Customized brackets overcome the individual variation of brackets and minimise the error.

1. Customized brackets
Dr.kalaiselvi.R MDS.,
Orthodontics and Dentofacial Orthopedics

2. synopsis
 Introduction
 Technology
 Semi- customized appliances
 Fully customized appliances
 Labial system
 Lingual system
 Customized ceramic brackets
 conclusion

3. INTRODUCTION
 Customised bracket CAD/CAM technology CAD/CAM technology has been used in dentistry since 1985.
 The Cerec system from Sirona (Siemens, Bensheim, Germany) was initially used in restorative dentistry for the
manufacture of single crowns and later multiunit bridges.
 In orthodontics, it was first applied to the fabrication of customised lingual brackets (eg, Incognito, 3M-Unitek;
Insignia, Ormco) and later robotic wire bending (eg, SureSmile, Orametrix).
 Most of today’s stock brackets have torque, tip and rotation prescriptions based on average tooth anatomy for the
average arch and facial shape. However, there is considerable individual variation in tooth structure, shape and
size, as well as arch and facial shape and form, which means that some teeth are not positioned ideally using
stock brackets .
 Claims are made that customised orthodontic appliances overcome these individual variations and can also
minimise clinician error in bracket positioning.
 Robotic wire bending, it is claimed, can further enhance this customisation with some reports suggesting that it
may lead to reduced treatment duration . Customised brackets are made using a digital model of the patient’s
teeth. The scan is submitted to the relevant company so that virtual brackets and can be placed in an ideal
position to achieve the ‘virtual set up’.
Orthodontics in the Digital Age (Australian Society of Orthodontists 2021)

4.  A novel customized system allows for assessment of changes in 3D and customization of treatment
planning brackets, and wires by means of intraoral scanning, cone-beam computed tomography
(CBCT), three dimensional (3D) photography, and computer-aided design and computer-aided
manufacturing (CAD/CAM) technologies .
 At present, a wide variety of customized orthodontic appliances, including metal labial or lingual
brackets and clear aligners are developing rapidly and receiving growing attention.
Customised precision prescription appliances or orthodontic treatment can be delivered
by either
• Customising or individualizing brackets to the patients tooth
morphology
• Customising the bracket- tooth surface composite/ resin
interface to the patients tooth morphology and planned
treatment needs
• Customising the archwires to the patients tooth
morphology and planed treatment needs
• Using selected prescription to semi- customize the
appliance
• A combination of the above
• Aligners
Yang et al. Progress in Orthodontics (2019) 20:39

5. Each company has their own technique for this customisation

6. TECHNOLOGY
 Digital imaging
 Computer modelling
 Robotics
 Metal injection moulding

7. SEMI-CUSTOMIZED APPLIANCES
 The term semi customized appliances is used to describe the variations from standard
straight wire technique such as inverting brackets or mixing of brackets from different
prescriptions in order to produce specific tooth movements of individual patients needs.
 Disadvantages are more variability than fully programed appliances, not fabricated
specifically to the patients needs, uses mixed prescription straight wire appliance.
FULLY CUSTOMIZED APPLIANCES
Designed to meet the specific needs of the patients malocclusion
Oramco - insignia
Incognito - custom made lingual appliances
Custom SL appliances
Clear aligners
OrthoCAD
Suresmile

8. INSIGNIA
 Insignia (Ormco, Orange, CA, USA) utilise a customised slot on a standard base.
 Insignia currently offers customized setup for conventional twin brackets for each
individual tooth and for Damon self ligating brackets ( custom prescription with
standard bas and pad)
 Insignia provides five sets of customized archwires , these are marked at the
midline and on the right hand side to ensure that they are fitted with the correct
orientation.
 The digital information is used to cut each bracket precisely using CAD/CAM
technology so the bracket has the appropriate thickness, inclination, torque needed
for ideal positioning for that tooth.
 Bonding jigs are fabricated that each bracket can be placed in the planned location
 Preliminary data indicate that treatment time is reduced in comparison to treatment
with conventional prescription brackets but some adjustment of the final archwires
is still required
 If patient debonded one of the customized brackets a replacement bracket and
bonding template can be available within 2-3 weeks.
 Every insignia case is accompanied with new clear jigs manufactured to fit like a
puzzle piece onto each patients unique occlusal anatomy.
 Simplified light curing from any direction even on occlusal surface can be done
Greco A 2011

