Variations in bracket placement in the preadjusted

orthodontic appliance
Nasib Balut, DDS, MS," Lewis Klapper, DMD, DScD, PhD, b James Sandrik, MS, PhD, = and
Douglas Bowman, MS, PhD '
Me.rico City, Me.rico, am/Chicago, IlL

This study was conducted to determine the accuracy of bracket placement with the direct bonded
technique. Ten orthodontic faculty members bonded a preadjusted orthodontic appliance on models
of five cases of malocclusion in a simulated clinical situation (mannequin). A total of 50 sets of
models served as the population of the study. Photographs of the models were measured to
determine vertical and angular discrepancies in position between adjacent bracket pairs from a
constructed reference line. Variations are evaluated with respect to the classification of malocclusion,
specific tooth type, and intra/inter operator differences. A mean of 0.34 mm for the vertical
discrepancies and a mean of 5.54 ~ for the angular discrepancies are found in placement of the
orthodontic brackets. (AMJ ORTHOD DENTOFACORTHOP 1992;102:62-7.)

T h e prcadjusted bracket system is the most the anterior bands at the junction of the middle and the
widely used in orthodontic therapy today. The basic incisal thirds of the crown was recommended. 2 Ricketts 3
premise of the preadjusted system is that proper bracket advocated the use of marginal ridges as guidelines for
position allows the teeth to be positioned with a straight band and bracket vertical positioning.
wire into an ocelusal contact with excellent mesiodistal More recently, Andrews 47 introduced the bracket-
inclinations (tips) and excellent faciolingual inclination ing technique of placing the straight guidelines of the
(torque). bracket (vertical tie wings) parallel to the long axis of
Most clinicians are aware that clinically the "straight the clinical crown and then moving the bracket up or
wire" (preadjusted) appliance does not eliminate wire down until the middle of its slot base is at the same
bending. Variations in tooth structure and malocclu- height as the midpoint of the clinical crown.
sions affect the final bracket positions. Variations from Thurow 8 showed that two different vertical positions
the straight wire appliance averages must be compen- of a bracket on a tooth will cause two different buc-
sated by bends placed in the arch wires. colingual axial inclinations (torque).
The present study was designated to evaluate vari- Meyer and Nelson 9 showed that an error of 3 mm
ations in placement in the vertical and angular bracket vertically in bracket placement on a premolar can result
position from the ideal with a preadjusted orthodontic in 15~ torque alteration and 0.04 mm alteration in the
appliance ("A" Company, Johnson & Johnson, San in/out adjustments.
Diego, Calif.). Variations in bracket position were eval- In orthodontics, what affects the design of the ortho-
uated with respect to the classification of maloeclusions, dontic appliances and their use is the inclination of the
specific tooth type, and intra/inter operator differences. labial or buccal surface of the tooth crown to the long
axis of either the entire tooth or the occlusal surface of
REVIEW OF THE LITERATURE the crown.
Bracket placement and tooth structure Kraus, t~ Taylor, 2 and Dellinger tt found great vari-
Originally Angle t taught that the best position of ations existed in tooth structure that can affect treatment
the band was where it fits better mechanically. Then, results.
if possible, the bracket should be placed at the center Improvements in bracket design were made incor-
of the labial surface of the tooth. Later, placement of porating tip, ~torque, ~2rotation, and differences in base
thickness 47.13 beginning with Angle in 1928 and, more
'Associate Professor, Universidad Intercontinental Mexico. recently, with Andrews in 1970 who introduced the
bAssociate Professor, Loyola University of Chicago. "straight wire concept" in preadjusted orthodontic ap-
'Chairman of the Department of Dental Materials, Loyola Uniser~ity of pliance.
Chicago.
aAssc,ciate Professor of Biostatistics, Lo) ola University of Chicago.
Roth 14 in 1975 evaluated the preadjusted bracket
8 / I / 27285 system after he had used it for 5 years. In 1981 he
62
 Volume 102 Variations in bracket placement in preadjusted appliance 63
Nunzber I

