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• W2084202197 abstract "Although the self-ligating edgewise bracket was introduced to orthodontists 75 years ago, recent advances in bracket technology have resulted in a number of new self-ligating bracket “systems” and greater interest in their use. Much of this interest is in response to information comparing the benefits of self-ligating systems with conventional edgewise brackets. Often, this information comes from marketing materials and nonrefereed sources claiming that self-ligating bracket systems provide superior treatment efficiency and efficacy. In response to and in support of these claims, there have been numerous articles in refereed journals. Adherence to the tenets of evidence-based orthodontic practice requires that, for any orthodontic intervention applied to a patient, 3 factors must be integrated: the relevant scientific evidence, the clinician's expertise, and the patient's needs and preferences. On the topic of self-ligating bracket systems, the current challenge for the clinician is to assess the merit of the assertions supporting the superiority of self-ligating brackets. Meeting this challenge requires knowledge of the strength of the evidence of these claims. The American Association of Orthodontists' Council on Scientific Affairs (COSA) looked at this topic from this viewpoint. Specifically, COSA asked: what is the strength of the research evidence to support claims that self-ligating systems are superior to conventional brackets? For the most noteworthy claims, the answers to this question are given below. Does lateral expansion of the dental arch by self-ligating brackets “grow” buccal alveolar bone?This claim is weakly supported by low-level evidence that has not been independently confirmed. Currently, no peer-reviewed scientific evidence supports this claim. The evidence in support of this assertion comes from a few case reports providing weak evidence that should be interpreted with caution.1Damon D.H. Treatment of the face with biocompatible orthodontics.in: Graber T.M. Varnarsdall R.L. Vig K.W. Orthodontics, current principles and techniques. Elsevier Mosby, St Louis2005Google Scholar Evidence that does not corroborate this assertion, found in a thesis2Paventy A. Facial alveolar bone evaluation with cone beam computed tomography in non extraction treatment using the Damon system: a prospective clinical trial [thesis]. University of Oklahoma, Norman, Okla2008Google Scholar and an abstract,3Cevidanes L, Treccani M, Myrda A, Melsen B. Transversal expansion and self-ligating brackets: a CBCT study. Book of abstracts of the 109th Annual Session of the AAO; 2009 May 1-5; Boston, Mass. Available at: http://www.aaomembers.org/mtgs/annual/2009/upload/AS09_Book-of-Abstracts.pdf. Accessed on September 1, 2009.Google Scholar also provide only weak evidence that should be interpreted with caution. Is lateral expansion of the dental arch by self-ligating bracket systems comparable with lateral expansion gained by rapid maxillary expansion (RME) followed by conventional edgewise treatment?This claim is weakly supported by low-level evidence that has not been independently confirmed. Currently, no peer-reviewed scientific evidence supports this claim. The evidence supporting this claim comes from a thesis and should be interpreted with caution until it is independently confirmed by peer-reviewed data.4Mikulencak M. A comparision of maxillary arch width and molar tipping changes between rapid maxillary expansion and fixed appliance vs the Damon system [thesis]. St Louis University, St Louis2007Google Scholar No peer-reviewed studies were found in the literature comparing lateral dental-arch expansion between self-ligating bracket systems and conventional edgewise bracket systems with or without RME. Is lateral expansion of the dental arch gained by self-ligating bracket systems stable in the long term?This claim is weakly supported by low-level evidence that has not been independently confirmed. Currently, there is no peer-reviewed scientific evidence that lateral expansion of the dental arch with a self-ligating bracket system has long-term stability. A few case reports have evaluated the long-term stability of lateral dental arch expansion with self-ligating systems.1Damon D.H. Treatment of the face with biocompatible orthodontics.in: Graber T.M. Varnarsdall R.L. Vig K.W. Orthodontics, current principles and techniques. Elsevier Mosby, St Louis2005Google Scholar These case reports provide only low-level evidence, and their findings should be interpreted with caution until they are independently confirmed by peer-reviewed data. In contrast, the long-term stability of RME has been evaluated by a systematic review of clinical trials.5Marshall S.D. English J.D. Huang G.J. Messersmith M.L. Nah H.D. Riolo M.L. et al.Long-term stability of maxillary expansion.Am J Orthod Dentofacial Orthop. 