curve of
spee.
MBT prescription is given below in table 6.20.
Origin of MBT Prescription
The inventors of this prescription claimed that
after working for 15 years they put forward
their treatment mechanics 52-53 and then
introduced this prescription in 1997 to
facilitate those treatment mechanics. Andrew
original findings and two Japanese studies 54, 55
were also taken into consideration apart from
their own clinical understanding in the
making of this prescription.
Justification of MBT prescription
The inventors of MBT prescription gave the
following justification for making of their
prescription.
Incisors
and mandibular arches were decreased
because there was no need to compensate
wagon wheel effects if clinician use lacebacks
during alignment and leveling and elastic
modules combined with lacebacks for space
closure.
To counter torque loss during space closure and
overjet reduction, positive torque in maxillary
incisors is increased from Andrews' values.
Two torque options are provided for central
incisors. Cases like class II div 2 can benefit
from higher torque value of 22°. Negative
lower incisor torque was increased to counter
increased incisor proclination that occur during
leveling curve of spee.
Canines
Canine tip was decreased and it was taken from
Andrew original research finding 39.Both
maxillary and mandibular canine torque is
available in 3 different options. In maxillary
arch -7° is taken from Andrew original research
findings while 0° and +7° torque taken to
accommodate different malocclusion.+7°
torque is good for cases with buccally placed
canines. 0° and +7° torque brackets are also
good for cases with narrow maxilla. In
mandibular arch negative torque is decreased in
canines to decrease incidence of gingival
recession. When there is increased negative
torque the canine crown moves away from the
132

labial soft tissue and its roots move closer to
labial cortex thus increasing incidence of
gingival recession. Also maxillary expansion
will favor from decreased negative torque in
lower canines as the lower canines crowns will
move out to support the expanded maxillary
canines.
Premolars
0° tip was given in upper premolars to allow
these teeth to angulate more towards class I
position. Another reason to decrease tip values
is that there are less chances of anchorage loss
in MBT system because of light continuous
force treatment mechanics. In lower premolars
the Andrew prescription value of tip was
retained as these values are close to Andrew's
original findings and also these help to better
orient lower premolars toward class I position.
Torque values in maxillary premolars were
retained from Andrew's prescription as they
were found satisfactory in most cases. In
mandibular premolars torque values were
decreased to avoid gingival recession which is
usually present in this area and to avoid
mandibular arch narrowing which will in turn
cause maxillary arch narrowing. Decrease
negative torque on premolars will also help to
decrease torque on molars.
Molars
Tip in the maxillary molars is decreased to 0°.
But positioning bands or tubes parallel to
buccal cusps or occlusal plane rather than
buccal groove was advocated. Because of
different placement position a 0° tip will make
molar angulation 5° for reason explained in
Roth prescription. The lower molars are given a
0° tip instead of 2° and it is advocated that lower
molar tubes or bands should be placed parallel
to occlusal plane rather than taking buccal
groove as a reference. Placing the molar tubes
with 0° tip parallel to occlusal plane will make
the final orientation of buccal groove 2° to
133
Selection of Bracket Prescription
occlusal plane perpendicular. So in terms of
orientation of maxillary and mandibular molar
there is no difference in final orientation of
molars in case treated in accordance with
Andrew prescription and MBT prescription.
Maxillary molar torque was increased from
Andrew standard prescription to -14° to avoid
palatal cusp hanging. In mandibular molars
torque was significantly decreased especially
the lower 2nd molar torque to support expanded
maxilla, to accommodate decreased negative
torque anterior in the arch and to prevent lingual
rolling of the lower molars which occur due to
use of class II elastic.
Proposed advantages of MBT prescription
Following advantages for MBT prescription
have been purposed by its inventors
Incisors Brackets
The increased torque on maxillary incisors will
rapidly correct incisor torque in class II div 2
cases. Increased positive torque on upper
incisors and negative torque on lower incisors
is helpful in class III camouflage cases and
cases treated with class II elastics. Decreased
tip will decrease demand on anchorage in initial
leveling and alignment. Because of 0° tip in
lower incisors the lower incisor brackets are
interchangeable.
Canine Brackets
Positive and zero torque brackets are helpful in
maxillary expansion and buccaly placed
canine's cases. Zero torque brackets are
especially helpful in gingival recession cases
and extraction cases to keep roots of teeth in
middle of alveolar process while translation
into extraction space. Zero or positive torque
lower canine's brackets are also helpful in class
II div2 cases where the canine root is placed too
labial. Maxillary negative torque brackets are
helpful in palatally impacted canines for proper
root placement while the positive torque

Selection of Bracket Prescription
brackets are helpful in cases where canine
is substituting the lateral incisor.
Premolars Brackets
0° tip in upper premolars brackets mean left
side brackets can be used on right side and vice
versa. 0.5mm increased prominence of brackets
is made for small maxillary 2nd premolars if
required. No tip in upper and positive tip in
lower premolars will help to achieve class I
dental relations. Premolar tubes have been
made for lower 2nd premolars to prevent
occlusal interference in some cases.
Molar Tubes and bands
In cases where final molars relations are class
II; placing 10° distal offset tube will yield poor
occlusal results. Placing lower 2nd molar tube
which has torque very close to upper 1st molar
and 0° tip and offset will yield required
results. It is better to place opposite side of
lower tube to have proper orientation of the
hook. Many companies make straight hooks
in lower molar bands so placing same side
lower 2nd molar band on upper 1st molar will
also yield the required results.
Class II elastics will cause less lingual rolling of
lower molars as they have decreased negative
torque. This negative torque in lower molars is
also advantageous in maxillary expansion cases
while upright lower teeth will support the
expanded upper arch.
Critical evaluation of origin of MBT
prescription
Critical evaluation is given here to open
reader's mind of different aspects and
limitations of the prescription and is no way
meant to downplay the inventors work.
Before going in evaluation of the prescription
itself, a brief insight is given about the
mechanics on which the prescription is based.
CHAPTER 6
Canine Tie Backs
Canine tie backs and lacebacks are important
part of MBT treatment philosophy. According
to MBT inventors this component of treatment
mechanics helps to control tip and prevent
anchorage loss in initial stages of treatment.
This also helps to avoid wagon wheel effects
compensation in their bracket prescription.
But different clinician can tie canine lacebacks
with different force 56 and different force level
can be applied by same clinician at different
appointments. A randomized clinical trial 57 has
shown that maxillary canine lacebacks don't
cause mesial molar movement and can prevent
incisor proclination up to 1mm.But in
mandibular arch58 canine lacebacks don't cause
any change in incisor position but can cause
significant posterior anchorage loss up to
0.8mm so canine tip backs shouldn't be used in
mandibular arch. So decreasing tip in maxillary
arch can be justified to some extent but not in
mandibular arch.
Elastic module tiebacks or Active ligature
Elastic module tie backs or active ligatures
have been recommended for space closure in
MBT system. The inventor proposed that using
these elastic modules activated by laceback
wire apply light continuous force for space
closure. Also use of these modules doesn't
cause loss of tip in incisors and there is no need
to go for wagon wheel effect compensation.
Effective torque control on incisor is also
proposed benefit of these modules.
A randomized clinical trial by Dixon60
comparing three methods of space closure
showed that elastic module tiebacks are least
effective in space closure as compared to NiTi
coil springs and power chains. NiTi springs
have more than double the rate of space closure
per month as compared to active ligatures. A
systematic review61 also concluded that NiTi
coil springs closes space at a faster rate and
134

produces a more consistent force as compared
to using active ligatures in sliding mechanics.
From this evidence it is clear that elastic module
lack evidence for their use in space closure.
Wagon wheel effects
The inventors of MBT prescription claims that,
their mechanics apply light continuous forces
so there is no need to go for wagon wheel effects
compensation. But this claim has a technical
shortcoming. Wagon wheel effects are due to
shape effect of a semicircle. As premaxillary
and anterior mandible alveolar area is shaped
like a semicircle so wagon wheel effects are
inevitable. Increasing positive torque on the
teeth, whether they are incisors or canines in
this semicircle area will bring their roots closer
to each other. It won't be affected whether
forces given are light or heavy for this torqueing
movement.
Space requirement
It has been explained before that increase in tip
will take space and decrease in tip will give
space. Torque whether positive or negative will
need space, until the arch is expanded.
Decreasing or increasing tip to give better
occlusion will change space requirements in the
arch. In MBT system tip is decreased and
torque is increased. But the interesting space
management issue is that by following MBT
mechanics you will express the entire tip built
within the bracket but not all the torque. For
example, a central incisor bracket of maxillary
incisor has 4° tip and 17° torque. By following
MBT mechanics we will theoretically express
up to 3.9° of tip but only 7° torque. So decrease
tip in MBT system will leave spaces in the arch.
After treating more than 150 extraction cases
with MBT system, I personally feel that
decreasing tip in maxillary arch has created
problem in closing spaces especially in anterior
teeth. In many cases I resorted to build up of
maxillary incisors even there was no Bolton
deficiency or tip and torque problems.
135
Selection of Bracket Prescription
Sliding mechanics and torque expression
MBT system as claimed by its inventors works
best on 0.022” slot and sliding mechanics
should be used on 0.019”x0.025” wire. A
0.019”x0.025” wire has 9.5° to 10° play on
0.022” slot. When full dimension wires are used
final torque expressed is exactly what is built
into the brackets. As explained before in
Andrew key 3 that when wire play is present
many factors start affecting the torque
expression. So when wire play is present and
full arch is bonded, measuring effective
torque on each tooth is like measuring forces
in an indiscriminate force system.
For example if all other factors are constant and
brackets are placed at the same height with all
the teeth having 0° inclination to occlusal plane
perpendicular, then a 0.019”x0.025” wire
passing through an upper central incisors
having 17° torque and lateral incisors having a
10° torque will not express any torque as the
wire play would be less than 10°. But if the
same wire is extended posteriorly and it passes
through the canine which has -7° torque then
wire engages slot of canine at an angle of 7°.
Becasuse canine lateral incisor torque
difference is 17° and there is 10° play so torque
expressed would be 7°. As a result of it positive
torque would be expressed on lateral incisor
bracket and negative torque would be
expressed on canine bracket. Most of this
torque would be expressed on lateral incisor as
it got smaller roots and relatively thin bone
around it. As the inclination of both these teeth
changes so the orientation of their slots to
neighboring slots. In lateral incisor as slot
opening rotate in a counterclockwise direction
due to expression of the torque the difference in
its slot orientation from that of central incisor
slot increase. If out of 7° torque more than 3° is
expressed on lateral incisor then wire exiting
lateral incisor bracket will engage central
incisor bracket at an angle and also will result in
expression of positive torque on that teeth.

Selection of Bracket Prescription
Another factor that comes into play when wire
is extended posteriorly from incisors to canine
is orientation of the wire. Because of positive
torque in incisor bracket their slot opening
would be directed downward so a rectangular
archwire exiting the slot would be upward
directed. Engaging this wire in canine will
cause intrusion of canine, negative torque and
slight counterclockwise rotation of canine
crown as force is buccal to center of resistance
of canine. The counterclockwise rotation of
crown will decrease some negative torque of
canine. The incisor will get extrusive and
positive torque effects.
On the canine side if wire is extended
posteriorly into 1st premolar bracket that has -7°
torque than no torque would be expressed on 1st
premolar as the difference between bracket
torque on canine and premolar would be less
than 10°.No torque would be expressed on 2nd
premolar having -7° torque and 1st molar having
-14° torque.
But the situation is much more different in
clinical cases where different brackets are
positioned at different heights, different teeth
have different inclination with reference to
occlusal plane perpendicular, different bone
density around different roots having different
root length, different interbracket distance
between teeth and different teeth have different
crown morphology. Apart from crown
morphology all these factors are irrelevant in
torque expression and the entire builtin bracket
torque is expressed when a full dimension wire
engages the slot.
Critical analysis of origin of prescription is
given.
Maxillary Arch
Incisors
1. Central incisor
The maxillary central incisor bracket is
CHAPTER 6
available in two torque options +17° and
+22°.The +17° torque option is not new in
orthodontics. It was already used before
MBT prescription as part of Roth super
torque prescription for class II div 2. The
+22° torque is something new but an
important part of MBT system as present in
Roth was that you don't have to express all
the builtin torque of prescription. Whether
the builtin torque is +17° or +22° you have to
express only 7° in case of class I or +12° in
case of class III camouflage. As the MBT
system advocate 0.019”x0.025” wire for
sliding mechanics, so the effective torque
expressed theoretically taking 10° wire play
would be +7° in +17° torque bracket and
+12° in +22° torque bracket . +7° torque for
upper incisor was present in class I skeletal
pattern in Andrew findings and +12° torque
was recommended for Class III camouflage.
The inventors of MBT prescription claimed
that they have taken in consideration of
Andrews' original findings, standard SWA
appliance prescription and two Japanese
studies while making of this prescription. If
these values were taken into consideration
the mean torque of these four studies for
central incisor would have been +9°.
Central incisor tip is kept at 4°. This is close
to mean tip of different studies which is 3.98°
and Andrew original norms of 3.59°.The
wagon wheel effects were not compensated
in central incisor tip.
2. Lateral incisors
Lateral incisor torque is kept at 10°.If
Andrew cephalometric study have been
followed the lateral incisor torque should
have been 13°. The wire play of a
0.019”x0.25” wire will theoretically result in
expression of no or 0° torque on maxillary
lateral incisor in 0.022” slot. If straight
archwire is passed the lateral incisor would
always be 7° less than central incisor.
136

Input from 3 studies and Andrew SWA should
have resulted in lateral incisor torque of 6°.
So such input was never taken. In reality
lateral incisor torque is virtually decreased if
someone is following MBT mechanics with
MBT prescription. If one is aiming to attain
ideal central incisor torque of 7° on a straight
wire he will get 0° torque on lateral incisor
following the same mechanics.
Tip or angulation value of lateral incisor is
taken from Andrew original norms. An input
from different studies should have resulted in
mean lateral incisor of 7° and not 8°.
Canines
Canine torque is available in three different
options -7°, 0° and +7°. -7° is the prescribed
torque and other 2 options are to deal a certain
group of clinical cases. -7° torque is clearly
taken from Andrew standard SWA or original
norms as input taken from all studies have
resulted in a -3° mean torque on canine. In
clinical setting reactionary torque of incisors
should also be added in this negative torque of
canine if wire play is present during expression
of torque.
Tip value in canine is also taken from original
Andrew's original norms but mean tip value of
8.7° from different studies is also close to MBT
prescription.
Premolars
1st and 2nd premolar torque is taken from
standard SWA prescription values. Input from
different studies would also make this torque
value as -7°.Unfortunately changing the
mechanics will change the torque values. Using
0.019”x0.025” wire instead of full dimension
wires on standard SWA prescription values will
result in expression of decreased torque on
premolars as canine anteriorly and molar
posteriorly has also negative torque so torque
on premolars would be lost in wire play.
137
Selection of Bracket Prescription
Tip value is also decreased from Andrew
original norms and is taken from inventors own
clinical experience. The mean value of tip from
different studies is 3° for 1st premolar and 4° for
2nd premolar. Decreasing the tip to facilitate
class I relations will severely jeopardies the
space requirement in the arch and contacts
point wouldn't be tight without resorting to
composite build ups.
Molars
Torque values for 1st and 2nd molar are same as
that found in Andrew medium translation series
molar brackets and that of Roth prescription.
The mean input of different studies is -7° for 1st
and 2nd molars so torque values of MBT
prescription for 1st and 2nd molar are more
negative than Andrew original norms and
combined input of different studies.
Tip of both molars is kept at 0° but different
positioning of molar brackets is advocated that
technically make 0° tip into 5° which is same as
that found in standard SWA for class I molars.
The mean tip of different studies is 5 ° for 1st
molar but 2.3° for 2nd molar.
10° distal offset is also present in maxillary 1st
and 2nd molar tube. This is ideal for class I
molars. In case of class II molar relationship it
is advocated to band lower 2nd molar of opposite
side on 1st molar. But lower 2nd molar has 4° less
torque than upper 1st molar and molar band
position also need to be altered to get only 0°
tip. Ideally upper 2nd molars should also be
banded with lower 2nd molars of opposite side.
Mandibular Arch
Incisors
Lower incisors have class III incisors torque
values of Andrew SWA. The mean input of
different studies is 0.4° torque for lower central
incisor and -0.5° for lateral incisor.
Tip in lower incisors is also decreased and is

Selection of Bracket Prescription
close to Andrew original norms. The mean tip
of different studies would be 1° for central and
0.8° for lateral incisors. As the lower incisors
are also present on a semicircle shaped area the
wagon wheel effect needed to be compensated
by decreasing the tip on increasing negative
torque.
Canines
Lower canine tip is available in three options -
6°, 0° and +6°. The -6° is the standard
prescription while the other two are
recommended for some specific type of
malocclusion. There is far less negative torque
in MBT prescription than Andrew original
finding and Andrew prescription. The mean
torque of different studies input and original
SWA is -10°. So torque on canine is taken from
inventor own clinical experience.
Tip on lower canines in MBT system is close to
Andrew original norms and mean tip of
different studies.
Premolars
Negative torque on lower premolars is
decreased and is far less than Andrew original
norms and mean value of different studies.
Negative torque was decreased to match with
decrease in negative torque in molar area, to
support expanded maxilla and to prevent
gingival recession in susceptible cases. But it's
not necessary that maxilla would be constricted
or need expansion in all the cases or gingival
recession would be present in all the cases.
Bicuspid tip is same as that of Andrew standard
SWA. Taking mean value of different studies
and standard SWA would result in 1st premolar
tip of 2.4° and 2nd premolar tip of 3.5°.
Molars
Negative torque on lower molars is decreased
and is far less than Andrew original norms and
mean of different studies. This decreased
CHAPTER 6
negative torque helps to prevent lingual rolling
of the lower molars in case someone uses class
II elastics or fixed functional appliances. But
majority of the cases in orthodontic practice
don't use these mechanics and using such
torque value increase the incidence of crossbite.
0° tip in lower 1st and 2nd molar is technically 2°
tip because of difference in band placement
position in Andrew and MBT prescription. So
tip values for molars are same as Andrew
standard SWA. These tip values are less than
mean of different studies and Andrew's
original findings.
From the above review it is clear that MBT
system has also its shortcomings.
Selection of Prescription
All the prescriptions work fine if one follows
the inventor's advocated mechanics. All the
prescriptions have their own limitations that
needed to be compensated by wire bending
or elastics to some extent. We still don't have
a prescription where a straight wire is used
throughout the treatment and no wire
bending is required. Also lack of consensus
on ideal position of the bracket on the tooth
limits the adaptation of a single prescription
62
universally. Jain et al found that there is no
clinical significance in final outcome
between MBT and Roth prescription and
quality of treatment depend upon clinician
experience and judgment. Moesi 63 in a study
on Roth versus MBT prescription found
that it is difficult to judge on a finished
case that which prescription was used
during treatment.
Unfortunately it's a reality that in ideally
finished cases where a prescription can best
be judged are only done in teaching hospitals
and most of the clinician doesn't aim for the
required level of perfection in their clinical
practice so tip and torque of the bracket are
not appreciated to the extent it deserves.
138

Clinician should choose a prescription in
which they find ease with mechanics
advocated for that prescription. Due to
various limitation of all prescription some
degree of wire bending and bracket position
alteration is always required and clinician
should remain mentally prepared for that.
All the cases must be finished in light of
Andrews' six keys or any other parameters
set by local examination bodies or ethical
councils.
Alteration of prescription
Alteration of the prescription is done by
experienced clinician to deal certain types of
malocclusion. Alteration can be done by adding
different prescription together or alternating
different tooth brackets in same prescription. A
few examples of alteration of different
prescriptions are given.
Class II div 1growth modification
In growth modification with fixed functional
appliances in class II cases, MBT and Roth
prescription can be combined. Roth
prescription has decreased incisor torque on
maxillary incisors as compared to MBT
prescription while MBT prescription has
increased negative torque on lower incisors to
keep the lower incisors roots upright. Clinician
either uses Roth prescription on maxillary
incisors only and all other teeth are bonded with
MBT prescription or MBT prescription is used
on mandibular incisors only and Roth
prescription is bonded on all other teeth. This
approach of bracket position will keep lower
incisors roots upright during their mesialization
while upper incisor inclination is decreased
thus decreasing the severity of class II and
adding a camouflage to it (Case example 1).
Class II camouflage
Class II camouflage requires decrease of upper
incisor torque and increase of lower incisor
139
Selection of Bracket Prescription
torque. In extraction cases this can be done
either by modifying the mechanics or using low
prescription positive torque on upper incisors
and increased negative torque brackets on
lower incisors. In modified mechanics using a
light rectangular wire for retraction of upper
incisors will result in loss of incisor inclination
while using heavier wire for mesializing of
lower incisors having negative torque brackets
will keep their roots upright and prevent
excessive inclination change of these incisors.
Using Roth maxillary incisor brackets on upper
incisors and MBT mandibular incisor brackets
on lower incisors is a viable option to decrease
the positive incisor torque. The MBT brackets
on lower incisor will maintain their inclination
while mesializing lower incisor either by class
II elastics or any other mechanics. In case
lower incisors are retroclined which is mostly
not the case in majority of class II cases as
dental compensations are present for skeletal
pattern, MBT brackets can be inverted to
introduce positive torque and increase
inclination of lower incisors.
If at the end of the final stages of overjet
correction maxillary incisor inclination is still
increased upper incisor brackets can be
inverted to decrease their inclination. Placing
the brackets upside down will reverse its torque
and make maxillary incisors torque negative
while tip will remain the same (Figure 6.50).
When the clinician feel that required torque has
been expressed and inclination of incisors is
ideal the clinician should either move back to
lighter wires or debond the case after necessary
settling. (Case example 2)
Class II Surgical cases
In class II surgical cases increased positive
torque is used on maxillary incisor and
increased negative torque is used on
mandibular incisors to make decompensating
easier. MBT prescription is well suited for this
task.
 CHAPTER 6
Selection of Bracket Prescription

A B

Figure 6.50 A. A left maxillary central incisor bracket. B. Same bracket inverted upside down. Inverting the bracket will
reverse the torque but the tip will remain the same. Both brackets have positive tip as mesial slot of the bracket is facing downward.

Case example 1. A young patient having skeletal class II with increased overjet was treated with
jasper jumper appliance. The mandibular incisors were bonded with MBT prescription while all
other teeth were bonded with Roth prescription. The increased negative torque in MBT
prescription will keep the lower incisors upright during fixed functional phase. A class II fixed
functional appliance cause lower incisor proclination.
140
 Case example 2. An adult patient was presented with class II skeletal base and class II sub Selection of Bracket Prescription
division right molar relations, having increased overjet and increase curve of spee in lower arch at
the start of treatment. The case was treated with orthodontic comouflage. MBT brackets were
bonded on lower incisors to maintain their inclination with use of class II elastics . All other teeth
were bonded with Roth prescription.At the end of treatment as upper incisor inclination was
increased and there was some overjet remaining the upper incisor brackets were inverted to close
the overjet and correct incisor inclination. Unfortunately more than required negative torque was
expressed on upper incisors.

Class II div 2 or super torque prescription for this

malocclusion. Usually super torque
In class II div 2 usually both upper and lower prescription is not available worldwide due to
incisors are retroclined. Roth advocated extra its low demand so clinician uses MBT
141
 CHAPTER 6
Selection of Bracket Prescription

prescription. MBT prescription has increased
upper incisors torque. Usually 22° torque
option is selected for upper central incisors
depending upon degree of retroclination of
upper incisors. For lower incisors if they are
retroclined MBT lower incisor brackets are
bonded inverted thus making their torque
positive. But in case of normal or increased
inclination of lower incisors MBT brackets are
placed in their normal upright position. (Case
example 3)

Case example 3. A moderate class II div II in an adult patient in which upper incisors were
retroclined and lower incisors were having normal inclination. Case was treated with MBT
prescription and 0.021” x 0.025” wire was used as final working wire to express greater amount of
positive torque on upper incisors. As the lower incisors have normal inclination, lower incisor
brackets were placed in normal upright position.

142

Class III camouflage
In class III camouflage lower incisors brackets
need increased negative torque while upper
incisors brackets need increased positive
torque. So MBT prescription is well suited for
class III camouflage cases. Even 22° torque
option of maxillary central incisors can be used.
An important modification that is done in class
III camouflage is reversing the tip of lower
canine brackets to improve class I canine
relationship. This is done by alternating lower
contralateral canine's brackets. Using right side
bracket on left side will reverse the tip but keep
the torque unchanged. As MBT prescription has
decreased tip on lower canines as compared to
Roth prescription so many clinician alternate
Roth prescription brackets on lower canines.
Class III surgical cases
In Class III surgical cases for effective
decompensation upper incisors needed to be
retroclined while lower incisors needed to be
proclined. If it is an extraction case the upper
incisors can easily be retroclined and their
inclination can be decreased by using smaller
dimension rectangular wires like 0.016x0.022
inch SS for retraction during sliding
mechanics. The lower incisor inclination can
be increased by placing inverted MBT
brackets on lower incisors so that their torque
will become positive.
If the case is nonextraction both upper and
lower incisor need decompensation then MBT
brackets are inverted on both upper and lower
incisors. Inverting the brackets on both upper
and lower incisors will reverse their torque.
Placing +6° torque bracket is not a problem on
lower incisors but placing a -17° central and -
10° lateral maxillary incisors bracket is an
issue. So when required torque is attained on
upper incisors the brackets are debonded and
placed in their normal upright position. If these
inverted brackets are kept throughout the
treatment then chances of incisors root damage
143
Selection of Bracket Prescription
increase as orthodontists need to keep heavy
wires in the brackets during surgery and these
wires will express majority of the bracket
torque. Rebonded brackets will only change the
torque introduced in the incisors when more
than required negative torque was previously
introduced. There is no need to rebond lower
incisors brackets as there is small torque
differential between upright and inverted
brackets. Rest of the teeth can be bonded with
MBT or Roth prescription.
As large torque differential is present in upper
incisors on inverting MBT prescription, regular
visit of the patient is necessary once the patient
is on heavy wires. Some clinicians instead of
inverting MBT upper incisors bracket uses
inverted Roth incisors brackets as they have
smaller torque differential on inverting the
brackets.
Palatally placed upper lateral incisors
A common malocclusion that is usually
encountered is palatally displaced maxillary
lateral incisors. After bringing the tooth in the
arch and doing necessary leveling and
alignment the crown of the tooth become
aligned but the root remain more palatally
placed than required. This clinical situation can
easily be handled by placing inverted lateral
incisor bracket in MBT or Roth prescription.
Usually this torque problem is encountered
near the end of treatment so when the required
torque is expressed, the case is shifted to lighter
wires, necessary settling is done and the
brackets are debonded. But if there is ample
time remaining to do any other mechanics
then brackets on lateral incisors are debonded
and rebonded in their upright position using
wire guidance. Keeping heavy rectangular
stainless steel wires even after the required
torque has been expressed will result in
expression of extra torque that will increase
chances of lateral incisor root resorption from
labial cortical plate (Case example 4).
 CHAPTER 6
Selection of Bracket Prescription

Case example 4. An adult patient with severe crowding in upper and lower arch. Both maxillary
lateral incisors were palatally displaced due to crowding. The case was treated with extraction of
maxillary and mandibular 1st premolars. MBT prescription was used and maxillary lateral incisor
brackets were placed inverted to express negative torque on lateral incisor. Near end of treatment
stage shown. On right maxillary lateral incisor optimum torque is expressed while left lateral
incisor root is still palatally displaced. Right maxillary lateral incisors bracket was placed upright
after optimum torque was expressed while left lateral incisors bracket is still placed inverted.

144
 Selection of Bracket Prescription
Lingually placed lower incisor example 8 & 9).

For cases in which lower incisors are lingually

displaced MBT brackets are well suited but if
someone is using Roth prescription which has
decreased negative torque on lower incisors,
MBT prescription bracket can be substituted
for Roth brackets on lower incisors.

Maxillary lateral incisor Substitution

Cases requiring extraction of maxillary lateral

incisors or missing lateral incisors needs
canines to substitute lateral incisors. In such
cases lateral incisors brackets are placed on
canine after flattening the labial surface of
canine. The canine brackets are placed on 1st
premolars. (Case example 5)

Palatally impacted Maxillary canines

Palatally impacted maxillary canines when

exposed and brought in the arch will have their
roots lagging back in the palate. Increased
negative torque is required on these brackets.
MBT brackets with -7° torque are well suited
for these situations. In case only MBT +7°
torque bracket are available for maxillary
canines then inverting the brackets will make
them -7° torque brackets while tip will remain
the same. If someone is using Roth
prescription, MBT prescription brackets with
negative torque replace Roth brackets only on
canines. (Case report 6 & 7)

Buccally displaced maxillary canines

Buccally displaced maxillary canines have a

prominent canine buldge. Positive torque
brackets should be used on the maxillary
canines to place their root in middle of alveolar
process or slightly more palatal. Positive torque
option on canine is available in MBT
prescription but not in Roth. In buccally
displaced maxillary canines either canine
bracket of Roth prescription should be inverted
or MBT positive torque canine brackets should
be combined with Roth prescription (Case
145
 CHAPTER 6
Selection of Bracket Prescription

Case example 5. A Case with a peg right maxillary lateral and missing left maxillary lateral.
Deciduous canine was present on left side of the maxillary arch. Mandibular arch has severe
crowding. The case was planned with extraction of lower 1st premolars and upper peg lateral on
right and deciduous canine on left. In maxillary arch labial surface, tip and proximal surface of the
canines were reshaped to match the appearance of lateral incisors. The lateral incisors brackets
were bonded on canines in mesiodistal middle of the tooth. Canine brackets were bonded to
maxillary 1st premolars slightly distal to mesiodistal middle of teeth. Group function instead of
canine guided occlusion was aimed in this case.

146
 Selection of Bracket Prescription
Case example 6 .A palatally impacted canine. MBT negative torque bracket of -7° bracket was used on
impacted canine after its eruption .At the end of treatment canine has optimum buccal bulge and soft
tissue margins.

Case example 7. A palatally impacted canine case also treated with MBT prescription but
unfortunately with 0° bracket as negative torque bracket was not available. Note no buccal canine
bulge is present and the canine also has improper position of the gingival zenith.

147
 CHAPTER 6
Selection of Bracket Prescription

Case example 8. A young patient presented with moderate crowding in upper and mild
crowding in lower arch. Molar relation was class II end-on bilaterally. Maxillary left canine
was buccally placed. Space was created in maxillary arch by distalization of molars with
cervical pull headgear and in mandibular arch space was created with proclination of incisors.
After space creation in upper arch positive torque on maxillary canine was given by choosing a
+7° bracket from MBT prescription.

148
 Selection of Bracket Prescription
Case example 9. A young patient was presented with severe crowding in upper arch with
bilateral buccally placed canines. Space in maxillary arch was created by distalization of molars
with distal jet. MBT prescription was chosen with +7° torque of canine bracket. As right canine
was more buccally placed at start of treatment it need extra torque by wire bending than using a
0.019”x0.025” wire with +7° torque canine brackets. Unfortunately that was not given and right
side canine is not having optimum inclination at the end of treatment.

