TECHNO BYTES
In-house precision bracket placement
with the indirect bonding technique
Mark Joiner
Santa Cruz, Calif
I
n the era of the fully banded standard edgewise or-
thodontic appliances, orthodontists most skilled at
wire bending generally achieved the best results;
several wire bends were unavoidable. The advent of
the straight-wire appliance ushered in a new era in or-
thodontic practice. Orthodontists could choose from
a variety of bracket prescriptions to achieve optimum
esthetics and functions with the least chair time, fewest
appointments, and greatest patient comfort. The theo-
retical ideal of treating a patient from start to finish
with no archwire bends was within reach at last. Also,
with the introduction of bondable brackets, appliance
placement could be rapid for the orthodontist and
pain-free for the patient, with no residual band spaces
to close at the end of treatment.
Unfortunately, the promise of rapid, efficient, and
comfortable orthodontic treatment with these precision
bracket systems has been less than fully realized for
most orthodontists because of improper bracket place-
ment. Many orthodontists still spend considerable
time detailing, particularly near the end of treatment,
to compensate for bracket-positioning errors.
One of Andrews’ 6 keys to occlusion1 is the achieve-
ment of even marginal ridges on the posterior teeth. It
could be argued that this goal is more easily reached
by orthodontists who still routinely band, rather than
bond, posterior teeth with straight-wire attachments
welded to the bands. It is relatively easy to visualize
and properly seat molar and premolar bands relative
to marginal ridges and with the occlusal edge of each
band parallel to the occlusal surface of the tooth. As
long as the manufacturer welds all the bracket slots or
tubes the same distance from the occlusal edge of the
band, the marginal ridges of the teeth should be even
Private practice, Santa Cruz, Calif.
The author reports no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Mark Joiner, 1773 Dominican Way, Santa Cruz, CA 95065;
e-mail, staff@joinerortho.com.
Submitted, January 2009; revised and accepted, April 2009.
Am J Orthod Dentofacial Orthop 2010;137:850-4
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.04.023
850
with each other with full-sized archwires in place.
Additionally, this generally places the slot in (or near)
the occlusogingival center of the anatomic crown of
the tooth, where most appliance systems require it to
be placed for proper torque expression.
Yet, with the widespread availability of chemical
conditioning agents and procedures to allow strong
bonding of brackets to porcelain, metal, and enamel,
many orthodontists now routinely bond brackets to
most or all posterior teeth. Unfortunately, proper place-
ment of direct-bonded brackets is challenging on the
posterior teeth, because they can be difficult to visualize
in the best of circumstances. The penalty for poor place-
ment, especially on posterior teeth, can be great because
these teeth tend to more readily extrude rather than in-
trude as an archwire levels out, potentially propping
open the bite and creating a fulcrum from which recov-
ery can be difficult.
Indirect bonding, although used routinely by a rela-
tively few orthodontists, allows excellent visualization
of all teeth; this is a great advantage, according to its
proponents. Perfect bracket placement on the stone
model should be simple, and, as long as the transfer
trays are properly made and seated, each bracket should
end up in its ideal position, right? Well, no. The problem
is that the teeth start out crooked, and getting the
brackets in just the right place on all of these crooked
teeth, even when you can hold the model in your hand
and look at the teeth from all directions, is still difficult.
This is especially so when it comes to the vertical
(occlusogingival) position of each bracket. Where is
the vertical center of the crown? A bracket-positioning
gauge, used by many orthodontists, is not of great
help because it assumes average-sized teeth and unworn
cusps. Also, it is difficult or impossible to use on molar
tubes. Besides, what we really want to see is even, level
marginal ridges, not necessarily level buccal cusps. We
need a means to place the bracket slots relative to the
marginal ridges of the posterior teeth so that all mar-
ginal ridges line up. If the cusps are unworn, and tip
and torque are properly expressed, this automatically
places the functional cusps on a level plane. Ideally,
bonded brackets would be positioned so that, if a molar
American Journal of Orthodontics and Dentofacial Orthopedics Joiner 851
Volume 137, Number 6

band is placed later, the marginal ridges of the banded

teeth are even with those of the bonded teeth. Even bet-
ter, we would like a simple means of placing anterior
brackets so that, whether the patient has small or large
teeth, long or short posterior cusps, the brackets are
placed approximately in the center of the crown on all
teeth; this is something no bracket-positioning gauge
can accomplish.
The goal of placing brackets perfectly so that few, if
any, archwire bends are needed was greatly furthered
for me after I began using a modified version of the in-
direct bonding technique promoted by Kalange.2 His
technique of bracket placement on models requires
drawing a line on each posterior tooth to connect the
mesial and distal marginal ridges. A second, parallel
line is drawn approximately 2 mm gingival to the mar-
ginal ridge line; this is the slot line, where the vertical
center of the bracket slot should be placed.
What I found potentially inaccurate with Kalange’s
technique was the drawing of the marginal ridge line; if
I could cut all the teeth out first, it would be easy, but
usually the adjacent teeth made proper visualization
and placement of this line on each tooth difficult.