Fig. 2. Occlusal view of one =diagnostic set-up" showing occlu-

as a template for the final ideal tooth position desired for each
case.
Ten faculty members from the Orthodontic Department
of Loyola University School of Dentistry were the subjects
of this study. Each faculty member was asked to place pread-
justed brackets ("A" Company) on five duplicated pretrcat-
ment orthodontic patient models, from first molar to first
Fig. 1. Front view of one "diagnostic set-up" showing idea! an- molar, inclusively. The models were mounted on a mannequin
gulation where teeth were positioned.
to simulate the patient (Fig. 3).
A total of 50 bonded cases of malocclusions served as
the population for this study (10 faculty members • 5 cases).
modified the appliance by altering the amount of pread- After the brackets were placed in the untreated models,
justment built into the brackets? 5 His objectives were the teeth Were sectioned from the base. The sectioned teeth
to have the teeth in overcorrected positions at the end were transferred to the occlusal registration made from the
of treatment when unbent, full-sized wires were used. diagnostic set-up for that patient and secured in place with
adhesive (cyanoacrylate).
All modifications and improvements in orthodontic
The sectioned teeth secured with adhesive to the occlusal
appliances were predicated on the ability of the clinician
registration were designated at the "transfer set-up." This
to accurately visualize and correctly place the bracket represents the ideala relationship of teeth desired in the fin-
on the tooth. No one has actually studied how well this ished case (Fig. 4).
is accomplished clinically. Five photographs were taken of each transfer set-up ori-
ented perpendicular to the crown of the teeth at a fixed distance
METHODS AND MATERIALS with a 90 mm macro lens (Panagor) and Minolta 35 mm
Pretreatment models of five orthodontic patients re'pre- single lens reflex camera body. The lens was set on a 1:1
senting different types of malocclusion were selected. One magnification ratio.
Class I, two Class II, Division 1, and two Class II, Division The resulting photographs were digitized on a Houston
2 malocclusion cases were taken from the Orthodontic De- Instrument Hi-Pad digitizer. The outer edges of each bracket
partment at Loyola University School of Dentistry. The mod- slot were used as reference. The vertical and angular differ-
els were duplicated and a "diagnostic set-up" was fabricated ences in brackets positions were measured between tooth pairs
from the duplicate models (Fig. 1). The teeth were positioned by digitizing the outer edges of each bracket with a program
to "ideal" angulation (agreed ideal according to Andrew.'s six written for an IBM mainframe computer (IBM Corp., White
keys of occlusion, as modified by Roth) and occlusal contact Plains, N.Y.).
and checked with articulating ribbon (Accu-Film, Parkell, The measurements were calculated from a reference line
Farmingdale, N.Y.) (Fig. 2). that was formed by connecting the outer edges of adjacent
An acrylic occlusal registration key (upper and lower) bracket pairs. The vertical measurements were calculated by
was fabricated from each diagnostic set-up. The key served measuring the difference between the perpendicular distance
64 Balut e t a / . Am. J. Orthod. Dente~w. Onhvp.
July 1992

Fig. 3. Duplicate model mounted on mannequin showing direct bonded brackets in place.

B
Fig. 4. Transfer set-up.

of the adjacent slot edges to the reference line (Fig. 5). The
angular measurements were calculated from the difference
between the arctangents of the slopes of the individual brack-
ets to a reference line connecting the outer occlusal edges of
the slots of the adjacent bracket pair (Fig. 5).
If the four points ',,,'ere on the reference line, the linear Fig. 5. Independence of vertical and angular relationships be-
and angular values would be "zero" for each tooth pair: (This tween adjacent bracket pairs. A, Bracket pair with both vertical
(line A not equal to line B) and angular differences to the ref-
would indicate ideal bracket placement on the models.) Any
erence line. B, Bracket pair with vertical difference but no an-
linear or angular differences observed represent errors in gular difference to the reference line. C, Bracket pair with an-
bracket placement. gular difference but no vertical difference (line E equals line F)
Two-way analysis of variance was used to determine to the reference line.
whether differences exist, and multiple comparison proce-
dures were made by a Tukey's HSD test to determine where
the differences exist. The experimental error of this study was RESULTS
determined by repeating measurements of two facult2r mem-
bers (10 cases) with a paired t test for the linear and angular Discrepancies w e r e found in p l a c e m e n t o f the ortho-
measurements. A mean of 0.005 mm of linear difference ',,,'as dontic brackets in height and angulation. A m e a n o f
found, and a mean of 0.087 ~ of angular difference was found, 0.34 m m for the linear m e a s u r e m e n t s and a mean o f
which was not statistically significant. 5.54 ~ for the angular m e a s u r e m e n t s were found (Table
Volume 102 Variations in bracket placement in preadjusted appliance 65
Number I