2008; 133: 780-781Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Residual expansion at 1 year postretention from treatment with RME and fixed appliances measured as intermolar width is approximately 4 mm.5Marshall S.D. English J.D. Huang G.J. Messersmith M.L. Nah H.D. Riolo M.L. et al.Long-term stability of maxillary expansion.Am J Orthod Dentofacial Orthop. 2008; 133: 780-781Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Are self-ligating bracket systems more efficient and more effective than conventional edgewise bracket systems in treating malocclusions?Current evidence does not support the assertion that self-ligating bracket systems are more efficient or more effective in treating malocclusions.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar, 7Fleming P.S. Johal A. Self-ligating brackets in orthodontics. A systematic review.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar Data from a few studies do indicate that chair time is, on average, 20 seconds less per arch, and final mandibular incisor inclination is, on average, 1.5° less for self-ligating bracket systems.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar Current evidence does not indicate differences between self-ligating systems and conventional systems for treatment time, rate of alignment, rate of space closure, final arch dimensions, or occlusal outcomes. This question was evaluated in a recent systematic review of clinical studies (in-vivo studies) comparing the 2 bracket systems.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar Treatment efficiency was determined by the treatment outcomes: total treatment time, rate of mandibular incisor alignment, rate of en-masse space closure, chair time, and bracket failure rate. Treatment effectiveness was determined by the treatment outcomes: occlusal indexes, arch dimensions, and mandibular incisor inclinations after incisor alignment or at the end of treatment. Fifteen studies met the inclusion criteria for this systematic review. Six of the outcomes—total treatment time, rate of mandibular incisor alignment, rate of en-masse space closure, bracket failure rate, occlusal indexes, and arch dimensions—were not significantly different between the 2 bracket systems.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar Only 2 outcomes, chair time and final mandibular incisor alignment, showed significant differences. Chair time was more efficient with self-ligating bracket systems because it took 20 seconds less per arch to open self-ligating slides compared with removing elastomeric ligatures. In a meta-analysis of data from 3 studies, mandibular incisor inclination was found to be 1.5° less for self-ligating bracket systems compared with conventional edgewise treatment.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar Do self-ligating bracket systems provide less friction between archwire and bracket?The evidence for less friction between archwire and self-ligating brackets presently comes from results found under specific laboratory conditions, which do not fully emulate a clinical setting. In-depth understanding of friction between bracket and archwire in vivo, and its relationship to tooth movement, remains uncertain. Reduced friction between bracket and archwire is the key to a number of assertions regarding self-ligating brackets. Proponents insist that reduced friction is coupled with lower, more physiologically harmonious forces during tooth alignment that promote alveolar bone generation and allow for greater lateral expansion of the dental arch—similar to lateral expansion seen with RME.1Damon D.H. Treatment of the face with biocompatible orthodontics.in: Graber T.M. Varnarsdall R.L. Vig K.W. Orthodontics, current principles and techniques. Elsevier Mosby, St Louis2005Google Scholar Greater lateral expansion, in turn, minimizes unwanted incisor proclination during nonextraction treatment of crowding and lessens the need for extraction treatment.1Damon D.H. Treatment of the face with biocompatible orthodontics.in: Graber T.M. Varnarsdall R.L. Vig K.W. Orthodontics, current principles and techniques. Elsevier Mosby, St Louis2005Google Scholar Also, the lower clinical force from reduced bracket-archwire friction is claimed to reduce orthodontic treatment pain.8Damon D.H. The Damon low-friction bracket: a biologically compatible straight-wire system.J Clin Orthod. 1998; 22: 670-680Google Scholar Low friction is also presumed to be responsible for faster tooth movement—thus, shorter treatment time.8Damon D.H. The Damon low-friction bracket: a biologically compatible straight-wire system.J Clin Orthod. 1998; 22: 670-680Google Scholar Is there evidence for reduced friction in self-ligating bracket systems? In a review of the literature, no in-vivo studies evaluating friction between bracket and archwire were found. To date, some in-vitro studies have addressed the question of friction and were recently evaluated in a systematic review.9Ehsani S. Mandich M.A. El-Bialy T.H. Flores-Mir C. Frictional resistance in self-ligating orthodontic brackets and conventionally ligated brackets: a systematic review.Angle Orthod. 