This document discusses various studies that have compared self-ligating brackets to conventional brackets. Some of the key findings include: - Studies have found that self-ligating brackets produce significantly less friction than conventional brackets ligated with elastics or metal ties. However, the amount of friction depends on factors like archwire size and bracket design. - When correcting large misalignments (6mm or more), passive self-ligating brackets were able to generate forces for alignment while conventional brackets did not produce any forces. - Most studies found no significant differences between self-ligating and conventional brackets in terms of efficiency of tooth movement, alignment times, rates of canine retraction, or anchorage loss. However

1. @nhalhamlan
@saudibraces
nasiralhamlan
@nasiralhamlan
ORTHODONTICS
Self-Ligating Brackets
Dr. Nasir Alhamlan
Saudi Arabia
Scientific Evidence

2. • Wire ligatures are better than elastomerics; producing 30%-50% of the friction forces
(Shivapuja and Berger, AJO&DO, 1994) but the forces still undesirable levels relative for
tooth movement.
• Elastomeric Ligatures in a ‘figure of 8’ configuration increase the friction by a factor of
70-220% compared to the ‘O’ configuration (Sims et.al, BJO, 1993)
• Force to the archwire produced by a wire ligature is very variable , even after training
in a standardized method of ligature tying (Iwasaki et.al, AJO&DO, 2003)
• Force has also been shown to be more variable for elastomeric ligatures than for passive
self-ligation (Thorstenson and Kusy, AJO&DO, 2001)
• Interestingly, the polymeric-coated SuperSlick ligatures (TP Orthodontics Inc. Indiana)
which were designed to reduce friction produced more friction than more conventional
elastomerics (Khambay et.al, EJO, 2004)
• Slick modules with standard stainless steel brackets generated significantly less friction
than the other types of modules or the Speed self-ligating bracket (Hain et.al, AJO&DO,
2006)
Friction

3. Conclusion:
- RS is negligible for both self-ligating brackets to any size of wire as well as well for
those with clips when coupled to wires that do not contact the clip.
- Once contacts the clip, the RS depends on the archwire size, the bracket design,
and the materials of the couple.

4. (Vourdouris, AJO&DO, 1997)
• Active (Sigma, AO), Passive (TwinLock and Damon, Ormco) with three
conventionally ligated brackets
- Elastomeric ligatures produced friction at 66.78 grams of frictional resistance.
- Metal ties produced friction at 53.28 grams.
- Active self-ligation produced friction at 31.0 grams.
- Passive self-ligation produced at 0.10 to 0.18 grams.
(Kim et.al., AJO&DO, 2008)
• Damon and In-Ovation brackets produced lower frictional force. However, the
authors note that when an archwire contacts the clip or slides of an active bracket like
In-Ovation, frictional force increases and can result in little or no tooth movement
Friction

5. (Badawi et.al., AJO&DO, 2009)
Concluded
-No orthodontic force system is
PERFECT
-All deliver forces that:
- Wanted in terms of force levels and
moments
- Unwanted in terms of force levels
and moments
- PSL delivers more Wanted and less
Unwanted forces and moments
Force

6. Conclusion: When correction of a large amount of misalignment (6 mm), a noticeable
amount of force for alignment was still generated by the passive Self-Ligating Brackets
while no force was released in presence of Conventional Ligation Brackets (Baccetti
et.al., EJO, 2011)

7. (Pandis et.al., AO, 2008)
The magnitude of moments is related:
➢ Geometry of the dental arch,
➢ Tooth position,
➢ Rigidity of the closing component of the bracket slot
❖ Damon2 (27.2 Nmm)
❖ In Ovation-R (9.0 Nmm)
❖ Conventional brackets (5.0 Nmm)
Moments

8. Force decay and deformation of orthodontic
elastomeric ligatures (Taloumis et.al., 1997)
Objective
Evaluate force decay, dimensional change and
permanent deformation of molded elastomeric
ligature.
Conclusion
The rapid force loss and permanent deformation of
these products may preclude their use for
rotational and torque corrections.

