Bracket Selection & Placement / Orthodontic Courses by Indian Dental Academy

The Implications of Bracket
Selection & Bracket Placement

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

Although many authors written -
finishing details in orthodontic
treatment,
No adequate attention impact of
proper bracket selection and
placement on finishing details.

Objective Versus Subjective
Assessments
some of the finishing details - discuss
involve variables that are quantifiable -
measured objectively.
The presence or absence of spaces can
be quantified.
Number of variables involve a high
degree of subjectivity--preferences of
patients and clinicians,
Partly due to the difficulty in quantifying
them due to the difficulty in obtaining
objective measurements.
Degree of mesio-distal tip U ant. teeth - to a
certain degree, with a difference in the esthetic
outcome of the treatment.
range of axial inclinations U ant. teeth -esthetic
appearance pleasing to the patient or the
clinician, without having any significant impact
on stability &result/pt.'s long-term dental
health and function.
A Three-Dimensional Graphic Analysis
There are many pre torqued and pre-angulated
appliance systems available to the orthodontic
practitioner today, and these prescriptions are
based on a foundation of clinical principles,

Selection of Brackets and Tubes
Mandibular second molars ought to be
aligned properly within the dental arches
at the completion of orthodontic
treatment- long-term
periodontal and dental health

mandibular molar tube- distal offset - on
the contact point b/w I,II molars-
undesirable DL rotation of mandibular
first molar
Requires compensation - offset in the AW

Arch wire adjustment - undo the movement expressed
by the offset built into the tubes.
This would argue in favor of a molar tube that does
not have a distal offset (Figs 5 and 6),
us to recognize that the morphology of the
buccal surface of the mandibular first molar dictates
that the mesiodistal position of the tube / bracket will
have an impact of the final position'
of the tube. However, our ability to affect the
mesiodistal position of the tube is quite limited.
This limitation is obviously greater with bands, since
the majority of practitioners today use preformed
bands with prewelded brackets and tubes. Since the
bands are preformed ,durability to change the
mesiodistal position of the molar is greatly inhibited.
With direct bonding, one might have slightly greater
flexibility, although the preformed shape of the bracket
base generally limits the amount" of modification
available to us (Fig 7). With indirect bonding,
particularly if a custom resin base is created, there is a
little more flexibility available to ,the clinician.

Bracket Selection and Effect on Third
Order Movements

Since the advent of pre torqued and preangulated brackets,
orthodontists have had a wide array of torques and
angulations to select from.
Each prescription is based on a foundation of clinical
principles, as well as the personal philosophical preferences
of the individual clinician.
There is considerable variation in the prescribed torques
and angulations between the Hilgers and the Alexander
prescriptions (Ormco Orthodontics, Orange, CA), for
example, not to mention added differences in mechanics
introduced by using the 0.018 slot or the 0.022 slot.
It is interesting to contemplate that one practitioner
treating a patient population in a given area may use an
Alexander prescription, with on the U CI + 14 of torque
ULI +7of torque canines -3 of torque.
Practitioner treating a similar patient population may use
the
Hilgers prescription, with +22 of central incisor torque, +
14 of lateral incisor torque, and+ 7 of canine torque.
These differences are substantial,

Differences become applicable only when full-size arch wires are
used-a relatively uncommon event. Further, the choice of
prescriptions may be governed by the practitioner's philosophy on
occlusal function and its potential impact on temporomandibular
disorders.

seen in Figure 8, same degree of torque placement in the tube on
the 17,27 as one has on the 16,26 --- lesser degree of torque
expressed on 17,27.

relative low position lingual cusps, ---- balancing interferences,
inadequate

settling of the posterior occlusion.

MBT 17,27 torque 4 degrees >16,26.

Torque should be increased to an even greater degree for the
average second molar- Dr. Sondhi

27.17 erupt --- buccal crown inclination & lingual root torque.

