A presentation about the direct bracketing technique. Mainly a tutorial for dental professionals interested in orthodontics

1. So do you know how to bracket?
A Basic Teaching Module
Dr Jean Marc Retrouvey
Dr F, Karen
Dr H, Manuela

2. • Precise bracket placement is
the most important aspect in
orthodontic alignment, after
correct diagnosis and
treatment planning procedures.
• This factor is most crucial
given the advent of pre-
adjusted brackets and straight
wire appliances.
• The duration of treatment is
shorter in cases where bracket
placement is optimal. Poor
bracketing will lead to extra
time spent finishing proper
alignment and occlusion, and
possibly treating iatrogenic
complications.

3. General steps in bracket
bonding

4. Objectives
• The aim of this presentation is to
illustrate step-by-step bracketing
techniques for undergraduate dental
students using multimedia in the form of
text, video and photos.

5. Prophylaxis
• Pre-bonding prophylaxis
procedure – Using oil-free
pumice mixed with water:
tooth surfaces where the www.toothology201.com
brackets are to be bonded
must be cleaned.

6. We use gel not liquid for
etching.
We prefer Ultradent Gel
Bonding kit

7. Isolation of teeth (Cheek retractors)

8. Enamel etching
In this step and all subsequent steps, salivary
control and maintenance of a dry,
uncontaminated field is essential.
The acid etch (35% H3PO4) is placed on
each tooth surface for ~15 seconds, then
suctioned with a high speed (HS) suction
and rinsed abundantly with water spray for
the same time.
Air dry the tooth surfaces until they appear
frosty white.

9. Acid Etching

10. Proceed by quadrants

11. Rinse each tooth for 15 seconds

12. Dry the field (Chalky white enamel)

13. Apply a light coat of resin

14. Sealing – A very thin layer of unfilled resin is
placed on the tooth surface, and gently air-
dried. It must be light cured for 20 seconds on
each tooth.
Bonding – Using a Ladmore composite
instrument, coat the bracket base evenly with
unfilled resin without any voids.
Place the bracket on the tooth surface and
press firmly in order to minimize resin excess
and bracket drift, and maximize bond
strength. Remove excess material with a
scaler.
Light cure for 20 seconds from the mesial and
20 seconds from the distal.
In general, the bonding material will take 24-
72 hours to set completely. Therefore patients
must be instructed to not eat hard foods
during this period to avoid any debonding
from occurring.

15. Cure resin for 10 seconds

16. Select the proper bracket

17. The coloured dot
must be placed
disto-gingivally
Twin straight wire brackets are used at McGill, and have a unique
prescription suited for each tooth. They are designed to obey Andrew’s 6
Keys of Occlusion.

18. Position the bracket as precisely as
possible

19. Visualization of position
When placing brackets it is important to view
the teeth from the correct aspect.
Do not view the incisors from the side, or
from above or below. This may require for
the patient to turn the head, and the dentist
to constantly change seating position.

21. Use a mirror to verify if the bracket is
centered on the crown

22. Excellent bracketing relies on proper visualization of the crown, its
convexity, and its long axis.
Use a mouth mirror to view the crowns from the incisal/occlusal
view to establish good angulation and to ascertain correct
mesio-distal positioning of the bracket.

23. Remove excess composite around
bracket

24. Excess composite
Remove excess composite around the
bracket with a scaler or an explorer before
light curing. If not, it will encourage plaque
accumulation.

25. Use height gage properly

26. The bracket placement gauge is used differently in different areas
of the mouth:
In the incisor regions, the gauge is placed at 90° to the labial
surface.

