BEGIN WITH

THE END IN MIND:

Bracket Placement and Early Elastics Protocols for Smile Arc Protection

Thomas R. Pitts, DDS, MSD primary concern and so must be the overriding
Reno, NV standard we use in developing a treatment plan and
evaluating the merit of a finish while, at the same
Editor’s Preface: For too long, orthodontic treatment time, striving for excellent occlusion. Facial esthetic
goals have been based and results assessed solely on standards have changed in the last 20 years with
a patient’s dentition and dental occlusion, often at the patients now wanting fuller lips, more vermillion
expense of facial esthetics. The Damon philosophy has display and broader arches. Facially based treatment
long emphasized the parallel importance of facial planning—that has at its core a smile arc protection
esthetics in diagnostics, treatment planning and results strategy—goes hand-in-hand with occlusal goals.
Dr. Thomas R. Pitts received his
undergraduate dental education
evaluation and has fully endorsed the concepts of With an ideal smile arc as the guide for the maxillary
from the University of the Pacific, Dr. David Sarver’s individualized approach, well- anteriors, my objective is to idealize canine-to-canine
Dugoni School of Dentistry where
he now serves as an adjunct asso-
recognized as the most progressive model available positioning and the anterior bite (Figures 1a-b).
ciate professor. Dr. Pitts earned an today. The foundation of the Sarver paradigm is to Leaving the maxillary anteriors forward in the face
MSD in orthodontics from the
protect the positive attributes of a patient’s facial keeps the upper lip full with the nasolabial angle as
University of Washington. He served
in the Army Dental Corps between esthetics while providing solutions for areas of defi- close to 90º as possible for mid-facial support while
1966 and 1968 and began in private
ciency. Central to any such discussion is the patient’s maintaining or enhancing the upper vermillion curl.
orthodontic practice in Reno,
Nevada, in 1970. Dr. Pitts is the smile arc, which the Damon philosophy incorporates Having used the passive self-ligating Damon®
founder of the well-respected in its treatment planning approach as the “smile arc
Progressive Study Club. He conducts
System appliance for 13 years, I know that when
in-office courses and lectures inter- protection strategy.” In his article, Dr. Pitts explains used properly, its effective-force mechanics foster
nationally and throughout the United how his bracket positioning and early light elastics appreciable arch adaptation that accommodates
States on clinical excellence and
practice management efficacy. protocols offer two tactical means of achieving the most complete dentitions. Except for third molars,
strategic goals of smile arc protection. I now extract teeth only to enhance facial esthetics
when a patient’s teeth are too far forward and they
The favorite occasions of my practice life are exhibit lip incompetence.
debonding appointments when we celebrate the
patient’s beautiful new smile and finished occlusion.
Since accurate bracket placement is the foundation
for a beautifully finished case, bonding appoint-
ments then run a close second in terms of my
favorite events. Developing acumen in this one
aspect of treatment—precise bracket placement—
A B
is the single most important protocol to achieving
Figure 1a-b. With an ideal smile arc as the guide for the
efficiency and an esthetically pleasing smile and maxillary anteriors, my objective is to idealize canine-
functional occlusion. So goes treatment planning to-canine positioning and the anterior bite.

and bonding, so goes treatment time and quality

finishing; hence, we begin each case with the end Although I put precise bracket placement at the top
in mind. of the list of treatment protocols that I consider
essential to efficiently shaping a beautiful ortho-
Facial and smile esthetics are typically the patient’s dontic finish, I also feel that other protocols—