The Implications of Vertical Placement
on Expressed Torque

impact of appliance choice -- expressed torque
counts> torque in the bracket on the tooth.
with the new higher resiliency archwires, --- force
diminution final activation -- diminution in force ---
17 torque in a bracket ---- fully expressed s.s. /
HANT Niti
Important to discern the differences --by vertical
bracket position changes on torque expression on
different teeth.
23,13 & 11,21-- degree of convexity of the labial
surface has a profound impact on this variable.
11,21 labial surface--- mild degree of convexity
when the bracket level is changed

change in-- vertical
position relative to the
archwire, -- slight
change in the
expressed torque.

vertical placement of
the bracket --modified
for deep overbites &
open bites without
introducing a
significant compromise
in the expressed
torque.

similar changes - vertical
position of the bracket --
does not merely change
its vertical orientation to
the arch wire.

A rather profound impact
on the expressed torque
is immediately apparent
(Fig 12 B & C) effect of
labial convexity surface

Choice of torque in the
bracket significant -
specific vertical
placement of the bracket
Figure 13 - Attention is drawn to the vertical
position of the maxillary canine & root angulation in
the labio-lingual plane

In Figure 14, the vertical position of the canine bracket -1mm
change, while maintaining every other variable
in the dental arch, and the appliance configuration
constant.
Canine-- extruded, -- equally evident that there
is a noticeable change in the labio-lingual inclination
of that'. tooth.

In Figure 15
vertical position
of the canine
bracket-- 2 mm,
quickly apparent
that the tooth
not only
extrudes, but
also shows--
change in the
labio-lingual
inclination.

Figure 16 is an occlusal view with the
original bracket placement,
Figure 17 is
an occlusal view with the bracket having been
moved gingivally by two millimeters.
Figure 18 clinicians - unable to
understand -occlusion not settle
For example,if it is the clinician's intent
to place a bracket at a height of 4.5
mm from the cusp tip, and the patient
happens to have bruxed enough to
flatten the cusp tip by 2 mm,
the habit of placing the bracket at 4.5 mm
create-interference of the canine in the
occlusion.

2mm of-cusp tip wear on the canine- is hardly
an unusual event - impact of this information -
carefully evaluated -the finishing details during
treatment.

An effort to overcome this by deliberate over
torquing or stepping out of the tooth, is unlikely
to create a favorable result.

Cases - appropriate - reshaping the lingual
surface of the maxillary canine.

The Effect that the Starting Position of
the Tooth Will Have on the Finished
Result .

Least understood aspects of treatment
PEA assumption- fixed degree of second
and third order adjustments built into the
bracket expressed in a uniform manner

Treatment - completed with a full sized
archwire 0.022x 0.028 archwire in a 0.022
x 0.028 slot, or a 0.018 x 0.025 archwire
in a 0.018 x 0.025 slot.

Clinicians - 0.018 x 0.025 slot -0.016 x
0.022 finishing archwire. Figure 19 A
incisor, such as that seen in a Class II Division 1
malocclusion.
Figure 22, finished position will be the same if a 0.018 x
0.025 archwire is used.
However, the finished position - different if a 0.016 x
0.022 archwire -archwire will not engage in the third order
until the tooth has been retracted to a certain degree.
Finishing With the Preadjusted Orthodontic Appliance
Final stage of orthodontic treatment, treatment
goals.
The generally accepted goals of treatment.
condyles in a seated position-in centric relation;
1 relaxed healthy musculature;
2 a "six keys"l,2 Class I occlusion with 3 mm of
3 overjet and overbite;
4 ideal functional movements-a "mutually protected"
occlusion;
5. periodontal health; and
6. best possible esthetics.
Goals viewed - from anterior to posterior.
The incisors - set in the face to establish proper
harmony between the upper lip, the lower lip
and the chin

In July of 2000, the American Board of Orthodontics~
Emphasis seven features of dental casts. These
features include:
1. Tooth alignment: The incisal edges of the anterior
teeth - aligned, - mesio-buccal and disto-buccal cusps
of the mandibular posterior teeth and the central
fossae of the maxillary posterior teeth.

2. Marginal ridges: The marginal ridges of adjacent
posterior teeth, in maxillary and mandibular arches
should be at the same vertical level.

