Placement of orthodontic brackets Prof . Maher Fouda

1. Placement of
orthodontic brackets
Prof. Dr. Maher Abdelsalam Fouda
Orthodontic Department
Faculty of Dentistry - Mansoura University

2. A Proper Finish
Begins With a
Proper Start

3. Perhaps the single-most-important
phase of orthodontic treatment is
proper bracket placement.

4. Taking time to achieve proper
placement at the outset can help
mitigate—or even eliminate—final
archwire bends and correction.

5. Facial Axis of the Clinical Crown (FACC).
The most prominent portion of the central
lobe on each crown’s facial surface. For
molars, the buccal groove that separates the
two facial cusps.

6. Facial Axis Point (FA point): The point on the
facial axis that separates the gingival half of the
clinical crown from the occlusal half.

7. Andrews® Plane: The surface or plane on which
the mid-transverse plane of every crown in an
arch will fall when the teeth are optimally
positioned. This plane virtually connects the
appliance through the FA point.

8. Upper Arch FA Point & FACC
Upper Arch Brackets On Andrews® Plane Line

9. Lower Arch FA Point & FACC
Lower Arch Brackets On Andrews® Plane Line

10. The accurately placed brackets will give better control on
three dimension position of the teeth during treatment.
An accurately placed bracket will also result in better
expression of its built in prescription and orthodontist will
need less wire bending and complex mechanics during
the course of treatment.

11. 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.

12. 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.

13. 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
.

14. Maxillary and mandibular incisors

15. Vertical lines showing mesiodistal center of the
upper and lower incisors. Brackets should be
placed at the recommended height on this line.

16. 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.

17. Bracket is placed slightly off center and toward
mesial, in case of canines

18. {
The vertical lines on maxillary and mandibular canines indicate the
mid developmental ridge of the canines and ideally the middle of
the brackets should coincide with this line.

19. 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.

20. Mandibular Premolars

21. 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.
M D

22. Mandibular Premolars
Maximum convexity lies slightly mesial to the
mesiodistal center. The cast of the patient should
be examined to detect position of the maximum
convexity

23. Mandibular Premolars

24. Mandibular Premolars

25. In mandibular premolars the buccal and lingual
cusps lies at the same level in the mesiodistal
perspective. So when placing
lower premolar brackets the scribe line of the
bracket should coincide with line connecting the
buccal and lingual cusps
Mandibular Premolars

26. A left lower 2nd premolar bracket bonded so that the
line connecting the buccal and lingual cusps passes
through the scribe line of the bracket. This is because
buccal and lingual cusps of the lower premolars should
be present at the same level in mesiodistal perspective.
Mandibular Premolars

27. 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

28. 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 while the lingual cusps have cusp fossa
relationship with lower premolars in class I & II molar occlusion

29. Maxillary Premolars
Maxillary premolars should have
slightly rotated position at the
end the treatment.

30. According to Andrew six keys of normal
occlusion the buccal cusps of upper premolars
should have a cusp embrasure relationship
with lower premolars

31. According to Andrew six keys of normal
occlusion the buccal cusps of upper
premolars should have a cusp embrasure
relationship with lower premolars

33. So if the buccal and lingual cusps 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 .

34. According to Andrew1 the buccal
cusps of upper premolars should
be slightly more distal than the
lingual cusps in the mesiodistal
perspective

35. 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

36. A. Keeping the buccal and lingual cusps of maxillary premolars in
the same mesiodistal perspective will cause poor occlusal results..
D. A bracket bonded slightly mesial to line connecting the buccal
and lingual cusp of maxillary 2nd premolar. Bonding the bracket in
this position will rotate the buccal cuspsdistally and lingual cusp
slightly mesial to get ideal relationship in a class I molar relationship

37. B&C. When the buccal cusp tips of the
maxillary premolars are in line with lower
embrasures their lingual cusps lies slightly
mesial to embrasures and rest at their
corresponding teeth fossas

38. According to McNamara such a position will also
help to improve class I & II dental relationships
E &F Like class I in class II molar finished cases maxillary
premolar buccal cusp is slightly distal to lingual cusp in
mesiodistal perspective to give ideal occlusal
relationships

39. For class III molar finished cases though there are
no guidelines available in the literature but the
author opinion is that upper premolars should be
bonded like class I cases in surgical and
orthopedic treatment..

