CLINICAL

A new table to guide bracket placement based on

the concept of “smile arc protection”

Drs. Tomás Castellanos and Thomas Pitts introduce a new table to guide vertical placement of brackets
based on the effect upon the smile arc

Summary limits, and thanks to the advances in today´s recommended attempt to place the brackets
Background/objective: The correct orthodontic technology, it is possible not in the best possible position to avoid further
placement of brackets is essential not only only to obtain an excellent occlusion but to repositioning and compensatory bendings
for functional but for esthetic smile success improve patient esthetics according to his/ as treatment progresses.
of the treatment. The objective of this paper her expectations. Planning the treatment Previously established positions for
is to introduce a new table to guide vertical based on facial esthetics as a purpose to bracket placements based on tooth dimen-
placement of brackets, based on the effect protect the smile arc is parallel to a strategy sions, as frequently taught in orthodontic
upon the smile arc. Therefore, the table is to achieve occlusal purposes. The functional courses and programs, are inappropriate
named Guide Position Smile-Arc (GPS-A). aim of orthodontics is always to achieve a for optimum esthetics. For instance, if one
Materials/methods: Two tables, one for mutually protected occlusion; that is, anterior assumes that all patients have the maxillary
upper dentition and one for lower dentition teeth protect posterior teeth from interfer- central incisors located 4.5 mm above the
were designed to guide the bracket place- ence during lateral and protrusive move- incisal edge, lateral incisors at 4 mm, and
ment, in order to obtain or retain the best ments, and posterior teeth protect anterior canines at 5 mm, and the orthodontist fails to
esthetic smile arc, based on the authors´ teeth as well, providing an adequate contact account for the relationship of incisal edges
clinical experience. The limitations of other in closed-mouth position. with the lower lip, the position may not adjust
commonly used tables (Alexander and The smile arc, in a frontal view, has been for the esthetic criteria needed. Customized
MBT™) are presented as antecedents of defined as the relationship of the curvature of appliance placements have as much impor-
the new table. the superior incisive and canine incisal edges tance as customized treatment plans.4
Results: Instructions to use the table are with the curvature of the inferior lip in smiling Dr. Tom Pitts has developed a protocol
described in detail. Indications for previous position. In an ideal smile arc, the curvature for Smile Arc Protection (SAP) bracket posi-
dental morphology adjustment, use of posi- of the superior incisal edge is parallel to tions that consistently produce beautiful
tioners, and specifications for special situa- the lowest smiling lip curvature. The term Smile Arcs. Dr. Tomas Castellanos has quan-
tions are described. “consonant” describes this parallel relation- tified this esthetic positioning by measuring
Conclusions/implications: The advan- ship. In a non-consonant or flat smile, the the length of the teeth. Hence, this is a “Tom-
tages of using this guide are summarized. maxillary incisal curvature is flatter than the Tom” production.
The clinical table provides an easy and reli- inferior lip in smiling position. The vertical positioning of brackets is
able guide for clinicians to place brackets for According to Frush and Fisher,3 a more a challenge for many orthodontists. This
predictable pleasant smiles and functional sharp curvature of the upper incisal edges problem diminishes when positioning
occlusions. from canine to canine is more attractive/ devices and customized tables are used to
youthful than a flatter curvature. Therefore, guide bracket placement, when using direct
Introduction in individuals who don’t show curvature of or indirect bonding.
Facial and smile esthetics are essen- the lower lip on smile, a smile arc is still the The Alexander technique5 uses the
tially inherent characteristics of the patient. most desirable. The ideal smile arc as a guid- premolar height (X in the Vary-Simplex table
Nonetheless, within morphologic-functional ance for anterior upper teeth indicates that for bracket heights) (Figure 1) for bracket
the purpose should be an ideal position from positions in the entire arch.
Thomas Pitts, DDS, MScD, received a BA from canine to canine and a functional anterior bite.
the University of Nevada, Reno. He earned a Accurate bracket positioning is essential Bracket Height
DDS from University of the Pacific and was
Valedictorian in 1965. He holds an MSD from
to finish treatment with an excellent occlusion Maxillary Arch
the University of Washington and is in private and beautiful smile. Additionally, the most Centrals X
practice in Killen, Texas. Dr. Pitts is Associate Laterals X - 0.5 mm
common reason for unnecessary delay of Cuspids X + 0.5 mm
Clinical Professor in the Orthodontic Department
of the University of the Pacific, Dugoni School of Dentistry in San
treatment and the discovery of difficulties Bicuspids X
1st Molars X - 0.5 mm
Francisco, California. in the final stage is the incorrect bonding 2nd Molars X - 1.0 mm
of the appliances. The need for excessive
Tomás Castellanos, DDS, MSc, DDS,
attended Pontificia Universidad Javeriana
first order bends is not due to a failure in Mandibular Arch
Centrals X - 0.5 mm
(Bogotá,Colombia). He has a MSc in Orthodontics design of the orthodontic appliances, but Laterals X - 0.5 mm
and Maxillofacial Orthopedics and attended due to incorrect bracket positioning. When Cuspids X + 0.5 mm
Nueva Granada Military University – CIEO. Dr. Bicuspids X
Castellanos is in exclusive private practice in
some teeth are in extreme malposition, it is 1st Molars X - 0.5 mm
orthodontics in Bogotá, Colombia. not always possible to place a bracket in an
ideal position during the first visit, but it is Figure 1: Table of Vari-Simplex bracket heights