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appliances: theory and practice . Am J
Orthod.1987; 73:485-498.
37. Afzal A1, Ahmed I. Leveling curve of Spee
and its effect on mandibular arch length. J Coll
Physicians Surg Pak. 2006 Nov;16(11):709-11.
38. Roth RH. Functional occlusion for the
Orthodontist. Part III. J Clin Orthod. 1981
Mar;15(3):174-9, 182-98.
39. Mclaughlin RP, Bennett JC, Trevisi
H.Systemized Orthodontic Treatment Mechanics.
New York:Mosby,2005.
40. S a m i r E . B i s h a r a . Te x t b o o k o f
Orthodontics.New York: Saunders,2001.
41. P ro f f i t W R , F i e l d s H W 2 0 0 0
Contemporary orthodontics, 3rd edn. Mosby, St
Louis, p. 344.
42. Andrews LF. The straight-wire appliance:
extraction brackets and classification of treatment.
J Clin Orthod.1976d; 10: 360-379.
43. Roth RH. Five year clinical evaluation of
the Andrews straight-wire appliance. J Clin Orthod.
1976 Nov;10(11):836-50.
44. Little RM. Stability and relapse of
mandibular anterior alignment: University of
Washington studies. Semin Orthod. 1999
Sep;5(3):191-204.
45. Freitas KM et al. Postretention relapse of
mandibular anterior crowding in patients treated
without mandibular premolar extraction. Am J

Selection of Bracket Prescription
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46. Little RM. Stability and relapse of dental
arch alignment. Br J Orthod. 1990 Aug;17(3):235-
41.
47. Erdinc AE, Nanda RS, Işiksal E. Relapse of
anterior crowding in patients treated with
extraction and nonextraction of premolars. Am J
Orthod Dentofacial Orthop. 2006 Jun;129(6):775-
84.
48. DENTSPLY. . http://www.dentsply.com/en-
us/orthodontics/brackets/metal-twin brackets
(accessed 15 Sept 2014).
49. Proffit WR, Fields HW & Sarver DM
Contemporary Orthodontics. 5th ed. New York:
Mosby; 2012.
50. McLaughlin RP, Bennett JC, Trevisi H.The
MBT™ Versatile+Appliance System, series, 1998-
2007 3M.
51. Mclaughlin RP, Bennett JC. The transit ion
from standard edgewise to preadjusted appliance
systems. J Clin Orthod. 1989 Mar;23(3):142-53.
52. Bennett JC, Mclaughlin RP. Controlled
space closure with a preadjusted appliance system.
J Clin Orthod. 1990 Apr;24(4):251-60.
53. Mclaughlin RP, Bennett JC .Finishing and
detailing with a preadjusted appliance system. J
Clin Orthod. 1991 Apr;25(4):251-64.
54. Sebata E. An orthodontic study of teeth and
dental arch form on the Japanese normal
occlusions. Shikwa Gakuho. 1980 Jul;80(7):945-
69.
55. Watanabe K, Koga M. A morphometric
study with setup models for bracket design. Angle
Orthod. 2001 Dec;71(6):499-511.
56. Khambay BS, McHugh S, Millett DT.
Magnitude and reproducibility of forces generated
by clinicians during laceback placement. J Orthod.
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2006 Dec;33(4):270-5.
57. Usmani T, O'Brien KD, Worthington HV,et
al. A randomized clinical trial to compare the
effectiveness of canine lacebacks with reference to
canine tip. J Orthod. 2002 Dec;29(4):281-6.
58. Irvine R, Power S, McDonald F. The
effectiveness of laceback ligatures: a randomized
controlled clinical trial. J Orthod. 2004
Dec;31(4):303-11.
59. Samuels RH, Rudge SJ, Mair LH. A clinical
study of space closure with nickel-titanium closed
coil springs and an elastic module. Am J Orthod
Dentofacial Orthop. 1998 Jul;114(1):73-9.
60. Dixon V, Read MJ, O'Brien KD,
Worthington HV, Mandall NA. A randomized
clinical trial to compare three methods of
orthodontic space closure. J Orthod. 2002
Mar;29(1):31-6.
61. Barlow M, Kula K. Factors influencing
efficiency of sliding mechanics to close extraction
space: a systematic review. Orthod Craniofac Res.
2008 May;11(2):65-73.
62. Jain M, Varghese J, Mascarenhas R, Mogra
S et al. Assessment of clinical outcomes of Roth and
MBT bracket prescription using the American
Board of Orthodontics Objective Grading System.
Contemp Clin Dent. 2013 Jul;4(3):307-12.
63. Moesi B , Dyer F, Benson PE. Roth versus
MBT: does bracket prescription have an effect on
the subjective outcome of pre-adjusted edgewise
treatment? Eur J Orthod. 2013 Apr;35(2):236-43.
152

Placement of orthodontic brackets
In this Chapter
Mesiodistal position of brackets
Checking mesiodistal position of the
brackets
Modifications in mesiodistal position of
the bracket
Axial or long axis position of the brackets
Importance of axial position of brackets
Checking axial position of brackets
Modifications in axial position of
brackets
Vertical position of brackets
Modifications in Vertical position of the
brackets
Prescriptions in preadjusted edgewise brackets
are built after taking prescription values from a
certain point or area on labial surface of the
tooth. The prescription built into the bracket
will work best if the brackets are placed at that
specific area. Mostly that specific area where
the brackets needed to be placed is also
pinpointed by the inventor of the prescription.
During orthodontic bonding of preadjusted
brackets the orthodontist must place brackets
accurately in vertical, mesiodistal and axial
planes as advocated for that prescription
or based on his clinical experience. These
153
CHAPTER
7
Importance of vertical position of
brackets
Bracket positioning gauges
Parts of gauges
Position of the gauge during bracket
placement
Bracket placement by wire guidance
Position of clinician during brackets
placement
accurately placed brackets will give better
control on three dimension position of the
teeth during treatment. An accurately placed
bracket will also result in better expression of
its builtin prescription and orthodontist will
need less wire bending and complex
mechanics during the course of treatment.
Mesiodistal position of brackets
It is a general saying in orthodontics that
brackets should be placed at mesiodistal center
of the teeth. This statement is partially correct as
this rule can't be applied to all the teeth. A more
Placement of orthodontic brackets
clear description for right mesiodistal position
of brackets was given by Andrew1 that brackets
should ideally be placed at the mid
developmental ridge of the teeth. The correct
mesiodistal position of brackets on different
teeth is given as under.
Maxillary and mandibular incisors
Bracket should ideally be placed at
mesiodistal center of maxillary and
mandibular incisors. The mid developmental
ridge of these teeth is also present at their
mesiodistal center of the labial surface (Figure
7.1).
Figure 7.1 Vertical lines showing mesiodistal center of
the upper and lower incisors. Brackets should be placed at
the recommended height on this line.
Maxillary and mandibular Canines
Placing brackets at the mesiodistal center of the
canines will result in contact point error and
slight rotation of the teeth as the mid
developmental ridge of upper and lower canines
lies slightly mesial to the mesiodistal center of
the teeth and is more mesial in case of lower
canines. So bracket is placed slightly off center
and toward mesial, in case of canines (Figure
7.2).
CHAPTER 7
Figure 7.2 The vertical lines on maxillary and mandibular
canines indicate the mid developmental ridge of the canines
and ideally the middle of the brackets should coincide with
this line.
Mandibular Premolars
Roth 2 purposed that premolars brackets should
be placed at area of maximum convexity which
is usually the mesiodistal center of the teeth and
mid developmental ridge also lies in this area.
Sometimes the area of maximum convexity lies
slightly mesial to the mesiodistal center but
degree of mesial deviation is less than that of
canines. The difference between bracket
placement on premolars and anterior teeth is
presence of a lingual cusp on premolars which
must be taken into consideration while placing
the brackets. In mandibular premolars the
buccal and lingual cusps lies at the same level in
the mesiodistal perspective. So when placing
lower premolars brackets the scribe line of the
bracket should coincide with line connecting
the buccal and lingual cusps (Figure 7.3).
154
 different from mandibular premolars as

Placement of orthodontic brackets

Figure 7.3 A left lower 2nd premolar bracket bonded so
that the line connecting the buccal and lingual cusps passes
through the scribe line of the bracket. This is because buccal
and lingual cusp of the lower premolars should be present at
the same level in mesiodistal perspective.
Maxillary Premolars
Bracket placement on maxillary premolars is
maxillary premolars should have slightly
rotated position at the end the treatment.
According to Andrew six keys of normal
occlusion the buccal cusps of upper premolars
should have a cusp embrasure relationship with
lower premolars while the lingual cusps have
cusp fossa relationship with lower premolars
in class I & II molar occlusion. So if the
buccal and lingual cusp are in one line in the
mesiodistal perspective than both buccal and
lingual cusps will have a cusp embrasure
relationship with lower dentition. Such a
relation is not acceptable (Figure 7.4A).
According to Andrew1 the buccal cusps of
upper premolars should be slightly more distal
than the lingual cusps in the mesiodistal
perspective (Figure 7.4A&C). So in maxillary
premolars, brackets should be placed so that
the scribe line of the bracket is slightly mesial
of up to 0.5 mm to the line connecting the
buccal and lingual cusps (Figure 7.4D ).

A B

C D
Figure.7.4 A. Keeping the buccal and lingual cusps of maxillary premolars in the same mesiodistal perspective will cause poor
occlusal results. B&C. When the buccal cusps tip of the maxillary premolars are in line with lower embrasures their lingual cusps
lies slightly mesial to embrasures and rest at their corresponding teeth fossas. D. A bracket bonded slightly mesial to line
connecting the buccal and lingual cusp of maxillary 2nd premolar. Bonding the bracket in this position will rotate the buccal cusps
distally and lingual cusp slightly mesial to get ideal relationship in a class I molar relationship.
155
Placement of orthodontic brackets
CHAPTER 7

E F
Figure.7.4 E &F Like class I in class II molar finished cases maxillary premolar buccal cusp is slightly distal to lingual cusp
in mesiodistal perspective to give ideal occlusal relationships.

According to McNamara3 such a position will

also help to improve class I & II dental
relationships (Figure 7.4 E&F).

For class III molar finished cases though there

are no guidelines available in the literature but
my personal experience is that upper
premolars should be bonded like class I cases
in surgical and orthopedic treatment. But if the
orthodontist is aiming class III camouflage than
upper premolars bracket should be bonded
slightly distal to mid developmental ridge so
Figure 7.5 Bands placed on upper and lower molars. The
that the buccal and lingual cusp have same mesial opening of the tube lies below the mesiobuccal cusp
prominence in mesiodistal perspective. Such of the molars. The rule hold true for both 1st and 2nd molars
in both arches.
arrangement always help to improve the dental
relationship in class III camouflage with final
molar relationship in class III and canine checked under both direct and indirect vision
relationship in class I. .For indirect vision diagnostic mirror is used
(Figure 7.6). Generally mesiodistal position of
Maxillary and mandibular molars upper incisors, premolars and molars brackets is
checked under indirect vision.
Conventionally bands are placed on the molars.
The most suitable band is one that snugly fit the
tooth. Whether molar bands or tubes are used,
the optimum mesiodistal position is decided by
taking the mesiobuccal cusp as reference. The
mesial opening of the tube should lie below the
mesiobuccal cusp at the correct vertical height
(Figure7.5).

Checking mesiodistal position of the

A
brackets
Figure 7.6 Mouth mirror used to check mesiodistal
The mesiodistal position of the bracket can be position of brackets in indirect vision. A. Upper incisors

156
 Placement of orthodontic brackets
B

Figure 7.7 A rotated maxillary 2nd premolar. As the tooth is

distopalatally rotated so the bracket is placed slightly more
distal than its required position.

C Clinical Notes
Sometimes due to severe rotation or
Figure 7.6 B. Lower incisors. C. Upper premolar and molar.
crowding the position of the tooth is such
Modifications in mesiodistal position of the that it's not possible to place bracket at the
bracket right mesiodistal center of the tooth (Figure
7.8). In such situations the bracket should
Alteration in mesiodistal position of the bracket
be placed as far as possible toward the
will alter the prescription of the bracket in terms
mesiodistal center of the tooth or toward the
of counter rotation. Some situations where
rotation. A flexible wire is passed and only
mesiodistal position of the bracket is altered are
the brackets wings toward the rotation are
given.
ligated. At subsequent visit the tooth is
Rotated teeth usually derotated enough to place bracket at
the right mesiodistal position. So the
In case of rotated teeth the bracket should bracket is debonded and either a recycled or
always be placed more on side of rotation in the new bracket is rebonded at the correct
mesiodistal plane (Figure 7.7). This mesiodistal position.
overcorrected position of the bracket will result
in early correction of the rotation and will also
accommodate the relapse factor after
debonding.

Figure 7.8 Rotated right upper central incisor. Correct

mesiodistal position of the bracket is not possible on the
first bonding visit due to rotation. The bracket should be
placed as far mesial as possible. The mesial side of the
bracket should not come in contact with left side incisor
because it will hinder the full insertion of the wire and also
make ligature placement extremely difficult if not
impossible.
157
Placement of orthodontic brackets
Clinical Notes
Sometimes the tooth is rotated 180° so that
the lingual side is on the labial side. Many
times this form of rotation is accepted. In
such situation the bracket is bonded on the
side of the tooth which is facing labial or
buccal (Figure 7.9).
Figure 7.9 Right lower lateral is rotated 180°.The
rotation was accepted and bracket placed on lingual side of
the tooth which was facing labially.
Clinical Notes
Another situation is maxillary lateral
incisor substitution by canine. In this
situation the slightly convex labial surface
of canine is made flat to give it shape of
lateral incisor and bracket is bonded at
mesiodistal center of reshaped canine
instead of slightly mesial. Placing the
bracket at the mid developmental ridge area
will cause poor contact point with the
central incisor as canine is also reshaped
mesiodistally. On premolar tooth which
will become future canine the canine
bracket is placed distal to the mesiodistal
center of the tooth. Placing the bracket
distally will rotate the tooth mesiopalatally
which increases the mesiodistal width of
future canine tooth, bringing the convex
part of the tooth mesial so that it look
similar to the mid developmental ridge of
canine. This position of bracket also helps
to hide the palatal cusp of premolar and
CHAPTER 7
improves the occlusal relation with the
mandibular canine. The palatal cusp needs
to be grounded to avoid premature contact
with opposing dentition.
Axial or long axis position of the brackets
Axial or long axis position of the bracket is
related to the angulation or tip of the teeth. In
conventional edgewise system where there was
no builtin tip, the brackets were placed
angulated on the tooth. The amount of bracket
angulation on the tooth was equal to the amount
of tip required (Figure 7.10).
Figure 7.10 Standard edgewise brackets has no builtin tip.
Bracket position didn't follow long axis of the crown or root
and were placed angular on the tooth equal to the amount of
tip required.
In preadjusted edgewise system as the tip is
already built within the brackets so placing the
bracket similar to standard edgewise will result
in increase or decrease of builtin tip. In
preadjusted edgewise system brackets are
positioned on the tooth so that their wings and
scribe line are parallel to long axis of clinical
crowns or long axis of the tooth (Figure 7.11).
But there is always some difference between the
angulation of long axis of the crown and long
axis of the tooth in the mesiodistal plane (Figure
7.12). Also placing bracket according to long
axis of tooth may result in wrong mesiodistal
158
 Placement of orthodontic brackets
A

Figure 7.12 There is always some difference between long

axis of clinical crown and long axis of the tooth.

C
Figure 7.11 A&B. A preadjusted bracket of maxillary left
lateral incisor .Placing the bracket parallel to long axis of
clinical crown will cause tooth to rotate in a clockwise
direction and express the builtin tip. C. Bracket placed so that
long axis of the tooth is parallel to long axis of bracket wings
and scribe line.
Figure 7.13 A lateral incisor bracket placed with
position of bracket on the crown. reference to long axis of clinical crown. X ray showing that
long axis of bracket not coinciding with long axis of the root
and because of this root of the lateral incisor is in close
Andrew purposed1, 4 that as the clinical crown is contact with central incisor root increasing chances of root
only visible in the mouth so the angulation of the resorption in this area.
tooth should be taken by taking the angulation
So brackets should ideally be placed by taking
of long axis of clinical crown (LACC) and not
the clinical crown as reference but root position
the long axis of the entire tooth. But taking only
should also be kept in mind. If there are chances
the long axis of clinical crown may result in
of adjacent root resorption by taking clinical
poor root parallelism and in some cases root
crown as reference then bracket position should
resorption due to roots approximation of
be modified and long axis of the tooth should be
adjacent tooth (Figure 7.13).
159
Placement of orthodontic brackets
taken as reference.
Taking the long axis of tooth can many a time
results in poor proportions of connectors and
embrasures (Figure 7.14). These proportions
can be corrected at end of treatment either by
composite build up or interproximal reduction.
A important for proper occlusal and esthetic
B teeth.
C If there is doubt in position of maxillary anterior
Figure 7.14 A. Golden proportion of connectors that
ideally should be present in finished cases. B .A case with
dilacerated central incisor root. If there is root dilacerations,
placing bracket by following the clinical crown will result
in ideal connector areas but greater chances of root
approximation and so root resorption. C. Bracket placed by
following the long axis of the roots. The golden proportion
of connectors is distorted. They can be resorted by
composite built up or interproximal stripping at the end of
treatment.
CHAPTER 7
Clinical notes
Some clinicians also take incisor edge as
guideline for long axis positioning of
brackets. But incisor edge is mostly uneven
due to trauma, attrition and mamelons. So
incisor edge shouldn't be taken as a
reference point for long axis position of the
bracket. Also gingival zenith shouldn't be
taken as a reference for long axis position of
the bracket as it can be effected by uneven
pattern of gingival recession (Figure 7.15).
Importance of axial position of brackets
Correct axial position of the bracket is very
relationship. As preadjusted brackets have built
in tip, a poor axial position of the bracket will
result in expression of increase or decrease
positive or negative tip. Increase in tip may
increase space requirement in the arch and also
increase risk of adjacent root approximation
(Figure 7.16). Change in tooth angulation will
also affect the golden proportions of connectors
and embrasures and so the smile esthetics of the
Checking axial position of brackets
The axial position of the brackets is checked
under both direct and indirect vision. Usually
maxillary anterior brackets and mandibular
brackets are checked under direct vision from
labial side of the tooth while maxillary posterior
brackets are checked under indirect vision using
diagnostic mouth mirrors.
brackets especially lateral incisor brackets some
clinicians favor to use indirect vision by
diagnostic mirror and use guidance from lingual
side of tooth.
Modifications in axial position of brackets
Modifications are made in axial position in the
160
 Placement of orthodontic brackets
A B C
Figure 7.15 A. Mamelons on central incisors. These mamelons will give a different long axis position of the tooth if taken as
reference for bracket positioning. B. Attrition of the incisor edge will also effect long axis position of the teeth. C. Gingival zenith
shifted mesial from their ideal position due to gingival recession. Taking gingival zenith as reference for axial position of the
bracket in these cases will result in wrong placement of the brackets.

A B C D

Figure 7.16 A&B. Preadjusted brackets not placed in

accordance with long axis of the tooth will result in increase or
decrease expression of tip than the built in tip. C.A x ray
showing that both decreased and increased tip of incisors due
to angular bracket placement. This increases chances of root
approximation and root resorption. D&E. Over angulated
brackets placed on central incisors can result poor proportion
E of connectors and embrasures leading to development of
black triangles.

following circumstances. achieving golden proportions of connectors

1. To avoid chances of root resorption due to
adjacent root approximation.
2. To avoid root resorption from dental or
orthodontic implants (Figure 7.17).
3. To avoid root resorption from teeth
impacted in the bones. i-e impacted canines
or mesiodens (Figure 7.18, Case example
7.1).
4. To accommodate crown morphology for
161
and embrasures.
5. In some surgical cases bracket position
is modified to move roots away from
surgical site (Wassmound procedure in
maxilla, Subapical osteotomy).
6. If teeth have slightly smaller size such as
peg laterals than it is better to increase the
angulation of the teeth rather then to go for
composite build ups.
Vertical position of brackets
Placement of orthodontic brackets
Figure 7.17 Orthodontic implants inserted for intrusion
of maxillary incisor. Note the position of lateral incisors at
both ends. The gingival wings of the brackets are facing
distal so they will rotate both lateral incisor roots toward
mesial. Initially such bracket placement will create space
for implant insertion and during intrusion it will ensure that
roots of lateral remain away from implants. Once the
intrusion is completed and the implants are removed,
bracket position is corrected so that lateral incisor have
optimum angulation.
Figure 7.18 A mesiodens present between roots of the
upper central incisors. Brackets are placed so that wings of
the brackets are facing mesial on gingival side. This will
rotate both the central incisors roots away from mesiodens
and will give good access to surgeons for removing it
without causing any damage to central incisor roots. The
bracket position needs to be corrected after mesiodens
removal otherwise black triangle will result in central
incisors.
CHAPTER 7
From the time of bracket evolution till date,
orthodontists have much debated the vertical
position of the bracket but have failed to reach a
consensus to lay down a uniform protocol.
Angle5 proposed that bands should be placed on
the tooth where they best fit mechanically and
bracket soldered to bands should be present on
center of the labial surface of the tooth. For
anterior teeth6 bands should be present at the
junction of the middle and the incisal thirds of
the crown.
When bonding was made available, edgewise
and Begg brackets were placed on tooth with
help of gauges 7 , 8 using one standard
measurement for all the patients. The vertical
positioning errors were corrected by wire
bending which was integral part of the
treatment. With the advent of straight wire
appliance 9 vertical position of the bracket
gained more importance. As morphology of
tooth is not uniform throughout its length
changing the vertical position of the bracket
will result in different expression of its builtin
prescription. Almost every orthodontist who
devised a bracket prescription also has
advocated a certain vertical position for those
brackets so that the builtin prescription should
be fully expressed.
Different guidelines for vertical position of the
brackets are given. Some commonly used
systems are explained in detail so that the
readers should have clear knowledge of
positioning bracket at the right vertical height.
Andrew Guidelines for bracket placement.
Andrew1 proposed that an ideal bracket siting
site should have the following properties.
1) It should be free of occlusal and gingival
interference.
2) The brackets siting site on a tooth should
have consistent angular relationship with its
occlusal plane and to the occlusal plane of
162
 Placement of orthodontic brackets

A B
Case Example 7.1 .A 16 year old patient was presented with bilateral palatally impacted canines with class II subdivision left
molar relationship on a moderate class II skeletal base. Right upper 1 st premolar and left upper 2nd premolar were having mesial
directed dilacerated roots. Extraction of both 1st premolars in maxillary arch and only right 1st premolar in mandibular arch was
planned. Initial records are given here. A. At first bonding visit bands were placed first and all maxillary arch brackets were bonded
according to wire guidance of 0.019”x0.025” wire. First order bends were given for better placement of brackets. Placing brackets
on wire guidance will avoid long phase of leveling and alignment before canine exposure and also root of the teeth will remain at
their place. Upper 1st premolars were not bonded as they will need extraction while maxillary laterals were not bonded because their
roots are close to impacted canines. B. Once the canines were exposed and erupted both lateral incisors and canines were bonded
too. Bracket position of all upper teeth was corrected .Segmental technique used in lower arch to relive lower incisor crowding and
help midline correction. Continued
163
Placement of orthodontic brackets
CHAPTER 7

D E

G H

I
Case Example 1 continued C&D. Rectangular wire in place .Central incisors have poor proportion of connectors even their
roots have ideal angulation and brackets are place according to long axis of the clinical crown.E.Central incisor brackets were
repositioned so that gingival part of the bracket is more mesial than incisor part.This will move the connectors down and will
decrease the incisal embrassure.Mild stripping of mesial side of central incisors was also done to avoid black triangles. F,G,H&I.
Post treatment records are given. Maxillary incisor dentition have ideal proportions of connectors. In OPG there is good root
parallelism. The root of maxillary left 2nd premolar is close to canine because of dilaceration.
164
 arch when all the teeth are ideally placed.
3) When the teeth are ideally positioned, the
middle of each bracket site must be at the
Andrew plane, where Andrew plane is a
surface plane on which mid transverse plane
of every crown in an arch will fall when the
teeth are optimally positioned.
The FA point was found to contain all these
three characteristics. Where FA point (facial
axis point) is center of facial axis of clinical
crown (FACC) and it virtually divides the
clinical crown into occlusal half and gingival
half. The FACC on each tooth correspond to
mid-developmental ridge and in case of molar it
is dominant vertical buccal groove. A
description of FACC, FA point and Andrew
plane is given in figure 7.19.
Figure 7.19
In some of his old writings Andrew 9 also
proposed using LA point (long axis point) for
bracket positioning, where LA point is the mid
of long axis of clinical crown (LACC).Though
Andrew1 later disown LACC and LA point but
amazingly description of LACC or FACC
remain the same in Andrew writings that was
mid developmental ridge and dominant vertical
buccal groove in case of molars.
Andrew from one of his study concluded that
clinician can easily visualize the center of
clinical crown and only need eye gauging for
accurate vertical and mesiodistal bracket
placement. In Andrew recommended technique
FA point is valid for healthy teeth. In case of
165
gingival recession Andrew1 quoted Gargiulo
Placement of orthodontic brackets
study10 that 1.8 mm should be subtracted from
anatomical crown to find the correct value of
clinical crown. This measurement must be
adjusted while placing bracket at FA point in
cases with gingival recession. Andrew 1
proposed that bracket must be accurately
placed within 2° of FACC and base point or
middle of the bracket should be within 0.5
mm of FA point.
Limitations of Andrew's Recommendations
Placing brackets with only guessing the correct
position will result in vertical positioning
errors. Not every orthodontist will place the
bracket at the same height. Even the same
orthodontist, after accidental debonding of
bracket will rebond the bracket at a slightly
different height. There would always be a
controversy between two orthodontists on the
right vertical height. Placing bracket is also
troublesome in gingival recession and gingival
enlargement as vertical adjustment in bracket
height in millimeters is again a matter of
guesswork.
Also no consideration was given for incisal and
occlusal edges which are functional and
esthetic units of teeth. Even an error of 0.5 mm
in anterior teeth is noticed by esthetic conscious
patients.
Eliades11 found out that positioning bracket at
FA point results in marginal ridge discrepancy
and poor occlusal contacts.
Roth Guidelines
Roth12 like Andrew also proposed center of
clinical crown for ideal bracket placement to be
used with his prescription. However Roth 13
advocated that for his prescription anterior
brackets should be placed slightly more incisor
than Andrew proposed center of clinical crown
or FA point to level the curve of spee.
According to Roth the upper central and lateral
Placement of orthodontic brackets
CHAPTER 7
incisor should either be at the same level or Table 7.1. Speed Bracket position guide for
lateral incisor should be 0.5 mm less prominent Roth prescription
than central incisor. The central incisors will
Teeth Maxilla Mandible
elongate 0.5 mm to 1mm more than the lateral
Central incisor 4 mm 4 mm
incisors after settling. Maxillary canine should Lateral incisor 4 mm 4 mm
be 1 to 1.5 mm below the occlusal plane while Canine 4.5 mm 4.5 mm
mandibular canine should be 0.5 to 1 mm above 1st Premolars 4.5 mm 4.5 mm
the occlusal plane. The upper and lower canines 2nd Premolar 4.5 mm 4.5 mm
1st Molar 4 mm 4 mm
also should be 1mm more prominent than
2nd Molar 3.5 mm 4 mm
lateral incisors and bicuspid.
the most variable in the arch so premolar
Most variation in bracket position are found in bracket height (X) should be taken as reference
bicuspids. In bicuspids the bracket should be .All the other brackets are placed with reference
placed at area of maximum convexity which in to premolar bracket height (X). To find
most cases is center of clinical crown. premolar bracket height, premolar clinical
crown height is taken and is divided into half.
In case of increase curve of spee the lower
The premolar normal bracket height (X) is
canine brackets should be placed more occlusal
usually 4.5 mm. The chart for bracket height
than the premolar brackets to avoid future wire
measurement is given (Table 7.2).
bending to level the curve of spee.

Limitations
Table 7.2. Alexander Bracket placement chart
Roth recommendations are good to attain a with Premolars (X) taken as Reference
functional occlusion but merely guessing the
right height while placing brackets with such Teeth Maxilla Mandible
Central incisor =X X-0.5mm
accuracy in millimeters is usually not possible.
Lateral incisor X-0.5mm X-0.5mm
Roth recommendation has same limitations in
Canine X+0.5mm X+0.5mm
vertical accuracy of brackets as of Andrew's
Premolars X X
recommendations.
1st Molars X-0.5mm X-0.5mm
To overcome vertical positioning errors many 2nd Molars X-1mm Not given
clinicians uses gauge to place bracket using
Limitation of above chart
Roth guidelines. According to Roth canine or
premolar teeth should be taken as reference Premolars in upper and lower arch were bonded
while placing brackets. A bracket positioning at same height. As 1st premolars cusps are longer
chart (table 7.1) advocated for speed brackets than 2nd premolars especially in lower arch so
having Roth prescription is given. No reference bonding all the premolar at the same height will
is found in literature whether this chart is result in marginal ridges discrepancy and
supported by Roth or it's just manufacturer premature occlusal contacts. Also no value was
recommendation. given for lower 2nd molars. To correct these
discrepancies Alexander15 modified his bracket
Alexander Guidelines
positioning chart (Table 7.3).
Alexander 14 advocated individualizing bracket
positioning for each patient to effectively use
his bracket prescription. According to
Alexander as premolar clinical crown height is
166
 Table 7.3.Alexander Bracket placement chart
with 1st Premolars (X) taken as Reference
Teeth Maxilla Mandible
Central incisor =X X-0.5mm
Lateral incisor X-0.25mm X-0.5mm
Canine X+0.5mm X+0.5mm
1st Premolars X X
2nd Premolar X-0.5mm X-0.5mm
1st Molars X-0.5mm X-0.5mm
2nd Molars X-1.5mm X-0.5mm
X=4mm for small crown and 4.5 mm for
average crown and 5 mm for large size crown.
In case of 1st premolar extraction 2nd premolar is
taken as reference. Alexander advocated
specific positioning gauges for bracket
placement. For ideal smile arc relationship
Alexander proposed that maxillary lateral
incisors brackets should be placed 0.25 mm
more incisal from central incisor.
Limitations
Alexander bracket positioning chart though
help to level incisor edges and give good
anterior aesthetics but taking premolar clinical
crown height as a reference mean the clinician
is denying all the variations in other teeth
clinical crown heights and morphology. Taking
half the height of clinical crowns in premolars
may result in marginal ridges discrepancy and
occlusal interferences. Wire bending is usually
needed to accommodate height differential
and settle down the occlusion. In modified
chart the lateral incisor bracket position was
0.25 mm more incisal than central incisor. In
my personal opinion it is extremely difficult to
place bracket with 0.25 mm accuracy even
with the help of gauge because of the play
between slot supporting part of the gauge and
slot of the bracket. Interestingly the Wick
stick gauge developed by Alexander as far as I
know is not calibrated in 0.25 mm difference
between its parts. In modified Alexander
bracket positioning chart upper 2nd molar
height is 1 mm greater than 1st molar. This
167
Table 7.4. Bishara bracket placement chart
Placement of orthodontic brackets
Teeth Maxilla Mandible
Central incisor 4mm 3.5mm
Lateral incisor 3.5 mm 3.5mm
Canine 4.5 4.5mm
Premolars and 4 4.0mm
Molars
can create marginal ridge discrepancy
between the maxillary molars in many cases.
Bishara vertical bracket positioning chart
Bishara16 recommended a vertical bracket
positioning chart (Table 7.4) for ideal bracket
positioning. The charts consist of standard
measurement which would be used for all types
of cases. Bracket positioning gauges are used to
place the brackets. Placing brackets from fixed
distance from incisors and occlusal edges will
give good anterior aesthetics.
Limitations
As the method contains a standard chart for all
types of cases so it fails to address individual
variations. Also it's a matter of common clinical
experience that molars cusps are smaller than
premolars. Placing brackets at the same height
will result poor marginal ridge relations and
opposing occlusal interferences. Gu ZX17 found
that to level marginal ridges 2nd premolar
bracket height should be 0.5 mm greater than 1st
molar and 1st premolar bracket height should be
at least 0.5 mm greater than 2nd premolar so
using Bishara chart will leave marginal ridge
discrepancy.
McLaughlin or MBT vertical bracket
positioning chart
McLaughlin 18 after conducting four different
studies on crown height proposed his own
method of bracket positioning. The method
consist of measuring crown heights, matching
obtained values with McLaughlin proposed
charts formulated from his study and placing
brackets by special gauges.
Placement of orthodontic brackets
CHAPTER 7
The method is given as follow: Table 7.5.Recommended bracket positioning
chart for maxillary arch(mm)
1) Measure the clinical crown height of fully
erupted teeth on the upper and lower study Cent Late Cani 1st 2nd 1st 2nd
cast by dividers and millimeter rulers. ral ral ne Prem Prem Mo Mo
olar olar lar lar
2) To obtain middle of clinical crown divide 6 5.5 6 5.5 5 4 2
the measured height of each crown into half 5.5 5 5.5 5 4.5 3.5 2
and round the obtained value to the nearest 5 4.5 5 4.5 4 3 2
0.5mm.For example if crown height is 4.5 4 4.5 4 3.5 2.5 2
10.75mm.Half the crown height would be 4 3.5 4.0 3.5 3 2 2
5.4 mm. Make this measurement to 5.5 mm. Table 7.6.Recommended bracket positioning
chart for mandibular arch (mm)
3) Create separate rows of measurements
for maxillary and mandibular teeth. Now Cent Late Cani 1st 2nd 1st 2nd
compare your values of maxillary and ral ral ne Prem Prem Mo Mo
olar olar lar lar
mandibular teeth with that of proposed
5 5 5.5 5 4.5 3.5 3.5
charts. If your chart measurement don't
4.5 4.5 5 4.5 4 3 3
exactly tally with that of proposed MBT
4 4 4.5 4 3.5 2.5 2.5
charts then find a row on the chart which 3.5 3.5 4 3.5 3 2 2
matches most of your recorded 3 3 3.5 3 2.5 2 2
measurements.
Table 7.7.Average values for bracket
4) After a specific row is selected, each for positioning In Adults
maxillary and mandibular teeth, position Central Lateral Canine 1st 2nd 1st 2nd
the bracket following the standard bonding Premolar Premolar Molar Molar
5 4.5 5 4.5 4 3 2
procedure.
4 4 4.5 4 3.5 2.5 2.5
5) Place the bracket on tooth in the Table 7.8.Average values for Bracket
mesiodistal and vertical middle of clinical positioning in children
crown by visualizing it. After placing the
Central Lateral Canine 1st 2nd 1st 2nd
bracket on the tooth use the bracket Premolar Premolar Molar Molar

positioning gauge (advocated special 4.5 4 4.5 4 3.5 2.5 2

gauges made by 3M Unitek) to adjust the 3.5 3.5 4 3.5 3 2 2
height of the bracket. By firmly Limitations
positioning the bracket, cement flash will
be squeezed from underneath the bracket. Due to individual variation of cusps height in
Remove the flash and cure the brackets. premolar region marginal ridges height
difference is seen in finished cases as posterior
6) Light cure cements are preferred for bracketing is not optimum17 to level marginal
brackets bonding because they give longer ridges.
working time.
Kalange method
Charts for vertical bracket positioning are given
(Table 7.5-7.8).In charts average values for Ricketts19 advocated the leveling of marginal
children and adults are also given. In children ridges in finished cases in posterior dentition.
the average values are 0.5 mm less on all teeth Kalange20 devised a practical method to level
than corresponding values for adult teeth. the marginal ridges by bracket placement.
168
 Kalange though favors indirect bonding but his

Placement of orthodontic brackets

technique of bracket positioning can be used in
direct bonding too.

Kalange method of ideal bracket placement has

the following steps.

1) Select a snugly fit 1st molar band in both

arches. Measure the distance from occlusal
edge of molar band to its slot. In case tubes
are placed on the molars instead of bands
then draw a line on the buccal side of molars
connecting its mesial and distal marginal
ridges. The slot of the tube lies 2 to 2.5 mm
below molar marginal ridge line. The lines
are drawn on dental cast in case of indirect
bonding or on the natural teeth in case of
direct bonding with a thin pencil.(Figure
7.20)
Figure 7.21 Marginal ridge line, slot line and long axis line
on the 1st and 2nd premolars.
scribe line of the brackets should be parallel
to this line for axial correction of bracket.
3) Measure the distance from cusp tip of
premolars, ideally from 1st premolars in both
arches and transfer it to respective arch
central incisors taking the incisor edge as
reference point (Figure 7.22). So the slot
line of premolars and central incisor are at
same distance from cusp tips or incisor
edges. This distance should ideally be 4 mm
for mandibular incisors and 4.5 mm for
maxillary incisors. For open bite cases this
distance should be increased from the
incisor edge for incisor bracket placement
and for deep bite cases this distance should

Figure 7.20 Horizontal lines drawn on the molars.

Lower line is the marginal ridge line while the upper line is
slot line for molar tube.

2) Join the mesial and distal marginal ridge

of premolars on the buccal side in upper and
lower cast. Draw another line gingival to
this marginal ridge line. The distance
between these two lines should be equal to
the distance measured from the molar band
edge to its slot or in case of tube it should be
2 to 2.5 mm (Figure 7.21). This second
gingival line is called the slot line. The
bracket slot of premolar brackets should be
coinciding with this slot line. Mark a line in
the mesiodistal center of the tooth following
long axis of clinical crown. The wings and
169
Placement of orthodontic brackets
Figure 7.22 Bracket height of central incisor taken from
1st premolar slot line.
be decreased from the incisor edge. Vertical
line showing the long axis of clinical crown
is also drawn in mesiodistal center of the
Figure 7.23 In maxillary arch distance from the central
incisor edge to slot line is measured and is decreased 0.5 mm.
This distance is then transferred to the maxillary lateral
incisor. In mandibular arch central and lateral incisor are
bonded at same level.
CHAPTER 7
center incisors.
4) The maxillary lateral incisors slot line
should be decreased by 0.5 mm from the
incisor edge while for mandibular lateral
incisor slot line distance should be same as
Figure 7.24 Canine bracket slot line measured and drawn
on the tooth.
central incisors (Figure 7.23).
5) The maxillary and mandibular canines
slot line distance should be 1 mm more from
their respective central incisor slot lines. In
case of canines the canine tip should be
taken as reference (Figure 7.24).
6) Vertical lines are also drawn on all the
teeth to mark the mesiodistal middle of the
crown.
Limitations of Kalange method
Kalange method is good to level marginal
ridges and give good anterior aesthetic by
placing anterior tooth edges at optimum level.
170
 But this method ignores individual variation in

Placement of orthodontic brackets

crown height of anterior teeth. Placing anterior
brackets too incisal or gingival will result in
different torque expression than builtin bracket
torque due to morphological variations of the
teeth.

