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Self-Ligating Brackets: An Overview

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DOI: 10.5772/20285 · Source: InTech

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 1

Self-Ligating Brackets: An Overview

Maen Zreaqat and Rozita Hassan
School of Dental Sciences, Universiti Sains Malaysia, Kelantan,
Malaysia

1. Introduction
The specialty of orthodontics has continued to evolve since its advent in the early 20th
century. Changes in treatment philosophy, mechanics, and appliances have helped shape
our understanding of orthodontic tooth movement. In the 1890‘s, Edward H. Angle
published his classification of malocclusion based on the occlusal relationships of the first
molars. This was a major step toward the development of orthodontics because his
classification defined normal occlusion. Angle then helped to pioneer the means to treat
malocclusions by developing new orthodontic appliances. He believed that if all of the teeth
were properly aligned, then no deviation from an ideal occlusion would exist. Angle and his
followers strongly believed in non-extraction treatment. His appliance, (Fig. 1), consisted of
a tube on each tooth to provide a horizontally positioned rectangular slot. Angle’s edgewise
appliance received its name because the archwire was inserted at a 90-degree angle to the
plane of insertion. The rectangular wire was tied into a rectangular slot with steel ligatures
(Proffit, 2000). A later shift in thought occurred when one of his pupils, Charles Tweed,
observed that some of the patients formerly treated by Angle exhibited a noticeable amount
of relapse. Tweed then re-treated a number of these cases by extracting four bicuspids to
resolve the crowding and in turn, developed his own treatment mechanics. Another shift in
orthodontics occurred when Larry Andrews introduced the straight wire appliance. Instead
of bending wires to place teeth in the proper orientation with an edgewise bracket,
Andrews‘ appliance had the angulation and torque values built into the brackets commonly
known as the appliance prescription. In theory, these pre-adjusted brackets eliminated the
need to repeatedly bend first, second, and third order bends each time the patient
progressed to the next wire. The straight wire appliance revolutionized orthodontics by
making the bracket much more efficient. Since then, many orthodontic companies have
developed their own bracket systems with specific prescriptions, treatment philosophies,
and mechanics. However, they all shared one common characteristic – ligatures must be
placed around tie wings on brackets to hold arch wires in the bracket slot.

2. Ligatures and ligation properties

Different types of ligatures have been used to hold the archwire in the bracket slot. Steel or
elastomeric ligatures have been used mainly. The steel ligatures are made of chrome-alloy
stainless steel with dimensions vary from .009” to .012” Inch in diameter and twisted with a
hand instrument. In some cases, these ligatures are coated with tooth-colored material such
4 Principles in Contemporary Orthodontics

as teflon for aesthetic reasons. Steel ligatures produce a variable effect on the
bracket/archwire junction depending on their tightness. The advantages with the steel
ligatures are that they do not deteriorate in the oral environment and they retain their shape
and strength. They also provide less retention of bacterial plaque and are easier to clean
than the elastomeric ligatures (Ridley et al., 1979). The drawbacks with steel ligatures are
that they are time-consuming and tiresome on the hand of operator (Maijer & Smith, 1990;
Shivapuja & Berger, 1994). Harradine, (2003), found that the use of wire ligatures added
almost 12 minutes to the time needed to remove and replace two archwires. They also
require careful tucking in of the ends to avoid soft tissue trauma and even then can
occasionally be displaced between appointments and cause discomfort (Schumacher et al.,
1990; Bendar & Gruendeman, 1993).

Fig. 1. Early edgewise appliance.

The introduction of elastomeric ligatures in the 1970s is also another milestone in
orthodontics which largely replaced steel ligatures. These are quicker and easier to place,
and they can be used in chains to close spaces within the arch or prevent spaces from
opening. However, conventional ligation with elastomerics fails to provide and maintain
full archwire engagement. In addition, they potentially impede good oral hygiene which is a
novel situation in orthodontics. Moreover, the physical properties of elastomeric ligatures
are imperfect. Elastic ligatures undergo permanent deformation in shape and thus force
decays with time. The force decay under constant force application to elastomeric material
showed that the greatest amount of force decay occurred during the few hours (Wong,
1976). In addition, they stain permanently shortly after being placed in the oral cavity. More
important, elastomeric ligatures have been shown to increase friction in the sliding
mechanic systems (Sims et al., 1993; Thomas et al., 1998), and increase the resistance to
movement in bracket/archwire systems by 50-175g (Echols, 1975).

2.1 Properties of an Ideal orthodontic ligation system

Regardless of the type of bracket and ligation used, there are several desirable properties for
an ideal orthodontic ligation system.
1. Secure and robust ligation
Secure , full archwire engagement maximizes the potential long range of action of modern
low modulus wires and minimizes the need to regain control of teeth where full
engagement is lost during treatment. Once a wire is ligated, it is desirable that it is resistant
Self-Ligating Brackets: An Overview 5

to inadvertent loss of ligation. Wire ligatures are good in this respect while elastic ligatures
are more easily lost. Elastic ligatures also experience significant force decay over time
(Taloumis et al., 1997).
2. Full bracket engagement
Full archwire engagement into the bracket slot is desirable to attain full expression of torque
particularly at finishing stages of treatment. Wire ligation can maintain adequate archwire
engagement between office visits. On the other hand, elastic ligatures frequently exert
insufficient force even on fairly flexible wires.
3. Quick and easy ligation
Wire ligation is a lengthy procedure and this is the main reason they are not frequently
used. Elastic ligatures are much faster to remove and replace (Türkkahraman et al., 2005)
4. Low friction
For sliding mechanics, brackets that experience low friction are the most desirable. Low
friction is important during the leveling and aligning stages of orthodontic treatment. It will
allow a more efficient force delivery, less force dissipation and thus a faster expression of
the wire. Low friction is efficient during space closure as well. Wire ligatures are superior to
brackets ligated by elastic ligatures in this respect and shown to produce only 30-50% of the
frictional forces produced by elastomerics (Shivapuja et al., 1994). Still, forces may reach
undesirable levels relative to levels considered ideal for tooth movement (Khambay et al.,
2004).
5. Improves patient comfort and hygiene
Wire ligatures can cause tissue laceration if the cut ends are exposed but they are very
hygienic. Elastic ligatures are more comfortable than wire ligatures but have the side effect
of being less hygienic.
Sliding mechanics in conventional brackets rely on filling the slot with the largest wire
possible to provide a certain degree of force control (direction and magnitude) needed to
move teeth. With enough force, teeth eventually move to the desired position. Because
archwires are held into place with either metal or elastic ligature ties, heavy forces must be
introduced into the system in order to overcome the friction created at the bracket/archwire
interface before tooth movement can occur. However, some argue that the heavy forces
generated by large sized wires and traditional ligation methods are not physiologic because
they create force systems high enough to overpower the lip, tongue, and cheek muscular.
Clinicians and manufacturers alike sought to develop a product that could replicate the time
saving properties of elastomeric modules while lessening or eliminating the friction they
caused. This eventually led to the development and popularization of selfligating brackets
because they satisfy both criteria and offer a philosophy of orthodontic treatment that
greatly differs from this classical school of thought.