12 Orthodontic practice Volume 5 Number 5

CLINICAL

For example, if the normal slot height

for a premolar bracket is 4.5 mm from the
occlusal cusp, the other indicated heights
demonstrated by this table should be 5.0
mm for canine, 4.0 mm for lateral, and 4.5
mm for centrals.
The MBT™ table (Figure 2) offers another
commonly used bracket positioning guide.
It suggests average positions for brackets
in the maxillary arch of 4.5 mm for the first
premolar (X - 0.5 mm.), 5.0 mm for canine
(X), 4.5 mm for lateral (X - 0.5 mm), and 5.0
mm for central (X).6
These and other techniques for bracket
placement, based on popular tables and
positioning devices, provide accuracy and
high reproducibility. Unfortunately, bracket
placements with these height discrepancies
typically flatten the smile curve.
Flattening of the smile arc during orth-
Figure 2: MBT™ Versatile+ Appliance Bracket placement guide
odontic treatment can occur by different
mechanisms. The normal alignment of maxil-
lary and mandibular dental arches may result based on the smile arc effect — therefore, The table facilitates the vertical place-
in a reduction of curvature of the upper inci- the table is named Guide Position Smile-Arc ment of brackets in positions that result in
sors with respect to the inferior lip curvature. (GPS-A) (Images 1 and 2). adequate smile curves, as well as mutually
Ackerman, et al.,4 evaluated smile arcs in protected occlusions.
treated and non-treated patients in their own Table suggested for vertical It takes into account occlusal morphology,
practices. Almost 40% of the treated patients placement of brackets such as the angle of the articular eminence that
presented discernible changes in the smile is more vertical in dolichocephalic subjects than
arc with flattening of the smile arc occurring Rationale in mesocephalic or brachycephalic patients.
in 32%. In the control group (which was the The table presented (Figures 3 and 4) is In dolicocephalic patients as compared to
treated group), 13% presented changes in based upon a great number of clinical studies brachycephalic, the molar cusps are higher
the smile arcs, but flattening occurred in only and measurements taken on plaster casts and fossae are deeper; anterior teeth clinical
5% of this group. They reported no gender and digital models from patients treated crowns are longer in a cervico-incisal direction.
differences regarding smile features in treated by the team of Drs. Tom Pitts and Tomás All these characteristics indicate that more
or untreated groups. Castellanos. Its versatility and efficacy will be overbite is necessary to disocclude posterior
The present article introduces a new the subject of other articles presenting cases teeth in eccentric movements in dolicocephalic
table to guide vertical placement of brackets, successfully treated applying this table. subjects. On the other hand, individuals with
shorter faces, flatter TMJ eminences, andan-
terior teeth with shorter clinical crowns, less
overbite is necessary to disocclude posterior
teeth in eccentric movements.4
Also when considering the incisal – smile
arc relationship, clinicians must extrude the
upper incisors in flat smile cases or maintain
the incisal smile arc when it is esthetically
adequate.
For a functionally adequate occlusion
and esthetic smile curvature, a divergence
must be kept between the occluso-gingival
position of the slot with occlusal cusps or
incisal edges, measured in mm, from the
second molar tube all the way to the maxil-
lary central incisor.
This divergence is important as well,
considering that the difference in mm
between the slot height of the central incisor
and the height in mm from the second molar
Image 1: Smile curve flattened after orthodontic treatment. Image 2: Consonant Smile Arc, result of bonding brackets tube gives an idea of the amount of overbite
Brackets bonded with conventional heights. (Patient treated with GPS-A (Guide Position Smile Arc) Tom - Tom (Patient one will obtain at the end of treatment. It also
by Dr. Tomas Castellanos — MBT brackets) treated by Dr. Tomas Castellanos — H4 brackets). affects the occlusal plane cant.
14 Orthodontic practice Volume 5 Number 5
CLINICAL