4 ci V O L 17 • NO 1 • 2009
soft- and hard-tissue contouring, variable torque, The study models are helpful in determining the
early light elastics and utilizing the proper archwires need for disarticulation buttons and recontouring
with precise timing—contribute appreciably to labial enamel. Like many of you, I keep the panorex,
that end. While I prefer to direct bond brackets and frontal facial and center intraoral photographs at
actually love the artistic challenge of doing so, my chairside during bonding. Since photographs can
positioning approach also seems to work well for be somewhat deceiving, however, I have the patient
those clinicians who prefer indirect bonding. In this stand up and smile for me just prior to sitting in the
article, I will cover my Damon bracket placement chair to check the smile arc and symmetry so that
protocols as well as the fundamentals of early light I have a visual in my mind during bonding that
A/P and vertical elastics. Using early light elastics continues to guide me in bracket placement.
(often referred to as “shorty” elastics or “shorties”) is
a relatively new protocol that I pioneered and which In another article in this issue of Clinical Impressions,
many Damon clinicians are finding an important Dr. Bill Thomas addresses torque selection so I’ll
adjunct to treatment. With them, the vertical dimen- only mention here that it is important to pay special
sion is now much more controllable and is yet attention to the lateral cephalogram to assess the
another means of protecting the smile arc. maxillary and mandibular incisors for the selection
of variable torques. In our finished cases, I expect
Basic Principles of the Pitts torque to be perfect. Proclined maxillary anteriors
Placement Protocol can ruin an otherwise beautiful result. Under-
There are certain bracket placement protocols torqued maxillary incisors and canines lead to a less
I employ: than desirable appearance and function.
1. Develop a detailed bonding plan prior to
bonding day and carefully select torques.
2. Ensure tray setup entails all the items Flashless bonding is a simple concept – just butter brackets with the
essential to efficient bonding.
proper amount of adhesive. The less flash, the healthier the tissue will be
3. Use two assistants to assist in bonding.
throughout treatment. My goal is to have no flash and no cleanup after
4. Recontour teeth for esthetics and bracket fit.
positioning the bracket. Superior bond retention requires that there be
5. Follow an exacting bracket placement
no bracket movement after positioning.
protocol to protect or enhance the smile
arc and align buccal segment cusp tips and
marginal ridges.
2. I ensure the tray setup entails
1. I develop a detailed bonding plan all the items essential to efficient
prior to the bonding appointment bonding.
and carefully select torques. There are a number of tools I consider essential to
I study the patient’s pretreatment records to our bonding protocol and to the bonding tray setup
develop a bonding plan prior to the bonding (Figure 2).
appointment. This planning process takes very
little time because I do it every day. The patient’s
• All the required brackets, including special
brackets and disarticulation buttons, etc., laid
photographs allow me to assess, among other out properly with the molar tubes preloaded
with adhesive and covered.
things, midlines, transverse plane, smile arc and
enamel display and to determine the torques for • Ortho Solo™ from Ormco, a universal sealant
and bond enhancer that I recommend for
the canines. The panorex lets me check for root effective bracket adhesion.
parallelism and positioning. The cephalogram helps
me decide the torque values for the maxillary and
• A two-inch, large-front-surface mirror1 that
offers a clear view of the occlusal surface of
mandibular incisor brackets. This careful analysis each tooth.
allows me to plan bracket positioning in order to
correct inclination. The bonding plan also takes
• Long cotton rolls rather than cheek retractors
for greater patient comfort and a better visual
Figure 2. Bonding Tray Setup

into consideration the patient’s tooth angulations, field.

marginal ridges, contact points, cusp heights, • Through-the-Lens Loupes from Orascoptic
provide a superior field of vision for bonding
anterior overlap, smile arc and missing teeth.
and debonding.

5
 disclusion. Reshaping the lingual surfaces of canines
• Keat tweezers from Zona Industries for secure
molar bracket delivery (Figure 3).
also facilitates Class II, Class III and vertical correc-
tion when using elastics. I also reshape the lingual
surfaces of the maxillary anteriors of some patients
of Asian and American Indian descent.