3. Buccolingual inclination: The torque features in the
molar regions should be correct, as measured using a
flat surface extending between the occlusal surfaces
of the right and left posterior teeth.
4.Occlusal contacts: Good posterior occlusion
should be achieved and evaluated based on the
adequacy of occlusal contact of molars and
premolars. A common problem area relative to
occlusal contacts is seen in the upper and lower
second molars.

5.Occlusal relationship: AlP relationship of molars,
premolars and canines is assessed using Angle's
classification.

6.Overjet: In the anterior region, the mandibular
incisors and canines should contact the lingual
surfaces of the maxillary incisors and canines. In
the posterior region, the buccal cusps of the
mandibular molars and premolars should contact
in the center of the occlusal surfaces,
buccolingually, of the maxillary molars and
premolars

7.Interproximal contacts: All of the
maxillary& mandibular teeth should
be in contact with one another, as
viewed from the occlusal surfaces.
Root -anglulation - the roots of the
maxillary and mandibular teeth should be
parallel
to one another and oriented perpendicular
to the occlusal plane.
The fewer the errors made as treatment
progresses the less work required during
finishing.
Horizontal Considerations
Coordination of Tooth Fit
A major finishing consideration in the horizontal
plane is the coordination of tooth fit between the
anterior and posterior segments.
60% of cases,--finishing stage approaches, --
crowns of the upper anterior teeth do not occupy
enough space m-d - crowns of the lower anterior
teeth.

Examples -
posterior occlusion is correct-the overjet and
overbite are each 3 mm, but
spaces remain in the upper arch, frequently in
the extraction site.

Overjet is correct, -buccal segments - slight to
moderate Class II position

Posterior occlusion is correct-all spaces are
closed, but there is inadequate overjet and
overbite in the anterior area.
20% of cases-> upper anterior tooth mass -
lower anterior tooth mass.

upper anterior crowns > crowns lower
anterior segment & patient shows some
excessive overjet - posterior segments are in
a Class I relationship.

Patients with large upper incisors some
Class III cases where upper incisors are
proclined forward and lower incisors
retroclined

T/T- enamel reduction in upper
anterior segment & residual
space.

In the horizontal plane, this
difficulty relates primarily to the
factors of tip in the anterior teeth
and bicuspids,incisor torque and
tooth size (Fig 1).

Establishing Correct Tip of the Anterior and
Posterior Teeth
Tip nearly full expression of the bracket tip - by the time
rectangular steel wires

Standard edgewise appliance, tip (second order) bends
were placed in the arch wires 2 reasons.

First, to properly position teeth relative to the 0 of tip in
the brackets.

Second, to compensate for the forces used to
move teeth (second order compensation), particularly in
extraction cases.

The Andrews nonorthodontic normal model study -baseline
reference for the tip figures in the human dentition

Fully programmed PEA- additional tip- added to the anterior
segments (second order compensation)

Heavy edgewise forces-previously.

Additional amounts of tip- added to- needed second order
compensation- counteract the force levels being used '(Fig
2)

True in the-canine region

Dependent - amount of force used during space
closure in extraction cases
Heavier forces are used>2
nd
order
compensation/ anti-tip required in the
appliance.& vice versa.

Direction of contemporary orthodontics- lighter
forces & minimal anti-tip-- less anchorage loss
during tooth movement and better parallelism
of roots, especially in the canine region.

Providing Adequate Incisor Torque

Torque control -weakness PEA--- two factors:

1) Approximately a 1 mm segment of rectangular
steel wire is placed in a bracket of about the
same dimension.

Small contact area -required - difficult
tooth movement, which involves moving
an entire portion of the root through
alveolar bone and

No use full size-- wires do not slide
efficiently through the posterior bracket
slots during space closure.

E.g. 0.018 x 0.025 or a 0.019 x
0.0250.022 slot,

0.016 x 0.022 or a 0.0175 x 0.025
0.018 slot.

< effectiveness rectangular wire, relative
to torque control (Fig 3).
Clinicians-- added modified
torque values- upper and lower
incisor brackets.
With most Class I and Class II
patients, there is a tendency for
upper incisors to be retroclined
and lower incisors to be
proclined (Fig 4).
Class I / Class II
m.o. -additional
palatal root torque
UI& labial root
torque LI (Fig 5).

upper and lower
anterior torque -
varies greatly,3
rd

order incisor
archwire bends --
needed.

