CLINICIANS CORNER

Bracket positioning and resets: Five steps to align crowns and roots consistently
Sean K. Carlson, DMD, MS,a and Earl Johnson, DDSb Mill Valley, Calif 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)

well-finished orthodontic case has the proper alignment of crowns and roots and level marginal ridges. With preadjusted brackets (straight-wire appliances), the position of the bracket on the crown determines the tooths final tip, torque, height, and rotation.1,2 Poorly positioned brackets result in poorly positioned teeth and necessitate many more archwire adjustments. This can lead to an increase in treatment time or a final occlusion that is less than ideal. Poor bracket positioning can render even the most customized prescription ineffective. Consider the endless number of bracket prescriptions on the market. Most differ by only a few degrees. Now, consider how much one can change the prescription by misplacing the bracket on the tooth.3 Orthodontists go to great lengths to ensure that each bracket is positioned as ideally as possible. Unfortunately, even under the best of circumstances, ideal bracket placement during initial bonding is often impossible because of limitations brought on by the existing malocclusion or operator error.4-6 Initial leveling often reveals bracket-positioning errors. The orthodontist should first recognize and then correct these errors early in the treatment process so that wire adjustments can be minimized later. The protocol below describes 5 steps for achieving crown and root alignment. We recommended that each step be performed on every patient undergoing fully banded therapy. Once integrated into the treat-

ment protocol, it can decrease treatment time and improve final results.
STEP 1: INITIAL BRACKET POSITIONING

aAssistant Professor of Orthodontics, University of the Pacific; and in private practice. bAssociate Clinical Professor of Orthodontics, University of California, San Francisco; and in private practice. Reprint requests to: Sean K. Carlson, 163 Miller Ave, Mill Valley, CA 94941. Submitted and accepted, March 2000. Copyright 2001 by the American Association of Orthodontists. 0889-5406/2001/$35.00 + 0 8/1/111220 doi:10.1067/mod.2001.111220

Ideally positioning brackets during initial bonding is challenging. Journal articles have described many direct and indirect bonding techniques in an effort to improve initial placement accuracy.7-14 Most of these bonding techniques have in common 4 elements that demand attention when positioning brackets: (1) base adaptation, (2) rotational position, (3) vertical position, and (4) slot angulation. Regardless of the bonding technique used, one should strive to optimize each bracket placement relative to these 4 categories. First, check to see that the contour of the bracket base follows the contour of the tooths surface. The bracket base may need to be modified to fit some teeth either by flattening the base or by increasing its concavity. An ideal base contour helps to ensure an even flow of adhesive during bracket seating. However, even when the contour of the bracket base is ideal, incomplete bracket seating can lead to unwanted rotations (Fig 1). Second, evaluate the rotational position of each bracket from the occlusal (Figs 2-5). Center the bracket mesiodistally for incisors and in line with the labial cusp tips for canines and premolars. Center the bracket in the buccal groove for molars. Third, determine the vertical position of each bracket by using well-fitted molar bands as benchmarks for the vertical position of the rest of the appliance. Position all the posterior brackets so the distance from the archwire slot to the marginal ridge is equal for all neighboring teeth (Fig 6). This will result in even marginal ridges when a straight wire is used. The distances from the slots to the cusp tips may vary. The anterior brackets should be positioned on the basis of the heights of the posterior

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Fig 1. Excess adhesive under mesial of left bracket will lead to undesired rotation.

Fig 4. Ideal rotational bracket positioning for maxillary posterior teeth as viewed from the occlusal.

Fig 2. Ideal rotational bracket positioning for maxillary incisors as viewed from the occlusal.

Fig 5. Ideal rotational bracket positioning for mandibular posterior teeth as viewed from the occlusal.