3. Self-ligating brackets
3.1 Definition
Self-ligating brackets are ligatureless bracket systems that have a mechanical device built
into the bracket to close off the edgewise slot. The cap holds the archwire in the bracket slot
and replaces the steel/elastomeric ligature. With the self-ligating brackets, the moveable
fourth wall of the bracket is used to convert the slot into a tube.
6 Principles in Contemporary Orthodontics

3.2 Philosophy of self-ligating bracket proponents

Light forces are the key to self-ligation. Proponents suggest that low force, low-friction
systems allow teeth to travel to their physiologic position because they do not overpower
the musculature or compromise the periodontal tissues. Ischemia is not induced in the
surrounding periodontal tissues because the forces generated by the small dimension, high-
tech archwires are too low to completely occlude the periodontal vascular supply. Heavy
forces on teeth cause hyalinization in the periodontal ligament space which brings tooth
movement to a halt. Self-ligating brackets place enough force on the teeth to stimulate tooth
movement without completely disrupting the vascular supply and therefore, tooth
movement is more effective and physiologic. The final position of the teeth after treatment
with the self-ligating bracket systems is determined by the balanced interplay between the
oral musculature and periodontal tissues and not by heavy orthodontic forces. Moreover,
the design in passive self-ligating bracket also enables teeth to move in the path of least
resistance. When the gate is in its closed position, the bracket essentially becomes a tube in
which the flexible nickel-titanium archwire can move freely. By greatly reducing the amount
of friction with passive self-ligating brackets, low force archwires can work to peak
expression and stimulate teeth to move in a more biologically compatible method (Fig. 2).
Teeth movement is also more efficient when they are allowed to move individually, and
passive self-ligating brackets offer more freedom for teeth to move to their natural position
even though they are still interconnected because the archwire is never tightly engaged with
the bracket slot (Damon, 1998).

Elastic ligatures create friction and Self-ligating brackets allow freedom of

require more force and more movement, resulting in faster treatment
frequent adjustments with gentler forces
Fig. 2. Traditional archwire ligation vs. self-ligating brackets.

Fig. 3. Active self-ligating brackets in open and closed positions.

Self-Ligating Brackets: An Overview 7

3.3 Classification
Two types of self-ligating brackets have been developed, active and passive. These terms
refer to the mode in which they interact with the archwire. The active type (Fig. 3) has a
spring clip that encroaches on the slot from the labial/buccal aspect and presses against the
archwire providing an active seating force on the archwire and ensuring engagement such
as In-Ovation (GAC International, Bohemia, NY, USA), SPEED (Strite Industries,
Cambridge, Ontario, Canada), and Time brackets (Adenta, Gilching/Munich, Germany).
In the passive type (Fig. 4), the clip does not press against the archwire. Instead, these
brackets use a rigid door or latch to entrap the archwire providing more room for the
archwire such as Damon (Ormco/”A”Company), SmartClip™ (3M Unitek, USA), and
Oyster ESL (Gestenco International, Gothenburg, Sweden).

Fig. 4. Passive self-ligating brackets in open and closed positions.

3.4 History and development of self-ligating brackets

Self-ligating brackets were first introduced in the mid-1930s in the form of the Russell
attachment by Stolzenberg (Fig. 5). The bracket had a flat-head screw seated snugly in a
circular, threaded opening in the face of the bracket that allows for quick and simple
archwire changes. Loosening the screw made the system passive and allowed bodily
translation on a round wire while tightening it made it active and provided root torquing on
a square or a rectangular wire. The bracket system was more comfortable for the patient and
resulted in shorter office visits as well. Unfortunately, the Russell attachment did not gain
much popularity and virtually disappeared from the market.

Fig. 5. Russell attachment in open and closed positions

8 Principles in Contemporary Orthodontics

The first modern passive self-ligating bracket (Edgelok- Ormco Corporation, Glendora, CA)
was introduced in the early 1970s. The bracket had a round body with a rigid labial sliding
cap (Fig.6). Because of its passive nature, orthodontists found precise control of tooth
movement to be a challenge. Although many design refinements have been introduced
since, the basic design has remained unchanged.

Fig. 6. Edgelok bracket in open and closed positions.

The prototypes of the first active self-ligating bracket (SPEED, Spring-loaded, Delivery)
were introduced into the market in 1980. The bracket features a curved, flexible super-elastic
nickel-titanium spring clip that embraces the bracket body and passes through the archwire
slot.
In 1986, the self-ligating Activa bracket offered another alternative. The Activa bracket had
an inflexible, curved arm that rotated occlusogingivally around the cylindrical bracket body
(Fig. 7). The arm could be moved into a slot-open or slot-close position with finger pressure
alone. Once closed, the rigid outer wall of the movable arm converted the bracket slot into a
tube. Another self-ligating bracket model, Time entered the marketplace in 1995. The Time
bracket (Fig. 8) features a rigid, curved arm that wraps occlusogingivally around the labial
aspect of the bracket body. The stiffness of the bracket arm prevents any substantial
interaction with the archwire, thereby rendering Time a passive bracket (Berger & Byloff,
2001).)

Fig. 7. Activa bracket.

Self-Ligating Brackets: An Overview 9

Fig. 8. Time bracket.

Perhaps the most renowned self-ligating bracket system was introduced by Dr. Dwight
Damon in 1996. The Damon™ SL I is an edgewise twin bracket with a metal labial cover that
straddles the tie wings. In 1999, the next generation Damon™ SL II was brought to the
market (Fig. 9). It differed from the original Damon™ SL I by incorporating a flat
rectangular slide between the tie wings. A special plier is used to open the metal gates
incisally in the maxillary arch and gingivally in the mandibular. Once the slides are closed,
the bracket becomes a passive tube. The Damon™ SL bracket system was designed to satisfy
the following major criteria (Damon 1998):
a. Andrews Straight-Wire Appliance concept
b. Twin configuration
c. Slide forming a complete tube
d. Passive slide on the outside face of bracket
e. Bracket opening inferiorly in both arches

Fig. 9. Damon™ SL II brackets in open and closed positions.