Figure 3. Keat tweezers offer a secure means

5. I follow an exacting bracket
of molar bracket delivery. placement protocol to protect
the smile arc and align buccal seg-
3. I use two assistants to assist ment cusp tips and marginal ridges.
in bonding. There are certain bracket placement principles to
I perform six-handed bonding with two assistants which I adhere. I have been using the Damon 3MX
helping one another in prepping the patient and (D3MX) appliance and now use the latest generation
then both assisting me during the bonding pro- Damon appliance, Damon Q™ (DQ). I bond the
cedure. Once the teeth have been pumiced, the mandibular arch first and then the maxillary arch:
assistants ensure that no saliva touches them. The second molar to canine on half of the arch, the same
assistants sit opposite one another with me in the sequence on the other half and then finish lateral
middle. I am right-handed so when I sit down to to lateral. I bond the maxillary arch in the same
bond—with the patient’s head directly in front of me sequence. I follow this procedure because I want
—the assistant to my right will load the brackets with the right side of the arch to mirror the left side in
adhesive and pass them to me. The assistant to my terms of bracket heights. I use a height gauge but
left vacuums and light cures as necessary while hold- only on canines and anteriors (both arches) to
ing both the large and small mirrors. This assistant ensure that the brackets are at the same height,
(the one to my left) also keeps a small micro-brush right and left. While this sequence is the order for
lightly saturated with Ortho Solo at hand to wipe bonding, the thought process is based on the bond-
away any negligible amount of flash. ing plan, developed from my study of where I want
to place each bracket.
4. Prior to bonding, I recontour teeth
for esthetics and bracket fit. I’ve learned over the years that I can save one to two
Before I pick up the first bracket, I perform macro- appointments by bonding every tooth at the bonding
enamel recontouring based, in part, on study of appointment even if I won’t be running a wire to all of
tooth anatomy via the stone models. Having prac- the teeth until later in treatment. Bonding all the teeth at
ticed this protocol over time, I now perform it in once also allows patients to get used to the brackets on
less than one minute. Softening tooth contours, their second molars at the same time as the other bonds.
buccal/labial surfaces, incisal tips and edges and Waiting to bond later in treatment lengthens treatment
A
plunging cusps enhances esthetics and assists in for me and disrupts my schedule.
contact relationships, esthetics and bracket and
occlusal fit. Bracket fit is obviously important to
achieving proper torque; occlusal fit is essential to I bond maxillary anteriors for esthetics and smile arc
minimizing interferences. Plaster models help deter- protection and the mandibular anteriors for overbite
mine if any facial enamel contouring is necessary, and overjet, bonding all other teeth for ideal occlu-
B
particularly on maxillary centrals and laterals. sion. I treat the mandibular anteriors to the maxil-
lary anteriors. Obviously, the canines are the
Unless they are worn off, almost all canines need transition from the anterior to the posterior seg-
reshaping for esthetics and occlusion (Figure 4a-c). ments and are integral to getting an esthetic and
The incisal edges of the central and lateral incisors functional occlusion. Keying off of the maxillary
usually require recontouring as well. Reshaping the canines helps me ensure that the canine-lateral and
C incisal surfaces of canines assists with smile arc canine-first premolar contacts are esthetic and
Figure 4a-c. Almost all ca-
nines need reshaping for protection and improves contact relationships with functional.
esthetics and occlusion. adjacent teeth yet does not interfere with canine

6 ci VOL 17 • NO 1 • 2009
In terms of the buccal segments, it’s mandatory that As a rule, I make very few wire bends
the marginal ridges and contact points be perfectly for these transitions because of the
aligned. Given the irregularity of buccal cusps, I feel bracket placement locations I use—
that using them as my primary bracket placement referencing the contact points while
reference for the buccal segments produces inconsis- keying off the canines. Dr. Mike
tent and substandard results. For me, contact points Steffan2 and I developed a method
make much more satisfactory references. If I get the to assist clinicians in perfecting this
brackets in the buccal segments placed correctly in technique—drawing lines on the
relation to the contact points, the marginal ridges stone models from contact point Figure 6. Marking the stone models between
of the posterior teeth will take care of themselves to contact point for the canines, the canines, premolars and molars from con-
tact point to contact point helps establish the
and the buccal segments will articulate properly. premolars and molars (Figure 6). O-G positioning reference.
Placing brackets relative to the contact points for
the canines and buccal segments and then using the Maxillary anteriors (Figure 7). Since the maxillary
slot of the maxillary canine bracket as the reference canine is the transition from the anterior to the
for placing the incisor brackets creates a sweeping posterior segment and
smile arc that is considered the hallmark of a establishes the sweep PITTS TRADITIONAL