The final overbite of any deep bite or

open bite also depends on elastics, dis-
articulation buttons, mini-screws, and other
auxiliary elements that potentiate the expres-
sion of the bracket’s torque. Of course, mini-
screws can also help enhance the maxillary
incisor position by intruding the mandibular
incisors when needed.
The transition point between the anterior
and posterior dental segments additionally Figures 3 and 4: Tables GPS-A lower and upper
establishes the track of the smile arc, and
therefore, the positioning for the whole dental
arch should be planned taking this point as
a clue.
When the maxillary incisors are further
extruded to enhance the smile curve and
enamel display, a deeper bite can be
produced by increasing the overbite. To avoid
this effect, the table introduces a compensa-
tion in the position of the slot of mandibular
canine-to-canine brackets.

Instructions to use the table

(Figures 3 and 4)
Previous to using the table, some patients
require a recontouring to provide basic ideal
morphology to each tooth. This ameloplastic
procedure is based in the study of plaster
Figure 5: Accurate measurement for each tooth with digital gauge (Mitutoyo™ Super-Caliper Solar-Powered Series 500 —
models and removes only the necessary Digital Caliper at www.amazon.com)
minimum dental enamel.
The ameloplasty includes pronounced
marginal ridges on the lingual surfaces, of
incisors’ angles and incisal ridges, as well
as irregular vestibular surfaces. Irregular
vestibular surfaces prevent an optimum
placement of brackets, which control rota-
tions and torque.1
In most cases, canines require re-
contouring to improve their role in the smile
arc. This process does not interfere with their
functional role of canine disocclusion.
Gingival margins are very important for
anterior esthetics. Sometimes clinicians
need to perform initial gingivoplasties with
laser, electro-surgery or any other similar
technique.
It is important to provide the right
morphology, but clinicians should not re-
contour all hard and soft tissues, since
leaving small discrepancies until the end of
treatment allows for final detailing when the Figure 6: The second step is to find the maxillary canine crown length and then the positions of the other maxillary teeth
teeth have the best possible position.
When teeth have fractures or abnormal
receive recontouring to avoid interferences gingival margin (after reconstruction,
wear, the teeth should be reconstructed
or early contacts. The same applies to the recontouring, or gingivoplasty).
prior to bracket bonding, in order to assure
lingual cusps of the premolars. 2. Find this measurement in the columns
the ideal dental anatomy. Clinicians should
After obtaining the ideal dental of the table GPS-A (Guide Position
communicate this to the patient, since future
morphology, the heights for bracket bonding Smile Arc upper), and choose the adja-
restorations may be necessary.
in the maxillary arch are selected as follows: cent number in the row. (Figure 6). The
If the maxillary molars present high and
1. Measure the length of the maxillary number in this file indicates the position
pronounced mesopalatal cusps, they should
canine crown, from the cusp tip to the for each bracket.

