strategies for bracket placement based on smile esthetics to protect mini , micro macroesthetics of face .

1. Strategies for Bracket Placement
Based on Smile Esthetics
BALUT et al - JCO/JUNE 2019
By
Dr.Ashok kumar A
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2. Introduction
• Smile is one of the most important expression contributing to facial attractiveness.
• With patients becoming increasingly conscious of a beautiful smile, smile esthetics has
become the primary objective of orthodontic treatment.
• The most important esthetic goal in orthodontics is to achieve a balanced smile, which can
be best described as an appropriate positioning of teeth and gingival scaffold within the
dynamic display zone.
Smile analysis and design in the digital era. Ackerman MB et al J Clin Orthod 2002; 2

3. • Although numerous cephalometric models have been developed to evaluate the beauty
of the face, facial harmony can be achieved even if the patient does not fit within these
norms.
• The orthodontic diagnostic process has shifted from an entirely cephalometric and hard-
tissue-based evaluation to one recognizing the importance of facial and smile
appearance and how they change over time .
• Greater emphasis is now placed on detecting and treating dentofacial alterations
according to soft-tissue needs, using the numeric data of the cephalometric analysis as a
support instead of as a determining factor.
Peck, H. and Peck, S.: A concept of facial esthetics, Angle Orthod. 40:284-318, 1970.3

4. Types of
smiles
Stage I
Posed smile
Stage II
Spontaneous
smile
Peck S, Peck L. Selected aspects of the art and science of facial esthetics. Semin Orthod 1995;1:105-26.
Ackerman J, Ackerman MB . A morphometric analysis of the posed smile. Clin Orthod Res 1998;1:2-11.
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5. Dynamic smile visualization and quantification: Part 2. Smile analysis and treatment strategies
David et al AJODO 2003
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6. • Standard approaches to orthodontic treatment
result in flattening the smile arc in about 1/3rd
of patients, probably because it was not a
factor considered in the treatment plan.
• So during the clinical examination, we should
document not only problems but also the
positive elements that need protection .
Interactions of hard tissues, soft tissues, and growth over time, and their impact on orthodontic diagnosis and
treatment planning Sarver, D.:AJODO 2015
An esthetic evaluation of lip-teeth relationships present in the smile.
AJODO Hulsey CM1970
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7. RECORDS IN TREATMENT OF THE SMILE
Direct biometric
measurements.
Static records
Dynamic
recordings
Dynamic smile visualization and quantification: Part 1. Smile analysis and treatment strategies
David et al AJODO 2003
Smile index
The lower the smile index the
less youthful the smile appears.
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8. • Cuspid smile - The action of all the elevators of the upper lip, raising it like a window shade .
• Complex smile - The action of the elevators of the upper lip and the depressors of the lower lip .
• Mona Lisa smile -The action of the zygomaticus major muscles, drawing the outer commissures
outward and upward, followed by a gradual elevation of the upper lip.
Cuspid smile
Complex
smile
Mona Lisa
smile
Smile Analysis and Design in the Digital Era ACKERMAN et al JCO/APRIL 2002
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9. Sarver, D. and Jacobson, R.S.: The aesthetic dentofacial analysis, Clin. Plast. Surg-2007. 9
Aesthetic approach to evaluation

10. The Eight Components of a Balanced Smile
Sabri, R.: The eight components of a balanced smile, J. Clin. Orthod. 39:155-167, 2005. 10

11. • Desai et al observed lip support and prominence are lost as people age; the thickness of
the upper lip reduces by 1.5mm, both at rest and in smiling , as a result, both incisor
display and upper gingival display reduces.
• And also observed overall reduction of 1.5-2mm in the vertical dimension of the smile
as part of the aging process..
• In addition, inter commissural width increases transversely with aging because of the
decline in both resting tonus and elasticity
• The present article proposes a method for bracket placement that accounts for such
characteristics as gingival contour, smile height, smile width, and smile arc accentuation
from premolar to premolar, primarily in the upper arch.
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Dynamic smile analysis: Changes with age, Desai, S et al AJODO-2005.