In using Kalange method of bracket positioning

for direct bonding lines are drawn by pencil on
the teeth. Some clinicians point out that these
Figure 7.26 The proximal edges of the band which
correspond to the molar marginal ridge are usually at
different height than their buccal counterparts.

accommodated in final calculation or it is a

better option to draw marginal ridge line and
slot line on molars too even a band is to be
placed on molars.

Modified Kalange Method

I use a personally devised modified method in

which molar and premolar brackets are bonded
with respect to marginal ridges and instead of
transferring 1st premolar height to central it
Figure 7.25 Lines drawn on the labial surface of the teeth transferred to lateral incisor in maxillary arch. A
can give good indication of bracket orientation without MBT advocated gauge is used to transfer closet
passing through the bracket sitting area.
height from 1st premolar to lateral incisor.
Central incisor and canines are bonded at same
pencil lines on the teeth will interfere with bond
height. In lower arch 1st premolar height is
strength. To contour this problem slot line and
transferred to both central and lateral incisors
vertical line should not cross the final bracket
and canine tip are kept 0.5 mm more prominent.
sitting area (Figure 7.25).Even if these lines
don't cross the bracket sitting area they give a Viazis guidelines
realistic guidance for correct orientation of
brackets. Central incisors brackets are taken as reference.
Both maxillary central incisor bracket (X) and
Selecting the height from molar band edge to mandibular central incisor bracket (Y) are
slot can also result in vertical positioning errors. placed at FA point which is center of clinical
Most of the companies make molar bands with crown. The distance from the incisor edge to FA
occlusal proximal edges which lie next to Table 7.9.Viazis (Bio efficient brackets )
marginal ridges more gingival than buccal and Vertical position guide 20
lingual edges (Figure 7.26). This variation is
more pronounced in upper arch. As these are Teeth Maxilla Mandible
Central incisor X mm Y mm
proximal edges of the band that must be in level Lateral incisor X-0.5mm =Y mm
with the marginal ridges so distance from Canine X+1mm Y+1 mm
buccal edge will result in faulty bracket 1st Premolars =X mm =Y mm
positioning. Either height difference between 2nd Premolar =X mm =Y mm
buccal and proximal edges should be 1st Molar X-0.5 mm Y-0.5 mm
2nd Molar X-1 mm Y-1 mm
171
Placement of orthodontic brackets
CHAPTER 7
Table 7.10.Gianelly Vertical Bracket Table 7.14.System used with Begg
position guide Appliance 22
Teeth Maxilla Mandible Teeth Maxilla and Mandible
Central incisor 4.5mm 3.5mm Central incisor 3.5 mm
Lateral incisor 4mm 3.5mm Lateral incisor 3.5mm
Canine 4.5mm 4mm Canine 4mm
1st Premolars 4mm 4mm 1st Premolars 4mm
2nd Premolar 4mm 4mm 2nd Premolar 4mm
1st Molar 3.5mm 3.5mm 1st Molar 5
2nd Molar 3mm or 3.5 3mm or 3.5
mm mm Table 7.15.Bracket position used for tweed
philosophy 17
Table 7.11 Terrell L Root(Level
Anchorage system ) Bracket position Teeth Maxilla Mandible
guide 21 Central incisor 4.5mm 4mm
Lateral incisor 4mm 4mm
Teeth Maxilla Mandible
Canine 5mm 5mm
Central incisor 4.5mm 4mm
1st Premolars 4.5mm 4.5mm
Lateral incisor 4mm 4mm
2nd Premolar 4.5mm 4.5mm
Canine 5mm 4.5mm
1st Molar 4.5mm 4.5mm
1st Premolars 4mm 4.5mm
2nd Molar 4.5mm 4.5mm
2nd Premolar 4mm 5mm
1st Molar 3.5mm 4mm to Table 7.16.Swain Bracket position guide 23
center
2nd Molar 3mm 3mm to Teeth Maxilla Mandible
mesial Central incisor 3.5 mm 3.5 mm
Lateral incisor 3.5 mm 3.5 mm
Table 7.12.John T Lindquist(Lewis Canine 4.5 mm 4 mm
Brackets) position guide 21 1st Premolars 3.5 mm 3.5 mm
2nd Premolar 3.5 mm 3.5 mm
Teeth Maxilla Mandible 1st Molar 3.5 mm 3.5 mm
Central incisor 4.5mm 4mm 2nd Molar 3 mm 3.5 mm
Lateral incisor 4mm 4mm
Canine 5mm 4.5mm Table 7.17.Ormco bracket (Bios Brackets)
1st Premolars 4.5mm 5mm position guide
2nd Premolar 4.5mm 5mm Teeth Maxilla Mandible
1st Molar 3.5mm 4mm Central incisor 4.4 mm 3.9 mm
2nd Molar 3.5mm 4mm Lateral incisor 3.8mm 3.9mm
Canine 4.4mm 4.6mm
Table 7.13.By William Thompson21 1st Premolars 4.1mm 3.9mm
Modern Begg four stages light wire 2nd Premolar 3.6mm 3.9mm
appliance
Table 7.18.Mcnamara Recommendations
Teeth Maxilla Mandible McNamara 3 proposed that bracket should be
Central incisor 3.5mm 3.5mm placed on maxillary incisors at 3.5 to 4mm from
Lateral incisor 3mm 3.5mm incisor edge. Maxillary central incisors and
Canine 4mm 4mm canines should be at one level while the lateral
1st Premolars 3.5mm 3.5mm incisors should be placed 0.5mm more incisal. In
2nd Premolar 3.5mm 3.5mm lower arch brackets are placed slightly incisal
1st Molar 3.5mm 3.5mm than middle of the tooth.
2nd Molar 3.5mm 3.5mm
172
 Table 7.19.Burstone method
Burstone 24 proposed that maxillary posterior
attachments should be placed as far gingival as
possible without the bracket impinging the
gingiva. This is usually 3.4 to 4mm. The final
position of upper canine tip should be 0.5 to
1mm more occlusal to bicuspids while the
maxillary central incisor are at the same level of
bicuspids. The maxillary lateral incisor edge is
0.5 mm gingival to central incisor. The first
molar bracket is attached so that its marginal
ridge is leveled with bicuspids while second
molar bracket is attached so that its marginal
ridge is level with 1st molars.
In mandibular dentition the incisor and bicuspid
are at the same level while canine tip is 0.5 to
1mm occlusal .Molar attachment are done
similarly like maxillary arch with leveling the
marginal ridges.
point is measured. Rest of the brackets are
placed with reference to these brackets at
proposed distance (Table 7.9) with the help of
bracket positioning gauges.
Some other bracket positioning charts
recommended with time are given.
Modifications in Vertical position of the
brackets
The vertical position of the bracket is altered
under some circumstances to give proper
occlusion and aesthetic at the end of treatment.
Some clinical scenarios where alteration in
vertical position of the bracket is recommended
are given below.
1. Openbite
In openbite cases if the plan is to
nonsurgically treat the case, then it is
advised by many clinicians that bracket
position should be modified to close the
bite. This is done by placing the brackets
more gingival on the tooth which are in
openbite. In most case of openbite, only
maxillary anterior teeth are contributing to
openbite and so bracket position alteration
173
should be done in maxillary arch only. But if
Placement of orthodontic brackets
mandibular arch has a reverse curve of spee
then bracket position alteration should also
be done in mandibular arch too.
Different rules for bracket placement in
openbite case have been advocated by
different clinicians. Only MBT and
Alexander guidelines would be given here.
Alexander 14 proposed that for anterior open
bite cases teeth which are in open bite
should be bonded 0.5mm more gingival
while teeth which are in occlusion should be
bonded 0.5mm more occlusal. While in
MBT system it has been proposed that teeth
which are in open bite should be bonded 0.5
mm more gingival than their prescribed
position. Rests of the brackets are bonded at
their normal height. Case examples for
anterior openbite are given in case examples
7.2-7.4.
2. Deep bite
In deep bite cases brackets are bonded
following opposite rules of openbite cases.
In MBT system teeth which are in deep bite
are bonded 0.5mm more incisal while in
Alexander discipline teeth which are in
deep bite are bonded 0.5 mm more incisal
while other teeth are bonded 0.5 mm more
gingival (case example 7.5).
3. Irregular incisor edges
If there are irregular incisor edges or long
cusp tips the clinician has 3 options to
manage the situation.
1. Recontouring of the incisor edges or cusp
tips before bracket placement.
2. Recontouring of the incisor edges or cusp
tips at end of treatment.
3. Composite filling of the incisor edges and
cusp tips.
Ideally teeth should be recontoured previous
Placement of orthodontic brackets
CHAPTER 7

Case Example 7.2 Anterior openbite in an adult patient. The openbite has both dental and skeletal component. Dentally the
openbite is contributed by upper and lower anterior teeth. The case was planned by upper 1st and lower 2nd premolar extractions.
In upper arch as only the anterior teeth are contributing to openbite so brackets are positioned 0.5mm more gingival from canine to
canine in maxillary arch in MBT system. In lower arch only the incisors are contributing to openbite so incisor brackets are bonded
0.5 mm more gingival than its calculated values on MBT charts. If Alexander charts are used to bond the same case the same rule
will follow on upper canine to canine and lower incisors. But bracket position is also altered in posterior dentition. In both
maxillary and mandibular posterior teeth which are in occlusion, brackets are bonded 0.5mm more occlusal.

Case Example 7.3 A n adult patient with skeletal openbite. The case was to be treated nonextraction and surgically by differential
maxillary impaction and mandibular setback. No alteration in bracket position was done but mechanics were changed. In lower
arch continuous archwire was used while in maxillary arch wire bending was used to divide upper arch into 3 segments. Canine to
canine and premolars to 2nd molars on both sides. In surgical cases no dental camouflage of openbite is done by varying the bracket
position.

174
 Placement of orthodontic brackets
Case Example 7.4 An openbite case treated with upper 1st and lower 2nd premolar extraction. In this case the upper incisor were
composite build up and all the brackets from 2nd premolar in upper and 1st premolar lower arch were bonded 0.5mm more gingival
while the 1st and 2nd molar tube were bonded 0.5 mm more occlusal in accordance with Alexander guidelines. If one follow
McLaughlin guidelines molars would be bonded according to chart values while all other teeth would be bonded 0.5 mm more
gingival.

Case Example 7.5 Deepbite A patient with class II div 2 having deepbite. The case was planned with extraction of upper 1st
premolars. At initial bonding only upper arch was bonded. In deepbite cases it is usually not possible to bond lower arch at
the start of treatment without raising the bite. In this case instead of raising the bite maxillary incisors were initially proclined
to attain their normal inclination. Brackets were bonded using MBT system. Brackets on maxillary six anterior teeth were
bonded 0.5mm more incisal than their advocated position on the chart. Once the maxillary incisors were proclined and bite
was sufficiently open to place lower brackets lower anterior six brackets were also bonded 0.5 mm more incisal from there
recommended position on the chart. All posterior brackets in both maxillary and mandibular arches were bonded at their
recommended height.

175
Placement of orthodontic brackets
CHAPTER 7

Case Example 7.6 Irregular incisor edges An adult patient with missing right lower 1st molar with class II molar relation
bilaterally. The case was planned with extraction of upper 1st molars. As the right upper central incisor edge is rounded it was made
flat at start of the treatment and all the brackets were bonded according to my personal modified method combining Kalange and
McLaughlin method.

Case Example 7.7 Irregular incisor edges A young patient with severe skeletal class II. The patient was given a hybrid twin
block. The left maxillary central incisor in this case was broken because of trauma. Instead of reshaping the incisor it was rebuild
with composite filling .Reshaping the incisor would lead to exposure of the pulp in this case. After functional phase the
brackets were bonded normal using a modified method.

176
 to bracket placement. If teeth are start of treatment. Usually composite filling

Placement of orthodontic brackets

recontoured previous to orthodontic
treatment there is no need to alter the bracket
height. But if it is planned to recontour at the
end of orthodontic treatment or composite
filling is needed at the end of treatment then
height modification of bracket is done at the
is reserved for cases with openbite or large
broken area of incisors. See case example
7.8.
4.Long canine tip
In cases where canine tip is long it's better

Case example 7.8 Irregular incisor edges A young patient presented with class II div 1 was treated with twin block and fixed
braces. Incisor edges were irregular at the start of treatment. Brackets were bonded according to MBT charts but upper incisors
were bonded 0.5mm more gingival. In cases where you are doubtful about final overbite it's better to leave incisor edges as such.
As the overbite was ideal at the end of treatment so incisor edges were reshaped. If this case have openbite at end or minimum
overbite then I would have gone for composite build up to increase the overbite.
177
Placement of orthodontic brackets
CHAPTER 7

Case example 7.9 A case with buccally placed canine having long tip due to lack of function and attrition. Brackets were
placed 1 mm more gingival and when the canine came in final occlusion the tip was rounded 0.5 mm. The extra 0.5 mm
prominence of canine was kept to accommodate vertical relapse as the canine was high in the arch. Leaving the canine tip as such
and going for ideal bracket placement will leave small open bite areas mesial and distal to the canine.

to place brackets 0.5mm more gingival than

standard values and reshape canine tips at
the end of treatment. Another option is to
reshape canine tip at the start of the treatment
and place bracket at its ideal position. Long

Clinical Notes
Placing bracket more gingival on canine
will bring it down. As the canine move
down the thick cingulum part of the canine
come in contact with lower dentition and
prevent further downward movement of the
canine. It is a good clinical practice to also
reshape the lingual portion of canine when
extruding it otherwise poor occlusion and
premature contacts will result. Case
example 7.10
Case example 7.10 A case with bilateral attrition of
maxillary canine. Canine brackets were bonded 0.5mm
more gingival but no reduction in thickness of lingual side
was done. In final occlusion lingual side of canine came in
premature occlusion before the canine can settle down.
Even settling elastic couldn't bring the canine down
.Openbite in canine area were present due to a small mistake
in an otherwise well finished cases.
In case of attrition of the canine the brackets
are placed 0.5-1 mm more gingival,
depending upon the severity of attrition. The
canine tip is reshaped at the end of treatment.

canine tips are usually found in impacted

canines or canine placed out of occlusion.
Lack of attrition will leave the tip longer than
usual (case example 7.9).

5. Attrition of the canine

Figure 7.27 Left maxillary lateral incisor placed high in

the arch. As the lateral incisor is placed extremely high so
bracket is placed 1mm more higher than recommended
values of charts to accommodate the relapse factor. All other
brackets are placed at their recommended heights.
178
 6. High buccally placed teeth
High buccally placed teeth should be
bonded 0.5 to 1mm high than their
recommended position to accommodate the
relapse factor. The higher the tooth is present
in the arch greater the relapse factor should
be added (Figure 7.27).
7. Gingival recession
Individual teeth with up to 1.5mm gingival
recession can be bonded more gingival so
that at end of treatment their gingival
margins should be at the ideal height. But
incisor or occlusal edge needed to be
reshaped by equal amount. In teeth with
more than 1.5 mm of gingival recession an
expert opinion from periodontist should be
taken and many a time gingival grafting is a
viable option than bracket position
alteration.
8. Premolar extraction cases
In MBT system for 1st premolars extraction
cases to avoid vertical step at extraction site
vertical height of bracket should be
increased by 0.5mm on upper and lower 2nd
premolars and 1st molars. In lower arch
vertical height of 2nd molar should also be
increased by 0.5mm. In case of 2nd premolars
extraction upper and lower molars vertical
height should be increased by 0.5mm.The
same rule of change in vertical height in
posterior dentition after premolar extraction
can also be applied to other systems of
bracket positioning.
9. Molar interference
If there is interference in molar region
McLaughlin 18 recommended that either
place the bracket or tube more gingival
where interference is present and give a step
bend in the wire or bite blocks should be
placed at the start of treatment or all lower
arch brackets should be placed more
179
gingival by equal proportions.
Placement of orthodontic brackets
Importance of vertical position of brackets
The vertical position of bracket is related to the
torque of the brackets. As inclination of the
teeth is measured at certain height on the labial
surface of tooth and this value was built within
bracket prescription so alternating the vertical
position of the bracket will affect the torque of
Selection of Optimum Vertical Height
As so many guidelines are present for
vertical height the clinicians are often
confused which height should be chosen?
Only Andrew advocated a vertical height
where he actually developed his
prescription. Unfortunately it has its own
limitations. Rests of them are only clinical
experiences or they are not devised by
inventor of any prescription. Till the
orthodontists don't agree on a single reliable
and reproducible method of vertical bracket
positioning the best solution is use a vertical
height that is advocated by the inventor of
the prescription. Experience and
knowledge with time will lead many
clinicians to use a modified vertical position
of their own which work with certain
prescription on a certain population group.
the brackets. Change in vertical position will
have small effects of torque on teeth which
has nearly flat labial surface such as incisors
while teeth with convex labial surface such as
canines and premolars has profound effect on
change in vertical position of the brackets. A
detail description of importance of vertical
position is given in chapter 6. A diagrammatic
description of change in vertical height and its
effects on root position is given in figure 7.28.
Bracket positioning gauges
Bracket positioning gauges are used to ensure
vertical accuracy of brackets on the teeth. Many
Placement of orthodontic brackets
CHAPTER 7

Figure 7.28 In upper row brackets are placed at

different heights on maxillary central incisors. The slots of
the brackets are then straightened imagining that full torque
is expressed and the brackets are superimposed.
Superimposition of the brackets show that brackets placed
incisal will express more positive torque while brackets
placed gingival will express more negative torque. In lower
row a bracket was placed on a maxillary central incisor
having ideal inclination of +7° with occlusal plane
perpendicular and alveolar bone boundaries were
stimulated. Superimposing this tooth bracket with brackets
placed at different heights is shown. It is clear from the
figure that small variation in bracket positioning are
acceptable but large variations will cause the roots of incisor
to come in contact with alveolar cortex so increasing
chances of root resorption. If the root cross the alveolar
cortex severe mobility of the tooth will result and extraction
become necessary.

180

Figure 7.29 A Boone gauge
Figure 7.30 Straight rod shaped gauges similar to
Alexander Wick stick for 0.22” and 0.018” slot.
Figure 7.31 Gauges recommended in MBT system
different instruments have been recommended
to check for vertical accuracy of seated brackets
ranging from periodontal probes to rulers but in
contemporary orthodontics two types of gauges
or their variations are usually used. These are:
1. Star shaped gauges or Boone bracket
gauges (Figure 7.29).
2. Straight rod shaped gauges or Dougherty
gauges (Figure7.30&7.31).
Most variations are found in Dougherty gauges
and these are also the author favorite for bracket
placement.
181
Parts of gauges
Placement of orthodontic brackets
All bracket positioning gauges have a holding
Figure 7.32 Parts of the gauges.
arm for holding the gauge with fingers during
bracket positioning, a tooth supporting arm
which rest on the incisor or occlusal surface of
the tooth and a slot supporting arm which is
seated in slot of the bracket. The holding arm is
the longest part of gauges while the slot
supporting arm is the shortest part of the
gauges. Different slot supporting arms are
available for 0.018” and 0.022” slots. Different
parts of the bracket gauges are given in figure
7.32.
Position of the gauge during bracket
placement
Positioning the gauge for checking the vertical
height is very important. In an unpublished
study i found out that a faulty positioning of
gauge can change bracket height up to 2mm
(Figure 7.33). For correct positioning the gauge
should be held in hand at right angle so that the
orthodontist vision should also be at right angel
to the gauge.
As explained before variation in position of the
bracket will result in change in torque
expression. Also variation of 2mm in brackets
height in anterior dentition has serious
implication in terms of anterior aesthetic and
Placement of orthodontic brackets
CHAPTER 7

Figure 7.33 Varying the angle the gauge over tooth can change the height of the bracket which
is usually in the range of 2mm. As the angle between the gauge and tooth decrease height of the
bracket on the tooth increases.

Figure 7.34 A Gauge placed perpendicular to the Figure 7.35 Gauge placed perpendicular to buccal surface
buccal surface of the molar. of canine.

smile arc. (Figure 7.34).

The gauge should always be placed
perpendicular to the labial or buccal surface of
the teeth. This makes the gauges parallel to the
occlusal surface in all the teeth except incisors
In lower arch if the incisors are upright the
gauge should be placed parallel to the occlusal
plane(Figure 7.36A). But if the lower incisors
182
 Placement of orthodontic brackets
A

C
Figure 7.36 A. If mandibular incisors have normal
inclination the gauge is placed straight and perpendicular to
the labial surface. B. If the inclinational is increased the
gauge is placed below the occlusal plane. C. If the
inclination is decreased the gauge is placed above the level
of occlusal plane so that it remains perpendicular to
orientation of labial surface of teeth. Figure 7.37 Different angulation of gauge in class I, class
II div 1 and 2.
are proclined the gauge is placed below the
occlusal plane and if the lower incisors are angle depending upon the severity of
retroclined the gauge is directed from above the malocclusion (Figure 7.37).
occlusal plane (Figure 7.36B&C).
Bracket placement by wire guidance
In case of upper incisors the gauge is placed
slightly upward angulated usually 15° to 20° to In this technique all the steps of conventional
the occlusal plane to make it perpendicular to bonding are done in usual way but before
the labial surface of the tooth as the upper curing the bracket a heavy wire is passed
incisor are slightly inclined forward over basal through the bracket slot and its bonded
bone(Figure 7.37). In case class II div 1 incisor neighboring brackets and bands. The
relationship where the upper incisors are mesiodistal position of the bracket is corrected
proclined the gauge is angulated more upward manually while axial and vertical positions are
as compared to normal incisor inclination guided by the heavy wire.
(Figure 7.37). In case of class II div 2 the gauge If clinician want to place brackets from start of
lies below the occlusal plane angulated at an
183
Placement of orthodontic brackets
treatment on wire guidance then wire guidance
is usually taken by passing the wire through
bands and then placing brackets on wire
guidance. If no band is placed then first bracket
is placed in usual way and all other brackets are
placed on its wire guidance.
Orthodontic brackets can be placed by wire
guidance if brackets are debonded when
0.016x0.022 inch or heavier wire is in place. If
brackets are placed in usual way then due to
small human errors, mostly it is not possible to
place the existing working wire after bracket
rebonding and clinician need to move back on
lighter wires. If position of bracket was correct
before being debonded then same recycled or
new bracket can be bonded using existing wire
guidance.
Brackets can also be placed on wire guidance
from the start of treatment if clinician does not
want to change the angulation of teeth and want
to do some specific mechanics without any time
delay. Such scenario is usually found in cases of
impacted teeth where neighboring teeth roots
are close to impacted teeth and any delay may
result in increased risk of root resorption from
impacted teeth.
Placing brackets on wire guidance is also
helpful in adjunctive orthodontics when only
one tooth need uprighting to create space for
future prosthesis. In such cases a heavy wire is
selected and all the brackets are placed on its
guidance while the tooth needing uprighting is
bonded in normal way without wire guidance.
Position of clinician during brackets
placement
In orthodontics literature very little interest has
been given to position of the orthodontist for
bracket placement. It is generally said that
while placing brackets orthodontist should
maintain a single position at which he can see
the teeth at right angle. Also the head of the
patient should not be moved again and again as
CHAPTER 7
this is not comfortable for the patient. I do agree
that changing chair position by the orthodontist
or changing the position of the patients head is
not comfortable for both the patient and the
orthodontist but for good bracket positioning
this need to be done. As the patient hasn't visited
the orthodontist to have rest on his dental chair
and also the orthodontist should set aside his
comfort for his work as he is paid for it. Some
positions used during bracket placement are
given to clarify the readers mind (Figure 7.38).
Before placing the brackets the position of the
dental unit should be properly adjusted.
Usually a dental unit is adjusted between 140°
to 150. At this position the clinician can easily
see the brackets at right angle. This setting also
helps to see axial position of some brackets
from 12 o' clock position. The clinician position
for bracket placement given here are for right
handed orthodontist. For left handed
orthodontist similar positions would be used
from the left side.
Upper and lower incisor bracket positioning
For upper central and lateral incisors, the
bracket should be placed with the bracket
holder on the mesiodistal and vertical center of
the tooth with the clinician sitting at 8 0' clock
position and the patient head tilted on his right
side toward the clinician. After the bracket is
placed, the height of the bracket is checked with
bracket positioner. The patient head is made
straight and orthodontist check it from 9 o'clock
positions with the gauge at right angle to his
vision.
To check the mesiodistal and axial position of
the bracket the orthodontist moves to 12 o'
clock position and place a diagnostic mouth
mirror at the incisor edge to indirectly check the
mesiodistal position of the bracket. This
indirect vision also help to correct the axial or
long axis position of the bracket to some extent
but direct vision will give an excellent picture
whether the wings of the bracket and the
184

Figure 7.38 Different positions of the clinician during bracket placement. 12, 9 and 3 o'clock positions are shown.
bracket scribe line is parallel to long axis of
clinical crown. While checking axial
inclination of maxillary lateral incisors
brackets it is a good practice to tilt the head of
the patient to opposite side. For right maxillary
lateral the patient head should be tilted toward
left side and versa.
The lower incisors brackets are placed in a
similar fashion as upper incisors brackets.
Vertical height is checked from 9 o' clock
position while 12 o'clock position is used to
check to mesiodistal and axial position of
185
Placement of orthodontic brackets
brackets. Diagnostic mouth mirror can be
placed gingival to the bracket to check
mesiodistal position of the bracket. Some
clinician prefer to check mesiodistal and axial
position of lower incisor bracket from 8 o'
clock position under direct vision with patients
head tilted towards the orthodontist.
Upper and lower canines
Positioning of right upper and lower canines
brackets is done at 9 o' clock position with the
mesiodistal and axial placement checked from
the same position while the vertical height of
Placement of orthodontic brackets
the bracket is checked with gauge from 11 o'
clock position. For left side upper and lower
canines the brackets are placed from 9 o' clock
position with the patient head tilted toward
right. The mesiodistal and axial positions of
brackets are checked under direct vision from
the same 9 o'clock position.
Upper and lower bicuspids
Upper right bicuspids brackets are placed at 9
o' clock positions and its vertical height is
checked with gauge from 11 o' clock position
with patients head slightly tilted toward left.
Many a time the cheek retractor hinders the
correct positioning of the bracket positioning
gauge. In such circumstances it's better to grip
the retractor with left hand and slightly retract it
while position the gauge so that it is at right
angle to tooth long axis and to the clinician
vision. Check the mesiodistal position of the
bracket from 11 or 12 o' clock position with
diagnostic mirror using indirect vision. This
vision also gives some hint about axial position
of the bracket but the correct axial position is
checked from 9 o' clock position under direct
vision with patient head tilted toward left.
Right lower bicuspids brackets are placed on
the tooth at 9 o'clock position. The vertical
height is checked and adjusted from 11o'clock
position. The clinician check axial and
mesiodistal position of the bracket at 10 o'clock
position under direct vision. Some clinician can
recheck the mesiodistal position of the bracket
under indirect vision by placing diagnostic
mirror on occlusal surface of bracket.
Upper left bicuspids are placed at 9 o' clock
position with the patient head tilted toward
right. The mesiodistal position is checked under
indirect vision with diagnostic mirror from 12
o' clock with the patient head tilted toward
right. The 12 o'clock position also give a good
view for axial position of bracket under indirect
vision but it's better to see axial position of
bracket from 8 o'clock position under direct
CHAPTER 7
vision with the patients head tilted toward right.
Lower left bicuspid brackets are placed from 9
o'clock positions with the patient head tilted
toward right. The mesiodistal and axial position
of the brackets are confirmed at 8 o'clock
position under direct vision.
Some clinician prefer to place left side cuspids
and bicuspids brackets from the left side using
equivalent positions that were used on right
side.
Reference
1. Andrews LF. Straight-Wire-The Concept and Appliance; L.
A. WellsCo., San Diego, California. 92107: 1989.
2. Graber TM Orthodontics: Current Principles & Techniques.
: Mosby; 1984.
3. McNamara JA, Brudon W & Brudon L. Orthodontic and
Orthopedic Treatment in the Mixed Dentition. : Needham Pr;
1993.
4. Andrews LF. The six keys to normal occlusion. Am J Orthod.
1972 Sep; 62(3):296-309.
5. Angle HE. The latest and best in orthodontic mechanism.
Dental Cosmos 1928; 70:11-43.
6. Taylor RMS. Variations in morphology of teeth. New York:
Charles C. Thomas, 1978.
7. McLaughlin RP, Bennett JC, Trevisi H .Systemized
Orthodontic Treatment Mechanics. 2nd ed.: Mosby; 2001.
8. Parkhouse R. Tip-Edge Orthodontics and the Plus Bracket.
2nd ed.: Mosby; 2008.
9. Andrews LF. The six keys to normal occlusion. Am J Orthod
1972; 62:296-309.
10. Gargiulo AW, Wentz FM, Orban B: Dimension and relations
of the dentogngival junction in humans, J Periodontal
32:262,1961.
11. Eliades T, Gioka C, Papaconstantinou S, Bradley TG.
Premolar bracket position revised: proximal and occlusal
contacts assessment. World J Orthod. 2005 Summer;6(2):149-
186
 55.

Placement of orthodontic brackets

12. Roth RH. Functional occlusion for the Orthodontist. Part
III. J Clin Orthod. 1981 Mar;15(3):174-9, 182-98.

13. Roth RH.The straight-wire appliance 17 years later. J Clin

Orthod. 1987 Sep;21(9):632-42.

14. Alexander RG. The vari-simplex discipline. Part 1. Concept

and appliance design. J Clin Orthod. 1983 Jun;17(6):380-92.

15. Alexander RG .The 20 Principles of the Alexander

Discipline. Chicago: Quintessence Pub.; 2008.

16. Bishara.SE Textbook of Orthodontics. Saunders; 2001.

17. Gu ZX, Duan YZ, Ding Y, Li BR, Shu L, Chen XP. Study on
the height of marginal ridge to cusp in posterior teeth and its
effect on brackets placement. Hua Xi Kou Qiang Yi Xue Za Zhi.
2008 Jun;26(3):271-4.

18. McLaughlin RP, Bennett JC. Bracket placement with the

preadjusted appliance. J Clin Orthod. 1995 May;29(5):302-11.

19. Ricketts RM. Bioprogressive therapy as an answer to

orthodontic needs. Part I. Am J Orthod. 1976 Sep;70(3):241-
68.

20. Viazis AD Atlas of Orthodontics: A Guide to Clinical

Efficiency. : Saunders; 1998.

21. Graber TM Orthodontics: Current Principles &

Techniques. : Mosby; 1984.

22. Salzman JA Orthodontics in Daily Practice. : Lippincott

Williams and Wilkins ; 1974.

23. Swain BF. Dr. Brainerd F. Swain on current appliance

therapy. Interview by Sidney Bradt. J Clin Orthod. 1980
Apr;14(4):250-64.

24. Burstone CJ Modern Edgewise Mechanics and the

Segmented Arch Technique. : ORMCO Corporation; 1985.

187
 Placement of orthodontic brackets
CHAPTER
7

188
 CHAPTER
Bonding in Orthodontics
8
In this Chapter

Tooth Cleaning
Enamel Roughening or acid Etching
Sealing the etched enamel surface
Bonding
Bonding in special circumstances
Indirect bonding

Historically orthodontic brackets were soldered

to bands and eventually banded to teeth. As
bands need space between the contact points at
time of their placement and leave spaces
between teeth at end of treatment so they were
not a preferred method.
With the introduction of acid etching by
Buonocore 1 in 1955 banding of teeth was
eventually abandoned with time and is now only
used on molars in cases requiring special
mechanics like headgears. Extensive details
about bonding are given in almost all the text
books of orthodontics so only a brief review on
this topic would be given here.
Bonding of brackets can be done either directly
or indirectly. Steps in direct bonding of bracket
are given.
2. Enamel roughening of labial or lingual
surface of tooth by acid etching
3. Sealing of etched surface
4. Bonding
1) Tooth Cleaning
This step is only done in patients in whom
there is plaque or thick pellicle layer over the
enamel surface at the time of bonding.
If only pellicle is present then pumicing of
teeth alone is sufficient but if plaque or
calculus is also present over the enamel
surface then scaling is done which is
followed by pumicing (Figure 8.1).

1. Tooth cleaning

189
Bonding in Orthodontics
Figure 8.1 Pumicing teeth with a polishing paste and
pumice powder.
Clinical Notes
Pumicing before etching is controversial 2-4
if conventional etching is done but clinician
should do pumicing if self-etching primer 5-7
is used.
2) Enamel Roughening or acid Etching
Enamel roughening or acid etching is done to
create retention areas for the adhesive on the
enamel surface.
Moisture control is important during this
step and rest of the steps that follows.
Good moisture control is provided by using
cheek/lip retractors and high volume
section. This arrangement of moisture
control is usually sufficient in majority of
the cases but in some cases where patients
have increased salivary flow, special
gadgets are available that combine lip/
cheek retractors, saliva ejectors and tongue
guards (Figure 8.2). Cotton rolls are also
used to increase moisture control. Some
clinician also uses antisialogogue like
atropine sulphate to create a dry field for
brackets bonding. Antisialogogues can be
used on patients having excessive salivary
flow but evidence 8 doesn't support their
routine use during orthodontic bonding.
Before going for enamel conditioning
enamel surface should be dried with oil free
air. Enamel conditioning is conventionally
CHAPTER 8
A
B
Figure 8.2 A Nola dry field system combining all the
necessary gadgets for good moisture control during enamel
conditioning. This system is especially helpful in indirect
bonding.
done with 35 - 37% phosphoric acid. Enamel
roughening by sandblasting has also been
proposed but sandblasted enamel yield lower
bond strength 9-13than acid etched enamel.
Sandblasting first followed by conventional
etching have also been proposed but bond
strength of brackets with this combination
technique is controversial 14, 15 than doing
conventional acid etching alone. Lasers have
also been advocated for enamel etching 16-19
either alone or in combination 20 with acid
etching. But due to high cost of lasers and
more safer application of conventional
etching the use of laser for enamel roughing
is still a novel approach in orthodontics.
In enamel etching with 37% phosphoric acid
the acid is available in both liquid and gel
form. The liquid form of the acid has
190

decreased viscosity and usually flows after
its application and come in contact with
gingiva thus causing soft tissue irritation.
Also liquid form will etch more than
required enamel surface. So a gel form
should always be preferred (Figure 8.3). It's
always better to etch the enamel surface
only on the future bracket siting area.
When large area of the enamel is etched
then most of the time clinician don't seal
the entire area by primer and these rough
surface act as future plaque retention areas.
B
Figure 8.3 A. Acid gel used to etch lower incisors. B.
Acid in liquid form. As liquid form of acid has more
viscosity so there are greater chances of this acid flowing
and touching the gingiva in mandibular teeth etching.
Clinical notes
Some clinician prefers to use 10 or 20%
polyacrylic acid etching for ceramic
brackets to decrease their bond strength.
Etching should ideally be done for 25 to 60
seconds. At the end of etching the acid should
be washed away from the tooth surface with
an abundant water spray. The acid plus water
spray should be immediately be sucked from
patient mouth with high volume suction. The
enamel surface is then dried with oil free air.
Some clinicians use special warm air drier to
dry the enamel surface (Figure 8.4). The
191
Bonding in Orthodontics
enamel should be frosty white after drying
the etched surface (Figure 8.5).
Clinical Notes
Decreasing the etching time will decrease
the bond strength. Ceramic brackets show
decreased bond strength 21,22 when enamel
surface was etched for only 20 seconds
than 60 seconds etching.
Figure 8.4 A warm air tooth dryer by Lancer orthodontics.
Figure 8.5 Frosty white enamel surface after drying the
etched enamel surface.
Moisture control should be maintained at
every cost. Sometimes due to irritation by the
washed away acid patient immediately rinse
after etching. If this happen or saliva comes
in contact with etched surface due to other
reasons the tooth surface should be dried and
re-etched again for a few seconds.
Clinical Notes
Some clinicians recommend use of self-
etching primer in case of ceramic brackets
Bonding in Orthodontics
CHAPTER 8
to decrease their bond strength but there is A randomized control trial 29 showed that
no evidence 23 to support this theory. bond strength is not affected by saliva
contamination in case of SEP and MIP.
3) Sealing the etched enamel surface
There is controversy 30-32on the use of sealants
The dry etched enamel surface is sealed with in orthodontic bonding but the proposed
application of primer or bonding agent advantages are increased bond strength and
(Figure 8.6). The primer is applied to the prevention of microleakage under the
tooth surface with the help of a primer brush. brackets.
Only a thin coat of primer is sufficient to seal
the enamel surface. Most clinicians then
light cure the primer or bonding agent.
Different types of curing lights are available
in the market but LED lights in wavelength
between 420-480nm are usually used (Figure
8.7). Plasma arc curing lights can do curing
in least time24 but they are expensive than
LED dental curing lights. A systematic
review 25 found no difference between
different curing lights in term of bracket
failure. So any light can be selected A
depending upon clinician ease of use and
cost effectiveness.