2009; 79: 592-601PubMed Google Scholar Under selected laboratory conditions where bracket slots are aligned parallel with the archwire, small-diameter round wires slide more freely through self-ligating brackets than conventional edgewise brackets ligated with steel or elastomeric ties. However, the surface contact between bracket, ligation instrument, and archwire is only 1 factor that opposes the motion of a bracket along an archwire in vivo. When force is applied (at the level of the bracket) between teeth fitted with an edgewise appliance in vivo, the biologic response of the alveolar bone produces tooth (and thus bracket) tipping. This, in turn, causes friction from a separate bracket—archwire interaction, termed binding, which has not been accounted for in most in-vitro experiments. When measurement of binding between archwire and bracket is part of an in-vitro experimental design, the results suggest that self-ligating brackets and conventional brackets behave similarly.10Burrow S.J. Friction and resistance to sliding in orthodontics: a critical review.Am J Orthod Dentofacial Orthop. 2009; 135: 442-447Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar That is to say, under the conditions where tooth tipping is emulated in vitro, conventional and self-ligating brackets are not different in their resistance to sliding along an archwire.10Burrow S.J. Friction and resistance to sliding in orthodontics: a critical review.Am J Orthod Dentofacial Orthop. 2009; 135: 442-447Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Moreover, additional oral environmental variables, including forces of mastication, degree of malocclusion, host response of the periodontal ligament and alveolar bone, bracket slot angulation and dimension, interbracket distance, temperature, and moisture that cannot be adequately duplicated in vitro, make any laboratory experiment difficult to extrapolate to the clinical setting.9Ehsani S. Mandich M.A. El-Bialy T.H. Flores-Mir C. Frictional resistance in self-ligating orthodontic brackets and conventionally ligated brackets: a systematic review.Angle Orthod. 2009; 79: 592-601PubMed Google Scholar At this time, the exact role of frictional forces opposing motion of a bracket along an archwire in vivo is not clear, and the relationship between bracket-archwire friction and tooth movement remains to be elucidated. Do self-ligating bracket systems provide lower clinical forces compared with conventional brackets?At present, no studies have measured the forces in vivo to answer this question. Two in-vitro studies suggest that initial forces on buccally or lingually displaced teeth might be greater in self-ligating systems compared with conventional brackets.11Petersen A. Rosenstein S. Kim K.B. Israel H. Force decay of elastomeric ligatures: influence on unloading force compared to self-ligation.Angle Orthod. 2009; 79: 934-938Crossref PubMed Scopus (20) Google Scholar, 12Franchi L. Baccetti T. Camporesi M. Giuntini V. Forces released by nonconventional bracket or ligature systems during alignment of buccally displaced teeth.Am J Orthod Dentofacial Orthop. 2009; 136 (e1-6): 316Abstract Full Text Full Text PDF PubMed Google Scholar This evidence is considered preliminary and should be interpreted with prudence until it is independently confirmed. Do patients treated with self-ligating bracket systems experience less pain during treatment?At this time, there is insufficient data that compare self-ligating bracket systems and conventional bracket systems with regard to the pain experienced by patients during orthodontic treatment. Three clinical trials (1 prospective cohort split-mouth design, 2 randomized clinical trials) compared the pain felt by patients treated with self-ligating brackets and conventional brackets.13Miles P.G. Weyant R.J. Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment.Angle Orthod. 2006; 76: 480-485PubMed Google Scholar, 14Pringle A.M. Petrie A. Cunningham S.J. McKnight M. Prospective randomized clinical trial to compare pain levels associated with 2 orthodontic fixed bracket systems.Am J Orthod Dentofacial Orthop. 2009; 136: 160-167Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 15Scott P. Sherriff M. DiBiase A.T. Cobourne M.T. Perception of discomfort during initial orthodontic tooth alignment using self-ligation or conventional bracket system: a randomized clinical trial.Eur J Orthod. 2008; 30: 227-232Crossref PubMed Scopus (74) Google Scholar These studies showed variations in the subjective pain experience measured within the first 8 days after tying in the initial 0.014-in diameter copper-nickel-titanium archwire (self-ligating brackets significantly less painful,13Miles P.G. Weyant R.J. Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment.Angle Orthod. 2006; 76: 480-485PubMed Google Scholar nonsignificant tendency to be less painful,14Pringle A.M. Petrie A. Cunningham S.J. McKnight M. Prospective randomized clinical trial to compare pain levels associated with 2 orthodontic fixed bracket systems.Am J Orthod Dentofacial Orthop. 