In 2002, the In-Ovation R™ by GAC was introduced. This bracket features an interactive clip
because it can provide both passive and active control depending on the archwires used.
Round leveling wires can freely move to correct rotations during the initial leveling and
aligning phase, while full size rectangular wires are fully engaged into the base of the
bracket by the clip in the later stages of treatment for better torque control. A new In-
Ovation C™ is now available which has a partial ceramic face for better esthetics (Figure 10).
10 Principles in Contemporary Orthodontics

Fig. 10. The GAC In-Ovation R™ and In-Ovation C™ bracket.

In 2004, 3M Unitek introduced the SmartClip™ self-ligating bracket, which is different from
other self-ligating brackets in that it does not have a slide or clip to hold the wires (Fig.11).
Instead it contains a nickel-titanium clip on each side of the twin bracket that locks in the
wire. The archwire is inserted by using finger pressure to push it past the flexible clip.
Remove requires a special instrument from 3M Unitek™.

Fig. 11. The unitek smart clip™ bracket.

With the increasing popularity of self-ligating brackets, many different bracket designs are
brought to the orthodontic marketplace each year. Consequently, the use of SLBs has
increased exponentially; over 42% of American practitioners surveyed reported using at
least one system of self-ligating brackets in 2008 (Keim et al., 2008). This figure was just
8.7%in 2002 (Keim et al., 2002). When choosing a self-ligating bracket system, it is important
to understand the different types of systems (active vs. passive) in order to obtain the best
and most efficient orthodontic results.

4. Clinical performance of self-ligating brackets

Recent advances in bracket technology have resulted in a number of new selfligating 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 and
claiming that self-ligating bracket systems provide superior treatment efficiency and
Self-Ligating Brackets: An Overview 11

efficacy. The proposed benefits include 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. However, these data come from marketing materials, nonrefereed sources,
or refereed journals. The purpose of this section is to review the clinically significant effects
of self-ligating brackets on orthodontic treatment with respect to the quality of available
scientific evidence. Comparing between self-ligating and conventional brackets in different
aspects will be addressed as well. These include:

4.1 Subjective pain experience

It is well documented that discomfort is a potential side effect during fixed appliance
orthodontic therapy and this can negatively influence the desire to undergo treatment,
compliance, and treatment outcome (Patel, 1992; Scheurer et al., 1996). A potentially
significant variable that influences treatment-related discomfort is the amount of force
applied to the dentition by the orthodontic archwire, particularly during the early stages of
treatment. Classical histological studies suggest that light forces are more biologically
efficient and less traumatic during orthodontic tooth movement (Reitan, 1956 ). Therefore,
the use of increased force levels might be expected to be associated with increased
discomfort. One of the factors affecting prospective tooth movement and hence the amount
of force required is the degree of friction that exists between the archwire and bracket; this
frictional resistance being influenced primarily by the physical characteristics of the
archwire and bracket materials (Ireland et al., 1991), archwire dimensions (Taylor & Ison,
1996), and the method of archwire ligation (Ireland et al., 1991; Shivapuja & Berger, 1994).
Indeed, a number of self-ligating bracket systems have been developed in recent years,
including Damon ™ , In-Ovation ™ , and SmartClip ™ with the proposed benefit of
reduced frictional properties ( Read-Ward et al. , 1997 ; Thorstenson & Kusy, 2001 ; Henao &
Kusy, 2004 ). Proponents and manufacturers of these systems suggest that their physical
properties produce lower force levels during tooth alignment and sliding mechanics, a more
biologically compatible force level and, therefore, a possible reduction in pain associated
with orthodontic tooth movement (Berger & Byloff, 2001; http://www.damonbraces.com ).
To date (March, 2011), there have been four published clinical trials investigating degree
and differences in perceived pain using self-ligating and conventional brackets (Pringle et
al., 2010; Mile et al., 2006; Scott et al., 2008; Fleming et al., 2009). Of these, one split-mouth
study considered pain reports after both the first and second visits, with patients indicating
which system was associated with the greatest discomfort (Mile et al., 2006). Data in three of
the trials are presented as continuous pain scores from 0 to 100 on a 100-mm visual analogue
scale (VAS) which is one of the most commonly used tools in the measurement of perceived
discomfort during orthodontic treatment (Pringle et al., 2010; Scott et al., 2008; Fleming et
al., 2009). One trial reported pain scores at 15 time intervals (Pringle et al., 2010), while two
trials used four time points: 4 hours, 24 hours, 3 days, and 7 days after appliance placement
(Scott et al., 2008; Fleming et al., 2009). The findings from these studies conflicted slightly
with one study reporting a tendency to less pain experience with Damon 3 SLBs, although
this finding did not reach statistical significance (Pringle et al., 2010). Three studies (Pringle
et al., 2010; Scott et al., 2008; Fleming et al., 2009) were regarded as being at low risk of bias,
and they reported similar outcomes permitting statistical comparison; pain scores at four
analogous time intervals were extracted from each study to facilitate this. Pain intensity over
12 Principles in Contemporary Orthodontics

the first 7 days was reported in these three studies involving 160 patients, with 83 in the SLB
group and 77 in the conventional bracket group. Patients in the SLB group reported a mean
difference in pain intensity of 0.99 to 5.66 points lower than in the conventional bracket
group, the greatest difference being reported 3 days after appliance placement. However,
differences were not of statistical significance.
Two studies, (Mile et al., 2006; Fleming et al., 2009), reported greater pain experience during
chairside manipulation of self-ligating appliances. However, as the mechanisms of archwire
engagement and disengagement are very different using SmartClip (Fleming et al., 2009)
and Damon 2 (Mile et al., 2006), it was felt that direct statistical comparison of this research
finding would be invalid.

