OUTLINE:

I. Background on the evolution of bracket positioning.

II. Positioning of brackets according to the
i. Mesiodistal position
ii. Axial / Angulation position
iii. Vertical position
III. Bracket positioning gauge
IV. Position of clinician during brackets placement
V. SAP technique
VI. Indirect bonding technique
VII. Lingual positioning of brackets
VIII. REFENENCES
 Ackerman wrote about disruptive orthodontic technology with the view that “orthodontics is the art of the
possible” rather than “the science of the improbable”. According to him, “Nothing in orthodontics is sacred, and
disruptive innovations are always around the corner.”
 I. Background on the evolution of bracket positioning.

Brackets are considered as the key constituent of the fixed orthodontic appliances used for the treatment
of different malocclusions. Besides the different types of orthodontic archwires that are inserted into the bracket
and ligation methods used, a three-dimensional (3D) configuration of tooth positioning is usually established.
To achieve this, utilizing the straight wire technique, an accurate bracket positioning is needed to effectively
express the built-in prescriptions that are differently programmed into the different types of bracket systems
available in markets. However, especially in direct bonding technique, it is difficult to do this and later wire
bending at the finishing stage might be needed to get the desired result of the orthodontic treatment.

The accuracy of brackets placement is a key factor in successful orthodontic therapy. Good placement of
orthodontic brackets guarantees a successful mechanical treatment. If the brackets are positioned correctly and
the tip, torque, and in–out compensations built into the appliance are suited to the patient’s dentition, only
minimal wire bending will be required ( McLaughlin and Bennett, 1991). Angle (1928) recommended that the
ideal position to place the bracket should be at the centre of the labial surface of the tooth. Later, placement of
the anterior bands at the junction of the middle and incisal thirds has been recommended (Balut et al. 1992).
These authors suggest that with the Tweed and Begg techniques the brackets should be placed by measuring the
distance from the incisal edge for anterior teeth and from the cusp tip for posterior teeth.

Andrews (1976, 1979) developed the straight-wire appliance and proposed that the brackets should be
placed at the midpoint of the facial axis (FA) point, as the midpoints of all the clinical crowns are located on the
same plane (Andrews plane), it was felt that the FA point was readily and consistently located. Ricketts (1976),
and later Kalange (1999), advocated the use of marginal ridges to guide the vertical positioning of brackets and
bands.

Some researchers have shown that the FA points between the teeth are not necessarily on the same plane
(Dellinger, 1978; McLaughlin and Bennett, 1995) and this led to other recommendations for ideal bracket
placement. McLaughlin and Bennett (1995) advocated the positioning of brackets at a measured distance from
the incisal edge, with different vertical positions recommended for different sized teeth.

TABLE REPRESENTING: THE VERTICAL HEIGHTS FOR BRACKET POSITIONING (in mm)

CENTRAL LATERAL CANINE 1ST PREMOLAR 2ND PREMOLAR

UPPER ARCH 5.0 4.5 5.0 4.5 4.0
LOWER ARCH 4.0 4.0 4.5 4.0 3.5
 They felt that the use of a bracket placement chart with the use of a Dougherty gauge dramatically
reduced the bracket placement errors in the vertical dimension, with a 50 – 60% reduction in the need to
reposition brackets. Regardless of which method is used for positioning brackets, there seems to be some
margin of deviation from the ideal location and this is before operator error is taken into account. Measuring
from the incisal edge and positioning at the FA point have been shown to be inaccurate for premolars and can
lead to marginal ridge discrepancies between the premolars and molars and a lack of occlusal contacts with the
opposing dentition ( Eliades et al. 2005).

Fukuyo et al. (2004) digitized the models of 40 patients with normal occlusion and compared three
methods of bracket placement (FA, height and marginal ridge methods). The bracket positions relative to a
constructed virtual bracket plane were determined. They found that even if the brackets were positioned ideally
for each technique, vertical errors will still occur and, therefore, suggested modifications to bracket positions for
each technique.

There are a number of prescriptions available, with the manufacturers recommending an optimum
position to maximize the efficiency of prescriptions for tooth movement. It would be beneficial to know if there
is a difference in the accuracy between the recommendations, as the less accurate the positioning of the
brackets, the more poorly they perform. Incorrectly positioned brackets can render even the most customized
prescription ineffective and increase treatment time and the number of archwire adjustments necessary (Carlson
and Johnson, 2001). {1}
II. Positioning of brackets:

Brackets are positioned acceding to the principle 6 described the rationale for the designs of specific
brackets. These brackets can be used to position the teeth in ideal locations in terms of both esthetics and
stability, but only if they are placed correctly on the teeth.

For proper bracket positioning, three dimensions must be considered:

1. Mesiodistal position
2. Axial – Angulation position
3. Vertical position

i. 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 clear description for
right mesiodistal position of brackets was given by Andrew 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

A. 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.

B. 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.

C. Mandibular Premolars :
• Roth 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

D. Maxillary Premolars :
• Bracket placement on maxillary premolars is different from mandibular premolars as 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 then both buccal and lingual cusps will have a cusp embrasure
relationship with lower dentition. Such a relation is not acceptable.

• According to Andrew the buccal cusps of upper premolars

should be slightly more distal than the lingual cusps in the
mesiodistal perspective. 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.
• According to McNamara such a position will also help to
improve class I & II dental relationships.

• For class III molar finished cases though there are no guidelines available in the literature. But if the
orthodontist is aiming class III camouflage than upper premolars bracket should be bonded slightly
distal to mid developmental ridge so that the buccal and lingual cusp have same prominence in
mesiodistal perspective. Such arrangement always help to improve the dental relationship in class III
camouflage with final molar relationship in class III and canine relationship in class I.