2009; 136: 160-167Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar or no pain difference compared with conventional brackets15Scott P. Sherriff M. DiBiase A.T. Cobourne M.T. Perception of discomfort during initial orthodontic tooth alignment using self-ligation or conventional bracket system: a randomized clinical trial.Eur J Orthod. 2008; 30: 227-232Crossref PubMed Scopus (74) Google Scholar). When tying in the second archwire (0.016 × 0.025-in diameter copper-nickel-titanium), a study reported that patients with self-ligating brackets experienced greater pain than those with conventional brackets.13Miles P.G. Weyant R.J. Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment.Angle Orthod. 2006; 76: 480-485PubMed Google Scholar These results should be interpreted with caution because of potential study bias. The prospective cohort study13Miles P.G. Weyant R.J. Rustveld L. A clinical trial of Damon 2 vs conventional twin brackets during initial alignment.Angle Orthod. 2006; 76: 480-485PubMed Google Scholar is considered to have a moderate to high risk of bias because it lacks sample size calculation, adjustment for confounders, and assessor blinding.6Chen S.S. Greenlee G.M. Kim J.E. Smith C.L. Huang G.J. Systematic review on self-ligating brackets.Am J Orthod Dentofacial Orthop. 2010; 137: 726.e1-726.e8Abstract Full Text Full Text PDF Scopus (126) Google Scholar, 7Fleming P.S. Johal A. Self-ligating brackets in orthodontics. A systematic review.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar The randomized trial14Pringle A.M. Petrie A. Cunningham S.J. McKnight M. Prospective randomized clinical trial to compare pain levels associated with 2 orthodontic fixed bracket systems.Am J Orthod Dentofacial Orthop. 2009; 136: 160-167Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar also has a moderate risk of bias. Although bracket type was allocated to patients randomly, “clinician and patient blinding of the bracket type was impossible.”14Pringle A.M. Petrie A. Cunningham S.J. McKnight M. Prospective randomized clinical trial to compare pain levels associated with 2 orthodontic fixed bracket systems.Am J Orthod Dentofacial Orthop. 2009; 136: 160-167Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar A recent systematic review of these and other studies comparing subjective pain experience for treatment with conventional brackets or self-ligating brackets found that neither system has an advantage in the first week after appliance placement.7Fleming P.S. Johal A. Self-ligating brackets in orthodontics. A systematic review.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar At this time, additional studies are needed to fairly and fully answer this claim. Are conventional edgewise brackets less hygienic than self-ligating brackets?Evidence does not support the claim that conventional edgewise brackets are less hygienic than self-ligating brackets. Some published reports suggested that elastomeric ligation of brackets is associated with increased plaque retention and aggravation of clinical periodontal health during orthodontic treatment.16Forsberg C.M. Brattstrom V. Malmberg E. Nord E. Ligature wires and elastomeric rings: two methods of ligation, and their association with microbial colonization of streptococcus mutans and lactobacilli.Eur J Orthod. 1991; 13: 416-420Crossref PubMed Scopus (110) Google Scholar, 17Sukontapatipark W. el-Agroudi M.A. Selliseth N.J. Thunold K. Selvig K.A. Bacterial colonization associated with fixed orthodontic appliances. A scanning electron microscopy study.Eur J Orthod. 2001; 23: 475-484Crossref PubMed Scopus (176) Google Scholar, 18de Souza R.A. de Ararujo Magnani M.B.B. Nouer D.F. da Silva C.O. Klein M.I. Sallum E.A. et al.Periodontal and microbiologic evaluation of 2 methods of archwire ligation: ligature wires and elastomeric rings.Am J Orthod Dentofacial Orthop. 2008; 134: 506-512Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar, 19van Gastel J. Quirynen M. Teughels W. Pauwels M. Coucke W. Carels C. Microbial adhesion on different bracket types in vitro.Angle Orthod. 2009; 79: 915-921Crossref PubMed Scopus (34) Google Scholar, 20Turkkahraman H. Sayin O. Bozkurt F.Y. Yetkin Z. Kaya S. Onal S. Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated patients.Angle Orthod. 2005; 75: 231-236PubMed Google Scholar Four trials made a direct comparison, in vivo, of conventional and self-ligating brackets on these issues.21van Gastel J. Quirynen M. Teughels W. Coucke W. Carels C. Influence of bracket design on microbial and periodontal parameters in vivo.J Clin Periodontol. 2007; 34: 423-431Crossref PubMed Scopus (54) Google Scholar, 22Pandis N. Vlachopoulos K. Polychronopoulou A. Madianos P. Eliades T. Periodontal condition of the mandibular anterior dentition in patients with conventional and self-ligating brackets.Orthod Craniofac Res. 2008; 11: 211-215Crossref PubMed Scopus (38) Google Scholar, 23Pellegrini P. Sauerwein R. Finlayson T. McLeod J. Covell D.A. Maier T. et al.Plaque retention by self-ligating vs elastomeric orthodontic brackets: quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven bioluminescence.Am J Orthod Dentofacial Orthop. 