27. In the canine, premolar and molar regions,
the gauge is placed parallel with the occlusal
plane

28. Place another bracket (22)

29. Verify bracket positioning

30. Position incisal edges or
marginal ridges
• Position all the teeth at their proper level
on the occlusal plane
• Bracketing position will dictate the amount
of extrusion
• Combination of extrusion-intrusion

32. Bracket height
• If the incisal edges are not worn out, you
may want to use a height gage to position
the bracket properly If

35. Common Errors in Bracketing

36. Vertical Errors in Bracket
Positioning
Placing a bracket too gingivally or incisally is one of the most
common errors in bracket placement.
This is more prevalent in teeth that have not fully erupted.
A bracket placed too gingivally will cause tooth extrusion, while if it is
too incisal, intrusion would occur.

37. Bracket placed too gingivally

38. Vertical Errors
Tips:
A)imagine where the centre of the crown would be if the tooth was
fully erupted.
B) View the tooth surface from a mesio-distal aspect during bracket
placement, and not from above or below.
C) Use gingival margins as a guide

39. Bracket placed too incisally

40. Vertical positioning
Vertical accuracy can be greatly improved by the
use of a height gauge and bracket positioning
charts.

41. Angulation Errors
These errors generally occur when the bracket is placed at an angle on the
crown. This is a common error when crowns have been worn down.
Trick: Visualize the long axis of the tooth and disregard the incisal edge as
a reference point.
When aligning the teeth the position of the gingival margin is given priority
over the position of the incisal edge.

43. Horizontal Errors
Placing brackets too mesially
or distally is common on
canines and premolars – teeth
with convex surfaces, as
opposed to the flat surfaces of
the incisors.

44. Tip: Visualization should be made from at least two
angles to prevent this error.
– One should look
directly from the
facial surface,
and should verify
occlusally with a
mirror to prevent
horizontal errors.

45. Too much composite on the bracket base will modify the labio
Bonding Errors
lingual position of the bracket. This will lead to misalignment
of the incisal edges

46. Bonding Errors
FIRST, IDENTIFY THE ERROR IF A BRACKET DEBONDS,
AND AVOID REPEATING IT
REBONDING
All resin on the affected tooth surface must be carefully
removed with a carbide bur.
In case a new bracket is not available, the base of the original
bracket must be sandblasted.
Once the tooth is cleaned, it is etched and sealed, and the
bracket is rebounded back into place.
The neighboring brackets are first re-ligated, and the
rebounded bracket is subsequently ligated.

47. Bracket positioning in the upper
Maxillary central incisors
anterior teeth
• General guidelines:
– The bracket slot must be parallel to the
occlusal plane. The horizontal bracket
components may also parallel the incisal edge
if not worn down.
– Place the bracket 4.0 mm from the incisal
edge, midpoint of the incisal-gingival height of
the bracket
– Centre the bracket mesio-distally over the
mid-developmental ridge

48. • Common errors:
– Bracket angulation: If angulation is
insufficient, root proximity and open incisal
embrasure with gingivally-placed mesial
contacts may result. If angulation is
excessive, overjet may be increased.
– Brackets placed too incisally (<4.0 mm)
– Excess resin on the bracket base

49. Bracket positioning in the upper
Maxillary lateral incisors
anterior teeth
• General guidelines:
– The bracket slot must be parallel to the occlusal
plane. The horizontal bracket components may also
parallel the incisal edge if not worn.
– Place the bracket 3.5 mm from the incisal edge,
midpoint of the incisal-gingival height of the bracket.
This will allow the lateral to be slightly above the
desired occlusal plane for good alignment and
function with the mandibular canine.
– Centre the bracket mesio-distally over the mid-
developmental ridge.
– Vertical tie wings must be parallel to the crown outline
and/or the mid-developmental ridge

50. • Common errors:
– Insufficient angulation: It is sometimes difficult to
visualize its long axis, and also due to the variable
morphology. It is a common error that the roots of
lateral incisors converge towards the centrals.
– Brackets placed too incisally: This is common in
smaller, poorly shaped laterals. These teeth would be
too high above the occlusal plane, and appear to be
too short relative to the canine and central incisor.
The contact areas would be too far gingival,
compromising esthetics

51. Maxillary canines
• General guidelines:
– The bracket slot should be parallel to the final
occlusal plane
– Vertical tie wings must be parallel to the mid-
developmental ridge
– Place the bracket 4.5 mm from the cusp tip
– Centre the bracket mesio-distally over the
mid-developmental ridge, which is mesial to
the midpoint of the tooth. This must be
verified from an occlusal view with a mirror
before light curing.