4.2 Bond failure rate

Treatment efficiency involves several factors including breakages. A higher bracket failure
rate results in extra visits for the patient and additional clinical time required for repairs.
The higher bracket failure rate demonstrated by any bracket system would need to be offset
by any time saving in ligation time as well as overall treatment time.
Two studies have considered failure of bonded attachments over 20 weeks (Miles et al.,
2006) and 12 months (Pandis et al., 2006) using Damon 2. The date used for assessing failure
or time taken for failure to occur was not reported, and only first-time failures for each tooth
were recorded. Miles et al., 2006, reported significantly more Damon brackets deboned
during the study. This higher failure rate could be due to operator inexperience with the
slide mechanism and also due to the bracket design because a shear force can be
inadvertently applied when operating the slide. The Damon 2 (as most self ligating bracket
designs) is also larger incisogingivally than the conventional twin bracket used and so more
likely to interfere with the occlusion.
Pandis et al., 2006, assessed the failure rate of self-ligating and edgewise brackets bonded
with a self-etching adhesive and conventional phosphoric acid etching in patients followed
for 12 months of active treatment. Similar treatment plans, and mechanotherapy were
selected for the study. GAC Microarch edgewise brackets and Oromco Damon 2 brackets
were bonded using a split mouth design, using the 3M Transbond Plus Self-etching primer
(SEP) and Transbond XT paste; and conventional acid etching, with Orthosolo primer and
Enlight paste, applied at an alternate sequence so that the adhesives were equally
distributed on the maxillary and mandibular right and left quadrants. No difference was
found for the failure rate of self-ligating vs. conventional bracket and between the two
bonding modes used. Also, no difference was identified between maxillary and mandibular
arch in failure incidence whereas a statistically significant difference was shown for right-
sided appliance which may be assigned to masticatory habits.

4.3 Plaque retention and periodontal health

Iatrogenic decalcification of tooth enamel and the development of visible white spot lesions
are undesirable and unfortunate consequences of fixed orthodontic therapy, potentially
undermining the esthetic benefits often achieved through correction of the malocclusion. It
is well documented that fixed appliances increase bacterial plaque accumulation and the
risk for white spot lesions (Gorelick et al., 1982; Geiger et al., 1983). During treatment, there
is demonstrated increased retention in the amounts of Streptococcus mutans and lactobacilli
in saliva and dental plaque (Forsberg et al., 1991). Bonded orthodontic brackets hinder
Self-Ligating Brackets: An Overview 13

access for good oral hygiene and create microbial shelters, resulting in the accumulation of
plaque. The appliance architecture specifically, the archwire ligation method is an additional
factor influencing bacterial colonization. Two trials have compared the impact of SLBs and
elastomeric ligation on plaque retention (Pellegrini et al., 2009, Pandis et al., 2010). Longer
term effects of bracket system on periodontal health and accumulation of debris has also
been assessed (Pandis et al., 2008).
Pellegrini et al., 2009, performed randomized clinical study to enumerate and compare
plaque bacteria surrounding 2 bracket types, self-ligating vs. elastomeric ligating using a
split-mouth design. Patients were recalled and assessed 1 week and 5 weeks after bonding.
Results showed that most patients bonded with self-ligating brackets had fewer bacteria in
plaque than did teeth bonded with elastomeric legated brackets both at 1 and 5 weeks after
bonding.
The oral cavity is a rich ecosystem with a plethora of microorganisms. While both
periodontal disease and caries are considered multifactorial diseases, plaque bacteria are the
major factor in their onset and progression. However, there are situations which comprise
what has been termed ‘ecological stress’, referring to the shift of the microbiological balance,
creating conditions conducive to the growth, and appearance of cariogenic and/or
periodontopathic bacteria (Marsh, 2003). The different components of the fixed orthodontic
system may contribute to a shift in the balance of the oral ecology. The presence of brackets
and ligatures has been shown to be been mainly associated with increased risk of
Streptococcus mutans and lactobacilli colonization, among other species, thus initiating a
series of events, which may lead to the development of pathology of the hard tissues such as
decalcification and, in specific cases, caries development. Moreover, the accumulation of
plaque and the resultant alteration of the local microbial milieu may expose the tissues to
the risk of developing periodontal inflammation (Øgaard et al., 1988; Fournier et al., 1998 ;
Naranjo et al. , 2006 ).
It has been proposed at bracket ligation mode has an effect on the microbiological profile of
the patients’ oral environment. Pandis et al., 2010, investigated the effect of bracket type
(conventional and selfligating) on the levels of streptococcus mutans and total bacterial
counts in whole saliva of , fixed orthodontic patients at the age range of 11-17 years. The
patients were subdivided into two groups with random allocation of bracket type
(conventional or selfligating). An initial saliva sample was obtained before the initiation of
treatment (T1) and a second sample 2 – 3 months following appliance bonding (T2). Salivary
streptococcus mutans and total bacteria were enumerated and analysed after growth in
culture. The levels of S. mutans in whole saliva of orthodontically treated patients do not
seem to be significantly different between conventional and self-ligating brackets. However,
the pre-treatment levels of S. mutans are significant predictors of the levels of S. mutans
after placement of orthodontic appliances.
Pandis et al., 2008, conducted a cohort study to determine values of periodontal indices for
patients treated with self-ligating and conventional brackets. All patients were 12-17 years
with aligned mandibular arches, and absence of oral habits and anterior crossbites. Outcome
variables were plaque index, gingival index, calculus index, and probing depth for the two
bracket cohorts and the results showed that under these conditions the self-ligating brackets
do not have an advantage over conventional brackets with respect to the periodontal status.

4.4 Torque expression and arch dimensional change

Correct buccolingual inclination of anterior teeth is considered essential to provide good
occlusal relationships in orthodontic treatment. Inclination of the maxillary anterior teeth is
14 Principles in Contemporary Orthodontics

