Customised Brackets

Dr.Anupa Rawat
PG Student
Dept of Orthodontics and
Dentofacial Orthopaedics
 CONTENTS

• Introduction
• Manufacturing process
• Customised Appliances
1. Insignia
2. Incognito
3. Harmony appliance
4. Lingual Matrix
5. iLingual 3D: (Jigs Lingual Orthodontics)
• Indirect Bonding
• Lingual laboratory procedures
1. TARG (Torque Angulation Reference Guide)
2. Customized lingual appliance set – up service system (class)
3. Bonding with Equal Specific Thickness (BEST) System
4.Slot Machine
5.Lingual Bracket Jig (LBJ)
6.Transfer Optimized Positioning (TOP/INCOGNITO I BRACES
system)
7.Korean Indirect Bonding Set-up (KIS) System
8.Hiro system
9.Convertible resin core system
10.Hybrid core system
• Selecting custom torque prescriptions for the straight-wire
appliance
• Conclusion
• References
 Introduction

• Why would the orthodontist want to customize treatment? Current

bracket systems are based on an average tooth shape—but only a small
percentage of our patients will have average teeth.

• The inter and intra-individual variation is the reason why orthodontists

must adapt their treatment to patient’s specific tooth shape and
morphology in order to achieve ideal alignment, esthetics, and occlusion.

• New three-dimensional technology in the design and production process

allows manufacturers to produce brackets individualized to each patient.
 THE PROCESS

Digital models are generated from impressions acquired before treatment.

to create a virtual setup.

Setup sent to orthodontist for refinement and approval

Brackets without slots are placed virtually on the teeth. The slots are cut into the
actual brackets based on their position on the tooth in the setup .

This will allow for insertion of a straight final full-size wire. The relative position
of a bracket to its tooth is recorded on the setup and transferred to initial model.

An indirect bonding tray composed of bracket transfer jigs is created to transfer

virtual position of bracket to patient’s mouth.

Orthodontic treatment will proceed by arch wire progression.

Digital setup with individually
defined bracket
bases.
• By using custom software, the bracket bodies are added to the setup
and the pad surfaces, and are arranged so that the slots are aligned in
the virtual arch wire plane.

• The vertical height, angulation, and torque are thus preset; only
optimal first-order (positioning thickness) adaptation is
performed manually by shifting and turning.
 Custom Orthodontic Bracket Systems
• Custom buccal or custom lingual appliances or a set of aligners
with attachments can be fabricated according to the instructions of
the orthodontist. An increasing amount of companies use
designing software to design custom orthodontic appliances
according to the wishes of orthodontist and the patient.

• The use of an indirect bonding tray for accurate bracket placement

and custom orthodontic wires bend by a wire bending robot has
increased treatment efficiency.
 INSIGNIA

• An Ormco system has been introduced for treating orthodontic patients

with custom buccal brackets.

• Insignia delivers a custom solution for a range of orthodontic brackets

placed on the buccal surface of the dentition. Eg-(DamonQ, Damon
clear and Inspire Ice brackets).

• Insignia uses a virtual planning system, which shows the limits of the
dental arch, because outline of mandibular alveolar can be evaluated
in the setup. Furthermore, occlusion of digital planning in this system
can be evaluated.
• The base of the brackets can be individualized and the virtual
bracket placement can be transferred to the dentition using
indirect-bonding transfer jigs.

Virtual Bracket Positioning

 Incognito™ Appliance System (3M Unitek™)

• Incognito™ is one of the first, time ‑tested, and highly accurate

systems. The most important part of the system is the ability to begin
with the end in mind.

• The orthodontist has the ability to communicate with Incognito™

laboratory team as to show how the teeth may be moved. The
laboratory team employs the orthodontist’s treatment plan to create a
final occlusion mounted on an articulator.

• This articulated setup is the foundation for customized brackets and

wires.
• The entire appliance is made using the state‑of‑the‑art CAD/CAM
technology. The setup model is scanned using a 3D scanner which
eliminates the need for physical models.

• Each individual bracket is custom made through CAD/CAM technology. An

indirect bonding tray is fabricated from the CAD/CAM system. Till this step is
50% of the technology and the other 50% is fabrication of customized
wires bent by robotics.

• A robot can heat‑treat the shape‑memory alloy (copper NiTi) wires into a
custom arch form and position for each individual tooth.
 HARMONY APPLIANCE BY AMERICAN ORTHODONTICS

• It is complete digitally customized self‑ligating (SL) lingual

system that offers exceptional control in all 3Ds from initial
passive phase with small round wires to finishing phase with
large rectangular wires actively ligated.