E. Maxillary and mandibular molars:

• 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.
 F. Checking mesiodistal position of the brackets
The mesiodistal position of the bracket can be checked under both
a) Direct
b) Indirect vision.
For indirect vision diagnostic mirror is used. Generally mesiodistal position
of upper incisors, premolars and molars brackets is checked under indirect
vision.

G. Rotated teeth :
In case of rotated teeth the bracket should always be placed more on side of rotation in the mesiodistal
plane. This overcorrected position of the bracket will result in early correction of the rotation and will
also accommodate the relapse factor after debonding.

ii. Axial positioning of 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 built-in 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.

In pre-adjusted 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 built-in tip. In pre-adjusted 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. 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.
 Also placing bracket according to long axis of tooth may result in wrong mesiodistal. Andrew purposed
that as the clinical crown is only visible in the mouth so the angulation of the tooth should be taken by
taking the angulation of long axis of clinical crown (LACC) and not the long axis of the entire tooth. But
taking only the long axis of clinical crown may result in poor root parallelism and in some cases root
resorption due to roots approximation of adjacent tooth. So brackets should ideally be placed by taking the
clinical crown as reference but root position should also be kept in mind. If there are chances of adjacent
root resorption by taking clinical crown as reference then bracket position should be modified and long axis
of the tooth should be taken as reference. Taking the long axis of tooth can many a time results in poor
proportions of connectors and embrasures. These proportions can be corrected at end of treatment either by
composite build up or interproximal reduction.

Correct axial position of the bracket is very important for proper occlusal and
esthetic 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. Change in tooth angulation will
also affect the golden proportions of connectors and embrasures and so the smile esthetics of the teeth.

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. If
there is doubt in position of maxillary anterior brackets especially lateral incisor
brackets some clinicians favor to use indirect vision by diagnostic mirror and
use guidance from lingual side of tooth.
 Modifications are made in axial position in the following circumstances.
1. To avoid chances of root resorption due to adjacent root approximation.
2. To avoid root resorption from dental or orthodontic implants.
3. To avoid root resorption from teeth impacted in the bones. (Impacted canines or mesiodens).
4. To accommodate crown morphology for achieving golden proportions of connectors 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 than to go for composite build ups.

iii. Vertical position :

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. Angle
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 teeth 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 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 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 built-in prescription. Almost every orthodontist who devised a bracket prescription
also has advocated a certain vertical position for those brackets so that the built-in prescription should be
fully expressed.

Different guidelines for vertical position of the brackets are given, some commonly used:

Andrew Guidelines:
For bracket placement Andrew 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
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 the 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.

In some of his old writings Andrew 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 Andrew 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.

Andrew recommended technique FA point is valid for healthy teeth. In case of gingival recession
Andrew quoted Gargiulo study 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 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

1. 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.
2. 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.
3. 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.

Roth Guidelines:
Roth like Andrew also proposed center of clinical crown for ideal bracket placement to be used with
his prescription. However Roth 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:
o Upper central and lateral incisor should either be at the same level or lateral incisor should be 0.5
mm less prominent than central incisor. The central incisors will elongate 0.5 mm to 1mm more
than the lateral incisors after settling.
o Maxillary canine should be 1 to 1.5 mm below the occlusal plane while mandibular canine
should be 0.5 to 1 mm above the occlusal plane. The upper and lower canines also should be
1mm more prominent than lateral incisors and bicuspid.
 Most variation in bracket position are found in bicuspids. In bicuspids the bracket should be placed at
area of maximum convexity which in most cases is center of clinical crown. In case of increase curve of
spee the lower canine brackets should be placed more occlusal than the premolar brackets to avoid
future wire bending to level the curve of spee.

Limitations Roth recommendations:

Roth guidelines are good to attain a functional occlusion but merely guessing the right height while
placing brackets with such accuracy in millimeters is usually not possible. Roth recommendation has
same limitations in vertical accuracy of brackets as of Andrew's recommendations. To overcome vertical
positioning errors many clinicians uses gauge to place bracket using Roth guidelines. According to Roth
canine or premolar teeth should be taken as reference while placing brackets.

Alexander Guidelines:
Alexander advocated individualizing bracket positioning for each patient to effectively use his bracket
prescription. According to Alexander as premolar clinical
crown height is the most variable in the arch so premolar
bracket height (X) should be taken as reference .All the
other brackets are placed with reference to premolar bracket
height (X). To find premolar bracket height, premolar
clinical crown height is taken and is divided into half. The
premolar normal bracket height (X) is usually 4.5 mm.

Limitation of above chart

Premolars in upper and lower arch were bonded at same height. As
1st premolars cusps are longer than 2nd premolars especially in lower
arch so bonding all the premolar at the same height will result in
marginal ridges discrepancy and premature occlusal contacts. Also
no value was given for lower 2nd molars.

To correct these discrepancies Alexander modified his bracket positioning chart. 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:
1. 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.
2. In modified chart the lateral incisor bracket position was 0.25 mm more incisal than central
incisor.
3. In modified Alexander bracket positioning chart
upper 2ndmolar height is 1 mm greater than 1st
molar. This can create marginal ridge
discrepancy between the maxillary molars in
many cases.

Bishara vertical bracket positioning chart:

Bishara recommended a vertical bracket positioning
chart 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:
1. 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.
2. Placing brackets at the same height will result poor marginal ridge relations and opposing
occlusal interferences. The level marginal ridges 2nd premolar bracket height should be 0.5 mm
greater than 1stmolar 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 (is an abbreviation for Richard McLaughlin, John Bennett and Hugo Trevisi)

Chart McLaughlin 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.

