CLINICAL TECHNIQUES

Bracket positioning in orthodontics:

Past and present
Dalia El-Bokle,a and Farooq Ahmedb
Giza, Egypt, and London, United Kingdom

Bracket positioning is a fundamental aspect of orthodontics, achieving a three-dimensional force delivery

using a straight-wire appliance. Ideal bracket placement aims to attain esthetic and functional tooth posi-
tion with a consonant smile arc, level marginal ridges and interdigitated buccal segments. Variation in
bracket positioning alters the expression of the prescription of the straight-wire appliance and, conse-
quently, tooth position in 3-dimensions. Various approaches have been proposed for ideal bracket posi-
tioning; however, shortcomings are evident and detailed in this paper. Furthermore, a new customized
method of bracket positioning "Smile arc and marginal ridge approach" is described to accomplish
bracket positioning goals consistently and reliably. (Am J Orthod Dentofacial Orthop Clin Companion
2023;XX:XX-XX)

O rthodontic treatment goals are to achieve ideal

esthetic and functional outcomes. Specific esthetic
goals are to attain ideal incisal show at rest and
smiling, with the incisal heights of the maxillary dentition
following the contour of the lower lip (consonant smile
arc). Other esthetic aims include a gradual increase in
embrasure space from the front to the back of the anterior
teeth. Posterior arch goals include bilateral balanced con-
tacts in static occlusion and canine guidance in dynamic
occlusion with no posterior non-working side interfer-
ences.1 To achieve these goals, posterior teeth require lev-
eled marginal ridges (MRs) and contact points, resulting in
ideal occlusal contacts between maxillary and mandibular
teeth and uniform crestal bone heights. The straight-wire
appliance (SWA) necessitates precise bracket placement
to achieve orthodontic treatment goals through tooth
movement in 3-dimensions.
Incorrect bracket placement can cause deviation from
ideal tooth positioning, leading to the lack of horizontal,
a
Private practice, Giza, Egypt.
b ning of treatment reduces the need for bracket
Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust,
and Treehouse Dental, London, United Kingdom.
All authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and none were
reported.
Address correspondence to: Farooq Ahmed, Guy’s Hospital,
Guy’s and St Thomas’ NHS Foundation Trust, Great Maze
Pond, London Bridge SE1 9RT, United Kingdom; e-mail, Farooq.
ahmed@kcl.ac.uk
vertical, and axial alignment. This may lead to premature
contacts, MR discrepancies, uneven interdental bone lev-
els, periodontal disease, esthetic problems, and mandibu-
lar displacement, potentially predisposing the patient to
temporomandibular disorder and relapse.2
During treatment, incorrect bracket placement can be
corrected through bracket repositioning or wire bends.
Repositioning brackets involves extra clinical time, mate-
rial, re-preparation of the tooth surface and disruption of
archwire sequence to realign and level. The additional
appointments required for repositioning extend the overall
treatment duration. Although finishing bends are without
material cost, they require significant clinical skill in wire
bending and extra chairside time. Adding multiple finishing
bends to an archwire may also lead to undesirable move-
ment in other planes of space and (or) unwanted recipro-
cal movements of adjacent teeth. Such reactionary
movements can be difficult to predict because of a stati-
cally indeterminate force system, and can result in an
occlusal discrepancy and high forces in the periodontal lig-
ament. Therefore, ideal bracket positioning at the begin-
repositioning, wire bends, and treatment duration.3
There is no consensus among orthodontists regarding
an ideal approach to bracket positioning.4 Below are four
common approaches to bracket positioning, their methods
and details of their advantages and shortcomings, followed
by a proposed new approach; Smile arc and marginal ridge
approach [SAMRA] to resolve the various shortcomings.