• It is the first lingual system which combines 3D digital setup,

customized pads, interactive SL brackets, robotically formed
arch wires, and anterior‑positioning jigs.
 Lingual Matrix

• It is another CAD/CAM‑customized straight wire system

invented jointly by Dr. Pravin Shetty and Dr. Manjul Jain.

• The system works on horizontal insertion brackets designed

with preformed lingual straight wires. It is based on the 3D
scanning of upper and lower models using 5‑axis optical white
light scanner, moving each tooth to its ideal position either

virtually/manually.
• Subsequently, the LINGUAL MATRIX (Lingual Matrix,
Mumbai, India) software produces a CAD model of lingual
bracket with a customized base manufactured by a laser sintering
machine to manufacture a customized single‑piece 3D lingual
bracket that adapts seamlessly to the shape and contour of the
teeth.

• The system offers single slot, twin slot, and self ligating brackets.

• The automation and digitization of the entire system promises a

perfect finish with minimum physical and mental fatigue.
 iLingual 3D: (Jigs Lingual Orthodontics)

• The first prototype of iLingual braces was developed in the year

2007 and thereafter several prototypes were produced to modify the
design and make it more user‑friendly and at the same time making
it more efficient for treatment.

• The brackets were made by CAD design manufactured with rapid

prototyping and casted in gold alloy. In 2009, iLingual ribbon
arch stock bracket (0.025” × 0.0175” slot size) was introduced
with vertical insertion in anteriors and horizontal insertion in
posteriors, the same was used with the modified setup for
individualization.
 INDIRECT BONDING PROCEDURE

• SILVERMAN AND COHEN introduced the first indirect-

bonding method in 1974 and used methyl methacrylate adhesive
to attach plastic brackets to model casts in the laboratory. An
unfilled BisGMA resin was used as an adhesive between etched
enamel and a previously placed adhesive
 SONDHIS METHOD

Laboratory procedure
Preparation of bonding trays
1. Working models are prepared

19
2. Application of separating medium and allowed to dry for
approximately 1 hour.

3-Positioning of brackets on the model.

4-curing of upper and lower models.

20
5. A Biostar unit to vaccum
form a 1 mm thick layer of
Bioplast, overlayered with
a 1 mm thick layer of
Biocryl is used for making
bonding trays.

6. The bonding tray’s hard

outer shell should be
trimmed away from all
heights of contour for
patient comfort and closer
fit because it only permits
firm seating of the soft tray.

7. The bonding trays are now

removed from the models and
sectioned off with a bur. 21
Placement of Bonding

Isolation of teeth that are to be bonded with plastic cheek

retractors, tongue away, and cotton rolls.Teeth are dried.

Etching solution 37% phosphoric acid is applied onto the teeth

and kept for 15 seconds.Rinse the tooth surfaces

The etched teeth should have a frosty appearance and be

completely desiccated. If a frosty appearance is not apparent,
repeat the etching process for 15 seconds.

Application of primer and curing

22
 • Resin A can be painted onto the tooth
surface with a brush, and

• Resin B can be painted on resin pads

Small amounts of the indirect in the indirect bonding tray.
bonding Resin A and B liquids
(Sondhi rapid set) should be
poured into the wells.

23
• Position the tray over the teeth and seat the tray with a hinge motion.

• With the fingers, apply equal pressure to the occlusal, labial, and buccal
surfaces.

• Hold for a minimum of 30 seconds. Allow 2 more minutes of cure time

before removing the tray.

Anoop Sondhi.Effective and efficient indirect bonding:Sondhi method.Seminars in

orthodontics;2007Vol 13,No 1
24
 Lingual Laboratory Procedures

• In the last two decades of the twentieth century, lingual

orthodontics saw the development and application of two major
techniques-

1. TARG (Torque/Angulation Reference Guide) and

2. CLASS (Custom Lingual Appliance Set-up Service)

Methods.
 TARG (Torque Angulation Reference Guide

• Torque Angulation Reference Guide (TARG) System

• The TARG machine was launched by the Ormco Society in 1984 as an

important aid to the laboratory technique.

• It allows the accurate placement of the brackets at a precise distance from

the incisal and occlusal surfaces of the teeth, as well as making it possible

to prescribe the torque and angulation for each tooth individually.

• This creates a “virtual” set-up, and the brackets can be bonded on the

malocclusion model, with each bracket having a specific resin modified base.
• The drawback, however, was that the original TARG machine did not
allow pre-programming of in- and out bends for individual teeth.