The method is given as follow:

1. Measure the clinical crown height of fully erupted teeth on the upper and lower study cast by
dividers and millimeter rulers.
2. To obtain middle of clinical crown divide the measured height of each crown into half and round
the obtained value to the nearest 0.5mm.For example if crown height is 10.75mm half the crown
height would be 5.4 mm. Make this measurement to 5.5 mm.
3. Create separate rows of measurements for maxillary and mandibular teeth. Now compare your
values of maxillary and mandibular teeth with that of proposed charts. If your chart measurement
don't exactly tally with that of proposed MBT charts then find a row on the chart which matches
most of your recorded measurements.
4. After a specific row is selected, each for maxillary and mandibular teeth, position the bracket
following the standard bonding procedure.
5. Place the bracket on tooth in the mesiodistal and vertical middle of clinical crown by visualizing
it. After placing the bracket on the tooth use the bracket positioning gauge (advocated special
gauges made by 3M Unitek) to adjust the height of the bracket. By firmly positioning the
bracket, cement flash will be squeezed from underneath the bracket. Remove the flash and cure
the brackets.
6. Light cure cements are preferred for brackets bonding because they give longer working time.
Charts for vertical bracket positioning are given.In charts average values for children and adults
are also given. In children the average values are 0.5 mm less on all teeth than corresponding
values for adult teeth.
Limitations:
Due to individual variation of cusps height in premolar region, marginal ridges height difference is
seen in finished cases as posterior bracketing is not optimum to level marginal ridges.

Kalange method:
Ricketts advocated the leveling of marginal ridges in finished cases in posterior dentition. He devised a
practical method to level the marginal ridges by bracket placement. He though favors indirect bonding
but his 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 1 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.

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. 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 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. 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 be decreased from the incisor edge. Vertical line showing the long axis of clinical
crown is also drawn in mesiodistal center of the 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 central incisors.
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.
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. But this
method ignores individual variation in 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 pencil lines on the teeth will
interfere with bond strength.

To contour this problem slot line and vertical line should not cross the final bracket sitting area. Even if
these lines don't cross the bracket sitting area they give a realistic guidance for correct orientation of
brackets. Selecting the height from molar band edge to slot can also result in vertical positioning errors.
Most of the companies make molar bands with occlusal proximal edges which lie next to marginal
ridges more gingival than buccal and lingual edge. This variation is more pronounced in upper arch. As
these are proximal edges of the band that must be in level with the marginal ridges so distance from
buccal edge will result in faulty bracket positioning. Either height difference between buccal and
proximal edges should be 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 transferred to
lateral incisor in maxillary arch. A MBT advocated gauge is used to transfer closet height from 1st
premolar to lateral incisor. Central incisor and canines are bonded at same height. In lower arch 1st
premolar height is transferred to both central and lateral incisors and canine tip are kept 0.5 mm more
prominent.
 Viazis guidelines
Central incisors brackets are taken as reference. Both maxillary
central incisor bracket (X) and mandibular central incisor bracket
(Y) are placed at FA point which is center of clinical crown. The
distance from the incisor edge to FA point is measured. Rest of
the brackets are placed with reference to these brackets at
proposed distance. With the help of bracket positioning gauges.
Some other bracket positioning charts recommended with time are given.

Modifications in Vertical position:

If 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. Open bite :
In open bite cases if the plan is to non-surgically 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 open bite. In most case of openbite, only maxillary anterior teeth are
contributing to openbite and so bracket position alteration should be done in maxillary arch only. But if
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 proposed that for anterior openbite 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. The rest of the brackets are bonded at their normal height.

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

3. Irregular incisor edges:

If there are irregular incisor edges or long cusp tips the clinician has 3 options to manage the situation:
a. Recontouring of the incisor edges or cusp tips before bracket placement.
b. Recontouring of the incisor edges or cusp tips at end of treatment.
c. Composite filling of the incisor edges and cusp tips.
 Ideally teeth should be recontoured previous to bracket placement. If teeth are 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 start of treatment. Usually composite filling is reserved for cases
with openbite or large broken area of incisors.

4. Long canine tip:

In cases where canine tip is long it's better 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 canine tips are
usually found in impacted canines or canine placed out of occlusion.
Lack of attrition will leave the tip longer than usual.

5. 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.

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.

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 1STpremolars extraction cases to avoid vertical step at extraction site vertical height
of bracket should be increased by 0.5mm on upper and lower 2ndpremolars and 1stmolars. In lower arch
vertical height of 2ndmolar should also be increased by 0.5mm. In case of 2ndpremolars 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 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 gingival by equal
proportions.

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 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.

III. Bracket positioning gauge

Bracket positioning gauges are used to ensure vertical accuracy of brackets on the teeth. Many 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.
a. Star shaped gauges or Boone bracket gauges.
b. Straight rod shaped gauges or Dougherty
Most variations are found in Dougherty gauges and these are also the author favorite for
bracket placement.

Parts of gauges:
All bracket positioning gauges have a holding 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.
 Position of the gauge during bracket placement positioning the
gauge for checking the vertical height is very important. A faulty
positioning of gauge can change bracket height up to 2mm. 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 smile arc.

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 A). But if the
lower incisors are proclined the gauge is placed below the occlusal plane and if
the lower incisors are retroclined the gauge is directed from above the occlusal
plane (Figure B&C).

In case of upper incisors the gauge is placed slightly upward angulated

usually 15° to 20° to the occlusal plane to make it perpendicular to the labial
surface of the tooth as the upper incisor are slightly inclined forward over basal
bone.

In case class II div 1 incisor relationship where the upper incisors are
proclined the gauge is angulated more upward as compared to normal incisor
inclination. In case of class II div 2 the gauge lies below the occlusal plane
angulated at an angle depending upon the severity of malocclusion.
IV. 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
this is not comfortable for the patient. 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.