Fig 3. Ideal rotational bracket positioning for mandibular incisors and canines as viewed from the occlusal angle.

in such a way that they can establish proper gingival and incisal edge relationships (Fig 7).15 Position the lower incisor brackets at equal distances from the incisal edges and slightly more incisally than the neighboring canines (Fig 8). Do not use fractured or worn incisal edges as guides for bracket positioning. Finally, determine the desired slot angulation of each bracket by evaluating the position of the roots. Use periapical radiographs as a guide during initial bracket placement (Fig 9). If the root is well aligned on the initial radiograph, be sure that the slot angulation is neutral. If the root alignment needs correction, incorporate the needed adjustment into the slot angulation during initial bracket placement (Fig 10).
STEP 2: PRIMARY EXPRESSION OF BRACKET PRESCRIPTION AND POSITION

brackets. The canine and adjacent premolar brackets should be positioned equidistant from the cusp tip, or with the canine cusp tip just slightly further from the bracket slot. Upper incisor brackets should be positioned

After initial bracket placement, the goal is to completely express the brackets prescription and position through complete leveling and aligning. For example,

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Fig 6. Ideal vertical positions of posterior brackets. Marginal ridges equidistant from wire slot.

Fig 9. Periapical radiograph of maxillary posterior teeth. Note mesial root inclination of second premolar.

Fig 7. Ideal vertical positions of maxillary anterior brackets. Note differences in incisal edges and gingival margins.

Fig 10. Tip adjustment in bracket positioning for second premolar with mesial root inclination.

Fig 8. Ideal vertical positions of mandibular anterior brackets. Incisor brackets positioned slightly more incisally than canines.

consider a patient who has a set of perfectly positioned brackets with a bracket prescription that is ideal for the shape of the teeth. In theory, treatment would require

only that the orthodontist level the bracket slots, finishing with a full-sized wire. The resulting tooth-to-tooth relationships should be ideal without wire adjustments. We do not encounter this situation often, but the lesson it provides is an important onefilling the bracket slot provides complete expression of bracket prescription and position. If, during the initial alignment stage, you find a severe bracket-positioning error, reset the bracket while still in the light initial wire (.014 or .016-in nickel-titanium). This reduces the need to drop down in wire size at the reset appointment. Minor bracketpositioning errors, on the other hand, are most efficiently corrected at the reset appointment after the reset evaluation. Completely seat a full-sized wire in each bracket slot before moving on to the reset evaluation. A smaller wire will only partially express the bracket prescription and position. We recommend a .018 .018-in Sentalloy wire (GAC International, Islandia, NY) for a 0.018 slot appliance. Allow sufficient time for

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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 patients chart. Abbreviations for each tooth specify necessary reset instructions.

this wire to completely express the bracket prescription and position (4-8 weeks).
STEP 3: RESET EVALUATION

The reset evaluation involves both a clinical examination and a radiographic evaluation. For most patients, the reset evaluation can take place within the first 6 months of active treatment. Perform the clinical examination at the appointment before the reset appointment and prescribe a root-paralleling radiographic series (Fig 11). Examine each tooth individually for bracketpositioning errors, paying close attention to base adaptation, marginal ridge height discrepancies, crown rotations, and nonparallel roots. We note the deficiencies in

each category in a specially designated area on the patients chart (Fig 12). Use abbreviations to specify the necessary reset instructions for each bracket. Our recommended abbreviations are as follows: a check mark indicates poor adaptation of the bracket base to the tooth. This might be a bracket that was not fully seated or a band with a distorted margin. An MO or DO indicates a rotational deficiency. An MO indicates that the mesial of that tooth needs to be rotated out toward the labial, and DO indicates that the distal needs to be rotated out. I for intrude and X for extrude indicate the necessary vertical adjustments. Finally, a D indicates that the root apex needs to be moved distally and an M indicates that the apex needs to be moved mesially.