With LED curing light, primer on enamel

surface is cured for 5 seconds. Some
clinicians don't cure the primer separately
and after placing the bracket with adhesive
on the tooth cure both the primer and
adhesive together. In self-cure cements the
sealant layer is cured by placement of B
bracket with attached adhesives.
Figure 8.6 A. A primer bottle with application brush. B.
Moisture insensitive primer (MIP) and self- Primer applied to lateral incisor surface.
etching primer (SEP) are also available. In
SEP etching and sealing is done in one phase.

Clinical Notes
Evidence 26, 27 shows that SEP can save time
during clinical bonding but evidence
related to increased risk of bond failure with
SEP is controversial with latest limited Figure 8.7 A LED B curing light with wavelength
between 425-490 nm.
evidence 28 showing that there is no
difference between SEP and conventional 4) Bonding
etching in terms of bond failure.
After the application of sealant on the tooth
192

surface the bracket is prepared by first
wetting the bracket base with primer (Figure
8.8). Usually a thin layer of primer is applied.
After the application of primer clinicians
light cure the primer and then apply adhesive
on the bracket surface. Some clinicians
don't apply primer over the bracket base
and directly apply adhesive on the base. No
evidence is available to support any
technique and clinicians are free to use the
technique in accordance with their clinical
experience. A thin layer of adhesive is
usually applied over the bracket base and
the brackets are placed over their proposed
final position on teeth (Figure 8.9). A heavy
force is usually applied from the back of
bracket holder to squeeze out all the extra
composite from underneath the bracket
(Figure 8.10).This extra composite is called
flash and it is removed from around the
bracket with the help of dental probe.
Figure 8.8 Applying bonding agent on the bracket base.
A 4.Less flash removal on bracket
B
Figure 8.9 An adhesive tube from 3M Unitek. The
193
Bonding in Orthodontics
adhesive is applied directly from the tube to the bracket
base. A thin layer of adhesive is usually used. The adhesive
can be spread over the bracket base with the help of dental
probe.
Figure 8.10 Composite flash present around the bracket
base. This composite flash is removed with the help of a
dental probe. This flash must be removed as it will act as
potential plaque retention area and also will lead to gingival
irritation and development of white spot lesions.
Clinical Notes
Usually application of primer on the tooth
surface and adhesive on the bracket base go
side by side. The clinician etches the enamel
surface and applies primer on it while his
assistant apply adhesive over the bracket
base at the same time.
Adhesive precoated brackets are also
available from many manufacturers. The
proposed advantages of these brackets are
1.Less chair side time.
2.Better infection control.
3.Consistent adhesive layer thickness
on all the brackets.
placement.
In adhesive precoated brackets each bracket
is sealed in a special packing. Due to
increase cost associated with these brackets
many clinicians don't find them a cost
effective choice.
Bonding in Orthodontics
Choice of adhesive
Choosing the right adhesive for bracket
bonding is very important. Luting adhesive
are recommended over filling adhesive for
orthodontic bracket bonding. In composite
resins different commercially available
adhesives are present in the market. All
manufacturers claim that their adhesive
provides better bond strength over other
companie's products. While choosing a
composite resin adhesive the orthodontist
must remember that fixed braces are
temporarly attached to teeth and bond
strength of 5.9 to 7.8 MPa is clinically
acceptable. A comparative study by
Sharma 33 concluded that commercially
available adhesives have higher bond
strength than minimum recommended
limits.
Resin modified Glass ionomer cement
(RM-GIC) is usually chosen for cases with
amelogenesis and dentinogenesis imperfect
as it is generally thought that it provide
lower bond strength than composite resin
but a systematic review 34 showed that
RM-GIC have the same clinical bracket
failure rate as composite resin adhesives
after 1 year.
After the placement of brackets on the teeth
usually the mesiodistal position of the brackets
is checked first then the vertical usually with
the help of positioning gauge and the last
position that is checked and corrected is axial.
For axial position checking some guidance is
also taken from patient study cast and OPG.
Clinical notes
The position of the bracket is corrected with
dental probe or interdental scaler. A
common problem that is encountered
while correcting the position is that bracket
gets attached with the instrument if the
CHAPTER 8
instrument or the bracket has magnetic
properties. This problem is common with
brackets undergone machining or milling
during manufacturing (Figure 8.11). Such
brackets will also offer greater friction
during sliding mechanics. Brackets and
instruments having magnetic properties
should be avoided for good bonding.
Using adhesive with increase filler contents
will also prevent increase bracket
movement or it's detachment from tooth
during position correction.
Figure 8.11 A bracket having magnetic properties. Such
brackets are difficult to bond at right position and also offer
greater resistance to sliding.
Once all the positions of a bracket are checked,
the bracket is cured at its place. Usually one
bracket is cured for 20 seconds with LED B
curing light (Figure 8.12).Mostly an orange
protective cover is present over the curing light
but orthodontists and his assistant should also
wear protective goggles during bracket curing
procedure (Figure 8.13). The patient should
also be given protective goggles or he should
be advised to close his eyes during the curing
process.
Bonding in special circumstances
Etching of bleached enamel
In some cases bonding of brackets on
194

Figure 8.12 Brackets cured by LED curing light.
Figure 8.13 Protective goggles used during bracket
curing.
previously bleached teeth is need. As decreased
bond strength 35-37 have been reported with
previously bleached enamel so different
waiting times for bonding of brackets after
bleaching have been recommended. The range
of waiting time 38-40 is from 24 hours to 14 days.
Bonding brackets to acrylic crowns
Composite resins have good adhesion with
acrylic crowns. Microretention on the crowns is
introduced with fluted carbide burs or roughing
the crown surface with the help of a dental
probe. After crown roughening most clinicians
then bond bracket without the application of
primer on the crown surface.
Bonding on Porcelain or ceramics
In orthodontic many a time porcelain crowns or
veneers are present on teeth before start of
195
Bonding in Orthodontics
treatment and they need to be bonded during
the course of orthodontic treatment. To bond
brackets, labial surface of prosthesis is needed
to be roughened. Various methods used for
roughening of porcelain surface are diamond
burs, sandblasting with aluminum trioxide,
sandblasting with silica and use of silane
coupling agents, conventional etching and
silane coupling agents, etching with 9.6%
hydrofluoric acid, 9.6% hydrofluoric acid and
silane coupling agents and use of Er: YAG
lasers. No clinical trial is available in the
literature on this issue and only laboratory
studies are present.
Sandblasting with aluminum oxide provide the
lowest bond strength 41 on porcelain or ceramic
veneers. Conventional etching with
phosphoric acid and application of silane
coupling agent 42 usually cause less enamel
damage. Er: YAG lasers 41, 43 though provide
optimum bond strength and minimum
porcelain damage still remains a novel
approach. 9.6% hydrofluoric acid alone or
combination with silane coupling agents is
usually used. According to Bishara44
hydrofluoric acid followed by silane coupling
is the most reliable technique but this also
produces the greatest damage to the porcelain
surface.
Indirect bonding
In indirect bonding brackets are first
individually placed on patient's dental cast
and then transferred by special carrier trays
into the patient's mouth. The purpose of
indirect bonding is to accurately place
brackets and save bonding time in clinical
practice.
In initial days of their introduction, indirect
bonding yield lower bond strength than direct
bonding but latest laboratory studies 45-47 have
shown that brackets bonded by indirect and
direct method have equivalent bond strength.
There are various techniques available for
indirect bonding. The author follows Sondhi
Bonding in Orthodontics
CHAPTER 8
technique with few personal modifications .The
technique is given as follow.

Technique

1. Take an impression of patient teeth with a

dimensional stable impression material and
pour it in dental hard stone.

2. Apply a water soluble separating medium

over the dental model. I usually prefer a cold
mold seal but other water soluble products Figure 8.15 Bracket placed and cured over the dental cast.
can also be used (Figure 8.14).

Figure 8.16 Separating medium applied over the brackets

to avoid adhesion of brackets to soft silicon vacuum formed
tray.

the brackets a 1 mm thin soft silicone tray is

Figure 8.14 Cold mold seal being applied on the maxillary
dental cast with help of brush. The model has palatal vacuum formed over the brackets.(Figure
coverage which ideally should not be present for good 8.17)
vacuum formation of trays. If present the palatal coverage
should be removed on a dental model trimmer.

3. Place brackets over the dental model.

There is no need to place primer on the dental
stone. Place primer and adhesive on bracket
in the same way as done in direct bonding or
adhesive precoated brackets can be used. The
brackets should be placed at the ideal
location on the model and flash around the
brackets should be removed. The brackets
are then cured by LED curing light as light
cure adhesives are used (Figure 8.15). A
4. Water soluble separating media is then
applied on the bonded brackets. A very thin
coat of the media is applied. A thick coat will
cause poor retention of the brackets in carrier
tray (Figure 8.16).

5. After applying the separating medium on B

196

C 10. Light cure the base of each bracket for
Figure 8.17 A. Palatal coverage of model trimmed for
easy vacuum formation. B. Model placed in a vacuum
former. C. Soft tray trimmed for easy placement of hard
tray.
6. Apply a thin coat of water soluble
separating media over the vacuum formed
soft tray placed on the dental model. This
will help in easy separation of carrier soft
tray from supporting hard tray.
7. Vacuum form a 1 mm thick hard silicone
tray over the soft tray. This outer hard tray
will support the inner soft tray and prevent it
from distortion during insertion in the mouth
(Figure 8.18).
Figure 8.18 A 1mm thick hard tray vacuum formed over a
soft tray. The yellowish tinge in the tray is that of a
separating medium applied between the trays.
8. Cut both trays on the dental cast with help
of cutting disc. The trays are cut on the
lingual side so that it covers half of all the
clinical crowns. On labial side the trays cut at
level of gingival wings or hooks of the
brackets if present.
197
Bonding in Orthodontics
9. The model is then immersed in water for
atleast 10 minutes to dissolve the separating
media. After 10 minutes the trays along with
brackets are removed from model in one
piece. Usually a dental probe is used to lift
the trays from the model on one side by
engaging the probe between the soft tray and
the model. If good separating medium was
used all the brackets will remain within the
carrier tray.
atleast 5 seconds so that any uncured
adhesive usually left in the middle of the
brackets at the initial curing is cured and
hardened.
11. Wash the inside surface of the tray with
tap water so that any separating medium or
any other cast material is removed from the
cured adhesive over the bracket base.
12. Sandblast each bracket base for 1 second,
keeping 10 mm distance between bracket
base and the blaster tip. Line pressure is
maintained at 90 psi and 50 µm aluminum
oxide sand is used. This step is done to
remove any attached dental cast material
over the adhesive and also to roughen the
adhesive. Some clinicians instead of using
sandblasting scratch the adhesive surface
with dental probe.
13. Wash the trays again to remove any sand
particles or other dust particles.
14. Separate the two trays from each other.
This can easily be done by engaging the
dental probe tip between two trays and lifting
the upper hard tray. This step is done to aid
final cutting of the two trays and also to
remove any adhesion areas between the two
trays if present (Figure 8.19). Sometime the
outer hard tray is so well adapted over the
inner soft tray and brackets that the two trays
cannot be separated. Peeling the soft tray
forcefully can many times lead to removal

of the brackets from the soft tray. If this is
Bonding in Orthodontics
the case it is better to cut the hard tray at
the level of gingival wings and sometimes
0.5 mm above it to remove any undercut
area. On brackets having hooks the hard
tray over it should be cut at the level of
mesial or gingival wing and not at the level
of hook.
Figure 8.19 Hard tray separated from soft tray for final
cutting and removal of any adhesion area between two
trays. Trays are only of one segment of the arch.
15. Once the hard tray is removed from the
soft tray, both trays are trimmed. The soft
tray is trimmed with the help of scissor so
that it is extended 0.5-1mm below the
bracket gingival wings while the hard tray is
cut at the level of gingival wings or some area
of gingival wings can be left uncovered from
the hard tray. The hard tray is cut with the
help of cutting disc.
16. A small middle mark is cut on the hard
tray which coincide with corresponding
upper or lower dental midline. This midline
mark will act as a reference point during trays
insertion and help in correct placement of the
trays.
17. If any bracket comes out of the soft tray it
should be adjusted back into the tray. But if
the tray has poor retention for the bracket
then the bracket should be taken out and
placed by direct bonding after recycling its
base by sandblasting.
CHAPTER 8
18. After both trays are trimmed to required
size, the soft tray is seated within the hard
tray. The clinician can practice placing the
trays over the models. If such an exercise is
made the trays should be washed and dried
after that. The trays are now ready for
indirect bonding.
19. For indirect bonding I mainly use Sondhi
indirect bonding kit by 3M Unitek. This kit
consists of two bottles having semi liquid
solutions. The liquid is poured in separate
small plastic wells provided with the kit.
Liquid from bottle A is placed with a primer
brush on the etched tooth surface and liquid
from bottle B is placed on the bracket base
surface covered with adhesive. Separate
brushes are used for liquid A and B. Indirect
bonding kits containing two bottle solutions
are also available from many other
manufacturers and clinicians can also use
them according to their convenience.
20. The patient teeth are cleaned and etched
similar to direct bonding. Good isolation of
teeth and high volume suction is necessary as
whole arch is etched in a single go. After
etching and drying the enamel liquid from
bottle A is pasted over all the teeth that
needed to be bonded. Liquid B is pasted over
the entire brackets base surface. It is better to
apply liquid first over the brackets than on
enamel to prevent moisture contamination or
it can be applied simultaneously by taking
help of an extra assistant.
21. After applying liquid over the brackets
and enamel surface the trays are placed by
taking guidance from mid reference mark.
Once the trays are firmly seated, movement
of the trays should be avoided. Finger
pressure should be maintained over the trays
for atleast one and a half minute or depending
upon specific product recommendations
(Figure 8.20).
22. After 2 minutes of trays insertion, the
198

Figure 8.20 Indirect bonding of upper arch.
trays are removed separately. The hard tray is
removed first by engaging the dental probe
tip between hard and soft tray from the labial
side. Rotating the probe handle will lift off
the hard tray from the soft tray.
23. The soft tray is then peeled off from the
brackets by first lifting it from one end in
posterior segment with the help of probe and
then griping it with fingers. Some clinician
instead of giving a peel off force rotate the
tray from labial to lingual starting from one
side with the help of dental probe. My
personal experience with indirect bonding is
that there are less chances of bracket failure if
the tray is rotated labial to lingual at each
tooth with help of dental probe than to peel it
off from the brackets.
24. Check position of each tooth clinically.
If some bracket is not placed at its ideal
location debond it, recycle it and rebond it
with direct bonding.
Clinical Notes
Sondhi indirect bonding kit is chemically
cured so it usually give less time for trays
insertion. A better option is to use
Transbond supreme lv, a light cure version
by the same company. In this light cure
adhesive there is no need to apply any
special primer on the etched enamel
surface. Enamel surface is etched and any
primer can be applied on it. All the bracket
bases in the indirect tray covered with
adhesive are coated with a very thin layer of
199
Bonding in Orthodontics
Transbond supreme lv. The trays are
positioned in the mouth and each bracket is
cured for 10seconds with LED curing light.
Soft and hard trays are then removed in
normal fashion and wires are passed
immediately after that.
Clinical Notes
Ideally tubes are bonded to molars in
indirect bonding but if bands needed to be
cemented than they should be placed after
indirect bonding. Separators shouldn't be
passed in molars after taking of impression
for fabrication of indirect trays. If
extraction is required during treatment it
should also be done after indirect bonding.
If the case has severe malocclusion the
indirect trays can be cut into 2 to 3 segments
for easy insertion.
If clinicians are new in indirect bonding
they should initially select case with well
aligned arches and divide the tray into three
segments, one anterior and two posteriors
for easy insertion.
Bonding by indirect method should be done
within 7 days of taking the impression for
bonding.
References
1. Buonocore MG. A simple method of increasing the
adhesion of acrylic filling materials to enamel surfaces. J Dent
Res 1955; 34:849-53.
2. Barry GR. A clinical investigation of the effects of
omission of pumice prophylaxis on band and bond failure. Br J
Orthod. 1995 Aug;22(3):245-8.
3. Ireland AJ, Sherriff M. The effect of pumicing on the in
vivo use of a resin modified glass poly(alkenoate) cement and a
conventional no-mix composite for bonding orthodontic
brackets. J Orthod. 2002 Sep;29(3):217-20; discussion 196.
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4. Lindauer SJ et al. Effect of pumice prophylaxis on the
bond strength of orthodontic brackets. Am J Orthod Dentofacial
Orthop. 1997 Jun;111(6):599-605.
5. Burgess AM, Sherriff M, Ireland AJ. Self-etching
primers: is prophylactic pumicing necessary? A randomized
clinical trial. Angle Orthod. 2006 Jan;76(1):114-8.
6. Lill DJ, Lindauer SJ, Tüfekçi E, Shroff B. Importance
of pumice prophylaxis for bonding with self-etch primer. Am J
Orthod Dentofacial Orthop. 2008 Mar;133(3):423-6; quiz
476.e2.
7. Pandis N, Eliades T. A comparative in vivo
assessment of the long-term failure rate of 2 self-etching
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8.
8. Ponduri S, Turnbull N, Birnie D, Ireland AJ, Sandy
JR. Does atropine sulphate improve orthodontic bond survival?
A randomized clinical trial. Am J Orthod Dentofacial Orthop.
2007 Nov;132(5):663-70.
9. Gray GB, Carey GP, Jagger DC. An in vitro
investigation of a comparison of bond strengths of composite to
etched and air-abraded human enamel surfaces. J Prosthodont.
2006 Jan-Feb;15(1):2-8.
10. Olsen ME, Bishara SE, Damon P, Jakobsen JR.
Comparison of shear bond strength and surface structure
between conventional acid etching and air-abrasion of human
enamel. Am J Orthod Dentofacial Orthop. 1997
Nov;112(5):502-6.
11. Canay S, Kocadereli I, Ak"ca E. The effect of enamel
air abrasion on the retention of bonded metallic orthodontic
brackets. Am J Orthod Dentofacial Orthop. 2000
Jan;117(1):15-9.
12. van Waveren Hogervorst WL, Feilzer AJ, Prahl-
Andersen B. The air-abrasion technique versus the
conventional acid-etching technique: A quantification of
surface enamel loss and a comparison of shear bond strength.
Am J Orthod Dentofacial Orthop. 2000 Jan;117(1):20-6.
13. Abu Alhaija ES, Al-Wahadni AM. Evaluation of shear
bond strength with different enamel pre-treatments. Eur J
Orthod. 2004 Apr;26(2):179-84.
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14. Suma S, Anita G, Chandra Shekar BR, Kallury A. The
effect of air abrasion on the retention of metallic brackets
bonded to fluorosed enamel surface. Indian J Dent Res. 2012
Mar-Apr;23(2):230-5.
15. Miles PG. Does microetching enamel reduce bracket
failure when indirect bonding mandibular posterior teeth? Aust
Orthod J. 2008 May;24(1):1-4.
16. Uşümez S, Orhan M, Uşümez A. Laser etching of
enamel for direct bonding with an Er,Cr:YSGG hydrokinetic
laser system. Am J Orthod Dentofacial Orthop. 2002
Dec;122(6):649-56.
17. Ozer T, Başaran G, Berk N. Laser etching of enamel
for orthodontic bonding. Am J Orthod Dentofacial Orthop.
2008 Aug;134(2):193-7.
18. Berk N, Başaran G, Ozer T. Comparison of
sandblasting, laser irradiation, and conventional acid etching
for orthodontic bonding of molar tubes. Eur J Orthod. 2008
Apr;30(2):183-9.
19. Başaran EG, Ayna E, Başaran G, Beydemir K.
Influence of different power outputs of erbium,
chromium:yttrium-scandium-gallium-garnet laser and acid
etching on shear bond strengths of a dual-cure resin cement to
enamel. Lasers Med Sci. 2011 Jan;26(1):13-9.
20. Dundar B, Guzel KG. An analysis of the shear
strength of the bond between enamel and porcelain laminate
veneers with different etching systems: acid and Er,Cr:YSGG
laser separately and combined. Lasers Med Sci. 2011
Nov;26(6):777-82.
21. Costa AR, Correr AB, Puppin-Rontani RM, Vedovello
SA, Valdrighi HC, Correr-Sobrinho L, Vedovello Filho M. Effect
of bonding material, etching time and silane on the bond
strength of metallic orthodontic brackets to ceramic. Braz Dent
J. 2012;23(3):223-7.
22. Gonçalves PR, Moraes RR, Costa AR, Correr AB,
Nouer PR, Sinhoreti MA, Correr-Sobrinho L. Effect of etching
time and light source on the bond strength of metallic brackets to
ceramic. Braz Dent J. 2011;22(3):245-8.
23. Fleming PS. Limited evidence suggests no difference
in orthodontic attachment failure rates with the acid-etch
technique and self-etch primers. Evid Based Dent. 2014
200

Jun;15(2):48-9.
24. Sfondrini MF, Cacciafesta V, Scribante A, Klersy C.
Plasma arc versus halogen light curing of orthodontic brackets:
A 12 month clinical study of bond failures. Am J Orthod
Dentofacial Orthop. 2004;125:342–347.
25. Fleming PS, Eliades T, Katsaros C, Pandis N. Curing
lights for orthodontic bonding: a systematic review and meta-
analysis. Am J Orthod Dentofacial Orthop. 2013 Apr;143(4
Suppl):S92-103.
26. Fleming PS, Johal A, Pandis N. Self-etch primers and
conventional acid-etch technique for orthodontic bonding: a
systematic review and meta-analysis. Am J Orthod Dentofacial
Orthop. 2012 Jul;142(1):83-94.
27. Elkhadem A, Orabi N. Weak evidence suggests higher
risk for bracket bonding failure with self-etch primer compared
to conventional acid etch over 12 months. Evid Based Dent.
2013;14(2):52-3.
28. Fleming PS. Limited evidence suggests no difference
in orthodontic attachment failure rates with the acid-etch
technique and self-etch primers. Evid Based Dent. 2014
Jun;15(2):48-9.
29. Goswami A, Mitali B, Roy B. Shear bond strength
comparison of moisture-insensitive primer and self-etching
primer. J Orthod Sci. 2014 Jul;3(3):89-93.
30. Varlik SK, Ulusoy C. Effect of light-cured filled
sealant on shear bond strength of metal and ceramic brackets
bonded with a resin-modified glass ionomer cement. Am J
Orthod Dentofacial Orthop. 2009 Feb;135(2):194-8.
31. Mahajan V. Effect of light-cured filled sealant on the
shear bond strength of metal, ceramic and titanium brackets
bonded with resin-modified glass ionomer cement. Indian J
Dent Res. 2013 Nov-Dec;24(6):745-9.
32. Bishara SE, Oonsombat C, Soliman MM, Warren J.
Effects of using a new protective sealant on the bond strength of
orthodontic brackets. Angle Orthod. 2005 Mar;75(2):243-6.
33. Sharma S et al. A comparison of shear bond strength
of orthodontic brackets bonded with four different orthodontic
adhesives. J Orthod Sci. 2014 Apr;3(2):29-33.
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34. Mickenautsch S, Yengopal V, Banerjee A. Retention of
orthodontic brackets bonded with resin-modified GIC versus
composite resin adhesives--a quantitative systematic review of
clinical trials. Clin Oral Investig. 2012 Feb;16(1):1-14.
35. Ozoe R, Endo T, Abe R, Shinkai K, Katoh Y. Initial
shear bond strength of orthodontic brackets bonded to bleached
teeth with a self-etching adhesive system. Quintessence Int.
2012 May;43(5):e60-6.
36. Ustdal A, Uysal T, Akdogan G, Kurt G. Effect of 16%
carbamide peroxide bleaching agent on the shear bond strength
of orthodontic brackets. World J Orthod. 2009 Fall;10(3):211-
5.
37. Adanir N, Türkkahraman H, Güngör AY. Effects of
fluorosis and bleaching on shear bond strengths of orthodontic
brackets. Eur J Dent. 2007 Oct;1(4):230-5.
38. Oztaş E, Bağdelen G, Kiliçoğlu H, Ulukapi H, Aydin I.
The effect of enamel bleaching on the shear bond strengths of
metal and ceramic brackets. Eur J Orthod. 2012
Apr;34(2):232-7.
39. Bishara SE, Oonsombat C, Soliman MM, Ajlouni R,
Laffoon JF. The effect of tooth bleaching on the shear bond
strength of orthodontic brackets. Am J Orthod Dentofacial
Orthop. 2005 Dec;128(6):755-60.
40. Bulut H, Turkun M, Kaya AD. Effect of an
antioxidizing agent on the shear bond strength of brackets
bonded to bleached human enamel. Am J Orthod Dentofacial
Orthop. 2006 Feb;129(2):266-72.
41. Aksakalli S, Ileri Z, Yavuz T, Malkoc MA, Ozturk N.
Porcelain laminate veneer conditioning for orthodontic
bonding: SEM-EDX analysis. Lasers Med Sci. 2014 Oct 26.
42. Herion DT, Ferracane JL, Covell DA Jr. Porcelain
surface alterations and refinishing after use of two orthodontic
bonding methods. Angle Orthod. 2010 Jan;80(1):167-74.
43. Yassaei S, Moradi F, Aghili H, Kamran MH. Shear
bond strength of orthodontic brackets bonded to porcelain
following etching with Er:YAG laser versus hydrofluoric acid.
Orthodontics (Chic.). 2013;14(1):e82-7.
44. Bishara SE, Ajlouni R, Oonsombat C, Laffoon J.
Bonding orthodontic brackets to porcelain using different
Bonding in Orthodontics
CHAPTER 8
adhesives/enamel conditioners: a comparative study. World J
Orthod. 2005 Spring;6(1):17-24.

45. Swetha M, Pai VS, Sanjay N, Nandini S. Indirect

versus direct bonding--a shear bond strength comparison: an in
vitro study. J Contemp Dent Pract. 2011 Jul 1;12(4):232-8.

46. Yi GK, Dunn WJ, Taloumis LJ. Shear bond strength

comparison between direct and indirect bonded orthodontic
brackets. Am J Orthod Dentofacial Orthop. 2003
Nov;124(5):577-81.

47. Linn BJ, Berzins DW, Dhuru VB, Bradley TG. A

comparison of bond strength between direct- and indirect-
bonding methods. Angle Orthod. 2006 Mar;76(2):289-94.

202
 CHAPTER
Debonding of orthodontic brackets
9
In this Chapter

Mechanical debonding of orthodontic Debonding by solvents

brackets
Debonding by Notching
Base Method
Ultrasonic debonding
Wing method
Impulse debonding
Mechanical debonding of metal brackets
Thermal Debonding
Debonding plier
Hot instruments Tips
Ligature cutters
Electrothermal debonding
Weingart plier
Laser debonding
Howe plier
Lift-off Debonding Instrument (LODI)
Bracket and adhesive removing plier
Self ligating brackets debonding
Lingual brackets debonding
Mechanical debonding of plastic
brackets
Mechanical debonding of ceramic
brackets

Fixed orthodontic brackets are temporary
appliances which are attached to the teeth for
certain period of time depending upon the
severity of malocclusion and needed to be
removed at the end of treatment. The removal
process is either called debonding or
debracketing. Debonding of orthodontic
brackets is done in clinical practice at two
occasions. First scenario is when position of
bracket is not considered correct and the second
scenario is at the end of orthodontic treatment.
The objective1 of debonding is to remove
orthodontic brackets and adhesive remnants
from the tooth and restore the tooth surface to its
pretreatment condition without causing any

203
Debonding of orthodontic brackets
CHAPTER 9
iatrogenic damage to enamel and tooth
supporting structures. So debonding procedure
in orthodontics can be divided into two steps2.

Step 1: Removal of bracket from the tooth

Step 2: Removal of adhesive remnants from

enamel

In debonding orthodontic brackets from the

tooth the site of bond failure is very important.
A
Bond failure is accessed by adhesive remnant
index (Table & Figure 9.1).Bond failure can be
adhesive and occur between bracket and
adhesive or between enamel and adhesive or it
can be cohesive occurring between the
adhesives cement itself. Though controversial
but bond failure at bracket adhesive interference
is considered more advantageous as there is
little damage to the enamel but more adhesive
needed to be removed from the tooth. If bond
failure occurs at enamel adhesive interference
B
there are more chances of enamel damage but it
also carry the benefit that less adhesive needed
to be removed from the tooth.

It is important to avoid iatrogenic damages to

the tooth during bracket and adhesive remnants
removal as improper debonding results in
cracks on enamel surface and enamel prisms
fracture. Esthetic problems, tooth sensitivity,
increasing risk of caries and pulp necrosis may C
also be seen after improper debonding.

Different methods of deboning orthodontic

brackets are as follow.
Table 9.1 Modified Adhesive remnant index by
Artun3

Score Description
0 All adhesive left on the bracket base
1 More than half of the adhesive left on
the bracket base
2 Less than half of the adhesive left on
the bracket base
3 No adhesive left on the bracket base.
The original index was based on enamel
surface rather than on bracket base.
D
Figure 9.1 A. The entire adhesive remained on the bracket
base so ARI score 0. B. More than half of the adhesive
remained on the bracket base ARI score 1. The picture
contains a plastic bracket. C. Less than half the adhesive left
on the bracket base with ARI score 2. D. No adhesive left on
the bracket base with ARI score 3.
204
 Debonding of orthodontic brackets
1. Mechanical debonding brackets fail to debond then a simultaneous
peel off force is also added. Tensile or pulling
2. Debonding by solvents
and shear or push (upward or downward
3. Debonding by Notching directed) debonding force is not given to
orthodontic brackets in clinical practice.
4. Ultrasonic debonding

5. Impulse debonding

6. Thermal debonding

1. Mechanical debonding of orthodontic

brackets

The most common mean of debonding

orthodontic bracket in clinical practice is by
using debonding pliers. To achieve this goal two
methods are used based upon at which level the
pliers are placed on the bracket during
debonding.

A) Base Method
A
B) Wing method

A. Base Method

In this method the beaks of the plier are

placed at the level of adhesive layer between
the bracket and tooth. Base method of
bracket debonding has three variations.

i. Horizontal or mesiodistal base method

ii. Vertical base method

iii. Diagonal method

B
In horizontal base method the beak of the
pliers are placed mesiodistal at the level of
the adhesive while in vertical base method
the beaks are placed occlusogingival in a
vertical fashion(Figure 9.2).In diagonal base
method the beaks of the plier are placed
distoincisal to mesiogingival or
distogingival to mesioincisal (Figure 9.2 C).
Clinical Notes
c
C
Usually a squeezing force is given to pliers in Figure 9.2 A. Horizontal base method. B. Vertical base
all variations of base method but if the method. C. Diagonal base method.
205
Debonding of orthodontic brackets
CHAPTER 9
In base method of debonding up to 1.5 times
more debonding force4 is required as
compared to wing method. The mechanical
base method of debonding often produce
sudden bond failure5 as heavy forces are
being applied by the plier so there are
chances of injury to the surrounding soft
tissue by the plier beaks. In base method of
debonding the bond failure usually occur
within the adhesive or at the level of enamel
A
adhesive interference. So there are less
chances of bracket distortion and many
debonded brackets can be recycled after this
method.
Clinical Notes
Adhesive layer beneath a properly bonded
bracket usually have a thickness below
0.5mm. So pliers used with base method
should have very thin sharp blades to engage
this layer. A plier with thick blades will cover
greater area of the bracket base and so will B
cause distortion of the bracket (Figure 9.3
&9.4). But no matter how thin the blades of
the plier are, some coverage of bracket base is
inevitable.

Figure 9.4 Bracket base distortion by thick blades of the

plier during different variation of base method. Such
brackets are not suitable for recycling. A. Base distortion on
horizontal base method. B. Base distortion on vertical base
method .C. Base distortion on diagonal base method.

heavy force applied during this method may

Figure 9.3 Two debonding pliers with different blades
width. Ideally for base method a plier with thin sharp blades
should be used. Thick blades will cause distortion of the
bracket base on debonding.
Clinical Notes
In base method of mechanical debonding of
brackets there is risk of enamel damage by tip
and blades of pliers and due to heavy forces
that are generated close to the enamel. Also
cause discomfort for the patient as the teeth
are usually sensitive and show some degree of
mobility at end of orthodontic treatment.
Patient discomfort can be decreased by
placing a gauze pack or cotton roll between
the teeth and asking the patient to bite on it
(Figure 9.5).
In base method of debonding the clinician has
poor grip over the bracket so there are greater
206
 Debonding of orthodontic brackets
chances of bracket to get dislodged in oral debonding has same horizontal, vertical and
cavity. To avoid such problem it is a good diagonal variations like that of base method
practice to squeeze plier with one hand and but horizontal variation is most commonly
keep the thumb and index finger of the other used (Figure 9.7).
hand over back side of plier head to prevent
accidental dislodging of the bracket and avoid
soft tissue damage on sudden debonding.
(Figure 9.6).
Horizontal base method should be preferred
with brackets having hook as it will limit
proper instrument placement in diagonal and
vertical base method.

Figure 9.5 A gauze pack between teeth to avoid

discomfort during debonding.

Figure 9.6 Fingers placed over the plier in base method of

debonding to control the amount of force and preventing
bracket dislodging in the oral cavity and soft tissue injury by
pliers beaks. Care should be taken that finger should be at
sufficient distance from the blades of the pliers otherwise
injury to the fingers can occur. C
Figure 9.7 A . Horizontal wing method . B Vertical
B. Wing Method wing method. C . Diagonal wing method.