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 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
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 canine’s brackets is done at 9 o' clock
position with the mesiodistal and axial placement checked from the same position while the vertical height of
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 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.{2}
V. SAP technique

Bracket positioning for Smile Arc Protection (SAP) is an innovation that blends the art of contemporary
esthetics with the science behind three-dimensional control of tooth position, making superior esthetic results
attainable and more predictable during orthodontic treatment. Creating extraordinary esthetic enhancement
through orthodontic treatment, it is essential that the clinician communicate to the patient what the new
“possible” means and how crucial role does a pleasing smile arc plays. The arc is considered to be of prime
importance in planning treatment based on upper incisor position, taking into account both the effects of
projected biomechanics and the soft-tissue changes expected with aging. With the steady increase in the
prevalence of no extraction treatment, early 3D control of upper anterior tooth positions has become paramount
in preventing the incisor flaring and flattening of the smile arc commonly associated with crowding relief.

Concept of Bracket Positioning

Positioning the upper brackets to protect or enhance the smile arc has come to be called SAP bracket
positioning. Although bracket positions are individualized to meet each patient’s esthetic needs, the upper
incisor brackets are generally placed more gingivally than the canine brackets. The lower posterior brackets are
placed somewhat gingivally to avoid occlusion, while the lower anterior brackets are placed somewhat incisally
to optimize overbite.

The steps involved in SAP positioning of the anterior brackets have been previously described. After
recontouring the canines and lateral incisors (if required), the incisal edges of the canine bracket wings are
positioned gingival to the mesiodistal contact line, as if the self-ligating bracket clip were closed. Next, the
distance from the canine bracket slot to the incisal edge of the canine is measured. The central incisor bracket is
placed about 1.5mm more gingival from its incisal edge than the canine bracket is from its recontoured incisal
edge. Finally, the lateral incisor bracket is positioned 0.75-1mm more incisally than the central incisor bracket.

SAP bracket positioning supports today’s esthetic philosophy of compensation for greater width in the
upper posterior teeth, with minimal negative space in the buccal corridors (referred to as the “12-tooth smile”).
This esthetic concept also calls for optimal axial inclination of the upper anterior teeth, with incisor dominance
and a curved smile arc of the upper incisal edges, following the curvature of the lower lip in a posed smile.

For many orthodontists, a combination of full enamel display of the upper anterior teeth with 1-1.5mm
of gingival display is the most esthetically pleasing and youthful proportion for a posed smile when assessed in
natural head position (NHP). Such dimensions are also beneficial if a smile is to age well. Some practitioners
have speculated that a more gingival positioning of the maxillary anterior brackets might cause undue tissue
swelling. The solution for this problem is to ensure that no composite flash remains around the gingival portion
of the pad. Of course, we also rely on good oral hygiene, proper nose breathing, and lack of sensitivity to
composite.
 A technique known as the “Active Early” approach comprises progressive case-management strategies
that complement SAP bracket positioning for early 3D control. Occlusal guides (bite turbos) and immediate
light, short elastics are used from the beginning of treatment to match the lower occlusal plane with the upper.
In a patient with deep overbite, this technique helps erupt the lower molars and extrude the upper anterior teeth
as it moves them slightly clockwise.
Protecting and Enhancing Smile Arcs

Factors that can make it more difficult to protect existing smile arcs or enhance inadequate smile arcs during
treatment it includes 5:
1. Inappropriate conventional bracket positioning, which typically reduces or flattens the smile arc (and
wire plane) during leveling.
2. The relative steepness or flatness of the occlusal plane (the flatter the plane, the more difficult it is to
manage the smile arc esthetically).
3. Incisor proclination, whether preexisting or iatrogenic.
4. A particularly broad anterior arch form, in which the excessive inter-canine span tends to flatten the
smile arc.
5. Steep upper canine tips and inappropriate canine bracket positioning in relation to the incisors.
6. Irregular shapes or size disproportions among the incisors and canines.

SAP bracket placement can positively affect each of these factors, as detailed below.

1. Effect of Bracket Position on Wire Plane

If a full enamel display with 1-1.5mm of gingival display provides the
most esthetically pleasing and youthful smile dimensions, it is important to
appreciate the negative effect of leveling especially upper incisor intrusion in
a deep-bite case on the smile arc. Upper incisor intrusion is only rarely
esthetically desirable, even for a Class II, division 2 malocclusion. If the
patient has a gummy smile, an esthetic smile arc should be developed by
using SAP bracket positioning and temporary anchorage devices or utility
aches for intrusion, rather than relying on bracket position.

To develop a pleasing smile arc and positively affect the anterior

portion of the upper occlusal plane cant, the maxillary anterior brackets are
positioned more gingivally for SAP than in traditional techniques. The
maxillary arch wire plane is then parallel to the upper lip, the incisal edges of
the upper anterior teeth will follow the lower lip with treatment.

The divergence of the wire from the occlusal cusp tips or incisal edges
increases from posterior to anterior. The greater the differential from the
buccal segments to the anterior segment, the more the wire plane helps
increase the maxillary occlusal plane cant in relation to true Frankfort
horizontal (NHP).When needed, miniscrews can be utilized as anchorage to
intrude the lower anterior teeth, allowing more vertical movement of the
upper incisors.
 Favorable wire planes produced by SAP bracket positions induce extrusion of the upper incisors
relative to the upper premolars, resulting in the application of a clockwise moment to the upper anterior
teeth from the outset of treatment.

When the occlusion is disarticulated with bite turbos and mechanics

are supported by very light, short elastics from the first appointment,
uprighting of proclined teeth will begin, even on light, round wires. Clinicians
report that these techniques can improve upper incisor and gingival display,
smile arc, and incisor inclinations as early as the third appointment.

