Professional Documents
Culture Documents
Appliance System
David Birnie
The Damon System (Ormco Corp., 1332 South Lone Hill Ave., Glendora, CA
91740-0000) is a passive self-ligation system that was originally introduced
in 1994. Since then, both the bracket and the philosophy behind the system
have undergone continuous evolution. If the development of the Edgelok
(Ormco Corp.) appliance by Wildman in 1972 and the development of the
SPEED (Strite Industries Ltd., 298 Shepherd Ave., Cambridge, Ontario, N3C
1V1 Canada) appliance by Hanson in 1980 marked the start of modern
self-ligating appliances, then the Damon System has probably been responsible
for a fuller understanding of the influence of passive self-ligation on orthodontic
treatment and the increasing popularity and utilization of the concept. (Semin
Orthod 2008;14:19-35.) © 2008 Elsevier Inc. All rights reserved.
Figure 5. Start of treatment. Right buccal segment Figure 7. End of treatment. Treatment duration, 22
half a unit Class II. Right permanent cuspid in the line months including time for upper right permanent
of the arch. (Color version of figure is available on- cuspid to erupt. (Color version of figure is available
line.) online.)
This is demonstrated in Figures 5-7 where ● Significant posterior expansion without the
the right buccal segment has been distalized half need for auxiliary expanders such as rapid
a unit to allow eruption and alignment of the maxillary expansion and quadhelices or W-
upper right permanent cuspid with gentle acti- springs; and
vation of the coil spring only; during distaliza- ● Posterior expansion that is not produced by
tion, no increase in overjet occurred. In nonex- the tipping movements normally expected
traction cases, this suggestion means that tooth with expansion achieved by the use of arch-
alignment results in: wires and cross-elastics alone.
● Less incisor proclination and less labial pro-
trusion than might be expected with a conven- Evidence for the Damon Philosophy
tional nonextraction treatment;
Archwire Placement and Removal
The speed of archwire ligation and release has
been studied by a number of authors3-6 and
self-ligating brackets have been shown to take
less time and also require less or no chairside
assistance. Turnbull and Birnie7 divided the
archwires into four different groups in ascend-
ing order of size. They found that:
● The time taken to ligate archwires decreased
with increasing archwire size. This was an un-
expected finding; it might be expected that
ligation of thicker wires might takes longer
because of greater difficulty in obtaining full
archwire engagement in the bracket. How-
ever, the difficulty of obtaining full archwire
Figure 6. Seven months into active treatment. Space engagement in the bracket with thicker arch-
has been opened for the upper right cuspid and the wires was offset by the tooth alignment pro-
upper right buccal segment has been distalized half a duced by earlier archwires.
unit by placing an open nickel titanium coil spring
one bracket width wider than the interbracket span ● The time taken to open the Damon self-ligat-
and replacing at each visit. The overjet is unchanged. ing brackets and to remove elastomeric liga-
(Color version of figure is available online.) tures was almost independent of archwire size.
22 D. Birnie
Dental Factors
Dental factors include:
● Space analysis,
Figure 9. Damon 3 MX bracket with gate closed. ● Arch width analysis, and
24 D. Birnie
Lower Arch
L1 L2 L3 L4 L5 L6 L7
● The inclination of labial and buccal segment obtain better orthodontic results than those with
teeth. compromised oral health. Particularly in the
preteen and teenage patient, the healthy peri-
Several decades ago, tooth extraction was neces-
odontium seems to have significant powers of
sary to obtain dental alignment because of the
adaptation and regeneration.
relatively unsophisticated appliances available.
Technically, it is often no longer necessary, ex-
cept in a few cases, to extract teeth to obtain Bracket Selection
alignment or to facilitate orthodontic mechan-
Obtaining the correct inclination of teeth during
ics. Extractions may be required, however, to
orthodontic treatment has always been challeng-
optimize facial balance or because of dental or
ing with orthodontic appliances based on the
periodontal pathology. In addition, tooth extrac-
edgewise system. The Damon System provides sev-
tion does not necessarily prove a guarantee of
eral torque options for incisor and cuspid teeth
posttreatment or postretention stability.
and these are shown in Table 1. In general, the
torque selected in each bracket should be de-
Cephalometry
signed to over-correct tooth position.