9. INCOGNITO ( CUSTOMIZED LINGUALAPPLIANCE)
 It is mainly fully programmed appliances ( means that all SWT features are involved) and either semi or fully customized to
the patient ( customized prescription, base and pad )
 Wire sequences smaller than usual because of the reduced inter bracket distance(012,016, 16 x 16 niti then 16x 16 SS
 It is considered a hybrid slot orientation appliances ( Ribbon arch slot vertically oriented placement of the AW similar to
Begg brackets in the anterior teeth and edgewise slot horizontal oriented placement of the AW similar to Angle Edgewise
brackets in the posterior teeth.
FEATURES ARE,
 Slot size is 0.018x0.025 inch because of the reduced interbracket distance.
 Bracket systems are – fully custom made bracket, fully custom made wire, thin profile leading to little discomfort.
 Arch wires used are ribbon wise configuration, vertical slot insertion in the anterior region from canine to canine and
horizontal slot insertion in the lateral segments.
 Order bends; the vertical height, angulation and torque are pre-set into each bracket so the need for maximum individuality
is met and the patients individual prescription is designed into the brackets.
 Indirect bonding protocol is used for the initial bonding, extraction is carried out after the appliances has been bonded.
 Occlusal pads helps in providing greater bond strength, act as bite plate, allowing for a direct rebonding procedure without
need of transfer trays or jigs.
 To improve anchorage , control splints can be made to lock teeth together.

10. Manufacturing process
Scanned surfaces are composed of differently sized triangles (standard
triangulation language, STL surfaces). More homogeneous surface areas are
represented by larger triangles, and less homogeneous surface areas by smaller
triangles. Minimum surface resolution: 0.02mm
Digital setup with individually defined bracket
bases.
State-of-the-art maxillary incisor bracket with vertical insertion direction. In this version,
ligating can be done with simple elastic module or with German overtie.
Positioning software allows optimum angulation of hook. Accessory occlusal hook is
optional. First-generation premolar bracket with horizontal insertion direction (left) and
state-of-the-art premolar bracket with vertical insertion direction (right).
A, Bracket bodies (blue) are loaded from bracket archive to dental arch fitted with individual
bases (yellow). Whereas second and third order are preset, bracket body can now be shifted and
turned in slot plane for optimal positioning. B, Bracket body and bracket base are then virtually
fused.
A, In rapid prototyping, brackets are first produced in wax, applied in 0.02 mm layers. Red
support wax required for 3D production is removed thermally. B, Wax lingual brackets
before casting. C, Gold lingual brackets after casting.
Two-phase silicone bonding tray with precoated
lingual brackets

11. Advantages
 Aesthetic
 Less enamel decalcification
 Efficient in OB reduction
 Good outcome compared to conventional
 No differences between labial and lingual
Disadvantages
 Cost
 Accessibility
 Speech and cleaning problem
 Variable lingual morphology
 Canine offset which need mushrooming of AW
 Reduced interbracket distance causing reduction in the arch wire flexibility
 Finishing and torque control is very difficult
Romano 1999, Linh 2005

12. SURESMILE
 Suresmile (Orametrix, Inc., Richardson, TX, USA) use customised wire and conventional brackets, with
clinicians choosing their preferred bracket.
 CBCT data can be merged with the virtual model when planning the tooth movement to visualise the
bone housing.
 Suresmile is more commonly used as a finishing wire after levelling and aligning, however, it is not just
used for finishing but can also be used in levelling and aligning as well as space closure.
 Bends will be incorporated in the main arch wire to maintain torque in space closure, similar to
combination arch wires.
 Orthodontics in the Digital Age According to a retrospective study , two groups of patients, one group
treated with Suresmile and one group treated conventionally, were compared by using the American
Board of Orthodontics Objective Grading system (ABO OGS).
 It concluded that Suresmile resulted in a lower mean ABO OGS score and a reduced treatment time
when compared to conventional approaches, demonstrating the potential to both decrease treatment time
and improve quality. However, one of the negative issues with Suresmile is bracket debonding during
the finishing phase which can make this stage of treatment more frustrating.
Larson B 2013

13. CUSTOMIZED CERAMIC BRACKETS
 CCB system makes it possible to realize mass customization for ceramic orthodontic brackets via
personalized design, 3D printing technique, heat-pressing technique, and lithium disilicate
materials.
1. CCB attained the multi-color appearance and individual contour by means of lithium disilicate
materials and custom molding design.
2. There were no statistically significant differences between CCB and certain commercial ceramic
brackets (P ≥ 0.05).
Yang et al. Progress in Orthodontics (2019) 20:39

14. conclusion
 From banded to bonded, from metal to ceramic and from physical to digital,
orthodontics keeps evolving. Technology may make orthodontics more ‘user
friendly’ and minimise the barrier to undertaking treatment, however, it does
not change the biomechanics and biological limitations of treatment.
 Many products are introduced into the market and claim superiority without
any peer reviewed research. As dental professionals, we still must provide
evidence-based and patient-centric orthodontic treatment with proper diagnosis
and treatment planning.