Taking “every patient, every appointment” clinical photos is exceptionally helpful in assessing
esthetic progress, so that case management can be adjusted accordingly. When additional retroclination
of the incisors is desired, the mechanics can be further supported by inverting the upper anterior brackets
180°, producing active lingual crown torque in the slot with dimensional archwires.

Inversion does not alter the tip or in-out geometry of well-designed incisor brackets.
Unfortunately, due to a number of common factors oversize bracket slots, inconsistent slot geometries
(as caused by poor manufacturing tolerance control), overly large slot corner radii, variable self-ligating
bracket rigidity, and use of excessively small wires even the highest quality appliances are not able to
deliver consistent expression of their stated torque prescriptions, because torsional play overrides the
differences between various prescription values. Moreover, most clinicians do not fill the slot, which
further degrades torsional expression.

The H4 bracket, which features a one piece self-ligating design, a rigid door, tight manufacturing
tolerances, and reduced slot depth (.026" vs. the typical .028"), overcomes some of these challenges and
improves efficiency by reducing torsional play. Its use in a well-developed clinical methodology can
allow a more purely “straight wire” approach, even when the bracket slot is not filled. The combination
of the H4 bracket and progressive “Active Early” case management strategies goes a long way toward
overcoming many of the control problems typically encountered with other passive self-ligating
appliance systems.
2. Effect of Bracket Position on Occlusal Plane :

Research has shown that actual clinical torsional play in self-ligating brackets can be as much as
two and a half times more than predicted by mathematical models, making reliable expression of 3rd-
order movements problematic. With SAP bracket positioning, the effective prescription of the bracket is
reduced relative to the occlusal plane, so that torsional moments for uprighting proclined teeth are
engaged early in wire progressions.

It is important to recognize that the

maxillary occlusal plane, as viewed in NHP, is a
significant contributor to the esthetics of the smile.
Obviously, the flatter the plane, the more difficult it
is to manage the case esthetically. Rotating the
maxillary occlusal plane clockwise will produce
more incisor display and a more convex smile arc.
Counterclockwise rotation, which can occur when the upper anterior brackets are placed incisally to the
recommended SAP positions, can result in esthetic decline.

In combination with the appropriate use of

bite turbos and immediate light, short elastics, SAP
bracket positioning helps control the cant of the
maxillary occlusal plane from the outset of
treatment, offering a wider range of treatment
options. Individual bracket positions should be
based mainly on the length of the canines and incisors, as well as the patient’s esthetic needs. If the
occlusal plane is flat, the gingival bracket divergence should be increased even farther from traditional
positioning to enhance enamel and gingival incisor display.

In a deep-bite case, the SAP bracket divergence in the upper arch is counteracted by increased over-
leveling of the lower arch to achieve an optimal overbite. Because it is crucial not to deepen the bite
while enhancing the smile arc with individual bracket positioning, 4 anterior bite turbos should be used
to allow eruption of the lower molars.
3. Effect of Bracket Position on Proclination :

One of the challenges presented by crowded non extraction cases is to control or correct
preexisting upper incisor proclination, or to prevent the proclination that often results from space-
gaining mechanics. Incisor proclination adversely impacts esthetics in many ways.

In the frontal smile, labial inclined incisors are visually shorter and make an esthetic smile arc more
difficult to obtain by reducing incisor dominance and the effective crown height and enamel display. In
the lateral smile, because the eye is capable of detecting roughly 5° or more of proclination, the viewer
will be more sensitive to changes in axial inclination than to the anteroposterior position of the incisors.

While esthetic incisor position has traditionally been assessed through cephalometric
measurements, it can also be evaluated by means of photographs taken in NHP with frontal, 45°, and
posed profile smiles. Again, “every patient, every appointment” clinical photos are important in tracking
esthetic progress and adjusting case management accordingly.

Since the most effective application of force is close to the center of resistance, bracket
positioning also has an important effect on torque. Gingival maxillary anterior bracket placement has
been criticized because it lowers the effective torque in the slot. If the incisal portion of the pad is fully
seated against the enamel, however, the change in effective torque will be minimal. With proclined
incisors, this slightly lower effective torque actually improves appliance performance by offsetting the
wire play associated with undersize finishing archwires. It is also useful in a situation where torque
within the slot is desirable. SAP bracket positioning moves the wire plane closer to the center of
resistance of the tooth, providing more control.

In crowded non extraction cases or patients with preexisting upper incisor proclination, SAP
bracket positioning has a positive effect because it lowers the effective torque prescription. Upper
anterior flaring can be controlled even more by inverting the brackets 180° and using .017" × .025"
wires in the .022" × .026" slots of the H4 brackets.
4. Effect of Broad Anterior Archform on the Smile Arc:
Archforms that are excessively broad in the anterior region tend to
flatten the smile arc as a geometric consequence of the extended intercanine
span. This flattening effect is compounded by incisal bracket placement on the
upper anterior teeth. Because the ligation method has no effect on archform,
SAP bracket positioning must be combined with an improved archform to
address this concern. The H4 Pitts Broad* archform is broad at the molars,
filling out the buccal corridors; tapered in the anterior segment, improving incisor flow and presentation;
and moderate in width at the canines, fostering a 12-tooth smile during animation.

5. Effect of Steep Canine Tips on the Smile Arc

Esthetically shaped canines at the proper inclination
are essential to a beautiful smile. Inappropriately shaped
canines can create two esthetic problems. If a steep, pointed
canine tip results in a “hanging” canine when the contact
point between the canine and lateral incisor is aligned. If the
canine tip is aligned with the lateral incisor but the contact point is too gingival, the embrasure will be
unsightly. Performing a positive or negative coronoplasty before bonding will optimize the esthetic
contours of the canine while still allowing canine disclusion.