Management of Tooth Size
Discrepancies

Tooth size is -7
th
key to normal occlusion
- the Andrews nonorthodontic normal
models had balanced tooth size.
Spacing in one arch / crowding in the
opposing arch.
Tooth size discrepancy small (U)LI
/large(L) LI
In the buccal segments small15,25- tooth size discrepancy

Evaluation of tooth size discrepancy Boltons analysis.
Tooth size discrepancy- reducing tooth mass in one arch
with interproximal enamel reduction (usually the lower
incisors)

Addition of tooth mass- restorative material (usually the
upper lateral incisors).

Minimal crowding -- anterior segments- Bolton analysis
confirms > tooth size LI - interproximal enamel reduction
procedures lower anterior segment.
Early reduction spacing in U arch- Restoration

Finishing stage- U ant. Segment > tooth mass --
interproximal enamel reduction the upper anterior segment

Controlling rotations
in-out compensation-built + with
correct bracket positioning rotation
control.
10 of rotation - upper molars, 0 -
lower molarsClass I Mo
Relationship

Anterior teeth -rotations
bracket slightly-in the-direction
rotation to-- correction.
33,43 brackets -- to the mesial
- rotates the mesial aspect
labially & provides better
contact with the distal aspect
32,42
It is beneficial in Class I and
Class II cases 14,24 brackets -
1/2 mm to the mesial buccal
cusps of the upper premolars to
rotate distally toward a Class I
position, and the palatal cusps
of these teeth to rotate mesially
occlude more accurately into
the fossae of the lower arch (Fig
7).

Maintaining the Closure of All
Spaces
important -spaces closed -
finishing stage -figure-8
ligature wires from molars to
cuspidswhen light wires -
extraction
cases, during the settling stage,
figure-8 ligaturewires -across
the extraction site to keep them
closed (Fig 8).
areas - space closure -
difficult, figure-8 ligature wires
/light elastic thread -maintain
space closure during settling.
Carrying out these simple
procedures eliminates the
troublesome problem of spaces
opening in the finishing stages
of treatment.

Horizontal Overcorrection
Horizontal overcorrection- Class II and Class III cases.
Finishing stages important- correct the AlP position of the
dentition - Class II or Class III elastics, headgear,
After correction completion, - methods of tooth-movement
can be discontinued /worn on a part-time basis.
The patient - observed 6-8 weeks.
Case stable-appliances -removed.
If not - cases horizontally over-corrected.
In Class II cases - anterior teeth edge to edge & held 6-8
weeks with nighttime
elastics- settling can be observed
(Fig 9).
Class III cases - horizontally over-corrected -producing 3 to
4 mm of additional overjet- observed - similar manner to
Class II cases (Fig 10).
Over-correction techniques -carefully followed, problems
during retention.

These can be due to late aberrant growth /reestablished
tongue or finger habits

Vertical Considerations
Establishing Correct Crown Lengths, Marginal ridge
relationship & Contact Points Correct bracket positioning -'
single most important mechanical step orthodontist- lead
to saving significant time during treatment.

Important - bracket placement- vertical bracket height-
errors are 3-D (effect the torque, in-out and height of the
tooth).
Mesio-distal, axial & thickness errors- one-dimensional.
vertical bracket height - key to correction -vertical crown
positioning, marginal ridge relationships,and contact points.

In initial leveling bracket repositioning corrected - before
placement of rectangular S.S.wires.

If - not done, -corrections -during the finishing stage -
bracket repositioning or wire bending (Fig 11).

Late corrections - do not ensure stability of vertical tooth
position.
It is - better for stability - relationships to be correct for
one to two years before bracket removal.
Thus, correct bracket placement at an early stage is critical
for stability.

Final Management of the Curve of Spee

Low angle cases.
In most average to low angle -to level the entire curve of
Spee. - include placement of bracketsor bands II molars to
complete theprocess (Fig 12).
If curve of Spee - not fully corrected in these cases -- LI --be
positioned >gingivally on the palatal surfaceUI. Make it difficult or
impossible to complete final space-closure in the upper arch & to
keep spaces closed.