15 Orthodontic practice Volume 5 Number 5

CLINICAL

3. Select in a similar way the height to

bond brackets for mandibular teeth:
a) measure the length of the crown of
the mandibular canine, from cusp tip
to gingival margin (after reconstruc-
tion, recontouring, and gingivoplasty);
b) find this number in the column of the
table GPS-A (Guide Position Smile Arc-
lower), and choose the number in the
adjacent row. This number indicates the
position for bonding each bracket in the
mandibular area (Figure 7).

Specific considerations
The maxillary second molars must always
be intruded. Its tubes are always positioned
to slightly intrude these teeth to provide a
negative coronal inclination and avoid func-
tional interferences.
The discrepancy between maxillary inci-
sors and the maxillary lateral incisor must be Figure 7: The third step is to find the lower canine crown length measurement and the subsequent positions for the mandibular
brackets
kept between 0.5 mm and 1 mm to allow the
movement of the mandibular canine during
protrusive excursions and, additionally, to
improve the smile arc. In general, this technique
Longer incisors require a larger height
difference. For those situations, the table allows the orthodontist to
includes two additional options.
At the level of the mandibular molars, it is obtain adequate occlusion
important to maintain an occlusal plane that
grants correct coupling with the antagonist and an esthetic smile
teeth.
Figure 8: Versatile high-precision positioner for proper loca-
We suggest for incisor, canine, and tion of each bracket from second molars to central incisors
Individualization of the table for cases treated (GPS-A is a versatile high-precision positioner from Ortho
premolar regions to use the calibrator placed
with premolar extraction Classic Inc. at www.orthoclassic.com)
at 90º respect to the tangent of the middle
Today’s effective mechanics, combining
zone. For the molar region, it is suggested
the use of mini-screws with passive self-
to place it parallel to the occlusal surface
ligation appliances for en masse movement of each molar (tracing an imaginary line REFERENCES
toward the place of molar extraction, has between the buccal and the lingual cuspids 1. Pitts T. Begin with the end in mind: Bracket placement and
reduced the frequency of patients treated of each molar). early elastics protocol for smile arc protection. Clin Impres.
2009;17(1):1-11. 
with premolar extractions. But when the
2. Sarver D, Ackerman MB. Dynamic smile visualization and
orthodontist decides that it offers the best Advantages derived from the use of this table quantification: Part 1. Evolution of the concept and dynamic
option, the table may be individualized. To • A reduction of errors in positioning, which records for smile capture. Am J Orthod Dentofacial Orthop.
2003;124(1):4-12.  
do this, the anterior segment is managed can be avoided, due to better precision, 3. Frush JP, Fisher RD. The dynesthetic interpretation of the
as conventionally indicated in the GPS-A • reproducibility, and predictability of the dentogenic concept.  J Prosthet Dent. 1958;8:558-581. 

table, but the discrepancy between premolar bracket bonding. 4. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. 
A morphometric analysis of the posed smile. Clin Orthod 
and canine for every case will be 0.5 mm, • It allows a practical, standardized Res. 1998;1(1):2-11. 

and the discrepancy between premolar and bonding procedure. 5. Alexander W. Build treatment into bracket placement. In:
The 20 Principles of the Alexander Discipline. Chicago, IL:
molar will be 1.0 mm in every case, to avoid • Avoids bracket repositioning and/or the Quintessence; 2008:59. 
introduction of excessive corrective wire
interferences and inadequate steps in these 6. McLaughlin R, Bennett J, Trevisi H. Systemized Orth-
bends. odontic Treatment Mechanics.  Philadelphia, PA: Mosby;
segments. 2001:60-65. 
• Reduces chair time and unnecessary
7. Echeverri E, Sencherman G. Neurofisiología de la oclusión.
discomfort to the patient. Columbia: Editorial Monserrate; 1991:175–189. 
Use of the positioner for vertical placement • Saving months of treatment, it becomes 8. Sarver DM. The importance of incisor positioning in the
of each bracket an effective tool to motivate patients. esthetic smile: the smile arc. Am J Orthod Dentofacial
Orthop. 2001;120(2):98-111.
The positioning gauge that measures • Allows better control of torque values.
the height to bond the brackets is placed
in a slightly different way, depending of In general, this technique allows the
the segment of dental arch that is being orthodontist to obtain adequate occlusion
considered.5 and an esthetic smile. OP

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