Cephalometry remains an important tool for the
orthodontist, but long and elaborate analyses High Torque Brackets
are unnecessary in most cases. It remains subser-
Examples of where high torque brackets may be
vient to facial analysis for many measurements.
used on upper incisors are as follows:
Some parameters (such as upper incisor inclina-
tion) can be visualized directly rather than being ● Extraction cases where treatment mechanics
measured from a lateral skull radiograph. In may excessively retrocline the upper incisors;
addition, treatment to mean values (such as for ● Class II Division 1 malocclusions where treat-
incisor inclination) do not recognize the signif- ment mechanics may excessively retrocline the
icant range of biological variability present in upper incisors; and
the population nor is this strategy a guarantee of ● Class II Division 2 malocclusions.
treatment stability.
Examples of where high torque brackets may be
The response of the facial tissues to tooth
used on upper cuspids are as follows:
movement, particularly proclination, is unpre-
dictable and so tooth movements planned to ● First premolar extraction cases; and
achieve favorable, or prevent unfavorable soft ● Cases where the crowns of the upper cuspids
tissue movements, should be executed with are palatally tipped.
caution.
Standard Torque Brackets
Oral Health
Standard torque brackets are used where the
Patients with good oral health, excellent oral inclination of the teeth is satisfactory before
hygiene, and a normal gingival biotype seem to treatment and the treatment mechanics will not
Damon Passive System 25
adversely affect the inclinations during treat- ● For deep bite cases, cuspid and incisor brackets
ment. should be progressively placed slightly more in-
cisally in both arches to aid bite opening.
● For open bite cases, cuspid and incisor brackets
Low Torque Brackets should be placed progressively slightly more gin-
Examples of where low torque brackets may be givally in both arches to aid bite closure.
used on upper incisors are as follows: ● Where teeth have to undergo significant trans-
lation, overangulation of the brackets to exag-
● Excessively proclined upper incisors; gerate the root movement in the desired di-
● Isolated upper incisors with palatally posi- rection will ensure adequate root movement
tioned roots (eg, upper lateral incisor in the occurs. Examples of malocclusions where this
palate); strategy is helpful include the correction of
● Malocclusions where treatment mechanics pseudotranspositions, the opening of space
may result in excessive upper incisor proclina- for restorative implants, and closure of large
tion; spaces such as moving lateral incisors into cen-
● Moderate and severe upper arch crowding; tral incisor spaces.
and ● Where teeth have incisal edge damage or are
● Anterior open bite cases with proclined substituting for other teeth, position the
incisors. brackets to obtain the correct gingival emer-
Examples of where low torque brackets may be gence profile and adjust the subsequent in-
used on lower incisors are as follows: cisal edge problem restoratively.
● Brackets are not inverted to change the torque
● Cases where it is necessary to control the pro- values as this may make the gates more vulner-
clination of lower incisors, eg; extreme lower able to inadvertent opening, and rarely gen-
labial segment crowding, cases using Class II erates enough torque to completely correct
elastics, and fixed Class II correctors attached the problem.
to the brackets, buccal tubes, or archwires;
and Instead, choose a bracket with a torque value
that will exaggerate the tooth movement re-
● Lingually placed lower incisors. quired (such as a low torque bracket for a pala-
The brackets with optional torque values should tally placed upper lateral incisor). This solves
not be used as “sets.” The clinician should study the first problem, but in most cases, additional
the case carefully beforehand and individually torque will need to be placed in the archwire to
select the bracket with the correct torque for obtain ideal root position.
each tooth.
too large to reliably support small-diameter spontaneously by this stage, particularly when, as
nickel titanium archwires; is often the case, the crossbite has not included
● Substantially correct all anterior rotations and the second molars. Where buccal segment cross-
partially correct posterior rotations; and bites persist, the use of a 0.016⬙ ⫻ 0.025⬙ pre-
● Initiate arch development by using light posted stainless steel archwire in the arch where
enough forces to allow the soft tissues to in- some buccal or lingual tipping is desired, to-
fluence arch shape. gether with the use of a 3/16⬙ (110 g) cross
elastic, will assist crossbite correction.
