direct bracketing technique for dental professionals
DESCRIPTION
A presentation about the direct bracketing technique. Mainly a tutorial for dental professionals interested in orthodonticsTRANSCRIPT
![Page 1: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/1.jpg)
So do you know how to bracket? A Basic Teaching Module
Dr Jean Marc Retrouvey
Dr F, Karen
Dr H, Manuela
![Page 2: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/2.jpg)
• 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.
![Page 3: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/3.jpg)
General steps in bracket bonding
![Page 4: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/4.jpg)
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.
![Page 5: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/5.jpg)
Prophylaxis
• Pre-bonding prophylaxis procedure – Using oil-free pumice mixed with water: tooth surfaces where the brackets are to be bonded must be cleaned.
www.toothology201.com
![Page 6: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/6.jpg)
Bonding kit
We use gel not liquid for etching.
We prefer Ultradent Gel
![Page 7: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/7.jpg)
Isolation of teeth (Cheek retractors)
![Page 8: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/8.jpg)
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.
![Page 9: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/9.jpg)
Acid Etching
![Page 10: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/10.jpg)
Proceed by quadrants
![Page 11: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/11.jpg)
Rinse each tooth for 15 seconds
![Page 12: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/12.jpg)
Dry the field (Chalky white enamel)
![Page 13: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/13.jpg)
Apply a light coat of resin
![Page 14: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/14.jpg)
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.
![Page 15: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/15.jpg)
Cure resin for 10 seconds
![Page 16: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/16.jpg)
Select the proper bracket
![Page 17: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/17.jpg)
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.
The coloured dot must be placed disto-gingivally
![Page 18: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/18.jpg)
Position the bracket as precisely as possible
![Page 19: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/19.jpg)
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.
![Page 20: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/20.jpg)
![Page 21: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/21.jpg)
Use a mirror to verify if the bracket is centered on the crown
![Page 22: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/22.jpg)
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.
![Page 23: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/23.jpg)
Remove excess composite around bracket
![Page 24: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/24.jpg)
Excess composite
Remove excess composite around the bracket with a scaler or an explorer before light curing. If not, it will encourage plaque accumulation.
![Page 25: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/25.jpg)
Use height gage properly
![Page 26: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/26.jpg)
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.
![Page 27: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/27.jpg)
In the canine, premolar and molar regions, the gauge is placed parallel with the occlusal plane
![Page 28: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/28.jpg)
Place another bracket (22)
![Page 29: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/29.jpg)
Verify bracket positioning
![Page 30: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/30.jpg)
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
![Page 31: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/31.jpg)
![Page 32: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/32.jpg)
Bracket height
• If the incisal edges are not worn out, you may want to use a height gage to position the bracket properly If
![Page 33: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/33.jpg)
![Page 34: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/34.jpg)
![Page 35: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/35.jpg)
Common Errors in Bracketing
![Page 36: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/36.jpg)
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.
![Page 37: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/37.jpg)
Bracket placed too gingivally
![Page 38: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/38.jpg)
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
![Page 39: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/39.jpg)
Bracket placed too incisally
![Page 40: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/40.jpg)
Vertical positioning
Vertical accuracy can be greatly improved by the use of a height gauge and bracket positioning charts.
![Page 41: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/41.jpg)
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.
![Page 42: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/42.jpg)
![Page 43: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/43.jpg)
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.
![Page 44: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/44.jpg)
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.
![Page 45: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/45.jpg)
Bonding ErrorsToo much composite on the bracket base will modify the labio
lingual position of the bracket. This will lead to misalignment of the incisal edges
![Page 46: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/46.jpg)
Bonding ErrorsFIRST, 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.
![Page 47: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/47.jpg)
Bracket positioning in the upper anterior teethMaxillary central incisors
• 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
![Page 48: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/48.jpg)
• 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
![Page 49: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/49.jpg)
Bracket positioning in the upper anterior teeth
Maxillary lateral incisors• 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
![Page 50: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/50.jpg)
• 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
![Page 51: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/51.jpg)
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.
![Page 52: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/52.jpg)
• 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.
![Page 53: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/53.jpg)
GENERAL ORTHODONTIC INSTRUMENTATION FOR FIXED
APPLIANCES
![Page 54: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/54.jpg)
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
![Page 55: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/55.jpg)
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.
![Page 56: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/56.jpg)
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.
![Page 57: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/57.jpg)
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.
![Page 58: Direct bracketing technique for dental professionals](https://reader035.vdocument.in/reader035/viewer/2022062513/5562def8d8b42aac778b52e9/html5/thumbnails/58.jpg)
Acknowledgments• Dr. Jean-Marc Retrouvey• Dr. Daniela Frey• Mr. Mike McHugh• Instructional Multimedia Services of McGill University
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.