If the bite -opened properly &the curve of Spee level--possible
to complete space closure in the upper arch with stability.

Upper bite plate retainers - show a tendency for bite deepening
during retention.

This type of relapse-- spacing in the upper arch and/or crowding
in the lower arch

High angle cases -- high angle+open bite tendencies-leavesome
curve of Spee in the back of the arch- particularly in the second
molar area.
This allows the bite to remain closed anteriorly.
If the back of the curve of Spee is leveled - > risk of opening the
bite.
For patients near the end of the growth period- difficult or
impossible to close this anterior open bite.
To prevent bite opening - curve of Spee - placed in the lower
archwire, and a step-up bend can be placed distal to the first
molar in the upper archwire.

Vertical Over-Correction-Deep Bite and open
Bite Cases

Beneficial - over-correction in deep bite and open bite cases.
This process begins with initial bracket placement.
Brackets - anterior teeth - 1/2 mm> gingival in open bite cases
&1/2 mm more incisal in deep bite cases.

Assists - over-correction process.

In deep bite cases- leveling of the curve of Spee - flat steel
rectangular archwire effective bite opening II mo. included.
If bite opening-not achieved using flat rectangular steel wires,-
bite opening curves can be placed (Fig 13).

Done as late as -finishing stage - normally completed earlier.

At end of treatment - deep bite cases - 1 to 2 mm of overbite.

Generally settle -3 to 4 mm of overbite.

Bite plate retainers - to prevent relapse

Adequate upper incisor torque - maintaining bite opening.

Open bite cases - to evaluate tongue position and tongue habits
before -fillishing stages
Problem - observed before- finishing stage, & Myofunctional
therapy initiated.

These cases will often benefit from the use of positioners -- help
bite closure.
Conventional upper retainer - a small hole- the palatal surface of
the acrylic for tongue positioning - to modify their tongue position
or activity,by holding the tip of the tongue in the roof of palate
during swallowing and other activities.

Tongue - re-assert itself, despite the best-efforts of the patient
and the orthodontist - patient informed of this possibility before
treatment.
Transverse Considerations

Archform and Archwire Coordination

Expansion - lower arch- canine region-instable

Lower arch -rolled in lingualy-- occurs in most palatal
expansion cases & many deep bite cases ---buccal up
righting in the lower arch is indicated for stability (Fig 14).

Evaluating- original cuspid position & the curve of Wilson in
the lower arch is important in determining the correct lower
archform.

By the finishing stage of treatment, the lower archform -
accurately established in the rectangular arch form.

(Fig 14).
178
The upper archform coordinated
with the lower (Fig 15).

Minor widening of the upper wire
posteriorly is

recommended for cases with a
relatively narrow maxilla.

After the rectangular wire stage,
settling of the case with light
archwire allows for further
archform adjustment and
stability.

Establishing Posterior torque:-

To provide adequate buccal root torque in the upper arch, it is
most important to have a wide enough maxilla.

maxilla - not wide enough- buccal cortical plate will not allow for
the incorporation of the appropriate amount of buccal root torque
at the completion of treatment.

Leads to palatal cusps - create interferences during lateral
excursions and compromises to proper functional occlusion.

Needs - evaluated carefully the beginning of treatment.
PEA- additional buccal root torque built into the upper molars-
additional
upper archwire bending needed in this area
Many PEA- added additional buccal crown torque in the lower
posterior segments relative to Andrews' norms.
This has minimized tendency -- lower posterior teeth to roll in
lingually.
Transverse Over-Correction

Cases that show narrowing - maxilla - adequately over-
expanded and held in the expanded position for an extended
period of time.
Maxilla expanded until palatal cusps of the upper arch are in
contact with the buccal cusps of the lower arch in the
posterior segments.

It is helpful to expand cases 1/2 years before full orthodontic
treatment & to maintain this expansion with a palatal bar.

Then stability is normally assured.

If expansion is performed at the beginning of orthodontic
treatment, a palatal bar -placed after the expansion
procedures.

This palatal bar can remain in position until the rectangular
stainless steel wire has been placed.