52. • Common errors:
– Bracket angulation and mesio-distal positioning: With
the mid-developmental ridge located mesially and the
convex shape of the crown, brackets are often seen
placed too far distally, as many use the cusp tip as a
reference for the horizontal centre of the crown. This
can create rotational errors and prevent the proper
alignment of interproximal contacts.
– Brackets placed too incisally: This is common in
canines that are not fully erupted.

53. GENERAL ORTHODONTIC
INSTRUMENTATION FOR FIXED
APPLIANCES

54. Examination kit
• Cotton pliers. This instrument
is used to hold brackets
securely when placing them
onto the tooth surface.
• Explorer. In orthodontics, this
is commonly used to remove
elastics, in place of a scaler. In
addition, it can be used to
remove excess resin after
bracket placement.
• Mouth mirror. This is used to
verify the MD position of the
bracket

55. Bidirectional ligature director.
This instrument is used to tuck
metal ligatures under the
archwire, to keep the ends free
from irritating the soft tissue.
Bracket height gauge. This is
used to measure the distance
from the occlusal/incisal
surface to the bracket slot.
Distal-end cutter. This
instrument cuts the distal end
of archwire while holding the
cut end. Therefore, this can be
used in an intraoral setting.

56. Mathieu plier. This is an instrument
that locks (like a haemostat) and
braces small metal parts. In general,
they are used to hold and twist the
ends of metal ligatures, and also to
place elastic ligatures.
Ligature-cutting plier. To avoid
damage to the instrument, these
pliers must only be used to cut small
gauges of “dead soft” stainless steel
ligature wire (<0.014”) intra orally.
Hard wire cutter. This instrument is
designed to cut thick wire (> 0.014”)
extraorally.

57. Ladmore composite instrument. This
non-stick instrument is used to
place resin onto the base of the
bracket.
Cheek and lip retractor. This is an
adjustable device that retracts away
the lips and cheeks to maximize
visibility and to minimize salivary
contamination.
Debonding plier. This instrument is
used to remove brackets by holding
the bracket mesio-distally and
applying slight pressure by torquing
or turning in a clockwise motion.

58. References
• Sondhi, A. (2003). The implications of bracket selection and bracket placement on finishing
details. Seminars in orthodontics, 9(3):155-164.
• McLaughlin, RP, Bennett, JC & Trevisi, H. (1999, Oct). Practical techniques for achieving
improved accuracy in bracket positioning. The orthodontic CyberJournal. PAGE/VOL
• Swartz, ML. (YEAR). Achieving a 97% bonding success rate. (JOURNAL NAME).
(VOL/NUMBER): PAGES.
• Swartz, ML. (YEAR) Brackets and bracket placement. (JOURNAL NAME). (VOL/NUMBER):
PAGES.
• Proffit, WR. (2000). Contemporary Orthodontics. (3rd ed). St. Louis: Mosby. 397-400.
• Graber, TM & Vanarsdall, RL. (2000) Orthodontics Current Principles and Techniques. (3rd ed).
St. Louis: Mosby. ch12.
• Isaacson, KG & Williams, JK. (YEAR) An introduction of fixed appliances. (3rd ed). London:
John Wright & Sons Ltd. ch 4-5.
• Bennett, JC & McLaughlin RP. (1993) Orthodontic treatment mechanics and the preadjusted
appliances. London: Wolfe Publishing. 55-64.
Acknowledgments
• Dr. Jean-Marc Retrouvey
• Dr. Daniela Frey
• Mr. Mike McHugh
• Instructional Multimedia Services of McGill University