particularly critical in establishing an esthetic smile line, proper anterior guidance, and a
Class I canine and molar relationship. Undertorqued maxillary anterior teeth affect the arch
length and the space requirements. It has been shown that for every 5° of anterior
inclination, about 1 mm of arch length is generated. (O’Higgins et al., 1999) Undertorqued
posterior teeth have a constricting effect on the maxillary arch, since they do not allow
appropriate cusp-to fossa relationships between maxillary and mandibular teeth (Gioka &
Iliades, 2004). The manufacturing process of brackets results in some variation in sizes and
characteristics, including dimensional accuracy and torque prescription consistency. Various
bracket manufacturing processes such as injection-molding, casting, and milling can affect
the accuracy of the prescribed torque values, and this has been reported to be about 5% to
10% (Gioka & Iliades, 2004). Huang et al., 2009, reported that torque angle/torque moment
behavior is determined by the characteristics of the archwire. The effect of the bracket
system is of minor importance, with the exception of self-ligating brackets with an active
clip (eg. Speed), which had the lowest torquing moments of all wires.
In relation to the mandibular arch, Pandis et al., 2007; Fleming et al., 2009; and Pandis et al.,
2010, reported similar increase in the proclination of mandibular incisors associated with
both appliance systems during arch alignment. In general, lateral cephalograms were traced,
and mandibular incisor position and inclination were assessed for patients by using angular
measurements of mandibular incisor to mandibular plane, mandibular incisor to nasion-
Point B line, and mandibular incisor to Point A-pogonion line. Garino & Favero, 2003,
stated that satisfactory control of tooth positions during the horizontal, mesio-distal, and
torque movements, both in the extraction and non-extraction cases were observed in Speed
bracket system
Self-ligating brackets seem to be equally efficient in delivering torque to maxillary incisors
relative to conventional brackets in extraction and non-extraction cases. Pandis et al., 2006,
conducted a randomized clinical trial employing a random distribution of variables among
the studied populations. Similar buccolingual inclination of maxillary incisors in extraction
and non-extraction treatment with self-ligating and conventional brackets was reported.
Treatment of a crowded dental arch on a non-extraction basis, without tooth size reduction
requires an increase in arch perimeter to allow resolution of crowding and achievement of
optimum arch alignment and leveling. Without active distal movement, changes typically
involve both transverse expansion and proclination. The ideal scenario would involve little
incisor proclination and intercanine expansion, with most of the arch perimeter increase
generated by expansion across the molars and premolars. The nature and magnitude of
these arch dimensional changes have implications on the long-term stability. Marked
expansion of the intercanine dimension and excessive proclination of the mandibular
incisors are considered to be particularly unstable (Mills, 1966; Burke et al., 1998). Relapse in
such cases may develop due to constriction of the expanded intercanine dimension and
uprighting of the mandibular incisors during the post-treatment phase, and is likely to
manifest as mandibular incisor irregularity.
Three studies investigated arch dimensions in conventional and self-ligating brackets (All
used Damon brackets). Jiang & Fu, 2008, and Pandis et al., 2009, reported the changes after
treatment in their prospective studies on non-extraction basis. For intercanine and
intermolar widths, there was no significant difference between the two groups. On other
hand, Scott et al., 2008, reported the change after progressing to 0.019 x 0.025-in stainless
steel archwires in a randomized controlled trial on extraction patients with greater incisor
Self-Ligating Brackets: An Overview 15

irregularity at the beginning of the treatment. They reported greater increase in intercanine
width, probably because the canines were retracted to a wider part of the arch. Intermolar
width was not increased with self-ligating brackets in that study, and, according to the
authors, it was probably related to forward sliding of the molars into a narrower part of the
arch in the extraction patients. In addition, different archwire sequences were used for the
two groups in the studies of Jiang & Fu, 2008, and Pandis et al., 2009, whereas Scott et al.,
2008, used the same archwires for both groups. The claims that self-ligating brackets
facilitate greater and more physiologic arch expansion and, therefore, allow more non-
extraction treatment require more evidence.

4.5 Orthodontic space closure

Only two studies considered the rate of orthodontic space closure. Miles, 2007, tested the
rate of space closure at intervals of 5 weeks until complete closure was achieved. This was a
prospective cohort study using a split-mouth design with moderate risk of bias. Miles
concluded that there was no significant difference in the rate of en-masse space closure
between SmartClip brackets and conventional brackets tied with stainless steel ligatures.
However, the sample size was small, and the possibility that any true difference could be
obscured in a split-mouth design should be considered. In a very recent study, Mezomo et
al., 2011, conducted a randomized clinical trial to measure space closure during the
retraction of upper permanent canines after first premolar extraction with self-ligating and
conventional brackets. In a random split-mouth design, the retraction of upper canines was
performed using an elastomeric chain with 150 g of force. The evaluations were performed
on dental casts at time intervals (T0, initial; T1, 4 weeks; T2, 8 weeks; T3, 12 weeks). The
amount of movement and the rotation of the canines as well as anchorage loss of the upper
first molars were evaluated. Results showed that distal movement of the upper canines and
anchorage loss of the first molars were similar with both conventional and self-ligating
brackets. However, rotation of the upper canines was minimized with self-ligating brackets
(P< .05). Existing evidence does not support the claim that lower friction in a self-ligating
system permits more rapid space closure in a clinical setting.

4.6 Efficiency of initial orthodontic alignment

Five studies with low to moderate risk of bias, including two randomized controlled trials
and three prospective cohort studies, investigated the rate of mandibular incisor alignment (
Fleming et al., 2009; Miles et al., 2006; Scott et al., 2008; Miles, 2008; Pandis et al., 2007).
Mandibular crowding was selected as a model for examining the efficiency of brackets
because correction of this discrepancy largely depends on the “free play” or clearance of the
archwire inside the slot walls. All self-ligating brackets were the passive type (Damon,
Ormco; SmartClip, 3M Unitek). Pandis et al., 2007, and Scott et al., 2008, reported days
needed for alignment but used different end points: visual inspection of correction of
proximal contacts and changing to 0.019 x 0.025-in stainless steel archwire. Pandis et al.,
2007, enrolled non-extraction patients (Fig. 12 & 13), whereas Scott et al., 2008, enrolled
extraction patients. Miles, 2008, and Fleming et al., 2009, reported reduction of irregularity at
various times of alignment. A standardized mean difference was calculated, and no
significant difference in efficiency of alignment in the mandibular arch was found between
both bracket systems. The efficiency of alignment was found to be associated with initial
irregularity only. The study of Fleming et al., 2009, used a 3-dimensional analysis, thus
16 Principles in Contemporary Orthodontics

making comparison unfeasible. However, they also concluded that, for non-extraction
patients with mild mandibular incisor crowding, self-ligating brackets were no more
effective at relieving irregularity.

Fig. 12. Alignment of crowded mandibular anterior teeth (canine to canine) with a
conventional edgewise brackets (Pandis et al., 2007)

Fig. 13. Alignment of crowded mandibular anterior teeth (canine to canine) with self-
ligating brackets (Pandis et al., 2007)

4.7 Apical root resorption

Apical root resorption (ARR) can be defined as blunting or shortening of the root apex, a
condition often associated with orthodontic treatment. The teeth more susceptible to ARR
are the maxillary and mandibular incisors, and especially the maxillary lateral incisors
(Linge & Linge, 1983; Mirabella & Artun, 1995).
The introduction of self-ligating brackets provoked the investigation of archwire ligation on
ARR. One of the first reports on the subject was by Blake et al., 1995, who tested the
hypothesis that an active self-ligating bracket with an active clip might induce more ARR;
their findings, however, did not confirm that hypothesis. The introduction of passive self-
ligating systems, with no active spring and alignment performed by wires engaged in a
passive tube, with more play, jiggling, and less friction raises again the question of their
Self-Ligating Brackets: An Overview 17

effect on ARR. Pandis et al., 2008, using panoramic radiographs, reported no mean
difference in the amount of apical root resorption of the maxillary incisors with Microarch
and Damon 2 systems. Similar results were obtained by Scott et al., 2008, who assessed
changes in root lengths of mandibular incisors on periapical radiographs following arch
alignment. The mean amount of resorption was slightly greater with the Damon 3 appliance
(2.26 vs. 1.21 mm), although the difference failed to reach statistical significance.