Wing method of debonding is similar to base
method of debonding with the only
difference is that the beaks or blades of the
pliers are placed at the level of bracket wings
rather than at the base level. Wing method of
207
Wing method is usually reserved for metal
and plastic brackets and is usually not
suitable for ceramic brackets as it will cause
wing fracture of the ceramic brackets. Two
types of forces can be applied to metal
Debonding of orthodontic brackets
CHAPTER 9
brackets by wing method.
If vertical wing method is used with these
1. Squeezing force types of brackets then both type of forces can
be used depending upon whether the plier
2. Subsequent squeezing and peel off force blades are placed above the level of slot base
or below it.
Squeezing force will peel off the bracket at
its both ends depending on which variation In canine and posterior brackets horizontal
of wing method is used. For example a wing method is preferred as hook of the
horizontal wing method used with squeezing bracket interfere with pliers in diagonal and
force will peel off the bracket at both mesial vertical wing methods.
and distal ends. In bracket debonding by
subsequent squeezing and peel off force, an
initial squeezing force is given to get proper
grip of bracket and then a peel off is given by
rotation movement of the wrist to lift the
bracket at its one end. Less force is required
to debond a bracket by squeezing force only.
In wing method, the bond failure usually A
occurs at the level of bracket adhesive
interference.

Clinical Notes
In wing method of debonding the type of force
given is related with type of plier and bracket
used (Figure 9.8). Pliers with broad tip are
usually reserved for subsequent squeezing
and peel off force. As these pliers also cover
some part of the stem of the bracket a
squeezing force alone usually don't results in
debonding of the brackets. Example of these
pliers includes Weingart and Howe pliers. A
debonding plier with thin blades can be used
both with squeezing only or subsequent
squeezing and peel off force depending upon
at which level the plier is placed. If the plier is
placed above the level of slot base then a
squeezing force only is sufficient to debond
the bracket but if the beaks of the plier is
placed below the slot base then a subsequent
squeezing and peel off force is necessary. This
is true for all variations of wing method with
Siamese or twin brackets. But in case of single
bracket and semi twin brackets a subsequent
squeezing and peel off force is the only option
if horizontal or diagonal wing method is used.
B
Figure 9.8 A. A debonding plier with thin blades. These
pliers though can be placed both above and below the slot
base level but placing them above the slot base is preferred
method. A squeezing force only is sufficient with these pliers
to debond the bracket. B. A Howe plier. As the pliers have
broad blades so they cover some part of the bracket stem for
proper grip. A subsequent squeezing and peel of force is
given with these pliers.
In wing method of debonding, higher the
plier is placed over the bracket greater would
be the chances of slot distortion. A squeezing
force only used with wing method of
debonding will result in distortion of the
bracket slot in almost all the instance (Figure
9.9).
Clinical Notes
In wing method if recycling is intended it is a
good practice to keep a slot keeper or a full
dimension wire in the slot and use vertical
208
 Debonding of orthodontic brackets
wing method with subsequent squeezing and clinician wants to avoid patient discomfort
peel off force. by applying minimum debonding force and
when recycling of bracket is not the
intention.
Base method can be used with all types of
brackets but wing method should be avoided
with ceramic brackets. Manufacturing
process of the brackets also affect their
debonding choice especially with wing
method. Bracket manufactured by
conventional methods having different
A hardness of slot/wing and base components
are easily debonded by wing method if good
brazing and welding procedure is used. But
in brackets manufactured by MIM process,
all parts of the bracket have same hardness
so using a wing method with squeezing only
force will distort the slot without debonding
the bracket in most of the instance. So either
subsequent squeezing and peel off force
should be used with MIM brackets in wing
method or a base method should be
B preferred.
In case of gingival hyperplasia wing method
of debonding is usually used. Wing method
of debonding is also a preferred choice with
brackets bonded on metal or porcelain
structures.
In patients with weak enamel structures like
cracked teeth, restored teeth, amelogenesis
C or dentinogenesis imperfecta a wing method
should be preferred over the base method as
Figure 9.9 Bracket wing distortion by A. Horizontal there are more forces applied and more
wing method. B. Vertical wing method. C. Diagonal wing chances of enamel damage in the later
method.
method.

Selection of mechanical debonding Mechanical debonding of metal brackets

method
The most atraumatic method of orthodontic
Base method is a preferred method during
metal bracket removal is to peel them off from
early and middle stages of treatment when
the tooth and cause bond failure at the bracket
debonded brackets can be recycled and
adhesive interference.
reused on the same patient. Wing method is
usually used at end of treatment when Many types of pliers are being used in
209
Debonding of orthodontic brackets
contemporary orthodontics to debond metal
brackets. Almost all manufacturers make their
own pliers and also have advertised some
special pliers for debonding brackets. These
pliers have their own benefits and limits. It is
not possible to explain details of all the pliers
but some of the most commonly used methods
are discussed below.
Bracket removing plier or Debonding plier
This is one of the most commonly used pliers to
debond orthodontic brackets (Figure 9.10).
Both base and wing methods with all their
variations can be used with this plier depending
on clinician desire of final outcome.
Figure 9.10 A debonding plier. The plier can be used with
both base and wing method.
Advantages
1. Wing method of debonding by using
CHAPTER 9
debonding plier may leave more adhesive
remnants on the enamel but is least harmful
for the enamel. Enamel damage was found
only 4 % with these pliers6.
2. Debonding plier can be used with both
base and wing method of debonding.
Disadvantages
Debonding pliers cannot be used with wire in
place in horizontal wing method.
Ligature cutters/Side Cutters
Ligature cutters or side cutters are used to
debond orthodontic brackets by only base
method of debonding (Figure 9.12). All the
variation of base methods can be used with
ligature cutters.
Advantages
1. Ligature cutter is a routine part of the
dental office so orthodontists don't have to
bear extra cost to buy a new instrument.
2. Debonding occurs in less than a second so
Clinical Notes
Some clinicians prefer a debonding plier in
which beaks of the plier remain 2-3 mm apart
on full closure of the plier (Figure 9.11). It is
believed that these pliers prevent base
distortion on base method and also are less
destructive for the enamel. But larger the gap
between the beaks of the plier, greater would
be their chances of ineffectiveness during
wing method.
Figure 9.11 Debonding plier with 2 mm gap between
the beaks on full closure.
210
 Debonding of orthodontic brackets
Figure 9.12. Ligature wire cutter used with different methods of bracket removal.

it is a time efficient method.

3. Ligature cutters can debond the bracket

even if the wire is within the slot.

Disadvantage

The main disadvantages of this method are:

1. There are greater chances of soft tissue

injury with sharp beaks of ligature cutters.

2. As heavy forces are transmitted at bracket A

adhesive interference there is greater risk of
enamel damage.

3. Debonding brackets by ligature cutter is

not advocated 6 if other methods of
debonding are available.

Clinical notes
Many clinicians use straight wire cutter with
base method of debonding. The blades of
straight wire cutter are thicker than ligature
cutter so there are greater chances of bracket
base distortion (Figure 9.13).
211
B
Figure 9.13 A. Ligature cutter used with vertical base
method. B. Straight wire cutter used instead of ligature cutter
with vertical base method. The blades of the straight wire
cutter are thick so using it will result in distortion of the
bracket base.
Debonding of orthodontic brackets
Weingart plier
Weingart plier is used only with the wing
method of debonding. Beaks of Weingart plier
are wider than debonding plier so when
gripping the wings of the bracket some area of
bracket stem is also covered by the plier.
Greater force is required to debond bracket by
Weingart plier as compared to debonding plier
(Figure 9.14). Effort should be made holding
plier high on the bracket without compromising
the grip of the plier.
Clinical notes
In debonding brackets with Weingart plier
subsequent squeezing and peel off force is
given. All variations of wing method can be
used with Weingart plier but horizontal wing
method is most preferred method with this
plier. As more force is required to debond
brackets with Weingart plier so this plier is
second to debonding plier.
Figure 9.14 A Weingart plier used with wing method
of debonding.
CHAPTER 9
Howe plier
Howe plier is also used with wing method of
mechanical debonding (Figure 9.15). Owing to
broader tip of Howe plier debonding forces are
evenly distributed throughout the bracket and
there are less chances of enamel damage7. But
more debonding forces are applied with Howe
plier as compared to debonding plier so
debonding plier is recommended over Howe
plier. Also Howe pliers are not routine
instrument used in dental office.
Figure 9.15 Howe plier used with wing method of
debonding. Horizontal wing method is most compatible
with Howe plier.
Lift-off Debonding Instrument (LODI)
Lift off debonding instrument or LODI is a
pistol grip debonding instrument in which a
wire loop is used to engage the bracket wings
(Figure 9.16).To debond a bracket instrument is
placed over the bracket and one of the bracket
wing is engaged in the wire loop of the plier.
Then trigger is lightly squeezed until both the
beaks of instrument rest evenly on the tooth
surface. After proper seating of plier the trigger
is squeezed slightly harder until the bracket is
lifted from the tooth surface. By squeezing the
trigger of the plier a tension force is delivered to
the brackets wing hooked in the wire loop and
bracket is debonded (Figure 9.17).
212
 Debonding of orthodontic brackets
wire in the slot would help to maintain the slot
dimensions and bracket can be recycled in
future if required.

Advantages

The advantages of LODI are:

1. LODI doesn't cause bracket base

distortion8. So it can be used as an
alternative for debonding pliers9.

2. Less force is required10 for debonding

Figure 9.16 A lift off debonding instrument with its wire
loop. The wire loop is used to engage the wings of the plier.
For debonding miniature and full size brackets separate wire
loops are available.
when tension is applied by LODI as
compared to conventional debonding plier.
3. With lift off debonding instrument patient
experience less pain11 as compared to
debonding with side cutters.

4. Brackets can be recycled6 and reused after

debonding if wire is left in place or a slot
keeper is used.

Disadvantages

Some of disadvantages associated with lift off

debonding plier are:

1. LODI bracket removal technique is

associated with ceramic damage12 while
debonding brackets on ceramic veneers.

2. Wing damage of bracket may occur if the

wings are brazed to the bracket body. So
ideally use metal injection molded brackets
to debond with these pliers.

3. Wire loop may break during debonding so

Figure 9.17 Bracket debonding by LODI. The bracket is
debonded by a tension force. it is needed to be replaced periodically.

4. LODI is not routine part of dental office.

Clinical Notes
Lift off debonding instrument can be used in
two ways either the archwire may be left in situ
or the slot keeper which is a 0.018x0.022 inch Clinical notes
wire embedded in a plastic handle may be LODI is effective in bracket debonding7 but as
placed in the bracket slot after the working arch tension force is involved there are greater
wire removal. In either case, the presence of a
chances of enamel damage6.
213
Debonding of orthodontic brackets
CHAPTER 9
Bracket and adhesive removing plier

Bracket and adhesive removing pliers are used

like a band removing plier (Figure 9.18). One
end of the plier which contains a plastic head
(Teflon pad) is placed over the incisal or
occlusal part of tooth and the other metal end of
the plier grip the bracket from the gingival side
close to bracket adhesive interference. Giving
squeezing force to the plier delivers a shear
force to the bracket. The same plier can be used
for adhesive remnants removal on the tooth Figure 9.19 A debonding plier specially made for self-
after debonding. ligating brackets.

on all brackets for easy ligation. These hooks

Figure 9.18 A adhesive removing plier.
Clinical Notes
Adhesive removing plier delivers a shear
force to the tooth so there are greater
chances of enamel damage. Also more force
is needed to debond a bracket so this
technique is more painful for the patient.
interfere with both vertical wing and base
method and make diagonal base and wing
method almost impossible to execute. Another
difference between labial and lingual brackets
is larger bracket base area and smaller slot area
of lingual brackets thus providing a smaller
lever arm to peel off bracket by wing method of
debonding (Figure 9.20). Also lingual brackets
have single slot or these are in semi twin design.
So squeezing the brackets by horizontal wing
method don't work.

Self ligating brackets debonding

Self-ligating brackets can also be debonded by

conventional method. Ideally the self ligating
clip of the bracket should be open while
debonding the bracket. Usually base method is
preferred if self-ligating brackets needed to be
recycled. Some manufacturers recommend
special pliers for debonding their self ligating
brackets (Figure 9.19).

Lingual brackets debonding

Lingual brackets have different shape from
labial brackets so the same general principle of
debonding cannot be applied to these brackets.
In lingual brackets gingival hooks are present
Figure 9.20 A lingual bracket on which vertical wing
debonding method with squeezing force was used .As slot of
bracket is much smaller than base so a smaller lever arm
was provided by the slot resulting in distortion of the slot
without debonding of the bracket.
214
 Debonding of orthodontic brackets
To debond lingual brackets horizontal wing debond anterior lingual brackets modified
method with subsequent squeezing and peel pliers are available in the market (Figure 9.23).
off force is used (Figure 9.21). On molar teeth
only a horizontal wing method with squeezing
force alone will debond the brackets as lingual
molar brackets are similar to labial brackets.

Figure 9.21 Horizontal wing method. Subsequent

squeezing and peel off force is used.

Horizontal base method works fine on lingual

brackets on buccal segment teeth. But the most
preferred method with lingual brackets in both
anterior and posterior segment in upper and
Figure 9.23 Various pliers used for debonding lingual
lower arch is using a combination of vertical brackets. As it's difficult to grip anterior lingual brackets
base and wing method (Figure 9.22). On the with conventional labial debonding pliers so special
lingual debonding pliers are available commercially.
incisal side the plier engages the bracket base
and on the gingival side the plier engages the Clinical notes
bracket hook. The bracket is peeled off from
If recycling of lingual brackets is intended then
the gingival side by rotation movement of the
horizontal wing method should be used with
wrist.
subsequent squeezing and peel off force.

Selection of mechanical debonding

Figure 9.22 Combination of wing and base method for
debonding lingual brackets .The bracket is peeled from the
gingival side.
Usually a debonding plier is used for lingual
brackets with both base and wing method. To
215
method for metal brackets.
Bracket removing plier is usually a preferred
instrument for debonding conventional and
self-ligating bracket as it can be used with
both base and wing method. For lingual
brackets in lower arch conventional
debonding plier can be used but for
maxillary anterior lingual brackets special
debonding pliers usually made by
manufacturer of brackets are recommended.
Debonding of orthodontic brackets
Mechanical debonding of plastic brackets
Plastic brackets can be debonded with both base
and wing method but base method is preferred
(Figure 9.24 & 9.25). As plastic brackets exhibit
bending distortion on debonding they can easily
be peeled off from the tooth with bond failure
occurring at bracket adhesive interference.
There is little danger of enamel damage on
debonding the brackets as plastic brackets are
associated with less bond strength than metal
and ceramic brackets. But care should be taken
not to damage enamel in base method by beaks
of the pliers.
Figure 9.24 Base method of debonding. Base method is
most preferred method in plastic brackets.
CHAPTER 9
Fig 9.25 Plastic bracket deboned with wing method.
Wing method is a less preferred method with plastic brackets
Clinical Notes
In wing method of debonding plastic brackets
horizontal wing method is preferred. Vertical or
diagonal wing method usually results in
distortion of the bracket slot without debonding
the bracket with both squeezing and peel off of
force (Figure 9.26). In horizontal wing method
a subsequent squeezing and peel off force is
given. A squeezing force alone usually results
in distortion of the slot in horizontal wing
method. Using horizontal wing method with
squeezing force only on plastic brackets with
metal slot usually results in detachment of slot
from main bracket body (Figure 9.27).
On debonding composite plastic brackets
special care should be taken as some of them
show odd behavior on debonding especially
ceramic reinforced plastic brackets (Figure
9.28). Ceramic reinforced plastic brackets
should be debonded by base method of
debonding.
216
 Debonding of orthodontic brackets
A

Figure 9.28 Ceramic reinforced plastic brackets. Using

wing method will cause bracket fracture similar to ceramic
B brackets. A base method should be used with theses brackets.

Figure 9.26 Bracket distortion with A. Vertical wing
method. B. Diagonal wing method.
Selection of mechanical debonding
technique for plastic brackets
For plastic brackets ideally base method of
debonding should be used. Both debonding
plier and ligature wire cutter can be used to
debond the bracket by base method.

Mechanical debonding of ceramic brackets

Mechanical debonding techniques have also

been used with ceramic brackets. As most fixed
appliance cases in orthodontic practice are done
with metal brackets so orthodontist use their
instinct mechanical debonding techniques of
metal brackets to ceramic brackets which result
in either bracket fracture or enamel damage.
The reason behind this is that orthodontist
failed to appreciate two main differences
between ceramics and metal brackets. These
are:

1) Bond strength
Figure 9.27 Using horizontal wing method on plastic
brackets with metal slots usually results in detachment of
2) Physical properties
metal slot from the main bracket body.
217

The tensile strength of enamel is 14.5 MPa 13
Debonding of orthodontic brackets
and it has been reported that enamel fracture
can occur at bracket bond strength of 13.5 MPa
14
. To save enamel fracture during debonding
clinical acceptable bond strength shouldn't
exceed 13.5 MPa. The minimum bond strength
to withstand orthodontic and masticatory forces
is recommended between 6 to 8 MPa 15 for all
types of brackets.
The bond strength of ceramic brackets whether
it is in chemical or mechanical retention base is
almost always greater than metal brackets and
is usually greater than 13.5 MPa. Theoretically
any bracket that has bond strength greater than
13.5 MPa should always fracture the enamel.
But it is not true for metal brackets which if
even have bond strength greater than 13.5 MPa
don't fracture the enamel. The difference comes
in physical properties of the brackets and the
type of force we give during debonding.
In terms of physical properties, ceramics are
third hardest material known to humans in
which strong ionic and covalent bonds are
present to hold the atoms 16, 17. These bonds are
directional and don't allow slip planes. In
contrast stainless steel is softer than ceramic
and has metallic bonds which allow slip planes.
To avoid enamel damage peel off forces are
given to orthodontic brackets instead of tensile
forces. These peel off forces when given to
stainless steel brackets result in distortion or
elongation of the metal due to presence of slip
planes and stresses are redistributed and
relieved. Distortion of stainless steel brackets
also causes cohesive failure within the adhesive
or adhesive failure at the bracket adhesive
interference. But unfortunately these peels off
forces cannot be given to ceramic brackets as
the elongation of ceramic brackets before
failure is only 1% as compared to stainless steel
brackets which elongate 20 % before failure 17.
So when same peel off debonding forces are
applied to ceramic brackets, redistribution and
CHAPTER 9
relieve of stress doesn't occur due to lack of slip
planes and strong interatomic bonding. If these
forces are applied at thin sections of ceramic
brackets like bracket wings or if bracket has
some inner fault lines due impurities or
preexisting cracks, fracture of bracket will
occur. But if these deboning forces are applied
at thick section of brackets like bracket base,
stresses are transferred to adhesive cement. In
case of ceramic brackets especially with
chemical retention base, bond between
adhesive and bracket is strong and lack of
bracket distortion don't cause bond failure at
bracket adhesive interference. So debonding
forces are eventually transferred to enamel and
causes its fracture.
Debonding methods
Before debonding any ceramic bracket by
mechanical means always remove flash around
the bracket base with a carbide bur on slow or
high speed handpiece using a water coolant.
This will allow easy grip of the plier in base
method of debonding and also help decrease
bond strength of the bracket. Ceramic brackets
being brittle can easily fracture and can
dislodge in oral cavity of patient or fragments of
bracket can fly and may enter the eyes. A gauze
pack or cotton roll is also placed in the patient
mouth during mechanical debonding of the
bracket to prevent dislodgment of the bracket in
the oral cavity and decreased the pain on
sensitive teeth. Protective dental glasses should
be used by the dentist and his assistant (Figure
9.29). Protective glasses can also be given to the
patient or at least he is requested to close his
eyes during debonding procedure.
Figure 9.29 Protective Dental glasses
218

For mechanical debonding of ceramic brackets
the best available option to debond the bracket
is follow manufacturer recommendations. This
saves the clinician from any legal issue in case
some iatrogenic damage occurs. Many
Debonding of orthodontic brackets
manufacturers recommend their special pliers
(Figure 9.30) or a specific debonding technique
for their manufactured brackets. Some ceramic
brackets have collapsible base and debonded
with wing method (Figure 9.31).

A B C
Figure 9.30 Various debonding pliers used with only a specific type of ceramic brackets. A. Transcend series 6000 debonding
plier by 3 M Unitek. B. Orthoclassic debonding plier to debond their version of ceramic brackets. C. Forestadent debonding plier.
Omrco nexsus system also uses this plier. As the plier fully enclosed the bracket thus decreasing the likelihood of flying
debris on bracket fracture.

A B C

D E

Figure 9.31 A &B. Clarity advance ceramic brackets with a collapsible base. The manufacturer recommends debonding this
bracket with horizontal wing method using Howe or Weingart plier. Bond failure occurs similar to metal brackets 18 C&D. Clarity
brackets with metal lined slot. Vertical slot and a collapsible base are added to bracket to aid easy debonding of brackets on
horizontal wing method with Howe or Weingart pliers. E. Special pliers are also available from manufacturer to debond Clarity
metal lined brackets. continued...
219
Debonding of orthodontic brackets
CHAPTER 9

B
F
Figure 9.32 Ceramic bracket debonded with A. Vertical
Figure 9.31 F. Bracket with chemical retention and base method. B. Horizontal base method.
collapsible base. Vertical wing method is recommended to
debond this bracket. Collapsible base brackets though
cannot be recycled and reused but are safest in terms of
debonding characteristics.

When manufacturer recommendations are not

present then usually a base method of
debonding should be applied (Figure 9.32). All
variations of base method can be employed
with ceramic brackets. Swartz 17 recommended
that for debonding chemical retention ceramic
Figure 9.33 A polycrystalline bracket fragments. Bracket
brackets, base method of debonding with was fractured after debonding with horizontal wing method
squeeze only force can be used so that bond with a debonding plier
failure occur within the adhesive and for
debonding mechanical ceramic bases slow
peeling force should be applied at bracket base.
Ceramic brackets with plastic bases can be
debonded with base method with subsequent
squeezing and peel off force. These brackets
will debond similar to metal bracket without
causing enamel damage. Wing method should
be avoided with ceramic brackets as it will
cause bracket fracture (Figure 9.33). If proper
debonding technique is not followed there are
Figure 9.34 Enamel damage caused by debonding the
greater risks of enamel damage (Figure 9.34). bracket with a peel off force using a Weingart plier with
horizontal wing method.

Clinical Notes
If proper debonding techniques fails or risk of
enamel damage is great due to nonvital teeth,
enamel cracks, enamel hypoplasia or if the
patient teeth are sensitive, grinding of ceramic
brackets is the only option.
A
220
 Debonding of orthodontic brackets
Before attempting to grind a ceramic bracket
protective glasses should be taken by the
operator and his assistant. Patient can also be
given protective glasses or asked to keep his
eyes shut while the ceramic bracket is being
grinded. Grinding of ceramic bracket produce
ceramic dust which has been associated with
skin and eye irritation 20.
Grinding of ceramic brackets is usually done
with high speed diamond burs or low speed
green stones with water coolant. This process is
Figure 9.36 A debonding plier with replaceable tips.
time consuming. To save time wings of the
brackets can be cut with ligature cutter and then Advantages
main body of ceramic bracket is grinded
(Figure 9.35). The advantages of mechanical debonding of
ceramic brackets are:

1. Time efficient

2. Most debonding pliers are normal

armamentarium of orthodontic office.

Disadvantages

The disadvantages associated with mechanical

debonding of ceramic brackets are:

1. Brittleness may cause problems such as

Figure 9.35 Grinding of ceramic bracket done as bracket
wings fractured during debonding. Its best to break the
remaining bracket wings by ligature cutters and grind the
remaining bracket base.
Clinical notes
For debonding ceramic brackets with
conventional pliers it is recommended 19 that
sharp edge plier with narrow blades are
preferred over wide dull blades. Narrow blades
have less contact area and generate less force.
For debonding brackets all that is needed is to
cause fracture in the brittle adhesive. As
ceramic brackets are harder than stainless steel
so debonding of the brackets cause wear of the
instrument. Debonding pliers with replaceable
tips are usually used (Figure 9.36).
221
breakage of bracket during mechanical
debonding.
2. Aspiration of fragments if bracket is
fractured or failed. As ceramic brackets are
radiolucent it is almost impossible to locate
them if aspirated.
3. Injury by the flying debris to patient oral
mucosa or clinician eyes on bracket fracture.
4. Portion of broken bracket need to be
grounded with high speed handpiece thus
increasing the debonding time.
5. The probability of enamel damage is
greater if the integrity of tooth structure is
already compromised by presence of
developmental defects, enamel cracks, large
restorations and nonvital teeth.
Debonding of orthodontic brackets
6. More time is required to debond ceramic
brackets mechanically as compared to metal
brackets as extra time is required to remove
flash either with burs or with the debonding
instruments.
7. Extra cost is involved to buy the
manufacturer recommended special
instruments, protective goggles and to replace
tips of pliers.
Clinical Notes 1
Enamel fracture or cracks can occur with
ceramic brackets debonding. This can due to:
1. Poor selection of cases.
Non-vital teeth, teeth with enamel cracks,
large restoration, hypoplastic and
hypocalcified teeth shouldn't be bonded
with ceramic brackets 21,22.
2. Improper debonding technique
This happen if clinician fails to follow
manufacturer recommended methods or
apply wing method of debonding on
ceramic brackets with non-collapsible
base. Rotation or tensile forces increases
chances of enamel fracture. Debonding
brackets from small teeth (mandibular
incisor) pose more risk and extra care
should be used while debonding on such
teeth.
3. Increased bond strength
Increased bond strength is associated with
ceramic brackets having chemical
retention bases or if the clinician uses a
highly filled adhesives. Ceramic brackets
with chemical retention bases should be
avoided in clinical practice.
Clinical Notes 2
Pain during mechanical debonding of
ceramic brackets is related to high bond
CHAPTER 9
strength, debonding brackets after doing
aggressive tooth movement (especially
doing pure tipping movement on light
rectangular wires) and pain threshold of the
patient.
Pain can be avoided during debonding by
asking the patient to bite on cotton or gauze
pack. Gauze or cotton pack will also help to
stop swallowing or aspiration of ceramic
bracket.
Ideally in patient having low pain threshold
and mobile teeth, mechanical debonding
methods and ultrasonic debonding technique
should be avoided. Using thermal, laser and
solvent debonding techniques are an
optimum solution.
Debonding by solvents
Various composite softening agents are used in
dentistry such as 75% ethanol, polyacrylic acid,
acetone , acetic acid and peppermint oil. These
softening agents have also been used in
orthodontics as debonding agent for ceramic
brackets.
In orthodontics to aid mechanical debonding
of ceramic brackets debonding agents usually
used are derivatives of peppermint oil. The
debonding agent can be applied at bracket base
and left around the base of the bracket for 60
seconds to 2 minutes to facilitate debonding.
The bracket is then debonded by mechanical
method. Application of debonding agent
facilitates bond failure at the adhesive enamel
interference without damaging the enamel 20,23.
The most commonly used debonding agent is
post-debonding agent by GAC, International,
Inc. However, a similar agent P-de-A, Oradent
Ltd. was not found to be very effective 24, 25 in
facilitating easy debonding.
222

Debonding by Notching
Notching of composite resin is done to aid easy
mechanical debonding of ceramic brackets.
Notching can be done at the time of bonding
orthodontic brackets or at the time of bracket
debonding.
Debonding of orthodontic brackets
easy and firm grip of debonding pliers or side
cutters during debonding. As there are greater
chances of enamel damage associated with this
method, so this method has been abandoned in
clinical settings (Figure 9.38).

Notching at time of bracket bonding

This method is used only in an experimental

study25 and has practical limitations so it not a
recommended method in clinical practice
(Figure 9.37).

Figure 9.37 Notched bracket and matrix strips. Notching

is done by placing matrix strip at time of bonding between
the enamel and bracket. Both enamel and bracket has a thin
coating of adhesive when the strip is placed. After curing of
adhesive the strip is removed thus leaving a notch below the
bonded bracket.
C
Notching at the time of bracket debonding
Figure 9.38 A. Purchase point created on occlusal side to
Notching at the time of debonding is done with facilitate grip of the plier in base method. B. Enamel surface
after debonding. Using a high speed handpiece to create
the help of a fissure bur during the process of purchase area will result in enamel damage. A groove is
flash removal. Nothing is done both at incisor visible in the enamel on the occlusal side. C. A damaged
bracket. There are greater chances of bracket damage by the
and gingival ends of bracket. Notching helps in bur in this method.

223
Debonding of orthodontic brackets
Ultrasonic debonding
Conventional mechanical debonding
techniques for ceramic brackets recommended
by manufacturers are associated with 10-35 %
of brackets fracture 26. To avoid ceramic
brackets fracture during debonding use of
ultrasonic devices have been advocated.
Ultrasonic devices can also be used to debond
metal and plastic brackets.
How it works
In ultrasonic method, ultrasonic scalers are used
to debond orthodontic brackets. The scaling tip
vibrates in the ultrasonic range of 18-50 kHz i.e.
18000 to 50000 times per second, with an
optimum frequency between 18 kHz to
32kHz.The scaler tip vibrates in a linear or
elliptical fashion depending upon the type of
ultrasonic scaler used. Vibrating metal tip
erodes adhesive and creates a purchase point 27
underneath the bracket base. Ultrasonic tip can
cause cohesive bond failure within the adhesive
or bond failure occurs at enamel adhesive
interference. So bracket damage is avoided.
Choice of Ultrasonic Scalers
CHAPTER 9
only magnetostrictive scalers with special tips
have been used to debond ceramic brackets but
in some case reports in non-index journals
piezoelectric scalers have also been used. Also
piezoelectric scalers can work at greater
frequency than magnetostrictive scalers and the
final enamel surface is also smooth 29.
In magnetostrictive scalers usually 30 KHz
scalers are preferred over 25 KHz scalers as
they are less noisy and of course have a greater
vibration speed.
Choice of the scaler tip
In literature 27, 28 ultrasonic scalers with
specialized tips (KJS, KJC) have been used for
debonding ceramic brackets. Contrary to
conventional ultrasonic tips which are curved
these tips are straight and are sharp at working
end. In clinical practice if debonding by
ultrasonic scalers is intended then the tips used
for interdental area are best suited for
debonding because they have a narrow and
pointed working end which make it easy to
create a purchase point under the bracket
(Figure 9.40).

Two different types of ultrasonic scalers are

commercially available. These are
piezoelectric and magnetostrictive scalers
(figure 9.39). The difference between them is
how they generate energy for vibration or
oscillation of their tips. The vibration pattern of
the tip between these two types of scalers is also
different. Piezoelectric scaler tip vibrate in a
linear back and forth fashion while
magnetostrictive tip can vibrate in long ellipse
or rotatory fashion depending upon its further
subdivisions. In terms of clinical significance
the difference in vibration pattern result in
generation of different cavitation bubbles
which might matters in periodontal health but
not for orthodontic bracket removal. So
theoretically both these types of scalers can be
used for bracket debonding. In literature 27, 28 Figure 9.39 A magnetostrictive and piezoelectric scaler
224
 Debonding of orthodontic brackets
bracket and the enamel to break the bond and
facilitate bracket removal.

Debonding time

Debonding time by ultrasonic scaler reported in

literature 26, 28, 30 ranges between 16.6 to 50
seconds.

Advantages

Using ultrasonic debonding has the following

advantages:

1. No bracket fracture occurs while using

Figure 9.40 Different scaler tip used to debond ceramic
brackets.
ultrasonic debonding.

2. Site of bond failure is at enamel adhesive

interference but decrease enamel fracture as
debonding force is lower 27,30. Site of bond
failure is also influenced by type of cement
used for bonding.

3. The same ultrasonic tips can be used to

remove adhesive remnants on enamel.

Disadvantages

1. More time is required26, 27 to debond

bracket as compared to mechanical and
thermal debonding.
Figure 9.41 A scaler tip engaged underneath bracket to
cause fatigue failure of bracket. 2. Vibration of ultrasonic tip used for
debonding is uncomfortable for the patient
Method of Ultrasonic debonding
as moderate forces are applied.
1. Remove composite flash around the
3. Wear of ultrasonic tip as the ceramic
bracket periphery before debonding ideally
brackets are harder than stainless steel tip.
with a slow speed 12 fluted carbide bur using
Scaler tip get blunt with time and needed to
a water coolant.
be replaced so it is not cost effective (Figure
2. Create a 0.5 to 1mm purchase point 27 9.42).
under the bracket by moving the scaler tip in
4. Soft tissue injury can occur as sudden
the mesiodistal direction (Figure 9.41).The
debonding of bracket occurs.
tip is directed towards the bracket to
prevent damage to the enamel. 5. The need for water sprays to avoid heat
buildup which may cause enamel or pulp
3. A rocking or pushing force is then applied
damage.
on the bracket by engaging the vibrating
scaler tip in the purchase point between the 6. Enamel damage can occur during creation
225
Debonding of orthodontic brackets
CHAPTER 9
of purchase point. recycled and reused. Impulse debonding
shouldn't be used with ceramic brackets as it
7. The bracket can dislodge in oral cavity as it is will cause bracket fracture.
not gripped during debonding procedure.
How it works

The theory behind impulse debonding is to

give a sudden impact shear type force to the
bracket base that is strong enough to debond the
bracket. The idea has been inspired from crown
removal in prosthodontics.

Figure 9.42 Wear of scaler tip by debonding of ceramic

Device
brackets.
Air pressure pulse device used in the studies31
for debonding metal brackets is Corona Flex by
Clinical notes
Kavo (Figure 9.43). A traditional crown
Sharp pointed tips should be used. Ideally remover can also be used (Figure 9.44).
select tips which are used to remove hard
calculus in interdental area. Always direct the
instrument toward the bracket and apply
moderate force on the scaler handle.

Selection of ultrasonic method

As ultrasonic debonding is not cost effective
and is time consuming so it is clinically
Figure 9.43 Air pulse device recommended in
useful when fractured bracket is needed to experimental studies for metal bracket removal. The knob on
be debonded. Instead of grinding the back control the amount of force and trigger button at front
is used to initiate the debonding process. It usually takes
bracket ultrasonic scaler can be used less than a second to debond a bracket by this method.
because it has fewer chances to cause
iatrogenic damage and leaves a smoother
enamel surface26 than a high speed
handpiece. It is a personal finding that
ultrasonic debonding is more successful
with weak adhesive such as low filled
composites and GIC.
Ultrasonic scalers are usually not used with
metal brackets because of other better
options available. In metal bracket
ultrasonic scalers can be used in cases of
amelogenesis and dentinogenesis imperfect.