pleasing dental appearance. for the smile arc, I

plan positioning for
Symmetrical gingival margins are an esthetic must the entire arch by first
for the six maxillary anterior teeth. With the use determining the posi-
of lasers and crown-lengthening procedures, it has tion for this bracket.
become easier for me to make the gingival heights In terms of occluso- Figure 7. Maxillary Bracket Positioning – Anteriors
symmetrical. The remainder of the article outlines gingival (O-G) M-D: Align bracket scribe line with crown-long axis at height of
contour. Must view from incisal or placement will appear too
the general guidelines I follow for placing brackets, placement of the mesial.
although there will be case-specific situations where maxillary canine, O-G: Position incisal edge of canine bracket wings at M-D contact line
with slots of lateral and central incisor brackets sequentially more
I will deviate from them. I have learned that gingival than slot of canine bracket.
the incisal edge of the
My 40-year study of bracket placement has led me to canine bracket wings need to be placed on a line
place brackets relatively more gingivally than most drawn from the mesial to the distal contact at the
practitioners. Even though my placement approach height of contour interproximally. I refer to this line
often results in positioning brackets near or under as the mesiodistal (M-D) contact line.
tissue on premolars and molars (which is the major
obstacle to my adopting indirect bonding), I rarely The O-G positioning for the maxillary central and
see labial/gingival decalcification on these teeth. lateral incisor brackets uses the canine bracket as
Figure 5 is a case example that demonstrates my the reference point, with the slot of the central
positioning approach. incisor bracket slightly more gingival (approximately
0.5 mm) than the slot of the canine bracket
A difficulty that I see many clinicians have is the (as measured from the recontoured tip) and
height transition from the first molar to second the slot of the lateral incisor bracket slightly
premolar and from the first premolar to the canine. more incisal than the central incisor bracket
(approximately 0.25 mm). Placing brackets
too incisally works against the smile arc and
hinders torque control.

The most common M-D placement error Figure 8. The most common M-D
placement error is positioning
clinicians make in the anteriors is positioning brackets too distally on the lateral
incisors and canines in both arches.
the brackets too distally, especially on the lat-
eral incisors and canines, both maxillary and
Figure 5. My O-G bracket positioning is slightly gingival to
conventional placement on both arches. mandibular (Figure 8). Magnification through

7
 correct placement,
the first premolar
bracket will appear
distal to the height
of contour; the
second premolar
Occlusogingival reference points are best bracket will at
seen from the incisal/occlusal aspect aided
by the use of a 2-inch large-front-surface times appear Figure 10. The most common placement
mirror.
mesial to the error on the maxillary premolars is plac-
ing the bracket too mesially. Note that
height of contour. the canine bracket was not placed
mesially enough.
The use of a two-inch, large-front-surface mirror offers a clear view of the occlusal The occlusal edge
surface of each tooth and allows me to place the brackets more accurately because of the bracket
the M-D reference points are best seen from this angle, particularly in the pre- wings should fall at the M-D contact line.
molar, canine and anterior regions. Using the large-front-surface mirror makes
it easier to keep the occlusal part of the pad touching evenly on the labial and Maxillary molars (Figure 11). Ormco makes M-D
buccal surfaces of the teeth. positioning of first molar tubes simple because it
manufactures this bracket pad with a buccal tip
loupes and the use of a large-front-surface mirror at that fits naturally into the buccal groove of the
bonding alleviates such errors and greatly enhances tooth. The mesial aspect of the bracket should be
finishing ease. in the middle of the mesiobuccal cusp. For accurate
cusp height transition from the first molar to the
My study has clearly shown me that the position of second premolar, I keep the occlusal edge of the first
the height of contour looks different when viewed molar tube pad on the M-D contact line.
from the incisal/occlusal aspect via the large mirror
PITTS
than when seeing it from the facial aspect. From the
facial aspect, it seems as if I place anterior brackets
mesial to the crown-long axis at the height of
contour but when viewed from the incisal/occlusal
aspect via the large mirror, the scribe line is actually
aligned with the crown-long axis at the height of Figure 11. Maxillary Bracket Positioning – 1st Molar
contour. M-D: Center buccal tip of tube pad over buccal groove of tooth.

OG: Position occlusal edge of tube pad at M-D contact line.