4.8 Total treatment time and occlusal indices

One prospective randomized clinical trial and three retrospective cohort studies compared
total treatment times between both systems. The very recent (February, 2011) multi-center
randomized clinical trial was carried out to compare the effect of bracket type (Damon3 self-
ligated or the Synthesis conventional ligated preadjusted bracket systems, both, Ormco,
Glendora, Calif) on the duration of orthodontic treatment and the occlusal outcome as
measured by the peer assessment rating (PAR). The use of the Damon3 bracket did not
reduce overall treatment time or total number of visits, or result in a better occlusal outcome
when compared with conventional ligated brackets in the treatment of extraction cases with
crowding. For the other retrospective studies, Eberting et al., 2001, and Harradine, 2001,
found significantly decreased treatment times of 4 to 6 months and 4 to 7 fewer visits with
self-ligating brackets, whereas Hamilton et al., 2008, found that self-ligating brackets appear
to offer no measurable advantages in orthodontic treatment time, number of treatment
visits, and time spent in initial alignment over conventional pre-adjusted orthodontic
brackets. However, the mean treatment times varied in the 3 studies, and the decision
regarding when treatment goals had been attained might have differed among the
investigators. The same 3 studies also compared the occlusal outcome after treatment.
Eberting et al., 2001, used American Board of Orthodontics scores, Hamilton et al., 2008,
used the index of complexity, outcome, and need, and Harradine, 2001, used the peer
assessment rating. Interestingly, an almost identical pattern was observed in the 2 forest
plots. The 2 smaller studies with passive self-ligating brackets (Damon, Ormco) favored self-
ligation (Eberting et al., 2001; Harradine, 2001); whereas the larger study with active self-
ligating brackets (In-Ovation, GAC) found no significant difference (Hamilton et al., 2008).
The results in occlusal quality showed no significant difference at the end of treatment.
However, caution should be used regarding these results, since the heterogeneity was high
and the 3 studies might have been susceptible to bias from their retrospective designs.
Studies with randomized or consecutive assignment are needed to provide further
information with more valid comparisons of treatment durations.

4.9 Stability
Some claim that lower forces produced by selfligating bracket systems might result in more
physiologic tooth movement and more stable treatment results. However, studies on
stability after treatment with self-ligating brackets are lacking at this time.

5. Active vs. passive self-ligating brackets

The Time, In-Ovation, and Speed brackets all have what is called a “spring clip” that
encroaches on the slot from the labial/buccal aspect providing an active seating force on the
archwire (Fig. 14). The debate over whether a self-ligating bracket should have an active or
18 Principles in Contemporary Orthodontics

passive ligation mechanism has been around since their development. Proponents of an
active clip claim that it provides a “homing action” on the wire when deflected, providing
more control with the appliance (Hanson, 1980). Such brackets have a flexible clip that
creates a passive slot depth of 0.0175” to 0.020”. With small round wires, the bracket is
passive, but with larger wires the flexible clip is defected labially and provides an active
seating force on the archwire. Passive self-ligating brackets have a slot depth of 0.028” and
do not exert an active force on the wire. Those who advocate a passive clip state that there is
less friction in the appliance during sliding mechanics because the slot provides more room
for the archwire and they provide no active seating force (Damon, 1998). Several studies
have tried to determine how a self-ligating mechanism affects friction during sliding
mechanics. Active and passive self-ligating brackets showed different behavior with regard
to their resistance to sliding (Brauchli et al., 2011). These studies have all consistently found
that when a small round wire lies passively in the slot, the self-ligating brackets produce
significantly less friction than conventionally ligated brackets (Berger, 1990; Thorstenson &
Kusy, 2001). This is presumably due to the absence of the ligation that provides a seating
force against the archwire. When wires of 0.018” or larger were tested, differences in friction
have been found between various self-ligating brackets. Therefore, it might be concluded
that low friction can be achieved with the use of passive self-ligating brackets or the
combination of low-dimension archwires and active self-ligating appliances.

Fig. 14. Profile views of time2 ™ (A), in-ovation R ™ (B), speed ™ (C)
Self-Ligating Brackets: An Overview 19

Redlich et al., 2003, found that the Discovery (Dentaurum; Espringen, Germany) and Time
(American Orthodontics; Sheboygan, WI) brackets produced about twice as much friction as
the control twin bracket with wire sizes greater than 0.018”. The authors attribute the higher
frictional forces in the Time brackets to the clip exerting excessive force on the wire. Read-
Ward et al., 1997, compared friction between three self-ligating brackets; SPEED (Strite
Industries, Ontario, Canada), Activa (‘A’ Company, San Diego, CA), Mobil-Lock Variable-
Slot (Forestadent, Strasbourg, France), and a conventional twin bracket Ultratrimm
(Dentaurum, Germany). Three stainless steel wires were tested; 0.020”, 0.019 x 0.025” and
0.021 x 0.025”. They found that with the 0.020” wire, the Mobil-Lock had the least amount of
friction, which was statistically less than the SPEED and Ultratrimm brackets. No significant
difference was found between the Mobil-Lock and Activa. It is important to note that the
Mobil-Lock and Activa have a passive ligation mechanism and that the SPEED bracket is
active with a 0.020” wire. With a 0.021 x 0.025” wire, the SPEED bracket produced
significantly greater friction than either the Mobil-Lock or Activa brackets. In a similar
study, Pizzoni et al.,1998, compared the Damon SL bracket to the SPEED bracket with an
active clip and two conventionally ligated brackets. The two self-ligating brackets were not
statistically different for a 0.018” wire, but when 0.017 x 0.025” wires were used, the active
clip on the SPEED bracket produced significantly greater friction than the passive Damon
bracket. The literature supports the claim that when using larger wires, passive self-ligating
brackets produce less friction than active self-ligating brackets.
The self-ligation design (passive versus active) appears to be the primary variable
responsible for the frictional resistance generated by self-ligating brackets during
translation. Passively ligated brackets produce less frictional resistance; however, this
decreased friction may result in decreased control compared with actively ligated systems.
Badawi et al., 2008, measured the torque expressed from two passive (Damon 2 and
SmartClip) and two active (In-Ovation and Speed) self-ligating orthodontic brackets. Results
showed that active self-ligating brackets demonstrated better torque control due to their
active clip forcing the wire into the bracket slot. The active self-ligating brackets expressed
higher torque values than the passive self-ligating brackets at clinically usable torsion angles
as well. Moreover, the clinically applicable range of torque activation was greater for the
active self-ligating brackets than for the passive self-ligating brackets.
Pandis et al., 2010, conducted a randomized clinical trial to compare the time required to
complete the alignment of crowded maxillary anterior teeth (canine to canine) between
passive (Damon MX, Ormco, Glendora, Calif) and active ( In-Ovation R, GAC, Central Islip,
NY) self-ligating brackets. The results showed that active and passive self-ligating brackets
have no difference in treatment duration in the correction of maxillary anterior crowding, in
contrast to the extent of crowding, which had an effect on the duration of treatment.