12. Smile Design Considerations
People with well-aligned teeth and a broad esthetic smile exhibit greater self esteem
and are perceived as being more attractive and smarter.
Beall et al. Can a new smile make you look more intelligent and successful? Dent. Clin. N. Am.- 2007.
The shape of the lips
Maxillary lip line
Curvature of the lower lip
Smile arc
Buccal corridors
Frontal occlusal plane
Dental and gingival components
The incisor
display
Smile arc
Anterior torque
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13. The incisor display
• Average maxillary incisor display - 1.91mm in Men and 3.40mm, in Women
• Female lip lines-1.5mm higher than male lip lines, 1-2mm of gingival display at maximum
smile could be considered normal for females.
High smile Average smileLow smile
Some esthetic factors in a smile, Tjan et al J. Prosth. Dent. 51:24-28, 1984. 13

14. Smile arc
• The curvature of the incisal edges appears to be more pronounced for women than for men, and
tends to flatten with age.
• Hulsey et al -The smile arc can be unintentionally flattened during orthodontic treatment by
Overintrusion of Maxillary Incisors - Bracket Positioning - Cant of the Occlusal Plane
StraightConsonant smile Inverted or Reverse
Some esthetic factors in a smile, Tjan et al J. Prosth. Dent. 51:24-28, 1984. 14

15. • Ackerman et.al observed that the main differences between treated and untreated
teenagers were the intercanine width and the smile arc; 33% of the orthodontic patients
showed a flattened arc, compared with only 5% of the untreated patients.
• Because the clinical crowns of the upper canines are longer than those of the other
anterior teeth, bonding brackets at the centers of the clinical crowns will make the
canines appear relatively extruded, spoiling the natural curvature of the anterior teeth.
• The common focus on extrusion of the maxillary canines for canine guidance results in
intrusion of the maxillary incisors and thus creates a flatter smile arc.
A morphometric analysis of the posed smile, Clin. Orthod res. Ackerman et al-1998.
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16. • When a patient presents with a consonant smile arc, the brackets should be positioned to
preserve the vertical position of the anterior teeth.
• If the smile arc is flat, the upper incisors should be extruded to enhance incisor display
and maintain the appropriate curvature of the upper arch relative to the lower lip.
• The width of the smile is directly related to the facial index ,Therefore, our focus on
smile arc design should extend from 1st premolar to 1st premolar, or even to the 1st
molars in some cases. Transverse development is advisable in patients with broad smiles.
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Proffit, W.R.; Fields, H.W.; Larson, B.; and Sarver, D.M.: Contemporary Orthodontics, 6th ed., 2018, p. 160.

17. • Some cephalometric angles routinely used to identify upper
incisor proclination, such as U1-SN or U1-FH, are modified
by the cranial base inclination.
• This could result in a misdiagnosis of proclination or
retroclination when the existing characteristics might be
esthetically appealing.
• The same situation applies when the crowns and roots of the
upper incisors have an uncommon anatomy and their long
axes do not coincide .
Maxillary incisor crown-root relationships in different angle malocclusions-Harris et al AJODO 1993. 17