40. But if the orthodontist is aiming class III
camouflage then upper premolar brackets should
be bonded slightly distal to mid developmental
ridge so that the buccal and lingual cusps have the
same prominence in mesiodistal perspective

42. {
Maxillary and mandibular molars
Conventionally bands are placed on the molars. The most
suitable band is one that snugly fits the tooth. Whether
molar bands or tubes are used, the optimum mesiodistal
position is decided by taking the mesiobuccal cusp as
reference.

43. {
The mesial opening of the
tube should lie below the
mesiobuccal cusp at the
correct vertical height

44. Bands placed on upper and lower molars. The
mesial opening of the tube lies below the mesiobuccal
cusp of the molars. The rule hold true for both 1st and
2nd molars in both arches

45. Checking mesiodistal position of the brackets
The mesiodistal position of the bracket can be checked under
both direct and indirect vision. For indirect vision diagnostic
mirror is used . Generally mesiodistal position of upper
incisors, premolars and molars brackets is
checked under indirect vision

46. Modifications in mesiodistal position of the bracket
Alteration in mesiodistal position of the bracket will alter the
prescription of the bracket in terms of counter rotation.
Some situations where mesiodistal position of the bracket is
altered are given.

47. 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.
A rotated maxillary 2nd premolar.
As the tooth is distopalatally
rotated so the bracket is placed
slightly more distal than its
required position

48. Clinical Notes
Sometimes due to severe rotation or
crowding the position of the tooth is such
that it's not possible to place bracket at the
right mesiodistal center of the tooth

49. Rotated right upper central incisor.
Correct mesiodistal position of the bracket is not possible on
the first bonding visit due to rotation. The bracket should be
placed as far mesial as possible. The mesial side of the
bracket should not come in contact with left side incisor
because it will hinder the full insertion of the wire and also
make ligature placement extremely difficult if not
impossible

50. In such situations the bracket should be placed as far as
possible toward the mesiodistal center of the tooth or toward the
rotation. A flexible wire is passed and only the brackets wings
toward the rotation are ligated. At subsequent visit the tooth is
usually derotated enough to place bracket at the right
mesiodistal position
So the bracket is debonded and
either a recycled or new bracket is
rebonded at the correct mesiodistal
position

51. Clinical Notes
Sometimes the tooth is rotated 180° so that the lingual side is
on the labial side. Many times this form of rotation is
accepted. In such situation the bracket is bonded on the side
of the tooth which is facing labial or buccal .
Right lower lateral is rotated
180°.The rotation was
accepted and bracket placed
on lingual side of the tooth
which was facing labially

52. Clinical Notes
Another situation is maxillary lateral incisor substitution by canine. In
this situation the slightly convex labial surface
of canine is made flat to give it shape of lateral incisor and bracket is
bonded at mesiodistal center of reshaped canine
instead of slightly mesial.

53. Placing the bracket at the mid developmental ridge area
will cause poor contact point with the central incisor as canine is
also reshaped mesiodistally. On premolar tooth which
will become future canine the canine bracket is placed distal to
the mesiodistal center of the tooth.

54. • It is necessary to position these brackets
gingivally to permit the re-contouring of the
canines required for esthetics and function.
• The orthodontist should place the brackets
according to gingival margin height rather
than incisal edge or cusp tip.

64. Placing the bracket distally will rotate the tooth
mesiopalatally which increases the mesiodistal width of
future canine tooth, bringing the convex part of the tooth
mesial so that it look similar to the mid developmental
ridge of canine

65. This position of bracket also helps to hide the palatal cusp of
premolar and improves the occlusal relation with the
mandibular canine. The palatal cusp needs to be grounded to
avoid premature contact with opposing dentition.