This phase of treatment normally lasts 10 to 20
The aims of this phase of treatment are to:
weeks and appointment intervals are at 10
weeks. ● Maintain the archform developed in the first
two phases,
Phase 2: High Technology Rectangular Wires ● Finish torque control,
● Consolidate posterior space, and
The second molars are normally engaged by ● Completely correct anteroposterior, buccolin-
the first archwires in this phase except in pa- gual, and vertical relationships.
tients with anterior open bites. This phase of
treatment normally uses two archwires: 0.014⬙ This phase of treatment lasts 8 to 10 weeks with
⫻ 0.025⬙ followed by 0.018⬙ ⫻ 0.025⬙ copper appointments at 10-weekly intervals. Where
nickel titanium wires. In cases that are well Class II or Class III elastics are being used, buc-
aligned at the start of treatment, these two cal segment correction occurs more quickly if
archwires can occasionally be replaced by a the molar distal to those to which the elastic is
single 0.016⬙ ⫻ 0.025⬙ copper nickel titanium placed are temporarily not included in the arch-
wire. The use of a wire with a 0.025⬙ first order wire.
dimension is critical to obtain tooth alignment
by almost completely filling the 0.027⬙ slot Phase 4: Finishing and Detailing
depth of a Damon bracket.
The stainless steel archwires may be continued
Where incisor intrusion is required, 0.017⬙ ⫻
in this phase. However, some detailed adjust-
0.025⬙ or 0.019⬙ ⫻ 0.025⬙ copper nickel titanium
ments to individual teeth may be required, in
archwires with preformed curves or reverse
which case 0.019⬙ ⫻ 0.025⬙ ß-titanium archwires
curves of Spee can be used in this stage. Addi-
allow individual adjustments to be made in the
tional torque can also be applied at this stage
archwire to optimize tooth positions. Settling
with the use of 0.019⬙ ⫻ 0.025⬙ copper nickel
elastics may be used to develop a well-interdigi-
titanium archwire preformed with 20° of torque
tated occlusion.
anteriorly.
The aims of this stage of treatment are to:
Managing Severely Displaced or Rotated Teeth
● Fully correct all rotations and obtain full align-
ment of all teeth, Severely displaced teeth are managed by creating
● Consolidate any anterior space and maintain space for the teeth with open coil spring; this
tooth contact, should be done with low forces and the coil spring
● Initiate torque control, should be no longer than the width of the space
● Initiate bite opening, and plus a bracket width (approximately 3 mm). A
● Continue arch development. traction hook is bonded to the displaced tooth.
The displaced tooth is tied to the archwire with
The duration of this phase of treatment is 20 to elastic thread. Two types of traction hook are used:
30 weeks. The first archwire is left in place for 8
to 10 weeks and the second for 4 to 6 weeks. ● A very thin wire loop traction hook on a bond-
able base. This is demonstrated in Figs 11 and 12
and used where there is very little space for the
Phase 3: Major Mechanics
displaced tooth or on rotated teeth some dis-
The archwires used in this phase are 0.019⬙ ⫻ tance from the line of the arch. It is positioned
0.025⬙ preposted stainless steel archwires. Many so that the lumen of the hook will allow the
buccal segment crossbites will have corrected archwire to pass through it as the tooth ap-
Damon Passive System 27
Figure 11. This patient has an upper left palatal cus- Figure 13. The upper left lateral incisor has a broad
pid that is rotated mesially. A traction hook has been traction hook in place with the 0.014⬙ copper nickel
placed on the mesial edge of the tooth to maximize titanium archwire running through its lumen. There
derotation as the tooth moves to wards the line of the is insufficient room to place a full-sized bracket. The
arch. The bracket system is Damon2 (D2) and the broader traction hook gives some rotational control
archwire 0.014⬙ copper nickel titanium. A length of and is usually replaced with a normal passive self-
coil spring one bracket width wider than the space has ligating bracket after one visit. (Color version of fig-
been placed and the tooth attached to the archwire ure is available online.)
with elastomeric thread. (Color version of figure is
available online.)
Figure 15. Extraoral photographs at the start of treatment aged 14 years 0 months. Note relatively immature
facial appearance. (Color version of figure is available online.)