Maxillary premolars (Figure 9). Using the large-
Maxillary Bracket Positioning – 2nd Molar
front-surface mirror, I align the scribe line of the M-D: Center buccal tube pad over buccal groove of tooth.
maxillary first and second premolar brackets with O-G: Position occlusal edge of tube pad 1.5 mm more occlusally than
the crown-long axis at the height of contour, para- 1st molar tube.

lleling the central groove and the M-D buccal line

angle. Placing the maxillary first premolar bracket The M-D positioning for the maxillary second molar
too mesially is easy to tube is the same as the first molar tube. In terms of
PITTS TRADITIONAL O-G positioning, I place this bracket approximately
do (specifically if you
are making the place- 1.5 mm more occlusally than the maxillary first
ment from the buccal molar bracket. This positioning and the -27º torque
aspect) and a common keeps roots buccally inclined and lifts lingual cusps
mistake (Figure 10). to keep them from interfering with mandibular
Such placement causes molars. A high percentage of maxillary second
Figure 9. Maxillary Bracket Positioning – Premolars rotations and throws molars need palatal cusp recontouring later in treat-
M-D: Align bracket scribe line with crown-long axis at height of off the buccal occlu- ment because the mesial inclines of these cusps are
contour. Must view from occlusal. If viewed from buccal, 1st pre-
molar placement will appear too distal; 2nd premolar too mesial. sion. Viewed from the major contributors to tooth interference.
O-G: Position occlusal edge of bracket wings at the M-D contact line. buccal aspect after

8 ci VOL 17 • NO 1 • 2009
 DEEP BITE OPEN BITE Figure 12. Mandibular PITTS TRADITIONAL
Bracket Positioning –
Incisors
M-D: Align bracket
scribe line with crown-
long axis at height of
contour. Must view
from incisal or place-
ment will apear too
mesial.

O-G: Deep Bite – Position Figure 14. Mandibular Bracket Positioning – 1st/2nd Premolars.
top of slot 3.5 from incisal M-D: Align bracket scribe line with crown-long axis at height
edge. of contour.

O-G: Open Bite – Position O-G: Position occlusal edges of bracket wings .5 mm gingivally to
top of slot 5 mm from M-D contact line.
incisal edge.

Mandibular incisors (Figure 12). For the best M-D buccal segments and occlusion. For the best M-D
positioning of the mandibular incisors, I align the positioning, I align the scribe line of the mandibular
bracket scribe line with the crown-long axis at the canine bracket with the crown-long axis at the height
height of contour while viewing the teeth from the of contour, again while viewing the tooth from the
incisal aspect using the large-front-surface mirror. incisal aspect. From long study, I’ve determined that
The O-G positioning of the mandibular incisors the best O-G position for the mandibular canine
depends on the vertical relationship of the bite. bracket is to place the incisal edge of the bracket
For a deep bite, I place the bracket so that the top wings on the M-D contact line.
of its slot is fairly incisally positioned, approximately
3.5 mm from the incisal edge of the tooth with the Mandibular premolars (Figure 14). For the best
maxillary anterior bite turbos already in place. On M-D positioning of the mandibular first and second
the mandibular arch, I like to over-level deep bites premolar brackets, I align the scribe line of each
to a reverse curve of Spee. Early light elastics, which bracket with the crown-long axis at the height of
I’ll discuss later in the article, accelerate bite opening contour (viewing the tooth from the occlusal aspect
and increase the vertical dimension by erupting the via the large mirror). I position the occlusal edge
buccal segments. For an open bite, I place each of the bracket wings 0.5 mm gingival to the M-D
mandibular incisor bracket so that the top of its slot contact line.
is fairly gingivally positioned, approximately 5 mm
from the incisal edge of the tooth. For me, open bites Mandibular molars (Figure 15/16). I position the
require some curve of Spee. first and second molar tubes the same way. For the
best M-D positioning, I center the buccal groove of
Mandibular canines (Figure 13). Like its counter- the molar tube over the buccal groove of the tooth.
part in the maxilla, the mandibular canine is the key Occlusogingivally, I position the occlusal edge of
to my positioning approach for the mandibular the bracket molar pads 0.5 mm gingivally to the

PITTS PITTS

Figure 15. Mandibular Bracket Positioning –

Figure 13. Mandibular Bracket Positioning – Canines 1st/2nd Molars
M-D: Align bracket scribe line with crown-long axis M-D: Center buccal tip of tube pad over buccal groove
at height of contour. Must view from incisal or of tooth.
placement will apear too mesial.
O-G: Position occlusal edge of tube pad .5 mm gingivally to
O-G: Position incisal edges of wings at the M-D contact line. M-D contact line.

9
 M-D contact line. In contrast to the maxillary
molars, I place the mandibular first and second
molar bracket at the same height occlusogingivally.