6. Effect of Irregular Tooth Shapes and Proportions on Bracket Position

Irregular tooth shapes or size disproportions
among the incisors and canines are best addressed
through positive or negative coronoplasty prior to
bracketing or, at least, early in treatment. Improving the
height-width ratio of the “white and pink” tissues is a critical esthetic requirement. Of the three means of
crown lengthening, two can be performed by orthodontists: adding composite resin to the incisal edges,
or soft-tissue revision with a diode laser. Today’s composite resin is easy to apply and durable over the
long term. (The third method of crown lengthening is to lift a periodontal flap and recontour bone
around the labial aspect of the tooth, which is generally performed by a periodontist.)

The esthetic principle of incisor dominance dictates that:

a. The upper central incisor must be the predominant tooth in the esthetic smile. This means it must
display the widest “actual” and “visual” crown and the widest flat surface for light reflection.
b. The upper central incisor must also be the longest tooth by both actual length and proximity to
the idealized lower lip curvature in the posed smile.

SAP bracket positioning facilitates incisor dominance because the divergence in bracket progression
places the central incisor bracket at the most gingival position of the upper anterior teeth.
Conclusion

In terms of the SAP bracketing concept and its recommended case management strategies, education of
all the takeholders including patients, referring dentists, parents, hygienists, and the orthodontist’s own staff
must convey a keen understanding of “what is possible”.

The SAP technique can easily be incorporated into a practice by using a combination of well-designed
orthodontic appliances manufactured to exacting standards and effective clinical protocols, as described in this
article. Clinicians thus have the means to improve the effectiveness and efficiency of treatment while providing
consistently excellent case results. Treatment planning for esthetic smile design will become more and more
predictable as it helps orthodontists open up “the art of the possible”. {3}

VI. Indirect bonding technique

All orthodontists share the goal of achieving excellent results when clinically treating patients. Despite its
complexity, treatment success relies on correct positioning of brackets during bonding, which will simplify
subsequent phases of orthodontic treatment in addition to increasing predictability of results. That’s why we
have 2 techniques for brackets bonding:

• Direct Bonding Technique:

When the direct bonding technique is used, the brackets are placed directly on the teeth, one tooth at a
time, and not on a plaster model. This method takes more time than the indirect bonding method because
each individual bracket is meticulously placed correctly from the start, taking into consideration the
teeth’s crown and root position.

• Indirect bonding technique:

The indirect bonding technique stands out for the procedure is carried out in the laboratory, followed by
transference to the patient's mouth by means of custom made trays.

Advantages associated with indirect bonding are:

1) Allowing better three-dimensional visualization of tooth positioning and, as a result, greater
accuracy while positioning brackets This advantage was confirmed by Hodge et al who found
that errors associated with bracket positioning were minimized when indirect bonding was
chosen over direct bonding, under any of three aspects of observation: height, mesiodistal
position and angulation. Better height positioning was also observed by Koo et al, while Aguirre
et al emphasized the higher technical precision provided by the indirect technique used for
brackets angulation on maxillary and mandibular canines and height positioning on maxillary
canines.
2) Reduced chair time,1 , 2 , 6
3) Little need for compensation bends.
 4) Reduced physical and mental stress, since the clinical procedure is simpler than direct bonding.
5) More comfort for the patient.

Disadvantages:
1) Time consuming due to laboratory procedures
2) Additional costs with material.

As a result of the growing popularity of indirect bonding, new techniques have been developed.
These techniques stand out especially on the bonding system applied (self or light-curing) and the
transfer tray used (hot glue, addition silicone, vacuum-formed, prototyped or associated methods).
Despite the variety of techniques proposed, indirect bonding is not considered a gold-standard
procedure yet, probably due to the numerous variables inherent to the process and which need to be
controlled if success is to be obtained.

All steps involved in indirect bonding are divided into three stages:
1) Clinical Stage I
2) Laboratory Stage
3) Clinical Stage II.

Clinical Stage I
a. Perform dental prophylaxis and upper and lower full-arch impressions with high quality alginate,
following the manufacturer's instructions. Examine in full detail the
impression obtained, in order to avoid potential flaws that may lead to
distortions in the dental cast, paying special attention to the areas
corresponding to teeth.
b. Obtain dental casts with type IV dental stone. This procedure should be
carried out judiciously so that dental casts are free from imperfections
(positive and negative bubbles). Surface flaws will hinder brackets and
tray fitting to the teeth, when the former are transferred to the oral
cavity. It is also necessary to wait for the stone to fully crystallize and
dry.

Laboratory Stage
1) Draw bracket positioning guidelines on the previously obtained cast. First, with the aid of a black pencil,
determine the long axis of each tooth on the center of its crown, using a panoramic radiograph as an
auxiliary method to observe tooth angulation and increase accuracy.
 With the aid of a red pencil, mark the projection of mesial and distal
marginal ridges on the buccal surface of premolars and molars, then join
the two points.

Horizontal red lines represent the height of posterior teeth marginal

ridges and establish the depth of occlusal contact. This procedure
should be repeated for all posterior teeth.

Draw bracket slot height using a black pencil, starting from the
first molar. This position depends on the type of malocclusion
and on the anatomical shape of teeth (fig. A).
In open bite and hyperdivergent faces, brackets should be
placed closer to the occlusal surface of teeth; that is, close to
the red line, thus avoiding teeth extrusion, which could
compromise treatment results. On the other hand, in deep
overbite malocclusions, when extrusion of posterior teeth is
necessary, brackets should be placed slightly further from the
red horizontal line.

2) With the aid of a drawing compass, determine the distance between the two horizontal lines in the first
molar (Fig B) and replicate it on the buccal surfaces of other remaining posterior teeth (Fig C), thus
establishing bracket slot height (Fig D).