Impulse debonding

Impulse debonding have been proposed 6, 31 to

debond metal brackets without distorting their Figure 9.44 A traditional crown removing plier used for
bracket removing. Bond failure occurs at bracket adhesive
base and slot characteristics so that they can be interference.
226

Clinical Notes
These appliances give a sudden shear type of
force with no control over the brackets so
brackets usually fly out of the oral cavity. To
gain better control over bracket during
debonding usually a finger is placed over the
bracket (Figure 9.45).
Debonding of orthodontic brackets
Selection of impulse debonding
Impulse debonding has bond failure at
bracket adhesive interference so it can safely
be used for debonding of metal brackets if
bracket recycling is intended. But this
technique is more painful for the patient than
wing and base method of mechanical
debonding. Extra time is required to remove
flash around the brackets with carbide burs.
So this technique should be used only when
mechanical debonding technique is not
available. This technique should be avoided
in mobile or sensitive teeth as greater
amount of debonding force is required.

Figure 9.45 As an upward shear force is applied with
this type of debonding and the bracket fly in upward
direction so it is better to keep finger over the bracket.
Clinical Notes
In impulse debonding more force is applied
than mechanical debonding of brackets. The
amount of force is greater from the impact
side where the instrument toggle is applied so
it is better to remove flash from that side
(Figure 9.46).
Thermal Debonding
As ultrasonic debonding is associated with
increase time and cost thermal debonding is
used as a time efficient and safe way to debond
brackets. Because of the potential risk of
iatrogenic damage associated with ceramic
brackets debonding, thermal debonding is
usually reserved for these brackets. Metal
brackets can also be debonded by this method
but mechanical debonding is preferred for these
brackets .Thermal debonding is contraindicated
for plastic brackets.

Principles of Thermal debonding

Thermal debonding of orthodontic brackets is

Figure 9.46
Instrument was engaged
from incisor side without
removing the flash.
Failure to remove flash
on the impact side
usually result in some
flash being attached on
the bracket thus
increasing chances of
enamel damage.
based on the principle of application of heat.
Polymers have a glass transition temperature
range 32 in which their physical properties can
change from rigid solids to viscous liquid. So
heating the polymer based composite materials
result in change in their structural properties
because when heat is applied van der Waals
forces that hold the polymers together are
weaken by vibration of polymer chains which
gain kinetic energy due to high temperature.
The glass transition temperature 33 of Bis-
GMA/HEMA composite resins is around 103

227
Debonding of orthodontic brackets
°C -159 °C depending upon the photoinitiator
used and the water contents. So when Bis-
GMA/ HEMA composite resins are heated
above this temperature the solid cement
become a viscous liquid 34.
For successful debonding, iatrogenic damages
to tooth structures should be avoided.
Effects of Thermal debonding on Enamel
Thermal debonding of orthodontic brackets can
damage tooth enamel directly or indirectly.
Direct damage can occur either by contact of
hot instrument tip with enamel or laser
irradiation of enamel. Both these iatrogenic
damages can be avoided by using small thermal
or laser tips and following the recommended
instructions. Indirect damage to enamel occurs
by conduction of heat from bracket to adhesive
resin and eventually to enamel. It has been
proposed35, 36 that if temperature of enamel is
kept below 300 °C then its crystal structure will
remain stable.
As tensile strength of the resin is temperature
dependent and is significantly reduced
37,38
above 150°C so heating the resin at this
temperature won't affect the enamel as the
temperature range is well below 300 °C.
Effects of thermal debonding on dental pulp
Because heat application is involved in thermal
debonding, there is a potential risk that these
procedures may lead to increase in pulp
temperature and eventually pulp damage. In an
experimental study on Mecaca rhesus monkeys
on the effects of externally applied heat on
dental pulp Zach and Cohen39 showed that an
intrapulpal temperature increase of 4° F (1.8°
C) did not cause any pulpal damage in their
sample. However, an increase in pulpal
temperature of 10° F (5.5° C) causes pulpal
necrosis in 15% of the teeth. As the temperature
increase from this limit chances of pulp damage
increases. As Mecaca rhesus monkey teeth are
CHAPTER 9
smaller than human teeth and have less dentine
than human teeth so it is generally presumed
that primate teeth show more increase in
intrapulpal temperature than human teeth. So
5.5 °C is taken in dentistry as a benchmark for
safe maximum increase in pulp temperature.
Apart from the temperature of the heating
element of thermal debonder, some other
factors also play important role to effect pulp
temperature.
1. Type of Bracket
2. Thickness of resin
3. Thickness of enamel
4. Thickness of dentine
5. Presence of any restorations in the teeth
Type of bracket
Type of bracket is important in thermal
debonding. Metal brackets are good conductor
of heat and electricity while ceramic brackets
are good insulators. Plastic brackets will simply
deform and melt on thermal application. Metal
brackets require 32 less heat and half time to
debond than ceramic brackets so there are
greater chances of pulp damage in debonding
metal brackets by thermal debonding.
Type of resin
The type of filler in composite cement also
affects thermal debonding. More the polymer
cross linking in the filler after curing of the resin
more would be the debonding time and so there
would be greater increase in pulp temperature.
Powder liquid resin system resulted in a lower
temperature change 32, 40 than the two-paste,
no-mix products and the light-cured materials.
No mix system is preferred 32 over two paste
system for thermal debonding as it requires
less heat.
228

Thickness of resin
Resin under the bracket also act as a heat
insulating zone for dental pulp. Greater the
thickness of resin under the bracket less would
be the temperature change at the dental pulp. So
a thin resin layer 40 will cause more buccal
surface and pulpal temperature change than
thick resin.
Thickness of Enamel
Enamel provide outer protective barrier for
pulp. With increased thickness of enamel less
heat would be dissipated to tooth pulp. Teeth
with attrition, erosion, abfraction and
amelogenesis imperfect are at increased risk of
pulp damage in thermal debonding.
Thickness of dentine
Dentine has low thermal conductivity and acts
as an insulating zone for the dental pulp both for
cold and hot temperature. So greater the
thickness of dentine 41 less would be the
temperature change in the pulp. Tissue fluid in
the dentinal tubules also dissipates the heat
generated during thermal debonding.
Presence of any restoration in the teeth
Patients with compromised teeth that have large
restorations or a questionable pulpal status
could behave adversely to amount of heat
applied during thermal debonding. More heat is
transferred to the dental pulp in case of
restoration and if there is resin filling it will also
become weaken by thermal debonding. In
compromised cases performing pulp vitality
tests before thermal debonding would inform
the operator about the status of the pulp and
thereby prevent the potential for pulpal damage
42
. Thermal debonding should be avoided in
patient having dental restorations.
Methods of thermal debonding
It is done by three methods
229
Debonding of orthodontic brackets
1. Hot instruments Tips
2. Electrothermal method
3. Laser debonding
Hot instrument tips
In this method the temperature of resin is
increased by placing a sharp hot instrument
within the bracket slot or saddle for less than 5
seconds and simultaneously giving a torsional
force to bracket by the same instrument.
Conventionally the instrument used was
backside of bracket holder after heating it on a
flame gun. This method went into disuse
because of following disadvantages
1. The clinician has no way to control the
amount of heat that is transferred to the
bracket and eventually to enamel and pulp.
So it poses a greater risk of iatrogenic
damage.
2. Brackets may fall in the mouth and hot
bracket may cause soft tissue burn.
3. Hot instrument may cause soft or hard
tissue damage on slippage due to sudden
debonding of brackets.
4. Debonding instrument usually gets
discolored after it is heated red hot.
Thermal debonding by hot instruments tips
have been abandoned in orthodontic practice.
Electrothermal debonding
Electrothermal debonding as the name indicates
uses electric energy to transfer heat to the
bracket for debonding. Electrothermal
debonders (ETD) usually uses 15 to 50 watts of
electric power 37,43 and its heating element is
warmed28,44 to 370 to 450 °F (188-232 °C) .
Usually 130+15 °C of heat is transferred to the
bracket by the ETD instrument 43 .This
temperature is within glass transition
temperature of adhesive. So the adhesive
Debonding of orthodontic brackets
CHAPTER 9
transform from solid to viscous liquid and LASER Debonding
debonding occurs. For ETD instrument the
manufacturer recommended that tip or blade The term LASER stands for Light
shouldn't be placed within bracket slot or saddle Amplification by the Stimulated Emission of
for more than 5 seconds. After the heating Radiation.
cycle, brackets are debonded by the tip of LASER was first introduced to the public in
debonder giving a torsional force by rotation 1959 by Gordon Gould. The light emitted by a
movement of the wrist. laser has three major characteristics
Various elctrothermal debonders were made 1. The light is of single wavelength. So it is
for commercial use in 1980s and 90s. They monochromatic light.
were quite useful for chemical retention base
of ceramic brackets. With improvement in 2. The light beam waves are in the same
design of bracket base and other methods phase or are coherent.
available these instrument went into disuse.
3. The light beams travel in parallel fashion,
so light is collimated.

B
Figure 9.47 A. Electromagnetic spectrum .B. Magnified view of the near ultraviolet, visible, near and mid infrared part of the
spectrum at which lasers exist.

230

Basic concepts
The main particle of light is photon. Photon is a
tiny particle of energy which travels in waves.
A wave has three basic properties.
Amplitude
It is the height of the wave from the zero axis to
its peak. Amplitude shows the amount of
energy for each photon. Larger the amplitude
greater would be the energy of photon. The
energy of photon is measured in joules.
Wavelength
It is the horizontal distance between any two
corresponding points on the wave and is
measured in meters, microns (10−6 meters) or
nanometers (10−9 meters).
Frequency
Frequency is the number of oscillations per
second, measured in hertz. As waves travel,
they oscillate several times per second.
Frequency is inversely proportional to
wavelength. The shorter the wavelength, the
higher would be the frequency.
The electromagnetic spectrum is given in figure
(Figure 9.47). On left side of this spectrum is
the ultraviolet part which consists of very short
wavelengths including gamma rays and x-rays.
As wavelength is inversely proportional to
energy, therefore these ultra-short wavelengths
c o n t a i n m o s t e n e rg y o f t h e e n t i r e
electromagnetic spectrum. That's why gamma
rays and x-rays are potentially carcinogenic and
mutagenic.
Next to ultraviolet part of the spectrum from left
to right is the visible part of the spectrum, the
part of the spectrum that is visible to the human
eye. These wavelengths, in increasing length
and therefore in decreasing energy are violet,
blue, green, yellow, orange, and red.
231
Debonding of orthodontic brackets
Next to visible red part of the spectrum on the
right side is the infrared part of the spectrum.
This part of the spectrum includes very long
wavelengths including radio, television,
shortwave, and microwave radiation.
How Lasers Work?
Different tissues in the body preferentially
absorb different wavelengths. In order for a
wavelength to have a therapeutic effect, it must
be well-absorbed by the target tissue. A
wavelength that is poorly absorbed by its target
tissue will have very little effects. A chart for
absorption of wavelengths by various tissues
chromophores is given (Figure 9.48).
Depending upon wavelength lasers in dentistry
can be classified as hard tissue lasers and soft
tissue lasers. Some lasers fall in both categories
because of diverse composition of hard and soft
tissue. For example as water is present in both
hard and soft tissues CO2 lasers can be used for
both hard and soft tissues. On the other hand
diode lasers are used only for soft tissues while
Er: YAG laser are used for hard tissues.
How laser debond brackets?
As explained above all lasers have a certain
wavelength and they carry energy at that
wavelength. Some lasers heat the brackets and
the hot brackets causes the adhesive to fail
while other laser passes through the brackets
and directly affect the adhesive by burning its
liquid (water or monomer) contents or effecting
its composition. Apart from wavelength other
factors must be kept in mind to avoid iatrogenic
damages to tooth structures. These are power
density of lasers mentioned in Watts, time
period in seconds, mode of operation of lasers
that is continuous or pulse, mode of application
which can either be point application or
scanning mode application. Composition of
adhesive and geometry of brackets also play
crucial role during debonding.
It is claimed that laser debond brackets by three
Debonding of orthodontic brackets
Figure 9.48 Absorption of wavelength by various tissues.
mechanism 45.
1) Thermal softening
When the power density of laser is low, less
energy is transferred by it to the brackets and
eventually to the resin. This less energy will
cause slow heat up of the resin or bracket
depending on laser and bracket type.
Monocrystalline brackets transmit laser energy
directly to resin while polycrystalline brackets
having multiple grain boundaries heats up and
transmit less heat energy to the resin. As tensile
strength of the resin is temperature dependent
and is significantly reduced above 150°C, this
slow heating of the resin will cause softening of
resin once this temperature is reached and
bracket slides over the tooth. Usually a
debonding force is applied to the bracket after
thermal softening. The amount of that
debonding force is fraction of a mechanical
debonding force. Ceramic brackets won't
distort under such heat as its thermal expansion
coefficient is twice than resin.
Thermal Ablation
Ablation is removal of material from the
surface of an object by vaporization, chipping,
or other erosive processes.
Thermal ablation occurs when the heating is
fast enough to raise the temperature of the resin
into its vaporization range before debonding by
thermal softening occur. Thermal ablation
result in bracket being blown off the tooth.
CHAPTER 9
Thermal ablation occurs at higher power
density than thermal softening. The higher
energy of the laser will cause evaporation of
liquid contents of resin and buildup of gases
below the bracket. This gas pressure will blow
off the bracket from the tooth without any
debonding force. Bracket geometry will affect
maximum transmittance of laser light and
therefore ablation.
As ablation proceeds rapidly there are little
diffusion of heat to bracket so the bracket
remains cool. Thermal ablation can occur even
after a single pulse if pulse energy is high
enough.
2) Photoablation
Photoablation occur when very high laser
energy is absorbed by the resin atoms. This
absorbed energy is greater than resin atom
dissociation energy levels. High gas pressure
will buildup below the bracket due to
decomposition of material and bracket will be
blown off from the tooth. Like thermal ablation
photoablation don't need any external
debonding force and occur after a single pulse
of high energy.
Thermal softening is a slow process and occurs
at low power density of laser while thermal
ablation and photoablation occur very rapidly
and at high energy density. Thermal softening
can result in increase in both bracket and tooth
temperature while in photoablation and thermal
ablation little heat diffusion occur so bracket
and tooth temperature remain near
physiological level. The difference between the
above processes can be made on how the
bracket comes off from the tooth e.g. sliding or
blown off.
A brief review of some of lasers used to
debond ceramic brackets is given:
Excimer Lasers
Excimer laser are used in wavelengths of 248
232

nm to 308 nm in ultraviolet region of
electromagnetic spectrum 45. Ultraviolet light
(200 to 300 nm) can readily transmit through
the ceramic material.
Excimer laser uses pulse energy of 111 milli
joule with power density of 17 w/cm2 for
debonding. Debonding is done with less than 5
seconds of bracket exposure by laser. A
continuous debonding force is placed on the
bracket during application of laser. Uses of
excimer lasers have only anecdotal evidence
and these lasers are not used for bracket
debonding in contemporary orthodontics.
Nd:YAG Laser
The Nd:YAG laser has a wavelength of
approximately 1064 nm, in the invisible near-
infrared portion of the electromagnetic
spectrum (Figure 9.49). The Nd:YAG
wavelength is highly absorbed by pigmented
tissue and little by dental hard tissue so this
laser is usually used as a soft tissue laser.
Strobl et al37 showed that the transmission of
Nd: YAG laser was greater for
monocrystalline brackets than polycrystalline
brackets. So greater incidence light reaches
enamel surface in case of monocrystalline
brackets. Also greater heat up of adhesive
occurs in case of monocrystalline brackets.
Different power densities have been proposed
for safe debonding of ceramic brackets with
this laser without causing enamel or pulp
damage. These are:
1. 3 to 33 watts for 3seconds for
monocrystalline brackets to a maximum of
24 seconds for polycrystalline brackets 45.
2. 3 Watts for 3 seconds 46.
3. High-peak power Nd:YAG laser at 2.0 J for
1.2-ms pulse duration with one pulse per
second shot and two points application on the
brackets47.
233
Debonding of orthodontic brackets
Debonding force is applied to the bracket
during laser application. Tocchio45 recommend
this force to be 0.8 MPa . Using 3 Watt for 3
second seems to be a reasonable approach.
Figure 9.49 Dental Nd:YAG laser system
Erbium Lasers
Within the erbium lasers, there are two different
wavelengths. These are Er,Cr:YSGG having a
wavelength of 2790 nm and Er:YAG laser with
a wavelength of approximately 2940 nm. Both
wavelengths are in the near to mid-infrared
portion of the electromagnetic spectrum and
these lasers are emitted in a pulsed mode. The
Erbium wavelengths have a high affinity for
hydroxyapatite and also for water.
Er:YAG lasers is usually used for ceramic
bracket debonding as it has less thermal effect
than the Nd:YAG or CO2 laser.
The most popular method 48, 49 of debonding by
Er:YAG laser on polycrystalline brackets is
using a 4.2 Watt laser which is moved over the
surface of bracket in a scanning fashion for 6
to 9 seconds (Figure 9.50). Debonding force is
applied on bracket after 45 seconds.
Debonding force after laser irradiation is
usually fraction of the mechanical debonding
force.
Carbon dioxide lasers
 CHAPTER 9
Strobl et al.37 showed that CO2 laser debonding
Debonding of orthodontic brackets

significantly reduced debonding force by

thermal softening of the resin.

Following settings have been recommended for

CO2 lasers in the literature.

1.Continuous mode at 18 W for 2 seconds 50.

2. Continuous mode at 14 W for 2 seconds 37.

3. Continuous mode 4 W or less with 5

seconds irradiation 36.
A B
Figure 9.50 A. Erbium based laser machine. B. Scanning 4. Normal pulse laser for 3 seconds at 3 W or
method is done by moving tip of laser instrument from one Super pulse laser at 2 Wfor 3 seconds 50.
end of bracket to another.
5. CO2 lasers using 188 W, 400 Hz with 5
Carbon dioxide laser is one of the earliest gas
seconds scanning movement over the bracket.
lasers to be developed and is invented by
Kumar Patel of Bell Labs in 1964. CO2 laser
has an active medium of carbon dioxide gas and
typically produces an invisible laser
wavelength of approximately 10,600 nm in the
mid-infrared portion of the electromagnetic
spectrum ( Figure 9.51).

As water and hydroxyapatite absorbs CO2

wavelength very well it is used as both a hard
and soft tissue laser.

In most studies in orthodontic literature, carbon

dioxide lasers have been preferred for
debonding because their wavelength is more
easily absorbed by the ceramic brackets.

The CO2 laser offers the option of operating

continuously or in a wide variety of pulse
repetition frequencies, from few hertz to well
over 100kHz.It can be in continuous mode,
super pulse mode ( short duration lasers with
gated pulse width of 1-500 millisecond
),normal pulse CO2 laser (gated pulse width of
5-500 millisecond) or ultra-pulse. Super pulse
CO2 laser are superior to normal pulse laser as
they are separated by sufficient time to allow
the tissue to cool between pulses thus allow
minimum thermal damage and carbonization.
Figure 9.51 A CO2 laser machine .Main disadvantage of
CO2 lasers are the increased bulk of machine and cost.
Choice of Brackets
Most commonly used ceramic brackets in
contemporary orthodontics are
monocrystalline and polycrystalline. Both
these brackets have different structure.
Polycrystalline brackets have multiple grain
boundaries and that makes difference in laser
deboning because these grain boundaries cause
234

lateral spreading of laser light. Because of
lateral spreading of laser light less light reaches
the adhesive below the bracket. In
monocrystalline brackets up to 80 % of laser
light reaches the adhesive surface.
Lasers are able to debond both monocrystalline
and polycrystalline brackets. Because of
suitable structural properties monocrystalline
brackets 37,45require less power density and less
time for debonding which is usually by thermal
ablation or photoablation. Monocrystalline
brackets remain cold after debonding. On the
other hand polycrystalline brackets need more
power densities of laser light and more time to
debond. Polycrystalline brackets usually heat
up under such power densities and debonding
usually occurs by thermal softening.
Polycrystalline brackets can also be debonded
by ablation of adhesive if the laser emitting
radiation is 4 to 7 µm range45. But there are more
chances of enamel or pulp damage in this range
if debonding of polycrystalline brackets is
attempted.
As monocrystalline bracket take less time and
less power density for laser irradiation it is
recommended 52 that they should be preferred
over polycrystalline brackets for laser
debonding.
Choice of Adhesive
Mimura and colleagues 53 investigated suitable
resin for laser debonding (CO2) and found that
MMA containing 4-META resins requires less
laser energy of up to 3W and less debonding
force than Bis-GMA which require up to 7W of
laser energy. It was recommended52 that if laser
debonding was intended in clinical use MMA
containing 4-META resins should be used for
orthodontic bonding.
In an in vitro study54 it was concluded that
orthodontic adhesive containing thermal
expansion microcapsules can be used with
CO2 laser for debonding with no reported
235
Debonding of orthodontic brackets
iatrogenic damage to tooth structures.
Safety with lasers
When operating a dental laser, safety of all the
people working in dental office should be the
first and foremost consideration. Anyone in the
vicinity of the laser should use protective
eyewear and high volume suction should be
used to evacuate vapor plums. Protective
eyewear can also be used with dental or surgical
loupes (Figure 9.52). These protective eyewear
are wavelength specific. Safety signs should be
put in place while doing laser debonding.
A
B
Figure 9.52 A. Laser goggles for specific wavelength. B.
Dental loupes with laser filters.
Selection of Lasers for debonding
Lasers for orthodontic debonding of
brackets still remains a novel approach as
laser system is not routine part of the dental
office and it takes more time to debond
bracket by this method. Laser should only be
used in cases where bracket fracture or risk
of enamel damage is too great like cracked
enamel, root canal treated teeth.A personal
non evidence based opinion for
polycrystalline brackets is to use scanning
m e t h o d w i t h E r : YA G l a s e r. F o r
monocrystalline brackets low power
settings can be used with same method.
Debonding of orthodontic brackets
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KG. Laser debonding of ceramic orthodontic
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Zhai JH. [Histomorphological effects of Nd:YAG
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ceramic orthodontic brackets. Am J Orthod
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48. Oztoprak MO, Nalbantgil D, Erdem AS, Tozlu

M, Arun T. Debonding of ceramic brackets by a new
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49. Nalbantgil D, Oztoprak MO, Tozlu M, Arun T.

Effects of different application durations of
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50. Obata A, Tsumura T, Niwa K, Ashizawa Y,

Deguchi T, Ito M. Super pulse CO2 laser for bracket
238
 CHAPTER
Adhesive Remnants Removal
10
In this Chapter

Hand instrumentation for adhesive Discs

removal
Finishing and polishing auxiliaries
Adhesive removing pliers
Ultrasonic scalers
Ligature wire cutters
Sandblasting or air abrasion
Hand Scalers
Adhesive remnants removal by Lasers
Rotatory instruments
Burs
Carbide burs
Diamond burs
Steel burs
Brown and green stones
Composite burs

After orthodontic brackets removal, adhesive Removal of these adhesive remnants should be
remnants needed to be removed from the tooth done without causing any damage to enamel.
so that enamel can be returned to its
pretreatment condition. These residual adhesive
if remained attached to the teeth will be a
potential plaque retentive area and may get
discolored with time.

The amount of these adhesive remnants

depends upon the type of bond failure. If bond
failure during debonding occurs at bracket
adhesive interference, more adhesive needed to Figure 10.1 Adhesive remnants on the tooth after
be removed as compared to a bond failure at debonding. Bond failure occur at the bracket adhesive
enamel adhesive interference (Figure 10.1). interference. Such bond failure require more time to clean
adhesive from the tooth enamel.
239
 CHAPTER 10
It has been reported 1 that the highest
Adhesive Remnants Removal

demineralization through microbial activity 10.

concentration of fluoride is found in the
outermost 20 µm of enamel and it rapidly Adhesive remnants removal can be divided into
decrease as the enamel proceeds towards two steps
dentin. Also apart from high mineral contents,
1. Removal of bulk adhesive
this outermost layer of the enamel contributes
in hardness of the enamel. Loss of this 2. Giving a smooth enamel surface
outermost enamel surface may lead to
decrease resistance of enamel to acids Various techniques have been proposed to
produced in plaque and make it more prone to accomplish these objectives. These are:
decalcification 2.
So loss of this outermost layer of enamel should 1. Hand instruments which include manual
be avoided. But unfortunately this is not scalers, debonding pliers and sandpapers.
possible clinically. It is shown that
2. Rotatory instruments which include high
(Table10.1) in almost all processes that
and low speed handpiece used with burs,
requires cleaning of enamel some degree of
disk and various finishing and polishing
enamel damage is inevitable. As the adhesive
points.
used for orthodontic bonding have
microretention within the enamel because of 3. Ultrasonic instruments which include
etching process or chemical composition of ultrasonic scalers (piezoelectric and
adhesive, some enamel loss during this magnetostrictive).
adhesive removal stage is inevitable 3, 4.
4. Air Abrasion which include sandblasting
`Table 10.1 Enamel Loss from different
procedures. 5. Lasers which include CO2 , Er:YAG and
Procedure Enamel loss in Nd :YAG lasers.
micron(µm)
Manual tooth 4.97 + 1.49 µm
A detail description of all the procedures will be
brushing5 20 or 80 given along with author personal opinion after
linear strokes/min going through all the literature and clinical
Pumicing with bristle 10.7+5.2 µm experience.
brush6
Pumicing with rubber 5.01+2.8 µm Hand instrumentation for adhesive removal
6
cups
90 second etching with 10 µm Use of hand instrumentation is one of the oldest
phosphoric acid6 techniques for adhesive remnants removal.
Enamel loss during 2.9 or <5 µm Methods used in hand instrumentation for
adhesive removal3,7 adhesive removal are still used by some
Enamel loss during 50 to 77 µm clinician but are usually not the first line of
bonding ,debonding
and polishing 6,8 choice and should be avoided if possible. These
Total thickness1,9 of enamel is 1500 to 2000 methods include:
µm
A. Adhesive removing pliers

Apart from adhesive removal, giving a smooth B. Ligature wire cutters

enamel surface is very important at the end of
C. Hand scalers
treatment as the rougher surfaces could
contribute to plaque accumulation, stain, and A. Adhesive removing pliers
240

Adhesive removing pliers are similar to band
removing pliers (Figure 10.2). These pliers are
used in a similar fashion to band removing
Figure 10.2 Adhesive removing plier with Teflon
supported end. The Teflon end usually break under
instrumentation or come out of the metal part after
sterilization due to different coefficient of expansion and
contraction than metal.
pliers. Some clinician also uses band removing
pliers as an adhesive removing plier (Figure
10.3).
A aerosol. Aerosol of composite resin may act as
B adhesive remnants removal after bracket
Figure 10.3 A. Band removing plier for adhesive
removal. The plier should be used at right angle to the facial
surface of the tooth. B. Plier at more than 100 degree to the
tooth. Such placement of the plier may result in breakage
of incisor portion of the tooth.
241
Adhesive Remnants Removal
Adhesive removing pliers have essentially one
cutting beak and one supporting beak. The
cutting beak is sharp while the supporting beak
consist of circular head which is usually made
from plastic, Teflon or sometimes with metal.
The supporting beak is seated on incisor or
occlusal part of teeth while the cutting beak
removes the adhesive remnants (Figure 10.3).
Clinical Notes
The supporting head of an adhesive removing
plier should ideally be made of a softer
material like Teflon. This softer material will
act as shock absorber if heavy forces are
applied during adhesive removal. The main
problem with soft supporting end plier is loss
of plastic head from metal beak, usually
under high heat of sterilization. Metal
supported head pliers are good for
sterilization but there are more chances of
damage to enamel as all the forces are
transmitted to the tooth.
Another clinical scenario is the grip of the
plier. The plier should always be at right
angle to the facial surface of the tooth
otherwise there is potential danger of
breaking the incisal edge of the tooth.
The theme of using these pliers is that these
pliers are cost effective and also usage of high or
low speed handpiece causes generation of resin
endocrinological disruptor. Adhesive removing
pliers though efficient in removing adhesive
remnants but leave deep scratches on enamel
(Figure 10.4).
Pus 6 found that adhesive removing pliers
causes greatest enamel loss. So adhesive
removing pliers are not an ideal choice 11-13 for
debonding.
B. Ligature wire cutters
Ligature wire cutters have two cutting beaks
Adhesive Remnants Removal
CHAPTER 10

Figure 10.4 Adhesive removed with adhesive removing

plier. Note the deep vertical scratches left on the enamel
surface. Due to iatrogenic enamel damage by plier beak this
method is usually not recommended for adhesive remnants
removal.

and are used horizontally or vertically to

remove adhesive. Ligature wire cutters are
effective in removing bulk adhesives especially
in cases where flash around brackets was not
removed at the time of bracket bonding. But D
they cannot be used to remove thin layer of
adhesive remnant and leave a rough surface
behind. Ligature wire cutters are usually not the
first line of choice to remove adhesives (Figure
10.5).

Figure 10.5 A. Ligature wire cutter used in horizontal

A fashion parallel to labial surface of the tooth. Placement of
pliers in this fashion is less damaging to enamel and are
effective in bulk adhesive remnants removal. B. Ligature
wire cutters in another horizontal position at right angle to
labial surface of the tooth. Using ligature cutter in this
fashion will leave deep scratches on the enamel and is
contraindicated. C. Ligature cutter used in a vertical fashion
parallel to labial surface of tooth. Ligature cutter can be used
in a horizontal or vertical fashion depending upon where the
clinician found a good retention of the instrument beak over
the adhesive. D. Ligature cutter used vertically at right angle
to the tooth. Again this is a damaging instrument position for
the enamel. E. Ligature cutter used vertically and taking
support from incisor edge like adhesive removing pliers.
This position of the plier should always be avoided as this
will cause damage to the incisor or occlusal edge in almost
all the instance.
B
242

C. Hand Scalers
Removal of adhesive remnant is done in many
orthodontic offices with hand scalers such as
H6/H7 scalers (Figure 10.6). But hand scalers
are not an ideal choice for adhesive removal as
they cause increase enamel roughness 11, 14,15
and increase time and effort for adhesive
removal. If hand scalers are used then final
finishing of enamel should be done with
finishing burs and pumicing should also be done
as a final step.
Hand scalers shouldn't be the choice for the
clinician to remove adhesive remnants in
contemporary orthodontics.
2. Rotatory instruments
Rotatory instruments such as high and low
speed handpiece are used with burs, discs,
finishing and polishing auxiliaries such as
points, cups ,tips and brushes to remove
adhesives remnants and return enamel to its
pretreatment condition with or without air or
water coolant. Of all these rotatory instruments
burs are the popular choices
Figure 10.6 Adhesive remnants were traditionally
removed from the enamel surface by manual interdental
scaler. This method require much effort by the orthodontist
and was very time consuming .This method also leave deep
scratches on the enamel surface and is usually not
recommended.
243
Adhesive Remnants Removal
Burs
Burs of various types are used to remove
adhesive remnants after bracket removal. As the
adhesive layer thickness16 is only 0.1 to 0.5mm
between the bracket and enamel therefore
extreme care should be exercised while using
burs because irreversible enamel damage may
occur if used carelessly. Various types of burs
used are
i . Carbide burs
ii. Diamond burs
iii. Steel burs
iv. Brown and green stones
v. Composite burs
Carbide burs
Carbide burs are ideal for cutting ductile
materials such as composite resins because
rotation of these burs result in generation of high
shear forces between the blades of the bur and
the surface of resin which result in plastic
ploughing of the resin 17. Many types of carbide
burs are available in the market and almost all of
them have been recommended for adhesive
removal in the literature.
Classification of carbide burs
Carbide burs are classified according to the
number of blades or flutes they have at their
cutting end. Carbide burs available in the
market usually carry 6 to 40 blades. Lesser the
blades or flutes a carbide bur carry, more the
resin would be accommodated between the
flutes of the bur so greater would be its cutting
efficiency. Burs with fewer flutes are coarse
burs and burs with increased number of flutes
are fine burs. Coarse carbide burs are used to
remove bulk adhesive while fine burs are
usually used for finishing procedures.
Carbide burs are identified by different
Adhesive Remnants Removal
numbers given by the manufacturer or are color
coded. For example F6; FG is a 6 fluted carbide
bur and F40; 118Ld is a 40 fluted carbide bur. In
color coding a white band around the neck of the
bur means that it is an ultrafine bur. An ultrafine
bur carries 30 or more flutes. A yellow band
indicates 16 or 20 flutes while red band
indicated 8 or12 blades bur. Some
manufacturers also use their own color coding
system. A classification of bur is given in
figure10.7.
Figure 10.7 Classification of carbide burs with color
coding around the neck of the bur.
Choice of Carbide Burs for adhesive removal
Carbide burs are available with simple blades
or flutes and flutes with crosscuts. Crosscuts
carbide burs are not recommended15 for
adhesive removal because they leave deep
scratches on the enamel. Carbide burs
recommended for removal of remnant adhesive
ranges from 8 flutes18 ,12 flutes 11,12,19,20,16 flutes 21
,30 flutes 15,21and 40 flutes 22 (Figure 10.8).
Of these 12 flutes bur is most commonly used in
dentistry and also known as universal carbide
bur.
The reason for this controversy in bur selection
is the failure to get a time efficient and effective
method for adhesive removal. Coarser bur are
CHAPTER 10
Figure 10.8 Different types of carbide burs from
coarse to ultrafine.6, 12, 18 and 40 flutes and carbide bur
with crosscuts.
more time efficient in removing bulk adhesives
while finer burs are more effective in giving a
smooth enamel surface. Bur selection is also
effected by type of bond failure. If bond
failure occurs at bracket adhesive interference
then too much adhesive needed to be removed
so using a finer bur won't be time efficient
procedure.
In a comparative study between coarse 6 blades
and ultrafine 40 blades bur, Jonke 23 showed that
ultrafine bur give a smoother surface than
coarse bur. Another benefit of using ultrafine
bur is that it also generates less heat23 than coarse
burs.
Choice of hand pieces with carbide burs
Use of both 4, 6,10,11,19,20,24,25 high and slow speed
handpiece have been recommended for use with
tungsten carbide burs.
The controversy in literature is again due to time
efficiency and final outcome. Low speed
Selection of carbide burs
Recommendations for carbide burs selection
are that always use a finer carbide bur. In case
too much adhesive needed to be removed
coarse bur can be used first to remove the bulk
adhesive but the final adhesive removal
should be done with a finer bur.
244

handpiece though takes more time than high
speed handpiece for adhesive removal but there
are fewer chances of enamel damage4, 6, 19 with
slow speed handpiece (Figure 10.9).
Figure 10.9 A slow speed handpiece with carbide bur.
Clinical Notes
It is better to use a slow speed handpiece with
carbide burs. But if large amount of a
adhesive is present then initially a high speed
handpiece is used to remove bulk adhesives.
The final layers of adhesive is then removed
with slow speed handpiece. Final layers of
adhesive can be also be removed with high
speed handpiece but avoiding its full throttle
while removing adhesive.
Type of coolant
As the adhesive remnant layer is very thin some
clinicians try to remove this layer without any
coolant or use air coolant to have a better
visibility. This practice is more predominant
with slow speed handpiece as it generates less
heat. But water coolant 11,13,26 should be used with
both slow and high speed handpiece to avoid
any damage to enamel or pulp by heat buildup
during the cutting process.
Clinical Notes
Mandibular anterior teeth are most
susceptible to thermal change as dentine and
enamel are thin in these teeth. Jonke 22
recommended using a water coolant when
removing adhesives especially with coarse
245
Adhesive Remnants Removal
tungsten carbide burs and if the adhesive
removal takes more than 10 seconds then
clinician should usually take a pause for few
seconds to allow the pulp to return to its
normal temperature.
Carbide burs alone or in combination?
Carbide burs though have good cutting
efficiency but have poor finishing properties.
Even the finest carbide bur leaves some enamel
roughness. Ryf 3 proposed that use of carbide
burs alone for adhesive removal and giving a
smooth enamel surface should be avoided.
Ideally after removal of adhesive by carbide
burs smooth enamel surface is achieved by
various finishing and polishing discs, cups and
points. The possible combinations will be
discussed later in the chapter.
Clinical Notes
Some clinician remove adhesive with a single
carbide bur or in combination of coarse and
fine carbide burs. The final few micron is left
on the enamel and normal scaling and
polishing is done after debonding. So the idea
behind leaving the final few microns is that if
this adhesive is removed enamel damage is
inevitable. Also this very thin layer of
adhesive would automatically be removed in
a couple of weeks by tooth brushing. This
practice should be used with caution as the
patient may complain of surface roughness
and discoloration. Also it is a common
finding that sometimes this left over layer is
too thick to be abraded with tooth brushing
even after a year and need to be removed by
instrumentation in dental office. This
approach lack an evidence based backing.
Diamond Burs
Diamond burs on high speed handpiece with
water coolant are also used by some
orthodontist for adhesive remnants removal
 CHAPTER 10
inefficient28 for adhesive removal and are not
Adhesive Remnants Removal

(Figure 10.10). In diamond type burs the

classification is made according to size of grit
on the bur. Smaller the grit size finer would be
the bur. A classification of diamond bur by grit
size is given in Table 10.2.
recommended for this purpose.
Brown and Green stones
Usually brown stones are used to remove bulk
adhesive remnants and green stone are used for
final polishing (Figure 10.11). But studies
14,15
found that green stone leaves heavy scratches
on the enamel and are not recommended for
adhesive remnants removal. Shofu Cooperation
Japan has recently introduced superfine brown
and green stones and these if used with carbide
burs have shown good final outcome 3 but these
burs should be used with caution as good
evidence is missing for use of this combination.