6. Clinical tips in application of self-ligating brackets

6.1 Archwire engagement with self-ligating brackets
With self-ligating brackets, it is much more important to fully engage the wire before clip
closure. The wire can be held into the slot base with a variety of tools such as ligature tucker,
or Mitchell’s trimmer. However, these only push on one side of the bracket and may fail to
fully engage the wire across the whole width of the slot. For this purpose, various
instruments were developed for engagement of wires, via balanced pressure on both sides
of the bracket such as the Cool Tool (Damon) which is rather akin to a torquing key, and the
20 Principles in Contemporary Orthodontics

R tool (GAC) which resembles a double ligature tucker and works in the same way. These
specific tools work very well and can reassure the clinician that slide closure is not being
attempted over an incompletely seated wire. They can also assist cheek/lip retraction
during slide closure and such a tool is recommended as a routine part of slide closure on
teeth where the wire requires lingual pressure for full engagement. In cases where teeth are
severely rotated and one end of the slot is too close to the adjacent tooth for an instrument to
be used to seat the wire, dental floss or a ligature wire looped over the archwire can be used
to fully engage the wire on that side. Harradine, 2003, suggested another useful manoeuvre
to engage very rotated or displaced tooth with any self-ligating bracket by closing the clip or
slide first, and then threading the aligning wire through the closed bracket before engaging
the other brackets, i.e. to first convert it to a ‘molar’ tube.

6.2 Opening clips/slides

In-Ovation brackets are opened by pushing in an occlusal direction on the tail of the clip
behind the bracket. An important point is to avoid getting excess composite resin near this
tail during bracket placement as it may can hinder or prevent clip opening particularly in
the lower arch, where the tail is not visible from the operator’s position. Time and Speed
brackets are opened with a probe or other fairly sharp instrument, such as a Mitchell's
trimmer using the hole in the clip. Very specific and extremely effective pliers for Damon
brackets are called Kasso Damon pliers. These pliers are recommended for all first-time
users since they make all slides very easy to open.

6.3 Prevention of wire pokes

Low friction increases wire displacement. Even with very irregular teeth, the very low
friction with self-ligating brackets enables aligning archwires to slip through the brackets
and an archwire end to protrude. This is clearly a potential nuisance which can be avoided
by using tie-backs with flexible wires over extraction sites to lessen the effects of occlusal
forces on unprotected spans of wire. Another way is thorough turning in the ends of flexible
archwires. An interesting innovation in this respect is the Bendistal plier described by
Khouri, 1998. This was designed to place an effective distal end bend in a super-elastic wire
without the need for over-bending which can be difficult and uncomfortable and also risks
the loss of a bonded molar tube.
Other options include the use of the crimp-on split tubes available from manufactures such
as Unitek and Oromco which can be squeezed onto almost all wires, require no fabrication,
are unobtrusive, and effective. It is recommended that these stops are not placed on a
significantly active part of the archwire as this would diminish the range of action of the
wire where it is most needed. Others suggested selective locking of individual brackets to
the archwire with elastomerics to resolve this drawback particularly in those designs which
have a full conventional tie-wing assembly.

6.4 Alterations in treatment mechanics

The combination of low friction and full, secure bracket engagement may help in some
alteration in treatment mechanics during the progress of treatment.

6.4.1 Longer appointment intervals

Full and secure wire engagement of self-ligating brackets along with the use of low modulus
wires makes an extension of the interval between appointments a logical step. Harradine,
2003, proposed patients' follow-up on an eight- to ten-week interval basis.
Self-Ligating Brackets: An Overview 21

6.4.2 Initial traction on lighter wires

The increased control of light forces enables more mesio-distal tooth movement to be
sensible on lighter, more flexible wires. Moreover, compressed coil springs to move teeth
apart can appropriately be placed from initial visits in many instances.

6.4.3 Separate movement of individual teeth

The control of rotation during traction on an individual tooth makes this option much more
feasible when required and with more anchorage conservation.

6.5 Bracket placement and bonding

Bracket placement and bonding is a curial step for the long-tem success of treatment.
Preferably, both arches should be bonded at the same session and from second molar to
second molar in each arch. For teeth that are well displaced from the arch line or where
there is insufficient space to place a bracket in ideal position, it is helpful to use a traction
hook to gain some initial control of these teeth. For rotated teeth, it is helpful to offset the
traction hook so that it is on the part of the crown furthest from the line of the line of the
arch to gain some spontaneous derotation.

6.6 Appliance debonding

Debonding of self-ligating brackets may occur by direct failure of the bracket adhesive
interface, cohesive failure of the adhesive, direct failure of the adhesive enamel interface or
combination of any of these. In Damon system, the best way to debond self-ligating bracket
systems is by squeezing two tiewings only with a conventional debonding plier as the
bracket will silently float off the adhesive. 3M Unitek™ has Distinguished debonding tool
designed for the 3M Unitek Self-Ligating Bracket Systems (Clarity SL Self-Ligating Brackets
and SmartClip Self-Ligating Brackets) which may be used with or without the archwire
engaged in the bracket slot.
However, the risk of enamel fracture has always been present with stainless steel and
ceramic brackets, particularly in teeth where the integrity of the crown is compromised.
Alternative methods of debonding metals and ceramic brackets have been designed to
minimize the potential for enamel surface. The main purpose of these new methods is to
reduce the force levels during the debonding process. Three debonding techniques have
been proposed (ultrasonic, electrothermal, and laser).
1. Ultrasonic Debonding
The ultrasonic technique uses specially designed tips applied at the bracket-adhesive
interface to erode the adhesive layer between the enamel surface and bracket base. The
resulting force magnitudes needed with the ultrasonic approach are significantly lower than
those required for the conventional methods of bracket removal (Englehardt et al., 1993;
Krell et al., 1993). However, the ultrasonic technique has a major disadvantage. Debonding
time using this technique is 30 to 60 seconds per bracket, compared with 1 to 5 seconds for
other bracket removal methods (Bishara and Trulove, 1990). In addition, there is excessive
wear of the relatively expensive ultrasonic tips. Consequently, this method of bracket
removal is not yet recommended for clinical use.
2. Electrothermal Debonding
Electrothermal debonding instruments are essentially rechargeable, cordless heating devices
that are placed in contact with the bracket. The instrument transfers heat through the
22 Principles in Contemporary Orthodontics