9. CONCLUSIONS
• Force decay of elastomeric ties results in increased aligning forces when
compared with fresh elastomerics.
• The unloading forces produced by a wire after force decay of the elastomers
are not statistically different from the forces present in self-ligating systems.
• Self-ligating brackets and relaxed elastomers create a system of greater
aligning forces when compared with fresh elastomeres.
Friction

10. • The type of ligature used influenced the amount
of force released by the orthodontic system
significantly more than the type of bracket
(Stainless Steel vs Ceramic) (Baccetti et.al., 2008)
• NCEL produced levels of force for tooth movement that were similar to those
generated by passive SLBs during alignment of buccally displaced teeth
(Franchi et.al., AJO&DO, 2009)
• SLBs and NCEL are valid alternatives for low friction during sliding
mechanics (Franchi et.al., AJO&DO, 2008)
• In Vitro : UELs may represent a valid alternative to passive SLBs for low-
friction biomechanics (Gandinia et.al., AO, 2008)
Friction

11. A Systematic Review (Ehsani et.al., AO, 2009)
Objective: To compare the frictional resistance between Self-Ligating and
conventionally ligated brackets in vitro.
Results: 73 papers were found. After applying the selection criteria, only 19 papers
were included in this review.
CONCLUSIONS:
• Compared with conventional brackets, SL brackets maintain lower friction
when coupled with small round archwires in the absence of tipping and/or torque.
• There is not enough evidence to claim that with large rectangular wires, in the
presence of tipping and/or torque and in arches with considerable malocclusion,
SL brackets produce lower friction compared with conventional brackets.
Friction

12. ( Baccetti et.al., EJO, 2011)
Comparison between Forces released by Passive Self-ligating
brackets (SLB), Slide ligatures on conventional brackets (SLCB),
and Conventional elastomeric ligatures on conventional brackets
(CLCB) during the alignment of apically or buccally malposed
teeth in the maxillary arch.
Results:
• No difference in the amount of force released in presence of a
misalignment of 1.5 mm.
• At 3 mm of apical misalignment a significantly greater amount of
orthodontic force was released by SLB or SLCB when compared
with CLCB, while no significant differences were found among the
three systems at 3 mm of buccal canine displacement.
• When correction of a large amount of misalignment (6 mm), a
noticeable amount of force for alignment was still generated by the
passive SLB and SLCB systems while no force was released in
presence of CLCB.
Orthodontic Forces

13. Holtmann et.al (2014)
OBJECTIVES:
The goal of this in vitro investigation was to experimentally assess the
effectiveness of different bracket-archwire combinations and the force levels
exerted in two-dimensional direction during correction of tooth malalignment. An
important aspect of this objective was to determine whether the behaviors of
conventional bracket systems with an elastic or steel ligature differ from that of
self-ligating brackets.
CONCLUSION:
Our investigation demonstrates that both conventional steel-ligated brackets and
self-ligating brackets, which are highlighted in the literature as highly efficient
systems, lead to equivalent corrective outcomes in the treatment of tooth
malalignments.

14. Montasser et.al (2014)
MATERIALS:
Three types of orthodontic brackets 1) conventional ligating, 2) self-ligating
(SmartClip a passive self-ligating bracket and Time3 an active self-ligating bracket),
and 3) a conventional low-friction bracket (Synergy).
CONCLUSION:
The resultant tooth alignment was the product of interaction between the archwire
type, bracket type, and bracket design including ligature type. Small cross-sectional
archwires might produce up to 95% correction if combined properly with the
bracket system. Elastomeric rings when used with conventional brackets limit the
efficacy of malalignment correction.

15. (Sifakakis et.al., Aust.OJ, 2010)
Objectives:
To compare the intrusive forces and labio-palatal moments generated at the
maxillary incisors by a 0.017 x 0.025 inch reverse curve NiTi wire using self-ligating
and conventional brackets.
Results:
Conventional brackets (=8.2 N) exerted 30% higher forces in comparison with the
Damon 3MX (6.3 N) brackets and 49% higher forces in comparison with the In-
Ovation R brackets (5.5 N) .
Conclusion:
Active self-ligating brackets may be more effective in torque expression than the
passive ones, but the conventional brackets showed the lowest torque, about 65% of
the values recorded for the self-ligating brackets.
Forces and Moments

16. • Conventional brackets exerted 30% and 49% higher forces in comparison with
Passive and Active SLBs respectively for intrusive forces at the maxillary incisors
(Sifakakis et.al; Aust.OJ, 2010)

17. • Frictional forces can be reduced during alignment:
- Self-ligating brackets,
- Small dimensions,
- Less stiff wires,
Therefore, under such conditions, the force required by the orthodontic wire to
overcome RS is reduced. This allows the wire to exploit its mechanical
characteristics more efficiently (Matarese et.al., AJO&DO, 2008)
Biomechanics
• The use of passive or active self-ligating brackets does not seem to affect
treatment duration for alleviating initial crowding (Pandis et.al, AJO&DO, 2010)