Table I. Mean, standard deviation, range, maximum values and minimum values of the linear and
angular discrepancies
I Standarddeviation I Maximum Minbnum
Mean = X (SD) Range value value
Linear discrepancies 0.34 0.29 1.80 1.80 0.00
(mm)
Angular discrepancies 5.54 4.32 29.10 29.10 0.00
(degrees)

Table II. Mean, standard deviation range of the vertical and angular discrepancies by faculty

Mean SD Range
Faculty
N = 110 Linear ] Angular Linear I Angular Linear I Angular
1 0.38 6.02 0.28 4.54 1.30 20.79
2 0.35 4.87 0.30 4.11 1.62 21.20
3 0.26 5.77 0.22 4.47 1.03 23.61
4 0.33 5.12 0.26 3.71 1.11 17.06
5 0.34 6.76 0.29 5.12 1.56 24.30
6 0.34 4.48 0.28 3.21 1.11 13.06
7 0.31 5.21 0.27 4.07 1.25 18.26
8 0.32 5.40 0.29 3.85 1.36 17.25
9 0.42 6.33 0.34 5.07 1.79 29.01
10 0.36 5.48 0.31 4.31 i.55 19.63

I) between adjacent bracket pairs (all faculty members, positions before debonding. This necessitates a perfect
all teeth). alignment of the marginal ridges, contact points, and
Table II shows the mean, standard deviation, and roots of the teeth. Factors such as error in bracket place-
range of the linear and angular discrepancies by faculty, ment, tooth irregularities, and variations in tooth struc-
indicating statistically significant differences in angular ture make it difficult to achieve these goals accurately
bracket position among faculty no. 2, no. 5, and no. with the preadjusted orthodontic appliance.
6. For the linear measurements, statistically significant In this study, model no. 2 had significantly less
differences were found between faculty no. 3 and no. angular discrepancy than model no. 5. The reason was
9 (P --< 0.01). that model no. 5 had a lower right first premolar severely
When the linear and angular discrepancies among malposed. The crowding and the size of the clinical
the five models were analyzed, there was no significant crown of that specific tooth made it impossible to place
difference among them in vertical discrepancy the bracket correctly. In addition, model no. 2 had
(P -> 0.05). Model no. 2 (Class II) showed significantly larger clinical crowns, not severely rotated teeth, mak-
less angular discrepancy than Model no. 5 (Class II) ing it less difficult for the operator to place the ortho-
(P -< 0.01). dontic brackets. There is no correlation between the
Tables III and IV indicate that the lower anterior type of malocclusion and the error in bracket placement.
teeth presented the least variation in bracket place- The error in placement seems to be more related to
ment, in both angular and vertical measurements the skill of the operator, tooth structure, size of clinical
(P ~ O.OOl). The teeth that showed the most angular crowns, and malposition of the tooth in the dental arch.
discrepancy were the upper anterior teeth and the upper In some cases, the operator has to compromise and
and lower canines (P ~ O.OOl). The upper second pre- place the bracket more gingivally because of interfer-
molars were the teeth which presented the most vertical ence with the long cuspal heights on opposing posterior
discrepancy in bracket placement (P < O.OOl). teeth. Since any effect o f bracket/tooth interference was
exchuted fronz this study, tile actual clinical accuracy
DISCUSSION of bracket positioning on the posterior teeth wouhl be
Toward the end of the treatment, the teeth must be much worse on a patient than was shown here.
brought as close as possible to their final and functional It appears that it was easier for the operators to
66 Balut el al. Am. J. Orthod. Dentofiw. Orthop.
July 1992

Table III. Mean of angular discrepancies of each faculty by tooth pair in degrees