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STEP 4: RESET APPOINTMENT

SUMMARY

The information gathered during the reset evaluation are the instructions for the reset appointment. Schedule the reset appointment with adequate time for debonding, debanding, bracket preparation, tooth preparation, rebonding, and rebanding. We recommend at least an hour for this appointment. It is easier to position brackets at the reset appointment than it is at the initial bonding. By the reset appointment, the tooth-to-tooth relationships have greatly improved, making it much easier to assess the relative positions of brackets between neighboring teeth. Also, visibility of each tooths facial surface is greatly improved. Remove the brackets and bands from teeth with positioning errors. Clean each tooth of excess composite or cement. Remove excess composite or cement from the bands and brackets by using a micro-etcher. Refit each band before cementation. Refitting the band is particularly important for rotational resets because initial band fitting and burnishing creates a rotational memory in the bands metal. This memory can be removed by reshaping the band with bird-beak pliers before refitting. Reposition the bands and brackets according to the principles described in step 1. Use the root-paralleling radiographs at chairside to determine the amount of tip correction. After cementation and bonding, fully engage the same .018 .018-in Sentalloy wire (GAC International) that was used for primary expression of bracket prescription and position. Use a lighter wire if the positional change of 1 or more brackets was severe.
STEP 5: SECONDARY EXPRESSION AND FINISHING

We have presented a protocol that addresses errors of initial bracket positioning and facilitates consistent crown and root alignment. By implementing this protocol, the clinician can expect decreased treatment times and superior results. We have found that although repositioning does not completely eliminate the need for wire bends during finishing, it does significantly reduce their number and complexity. This protocol can be adapted to fit numerous treatment philosophies and can be applied to an appliance of any slot size.
REFERENCES 1. Swain BF. Straight wire design strategies: five-year evaluation of the Roth modification of the Andrews straight wire appliance. In: Orthodontics: state of the art, essence of the science. St Louis: CV Mosby; 1986. p. 279-98. 2. Creekmore TD, Kunik RL. Straight wire: the next generation. Am J Orthod Dentofacial Orthop 1993;104:8-20. 3. Balnut N, Klapper L, Sandrik J, Bowman N. Variations in bracket placement in the preadjusted orthodontics appliance. Am J Orthod Dentofacial Orthop 1992;102:62-7. 4. Zachrisson BU, Brobakken BO. Clinical comparison of direct versus indirect bonding with different bracket types and adhesives. Am J Orthod 1978;74:62-78. 5. Aguirre MJ, King JG, Waldron JM. Assessment of bracket placement and bond strength when comparing direct bonding to indirect bonding techniques. Am J Orthod 1982;82:269-76. 6. Koo BC, Chung C-H, Vanarsdale RL. Comparison of the accuracy of bracket placement between direct and indirect bonding techniques. Am J Orthod Dentofacial Orthop 1999;116:346-51. 7. Silverman E, Cohen M, Gianelley AA, Dietz VS. A universal direct bonding system for both metal and plastic brackets. Am J Orthod 1972;62:236-44. 8. Moin K, Dogon IL. Indirect bonding of orthodontic attachments. Am J Orthod 1977;72:261-75. 9. Hoffman BD. Indirect bonding with a diagnostic setup. J Clin Orthod 1988;22:509-11. 10. Hickham JH. Predictable indirect bonding. J Clin Orthod 1993;27:215-17. 11. Moskowitz EM, Knight LD, Sheridan JJ, Esmay T, Tovilo K. A new look at indirect bonding. J Clin Orthod 1996;30:277-81. 12. Kasrovi PM, Timmins H, Shen A. A new approach to indirect bonding using light-cure composites. Am J Orthod Dentofacial Orthop 1997;111:652-6. 13. Simmons M. Improved laboratory procedure for indirect bonding of attachments. J Clin Orthod 1978;12:300-2. 14. Thomas R. Indirect bonding: simplicity in action. J Clin Orthod 1979;13:93-105. 15. Garber DA, Salama MA. The aesthetic smile: diagnosis and treatment. Periodontol 2000 1996;11:18-28

After the reset appointment, fully express the new bracket positions by applying the same principles used in step 2. Secondary expression is usually complete within 6 to 8 weeks. The amount of time depends on the severity of the original positioning errors. After secondary expression, an adjustable wire can be inserted for finishing. At this stage the orthodontist can be confident that root alignment has been achieved and no further adjustments for root tip will be needed. Treatment can be completed with your choice of finishing procedures.