Fiber glass reinforced composite burs

Fiber-reinforced composite bur (Stainbuster,

Figure 10.10 Ultrafine diamond bur. Some clinician use
ultrafine diamond bur to remove adhesive remnants
Abrasive Technology Inc, Lewis Center, Ohio)
removal. These burs have better cutting efficiency than is also used for resin removal (Figure 10.12).
carbide burs so are more time efficient in removing
adhesives but there is greater risk of enamel damage with
This bur is reinforced by zircon rich glass fibers.
these burs. The bur is used with a slow speed handpiece and
usually with a water coolant.
Table 10.2 Classification of diamond
burs Karan29 proposed that the composite bur used
for resin removal creates smoother surfaces but
Code Description µ takes more time as compared to coarse carbide
SF Superfine 30 bur. Composite burs are usually used in
F Fine 50 combination with tungsten carbide burs. The
M Medium 107-120 initial layers of adhesives are removed with a
C Coarse 150-180
SC Super coarse 180-250
All types of diamond burs have more cutting
efficiency than carbide burs but diamond burs
cause brittle fracture of the enamel27 and may
lead to crack initiation within the enamel as
these burs generate large tensile stress within
the enamel. Therefore diamond burs are not
recommended7, 12, 15, 17, 19, 21, 28 for adhesive removal
as there are greater chances of enamel damage
A B C
with these burs.
Figure 10.11 A&B. Brown and green stone burs. These
Steel burs burs are used with slow speed handpiece with air or water
coolant for adhesive removal. Brown stone has better
cutting efficiency while green stone has better polishing
Stainless steel burs were found to be most properties. C. A green stone bur on slow speed handpiece.
246

Figure 10.12 Fiber reinforced composite burs used alone
or in combination with tungsten carbide burs.
coarse carbide bur and final finishing and
polishing is done with composite burs.
Discs
Different types of discs are available to be used
alone or in combination with different types of
burs for adhesive remnants removal and to give
a smooth enamel surface. If these discs are used
alone for adhesive removal and enamel
polishing they usually give a smooth surface but
don't remove the adhesive. The reason behind
this is that most of these discs were introduced
for composite resin restoration finishing and
polishing. So when used alone they give a
smooth polished resin surface which is difficult
to be demarcated from the enamel but leave
much adhesive remnants behind as compared to
carbide burs4.
Clinical Notes
When using discs for adhesive remnants
removal it is a good practice to use resin
discoloring agent to aid in complete adhesive
removal from the teeth.
These discs are usually marketed by the
manufacturer name.
1.PoGo discs
247
Adhesive Remnants Removal
2. Sof-lex discs
3. Super Snap discs
Po Go™ Polishers (discs, cups and points)
Because the one step PoGo™ Polishers are used
collectively so rather than giving description of
only discs the whole system would be
explained. PoGo™ Polishers (discs, cups and
points) by Dentsply are single-use diamond
impregnated cured urethane dimethacrylate
resin polishing devices which are premounted
on a plastic mandrel and are used with slow
speed handpiece (Figure 10.13). The one step
system was originally introduced to remove
bulk adhesive and give a smooth enamel finish
if used in sequence of discs, cups and points. But
using them alone is a time consuming process
and it is better to use 30 them with carbide burs.
The initial layer is removed with carbide burs
and finial layers and polishing is done with
PoGo polishers.
PoGo™ Polishers 31 gives a smooth enamel
surface and were found superior in terms of final
outcome than Soflex discs 30, 31 and super snap
discs 30, 32.
Sof-lex discs
Sof-lex discs by 3M Unitek are used in dentistry
for single use finishing and polishing of
different restoration. There discs are available
Figure 10.13 PoGo™ Polishers

Adhesive Remnants Removal
in two different thicknesses, normal and extra
thin. The extra thin type is recommended for
polishing in interproximal areas. The normal
type is usually used in orthodontics for adhesive
remnants removal and giving a smooth enamel
surface. These discs are available in four
different types (coarse, medium, fine and extra
fine) and are color coded according to the grit
size (Figure 10.14). Using these discs in a
sequence from coarse to extra fine will give a
smooth enamel surface. Sof-lex discs can be
used alone or used in combination with tungsten
carbide burs. Using the discs alone for adhesive
removal and enamel polishing is more time
consuming than using it in combination26.
There is controversy in literature regarding
effectiveness of Soflex discs. Campbell 15 ,
Cehreli 21 and Ozer 26 found these disks to be
effective in giving a smooth enamel finish
while Elides 17 found inconsistent results and
Eminkahyagil 4 found these discs as time
consuming and leaves most adhesive remnants.
Tüfekçi 33 found that these disks are more
damaging to enamel as compared to carbide
burs in case of white spot lesion.
From the above literature review following
recommendation can be made. Use these disks
Figure 10.14 Normal type Sof-lex discs .Coarse, medium,
fine and ultrafine disks are given in sequence.
CHAPTER 10
in combination with carbide burs and avoid
their use on teeth with white spot lesions.
Super Snap Discs
Super snap discs by Shofu Dental Corporation
are polishing discs that are used to leave a
lustrous enamel surface and are single use only.
They are almost always used in combination
with carbide burs for final enamel finishing.
These discs are available in two sizes depending
upon the width of the disc which are available in
normal and ultrathin variation. The ultrathin
disc is reserved for interproximal areas while
the normal type is usually used for adhesive
remnants removal. The normal type is
available in four different grit sizes of silicon
carbide and aluminum oxide (Figure 10.15).
Each grit size is given a different color which
are black (coarse), violet (medium), green
(fine) and red (ultrafine). Apart from adhesive
removal another advantage of super snap discs
are that they are paste-impregnated so when
exposed to water they release a high quality
polishing paste. Super snap discs were found
to be less aggressive and give a better surface
finish than Sof-Lex discs 30,34.Super snap discs
can be used alone for adhesive removal but
are usually reserved for final polishing of the
enamel when all the adhesive remnants have
been removed by other methods, usually by
carbide burs.
Figure 10.15 Super snap discs. Super Snap discs are used
only with slow speed handpiece.
248

Finishing and polishing auxiliaries
Various polishing auxiliaries such as points,
cups, tips and brushes are used as a final step to
give a smooth enamel finish after adhesive
remnants have been removed (Figure 10.16).
These auxiliaries are used on slow speed
handpiece with air or water coolant and
sometimes even without a coolant. Points are
usually used to remove gross scarring that
occurs after the use of burs while removing
adhesive remnants.
Pumicing is considered as necessary final step
after all adhesive remnants removal procedures
11, 14
. speed handpiece with air coolant to remove bulk
Pumicing give smooth enamel surface and also
removes some adhesive remnants if present
14
.Usually fine slurry of pumice is used with
rubber cups or bristle brushes on slow speed
headpiece. The bristle brush is usually coated
with zirconium silicate and causes
l1
considerable abrasion of enamel . Rubber
cups are preferred over bristle brushes as they
cause less enamel damage 6.
At present there is no consensus on one single
best protocol of adhesive removal and returning
A B C ŸUse brown and green cups in dry state at end.
Figure 10.16 A. Enhance polishing point. Polishing
points are used to remove gross scarring .B. Bristle brush
used for pumicing. C. Rubber cups. Rubber cups are better
choice for pumicing enamel surface at the last stage of
debonding than bristle brushes as the latter cause more
enamel damage than rubber cups. All of the above finishing
auxiliaries are used with slow speed handpiece.
249
Adhesive Remnants Removal
the enamel to its pretreatment condition with
rotatory instruments but some possible
combinations to achieve this goal are given
which were published in different index
journals.
Gwinnett Recommendation 197710
ŸUse green rubber wheel followed by pumice
with composite finishing paste.
Retief Recommendation 1979 12
ŸDebond brackets with bracket removing plier.
ŸUse 12 bladed tungsten carbide bur at high
of the adhesive.
ŸDo finishing of the adhesive residue with
graded polishing discs. The polishing discs
should be used with light pressure and adequate
air cooling.
ŸFinal finishing with rubber cup and water
slurry of pumice.
Campbell Recommendation (1995) 15
ŸUse a 30 bladed tungsten carbide bur with high
speed handpiece. Avoid touching the enamel
while removing the resin.
ŸFor proper visibility of resin layer apply
discoloring solution to the resin pad.
ŸUse Enhance points and cups to remove
scarring. For deep development grooves, points
are especially useful.
ŸUse water slurry of fine pumice with a rubber
cups for polishing.
First use brown (coarse cups) and then green
cups (fine cups).
Zarrinnia Recommendations 1995 28
ŸUse bracket removing plier with wing
Adhesive Remnants Removal
technique to debond the brackets. It will cause
bond failure at bracket adhesive interference.
ŸRemove bulk of the remaining resin with a 12-
bladed tungsten carbide finishing bur operated
at high speed handpiece with air coolant.
ŸFinishing of the residual resin and underlying
enamel is done stepwise with medium, fine
and superfine Sof-Lex discs operated at slow
speed handpiece with air coolant.
ŸFinal finishing is done with a rubber cup and
zircate paste.
Ulusoy Recommendations 2009 30
ŸUse 12 flutes or 30 flutes tungsten carbide bur
on high speed handpiece with water coolant to
remove bulk of the adhesive.
ŸUse one step diamond coated PoGo micro-
polisher point on slow speed handpiece with air
coolant to give a smooth enamel surface.
ŸOne step PoGo micro-polisher point can be
used alone to remove bulk adhesive and to give
a smooth enamel surface but it is a very time
consuming process.
Karan Recommendation 2010 29
ŸUse 8 flutes tungsten carbide bur at slow speed
handpiece with water coolant to remove bulk of
the adhesive.
ŸRemove the final layer of adhesive with fiber
glass composite bur.
Good evidence for this crucial stage treatment is
lagging. Author personal view is to use 12 flutes
carbide bur on slow speed handpiece with water
coolant to remove adhesive remnants. Use pogo
multipolisher or composite bur to give smooth
enamel finish. Do scaling if necessary for
plaque removal and not for adhesive remnants
removal. The final step of pumicing is done with
rubber cups.
CHAPTER 10
3. Ultrasonic scalers
As ultrasonic scalers have been used for bracket
debonding so the same instruments are also
been recommended by some clinicians for
adhesive removal. The tip of scaler is moved
over the adhesive until the gray foot print left by
the ultrasonic tips on the enamel surface is no
longer visible. The gray footprint effect is result
of silica content of the composite which abrade
the surface of the ultrasonic metal tips (Figure
10.17). The absence of gray footprints indicate
that all the composite have been removed from
the surface. Ultrasonic scalers are always used
with water coolant.
Figure 10.17 Gray footprint left on the enamel surface.
The snap was taken without water coolant as water coolant
wash away the foot prints.
Ultrasonic scalers are more efficient in
removing adhesive remnants of GIC or RMGIC
than composite resins. But in contemporary
practice most brackets are bonded with luting
composite cements and multibladed carbide
burs are better choices in removing those resin
remnants than ultrasonic scalers. Use of
ultrasonic scalers for adhesive removal has only
been recommended in studies conducted more
than 20 years ago 35,36. Removal of adhesive with
ultrasonic scaler is a very time consuming
process and as the vibrating instrument is
repeatedly moved over the enamel, so there are
greater chances of enamel damage (Figure
10.18). With the advent of new methods it has
been shown that ultrasonic scalers cause more
enamel loss.20, 24, 25 and surface roughness 15, 21.
250

Figure 10.18 A finished case in which adhesive remnants
were removed with ultrasonic scaler. The enamel surface is
not smooth and thin layer of adhesive still remain on the
surface.
Ultrasonic scalers are not an ideal choice for
adhesive remnants removal as they lead to
excessive enamel loss. If ultrasonic scaler is
the only option for adhesive removing then
final pumicing should be done to give a
smooth enamel finish.
Sandblasting or air abrasion
Sandblasting or air abrasion with bioactive
glasses is used in orthodontics for enamel
etching, bracket recycling and increasing
brackets base retention. Sandblasting is also
proposed for adhesive remnants removal after
bracket debonding 18. Kim 18 proposed that
adhesive remnants removal with intraoral
sandblasting is similar to that after removal with
a bur on slow speed handpiece. Amount of
enamel loss by sandblasting as compared to
conventional techniques is still controversial18,
37
. suck away aluminum oxide particles from the
Method
A pen tip intraoral sandblaster (Micro-etcher II)
is used with 50 µm aluminum oxide (Figure
10.19). It is important to use small grit of sand as
it will give smooth enamel surface at the end of
adhesive removal. Using large sand particles
will remove the adhesive more quickly but also
will roughen the enamel surface. The nozzle of
the sandblaster is placed perpendicular to the
enamel surface at a distance of 5- 10 mm. The
air pressure is maintained at 90 psi. It usually
251
Adhesive Remnants Removal
A
B
C
Figure 10.19 A. Microetcher II. This type of
microetcher requires conventional source of oil free
pressurized air from the compressor. B. Modified
microetcher which can be directly attached to dental unit
like a high or slow speed handpiece. C. A microetcher
used with sandtrap. The sandtrap plastic device is
necessary for intraoral sandblasting.
takes 15 to 30 seconds to remove adhesive
depending upon the type of bond failure, size of
sand particles and the air pressure .The
sandblaster is used intra orally in combination
with a plastic device (Sand-Trap, Danville
Engineering) which is designed to confine and
tooth surface.
Advantages
ŸThe advantages of intraoral sandblasting for
adhesive remnant removal are:
ŸIntraoral sandblasting don't cause increase in
pulp temperature as compared to burs used with
slow or high speed handpiece.
ŸEasy demarcation can be made between
adhesive and enamel while this is not possible in
using handpiece with water coolant.

Adhesive Remnants Removal
Disadvantages
The disadvantages are
ŸExtra Cost.
ŸTime taken by sandblasting for adhesive
removal is 5 sec while with tungsten carbide bur
on handpiece its only 3 seconds 18.
ŸVisualization of enamel surface is difficult if
sandblaster is used in combination with plastic
device for suction of aluminum oxide. If the
plastic device is not used flying dust particle
will cause irritation for patient and clinician.
ŸNeed for protective mask, eye wear and a
plastic device.
Clinical Notes
Polishing is required after sandblasting to
give a smooth enamel finish 37.Polishing can
be done by pumicing with rubber cusps.
Adhesive remnants removal by Lasers
Lasers have also been used in experimental
studies to remove residual adhesive from
enamel after brackets debonding. Though all the
lasers used were effective in removing adhesive
the limitation of these studies is that these were
done on extracted teeth and no variable was
included to measure pulp temperature after
orthodontic adhesive removal. In contrast to
bracket debonding where lasers are focused on
the brackets in adhesive removal, laser come
very close to enamel surface and there are
greater chances of enamel damage and pulpal
death.
Methods
For removal of adhesive residue lasers are used
with following setting:
Er:YAG lasers: Used in a noncontact mode
perpendicular to the enamel for 350µs with a
pulse reception rate of 4 Hz having 250 mJ of
CHAPTER 10
energy 19.
it with 2 W for 100
38
CO2 Lasers: Use
millisecond.
Nd:YAG Lasers : Use39 it for 3seconds
lasing time with 100 Hz frequency.
There is controversy regarding more 19, 39-41
enamel loss by lasers as compared to
conventional methods.
Presently adhesive removal by laser still stands
a novel approach and need further research and
is not recommended for adhesive removal in
dental office.
Ideal method for adhesive Removal
Contemporary methods used by many
clinicians after debonding for adhesive
remnants removal are though successful for
adhesive removal but some enamel loss is
inevitable with all these methods. So the best
way to choose a method is that causes least
enamel loss and give the smoothest enamel
surface.
Wi t h t h e m e t h o d s d e s c r i b e d h a n d
instrumentation shouldn't be the first choice
and laser debonding is in experimental stage
and still not recommended for in vivo
applications. Sandblasting though effective
in adhesive removal is expensive and still
need rotatory instruments at end for giving
smooth enamel surface. This leaves various
rotatory instruments as the first choice for the
task.
In rotatory instruments there is controversy in
literature on effectiveness of various
devices. This is because different methods
have been used to access enamel roughness
in different studies.
Though not supported by evidence the author
favored method is to remove bulk adhesive by
12 blades tungsten carbide bur at slow speed
252

handpiece with water coolant if the bond
failure had occurred at bracket adhesive
interference. If bond failure had occurred at
enamel adhesive interference than carbide
bur should be omitted. Use pogo
multipolisher or composite bur to give
smooth enamel finish. Do pumicing with
rubber cups as a final step.
42
A systematic review by Janiszewska found
tungsten carbide burs faster and effective than
other available methods and causes least
enamel damage. It was further recommended
42
that carbide burs should be followed by
multi-step Sof-Lex discs and pumice slurry
for effective enamel polishing.
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6.

254
 CHAPTER
Recycling of orthodontic brackets
11
In this Chapter

Introduction Chemical Method

Recycling of orthodontic brackets Sandblasting
Ultrasonic Cleaning Laser Recycling
Electropolishing
Adhesion Enhancement
Silane coupling Agents
Adhesion Boosters
Rotatory instruments
Flame Method
Buchman modiifed flame method
Modified Buchman method ,The Acid
Bath
Limitations of flame method
Lew and Djeng Method

Introduction these circumstances are as follow.

Recycling or reconditioning are different terms 1. Bracket debonded by patients

used for reusing orthodontic brackets which
This usually occurs while masticating hard
were once bonded in clinical practice and were
food, aggressive tooth brushing or by traumatic
latter debonded accidently by the patient or
forces especially in children while playing
intentionally by the clinician. 5% to 7% of
sports. Some externally motivated patients also
brackets bonded with light cured or chemical-
intentionally debond the brackets to show their
cured composite resins debond1, 2 in clinical
unwillingness towards treatment.
practice under different circumstances. Some of
255
Recycling of orthodontic brackets
2. Bracket debonded by the clinician
Debonding of bracket can also occur in dental
office due to poor isolation while bonding,
improper placement of bonding tray in indirect
bonding technique, engaging heavy wire
without proper alignment and leveling or other
improper mechanics. Sometimes clinician
intentionally debond the bracket to correct its
position.
Once a bracket is debonded due to any reason
the clinician has the following options:
·Bond a new bracket
This is the best option available to the
clinician.But many times this option is not
fissible.Many orthodontic companies and their
distributers sell brackets as one complete set,
containing a single bracket for each individual
tooth and don't sell loose brackets for an
individual tooth. This is because packing a
single bracket is not cost effective for the
manufacturer and without packing there are
greater chances of cross infection. Also
taking a single bracket from a complete set is
not a cost effective option for many clinicians.
·Bond the same bracket without recycling
Some clinicians rebond the same debonded
bracket to the same patient after washing and
drying it. At least one study3 in literature have
shown acceptable bond strength with this
method using ceramic brackets. But this is only
theoretically possible in ARI score 3 with no
adhesive left on the bracket.
Clinic Notes
It usually happens in clinical practice that
while placing ligatures a bracket comes off
from the tooth. In busy clinical practice the
clinician is usually out of time. So instead of
following the standard procedure the
clinician remove some of ligatures keeping
the ligature on debonded bracket, rotate the
CHAPTER 11
bracket in case of round wires or slides the
bracket over the wire in case of rectangular
wire and place some composite on the back
of the bracket. The bracket is moved back to
its correct position and cured in place.
This technique always results in weak bond
strength and effect 1st order tooth position as
composite thickness would be increased
below the bracket.
The clinician should always follow the
standard bracket positioning protocols but if
the choice is between placing and not placing
the bracket than a bracket should always be
placed.
ŸCement a band with welded or soldered
bracket
Bracket welded or soldered to a band is a good
option in lower premolars if there is repeated
bond failure due to heavy masticatory forces. If
bond failure occurs twice by the patient in lower
premolars especially during mastication then it
is a good option to cement bands than to bond a
bracket. Placing bands have their own
shortcomings in occlusal outcome at final
stages of treatment. Poor contact points would
be present after removal of the bands and
clinician have to move back to bonded
attachment at the final stage of treatment or has
to close spaces by giving active retainers.
Clinical notes
Placing new brackets is the best option if the
patient is compliant. In noncompliant patients
and patient that are fond of contact sports,
bands should be preferred if there is frequent
bond failures. Banding is also done on lower
premolars in some low angle case where there
is increased muscle tone. Some clinicians
prefer banding at both ends of fixed functional
appliance attachments as heavy forces are
applied. Also banding is a better option in cases
with amelogenesis and dentinogenesis
imperfect.
256

· Bond a Recycled bracket
The third option available to the clinician is to
rebond a recycled bracket. In recycled brackets
the clinician has the following option:
1. Recycle the patient existing bracket.
2. Use a bracket recycled in dental office that
was once bonded to some other patient.
3. Use a recycled bracket bought from a
commercial company.
Recycling of orthodontic brackets
Recycling of orthodontic brackets is the most
cost effective method and is being used by many
clinicians around the world but is viable only if
the bracket being recycled have not been
distorted. Recycling of orthodontic bracket is
also being approved by FDA. The FDA4
standards are that bracket can be recycled if
the physical characteristics and quality of the
brackets are not adversely affected, so that the
bracket remains safe and effective for its
intended use.
Recycling brackets have litigation issues as
most of the brackets are marketed as Single Use
Only. Recycling of patient existing bracket has
the least chances of cross infection. I personally
have some reservation about usage of other
patient brackets that have been recycled in
dental office. Buying recycled brackets from
specialized companies or sending your used
bracket for recycling to those companies is a
much debated topic. Some companies
especially in US are FDA approved and has
certification to recycle brackets. That is one of
reason that using recycled brackets is more
popular in USA and less popular in other
developed countries. In UK under NHS
orthodontist don't use recycled brackets.
Written consent should always be taken from
the patients before bonding a recycled bracket.
Recycling of orthodontic brackets can be
257
Recycling of orthodontic brackets
immediate5 that it can be done within the dental
office or delayed that it can be done by
specialized companies.
Clinical Notes
For recycling non distorted bracket should be
selected. Clinician should make every effort
to avoid using brackets that were debonded
by wing method. Some brackets debonded by
base method are also sometimes distorted.
The clinician can confidently recycle only
those brackets which were debonded due to
poor isolation or technique at time of bracket
bonding. For all other brackets the slot and
base should be checked for distortion before
recycling. So clinician should keep a
magnifying glass if not microscope in dental
office to check bracket distortion before
recycling them.
Different methods used for inoffice recycling
are
1. Rotatory instruments
2. Flame Method
3. Chemical Method
4. Sandblasting
5. Lasers
Before going into the details of these methods, it
is important to mention some auxiliary
procedures which are used in recycling of
orthodontic brackets. These are:
A. Ultrasonic Cleaning
B. Electropolishing
C. Adhesion Enhancement
A. Ultrasonic Cleaning
Recycling of brackets involve heat, chemical
solvents or aluminum oxide sand. Before
rebonding the brackets need to be cleaned
Recycling of orthodontic brackets
CHAPTER 11
from any remains of burnout adhesive
remnants, plaque, dust particles, metal
oxides, tarnish and chemical solvents
(Figure 11.1).

This cleaning is usually carried out in

ultrasonic cleaners (Figure 11.2). Ultrasonic
cleaner as the name indicates uses ultrasound
in range of 20-400 kHz for cleaning of
brackets along with an appropriate cleaning
solvent. For orthodontic purpose the
cleaning solvent contain a solution of C
cleaning and disinfectant agents (Figure Figure 11.1 A. Burned adhesive remnants on bracket base
11.2 B&C). The bracket are placed in a after flame method. B. Remnant of aluminum oxide on
bracket base after recycling by sandblasting. C. Plaque
carrier tray and immersed in a solution of accumulation in slot and saddle of bracket .All the above
solvent within the cleaner. In bracket brackets need ultrasonic cleaning to increase bond strength
and for optimum oral hygiene.
recycling usually 10 to 15 minutes
ultrasonic cleaning is required. The time is
set by rotating the knob of cleaner. At the
end of ultrasonic cleaning bracket are
washed in tap water and dried before
proceeding to electropolishing and
bonding.
A

B C

Figure 11.2 A. Ultrasonic cleaner with setting knob. B.

Cleaning solution. C. Disinfecting solution.

A. Electropolishing

Electropolishing, also known as

electrochemical polishing or electrolytic
B
258

polishing works on the principle of anode
cathode reaction. It is done for metal
brackets to remove material from the surface
of bracket to decrease surface roughness and
prevent corrosion 6 by removing the oxide
layer (Figure 11.3). Electropolishing is
usually the last step of recycling process 7.
C B
Figure 11.3 A. Surface roughness of bracket stem by
corrosion. B. Corrosion material attached to bracket base
even after sandblasting. C. Rough wings of the brackets.
Electropolishing is done to smooth all these surfaces.
In this process the brackets are placed in a
basket container which is then immersed in a
solution of electrolytes with in the
electropolishing unit (Figure11.4). There are
different types of electrolyte solutions for
different metals (Figure 11.4 B&C). So it is
259
Recycling of orthodontic brackets
important to use the right electrolyte
solution. A low voltage direct current is then
passed through the solution after making the
time setting. Usually 30 to 45 seconds are
required for orthodontic brackets8. Greater
the time the brackets are electropolished
more metal would be removed and smoother
surface will result. All the process is
automatic and orthodontist simply need to
place the carrier basket of brackets within the
electrolyte solution and make the time
settings. Most machines give an acoustic
signal at the end of electrolytic reaction.
C
Figure 11.4 A. Esmadent E279 dental office
electropolisher. B. Esma Ortho 273 Electrolyte solution for
stainless steel. C. Esma Brite E272 electrolyte for cobalt
chromium brackets.
At the end of electropolishing the brackets
are placed in sodium bicarbonate solution to
neutralize the electrolyte, followed by hot
water rinsing.
Recycling of orthodontic brackets
Advantage of Electropolishing
1. Increase corrosion resistance of metal
brackets.
2. Decrease plaque retentive area.
3. Restore luster of bracket.
Disadvantages
1. Decrease in bracket base roughness by
leveling the undercuts will result in
decrease in bond strength.
2. Enlargement of bracket slot so there
would be increased wire play and
decreased torque control9 in
electropolished brackets.
3. Electropolishing reduces thickness of
the wing. Such brackets are more prone to
wing fracture during ligature tying and at
time of debonding.
4. Electropolishing dissolve and weaken
the brazing that keeps multipart of brackets
together.
Clinical notes
Orthodontic brackets undergone repeated
recycling and subsequent electropolishing
have decreased effective torque. To
accommodate the torque loss extra torque is
needed to be given by torsion in the wires.
Conventional brackets made by casting and
brazing process undergone electropolishing
more than a couple of times should be
debonded with base method of debonding as
there is potential danger of breaking the
bracket into parts on debonding by wing
method.
C. Adhesion Enhancement
New brackets have almost always higher
bond strength10-14 than recycled brackets.
Sometimes the bond strength of recycled
CHAPTER 11
brackets is less than minimum accepted
value15 which is 5.9MPa to 7.8MPa. To
increase the bond strength of orthodontic
brackets various bond enhancement
techniques are used. These are:
1. Silane coupling Agents
2. Adhesion Boosters
1. Silane coupling agents
Silane coupling agents are used to increase
bond strength of recycled brackets. As
explained earlier silane coupling agent have
a bipolar structure16 and can connect silicone
dioxide groups on activated metal and
ceramic brackets at one end and adhesive
resins of a Bis GMA or methyl-methacrylate
on the other end. But silane coupling agents
have poor adhesion with metals and
ceramics. To facilitate adhesion , metal and
ceramics surface are coated with silica17 by
flamepyrolytic or tribochemical systems
(Figure 11.5).
A tribochemical coating is added to bracket
base in a similar fashion to sandblasting
.Particle size of tribochemical coating is
between 30 um to 110 um 16,18. A line pressure
of 40.6 Psi for 13 seconds have been
advocated 16, 19 for tribochemical coating.
2. Adhesion Boosters
Adhesion promoters or boosters are
multifunctional molecules and are available
as a tooth surface primer advocated by
Bowen 20to increase the bond strength of
composite resin to tooth surfaces. These are
applied to enamel and they adhere
chemically to the enamel and at the same
time interact with the composite resin 21.
In orthodontics adhesion booster are also
suggested 10 to increase bond strength especially
with metal and plastic brackets. In orthodontics
instead of application on enamel, adhesion
260

A
B C
Figure 11.5 A. Machine used for silica coating of
brackets. B. Rocatec plus 110 micron Silica - Alumina
oxide for tribochemical coating. C. Monobond plus silane
coupling agent. Applied by brush on bracket base after the
bracket has been silica coated.
boosters are applied to the bracket base because
bracket adhesive interference is the weakest
link in case of recycled brackets. Adhesion
22, 23
boosters have shown increased bond
Methods of bracket recycling
strength of recycled bracket equal to that of new
brackets.
Different adhesion booster are available in the
market and especially useful for recycled
brackets. These are All Bond 2, Ortho Solo,
Enhance LC and Mega bond (Figure11.6).
Enhance LC is more effective when applied on
enamel and usually is not recommended 24 for
orthodontic brackets. All Bond 2 and Ortho Solo
increases bond strength 22, 25 of new and recycled
brackets and are usually recommended for
orthodontic purpose. Ortho Solo was found to
be more effective 25 with certain composites.
261
Recycling of orthodontic brackets
A B
Figure 11.6 A. Ortho Solo. Directly applied to the
bracket base by brush. B. All Bond 2 is available in a two
bottle solution. Equal amounts of Primer A and B is mixed
in the mixing well. It is applied on the bracket base and dried
for 5-6 seconds with air syringe. Composite is then applied
to bracket base. A modified version of All Bond 2, the All
Bond 3 is also available in market with the manufacturer
claiming better adhesion properties.
Clinical Notes
Adhesion booster shouldn't be used with
recycled ceramic brackets as even recycled
ceramic brackets have clinical acceptable
bond strength. Adhesion booster should not
be applied to enamel surface as it will
increase risk of enamel damage at debonding
and also greater time would be required for
adhesive remnants removal after debonding.
1. Rotatory instruments
Various rotatory instruments are used for
removal of adhesives from the bracket base.
These are:
· Tungsten carbide burs
· Gold plated carbide burs
· Silicon carbide green stone
In rotatory instruments tungsten carbide
burs14, 26 and gold plated carbide burs27 offer
significantly decreased bond strength and are
not recommended for bracket recycling.
Recycling of orthodontic brackets
CHAPTER 11
Silicon carbide burs also offer decreased
bond strength 14,28-31but within clinical
acceptable limit28, 32. Grinding by silicon
carbide bur should only be used when other
methods are not available (Figure 11.7).

A B

Figure 11.7 Bracket recycled by silicon carbide bur. Note

the bracket mesh is damaged. All rotatory instruments are
ineffective in removing adhesives from undercuts and from
the holes of the mesh. Any effort to remove adhesive from
these areas result in leveling of bracket base.
C
2. Flame Method

Flame method as the name indicates is

based on principle of heat application.

One way to recycle brackets is to hold the

bracket in a bracket holder under direct flame D
until the bracket becomes red hot. Then Figure 11.8 A. Bunsen flame. B. Flame gun .Flame gun
quench the bracket in water at room is more convinient in dental office than bunsen flame. C.
Bracket are heated under flame gun or bunsen flame until
temperature and dry the bracket in air stream they become red hot. D. Discoloured bracket holder used
(Figure11.8). Remove burned adhesive on routinely for flame method of recycling.
bracket base by dental probe. This is quick in
office method for recycling metal brackets.
But this method will cause bracket to discolor
and also decrease the bond strength below
acceptable limits 27,29,30 (Figure 11.9). Flame
method also cause discolouration of bracket
holding instrument.

To avoid problem of discolouration and to

increase bond strength Buchman33 introduced
modified flame method.
A
Figure11.9 A. Bracket recycled by flame method.
Adhesive remnants remain in bracket mesh decreasing the
bond strength. These adhesive remnants will remain in the
mesh if sandblasting or ultrasonic cleaning is not done .
262
 Recycling of orthodontic brackets
Also changes in metalic structure at atomic
level cannot be avoided by Buchman method.