Tooth pair
(n = 5) 5

Mttrillary arch
i-I 10.30 13.29 7.42 6.46 7.16 4.80 2.95 6.27 7.76 8.69 7.56
1-2 7.14 2.96 6.40 3.56 7.10 4.52 4.12 3.32 3.51 3.61 4.62
2-1 5.87 5.45 4.32 4.04 4.93 6.91 4.02 4.92 5.32 6.16 5.19
2-3 6.97 4.76 7.72 3.13 8.33 7.41 6.60 6.01 6.88 4.32 6.21
3-2 6.61 5.54 7.09 4.08 8.89 1.96 6.96 9.43 3.73 6.14 6.04
3-4 6.24 4.14 3.95 4.87 13.17 5.95 5.58 4.44 7.12 11.61 6.90
4-3 8.20 4.95 5.49 5.58 7.05 5.53 6.52 7.93 5.39 5.98 6.26
4-5 4.76 2.21 3.64 2.62 6.23 3.25 1.91 5.23 5.89 5.64 4.13
5-4 6.03 5.87 5.27 5.36 8.31 3.18 7.69 7.30 5.56 4.13 5.87
5-6 3.95 5.52 3.84 3.86 3.24 3.56 3.94 6.05 5.48 7.69 4.71
6-5 2.90 3.72 8.34 6.80 9.93 3.99 3.32 7.57 8.50 6.49 6.15
Mandibular arch
1-1 4.11 3.37 3.72 4.74 3.11 2.14 2.93 3.85 5.94 2.35 3.62
1-2 5.33 2.98 2.27 3.09 3.21 4.13 4.66 4.52 7.12 2.74 4.00
2-1 5.92 3.56 4.28 2.32 7.12 6.44 2.10 3.29 5.66 4.35 4.50
2-3 5.22 5.58 3.68 7.77 4.31 4.05 5.78 7.24 11.63 4.62 5.98
3-2 6.56 5.55 4.79 5.38 6.08 2.48 5.83 4.25 9.30 3.48 5.37
3-4 5.72 3.00 5.99 9.70 6.63 4.66 7.52 3.65 9.10 6.61 6.25
4-3 11.16 7.01 9.32 6.28 6.97 5.55 7.77 5.14 7.83 6.10 7.31
4-5 4.29 3.82 8.44 7.02 7.00 4.11 7.89 4.39 7.59 5.69 6.02
5-4 4.24 2.28 8.39 5.20 7.56 4.21 4.45 4.82 3.26 5.63 5.00
5-6 4.15 7.99 6.77 8.46 4.72 3.86 7.73 6.19 4.47 9.95 5.93
6-5 4.80 3.54 5.34 2.24 7.65 5.90 4.44 2.92 2.32 3.51 4.26

Table IV. Mean of vertical discrepancies by tooth pair in millimeters

Mttrillary arch
1-1 0.27 0.24 0.27 0.11 0.14 0.33 0.06 0.18 0.13 0.21 0.19
I-2 0.57 0.44 0.24 0.44 0.46 0.40 0.21 0.21 0.28 0.55 0.37
2-1 0.67 0.57 0.60 0.51 0.31 0.39 0.16 0.36 0.48 0.33 0.44
2-3 0.54 0.18 0.16 0.23 0.26 0.33 0.23 0.18 0.58 0.29 0.30
3-2 0.66 0.63 0.27 0.30 0.17 0.13 0.33 0.12 0.41 0.30 0.33
3-4 0.52 0.39 0.28 0.44 0.42 0.46 0.50 0.45 0.54 0.49 0.44
4-3 0.33 0.66 0.40 0.19 0.47 0.19 0.31 0.37 0.21 0.20 0.33
4-5 0.37 0.45 0.19 0.35 0.48 0.44 0.52 0.55 0.33 0.36 0.40
5-4 0.24 0.30 0.24 0.34 0.28 0.31 0.35 0.69 0.44 0.23 0.34
5-6 0.62 0.75 0.30 0.61 0.63 0.87 0.82 0.82 0.63 0.99 0.70
6-5 0.55 0.30 0.28 0.36 0.63 0.65 0.32 0.57 0.38 0.28 0.43
Mandibular arch
I-I 0.22 0.22 0.13 0.16 0.11 0.19 0.19 0.22 0.37 0.31 0.21
I-2 0.19 0.06 0.06 0.21 0.26 0.19 0.14 0.14 0.25 0.15 0.16
2-1 0.19 0.17 0.11 0.22 0.26 0.14 0.17 0.23 0.42 0.19 0.21
2-3 0.31 0.41 0.28 0.29 0.27 0.14 0.29 0.18 0.82 0.30 0.33
3-2 0.31 0.26 0.42 0.27 0.40 0.50 0.31 0.21 0.69 0.47 0.38
3-4 0.33 0.11 0.18 0.34 0.22 0.34 0.19 0.28 0.68 0.31 0.29
4-3 0.33 0.44 0.29 0.39 0.34 0.34 0.37 0.37 0.37 0.48 0.37
4-5 0.37 0.39 0.35 0.46 0.37 0.30 0.22 0.26 0.28 0.51 0.35
5-4 0.31 0.30 0.34 0.34 ().47 0.33 0.45 0.39 0.38 0.44 0.37
5-6 0.18 0.30 0.20 0.45 0.21 0.24 0.43 0.13 0.34 0.40 0.28
6-5 0.22 0.23 0.23 0.20 0.34 0.31 0.43 0.06 0.23 0.18 0.21
Volume 102 Variations bl bracket placenlent in preadjltsted appliance 67
Number 1