Month 2023, Vol 00, Issue 00 1

El-Bokle and Ahmed
CURRENT BRACKET POSITIONING APPROACHES
Middle-middle approach
Andrews’ SWA incorporated ideal characteristics of nor-
mal occlusion, in the first, second, and third order. The
bracket is placed where it mechanically fits best to achieve
ideal prescription expression, and to enable consistent
positioning. Andrews recommended bracket positioning
on the facial axis (FA) point because of the perceived ease
of identification.5,6 The FA point is defined as the center of
the FA of the clinical crown (FACC), determined by the
mid-developmental ridge (most prominent portion) of the
labial or buccal surface.7,8 By positioning brackets on the
FACC, theoretically, the mid-transverse plane of the teeth
align, which results in the optimal positioning of each
tooth; however, this requires ideal tooth size and propor-
tion.
It is impractical and time-consuming to clinically deter-
mine the FACC point for each tooth using dental calipers.
According to Armstrong et al,9 the visual assessment of
the FACC is both inconsistent and inaccurate, as it is influ-
enced by various factors, such as altered passive eruption
or swollen gingiva, wear of the incisal edges, and asym-
metric morphology of teeth, resulting in aberrant bracket
positioning. The variability of the buccal surface morphol-
ogy is an important factor in locating the true FACC point,
as it may not necessarily coincide with the most prominent
portion of the labial surface,7 as well as considerable eth-
nic group variation of crown shape or size.10 When tooth
size disproportion or unequal attrition is present, MRs are
not amenable to leveling. One study investigated bracket
positioning using the FA point on posterior teeth and
showed, on average, 1 mm of irregular MR levels, mainly
due to variation in anatomy (Fig 1).11 In addition, up to one-
third of smile arcs are flattened through iatrogenic pro-
cesses with the middle-middle approach.12
Marginal ridge approach
Ricketts13 first proposed the MR as a reference for verti-
cal bracket positioning and subsequent leveling.14 This
approach disregards the labial or buccal height of the
tooth as a determinant of vertical positioning. The
Fig 1. Occasional uneven MRs when brackets are positioned on
the FA point.
2 AJO-DO CLINICAL COMPANION
approach involves identifying the MR of each posterior
tooth and establishing the MR line, from which the vertical
position of the bracket, known as the slot line (SL) can be
identified.15 Posterior brackets are positioned initially, fol-
lowed by anterior brackets, occasionally using the first
premolar as the reference.16 The proposed advantage of
this approach is a reduction in vertical bracket positioning
errors, specifically in the posterior segment, because of
anatomical variation in cusp heights and wear. This
approach has also been implemented in Kalange’s indirect
bonding technique.17
The marginal ridge approach is specific to the posterior
segment, with variability in bonding the anterior segment.
It is difficult to implement this approach clinically during
direct bonding as MR levels cannot be located accurately
from the buccal aspect (Fig 2).
Bracket chart approach
Bishara first proposed the use of bracket charts.18 This
approach achieves bracket positioning in the middle of the
tooth (mesiodistally) using the incisal or occlusal edge as
the vertical reference point.19,20 Bracket placement with
MBT charts follow a pattern established from the crown
height of the first premolar, using the corresponding row
values from the chart to determine bracket height from the
incisal edge (Table I). The general pattern of anterior teeth,
with MBT charts, involves placing the maxillary canine and
central incisor brackets at the same height, with the lateral
incisor bracket 0.5 mm more incisal. The proposed advan-
tage of this approach is a reduction of vertical errors com-
pared with Andrews’ middle-middle approach.9 Vertical
bracket positioning is considered reliable when this
approach is applied using a bracket gauge.21 Vertical accu-
racy is higher using bracket height positioning gauges than
with Boone gauges (mean difference, 0.96 mm; P
<0.001).21
The reliability of this approach is based on the premise
of ideal tooth size; however, it is not accurate for arches
with tooth size discrepancies, or teeth with worn edges or
cusp tips. The maxillary and mandibular premolars had
Fig 2. Locating the MR line clinically is difficult as MRs cannot
be seen from the buccal aspect.
 El-Bokle and Ahmed

