It’s perfectly natural to want your smile to look good with braces on. Your smile will be affected by the type of braces you’re getting, and even their position on your teeth. Perhaps you’ve had braces before, or your friends did, but yours are placed unusually high on your incisors, close to the gumline. Is that normal?
Orthodontists sometimes place brackets very high on the upper teeth intentionally, following a technique called “smile arc protection” or SAP. Braces may be placed high on the teeth because of tooth size, tooth wear, tooth position or open bite, depending on the patient’s individual needs.
Bracket positioning depends entirely on what the orthodontist is trying to achieve, but it does follow some trends and techniques that we’ll share in this article. So if your bracket placement doesn’t seem quite natural to you, perhaps we can ease your mind.
How orthodontists usually position brackets
Placing brackets in their correct positions is crucial for getting a good bite and an esthetic smile line. For a long time, the center of the tooth was the ideal area to place a bracket. But finding the center is relative because the tooth has to be measured from its tip or incisal edge to the gum, and that’s not always possible:
- the tooth could be incompletely erupted (still stuck in the bone);
- the tooth could have overgrown gums which make it appear shorter;
- the tooth may have signs of wearing or it could be chipped;
- some teeth can be disproportionately large, while others are very small.
In order to get the best results, many orthodontists now use a different method called “The MBT Versatile+ Appliance System Bracket Placement Chart.” This chart is a result of years of studies and thousands of measurements, and it’s very useful because instead of finding the center of the tooth, we measure the bracket’s position from the tooth’s edge.
How this technique works:
- the orthodontist measures all the patient’s teeth on the dental cast and chooses an average;
- based on that average, the orthodontist positions the brackets at the correct vertical height using a tool called a gauge;
- toward the end of the treatment, certain brackets are repositioned to fine-tune the treatment results.
Naturally, with every rule come exceptions, and as doctors, we use our better judgment in certain situations that require different positioning. Teeth with extended wear or odd shapes and sizes will not be treated the same as normal teeth when it comes to bracket positioning.
Even groups of teeth can be excepted from the rules. For example, if a patient has an open bite that’s about to be corrected dentally with braces, the orthodontist will intentionally place the brackets closer to the gumlines on both the upper and lower incisors. This, coupled with up-and-down elastics, will force the incisors to come closer together.
Nowadays, we have dental scanners and computer programs helping us with ultra-precise bracket positioning. The appointments go smoother and faster, too, but the orthodontist is still responsible for treatment planning and choosing the correct bracket positioning method.
‘Smile arc protection’ technique
If your brackets are all the way up in your gumline, and not just higher than average, then that’s a different technique called SAP – or Smile Arc Protection. It doesn’t have that many users around the world, so that’s why it may look odd to you. But if it’s your orthodontist’s preference, you should trust that they know what they’re doing.
“Smile Arc Protection” is an orthodontic treatment philosophy that’s looking to align the upper front teeth edges so that they closely follow the contour of the lower lip. This esthetic preference comes as a reaction to many post-braces smiles that are left flat, with insufficient tooth display.
While it sounds great in theory, SAP positioning is not a “one-size-fits-all” approach. Using conventional brackets in an unconventional position should only be done in certain situations, because it may affect the bite, the teeth’s inclination and even the gums’ health.
Let’s explore the advantages and disadvantages of placing brackets so high near the gumline:
SAP bracket positioning advantages:
- It leads to a more natural, youthful look, with better tooth-gum-lip esthetic proportions;
- It’s perfect for cases with insufficient incisal display, when teeth aren’t showing from underneath the lips;
SAP bracket positioning disadvantages:
- SAP can lead to a smile that’s too gummy and unpleasant for the patient;
- As the upper incisors are brought down, the lower incisors must also be intruded (lowered into the bone). This is an invasive movement and miniscrews are often needed.
- Since the brackets are placed so high, flashes of composite from the bracket pad could flow toward the gums, irritating the gums and causing them to grow over braces.
- SAP affects the bite and can’t be universally recommended.
It is my opinion that since the SAP technique is not widely practiced, its implications on oral health aren’t that well studied. SAP bracket positioning may work well in the hands of a skilled orthodontist that knows how to counteract the effects of conventional brackets, but there is a learning curve to it.
While getting a flat smile after braces can feel like a failure, it’s not always possible to achieve a smile that follows the lower lip, and often orthodontists need to settle for a compromise between esthetics and function.
The smile arc will depend on the patient’s own skeletal pattern, lip size and tonicity, tooth size, and bite – all things that are very much interconnected. So when it’s possible to create a beautiful, youthful arc, that’s great. But otherwise, the health of the bite, TMJ structures, teeth, and gums should dictate the treatment.
If you’re still not convinced that your orthodontist is doing the right thing by placing your upper braces so high, it’s always better to express your concerns. I’m sure your orthodontist will be more than happy to explain his or her technique, and even show you pictures of similar cases they’ve treated.
And if your brackets stay placed that high up the entire treatment, be extra careful with your oral hygiene to avoid gingivitis. Once the gums swell, it’s really difficult to get the swelling to go down. I wrote this extensive article on gums growing over braces to help prevent it from happening to you.