visualize the long axes of the lower incisors and to placement in this study are unstable tooth positions,
place the bracket appropriately and at the correct height. lack of root paralleling, food impaction because of mar-
The upper anterior teeth and the upper and lower ginal ridge discrepancies, and failure to establish the
canines showed the most angular discrepancy. It ap- very specific occlusal scheme of canine rise or mutually
pears that the operators have difficulty in judging root protected occlusion.
angulation of these teeth. It should not be interpreted froth this study that
The teeth that presented the most difficulty in ver- achievement of acceptable orthodontic results is im-
tical bracket placement were the upper second pre- possible with straight wire therapy. With proper wire
molars, possibly because of the length of their clinical bending or rebonding bracket positions, an excellent
crowns (which are sometimes short). This is exacer- result can certainly be achieved; however, increased
bated by the molar arch wire slot being gingivally po- time and effort must be expended by the orthodontist
sitioned on the molar as a result of the headgear tube and the patient to accomplish these goals.
being occlusally positioned.
The observed mean angular discrepancy of 5.54 ~ REFERENCES
plus the standard deviation of 4.32 ~ indicates that a 1. Angle HE. The latest and best in orthodontic mechanism. Dental
bracket error of 10~ between bracket pairs, with the "A" Cosmos 1928;70:il43; 1929;71:164.
2. Taylor RMS. Variations in morphology of teeth. New York:
Company appliance, would occur with the same fre-
Charles C. Thomas, 1978.
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This is somewhat surprising when one considers that 1979.
few orthodontists request more than 10~ of tip be built 4. Andrews FL. The Straight Wire Appliance origin, controversy,
into their preadjusted appliance prescriptions. commentary. J Clin Orthod 1976;10:99.
5. Andrews FL. Straight Wire Appliance, arch form, wire bending
Although 3 of the 10 faculty members differed sta-
and experiment. J Clin Orthod 1976;10:8.
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ments, their vertical measurements were statistically Orthod 1976;10:174.
indistinguishable (means of 0.35 mm, 0.34 ram, and 7. Andrews FL. The S.W.A. syllabus of philosophy and tech-
0.34 mm). Those two faculty members who differed niques. San Diego: LF Andrews Foundation for Orthodontic
Education and Research, 1974.
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8. Thurow CR. Edgewise orthodontics. 3rd. ed. St. Louis: CV
no statistical differences in their angular bracket place- Mosby, 1972.
ment measurements (means of 5.77 ~ and 6.33~ 9. Meyer M, Nelson G. Preadjusted edgewise appliance, theory
No faculty member was statistically different from and practice. AM J OR'nlOD 1978;73:485.
any of the other faculty members in both vertical and 10. Kraus SB. Dental anatomy and occlusion. Chapter I. Baltimore:
Williams and Wilkins, 1969.
angular discrepancies in bracket placement. This in-
11. Dellinger LE. A scientific assessment of the straaight wire ap-
dicates that there is no systematic difference among the pliance. AM J OR'IIIOD 1978;73:290.
faculty members in bracket placement. It would be rea- 12. Jarabak RL. Development of a treatment plan, in the light of
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13. Andrews FL. The six keys to normal occlusion. AM J OR.'RIOD
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bracket positional variation may occur. Figs. 5, A to C 15. Roth HR. Functional occlusion for the orthodontists, part i11.
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The fact that the majority of the faculty members Reprint requests to:
were so similar in their results seems to indicate a basic Dr. Nasib Balut
Manuel E. Izaguirre 11-601-602
human limitation in direct placement of the brackets in CTO Comercial Satelite
the mouth. EDO de Mexico City
The clinical implications in the error of bracket Mexico 53100