2009; 135 (e1-9): 426Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 24Pandis N. Papaioannou W. Kontou E. Nakou M. Makou M. Eliades T. Salivary streptococcus mutans in patients with conventional and self-ligating brackets.Eur J Orthod. 2010; 32: 94-99Crossref PubMed Scopus (46) Google Scholar Van Gastel et al21van Gastel J. Quirynen M. Teughels W. Coucke W. Carels C. Influence of bracket design on microbial and periodontal parameters in vivo.J Clin Periodontol. 2007; 34: 423-431Crossref PubMed Scopus (54) Google Scholar used a prospective cohort design (split-mouth technique; n = 16) to evaluate clinical periodontal parameters and the presence of anaerobic and aerobic bacteria associated with teeth bonded with conventional and self-ligating brackets over the 7 days immediately after bracket bonding. No significant differences in gingival bleeding or probe depths were noted between the cohorts. Plaque accumulation was greater on teeth bonded with self-ligating brackets, with the plaque containing more anaerobic bacteria. Pandis et al22Pandis N. Vlachopoulos K. Polychronopoulou A. Madianos P. Eliades T. Periodontal condition of the mandibular anterior dentition in patients with conventional and self-ligating brackets.Orthod Craniofac Res. 2008; 11: 211-215Crossref PubMed Scopus (38) Google Scholar used a prospective cohort design to evaluate 50 patients bonded with conventional brackets and 50 patients bonded with self-ligating brackets. The outcomes of interest were plaque, gingival, and calculus indexes, and probing depths. The 2 bracket cohorts showed no differences in these periodontal indexes after an average of 18 months of orthodontic treatment. Pellegrini et al23Pellegrini P. Sauerwein R. Finlayson T. McLeod J. Covell D.A. Maier T. et al.Plaque retention by self-ligating vs elastomeric orthodontic brackets: quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven bioluminescence.Am J Orthod Dentofacial Orthop. 2009; 135 (e1-9): 426Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar measured bacteria counts around conventional brackets and self-ligating brackets at 1 week and 5 weeks after appliance placement. Using a split-mouth experimental design (n = 14), they measured total bacteria and total oral streptococci. At 1 week, the total bacteria and total oral streptococci were greater around conventional brackets (P <0.05). However, at 5 weeks, total bacteria were not significantly different on the 2 bracket types, whereas total oral streptococci remained elevated around conventional brackets.23Pellegrini P. Sauerwein R. Finlayson T. McLeod J. Covell D.A. Maier T. et al.Plaque retention by self-ligating vs elastomeric orthodontic brackets: quantitative comparison of oral bacteria and detection with adenosine triphosphate-driven bioluminescence.Am J Orthod Dentofacial Orthop. 2009; 135 (e1-9): 426Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar In contrast, Pandis et al24Pandis N. Papaioannou W. Kontou E. Nakou M. Makou M. Eliades T. Salivary streptococcus mutans in patients with conventional and self-ligating brackets.Eur J Orthod. 2010; 32: 94-99Crossref PubMed Scopus (46) Google Scholar conducted a more recent prospective cohort study (n = 32) and failed to corroborate a difference in total bacteria when comparing conventional and self-ligating brackets at 12 weeks after appliance placement. These studies have been evaluated in a systematic review, with the conclusion that there is insufficient evidence that self-ligating brackets are more hygienic that conventional brackets.7Fleming P.S. Johal A. Self-ligating brackets in orthodontics. A systematic review.Angle Orthod. 2010; 80: 575-584Crossref PubMed Scopus (102) Google Scholar Two of the 14 most notable assertions made in support of self-ligating bracket systems— reduced chair time and control of mandibular incisor inclination—are supported by the current evidence. The evidence for 9 of the 14 claims regarding self-ligating bracket systems have some peer-reviewed data, but the evidence does not indicate clear differences at this time for reduced friction between archwire and bracket, reduced clinical forces, reduced treatment time, faster alignment, faster space closure, different arch dimensions, better alignment and occlusal outcomes, less patient pain, and more hygienic. Three of the 14 claims in support of self-ligating bracket systems—lateral expansion of the dental arch grows buccal alveolar bone, lateral expansion of the dental arch is comparable with expansion by using RME and conventional edgewise brackets, and lateral expansion of the dental arch is stable in the long term—have no supporting peer-reviewed data at this time." @default.
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