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Orthodontists strive for accurate bracket positioning because it makes achieving a superior occlusion easier.
Whether one uses a direct or an indirect bonding technique, the initial appliance placement typically includes
some bracket-positioning errors. The clinician either corrects these errors during treatment or tediously
repeats archwire bends to compensate for the misplaced brackets. The clinician should assess bracket
positioning early in treatment by clinical and radiographic evaluations and then correct all positioning errors
during a single dedicated reset appointment. This article describes a 5-step protocol for assessing and
correcting bracket-positioning errors. (Am J Orthod Dentofacial Orthop 2001;119:76-80)
A
well-finished orthodontic case has the proper ment protocol, it can decrease treatment time and
alignment of crowns and roots and level mar- improve final results.
ginal ridges. With preadjusted brackets
(straight-wire appliances), the position of the bracket on STEP 1: INITIAL BRACKET POSITIONING
the crown determines the tooth’s final tip, torque, Ideally positioning brackets during initial bonding
height, and rotation.1,2 Poorly positioned brackets result is challenging. Journal articles have described many
in poorly positioned teeth and necessitate many more direct and indirect bonding techniques in an effort to
archwire adjustments. This can lead to an increase in improve initial placement accuracy.7-14 Most of these
treatment time or a final occlusion that is less than ideal. bonding techniques have in common 4 elements that
Poor bracket positioning can render even the most demand attention when positioning brackets: (1) base
customized prescription ineffective. Consider the end- adaptation, (2) rotational position, (3) vertical position,
less number of bracket prescriptions on the market. and (4) slot angulation. Regardless of the bonding tech-
Most differ by only a few degrees. Now, consider how nique used, one should strive to optimize each bracket
much one can change the prescription by misplacing placement relative to these 4 categories.
the bracket on the tooth.3 First, check to see that the contour of the bracket
Orthodontists go to great lengths to ensure that each base follows the contour of the tooth’s surface. The
bracket is positioned as ideally as possible. Unfortu- bracket base may need to be modified to fit some teeth
nately, even under the best of circumstances, ideal either by flattening the base or by increasing its con-
bracket placement during initial bonding is often cavity. An ideal base contour helps to ensure an even
impossible because of limitations brought on by the flow of adhesive during bracket seating. However,
existing malocclusion or operator error.4-6 Initial level- even when the contour of the bracket base is ideal,
ing often reveals bracket-positioning errors. The ortho- incomplete bracket seating can lead to unwanted rota-
dontist should first recognize and then correct these tions (Fig 1).
errors early in the treatment process so that wire adjust- Second, evaluate the rotational position of each
ments can be minimized later. bracket from the occlusal (Figs 2-5). Center the bracket
The protocol below describes 5 steps for achieving mesiodistally for incisors and in line with the labial
crown and root alignment. We recommended that cusp tips for canines and premolars. Center the bracket
each step be performed on every patient undergoing in the buccal groove for molars.
fully banded therapy. Once integrated into the treat- Third, determine the vertical position of each bracket
by using well-fitted molar bands as benchmarks for the
aAssistant Professor of Orthodontics, University of the Pacific; and in private vertical position of the rest of the appliance. Position all
practice. the posterior brackets so the distance from the archwire
bAssociate Clinical Professor of Orthodontics, University of California, San
Francisco; and in private practice. slot to the marginal ridge is equal for all neighboring
Reprint requests to: Sean K. Carlson, 163 Miller Ave, Mill Valley, CA 94941. teeth (Fig 6). This will result in even marginal ridges
Submitted and accepted, March 2000. when a straight wire is used. The distances from the slots
Copyright © 2001 by the American Association of Orthodontists.
0889-5406/2001/$35.00 + 0 8/1/111220 to the cusp tips may vary. The anterior brackets should
doi:10.1067/mod.2001.111220 be positioned on the basis of the heights of the posterior
76
American Journal of Orthodontics and Dentofacial Orthopedics Carlson and Johnson 77
Volume 119, Number 1
Fig 1. Excess adhesive under mesial of left bracket will Fig 4. Ideal rotational bracket positioning for maxillary
lead to undesired rotation. posterior teeth as viewed from the occlusal.
Fig 2. Ideal rotational bracket positioning for maxillary Fig 5. Ideal rotational bracket positioning for mandibular
incisors as viewed from the occlusal. posterior teeth as viewed from the occlusal.
Fig 6. Ideal vertical positions of posterior brackets. Mar- Fig 9. Periapical radiograph of maxillary posterior teeth.
ginal ridges equidistant from wire slot. Note mesial root inclination of second premolar.
Fig 7. Ideal vertical positions of maxillary anterior brackets. Fig 10. Tip adjustment in bracket positioning for second
Note differences in incisal edges and gingival margins. premolar with mesial root inclination.
Fig 11. Root-paralleling radiographic series. Note the mesial root inclination of the mandibular left
first premolar and maxillary left lateral incisor.
Fig 12. Bracket-positioning errors noted in a designated area of the patient’s chart. Abbreviations for
each tooth specify necessary reset instructions.
this wire to completely express the bracket prescrip- each category in a specially designated area on the
tion and position (4-8 weeks). patient’s chart (Fig 12).
Use abbreviations to specify the necessary reset
STEP 3: RESET EVALUATION instructions for each bracket. Our recommended abbre-
The reset evaluation involves both a clinical exam- viations are as follows: a check mark indicates poor
ination and a radiographic evaluation. For most adaptation of the bracket base to the tooth. This might
patients, the reset evaluation can take place within the be a bracket that was not fully seated or a band with a
first 6 months of active treatment. Perform the clinical distorted margin. An “MO” or “DO” indicates a rota-
examination at the appointment before the reset tional deficiency. An “MO” indicates that the mesial of
appointment and prescribe a root-paralleling radio- that tooth needs to be rotated out toward the labial, and
graphic series (Fig 11). “DO” indicates that the distal needs to be rotated out.
Examine each tooth individually for bracket- “I” for intrude and “X” for extrude indicate the neces-
positioning errors, paying close attention to base adap- sary vertical adjustments. Finally, a “D” indicates that
tation, marginal ridge height discrepancies, crown rota- the root apex needs to be moved distally and an “M”
tions, and nonparallel roots. We note the deficiencies in indicates that the apex needs to be moved mesially.
80 Carlson and Johnson American Journal of Orthodontics and Dentofacial Orthopedics
January 2001