18. BUT, not all studies agree with faster alignment with self-ligating systems,,,!!
• SL brackets were no more efficient than CL brackets in anterior alignment or
passive extraction space closure during the first 20 weeks of treatment (Ong et.al,
AJO&DO, 2010)
• Efficiency of alignment in the mandibular arch in nonextraction patients is
independent of bracket type was accepted. Alignment efficiency is largely influenced
by initial irregularity (Fleming et.al, AJO&DO, 2009)
• The use of passive or active self-ligating brackets does not seem to affect
treatment duration for alleviating initial crowding (Pandis et.al, AJO&DO, 2010)
Biomechanics

19. Fansa M, Keilig L, Reimann S, Jäger A, Bourauel C. The leveling effectiveness of self-
ligating and conventional brackets or complex tooth malalignments. J Orofac Orthop.
2009 Jul;70(4):285-96. German
USED:
- Nine self-ligating bracket systems (Forestadent-Quick, in active and passive variants,
Dentsply GAC In-Ovation, adenta TIME, Ormco Damon 2 and Damon 3MX, UP-
Dental Opal-M and Opal-2, Strite SPEED
system.
- One conventional bracket system (Dentaurum discovery)
CONCLUSIONS: The study demonstrated that bracket selection has a negligible
influence on leveling effectiveness. Although self-ligating brackets are easier for the
orthodontist to manipulate and provide patients with esthetic and wearing comfort
advantages, they are NOT superior to conventional brackets in terms of their
biomechanical characteristics.
Biomechanics

20. Fansa et.al (2009). The leveling effectiveness of self-ligating and conventional
brackets or complex tooth malalignments.
USED:
- 9 self-ligating bracket systems and 1 conventional bracket system.
-CONCLUSIONS: The study demonstrated that bracket selection has a negligible
influence on leveling effectiveness. Although self-ligating brackets are easier for the
orthodontist to manipulate and provide patients with esthetic and wearing comfort
advantages, they are NOT superior to conventional brackets in terms of their
biomechanical characteristics.
Biomechanics
Comparison of frictional resistance between self-ligating and conventional brackets
tied with elastomeric and metal ligature in orthodontic archwires (Leite et.al., 2014).
Friction was influenced not only by the type of bracket, but also by the ligating systems.

21. CONCLUSIONS
• The rates of distal movement of the upper canines were similar with both
conventional and self-ligating brackets.
• Rotation of the upper canines during retraction was minimized with self-ligating
brackets.
•Anchorage loss of the upper molars was similar with both conventional and self-
ligating brackets (Mezomo et.al., AO, 2011)
• Canine retraction by sliding the tooth along an undersized (0.018-inch)
archwire tends to be faster with conventional than self-ligating brackets,
probably because the narrower self-ligating brackets (Damon 3 & SmartClip)
lead to greater elastic binding and resistance to sliding is much more determined
by this than by friction (Burrow, AO, 2010)
Maxillary Canine Retraction

22. • (Vourdouris, AJO&DO, 1997) Light clinical force application permits anchorage
conservation because of low-friction properties.
• (Yee et.al., AJO&DO, 2009)
- Heavy force increases anchorage loss,
- Maximum anchorage cases would benefit from light forces.
• (Southard et.al., AJO&DO, 2007) Does friction between brackets and archwires result
in increased anchorage loading during sliding mechanics? No. If the teeth are free to
slide along the archwire, friction between brackets and archwires does not increase
anchorage loading
Anchorage

23. • SL brackets demonstrate dramatically less friction. Such reduction in friction can help
shorten overall treatment time, especially in extraction cases (Berger, JCO, 2000)
• There was no significant difference in the rate of en-masse space closure between passive
SmartClip brackets and conventional twin brackets tied with stainless steel ligatures (Miles,
AJO&DO 2007)
• SL brackets were no more efficient than CL brackets in anterior alignment or passive
extraction space closure during the first 20 weeks of treatment (Ong et.al, AJO& DO, 2010)
• A lack of supporting evidence does not invalidate the appliances (Self-ligating); indeed, the
preadjusted edgewise appliance also has little evidence to support its widespread adoption
(Fleming et.al., JCO, 2008)
Efficiency

24. Rapid Tooth Movement with a Low-Force, Low-Friction Bracket System
Case report: Light forces can be used to move teeth rapidly, with only transient
patient discomfort. After extraction of the first premolars, the lower canines drifted
distally even before orthodontic force was applied. Although root resorption might
be expected with such rapid tooth movement, the post-treatment panoramic
radiograph did not indicate any periodontal problems
(KAI-WOH LOH, JCO, 2007)
Efficiency- Extraction