This wire provides adequate stiffness to maintain the
expansion that has been achieved.

Torque in the posterior brackets of the upper arch, as well
as some additional buccal root torque in the archwire --
beneficial at this time, to allow the posterior segments to
settle properly.

Dynamic Considerations--Establishing Centric
Relation, Checking--Functional Movements and
Reviewing TMJ Needs

Evaluate orthodontic cases CR at the beginning of
treatment, monitor this position throughout
treatment finishing stage

Class I occlusion condyles in centric relation
checked-- interference during protrusive and lateral
excursions.

If the patient has a history of clenching,TMJ sounds
or muscle dysfunction-Beneficial to provide them
with a night guard type of retainer after treatment.

COrrection of Habits
70% to 80% of tongue thrusting & tongue posturing habits
will be corrected before the finishing stages of treatment.

For two main reasons:
1) As the patient grows, the airway size increases
and the tongue assumes a more posterior position;
2) As the dental environment is improved orthodontically,
the tongue and lip musculature have the opportunity to
adapt to this improved environment & normal function can
begin to occur.

Severe problems - referred to Myofunctional therapist on pts
first examined.

Minimal to moderate problems - the habit is not under
control by the time rectangular stainless steel wires are
placed -referral for Myofunctional therapy is appropriate.
use of tongue spurs (Fig
16)- the patient adjusts to
them within 24 to 48 hours
with little difficulty,
serve - reminder for
correct tongue position.
Used in conjunction with
basic Myofunctional
therapy instructionswhich
include:
1) Placement of the tongue
in the "neutral position" on
the palate, away from the
incisors;
.2)Lips together& Muscle
strengthening exercises,
including bilateral chewing
with lips together.

Cephalometric and Esthetic Considerations

Helpful - progress head films halfway through orthodontic
treatment to determine how the skeletal, dental& soft tissue
components are being managed.

Progress head films reassessment

Final cephalogram 3 to 4 months before debanding, rather
than after treatment.

It is better to take the head film before debonding- tooth
positions - corrected if necessary.


Progress and final cephalogram

1) soft tissue profile,

2) the antero-posterior position of the incisors torque of the
incisors,

3)the changes in the mandibular plane of the patient,

4) the degree to which vertical development of the patient has
occurred/ restricted, and

5) the success in correcting the horizontal, skeletal and dental
components of the problem.

6)Evaluation involves superimposition of progress and final
radiographs with the initial cephalometric radiograph, to
accurately determine the changes that occurred.

The difficulty - significant variability in the position of cranial
base structures, and this variability usually increases as the
degree of facial deformityincreases.

> difficult - more unreliable these relationships become,
leaving the clinician in the position of making primarily
subjective clinical judgments.

Secondly, traditional cephalometrics evaluate

-primarily dento-skeletal relationships-<emphasis on the
soft tissues of the face.

Both the hard and soft tissues should be adequately
evaluated cephalometrically.

In 1999, Arnett soft tissue cephalometric analysis,"Ideal
M& F norms - investigated in the study.

These norms can be used in their entirety as a supplement
or a replacement for current cephalomeric methods.

The Final Phase of Finishing-Settling of the Case
Rectangular stainless steel wires
1)overbite control, 2)AlP correction,
3)and space closure,

- restrictive for settling of the teeth in the closing stages -
treatment.
Lighter wires-- 0.014 or 0.016 round heat activated nickel
titanium (RANT) wire is used in the lower arch, coordinated to
the individual arch form for the patient.
Upper arch an0.014 round sectional wire can be placed from
lateral incisor to lateral incisor.
These wires can be accompanied by the use of vertical
triangular elastics where settling needs to occur .
The better the bracket placement, the less elastics need to be
used in this way.
It is beneficial to keep all bands and brackets on the teeth
during settling, so that if unwanted changes occur ,these can
be corrected.
Managing the case in this manner allows teeth to individually
settle into their final positionsbefore appliance removal.
Patients can be seen at approximately one to two week
intervals


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What are some factors that influence finishing details in orthodontic treatment?

What are some objective and subjective assessments of finishing details discussed?

The Implications of Bracket

Selection & Bracket Placement

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