3) Calculate and transfer the slot height of incisors and canines to the cast using a bracket placement
marker gauge. Reference tables can be used to determine bracket height of anterior teeth, according to
the type of vertical malocclusion. In open bite cases, brackets can be placed more gingival on incisors
and canines; whereas in deep bite malocclusions, they can be placed slightly closer to the incisal edges.
In most cases, we recommend placing the canine bracket at the same height as the first premolar.

4) Measured from the slot to the cusp tip. For lateral incisors, subtract 1 mm from
canine’s height, and for central incisors, add 0.5 mm to lateral incisors height.
5) Treatment plan should be reviewed with casts in occlusion, and brackets
previously selected prior to drawing the guide lines on the lower cast, so
as to avoid setbacks during definitive bonding, such as lower brackets
interfering in post bonding occlusion.

6) Apply a thin layer of separator, mixed with water in a 1:1 ratio, over cast
teeth surfaces. Brush the material in the same direction and wait for at least
20 minutes for it to dry completely.

7) Apply orthodontic light-curable adhesive to the bracket base and position it over the cast surface.
Follow the previously established bonding guide, so that slot and long axis of brackets lie over the
drawn guide lines. Press the bracket over the pre-established location and remove excess adhesive. Once
all brackets were placed and positions were checked, use a light-curing unit to cure the adhesive
according to the manufacturer's instructions. Should this type of unit be unavailable, use conventional
light-curing devices, directing the beam towards the mesial and distal sides of each bracket, for 15
seconds each and at 2 to 3 mm distance.

8) Manufacture the transfer tray. Using a vacuum former, thermoform a 1-

mm thick sheet of Ethylene Vinyl Acetate over the cast. After heated, once
the sheet reaches 10 to 12 mm of distortion, according to manufacturer's
instructions, it is ready to be formed. Trim excess material with scissors
and spray a thin layer of silicone over the tray to help separate it later from
the second tray, to be made with more rigid material.
Thermoform a 1.5-mm thick sheet of Polyethylene Trephthalate Glycol
and trim both plates using a carborundum disk, 2 to 3 mm above the
cervical margin of teeth, on both buccal/labial and lingual/palatal
surfaces .

9) Separate the Cristal tray from the set, trim its labial/buccal surface up to
the gingival margin of bracket wings, eliminating retention. Use a Scotch
Brite brush to finish it and rinse with water and soap.

In the meantime, immerse the cast and the Soft tray in water for 15
minutes to dissolve the separator.
 Press delicately each bracket to dislodge it from the cast.

Fit the Cristal tray over the Soft tray and remove them from the dental
cast. Clean the Soft tray and the adhesive bases with water and soap,
abrading them gently with an interdental brush, rinse and dry them
completely with oil-free compressed air. Trim any excess of Soft tray material with scissors, without
detaching it from the outer tray.

10) After stone blasting on bracket bases for 2 seconds to remove residual separator, an opaque surface will
form. It is recommended that stone blasting be carried out using 50µm particle size aluminum oxide
under light pressure. Additionally, special care should be taken not to excessively abrade the adhesive.
Clean trays with oil-free compressed air.

Clinical Stage II
1) Without detaching the trays, cut vertical slits on the Soft tray, above the mesial and distal bracket wings,
using a sharp tip pair of scissors. This procedure will facilitate tray removal after bonding. Slits should
be cut immediately prior to the clinical stage, to avoid undesired bracket displacement in between
procedures, since they decrease tray retention.

2) Perform prophylaxis using extra-fine pumice or oil-free paste, and

etch teeth areas to be bonded with 37% phosphoric acid during 20
seconds. Wash, for additional 20 seconds, each etched surface.
3) Isolate area with cotton rolls and dry thoroughly.
4) The decision whether to bond the full arch at once or in separate
parts, by cutting trays into two or three segments, is influenced by
the quality of isolation achieved and ease of insertion of the transfer
tray.
5) Select and apply adhesive to tooth surface and bracket base,
following the manufacturer's instructions. A thin layer of material
should be applied to the etched tooth surface, followed by gentle air
spray and reapplication. A single application over bracket base
should also be carried out.
 6) Carefully position the tray over teeth. Once
completely fitted, it is not recommended to
exaggerate on the pressure to stabilize it. Visually
confirm tray correct position through the clear
tray and light-cure each mesial and distal bracket
edges during 10 seconds or use multiple tip light-
curing devices for indirect bonding.

7) Remove the firm Cristal tray with the aid of a

smooth tip instrument, first pressing to dislodge it
towards the occlusal edge.

Use Mathieu pliers to pull the Soft tray off the previously slit areas
above each bracket, releasing residual retentions, then fully remove
the tray.

8) Remove cotton roll isolation and any excess adhesive with proper
instruments. Should excess adhesive be noticed around brackets, use
specific low-speed burs to remove it. Floss interproximal areas to secure
they are clean. Orthodontic wires can be inserted immediately.

A critical factor concerning the indirect bonding technique is transferring brackets to teeth with precision
and adequate bond strength, circumstances are influenced solely by material selection and method of building
up a transfer tray. The exclusive use of soft materials can result not only in imprecision in bracket positioning,
but also in high incidence of bond failure as a result of poor fitting. Faced with a variety of trays made up of
different types of material, Addition silicone trays displayed improved accuracy, but only in the occlusogingival
plane. {5}
According to a study made on 1988

There were no significant differences in strength among direct, void-free indirect, and sealed indirect
bonds. Indirect bonds with voids were only half as strong. This seems to indicate that sealing around brackets
immediately after positioner removal might be a worthwhile clinical routine. Forty-four percent of the direct
bonds fractured predominantly at the bracket-adhesive interface, whereas 72% of the indirect bonds failed
mainly at the enamel-resin interface. Grouping the data according to failure location showed no difference in
bond strength between those that failed at the enamel and those that failed at the bonding pad. Thus the indirect
bonding promised similar bond strength and easier deboning because less resin was left on the teeth. {6}

According to another study made in 2013

The total time spent with the DBB technique was shorter than that with the IBB approach. However, the
clinical step took less time with IBB in comparison to DBB. The time spent for laboratorial positioning of the
brackets and clinical insertion with IBB was similar to that observed with DBB, which justifies the advantages
of the IBB technique in comparison to the DBB procedure. Both approaches (IBB and DBB) exhibited similar
prevalence of loose bracket and the highest number of failures occurred in the lower jaw. {7}
IBB: Indirect bracket bonding.
DBB: Direct bracket bonding.