25. • Light forces can be used to move teeth rapidly, with only transient patient
discomfort (KAI-WOH LOH, JCO, 2007)
• SL brackets were no more efficient than CL brackets in anterior alignment or
passive extraction space closure during the first 20 weeks of treatment (Ong et.al,
AJO&DO, 2010)

26. • The Damon System corrected moderate crowding in patients (irregularity index
5) 2.7 times faster than the conventional brackets (Pandis et.al., AJO&DO,
2007)
Efficiency- Irregularity Correction
• Efficiency of alignment in the mandibular arch in nonextraction patients is
independent of bracket type (Fleming et.al; AJO&DO, 2009)

27. Efficiency- DisplacedTooth
(Baccetti et.al., AO, 2009)
• When minimal apical displacement is needed (1.5 mm), the differences in performance
between low-friction and conventional systems are minimal.
• Significantly differences when correction of a misalignment of greater than 3.0 mm

28. (Pandis et.al., AJO&DO, 2007)
• Treatment using the Damon System results in greater intermolar width than
conventional treatment with no difference in the amount of mandibular incisor
proclination
(Tarek El-Bialy, SOS Meeting, 2011)
• Three Dimensional Analysis of Treatment Outcome when Using Self-Ligating System“
(Mikulencak, AJO&DO, 2007)
• No significant changes were observed in the canine area.
• The Damon System provides comparable arch width expansion to RPEs with no
difference in the amount of molar tipping.
Efficiency- Expansion

29. (Pandis et.al., AJO&DO, 2007)
• Treatment using the Damon System results in greater intermolar width
than conventional treatment with no difference in the amount of
mandibular incisor proclination
(Chen et.al., AJO&DO, 2010)
• Analyses also showed a small, but statistically significant, difference in
mandibular incisor proclination (1.5 less proclination with self-ligating
brackets compared with conventional brackets)
Incisor Proclination

30. We would expect to see more vertical canine movement and less tipping of the adjacent
teeth with passive ligation compared with conventional ligation (Badawi et.al.,
AJO&DO, 2009)
Vertical Retraction

31. • The Damon patients reported an average of 60% less discomfort than those treated
with conventional braces (Tagawa , CI, 2005)
• The Damon 3 appliance resulted in lower pain intensity, on average, when compared
with the Tru Straight appliance (Pringle et.al., AJO&DO, 2009)
• Patients treated with conventional brackets seem to experience higher and more
intense pain and for a longer period than those treated with self-ligating brackets
(Tecco et.al., EJO, 2009)
• The Damon 2 brackets were initially less painful than the conventional twin bracket
but were more painful when tying in the second archwire (Miles et.al., AO, 2006)
• Bracket type had no effect on subjective pain experience during the 1st week after
initial placement. However, significantly greater discomfort was experienced during
archwire insertion and removal with the SmartClip appliance (Fleming et.al., AO, 2009)
• SLBs do not confer advantage with regard to subjective pain experience (Padhraig
et.al., AO, 2010)
Pain and Discomfort

32. Pain and Discomfort

33. CONCLUSIONS
• There is insufficient evidence to support the use of self-ligating fixed orthodontic
appliances over conventional appliance systems or vice versa.
• SLBs do not confer advantage with regard to subjective pain experience.
• There is insufficient evidence suggesting that orthodontic treatment is more or less
efficient with SLBs
Pain and Discomfort

34. •Elastomeric rings significantly increase the microbial accumulation on tooth
surfaces adjacent to the brackets (Forsberg et.al., EJO 1991)
•The elastomeric rings were associated with a higher score for plaque index and
bleeding than steel ligatures (de Souza, et.al., AJO&DO, 2008)
•Comparison Elastomerics and Wire Ligatures with respect to various measures of
plaque quality and quantity, gingival index, probing depth and bleeding on probing.
The bacteriology results slightly favoured wire ligation, but not to a significant
extent, but the important sign of bleeding on probing was substantially higher with
elastomeric ligation (Turkkahraman et.al., AO, 2005)
Plaque Retention

35. Plaque Retention

36. Conclusions: SL appliances promote reduced retention of oral bacteria (Pellegrini
et.al., AJO&DO, 2009)
Plaque Retention

37. Conclusion: 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. The pre-treatment levels of S. mutans are significant predictors
of the levels of S. mutans after placement of orthodontic appliances, while this
was not the case for total bacterial counts (Pandis et.al., EJO, 2010)
Salivary Streptococcus Mutans Levels