• Didier Fillion, improved this method in 1987 by adding an

electronic device to the TARG machine with the purpose of
measuring tooth labio- lingual thickness. This improvement reduced
the number of first-order bends in the wire, compensating for the
difference in tooth thickness and making the distance from the slot
to the labial surface uniform.

• Using his DALI (Dessin Arc Linguale Informatise) computer

program he produces an individualized archwire template.
The Electronic TARG has a precise measuring device that
measures the distance (thickness) between the labial surface of
the tooth and the slot of the bracket.
The DALI software coordinates upper and lower arch designs,
making it possible to have the wires constructed in advance, thus
reducing chair side time.
2. CUSTOMIZED LINGUAL APPLIANCE SET – UP
SERVICE SYSTEM (CLASS)

• The CLASS technique offers a method of lingual bracket

placement that takes in account the anatomic discrepancies in the
lingual surfaces of the teeth.
• This is accomplished by first constructing an ideal diagnostic set -
up from a duplicate set - up model of the patient’s ideal
malocclusion.
• This ideal set - up or template is then used as a physical guide to
place the lingual brackets in an ideal configuration.
• The brackets are placed on the diagnostic set - up using
composite adhesive, which acts as spacer between the metal
mesh pad and the individual dental surfaces.

• After the brackets are placed on the ideal diagnostic set- up,
they are next transferred back to the malocclusion cast.

• At this point, transfer trays are fabricated so the brackets can

be delivered clinically via the indirect bonding method.
Thickness difference between different teeth need to be compensated for
during bracket positioning to allow working with a straighter arch wire.
Bonding with Equal Specific Thickness (BEST) System
• In 1986, Fillion developed a new system. He realized that there was an
important feature missing from the original TARG machine—a device
to measure the distance in the horizontal plane from the labial surface of
the tooth to the slot of the lingual bracket.

• He added a precise measuring device to the original TARG machine to

allow compensation for the different thickness between the teeth.

Vasumurthy S.Lingual orthodontics.Indian journal of dental

advancements;2009 1(1)
Slot Machine
• The slot machine was designed by Thomas Creekmore for the
placement of both conventional and lingual brackets directly
onto the malocclusion model.

• The procedure consists of positioning each tooth to a prescribed

torque and angulation; the machine orientates the bracket slot
with the Andrews labial archwire plane (LA plane).
• The slot machine can be used for the placement of brackets
having either horizontal or vertical access archwire slots.

• The fact that no model tooth set-up is required is a major

advantage, but the difficulty in managing the many pieces of
the slot machine might be seen as a disadvantage.

Vasumurthy S.Lingual orthodontics.Indian journal of dental

advancements;2009 1(1)
Lingual Bracket Jig (LBJ)
• The LBJ developed by Geron is the only system that allows direct as
well as indirect positioning of brackets. It consists of a set of six jigs
for the anterior maxillary teeth, one universal jig for the posterior
teeth, and a special ruler.

• The jigs transfer the Andrews labial bracket prescription to the lingual
surface. An occlusal stop measures the height of the bracket from the
incisal edge.

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
Lingual bracket jig; can be used indirectly on the malocclusion model
or for direct bonding in the mouth.
 Transfer Optimized Positioning (TOP/INCOGNITO I
BRACES system)

• The TOP system uses a set-up technique similar to that used for the
BEST system, allowing the brackets to be placed directly on the
malocclusion model.

• The technique uses the TARG Professional, which has a bracket holder
for twin brackets and tubes in addition to the horizontal and vertical
measuring systems first described by Fillion.

• The target set-up is used to find the optimal height for the brackets

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
Korean Indirect Bonding Set-up (KIS) System
• The KIS system was developed by members of the Korean Society
of Lingual Orthodontics (KSLO) and uses a bracket-positioning
machine that allows the positioning of all brackets at once.

• Once again it is necessary to create a set-up model; however, the

set-up is created with the help of a special set-up model gauge for

increased precision.

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
KIS system; all brackets are positioned at the same time
Hiro System
• Two laboratory techniques that do not require special equipment
are the Hiro system and the Convertible Resin Core system.
• The Hiro system was created by Toshiaki Hiro and improved by
Kyoto Takemoto and Giuseppe Scuzzo.
• It still relies on the preparation of a set-up model where the teeth
are sectioned and correctly aligned.
• The brackets are positioned and placed on the set-up model with
the help of a full-sized rigid rectangular archwire.