● The Herbst axles are placed on the archwires. ● In the upper arch, the Herbst axles are placed
In the upper arch, the 2-mm Inconel tube between the upper first and second molars. In
projection should face anteriorly, and in the the lower arch, the Herbst axles are placed
lower arch posteriorly. This is to maximize the between the lower cuspids and the lower first
distance between the axles. premolars. The Inconel tube should be an
30 D. Birnie
Retention
Retention is normally with a fixed solid 0.026⬙
stainless steel wire retainer from the lingual
Figure 17. Cephalometric radiograph at the start of surface of lower cuspid to lower cuspid. The
treatment.
wire is only bonded to the lingual surfaces of
the lower cuspids, which are lightly sand-
exact but not tight fit between the intertube/ blasted before etching. The ends of the wire
interbracket space. are flattened, contoured, and sandblasted to
● The Herbst piston/cylinder assembly is then maximize retention. In the upper arch, a
cut to provide approximately 4 to 6 mm of braided retainer wire (Reliance Orthodontic
initial protrusion. The piston should be Products, PO Box 678, Itasca, IL 60143) is
trimmed so that it does not protrude more bonded to the palatal surfaces of the four
than 3 mm out of the back of the cylinder in upper incisors ensuring that it does not inter-
the closed position so as to avoid irritation to fere with the lower incisors. Upper and lower
vacuum formed retainers are used in addition cellent control of tooth position. All contem-
on a nighttime-only basis. porary modalities of orthodontic treatment
For patients who have had correction of a Class can achieve tooth alignment; passive self-liga-
II skeletal pattern, a Damon splint and tongue tion, however, does achieve results effectively,
trainer is used to maintain Class II correction over efficiently, and in a manner that corresponds
the long term. This is shown in Fig 14. with patient values. In addition, practitioners
experienced with the technique perceive that
additional, unexpected patient benefits occur
Summary
that are not traditionally associated with con-
Passive self-ligation offers the most direct ventional orthodontic treatment. However,
transmission of force from archwire to tooth these need further evaluation to understand
with very low friction, secure ligation, and ex- and substantiate them. Mastering self-ligation
is challenging, however, and it is not a tech- occur during his teenage years. He has a left
nique that requires less clinical judgment or unilateral crossbite. The lower right central in-
proficiency. Effective health care interventions cisor has a long clinical crown (see Figs 15-17).
must have an evidence base; that evidence All permanent teeth were present on the dental
base is a combination of clinically relevant pantomogram except for the upper third mo-
research, clinical expertise, and patient val- lars. His oral hygiene was good although still
ues.22 For passive self-ligation, the clinically capable of improvement.
relevant research base is small because interest
in the subject has only commenced relatively
recently, but is growing steadily; clinical exper-
tise has allowed the technique to evolve and
mature and its flexibility allows it to respond
to patients’ needs and preferences.
Case Presentation
This case is presented because it is challenging and
controversial. It was treated by the author shortly
after changing over completely to passive self-liga-
tion in 2001. There are many possible ways of
treating it. Important questions, however, are:
● What caused the malocclusion?
● What treatment would provide the best opti-
mization of facial appearance, smile esthetics,
oral health, and stability?
Patient 09038801 presented at 14 years 0 months
with moderate upper arch crowding and severe
lower arch crowding. His facial appearance was
prepubescent, he did not seem to have entered
his pubertal growth spurt, and it was thought Figure 22. The posttreatment cephalometric radio-
that significant nasal tip and chin growth would graph.