Table I. Comparison of MBT bracket chart and SAP chart of ver- point. The lateral incisor bracket and the maxillary central
tical bracket positioning incisor bracket are usually placed 0.75-1.0 mm and
1.5 mm more gingival to the canine bracket, respectively.
Variables 1 2 3 4 5 6 7 Gingivally placed anterior brackets can result in a
reverse curve of Spee in the maxillary arch and an increase
Maxilla in overbite due to relative extrusion. Occlusal plane rota-
MBT Average 5.0 4.5 5.0 4.5 4.0 3.0 2.0 tion can also occur in a clockwise direction. Gingival swell-
ing can occur from the lack of clearance between the
SAP, 11 mm 6.5 5.5 5.5 5.0 4.5 3.5 2.5
bracket and gingiva especially with suboptimal oral
(GSP-A)
hygiene. Anterior embrasures can be significantly steep-
Mandible ened with this approach and may appear unsightly.
MBT Average 4.0 4.0 4.5 4.0 3.5 2.5 2.5
Current bracket base designs consist of compound con-
touring, which relies on bracket positioning on the FACC
SAP, 10 mm 5.0 5.0 5.5 5.5 5.0 4.0 4.0 point. Significant positional deviation from this point can
(GSP-A) lead to improper seating of the bracket, resulting in
Note. Table adapted from McLaughlin et al36 and Castellanos and altered expression of the prescription.27
Pitts.26
GSP-A, guide position smile arc. A NEW COMBINED APPROACH: SAMRA
A new approach is detailed below, incorporating fea-
clinically significant MR height discrepancies when this tures from previous approaches to achieve the ideal goals
approach was evaluated.22 Although this approach has of bracket positioning in three planes. This approach can
improved vertical height accuracy, angular errors (consid- be used with direct as well as indirect bonding. Bracket
ered a more significant bracket positioning error) were positioning is formulated by assessing physical or digital
high, with an average error of 5.54°.23 Esthetics of the smile study models, with the demarcation of vertical, axial, and
can be detrimentally affected with bracket charts, as the mesiodistal planes. Identification of the planes is detailed
maxillary canine brackets are placed 0.5 mm gingival rela- below. With the use of SAMRA, dental and gingival anat-
tive to the lateral incisor, resulting in a flat smile arc (Fig omy is considered, with recontouring of uneven incisal
3). edges and worn cusp tips before bracket positioning, to
Smile Arc Protection approach. The SAP24 approach enhance esthetics and to ensure that anatomic reference
was introduced by Thomas Pitts in 2009.25 This approach points are reliable. Consideration of the desired gingival
is based on the vertical position of the maxillary incisors margin levels in patients with a high smile line is taken into
relative to the upper lip, in order to achieve a consonant account to decide between recontouring and restoring a
smile arc. Bracket positioning of the teeth is established defective incisal edge.
using the crown height of the canine tooth. The canine The posterior segment is bonded first. The MR line is a
crown length is measured from the zenith of the gingiva to vertical reference in the posterior segment from the termi-
the cusp tip (termed guide position smile arc). The corre- nal molar to the canine tooth. First, the mesial and distal
sponding values from the bracket chart are used to deter- MRs are identified and marked on the dental models. Then
mine bracket heights of the other teeth from the incisal the marks are carefully projected buccally and joined using
edges (Table I).26 The canine bracket is placed gingival to a sharp pencil forming the MR line.13,28 Bracket positioning
the mesial and distal contact line slightly incisal to the FA starts with the first molar; in most patients, the end of the

Fig 4. Construction of the SL occurs after identifying and

drawing the MR line (black) on the buccal surface. The end of
the buccal fissure is used to locate the SL (red). X, The
Fig 3. Flat smile line because of bracket chart approach. distance between the MR and SL.

Month 2023, Vol 00, Issue 00 3

El-Bokle and Ahmed
Fig 5. The distance between the MR and SL (ie, X) is transferred
to all the posterior teeth and the canines.
buccal fissure (usually at the maximum occlusogingival
convexity of the buccal surface) is marked, and the SL is
drawn through it parallel to the MR line (Fig 4). The dis-
tance between the MR and SL is then measured and trans-
ferred to the adjacent posterior teeth (Fig 5). Such vertical
slot positioning coincides with the green zone for ideal tor-
que expression (Fig 6). Bonding gingival to the green zone
results in more negative torque expression and vice
versa,11,23,29 which is more critical when bonding posterior
teeth, especially mandibular premolars and molars,
because of their convex buccal surfaces. Small differences
within the safe zone have negligible effects on torque
expression, § 0.5 mm = 2.13°, whereas bonding outside of
the zone for posterior teeth, § 1.5 mm results in a 9.04°
torque discrepancy.30
In the maxillary arch, the lateral incisor bracket is
placed at the same level from the incisal edge as the
canine bracket. The central incisor bracket is placed 0.25-
0.50 mm further gingival than the lateral incisor, depend-
ing on tooth size (the larger the tooth, the larger the step)
(Figs 7, A and B). The central and lateral incisors in the
mandibular arch are positioned at the same height;
0.5 mm more incisal than the mandibular canine bracket
height.
A vertical line is drawn through the center of each tooth
after the identification of the mid-developmental ridge
(most prominent portion) of the labial or buccal surface
perpendicular to both the MR and SL, representing the
long axis or FA. The center of the bracket should coincide
with this line when checked from the occlusal plane,
Fig 6. Green or safe zone of vertical bracket positioning. If
brackets are placed within the safe zone, ideal or close to ideal
torque expression occurs. Positioning outside this zone will
result in underexpression or overexpression of the torque
prescription.
4 AJO-DO CLINICAL COMPANION
Fig 7. A, SL (red), axial lines (blue), and distance from the
incisal edge to slot line for maxillary teeth (Y); B, SL (red), axial
lines (blue), and distance from the incisal edge to slot line for
mandibular teeth (Z).
except for canine brackets. Maxillary and mandibular
canine brackets should be placed 0.5-1.0 mm mesial to
the FA, depending on the mesiodistal canine width (Fig 8).
The long axis of the bracket should be aligned with the
FA line of the tooth and is identified through clinical and
radiographic methods. A panoramic radiograph or cone-
beam computed tomography is used to confirm the FA of
the crown and root (usually coincident), ensuring root par-
allelism. In the case of root dilaceration, only the crown FA
is considered.
After the identification of the FA and SLs on the dental
cast, the vertical distances from the cusp tips or midincisal
edges to the intersection between the FA and the SLs are
measured and recorded on the model using calibrated dig-
ital calipers or a gauge of 0.25 mm increments. The vertical
and axial bracket position for each tooth is then replicated
intraorally during direct bonding. The bracket gauge or cal-
ipers are held perpendicular to the facial surface, as
Fig 8. The canine axial line should be drawn slightly mesial to
the long axis of the tooth. The mandibular left canine
demonstrates correct positioning slightly mesial to the middle
of the tooth, while the mandibular right canine shows incorrect
positioning being placed on the middle of the tooth.