Bracket Repositioning More Efficient

than Bending Wires
In my experience, having to place excessive wire
bends is not the fault of the orthodontic appliance
design; it’s inappropriate bracket positioning.
Because of malposed teeth (or an off day), it isn’t Figure 16.The best M-D positioning for the lower
molars is to center the buccal tip of the molar tube
always possible to position each bracket accurately over the buccal groove of the tooth.
at the initial bonding, but unless I reposition certain
brackets, I will need to make compensating wire
bends later in treatment, which introduces response to the Damon System/early elastics proto-
preventable uncertainty. col that I now start light elastics (never more than
2 oz. to start) at the bonding appointment on most
of my cases to accelerate treatment time and enhance
treatment quality (Case 1). Their use allows me to
I keep repositioning trays at each chair at all times so that
progress gently in cases requiring Class II (full), Class
I’ll be more likely to rebond a misplaced bracket rather than
III, deep bite, open bite and even crossbite elastics.
relying on time-consuming wire bending that can extend treat-
ment time.
Because teeth are being erupted/intruded in the
proper direction, early light elastics allow slight A-P
correction concurrent with arch leveling. In deep
For me, failing to reposition brackets and relying bites, the general rule of thumb is to keep the elastics
excessively on wire adjustments is inefficient. Many more posteriorally positioned in the buccal seg-
clinicians estimate that repositioning brackets saves ments; in open bites, more anteriorally positioned.
an average of six months of treatment time. To oper- This protocol allows me to enhance enamel display
ate efficiently, I have 25 trays set up and kept within upon smiling by changing the vertical dimension
easy access to every chair for these rebondings. Prior rather than by simply intruding upper anterior teeth.
to removing the original bonds, I have the patient No adverse effects have been noted with using these
stand up and smile so I can visualize where I want early light elastics in my practice. With them, I now
the teeth to be positioned and then I measure where can control vertical and A-P correction much more
the brackets had been positioned so I can reposition efficiently and esthetically. Being able to control the
them appropriately. I recontour teeth as needed. vertical dimension further enhances the opportunity
to produce an esthetically pleasing smile arc.
Early Light Elastics Begin Correction
Concurrent with Arch Leveling to Because light elastics break easily and full-time wear
Protect the Smile Arc is critical to success, I always recommend that
The underlying principle of the Damon philosophy patients carry a supply with them wherever they go.
is maintaining effective forces in large passive Patients will not be comfortable with early elastics
lumens throughout all phases of treatment for wear for a few days. Those with deep bites who have
optimum tooth movement. I have long been uncom- disarticulation buttons placed on their anterior
fortable with the heavy forces to which I used to teeth will not be able to chew on their molars for
subject patients when beginning A-P, vertical and several weeks and will need a diet of softer foods
transverse correction with elastics after leveling the in small bite sizes until their back teeth touch.
arch. Several years ago I began using light elastics I recognize that patients are much more motivated
beginning at the bonding appointment on deep-bite to comply with such protocols early in treatment
cases in order to extrude posterior teeth in the pro- and this fact has certainly contributed to my success
per direction. I was so taken aback by the wonderful in this regard. Mentioning to patients that full-time

10 ci VOL 17 • NO 1 • 2009
wear can save many months of treatment has also proven to be an buccal cusps, marginal ridges and contact points to align called
effective motivational tool. for a new positioning protocol—one based on the guidelines I’ve
outlined in this article. As I mentioned previously, I truly enjoy
Dr. Stuart Frost of Mesa, Arizona, and I put together several charts the artistic challenge of direct bracket placement with the Damon
that outline the basic protocol for elastics progression from the appliance and have gotten to the point where I have to reposition
early stages of treatment through finishing for the classic maloc- very few brackets to get to excellent finishes with remarkable
clusion types (visit DamonSystem.com/elastics). While there are a efficiency. I notice that my students at UOP are also getting very
myriad of ways to configure early light elastics, I find that keeping good finishes without an appreciable number of rebonds. If we are
the length the same while progressing in weight is the simplest to walk our talk of excellence in our specialty, we must begin our
way of maintaining inventory and keeping track of their use. cases with the end of excellence in mind. ci

CONCLUSION ACKNOWLEDGMENT: I'd like to give special thanks to my asso-

I realize that my bracket placement protocols are quite different ciate, Dr. Mark Handelin, for taking photographs and pulling the
from traditional placement and will take study, but having put records and other images for this article.
many years into analyzing my case results and those of my
partners and students at University of the Pacific, I have come
1
Idea from Dr. Louis Anderson, Katy, TX
to realize that protecting or enhancing the smile arc and getting 2
Dr. Mike Steffen, Edmond, OK

CASE 1 – Early Light Elastics.