Damon Passive System 33
Table 2. Cephalometric and Study Cast Values at the Start of Treatment and Four Months after the End of
Active Treatment (First Retainer Check)
Units 18 March 2002 11 March 2005 Difference
Skeletal measurements
SNA degrees 83.4 83.0 ⫺0.4
SNB degrees 77.9 77.3 ⫺0.6
ANB degrees 5.6 5.7 0.1
SN-maxillary plane degrees 4.2 5.6 1.4
Maxillary-mandibular plane degrees 27.8 28.2 0.4
LAFH mm 55.2 62.1 6.9
UAFH mm 50.2 54.7 4.5
LAFH/TAFH % percent 55.1 56.7 1.6
LPFH mm 24.3 27.8 3.5
UPFH mm 45.0 47.5 2.5
PFH mm 69.4 75.3 5.9
Wits appraisal mm 3.0 4.4 1.4
Teeth
Overjet mm 7.6 2.8 ⫺4.8
Overbite mm 3.2 1.3 ⫺1.9
UI-Maxillary plane degrees 113.9 114.9 1.0
LI-Mandibular plane degrees 87.4 97.5 10.1
Interincisal angle degrees 131.0 119.3 ⫺11.7
L1-Apo mm 0.2 3.4 3.2
L1-Facial plane mm 3.0 6.1 3.1
Soft tissue
Upper lip to E-plane mm ⫺1.3 ⫺5.1 ⫺3.8
Lower lip to E-plane mm 1.3 ⫺0.2 ⫺1.5
Nasolabial angle degrees 114.4 121.7 7.3
Chin thickness mm 10.6 9.5 ⫺1.1
B-NPo mm ⫺1.1 ⫺2.4 ⫺1.3
L1-Mandibular plane mm 34.6 39.5 4.9
Lower study cast
Inter cuspid width mm 19.2 29.4 10.2
Inter first bicuspid width mm 29.6 38.1 8.5
Inter second bicuspid width mm 38.2 43.8 5.6
Inter first molar width mm 49.6 50.7 1.1
Inter second molar width mm 52.2 55.9 3.7
Upper study cast
Inter cuspid width mm 31.4 38.4 7.0
Inter first bicuspid width mm 39.0 46.4 7.4
Inter second bicuspid width mm 41.0 51.1 10.1
Inter first molar width mm 47.0 55.1 8.1
Inter second molar width mm 52.3 58.1 5.8
SNA, Sella-Nasion-A point; SND, Sella-Nasion-B point; ANB, A point-Nasion-B point; LAFN, lower anterior facial height; UAFH,
upper anterior facial height; LAFH/TAFH%, lower anterior facial height as a percentage of total anterior facial height; LPFH,
lower posterior facial height; UPFH, upper posterior facial height; UI, upper incisor; LI, lower incisor; Apo, A Point-Pogonion;
E-plane, Rickett’s esthetic plane; B-NPo, B-Point-Nasion-Pogonion.
Figure 18 shows treatment progress after 7 been maintained with a continuous tie or stops
months of treatment. Alignment has been distal to both upper cuspids.
achieved in the upper arch, but there is still Figure 20 shows 25 months into treatment.
insufficient space for the lower left lateral inci- The second molars were bonded 16 months into
sor. No crossbite correction has yet taken place; treatment, and crossbite correction then oc-
note that the right second molars, which are just curred spontaneously without the need for aux-
visible, are not in crossbite. iliary appliances or cross elastics. Once stainless
Figure 19 shows 15 months into treatment. steel archwires were placed, the upper archwire
Alignment within the arches has been achieved, was expanded and the lower contracted to en-
but crossbite correction has not yet taken place. sure maximal correction.
Once alignment of the upper labial segment had Figure 21 shows 12 months after the end of
been obtained, the consolidation should have active treatment and 1 year into retention. The
34 D. Birnie
Figure 23. Extraoral photographs taken 12 months after the end of active treatment showing that significant
facial maturation has taken place. Nasal growth has taken place and the hyoid bone is now much more
prominent. (Color version of figure is available online.)
Figure 24. Superimposition of the start and finish cephalometric tracings. The amount of nasal growth relative
to lip growth is demonstrated. The upper incisors have retained their inclination, but there has been proclina-
tion of the lower incisors. (Color version of figure is available online.)
Damon Passive System 35
clinical crown heights of the lower incisors have 9. Pizzoni L, Raunholt G, Melsen B: Frictional forces
equalized. In addition to the fixed retainers, the related to self-ligating brackets. Eur J Orthod 20:283-
291, 1998
patient wears vacuum formed retainers in the
10. Khambay B, Millett D, Mc Hugh S: Evaluation of meth-
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Figure 22 shows the posttreatment cephalo- J Orthod 26:327-332, 2004
metric radiograph. Table 2 shows the cephalo- 11. Thorstenson BS, Kusy RP: Comparison of resistance to
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first retainer check four months after the end of ond-order angulation in the dry and saliva states. Am J
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12. Sims APT, Waters NE, Birnie DJ: A comparison of the
Figure 23 shows the patient’s facial appearance
forces required to produce tooth movement ex vivo
12 months after the end of active treatment. Sig- through three types of preadjusted brackets when sub-
nificant maturation of the face has taken place jected to determined tip or torque values. Br J Orthod
including nasal tip growth and development of the 21:367-373, 1994
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