According to the most recent study done in 2019:

Within the limitation of this systematic review, clinical evidence suggested that the direct and indirect
bonding techniques had no significant difference in bracket placement accuracy, oral hygiene status and bond
failure rate for bonding non-customized labial/buccal orthodontic brackets. The indirect bonding might require
less chair side time but more total working time in comparison with the direct bonding technique. High-quality
and well-designed randomized controlled trials are needed in order to make a conclusive recommendation. {8}
VII. Lingual positioning of brackets

BONDING IN LINGUAL ORTHODONTICS:

In order to fully exploit the potential of the device used in lingual orthodontics, it
is imperative that the brackets be positioned with 100 % accuracy. A key factor
for successful correction of a malocclusion with lingual orthodontics is precise
and accurate bracket positioning.

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 setup from a duplicate set -
up model of the patient’s ideal malocclusion. This ideal setup 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 setup 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 setup, 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.

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.

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.
Slot Machine:
The slot machine was designed by “Thomas Creekmore” for the
placement of both conventional and lingual brackets directly on to 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 setup is required is a major advantage, but the difficulty in managing the many pieces of the slot machine
might be seen as a disadvantage.

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.

Transfer Optimized Positioning (TOP/INCOGNITO I BRACES system):

The TOP system uses a setup 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 setup is used to find the optimal height for the brackets.

Korean Indirect Bonding Setup (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 setup
model; however, the set-up is created with the help of a special setup model gauge
for increased precision.

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 mode lwhere the teeth
are sectioned and correctly aligned. The brackets are positioned and
placed on the setup model with the help of a full-sized rigid rectangular
archwire.
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 setup model to position the brackets.

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.

Simplified Technique:
The Simplified Technique is associated with the development of the new STb
brackets. The brackets are positioned directly on the malocclusion model by
using a bracket placement plier or simple tweezers.

Orapix System:
The newest lingual orthodontic laboratory technique is the Orapix system,
which is still in its final phase of refinement. A scanner will scan a patient’s
model and create a three dimensional (3D) data file. The orthodontist will
receive the 3D data file of the patient and a 3-Txer software package via the
Internet. With the 3-Txer software the orthodontist will visualize a 3D model
and will be able to create his own virtual setup on his computer for that
particular patient.

RETENTION IN LINGUAL ORTHODONTICS:

a. Clear retainer.
b. Begg-Type retainer.
c. Spring Retainer.
d. Passive lingual retainer.
 e. Active lingual retainer (bonded).

CONCLUSION:
During the last few years the work of few specialists has led to the modification of the main steps of the lingual
technique, as well as of the labial technique, allowing an easier approach for lesser experienced Orthodontists.
Lingual Orthodontics needs wider diffusion, it should become part of every Orthodontists cultural baggage. {9}

According to a study done on 2007:

Labial and lingual systems have the same level of inaccuracy. For both systems, indirect bonding significantly
reduces absolute TqE and RotD. The TqE found to be able to cause transverse discrepancy (scissors or
crossbite) combined with disclusion with antagonist teeth. The RotD found can result in irregular interproximal
contact points.{10}
TqE: Torque error
RotD: rotation deviation
VIII. REFENENCES
{1} Armstrong D, Shen G, Petocz P, Darendeliler MA. A comparison of accuracy in bracket positioning
between two techniques—localizing the centre of the clinical crown and measuring the distance from the incisal
edge. The European Journal of Orthodontics. 2007 Jul 27;29(5):4306.
{2} Kamak H. Orthodontic brackets selection, placement and debonding. Journal of Orthodontic Research.
2015 Sep 1;3(3):208-.
{3} Pitts TR. Bracket Positioning for Smile Arc Protection. Journal of clinical orthodontics: JCO. 2017
Mar;51(3):142-56.
{5}Nojima LI, Araújo AS, Alves Júnior M. Indirect orthodontic bonding-a modified technique for improved
efficiency and precision. Dental press journal of orthodontics. 2015 Jun;20(3):109-17.
{6} Hocevar RA, Vincent HF. Indirect versus direct bonding: bond strength and failure location. American
Journal of Orthodontics and Dentofacial Orthopedics. 1988 Nov 1;94(5):367-71.
{7} Bozelli JV, Bigliazzi R, Barbosa HA, Ortolani CL, Bertoz FA, Faltin Junior K. Comparative study on direct
and indirect bracket bonding techniques regarding time length and bracket detachment. Dental press journal of
orthodontics. 2013 Dec;18(6):51-7.
{8} Li Y, Mei L, Wei J, Yan X, Zhang X, Zheng W, Li Y. Effectiveness, efficiency and adverse effects of using
direct or indirect bonding technique in orthodontic patients: a systematic review and meta-analysis. BMC oral
health. 2019 Dec;19(1):137.
{9} Student PG. Lingual Orthodontics. IJDA. 2009;1(1):31.
{10} Shpack N, Geron S, Floris I, Davidovitch M, Brosh T, Vardimon AD. Bracket placement in lingual vs
labial systems and direct vs indirect bonding. The Angle Orthodontist. 2007 May;77(3):509-17.