Fig 9. Transferring measured bracket positions using SAMRA
from the cast to the patient using dental calipers.
angulation variation can alter the vertical measurements
up to 2 mm31 (Fig 9). To aid the process, a clinical assistant
can hold the model with the marked measurements to the
clinician during bracket positioning, or a digital scan with
the measurements can be projected on a large screen visi-
ble during bonding. The advantages and disadvantages of
SAMRA have been compared with the previously men-
tioned approaches (Table II).
To improve occlusal outcomes anteriorly and increase
incisor show, anterior extrusion can be achieved by posi-
tioning the anterior brackets (canine to canine) 1.0-1.5 mm
more gingival, depending on tooth size (Fig 10, B).32 Ante-
rior brackets (canine to canine) can be positioned 1.0-
1.5 mm more occlusal for relative intrusion (Fig 10, C).32
A compensated tip may be added during bracket position-
ing in selected patients to counteract or accentuate the
expected tooth tipping during tooth movement (eg, canine
retraction, root uprighting, and closure of a wide diastema).
Brackets can be placed mesial or distal to the FA to con-
trol tooth rotation (eg mesiopalatal rotation of maxillary
molars in patients with maxillary first premolar extraction).
Such a customization can also obviate the need for antirota-
tion bends required during space closure in premolar
extractions, as canine teeth tend to rotate distopalatally
and second premolars to rotate mesiopalatally.
DISCUSSION
Orthodontists using current bracket positioning techni-
ques have deficiencies that often require repositioning or
compensatory bends. SAMRA has been developed through
a detailed appraisal of previous techniques and can be
considered a customized, reliable method for bracket posi-
tioning. It takes into consideration both esthetics and func-
tional occlusion. The approach has been described as a
direct method but can also be applied with indirect bond-
ing for greater accuracy.
Month 2023, Vol 00, Issue 00
El-Bokle and Ahmed
The advantage of SAMRA is that it combines the func-
tional and occlusal benefits of the MR approach with the
esthetic premise of the SAP approach (Fig 11). Vertical
positioning of posterior brackets (SL) is determined
according to a fixed distance from their respective MRs.
The distance is based on the clinical molar crown height,
not average measurements or visual estimation of the
tooth center. Tooth wear or tooth size variation does not
alter the reliability of bracket placement, ensuring level
MRs and contact points necessary for optimum mastica-
tion and periodontal health (included in American Board
of Orthodontics grading). Anteriorly the difference
between bracket heights is not fixed and varies propor-
tionally depending on tooth size; a subtle vertical differ-
ence between anterior bracket heights achieves a
consonant smile arc while avoiding steep and unsightly
embrasures. This approach can also be customized to
help correct overbite and incisal show. Axial advantages
of this approach are 2-fold, identification and clinical
application. Identification of the axial plane occurs
through both clinical and radiographic methods, whereas
previous methods only applied clinical means, which are
subject to visual error, as well as variation in buccal mor-
phology resulting in greater errors in clinical positioning.
SAMRA allows for accurate transfer of the precisely deter-
mined bracket positions from dental casts to the patient’s
teeth during direct bonding. Mesial positioning of the
canine bracket on the FA results in a mesial out rotation,
creating an ideal MR contact between the convex facial
profile of the canine and the relatively flat lateral incisor.
Bonding molar tubes in the center of the tooth avoids a
distolingual rotation, especially in patients with molars
with a large distal cusp.
Occlusal function is a key parameter of orthodontic
treatment outcomes, with ideal interdigitation imparting
occlusal stability.33 Bracket positioning and occlusal out-
comes have been investigated by Eliades et al34 who con-
cluded that placing the slot in the FACC point of premolar
teeth can result in a discrepancy of MR heights between
premolars and molars and a lack of occlusal contact with
the opposing teeth. Canine guidance varies among the ear-
lier described approaches, with bracket charts more likely
to achieve better canine guidance than the SAP approach.
In SAMRA, canine guidance is readily achieved through a
subtle transition of anterior vertical positioning (compared
with steep transitions of SAP) and a 0.5 mm gingival posi-
tion of mandibular canine brackets to favor canine guid-
ance.
Accuracy of direct bracket placement has been found
to vary significantly,9 independently of clinical experience
or specialist training.35 This new approach seeks to
improve the accuracy of bracket positioning with esthetic
and functional goals but also increase reliability through a
clear method of direct bracket positioning.
5
El-Bokle and Ahmed