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
HIRO system; the transfer trays are made individually and
transferred directly from the set-up model to the mouth.
Convertible Resin Core System
• The Convertible Resin Core system uses hard resin to prepare the
individual transfer trays and an elastomeric ligature to hold the
tray and bracket together.

• This allows accurate repositioning of the bracket within the resin

core and the trays can be reused in cases of bracket failure. The use
of unitary trays makes the initial bonding session longer and the
technique still relies on a set-up model to position the brackets.

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
Hybrid Core System
• This is not so much a bracket-positioning system but rather a bracket-
transfer system. The Hybrid Core system developed by Matsuno combines
the favorable properties of silicone and composite resin in the construction of
its indirect transfer tray.

• Silicone covers the bracket and this in turn is covered by composite resin.
This combination allows for stable positioning of the transfer tray within the
mouth, followed by easy removal of the silicone component from the bonded

bracket.

Laura Buso-Frost and Didier Fillion. An Overall View of the Different Laboratory
Procedures Used in Conjunction with Lingual Orthodontics. Seminars in Orthodontics,
Vol 12, No 3 (September), 2006: pp 203-210
Selecting custom torque prescriptions for
the straight-wire appliance
 Torque

• ‘Torque’ is defined as a force causing twist in a structure. The

resulting twist of the mechanical part is called ‘torsion’.
• Torque or root movement of a tooth is achieved by keeping the
crowns stationary and applying a moment to force only to the
root.
• The centre of rotation of a tooth is at the incisal edge in case of
root movement.
• The M/F ratio should at least be 12:1 to achieve root
movement.
• When a rectangular wire is twisted and
inserted into the slot, the opposite sides of the
wire contacts the slot which creates a couple
and generates a moment large enough for root
movement.

• Amount of torque a bracket expresses is the

difference between degree of torque built
into its slot and degree of play between slot
and rectangular wire engaged

• Wire play – as wire can’t be fully expressed

into complete size of bracket lumen.
Slot play- A bracket can rotate in either direction around the flat archwire until
the slot play is used up and the wire locks between the slot walls (slot lock).
The amount of slot play is specific to each individual wire-slot combination.
• Selecting custom torque prescriptions based on treatment needs of
each patient can reduce the amount of routine archwire torque
adjustment needed and speed torque correction, thus reducing the total
treatment time.

• Using the appropriate torque prescription prevents iatrogenic torque

problems and allows most torque corrections to be done earlier with
more resilient nickel-titanium and beta-titanium wires.

• As a result, fewer time-consuming final torque adjustments are needed

with stainless steel finishing wires, resulting in shorter treatment time.
• Any bracket can rotate freely about a rectangular archwire until
the wire becomes locked against the bracket slot walls (slot
lock).
• The total amount of free rotation for each tooth crown, from lock
point to lock point, is twice the amount of nominal slot play .
• Since the bracket can rotate about the archwire in 2 opposite
directions, 2 slot lock points are created.
• Every combination of archwire shape and specified slot size has a
slot play for that particular combination.
Meling et al published a formula for calculating slot play, taking into
consideration :-
• For all teeth, the desired torque prescription calculations are based
on the slot play of the final finishing or detailing archwire.

• Ideally, the final finishing archwire will bring each tooth to its
desired faciolingual angulation. To achieve this, the clinician must
choose a torque prescription and wire size combination that
will cancel out the slot play at the crown's desired final
inclination
• A bracket’s torque prescription the angle that the occlusal and
gingival slot walls make with the plane of the bracket base. Angle’s
original prescription was 0 for all teeth.

• Nominal values are the amount in degrees that the slot inclination
deviates from Angle’s 0 orientation.

• By convention, a positive torque value essentially means that lingual

root torque would be created by a large unadjusted rectangular
wire; conversely, a negative torque value means that facial root
torque would be created.
• If a flat, unadjusted rectangular wire is placed in an edgewise slot
and does not lock against the slot walls, it will provide no
labiolingual forces on the tooth root (torque).

• If, on the other hand, the wire must be twisted before seating in the
slot and remains twisted after ligation (slot locked), it will apply
forces to the roots.
• The 2 lock points create a range of uncontrolled crown torque
values 2 slot-plays wide. The 2 lock points form the
boundaries of the “torque trap.”

• If the initial root angulation is within this range, no torque is

applied until the root position changes enough to lock the bracket
against the wire.

• These lock points also define the desired final inclinations of any
teeth with their root positions initially beyond the lock points.
• Roots previously outside the trap demonstrating any excessive
labial or lingual root positions (eg, Division 2 incisors) will be
attracted to the nearest border of the trap
• The key point is that, before treatment starts, the clinician,
knowing the slot play of the final wire, can pick an optimal
prescription that will set the borders of the torque trap that
either will move the tooth to the desired inclination or prevent
it from escaping it.