66. Axial or long axis position of the 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

67. Standard edgewise brackets has no built in tip. Bracket
position didn't follow long axis of the crown or root and
were placed angular on the tooth equal to the amount of
tip required.

68. 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 .

69. A pre adjusted bracket of maxillary left lateral incisor .Placing
the bracket parallel to long axis of clinical crown will cause tooth
to rotate in a clockwise direction and express the built in tip.

70. 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 .
There is always some
difference between long
axis of clinical crown and
long axis of the tooth

71. Also placing bracket according to long
axis of tooth may result in wrong
mesiodistal position of bracket on the
crown.

72. 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

73. A lateral incisor bracket placed with reference to long axis of
clinical crown. X ray showing that long axis of bracket not
coinciding with long axis of the root
and because of this root of the lateral incisor is in close
contact with central incisor root increasing chances of root
resorption in this area.

74. 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 betaken
as reference.

75. Taking the long axis of tooth can 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.

76. A. Golden proportion of connectors that ideally should be
present in finished cases. B. A case with dilacerated central
incisor root. If there is root dilacerations, placing bracket by
following the clinical crown will result in ideal connector
areas but greater chances of root approximation and so root
resorption.

77. C. Bracket placed by following the long axis of the
roots. The golden proportion of connectors is
distorted. They can be resorted by composite built
up or interproximal stripping at the end of
treatment

78. Clinical notes
Some clinicians also take incisor edge as
guideline for long axis positioning of brackets. But
incisor edge is mostly uneven due to trauma,
attrition and mamelons. So incisor edge shouldn't
be taken as a reference point for long axis
position of the bracket.

79. Also gingival zenith(top) shouldn't be taken
as a reference for long axis position of the
bracket as it can be effected by uneven
pattern of gingival recession

80. A. Mamelons on central incisors. These mamelons will give a
different long axis position of the tooth if taken as reference for
bracket positioning. B. Attrition of the incisor edge will also effect
long axis position of the teeth. C. Gingival zenith shifted mesial
from their ideal position due to gingival recession. Taking gingival
zenith as reference for axial position of the
bracket in these cases will result in wrong placement of the
brackets

81. Importance of axial position of brackets
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

82. A&B. Preadjusted brackets not placed in accordance with long axis of
the tooth will result in increase or decrease expression of tip than the
built in tip. C.A x ray showing that both decreased and increased tip of
incisors due to angular bracket placement. This increases chances of
root approximation and root resorption.

83. D&E. Over angulated brackets placed on
central incisors can result poor proportion of
connectors and embrasures leading to
development of black triangles

84. Change in tooth angulation will also affect the golden
proportions of connectors and embrasures and so the smile
esthetics of the teeth.

85. Checking axial position of brackets
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.

86. 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.

87. Modifications in axial position of brackets
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.

88. 3. To avoid root resorption from teeth
impacted in the bones. i-e impacted
canines or mesiodens ..)

89. Orthodontic implants inserted for intrusion of maxillary
incisor. Note the position of lateral incisors at both ends.
The gingival wings of the brackets are facing distal so they
will rotate both lateral incisor roots toward mesial. Initially
such bracket placement will create space for implant
insertion and during intrusion it will ensure that roots of
lateral remain away from implants.

90. Once the intrusion is completed and the implants
are removed, bracket position is corrected so that
lateral incisor have optimum angulation

91. A mesiodens present between roots of the upper central
incisors. Brackets are placed so that wings of the brackets
are facing mesial on gingival side. This will rotate both the
central incisors roots away from mesiodens and will give
good access to surgeons for removing it without causing
any damage to central incisor roots.

92. The bracket position needs to be corrected
after mesiodens removal otherwise black
triangle will result in central incisors.

93. 5. In some surgical cases bracket position is modified to
move roots away from surgical site (Wassmound procedure
in maxilla, Subapical osteotomy).
4. To accommodate crown morphology for achieving
golden proportions of connectors and embrasures

94. 6. If teeth have slightly smaller size
such as peg laterals than it is better to
increase the angulation of the teeth
rather then to go for composite build
ups