bracket, softening the adhesive and allowing bond failure between the bracket base and the
adhesive resin (Sheridan et al., 1986; Scott, 1988). This method is a quick and effective way to
debond a bracket. Its major disadvantage is related to the relatively high temperatures
generated at the heated tip. Pulpal damage and mucosal burns are possible.
3. Laser debonding
Debonding ceramic brackets was attempted using both CO2 and YAG lasers 5s in
combination with mechanical torque. The use of a laser is conceptually similar to the use of
the electrothermal approach, that is, through heat generation to soften the adhesive. The
laser approach, although still experimental, is more precise with regard to time and amount
of heat application, and therefore would have better control of the amount of heat
transmitted to the tooth (Hayakawa, 2005; Feldon et al., 2010). A major disadvantage, in
addition to the effects of the thermal energy on the pulp, is the high cost of the instrument

6.7 Retention
Retention is one of the controversies of modern orthodontics, with uncertainty being the
only certainty. Angle, 1907, stated that "the problem involved in retention is so great, often
being greater than the difficulties being encountered in the treatment of the case up to this
point". Bramante, 1990, attempted to rationalize the problem and demonstrated that teeth
moved through bone by orthodontic appliances often have a tendency to return to their
former positions. Moreover, arch form, particularly mandibular arch form, cannot be
permanently altered by appliance therapy which means that bone and adjacent tissues must
be allowed time to reorganize after treatment. Thus, definite retention is necessary if the
finished result of active orthodontic treatment is to be maintained. There is no agreement in
the literature of a uniform system of retention, and the clinical orthodontist, in consultation
with each patient, must determine the appropriate retention regime for each case.
(Zachrisson, 1986). Many appliance types have been used for the retention of post-
orthodontic treatment. The first appliances proposed were based on banded fixed
appliances (Angle, 1907), then removable retainers were advocated as Hawley retainer, clear
overlay removable retainer. Most recently, the use of bonded fixed retainers has been
introduced (Kneiflm, 1973; Rubenstein, 1976). These retainers have employed multistrand
wire include different wire types with differing diameters. The proposed advantages of the
use of multistrand wire are that the irregular surface offers increased mechanical retention
for the composite without the need for the placement of retentive loops, and that the
flexibility of the wire allows physiologic movement of the teeth, even when several adjacent
teeth are bonded (Artun, 1984).
Relapse is a long-term problem and long-term follow-up of patients is practically difficult
and financially demanding. The literature demonstrates that, at the time of writing, evidence
that addresses the effectiveness of different retention strategies used to maintain tooth
position after treatment by Self-ligating orthodontic appliances is lacking. However, Dr.
Dwight Damon proposed the use of bonded upper retainer (lateral incisor to lateral incisor)
made from 0.16"* 0.022" flat braided archwire and placed on the cingulae of upper incisors
to prevent spontaneous debonding. In the lower arch, bonded lower retainer (from canine to
canine) using 0.025 single strand stainless steel is recommended as well. Clear overlay
retainers are to be used in addition on a night time basis.
Self-Ligating Brackets: An Overview 23

7. Limitations of self-ligating brackets

Full archwire engagement, low friction between bracket and archwire, and faster archwire
removal and ligation are inherent features of self-ligation brackets which have been clearly
demonstrated and quantified in work by various authors. However, self-ligating brackets
have some drawbacks that may hinder the wide spread in their use. First: is a clip that is
designed to flex, more prone to breakage or permanent deformation or to inadvertent
opening or closing? This question has not been formally investigated. Studies involving the
use of different self-ligating brackets in the same patient or randomly assigned to different
patients are needed to test such hypotheses. Second: the higher profile in self-ligating
brackets, due to the complicated mechanical design, potentially causes more occlusal
interferences and lip discomfort. Moreover, currently available self-ligating brackets are
more expensive than most good quality tie-wing brackets. However, this significant extra
cost must be measured against savings in time—an expensive commodity. If self-ligating
brackets save any appreciable chairside time as some studies suggest this would provide an
offsetting saving.

8. Conclusion
Self-ligating brackets (SLBs) are not new conceptually, having been pioneered in the 1930s.
They have undergone a revival over the past 30 years with a variety of new appliances being
developed. It is divided into 2 main categories, active and passive, according to the
mechanism in which they interact with the archwire (encroaching on the slot lumen or not).
Self-ligating bracket systems were built on the philosophy of delivering light forces on a
low-friction basis, thus insuring more physiologic tooth movement and at balanced oral
interplay.
These systems have been gaining popularity in recent years with a host of claimed
advantages over conventional appliance systems relating to reduced overall treatment time,
less associated subjective discomfort, promotion of periodontal health, superior torque
expression, and more favorable arch -dimensional change. Other claimed advantages
include possible anchorage conservation, greater amounts of expansion, less proclination of
anterior teeth, less need for extractions, and better infection control. However, many of these
claims were based on retrospective studies which are potentially biased as there are many
uncontrolled factors which may affect the outcome. These include greater experience,
differing archwires, altered wire sequences, changes in treatment mechanics, and modified
appointment intervals. Observer bias may inadvertently affect the outcome as the
practitioner may unknowingly be doing ‘‘a bit more’’ due to enthusiasm with the new
product. In this regard, more prospective clinical trials with randomized or consecutive
assignment and using identical wire sequences and mechanics are preferred.
While Advocates claim that low-friction SL brackets coupled with light forces enhance the
treatment efficiency and address the clinical superiority of self-ligating brackets, other team
believes that bracket type does not appear to have a significant influence on treatment
efficiency. Treatment efficiency is the product of many mechanical and biologic factors. It is
unlikely that any one factor is responsible for the efficiency and rate of tooth movement. The
biology of tooth movement is a complex and highly coordinated process at the cellular,
molecular, and genetic levels. Individual variation undoubtedly has a fundamental
underlying role in tooth movement and treatment efficiency. SL bracket systems are only a
24 Principles in Contemporary Orthodontics

tool that we use today; therefore, they are just a component of orthodontics. Among other
things, orthodontics deals with science/ evidence, psychosocial issues, record taking,
diagnoses, treatment, treatment outcomes, artistry, enhancements, and quality-of-life issues.

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28 Principles in Contemporary Orthodontics

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 30 Principles in Contemporary Orthodontics

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