• A small selection of off-the-shelf bracket prescriptions will

usually provide torque values that are close enough. The end
point is to minimize repeated routine torque adjustments.
• Andrews’ torque norms are the final torque goals. His seminal
research in tooth anatomy, normal occlusions, and treatment
goals has produced excellent norms for the labiolingual
inclination of facial surfaces of clinical crowns.

• These norms reflect normal crown inclinations and their

corresponding normal labiolingual root positions . All of his

torque values are measured in relation to the occlusal plane .

• In extraction patients, both the maxillary and mandibular anterior
teeth are usually retracted to some degree. Retraction forces tend to
tip the crowns lingually, whereas excessive slot play can lead to
insufficient lingual root torque at the end of movement.

• Class II mechanics often produces a similar effect. To prevent

excessive maxillary incisor lingual tipping, select a bracket
prescription that equals the target torque plus the slot play.

• Retraction will just tip the incisor lingually until the slot play is used
up, then the archwire will lock in the slot at the proper inclination
and resist any further lingual tipping
Root torque generated by a flat wire twisted, as needed, and inserted in brackets with
various slot inclinations.

Corrective torque is developed by bracket inclinations past the slot lock points. Note
the lack of any torque control between the lock points in the torque trap section.
Torque generated by root position. Any root position outside the slot lock points will be
torqued toward the closer slot lock point. Any root position between the slot lock points is
not controlled by wire torque, but it cannot escape past either slot lock point because of
resistant torque buildup
Choose which edge of the torque trap will be active:
1. High torque or low torque position on the torque trap.

2. To correct or prevent excessive facial root positions, add the slot play to
the target torque.

3. To correct or prevent an excessive lingual root position, subtract the slot

play from the target torque.

4. Many off-the-shelf prescriptions can be used.

5.Realistically, very few different prescriptions are needed for any given
tooth.Use only 1 prescription for the mandibular canines, all premolars,
and all molars.

6. Minor torquing adjustments are usually made only in final finishing arch.
 • By selecting the torque prescription needed on a patient-to-
patient basis, the practitioner can use thick unadjusted nickel-
titanium and beta-titanium archwires to efficiently correct
existing aberrant torque situations.

• Proper selection also enables a practitioner to avoid creating

poor iatrogenic torque situations that will then need to be
corrected later.

Earl Johnson. Selecting custom torque prescriptions for the straight-wire appliance. (Am J
Orthod Dentofacial Orthop 2013;143:S161-7)
SITUATIONS TYPE OF TORQUE IN THE BRACKETS

Class I malocclusion with mild crowding Standard

Class I malocclusion with severe crowding Low torque

and incisor proclination

Class II mechanics using Herbst,MARA

PROBLEM
Maxillary lingual inclination Super torque
Mandibular incisor proclination Low torque

Class II mechanics using reverse pull

headgear,facemask therapy
PROBLEM
Maxillary incisor proclination Low torque
Mandibular incisor lingual inclination standard

Non extraction Standard/low torque

crowding

Generalised spacing High torque

 Conclusion

• Customized systems allow orthodontists to initiate treatment

with the final goal in mind, and streamline mechanics towards
a pre-established result. These techniques start by creating a
setup of the desired outcome that serves as a diagnostic aid
and is used for appliance fabrication.
 References
• Laura Buso-Frost and Didier Fillion. An Overall View of the
Different Laboratory Procedures Used in Conjunction with Lingual
Orthodontics. Seminars in Orthodontics, Vol 12, No 3 (September),
2006: pp 203-210

• Vasumurthy S.Lingual orthodontics.Indian journal of dental

advancements;2009 1(1)

• Dirk Wiechmann, Customized brackets and archwires for lingual

orthodontic treatment. Am J Orthod Dentofacial Orthop
2003;124:593-9

• Kothari: Digital lingual orthodontics - the next stepJournal of Indian

Orthodontic Society | Vol 50 | Special Issue | December, 2016
• Revankar et al.Lingual Orthodontics simplified : Incognito
customization perfected. APOS Trends in Orthodontics.July
2013;Vol 3,Issue 4.

• Anoop Sondhi.Effective and efficient indirect bonding:Sondhi

method.Seminars in orthodontics;2007Vol 13,No 1

• Earl Johnson.Selecting custom torque prescriptions for the

straight-wire appliance.Am J Orthod Dentofacial Orthop
2013;143:S161-7.