38. JADA,Vol. 140, July 2009, p836
Salivary Streptococcus Mutans Levels

39. (Pandis et.al., OCR, 2008)
Self-ligating brackets do not have an advantage over conventional brackets with respect
to the periodontal status of the mandibular anterior teeth…
The clinical variables:
❖ Plaque index
❖ Gingival index
❖ Calculus index
❖ Probing Depth
Periodontal Condition

40. (YAMAGUCHI ET.AL., WJO, 2009)
▪Introduction: Metabolism by peptidases plays an important role in modulating the levels of
biologically active neuropeptides. One of these neuropeptides, substance P (SP), a
component of gingival Crevicular fluid (GCF) may exponentiate the inflammatory process
during orthodontic tooth movement.
▪Aim: of this study was to investigate the GCF levels of SP in patients using different
bracket system by Split mouth technique in the maxillary teeth. The teeth on the
mandibular left side without any orthodontic attachments served as controls
▪Results: GCF levels of SP for the Damon System sites were significantly lower than for the
teeth with conventional brackets.
▪Conclusion: This result indicates that the Damon System inhibited an increase in the
amount of SP in the GCF. Thus, the Damon System is useful to reduce the inflammation
and pain resulting from orthodontic forces.
Pain and Periodontal Condition

41. • Self-ligating brackets do not have an advantage over conventional brackets with respect
to the periodontal status of the mandibular anterior teeth (Pandis et.al., OCR, 2008)
❖ Conclusion: Damon System is useful to reduce the inflammation and pain
resulting from orthodontic forces (Yamaguchi et.al., WJO, 2009)

42. Conclusion: No differences in terms of white spot lesion formation were found between
conventional straight wire and self-ligating brackets, and white spot lesion formation
does depend largely on patients’ oral hygiene status, not the type of bracket or ligation
used (Polat et.al., WJO, 2008)
White Spot

43. Case Report
Trifocal distraction-compression osteosynthesis with orthodontic miniscrews and passive
self-ligating brackets helped establish bone continuity in a bony defect area, created
anterior curvature of the alveolar bone, and provided good-quality regenerated bone for
implant placement (Baek et.al., AJO&DO, 2008)
Trifocal distraction-compression osteosynthesis in conjunction with passive self-
ligating
Distraction

44. Damon patients were treated in an average of 6.33 months less time than those treated with
conventional twin brackets (Eberting et.al.,2001)
Reduce Treatment Length

45. Damon patients were treated with 7 fewer appointments than those treated with
conventional braces (Eberting et.al.,2001)
Reduce Number of Appointments

46. Patients treated with the Damon System reported greater satisfaction with their treatment
(Eberting et al., 2001)
Patients Satisfaction

47. Starting from statistically equivalent PAR scores, Damon cases finished an average of 20%
better than non-Damon cases (Harradine, 2001)
Better Finished Cases

48. Reasons For Not Accepting Self-Ligating System:
• Low Force Orthodontics System!
• Scientific Evidence (e.g. Study Design…),
• Postgraduate Training:
o 80% of Canadian orthodontic residents plan to use SLB (Noble et.al, 2009).
o 63% of USA orthodontic residents plan to use SLB (Noble et.al, 2009).
o 50% of Saudi orthodontic residents plan to use SLB (Alhamlan et.al., 2013).
•Time to change!
•History?..Design of Brackets…Not Manufacturing well!
•Price

49. In Closing………………………

50. ❑ “I continue to tell graduates at the University of the Pacific that if I were practicing today
by the standards I was taught in the 1960s, I would be guilty of malpractice. We have come a
long way and the changes have been most rewarding for our patients and fellow
practitioners” (Letter for the Editor by Dugoni, Dean and Professor of Orthodontics, University of Pacific , and President of
ADA, AO, 1990)
❑ “The truth is that the most important attribute of a thoroughly competent clinician is clinical
judgment, which develops from sound experience and is BOLSTERED by, but NOT BASED
EXCLUSIVELY ON, systemic scientific evidence” (Ackerman et.al; 2006)
❑ What is Clinical Judgment?
• Deciding what is needed for a patient based on information or evidence derived from averages
and previous experience.
• It is PERCEPTION based on experience with sometimes little immediate scientific evidence to
support it (Ackerman et.al; Aust OJ, 2004)
A lack of supporting evidence does not invalidate the appliances (Self-ligating); indeed, the
preadjusted edgewise appliance also has little evidence to support its widespread adoption
(Fleming et.al., JCO, 2008)
In Closing………………………

51. Thank YOU
To be cont.