Clinical Notes
A separate bracket holders should be used for
recycling of brackets by flame method . Also
clinician or his technician should use special
thermal insulating gloves while using flame
method. If such gloves are not avaliable its
better not to use gloves than using latex
gloves.Latex gloves if get burned stick to
your skin and causes servere damage.
B
Modified Buchman method ,The Acid
Bath

Instead of sanblasting Dawjee 35 suggested

C
Figure 11.9 B. Bracket recyled by flame method has lost
its metalic lusture. C. Right central and left lateral incisal
bracket recycled by flame method.Such discoloured
brackets are easily noticed and raise esthetic concerns of the
patient.
Buchman modifed flame method:
Hold the bracket secured in a bracket holder
in a bunsen flame at approximately 1200° C
for 5 seconds till the bonding agent is
iginated and burned off then quench the
bracket in water at room temperature.
Sandblast the base of bracket with 50 µm
aluminum oxide for 10 seconds. Keep the
bracket base perpendicular to tip of
sandblaster with a 10 mm distance between
the two. Line pressure is maintained32 at 72.5
psi.The bracket is then electropolished for 20
seconds .
Because of electropolishing in this method
bracket lusture is restored but controversy
still exist 14,34 about increase in bond strength.
263
that the flamed brackets shouuld be
submerged in an acid bath of 32%
hydrochloric acid and 55% nitric acid, mixed
in a 1:4 ratio for 5 to 15 seconds. This process
dissolves any adhesive residue from the
bracket base, remove tarnish from the
brackets and has a disinfectant effect. The
bracket should be rinsed under running water
for 30 to 60 seconds after the acid bath.
Limitations of flame method
The use of heat in flame method can effect the
microstructure of brackets. As most
orthodontic brackets are made of austenitic
stainless steel and if steel is heated between
400°C to 900°C chromium carbide
precipitation36 will occur leading to structural
weekening of the steel. In addition, the loss of
chromium from the metal will result in
decrease in the corrosion resistance and
dimensional stability of the alloy (Figure
11.10). Temperatures above 650°C will
anneal (soften) the metal thus effecting the
capability of bracket slot for a effective
torque control .
Flame method though give acceptable bond
strength but as a temperature of
Recycling of orthodontic brackets
approximately 1200° C is used in flame
method therefore it is not ideal for metal
brackets. But because of low cost and
covinience of use this is one of the most
popular method in underdeveloped countries.
CHAPTER 11
acetone on bracket base. Dry the bracket with
compressed air (Figure 11.11).
Many contemporary brackets uses
mechanical retention .But if some bracket has
combination of mechanical and chemical
retention or chemical retention alone before
debonding than chemical retention would be
lost by flame method (Figure 11.11C). This
chemical retention can be restored by
applying silica coating and silane coupling
agent on a recycled bracket base.

Figure 11.10 A bracket recycled by flame method

and used in clinical practice for a year. Rusting of the
bracket is evident as flame method weaken the metal
structure of bracket.

Clinical Notes
A
In self ligating metal brackets flame method
will only discolor the brackets if its solely
made of stainless steel. This is usually the
case in passive self ligating bracket where the
self ligating clip is also made of stainless
steel. In active self ligating brackets the self
ligating clip is usually made of NiTi. Flame
method will simply diminish the shape
memory of the NiTi clip and the bracket after
recycling will behave as a passive self
B
ligating bracket.So active self ligating
brackets should not be recycled with flame
method.

Recycling Ceramic brackets

Lew and Djeng Method 37

Hold the debonded bracket in tweezer or C

bracket holder and heat it on a orthodontic
flame gun until it turns cherry red. Allow the
bracket to cool slowly until it reaches room
temperature. Remove the burned chalky
white adhesive on bracket base by tapping
the bracket on table top or using dental probe .
Apply 100 % isopropyl alcohol or pure
Figure 11.11 A. Ceramic bracket is heated until it
became cherry red. B. A recyled bracket with mechanical
base.Some adhesive still remain embeded within the
bracket base.This can be removed with dental probe or
ultrasonic cleaning. C. A recycled ceramic bracket with
previous chemical base. Silane coating of the bracket is lost
if recycled by flame method. A new coating needed to be
done after the recycling process.
264
 Recycling of orthodontic brackets
Bond strength of recycled ceramic bracket by
material.The exact compsotion of the
flame method38,39 is found to be less than new
material is not revealed by the manufacturer
brackets but within clinical acceptable limit .
even on personal communication. This
This less bond strength has advantage of less
attaching material don't withstand the high
enamel damage during debonding. As
temperature of flame method. It is a personal
ceramic brackets are manufactured at high
experience that in some brackets the slot
temperature the application of heat for
even slide within the bracket immediately
recycling has no deteriorating effect on
mechanical properties as compared to metal after heating.
brackets. Flame method can effectively be Ceramic bracket cannot be electropolished .
used with mechanical base ceramic brackets. Electropolishing the metal lined slot may
weaken the union between the bracket and
Clinical Notes
slot. So it should be done with caution.
Debonded ceramic brackets used within
patient mouth have plaque and other
bacterial product of oral cavity attached to
them. Recycling of these brackets by flame
method will discolor the brackets (Figure
11.12). So brackets should be cleaned by
ultrasonic cleaning both before and after
recycling. Any adhesive remnants remained
on bracket base can be removed with dental
probe or sandblating. Sandblasting should be
avoided in monocrystalline bracket as it A
increase chances of bracket fracture.

Figure 11.12 Ceramic recycled by flame method .
Discoloration of the bracket face occur due to plaque
remnants on the brackets . This discoloration is more with
polycrstalline brackets than monocrystalline brackets.
Clinical notes
In ceramic brackets with metal lined slot the
slot get discoloured on flame method
(Figure11.13). Also the metal slot is retained
within the bracket by a unknown
265
B C
Figure 11.13 A. Discolored SS slot of the bracket after
flame method. B. A bracket slot of new bracket attached to
main bracket body by some unknown material. C. Bracket
slot after flame method. Some attachment material is lost
with flame method.
Clinical Notes
In self ligating ceramic brackets flame
method will always discolor the self ligating
component of ceramic bracket as this part of
the bracket is made of metal. Flame method
is contraindicated with active self ligating
ceramic brackets for reason explained
before.
Recycling of orthodontic brackets
3. Chemical Method
Various chemicals are used for removal of
adhesives from the bracket base. If brackets
are immerced in a 95 % sulphuric acid
solution for 10 minutes all adhesive from the
bracket base would be removed but bond
strength after recyling is less than
acceptable27,29. 3% hydrofloric acid have been
used but have shown decreased bond
strength19,39 which is below clinical
acceptable limits.
Alpident company provide a non acidic
solution for recycling brackets. The company
don't reveal the chemical composition of
this soloution. In this method the brackets
are washed in this solution followed by
drying the bracket and heating them at 350°
C for 24 hours. Brackets are then washed
again twice in the non acidic solution, dried
and electropolished for 20 seconds and then
sterilized at 250 °C. This method was found
to be effective for both stainless steel 40 and
ceramic brackets41.
4. Sandblasting
Sandblasting or air abrasion was introduced42,
43
in 1950s. It uses a high stream of aluminum
oxide which is propelled by compressed air. It
was originally used in dentistry to increase
the retention of crowns and veneers. In
orthodontics it was introduced 45, 45 to increase
the mechanical retention of new orthodontic
attachments by roughening the internal
surface of bands and brackets bases.
Sandblasting by aluminum oxide has shown
promising results in recycling of all types of
orthodontic brackets. These air borne sand
particles remove residual adhesive material
from debonded bracket bases and result in
increased bracket base surface area by
increasing surface roughness. This technique
is extremely useful as it can be done in the
dental office.
Method
CHAPTER 11
In this method the debonded bracket is
gripped in a bracket holder with base of
bracket facing outward. Depending upon its
types the sandblaster can be directly attached
to the dental unit or it can be a specialized unit
requiring only air and electric supply. In
specialized sandblasting units sandblasting
of debonded bracket is mostly done in a dust
confinement chamber. The chamber consists
of roof glass door so that the operator can
place things within the chamber and also
control the blasting procedure. The chamber
also consists of light source within for easy
visibility. There are two side doors on left and
right of the chamber from which the operator
enter his hands and hold the bracket holder in
one hand and sandblaster pen in other hand.
Within the chamber the bracket is held by a
bracket holder in such a way that the base of
the bracket is at right angle to tip of
sandblaster. A foot paddle controls the line
pressure. Ideally sandblasting should be
followed by ultrasonic cleaning to get rid of
sand particles embedded within the bracket
base 46.
The complete description of sandblasting is
given in figure 11.14.
Particle size of sand
The selection of sand size is somewhat
Clinical Notes
Sandblaster used for recycling bracket has a
pencil tip and is directed at the center of
bracket. Many a time after few seconds of
sand blasting, the center is free of adhesive
remnants while a thick layer of adhesive
remain attached at the corners. This usually
happen when flash is not properly removed
during bonding. Pointing the blaster tip
towards the center of bracket will damage
the bracket base. At this point it is better to
point towards the base area where the
adhesive is present.
266
 Recycling of orthodontic brackets
A B

C D E

F
Figure 11.14 A . Commercially avaliable sandblasting units .The unit has two sand jars to keep different types of sand. The
jar selection knob can be moved up or down to select the type of sand used.The line pressure knob is rotated to select amount
of air pressure for sandblasting procedure.B. The line pressure meter showing air pressure avaliable for sandblasting. C.Foot
paddle.As both the technician or clinician arms are engaged with in the blasting chamber so sandblasting is controlled by
foot paddle. D. Sandblastler pencil tips .The two tips are connected to separate sand jars . E. Sandblasting of debonded
bracket. The bracket is kept perpendicular to sandblaster tip.Ideally a 10 mm distance should be kept between the sandblaster
tip and the bracket base. F. A portable sandblaster specifically for orthodontic purpose with small sand jar .

controversial in literature. In literature

usually 50 µm 18, 23, 27,28,30,32, 47-53 or 90 µm 54, 55
particle sized aluminum oxide is used. In one
study16 120 µm particle size sand has also
been used. So more studies favor 50 µm
particle size as the larger sand particles can
damage the mesh of the bracket56.
Line pressure
Line pressure of 29 psi 16, 50 psi 18, 23,28,30,56, 72.5
Clinical Notes
50 µm aluminum oxide particle size
effectively remove adhesive from the bracket
267
base and give smooth surface. But if the
clinician want to increase the surface area of
the bracket by increasing the bracket micro
roughness then he should use 90 µm. Sand
particle using 90 µm sand particles is more
effective in integral base or bracket with
decreased mesh number (Figure 11.15a). 90
µm particles will level the mesh in brackets
with increased mesh number or thin wire
diameter. Brackets with laser structured
mesh having smaller depth of holes would
also be leveled by 90 µm aluminum oxide
particles.

psi 32, 75 psi 53 and 90 psi 51, 54 has been
Recycling of orthodontic brackets
recommended in the literature. Usually
smaller the particle size greater would be the
line pressure needed for effective sand
blasting. 90 µm aluminum oxide is effective
when used between 60 to 90 psi line
pressures. For 50 um aluminum oxide 90 psi
line pressure should be used.
Distance between bracket base and blaster
tip
The distance between bracket base and
blaster tip can be kept at 3 mm 50 ,5 mm 54 and
10 mm 27,28,32,48,52,53,55. If distance is too small the
blaster tip will project sand only on a small
area of bracket and if it's too large
sandblasting won't be effective. 10 mm is
usually the preferred distance. The distance is
also affected by base surface area of the
bracket. For large bracket base surface area
the distance should be increased.
B to increased time of sandblasting and decreased distance
Figure 11.15 A .Integral bracket bases sandblasted with
90 µm to remove adhesive and increase bracket base
surface area. B. A laser structured mesh. As laser structured
CHAPTER 11
mesh have small holes so sandblasting this bracket base
with 90 µm particle size will level the base of the bracket
and decrease the bond strength.
Time required
The time required to remove adhesive from
the bracket base ranges from 7 to 40
seconds16, 23,27,32,54, 55. However Millett 44 found
that sandblasting new bracket base for 9
seconds cause distortion of mesh structure.
Visual inspection of bracket base for
adhesive removal is more important than
doing sandblasting for a specific time (Figure
11.16). Following factors will dictate the
total time spent.
· Site of bond failure
· Size of sand particles
· Type of adhesives
· Distance between bracket base and blaster
tip
· Line pressure
If the bond failure occur at the bracket
adhesive interference then less adhesive is
needed to be removed and less time will be
Figure 11.16 Central mesh of the bracket destroyed due
between bracket base and blaster tip. Adhesive remnants
still remain at corners of the brackets.Visual inspection of
the bracket during sandblasting is more important than
doing sandblasting for a specific time.
268
 Recycling of orthodontic brackets
required. The greater the size of sand · Bracket base design
particles and more the line pressure ,less
time would be spent to remove adhesives. · Type of adhesive used
Filled adhesives take more time to remove · Enamel cleaning procedures
than unfilled adhesives and 5 to 10 mm
distance should be kept between bracket · Number of Recycling
base and tip of the blaster. If distance is
greater than 10 mm more time would be Bracket base design
spent to remove adhesive. Bracket base design determines their
Effectiveness of sandblasting adhesive capacity 57 and so the bond
strength. It is easy to remove adhesive from
Sandblasting with aluminum oxide is used in simple bracket base design like straight
orthodontics for its simplicity and grooves, projections than complex designs
effectiveness 32,50. As compared to commercial like undercut channels dove tail grooves
methods of bracket recycling sandblasting (Figure 11.7). Also more complex the
can be done within the dental office but it bracket base more time would be spent to
takes more time than flame method and clean the bracket base 50, 60. In mesh bracket
grinding method of recycling 50,51. its easy to remove adhesive from single
mesh base than double mesh base .60 gauge
Bond strength values after recycling by mesh perform better than 80 or 100 gauge
sandblasting is controversial. It has been mesh after recycled by sandblasting 50.
found that sandblasting for bracket recycling
has no uniform effects57. Studies have
reported higher bond strength 28, 58-59 , no
difference or comparable bond strength26,54,55,60
and lower bond strength 12, 14, 23, 27, 48, 52, 61, 62 than
new brackets. In most of the above mentioned
studies bond strength after recycling was
found within clinical acceptable limits. So
sandblasting can effectively be used for
bracket recycling.

Clinical Notes
Some studies16,23 ,63 have recommended use of
silane coupling agents with silica coating to
increase the bond strength of brackets
recycled by sandblasting. This approach is
extremely useful for plastic brackets as these
brackets have the lowest bond strength
among all types of brackets used in
contemporary practice.
Figure 11.17 A dove tail base design of a plastic bracket
destroyed by sandblasting. Undercut areas of this design are
Factors that may affect bond strength of impossible to clean by sandblasting. With plastic bracket
use of adhesive booster or silane coupling agents can
recycled brackets by sandblasting are: increase the bond strength.
269
Recycling of orthodontic brackets
Types of adhesive used
Composite adhesives have a higher shear
bond than cyanoacrylate adhesive at the
second bonding11 and also from glass
ionomer cements.
Number of recycling
Only one recycling has been advocated after
sandblasting 27, 48 if the bracket fails after first
recycling a new bracket should be used.
Repeated recycling will decrease the
effectiveness of sandblasting and destroy the
base of the bracket.
Clinical Notes
Use of primer or bonding agents will increase
the bond strength of sandblasted recycled
brackets27, 48. Sealant or primer will also
increase bond strength of ceramic brackets 62.
5. Laser Recycling
Lasers have been proposed for recycling of
orthodontic brackets. Laser recycling was
found extremely useful for recycling of both
metal and ceramic brackets. Basic
mechanism on working of lasers have
already been discussed in debonding
chapter. As orthodontic adhesive absorbs 64
more than 95% of ultraviolet and near-
infrared light at thickness of 0.1 to 0.5mm so
lasers can effectively remove adhesives from
bracket base.
Different lasers recommended for bracket
recycling are
1. KrF Lasers
2. Er,Cr:YSGG Lasers
3. Er:YAG Lasers
4.CO2 Lasers
1. Krf Lasers
CHAPTER 11
KrF with wavelength of 248nm has been
proposed 31 for adhesive removal with
following settings:
Energy density at 1.3J/cm2
Repetition rate at 2 Hz
The bracket base is held perpendicular to
the laser. 50 to 200 impulses are usually
required for complete adhesive removal
from bracket base.Bond strength attained
with this method was found superior31 to
sandblasting and flame method.
Er,Cr:YSGG Lasers
Composites resins used for orthodontic
bonding have considerably greater
absorption of Er,Cr:YSGG lasers than
ceramic or metal brackets so this laser can
effectively be used for bracket recycling.
Water or air coolant should be used during
recycling procedure to avoid increase in
bracket temperature.
Er,Cr:YSGG lasers are found 28,56,65 useful for
recycling of brackets when operated in non-
contact mode at power setting of 3.5 ,3.75 or
4 watts .4 watts power setter is more effective
but 3.5 watt is safe 28 in terms of bond strength
so 3.5 watts should be used .Pulse repetition
rate of 20 Hz is used with pulse duration of
140 μs.The bracket base is held
perpendicularly at a distance of 1mm from
the laser tip. A 55 % water and 45 % air spray
or 50-50 % each should be used as coolant.
Bracket is irradiated till all the adhesives
from base of bracket is removed.
This method of recycling is found superior
28,56
to conventional method of recycling.
Er:YAG Lasers
Er:YaG lasers with a wavelength of
approximately 2940 nm are also proposed 66,67
for bracket recycling with following settings .
270

Use 250 mJ energy with repetition rate of 12
Hz with an average power of 3 W for 5
seconds. Brackets are recycled in a non-
contact mode and held perpendicular to
device tip.
While Yassaei 53 recommended energy of
275 mJ with repetition rate of 20 Hz with an
average power of 5.5W for 25 seconds using
a air and water coolant . Brackets are recycled
in a non-contact mode and held perpendicular
at a distance of 5 to 7 mm from the device tip.
Er: YAG lasers bracket recycling is found
superior to conventional method of bracket
recycling and even superior 53 to CO2 laser
bracket recycling (Figure 11.18).
Figure 11.18 Er: YAG lasers for stainless steel bracket
recycling.
CO2 lasers
Co2 lasers have also been used for recycling
of the brackets. Following settings have
been proposed 53.
Power output of 5 W with repeating time of
100 ms , pulse duration of 50 ms and spot
size of 0.1 mm. The bracket base is held 2 to 3
mm from the device tip and irradiation is
performed for 1.5 minutes.
Bracket recycled by CO2 lasers yield less
bond strength than other types of lasers.
Because of high cost associated with lasers
so these are rarely used in clinical practice
for recycling brackets.
271
Recycling of orthodontic brackets
Specialized companies for bracket
recycling
There are commercial companies that offer
recycling of all types of orthodontic brackets
and bands. These companies also sell
recycled brackets at a much lower price than
new brackets. The charges for recycling of
brackets are far less than buying new
brackets.
Some of the companies are
1. Ortho-Cycle
2. Esmadent
3. Ortho bonding
4. Alpident
5. ORTHOTRONICS
1. Ortho-Cycle
Orthocycle Company (Hollywood, Florida,
USA) claims that it is the first and only
company in its field that has been certified
ISO 9001:2008, 13485:2003 and CE Mark.
The recycling process of this company use
chemical solvents for bracket recycling. The
brackets are immersed in solvents and high
frequency vibrations are carried out at
temperatures below 100°C to remove the
composite. This is followed by heating to
250°C for sterilization and then brackets are
electropolished for 45 seconds. The company
states 68 that 5-10 μm of metal is removed by
its recycling process as compared to50 µm of
metal by flame method and electropolishing,
which is 30 percent of mesh height. An
optional silanation process is also offered by
Ortho-Cycle, to increases retention of
bracket base.
The recycling process used by Ortho Cycle
company don't cause changes in mechanical
properties 33 of brackets but bond strength of
recycled bracket is less 55,69,70 than new
Recycling of orthodontic brackets
brackets.
2. Esmadent
Esmadent, a division of Esma Chemical.
Highland Park, IL also offers bracket
recycling. The company also offer a
commercial bracket recycling machine called
Big Jane machine (Figure 11.19). With this
system, the brackets are heated to 454°C for
45 to 60 minutes in left half of big Jane
machine which is a furnace. Following this
the hot brackets are quenched in a cold
cement solvent provided by the company and
then ultrasonically cleaned for 10-15
minutes. The brackets are then washed, dried,
and electropolished for 30-45 seconds.
Electropolishing is done in right chamber of
big Jane machine. The brackets are then
placed in sodium bicarbonate solution to
neutralize the electrolyte, followed by hot
water rinsing.
BIG JANE
Figure 11.19 Big Jane machine by Esmadent
As heat is involved in this process this
method is also called thermal method of
bracket recycling. Because heat is used to
recycle brackets is above temperature 450 °C
this method71 will cause carbide precipitation
and so decrease in corrosion resistance and
dimensional stability of the brackets.
The bond strength provided with this method
is less 55, 69 than new brackets though it is in
clinical acceptable limits72. Buchman 33
CHAPTER 11
graded this method of recycling inferior to
Ortho-Cycle while Basudan 32 didn't
recommend this method as it's more
complicated and takes more time to recycle
brackets.
A personal search in January 2014 for new
big Jane machine revealed no result. Only
used machines were found being sold on
ebay.com. Even on company website no
information on bracket recycling is available
and no bracket recycling machine is for sale.
3. Ortho Bonding Company
This company doesn't offer any details on its
method of adhesive removal but it requests
that the bonding agent used with brackets
should be mentioned when the brackets are
sent for recycling. From this it is assumed33
that this company uses heat for recycling the
brackets.
Ortho bonding method result in change in
mechanical properties of the bracket and
therefore it is less acceptable 33.
4. Alpident
Alpident offer commercial recycling of
brackets and also offer a no acidic solution for
bracket recycling. The recycling process of
this company involves both heat and non-
acidic solvent.
5. ORTHOTRONICS
The only information this company provide
is that it do a low temperature recycling and
then super etch the bracket base by
sandblasting to increase retention. No study
till date has been conducted to show
effectiveness of this company recycling
procedure.
Number of times a bracket can be recycled
The total number of times a single brackets can
be recycled is controversial. Commercial
272

companies or reserch sponsered by these
companies put the number much higher. So
there is bais in some studies on this issue .
Different studies found that brackets can
effectively be recyled one time 10,11,27,48,73 ,2 times
5,74
, 4 times 69,5 times 75 and 10 times 41.In most
of these studies effectiveness of recycling is
seen in terms of clinical acceptable bond
strength. But recycling processes involving
electrpolishing will effect slot dimnension. As
ceramic brackets have higher bond strength and
don't have slot alteration problems they can be
recycled more times than metal brackets .
It is a personal opinion that metal brackets
should be only recyled once and ceramic
brackets twice. Only those brackets should be
recycled which don't show distortion and
corrosion of any of its part.
Advantage of Recycling
The only and only advantage of bracket
recycling is cost effectiveness.
Disadvantages of Recycling
The disadvantage of recycling are .
1. More time is spent in recycling than using
a new brackets.
2. Most commercial companies sell brackets
for single use only. Recycling them may lead
to litigation issues if some complication like
material allergy occurs.
3. Bond strength attained after recyling is
mostly lower than new brackets. So there are
greater chances of failure of recycled
brackets.
4. Some recycling techniques result in
decrease of corrosion resistance and
dimensional stability of brackets.
5. Bracket discolouration occur especially
after direct flame method.
273
Recycling of orthodontic brackets
6. Many brackets have slot or base
distortion at time of debonding which are
not easily noticed at recycling. Using these
brackets will yield poor torque control and
final occlusal results.
7. Loss of identification marks of brackets
can occur after recycling.
8. Burning of compositive resin by
application of heat will result in release of
toxic fumes.
9. Greater chances of cross infections
especailly if recycled brackets of other
patients are used.
10. Recycled brackets especially recycled by
heat and chemicals release more ions in
oral fluids than new brackets. The total
amount of ions released from recycled
brackets increases with time 74 ,76.
Selection of best Recycling Method
In short inoffice reconditioning by
sandblasting is the best method. Lasers
though very effective still remain a novel
approch as the high cost involved in buying
these devices. Ultrasonic cleaning should
always be done after every recycling method
used. Using commercial recycling
companie's brackets is a viable option but a
literature search and pros and cons should be
studied before selecting a specific company.
Use of adhesion boosters or promoters are
especially helpful for plastic brackets.
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276
 INDEX
A Bracket prominence,63,86,87,113,
Abfraction, 229
Access bevel, 82
Accessary slots, 61,65,77,79
Accessory tube, 82
Acetone, 222,264
Active ligatures, 134,235
Active self ligating brackets,72,73,264
Adhesion boosters, 255,260,261,273
Adhesion enhancement, 255,257,260
Adhesive precoated brackets,193,196
Adhesive remnants,210,261,265,268
Adhesive removing plier 203,214,240
AISI 21,24,25
All Bond 2, 261
All Bond 3, 261
Alumina Brackets,36
Amelogenesis imperfect,229
Andrew plane,165
Antirotation,98,116
Antisialagogues,190
Aperture diameter,45,46
ASTM,27
Attrition,33,34,160,161,178,229
Austenitic stainless steel,24,25,32,263
Auxiliary features,77,123,
Auxiliary procedures,257
Auxiliary spring ,6,65,67,
Axial position,114,160,161,184,194
B Composite resin ,56,194,223,227,241
Band removing plier ,214,241
Bandeau appliance,1,2,3
Base method, 19,203,205,207.209,257
Begg appliance,5,6,61,172
Big Jane machine,272
Bis GMA ,227,228,235,260
Black triangle,94,161,162,164
Bleaching ,195
Bonding base shape ,57
Bracket base surface area,56,57,59,266
Bracket identification
Bracket identification marks ,58,80
Bracket removing plier ,210,215,249
Bracket sitting area,171
Bracket stem,18,100,208,212,259,
Brazing,13-21,38,42,209,260,
Bristle brush,240,249
Broussard bracket,8
Brown and green stones,243,246
Brown part,16
Buccal groove,88,93,97,127,128,133
Bunsen flame,262
C Deligation saddle,82
Calcium phosphate ceramics,36-38
Canine tie backs ,134
Carbide burs,195,227,243-253
Casting,14,,15,18,23,27,43,47,51.260
Central fossa,84
Ceramic injection molding ,18,36
Ceramic reinforced plastic,216,217
Chamfered slot walls,70,72
Chemical Retention ,50-57,218,220
Chromium oxide,22,26,28,
Chromophores,231
CO2 laser 234,235,252,270
Cobalt Chromium Brackets,27,50,259
Cold working,20,23
Collapsible base ,219,220,222
Composite burs , 243,246,247
Composite plastic brackets ,32,216
Compound contoured base,57,59,104
Computer numerated milling ,16
Connectors,94,160,161,164
Contact angle ,30,46,66,69,102
Contact points,117,118,189,256
Contact sports,256
Continuous mode ,234
Convenience features ,79-82
Corrosion resistance,17,19,21,24-
28,111,260
Counter buccolingual tip,102
Counter rotation ,116,117, 120,122 ,124-
126,130,131,157
(I)
CP titanium,28-30
Cracked teeth ,209
Crown Angulation ,92-94
Crown inclination,99
Crown morphology,136,161
Crown remover,226
Curve of Spee,117, 118,121,123,129, 132,
165,166, 173
D
Debonding plier,205,206,208,210-230
Debracketing, 203
Dentinogenesis imperfect,194,209, 226, 256
Differential anchorage ,6,10
Direct bonding ,169,171,189,256
Distal offset ,88-90,134,137
Distal translation ,95,96,117,124-126
Double mesh base,42,44,269
Dougherty gauges,181
Duplex stainless steel,26
Dust confinement chamber,266
Duplex stainless steel,26
Dust confinement chamber,266
E
E arch,3,4
Edge bevel,107,108
Edgewise appliance,7,13,64,104
Elastic ligatures,72,82
Elastic modules tie backs,132,134
Electrolytic solution ,259
Electromagnetic spectrum,230,231, 233, 234
Electropolishing
Electrothermal debonder , 229
Embrasure,91,92,94,155,160,161,164
Embrasure line,85-90
Enhance polisher,249
Er,Cr:YSGG lasers ,270
Er:YAGlasers,195,233,252,270,271
Erosion ,229
Esmadent,259,271,272
Ethanol ,53,222
Excimer lasers ,232,233
 INDEX
F L
FA point,58,121,165,171,
FACC,92,93,97,99,105,165
Facial point ,85-87
Facial prominence ,85,86,88,90
FDA,257
Feedstock,16
Ferritic stainless steel,25
Fiber reinforced ,246,247
Filling adhesive ,194
First order bend,61,62,163
Flame gun ,229,262,264
Flame method ,19,48,50,70,257,258, 262-
265,270,273
Flamepyrolytic method,260
Flash ,22,168,193,196,218,222-227,
242,266
Foil mesh base ,42,43,47
Free play,107
Frequency,224,231,251,271
Friction resistance,16-18,27,29,31,32,
37,70-73
Gated pulse mode ,234
Gauze or woven mesh base,42,43,46, 50
Gingival hyperplasia,77,209
Gold plated carbide bur,261
Green part ,16
Hand scaler,240,243
Hard tissue lasers,231
Headgear tube,82
HEMA,227,228
Horizontal slot,5,10,65,80
Howe plier,208,212
Hybrid copolymer,32
Hydrofluoric acid,195
Implants,28,34,161,162
Impulse debonding,205,226,227
In and out bends,8,9
Indirect bonding,169,190,195,198,256
Integral bases,47
Interarch relationship,84
Isopropyl alcohol,264
Kinetic energy,227
Kobayashi hook,78
KrF Lasers,270
Microetched bases,42
Microleakage,192
Microretention,47,48,195,240
Mid-developmental ridge,92,93,154,156,158,165
LA point,121,165
LACC,92,93,99,105,159,165 Milling,14-18,20,21,37,47,194
Laminated mesh base,42 Mini mesh base,42
Minimum Translation series,95,96,102,123-125
Lang brackets,8
Laser structured bases,48,50,54,267,268 Moisture insensitive primer,192
LED curing light,192,195,199 Molar offset,88,90-93,98,127
Lewis brackets,7,8 Moment arm,66,69
Lift off debonding plier,199,212,213 Monobond plus,261
Ligature cutter,82,210,211,221,242 Monocrystalline brackets,35,37,38,55,
Light wire appliance,6,9,10,172 232,233,235,265
Line pressure,47,197,260,263,266-269
Lingual brackets,10,111,214,215
Long axis position,93,158,160,161,184 N
Luting adhesive,50,53,194 Nd:YAG,35,48,233,252
Nickel allergy,19,20,22,28,30,31,33
M Non vital teeth,220,221
Notching,205,223
Magnetostrictive scaler,224,240
Manufacturer tolerance,99,108
Marginal ridges,166-173
Martensitic stainless steel,25,26
O
Occlusal plane,92,93,97-
Maximum translation series,95,96,102,123,124
99,105,106,112,117,127,129,133,135,
Meccaca Monkey,228
136,162,166,182
Mechanical Retention,42,46-48,50-
Open area percentage,46,47
52,54,55,218
Optimesh base,42
Mechanotherapy,107,109,126,130
Ormesh base,42
Medium translation,95,96,102,119,124,125,137
Ortho bonding,271,272
Mesh diameter,44,45
Ortho Solo,261
Mesh gauge,44
Orthotronics,271,272
Mesh number,44-46,50,267
Mesh type bases,48,50
Mesial offset,90,122,126
Mesial translation,95,96,124,125 P
Mesiobuccal cusp,84,88,91,92,97,98,123,127,156 Passive self ligating
Mesiobuccal groove,88,91,92 brackets,10,72,73,109,264
Mesiodens,161,162 Pellicle,189
Mesiodistal Crown tip,92 Peppermint oil,222
Mesiodistal position,153,154,156,157,183-186,194 Perforated bases,42,43
Mesiolingual cusp,84,91,92,127 Phosphoric acid,190,195,240
Metal injection molding,14-18,27,47 Photoablation,232,235
Metal sintered bases,48 Photoetched bases,42,47
Metallic luster,263 Photon,231
Micro mesh base,42 Piezoelectric scaler,224,240
(II)
Pin and tube appliance,4
Plasma arc curing light,192
INDEX Separators ,199
Shape of brackets,80
Torque in the Base,58,100
Torque in the face,58,59
Plasma coated brackets,48,50 Siamese bracket,7 Torque play,15,72,107,108,110
Plastic Brackets,14,19,31-34,51-53,68-71 Side cutter,210,213,223 Torque zone,112
Plastic injection molding,19,31 Silane coupling agent,50- Torqueing springs ,63,79
Plastic primer,51 54,195,260,261,264,269 Tribochemical method ,260,261
PoGo polisher,247,250,253 Silica coating,52,261,264,269, True twin brackets ,68,69
Polyacrylic acid,191,222 Silica lined slot,70 Tungsten carbide bur,244-253,261
Polycrystalline brackets,18,34-38,55,232-235 Silicon tray,196,197 Twin bracket,7,35,56,68,69,208
Polymer mesh base,51,54 Single mesh base,42,44,269 Twin wire appliance,6,7
Polyoxymethylene Brackets,31,32 Single slot brackets,7,67
Sintering,16-18,26,35,36
Polyurethane brackets,31,32
Porcelain veneers,195
Power arms,77-79,81,94,95,99
Slip planes,218
Slot base,71,72,86,87,105,
U
Preadjusted edgewise 110,116,117,208 Ultra pulse mode ,234
Slot creep,32 Ultrasonic cleaning ,257,258,262,264-266,273
appliance,8,9,64,83,102,153,158
Precious metal brackets,21,30,31,51 Slot point,58,77,86,87,94,95,116 Ultrasonic debonding ,22,224-227

Precipitation hardening,25,26 Slot rotation,116 Ultraviolet light ,233

Prescription,9,10,15,22-24,61-63,67, 69, So flex discs,247,248,253 Universal brackets ,6,7

83,87,90-96 Sodium bicarbonate,259,272

Primer 31,32,51.190,191,199,260, 261, 270
Protective goggles ,194,195,222
Soft tissue lasers,231,233,234
Soldered,2,4,7,13,162,189,256
Speed brackets,166
V
Pulse mode ,231,234 Van der Waal forces ,227
Pumicing,189,190,199240,243,249-253 Standard brackets,61,69,95,100,
Vertical groove ,93
102,119,120,129
Vertical Mid Scribe line,79

R Steel burs,139,243
Recycling ,110,198,206,208,209,215,227,251,255
Replaceable tips,221
Resin modified Glass ionomer cement,56,194
Ribbon arch appliance,4-6,61
Roller coaster effects,34,121
Rotatory instruments,240,243,252,255,257,261
Roth extra torque,131
Roth Surgical,129,130
Steel ligatures,34,72,109
Straight wire appliance,8,9,58,84,94,
100,102,117,119,162
Super Austenitic Stainless steel,25
Super Ferritic stainless steel,25
Super pulse mode,234
Super snap discs,247,248
Super torque,123,127,128,131,136,141
Supermesh base,44,50
Vertical slot ,5,7,8,61,65,67,79,80,219
Vickers hardness,17,23,109
W
Wagon wheel effects,114,115,119,132,
134-136
Wavelength ,192,230-235,270
Weingart plier,212,219,220
Wick stick,167,181

S T Wing method,19,205-210,212,214-217,
219,257,260
Wire bevel,108
Thermal ablation ,232,235 Wire diameter ,44-46,267
SAE,21
Thermal softening ,232,234,235 Wire guidance,110,143,163,183,184
Sandblaster,251,252,266,267
Third order bends,63
Scaling,189,224,245,250,
Tip edge,10,65,67,79
Second order bends,62
Self etching primer ,190
Self ligating brackets ,9,10,72,109,
Tip edge plus brackets,10,65,67
Tipping,4,10,64,65,123,129 Z
Tipping springs,65
214,264,265 Zirconia Brackets,36,38
Titanium brackets,21,27-31,50,111
Separating medium ,196,197
(III)