Dr. Tom Pitts

Pretreatment

Initial Bonding: Early light elastics

and bite planes

11 Weeks: Class II Canine and

5 mm overjet

11
 CASE 2 – Pitts Bracket Placement with the Damon
System Appliance. No Early Light Elastics.
Dr. Tom Pitts

Pretreatment Diagnosis 28 Months: Treatment Complete (records

Class I mesofacial female, age 27 years 1 month, taken 1 week before debonding)
presented with severe crowding, mucogingival Note the change in incisor inclination.
issues and functionally exhibiting a minor
CR/CO slide. Posttreatment
Achieved all goals for functional occlusion (manip-
Facial/Soft Tissue/Macroesthetics1: Flat profile, ulated to coincident CR/CO) and enhanced anti-
deep labial furrows and thin lips with slightly aging facial and smile esthetics. Accomplished
recessive upper lip. Well-proportioned chin-to- proper tooth inclinations and enhanced smile arc
nasolabial relationship but minimal vermillion and enamel display, diminished labial furrows and
display. improved vermillion curl, incisal display and lip
fullness. Vertical, transverse and A-P changes were
Smile/Miniesthetics1: Asymmetric smile with low all positive. Microesthetic analysis reveals muco-
commissure on the right, adequate incisal display gingival enhancement, greater contact connectors
and smile arc, good upper midline position but and an esthetically pleasing emergence profile.
severe crowding, narrow arches and large buccal Delivered fixed retainers U/L and removable
corridors. retainers (.040 slipcovers) for nighttime wear.
Looking back, I would have liked more lingual
Teeth/Microesthetics1: Satisfactory tooth shade crown torque and distal root tip on UR2.
and shape. Gingival shape shows forward root
position and labiogingival recession on U/L3s & Case Discussion
LL1. Incisors bell-shaped with minimal connector This patient’s result not only demonstrates my
areas for contacts. Lower midline shifted 5 mm to years of bracket placement analysis, it also exempli-
left. U2s in lingual crossbite with dilacerated LR5 fies a paradigm shift in orthodontic treatment that
root tip. mandates enhanced facial esthetics as well
as a beautiful smile and functional occlusion.
Treatment Plan (Including Anti-Aging Specifically, esthetic facial standards now favor
Goals) greater lip projection, lip curl and vermillion
Treat nonextraction (except for 3rd molars) to display. Such contemporary esthetic orthodontic
achieve functional occlusion and enhanced facial finishing is made possible by the proper placement
and smile esthetics. Employ passive self-ligation of passive self-ligation that offers low-friction slid-
(Damon3/D3MX), developing arches slowly to ing mechanics, which when combined with proper
relieve crowding. With proper torques and bracket bracket placement and variable torques, deliver
positioning, counteract proclination of the buccal what patients want. This patient says she feels that
segments and anteriors, the latter to protect the she looks years younger and I have not been able
smile arc. (Invert STD torque on upper incisors to achieve such esthetic goals with any other
with +12º becoming -12º for 1s; +8º becoming methodology.
-8º for 2s. Use low torque on L3-3.) Minimize
exacerbation of labiogingival recession. Idealize
1
occlusion to enhance Macro-, Mini-, and Micro- Sarver, D. Soft-tissue based diagnostics and treatment planning.
Clinical Impressions, Vol 14, No 1, 2006: 21-26
esthetics; i.e., minimize buccal corridors and
protect smile arc and incisal display, add lip
fullness with more vermillion curl and reduce
depth of labial furrows.

17 Months: Differential Torque

Continues to Work
Of particular note is that at 17 months, incisors are
still proclined, but allowing the differential torques
and prescribed Damon wire sequence time to work
out will foster proper lingual incisor inclination as
the arch continues to develop.

12 ci VOL 17 • NO 1 • 2009
Pretreatment

17 Months: Differential Torque Continues to Work

28 Months: Treatment Complete (records taken 1 week before debonding)

Posttreatment

13