18. Anterior torque
Anterior tooth morphology and its effect on torque Van Loenen et al EJO.2005. 18

19. • Canines must be upright to make a smooth transition from the anterior teeth,which
have positive torque - to the posterior teeth, with fundamentally negative torque.
Variations in bracket placement in the preadjusted orthodontic appliance Balut et al AJODO-1992..
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20. Bracket Placement Guidelines
Evaluate the form and shape of each clinical crown.
Evaluate the initial gingival shape and contour
Place brackets in the upper arch before the lower arch.
Adjust for smile height.
Bond the lower arch.
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21. 1. Evaluate the form and shape of each clinical crown
Establish correct fine esthetics & the ideal
gingival contour - after alignment, & will
ensure that the tooth can recover its function
in occlusion and mandibular movement.
Modify any worn or chipped incisal edges and tooth dimensions before bonding.
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22. 2. Evaluate the initial gingival shape and contour
• If the patient exhibits reduced crown height due to altered passive eruption (excessive
gum overlapping over the enamel limits), a gingivoplasty might be advisable to help
visualize the best bracket placement.
• If delayed active eruption is causing a lack of incisor height, a periodontal consultation
is indicated.
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23. 3. Place brackets in the upper arch before the lower arch
• The upper dentition, framed by the lips in a natural smile, allows visualization of the
treatment plan from beginning to end ..
• Bracket placement method, beginning with the canine, which guides excursive
movements and serves as the transition tooth between the anterior and posterior dentition.
4. Adjust for smile height
• The height of the canine bracket will depend on the consonance of the patient’s
original smile and incisor display.
• As the tooth display increases at rest and in smiling, the degree of gingival
positioning of the canine bracket should decrease .
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24. • The crown size, & consequently the bracket height, diminishes gradually, creating
divergence from posterior to anterior in the upper occlusal plane that will benefit the
incisor exposure.
• In open-bite cases without excessive gingival display, more superior anterior bracket
placement than posterior bracket placement is suggested. This will help close the bite by
intruding the posterior teeth while extruding the anterior segment.
Bonding heights on upper teeth for low smile height (reduced upper incisal exposure).
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25. With average smile height, the brackets should be placed closer to the center of the
clinical crowns, although protection of the smile arc should always be kept in mind.
Recommended bonding heights on upper teeth for average smile height.
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26. • Bracket placement can mask an excessive gingival display, depending on the etiology
of the gummy smile.
• Again, the vertical position of the incisal edge is a major factor to avoid flattening a
consonant smile arc in an attempt to reduce gingival display.
Recommended bonding heights on upper teeth for high smile (excessive gingival exposure).
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27. • It might appear that an improper step would be created between these teeth, the difference
in crown dimensions between the canine and premolar allows the contact point to be more
incisal without generating a step that could compromise the occlusion .
A. Recommended bonding heights for low smile height
B. Despite difference in bracket height between canine and first premolar, no step created in occlusion.
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28. • Placing a bracket too high can promote gingivitis and increase the risk of enamel fracture
during debonding, because of the thinner enamel in the cervical area.
• In selected cases where the incisor is covered by the upper lip, however, this approach will
be effective.
• Canine rise would compromise canine protection during excursive movements ,if the torque
is correct in both the upper and lower canines, this protection will not be compromised.
• If canine protection is not obtained by the third phase of treatment, minor extrusive bends or
repositioning of the lower canine bracket can help accomplish this goal.
• A posterior group function is also an acceptable result.
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30. 5 .Bond The Lower Arch
• The recommended heights of the brackets and tubes does not vary in the lower arch.
Again, the individual patient’s morphological characteristics must always be
considered. Minor changes can be made in the final stages of treatment.
To improve leveling & alignment in this case, incisor brackets rebonded higher(central,1mm;lateral,.5mm)
& canines rebonded more occlusally (right, 1mm; left, .5mm) & Smile esthetics improved within 4 months
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31. If a disharmony in the gingival tissue is detected in the occlusal frontal image, a
periodontist should be consulted for a possible gingivoplasty. Such minor details can perfect
the treatment outcome by adding symmetry and balance to the patient’s final smile.
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32. Bracket Positioning for Smile Arc Protection –Dr.PITTS JCO/MARCH 2017
• Positioning the upper brackets to protect or enhance the smile arc has come to be called
Smile Arc Protection (SAP) bracket positioning.
• The upper incisor brackets are generally placed more gingivally than the canine brackets.
• The lower posterior brackets are placed somewhat gingivally to avoid occlusion, while the
lower anterior brackets are placed somewhat incisally to optimize overbite.
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38. CONCLUSION
• Although the concept of smile analysis is not new but is often not incorporated in
orthodontic treatment planning.
• It is therefore emphasized that all the above discussed elements of smile analysis should
be considered as guidelines and reference points for beginning esthetic evaluation,
treatment planning and subsequent treatment .
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39. Reference
• Smile analysis and design in the digital era. Ackerman MB et al J Clin Orthod 2002;
Peck, H. and Peck, S.: A concept of facial esthetics, Angle Orthod. 40:284-318, 1970.
• Interactions of hard tissues, soft tissues, and growth over time, and their impact on
orthodontic diagnosis and treatment planning Sarver, D.:AJODO 2015
• Contemporary Orthodontics – WILLIAM R. PROFIT 6 th EDITION
• Sabri, R.: The eight components of a balanced smile, J. Clin. Orthod. 39:155-167,
2005.
• A morphometric analysis of the posed smile, Clin. Orthod res. Ackerman-et al-1998
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