Table II. SAP chart of vertical bracket positioning

Approach Middle-middle MR approach Bracket chart SAP approach SAMRA

approach (MMA) (MRA) approach (BCA)

Positioning of FA point MR height (posterior Predetermined height Predetermined height Posterior teeth: MR
bracket only) from incisal edge to from incisal edge to height
bracket slot bracket slot with ver- Anterior:
tical compensation customized from U
for smile arc 3-3 with more subtle
steps than SAP
Advantages Anatomic position Level posterior MRs Better vertical accu- Better vertical accu- Level posterior MRs
racy than MMA9 racy than MMA and a and a consonant
consonant smile arc smile arc
Wear aberrant gingi-
val levels do not
affect posterior
positioning and are
adjusted before
anterior positioning
Identifies MRs and
axial lines accu-
rately on models
Mid-transverse planes Reduce posterior Reliable vertical posi- Reliable vertical posi- Reliable vertical posi-
align (if optimal tooth positioning error tion when combined tion when combined tion (digital calipers)
size) with gauge21 with gauge
Wear and gingival Smile arc is main- Smile arc is main-
aberrancy does tained/corrected tained/corrected
not affect the
positioning
Less positioning
errors
Disadvantages Poor reliability and Posterior bracket Wear and tooth size Wear and tooth size Time is taken to
accuracy when visu- positioning only variation result in variation result in assess models
ally assessed incorrect bracket incorrect bracket
positioning positioning
Wear, tooth size varia- Difficult to assess Clinically significant A reverse curve of Requires use of
tion, and gingival MR heights MR height Spee in the maxillary calipers
aberrancy result in intraorally discrepancies22 arch and possible
incorrect bracket bite deepening
positioning
1 mm irregular MR Smile arc is not An angular error of Gingival swelling
level on average34 considered 5.54°23 because of lack of
clearance between
bracket and gingiva
One-third of smiles Smile arc is likely to be Steep anterior embra-
flattened12 flattened because of sures could be
the central incisor unesthetic
and canine brackets
are vertically posi-
tioned at the same
height
Potential improper
seating of brackets
(anterior teeth gingi-
vally positioned)
Prescription expres-
sion is reduced
(anterior brackets
gingivally positioned)
Note. Table 1, figures taken from Castellanos 2014, with 0.5 mm direpency from Pitt’s original proposal.26

6 AJO-DO CLINICAL COMPANION

 El-Bokle and Ahmed

Fig 10. Vertical bracket variation for specific malocclusions: A, Average vertical relationship (scenario 1); B, Anterior open bite,
increased distance between MR line and slot line for anterior extrusion of 3-3 (scenario 2); C, Increased overbite; reduced distance
between MR line and SL for the anterior intrusion of 3-3 (scenario 3).

AUTHOR CREDIT STATEMENT

Dalia El-Bokle contributed to the conceptulization, orig-
inal manuscript preparation and manuscript review and
editing, and Farooq Ahmed drafted the original manuscript
preparation and manuscript review and editing.

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