Subsequent drawing of the slot line 2 mm gingival to
the marginal ridge line could introduce additional
inaccuracy.
Described here is a modification of Kalange’s tech-
nique that I believe improves accuracy and repeatability.
It does not use advanced computer technology and
might be a disappointment to those accustomed to see- Fig 1. A, Alvin 508 bow compass and Draft/Matic
ing such things in the ‘‘Techno Bytes’’ section of this mechanical pencil; B, pencils positioned in the 2
journal. But the simplest, least-expensive technologies compasses.
are often the most easily attempted and, ultimately,
accepted.
the band to the center of the slot or tube; this is usually
about 2 mm but can vary depending on the manufac-
MATERIAL AND METHODS turer. The exact distance can be measured with a caliper
The tools of this bracket placement technique are or Boley gauge (Fig 2, B). Another way of looking at
simple: 2 bow compasses (model 508, Alvin, Boston, this is to adjust the distance between the marginal ridge
Mass) and 3 mechanical pencils (Draft/Matic, Alvin) and the slot line based on tooth size, and any bands
(Fig 1, A). In Figure 1, B, the compass in the center should be seated more or less relative to the marginal
(compass 1) is adjusted with the aid of a millimeter ruler ridges. Compass 2 (Fig 1, B; left) has its steel stylus
(Fig 2, A) so that the tip of the lead in the pencil is ap- set considerably longer than the pencil; the exact
proximately 2 mm longer than the long axis of the com- amount is not important, as long as the side of the steel
pass (with the steel leg of the compass representing the stylus can rest on the cusp tip of the first premolar per-
long axis). For a patient with large teeth, this distance pendicular to the long axis of the tooth, before the pencil
can be set a little longer than 2 mm; for a patient with lead touches the buccal surface.
small or short teeth, it should be a little shorter than 2 Accurate bracket placement begins with drawing
mm. This ensures that the slots or tubes are in the center the long axis of each crown. A point source of light shin-
of the anatomic crowns, regardless of tooth size. If ing on the side of the teeth illuminates developmental
bands are to be placed alongside bonded brackets, lobes or grooves on the labial surface and will help
then this measurement should perhaps be exactly the you locate the long axis (Fig 3). To construct the slot
same as the vertical distance from the occlusal edge of line, place the steel stylus of compass 1 on the marginal
852 Joiner
Fig 2. A, Millimeter rule to measure the lead tip in the
pencil; B, caliper or Boley gauge to measure vertical dis-
tance from occlusal edge of band to the center of the slot
or tube.
ridge of a posterior tooth, with the long axis of the com-
pass parallel to the long axis of the crown, and then ro-
tate the compass slightly to make a pencil mark on the
buccal surface (Fig 4, A). Place these dots on the mesial
and distal aspects of each posterior tooth. You can use
the adjustment wheel of the compass to move its legs
as close to each other as practical to allow the 2 dots
on each tooth to be widely separated (Fig 4, B). For
buccally or lingually tipped teeth, the long axis of the
compass should be tipped accordingly.
It is a simple matter then to connect the dots on each
tooth with the pencil (Fig 4, C). This establishes the slot
line. Some orthodontists may prefer to deviate from pre-
cisely connecting the dots on some teeth; for instance,
slanting the line on the maxillary second molar so that
it is slightly more occlusal on the distal aspect of the
crown will aid in creating a slight curve of Spee and
avoiding overuption of this tooth.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2010
Fig 3. Illuminating the tooth to accurately locate the long
axis.
Next, mark the anterior teeth so that the anterior slot
lines are properly placed relative to the posterior teeth.
For both arches, I use the first premolar as the reference
tooth by transferring the distance between its cusp tip
and its slot line to the lateral incisor. To accomplish
this, place the steel stylus of compass 2 on the cusp
tip of the first bicuspid, parallel to the occlusal plane,
and rotate the adjustment wheel until the tip of the pen-
cil is resting on the slot line in the center of the crown
(Fig 5, A).Transfer this distance to the lateral incisors
by placing the side of the steel stylus on the incisal
edge, again parallel to the occlusal plane, and draw
a short line on the crown long axis line (Fig 5, B).
In the mandibular arch, mark the central incisors in
the same manner, by using the same distance obtained
from the mandibular first premolar. Rotate the compass
adjustment wheel to add 0.5 to 0.75 mm to the distance
between the side of the steel stylus and the pencil tip,
and mark the canines in a like manner.
For the maxillary arch, rotate the compass adjust-
ment wheel to add about 0.5 mm to the distance used
for the lateral incisor, and mark the canines; mark the
central incisors after opening the compass legs slightly
farther.
Attrition to the first premolars or anterior teeth must
be accounted for when using compass 2; hold the steel
stylus away from the cusp tip or incisal edge by an
amount equal to the amount of attrition that you esti-
mate has occurred. Similar adjustments should be
made for unusual teeth, such as peg-shaped lateral inci-
sors or unusually long, pointed canines. The placements
suggested for the anterior tooth slot lines relative to the
first premolars are suggestions only. Other orthodontists
might prefer more or less distance from the cusp tip or
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 6
Fig 4. Construct the slot line for each tooth: A, place the
stylus of compass 1 on the marginal ridge of a posterior
tooth, with the long axis of the compass parallel to the long
axis of the crown; B, rotate the compass slightly to make
a pencil mark on the buccal surface; C, connect the dots.
incisal edge to the slot line, depending on the preferred
overbite, the amount of step between the maxillary cen-
tral and lateral incisors, and so on. The placements I
suggest differ from those of Kalange.1 He instructed
Joiner 853
Fig 5. Transfer the slot line from the posterior teeth to
the anterior: A, place the stylus of compass 2 on the
cusp tip of the first premolar and rotate the adjustment
so that pencil tip rests on the slot in the center of the
crown; B, transfer the distance to the lateral incisors.
that, in the maxillary arch, the premolar cusp tip to
slot line distance should be transferred to the central
incisor, with a reduction of 0.5 mm to the lateral incisors
and an addition of 1.0 mm to the canines; in the mandib-
ular arch, he suggested the same settings as I do to the
incisors, but added 1 mm rather than 0.5 to 0.75 mm
to the canines.
Next, lengthen the short slot line so that it is visible me-
sially and distally after the bracket is placed (Fig 6, A).
Knowledge of the degrees of mesiodistal tip built into
each bracket is important so that the crown long-axis
line and the slot line align with both the slot and mesio-
distal tip of the bracket. Placing the brackets on the
models is then a straightforward matter of lining up
each bracket with the slot line and crown long-axis
line drawn on each tooth. For actual placement of
brackets, you can use a light-cured composite; this
854 Joiner
Fig 6. A, Lengthen the short slot line so that it remains
visible; B, after the bracket is placed.
allows placement of brackets to the models by a labora-
tory technician for further checking and adjustment by
the orthodontist. Error can be introduced at this point if
you are not sighting exactly into the slot of the bracket,
perpendicular to the base of the slot. Placing the exact
center of the slot of each bracket over the slot line
drawn on the model is aided by a point light source be-
hind and slightly to the side of the head of the techni-
cian, so that the light is reflected off the bottom of the
slot of the bracket (Fig 6, B).
Place the models in a light-curing oven for 6 minutes
to harden the composite, and then fabricate the transfer
trays. Many techniques and materials have been
promoted over the years for construction of the transfer
trays, and it is not the intent of this article to provide
highly detailed instructions on my technique. I use
a clear double tray and light-cure the brackets onto the
patient’s teeth. The soft layer enveloping the brackets
is a transparent 2-part polyvinyl siloxane material
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June 2010
(RM bond Inner Tray Material, Rocky Mountain Ortho-
dontics, Denver, Colo), which is syringed around the
brackets and over the occlusal surfaces and incisal edges.
The more rigid outer tray is .040-in thick A1 plastic
(GAC International, Bohemia, NY), formed over the
inner tray and teeth on a Biostar unit (Great Lakes Ortho-
dontics, Tonawanda, NY). After the models are soaked in
water and the trays and brackets are removed and the
trays trimmed, the composite on the bracket bases is
lightly microetched, and Enhance (Reliance Orthodon-
tics, Itasca, Ill), a 2-part adhesion booster, is mixed and
painted on each bracket base.
At the chair, after a thin layer of light-curable
sealant is painted on the etched enamel, a small line
of flowable composite (Flow-Tain, Reliance) is syringed
onto the gingival aspect of each bracket base, and the
tray is placed onto the teeth. Each bracket is cured for
10 seconds, and then the trays are removed, and each
bracket is cured for an additional 10 seconds.
DISCUSSION AND CONCLUSIONS
The advantages of indirect bonding relative to direct
bonding are numerous, and I believe they outweigh
the perceived disadvantages of increased laboratory
time and technique sensitivity.3 However, the ex-
pected advantage of increased accuracy in bracket
placement has been questioned.4,5 This is not really
surprising, because most orthodontists who try
indirect bonding still use a gauge, or they ‘‘eyeball’’
bracket position.
I would be less than candid if I implied that using the
measuring technique I advocate here has eliminated all
wire bending or bracket repositioning in my practice—
it has not. However, bracket positioning errors are far
fewer than they were when I guessed at proper bracket
positions. Individual variations in tooth anatomy might
be what keeps this technique from being an ideal ‘‘one
size fits all’’ solution to bracket positioning problems.
REFERENCES
1. Andrews LF. The six keys to normal occlusion. Am J Orthod 1972;
62:296-309.
2. Kalange JT. Ideal appliance placement with APC brackets and
indirect bonding. J Clin Orthod 1999;33:516-26.
3. Kalange JT. Indirect bonding: a comprehensive review of the
advantages. World J Orthod 2004;5:301-7.
4. Koo BC, Chung C, Vanarsdall RL. Comparison of the accuracy of
bracket placement between direct and indirect bonding techniques.
Am J Orthod Dentofacial Orthop 1999;116:346-51.
5. Hodge TM, Dhopatkar AA, Rock WP. A randomized clinical trial
comparing the accuracy of direct versus indirect bracket place-
ment. J Orthod 2004;31:132-7.