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227]

18 Original article 

Effectiveness of the Damon system in the treatment of

nonextraction orthodontic cases
Yasmine M. Sayeda,b, Safaa M. Gaballahb, Eman M. El Shourbagyb

Orthodontic Department, Faculty of Dentistry,

a
Cairo University, Cairo, Egypt, bOrthodontic
Department, Faculty of Dentistry, Tanta
University, Tanta, Egypt
Correspondence to Yasmine M. Sayed, MDS,
Orthodontic Department, Faculty of Dentistry,
Tanta University, Tanta - 27941, Egypt
Tel: +20 100 313 0308; Fax: +20 040 3345314;
e-mail: jasymme@yahoo.com
Received 22 February 2016
Accepted 17 March 2016
Tanta Dental Journal
2016, 13:18–27
Objectives
The purpose of this study was to evaluate the dental, skeletal, and soft-tissue change in
crowding cases treated with nonextraction approach using the Damon system.
Materials and methods
The sample included 20 patients, with an average age of 17.8 ± 3.7 years, selected on the
basis of pretreatment class I skeletal and molar relationships with an acceptable soft tissue
facial profile, and a moderate crowding range between 4.0 and 9.0 mm for the maxilla and 2.0
and 6.0 mm for the mandible. None of them had received any orthodontic treatment before,
or had extraction or any congenital anomalies such as supernumerary teeth.
Results
The evaluation of the study was performed by detecting the dental, skeletal, and soft tissue
changes between pretreatment and post-treatment study models and lateral cephalometric
radiographs. The paired t-test was used for statistical analysis. The treatment required
20.7 ± 2.2 months to be finished, with an average of 13.8 ± 1.5 appointments.
Conclusion
The results of this study revealed that the correction of crowding was achieved through
expansion of the dental arches and mandibular incisors proclination.

Keywords:
damon system, expansion, nonextraction, self-ligating brackets

Tanta Dental Journal 13:18–27

© 2016 Tanta Dental Journal
1687-8574

significant expansion in all measurements in both

Introduction
Self-ligating brackets are not new conceptually, having
been pioneered in the 1930s. In the mid-1990s,
Dwight Damon was intrigued by the idea of lateral
posterior expansion using the Damon system. Damon
developed a theory asserting that low friction and light
forces distribute expansion forces gently and produce
more biologically stable results. His philosophy was the
impetus for the creation of his orthodontic appliance
system [1]. The use of self-ligating brackets has
gained popularity recently in orthodontic treatment:
in particular, the Damon appliance system. The
Damon system uses passive self-ligation with the use
of light forces of copper–nickel–titanium (CuNiTi)
archwire to achieve arch development and to relieve
dental crowding. Since then, both the brackets and
the philosophy behind the system have undergone
continuous evolution with the most recent bracket
being the Damon Q. Dr Damon claimed that a
significant amount of crowding could be relieved
without extractions with faster treatment time,
increased patient comfort, fewer visits, and excellent
final results [2]. Several investigations have studied the
above-mentioned claims of the Damon system.
A constant agreement was found among studies
that the Damon system produced a statistically
arches, with most of the expansion occurring at the
premolars [3–10]. However, another study [11] found
that a significant change was not seen in the canine
area. Mikulencak [11] also showed that the maxillary
arch expansion produced a 0.5° palatal uprighting of
the maxillary molars during treatment. In contrast,
Jackson [5] found that the amount of tipping did not
show a significant association in either group. Many
authors [3,6–9] reported that an alignment-induced
increase in the proclination of the mandibular incisors
was observed for both bracket groups. In a study by
Ehsani [6] and Fleming et al. [10], Damon treatment
resulted in a lingual root torque of upper incisors. In
contrast, Vajaria et al. [9] found that the upper incisor
position and angulation were not altered significantly,
and Pandis et al. [12] found that self-ligating brackets
seem to be equally efficient in delivering torque to
maxillary incisors relative to conventional brackets in
extraction and nonextraction cases. Al-Sanea [4] and
Huang et al. [8] revealed an increase in anterior arch
depth in both arches.
This is an open access article distributed under the terms of the Creative
Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non-commercially, as
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© 2016 Tanta Dental Journal | Published by Wolters Kluwer - Medknow DOI: 10.4103/1687-8574.186942
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Damon system in nonextraction orthodontic cases Sayed et al.   19
Aim of the work
The current clinical trial aimed to evaluate the changes
that occur after treatment with the Damon system and
to investigate whether or not the goals of the Damon
system were met over the course of orthodontic
treatment.
Materials and methods
The sample of this study consisted of 20 patients
seeking orthodontic treatment in the Orthodontic
Department, Faculty of Dentistry, Tanta University.
The patients’ ages ranged from 13 to 23 years at the
start of the treatment. Patients with good oral hygiene,
permanent dentition, class I skeletal relationship with
an acceptable soft tissue facial profile, class I molar
relationship, and moderate maxillary and mandibular
dental arch crowding were included in the study.
Patients who had received any orthodontic treatment,
extraction of any permanent teeth except third molar,
skeletal discrepancy, and presence of supernumerary
teeth or other congenital anomalies were excluded
from selection. Written informed consent was obtained
from each patient before orthodontic treatment. The
following were recorded before treatment (T1) after
thorough clinical examination with medical and
dental history and after treatment (T2): extraoral and
intraoral photographs; panoramic radiographic film;
lateral cephalometric radiographs; and study models.
All patients were treated with a nonextraction approach
using the Damon system appliance. Damon Q brackets
(Ormco Corporation, Orange, California, USA) were
bonded to the teeth from second premolar to second
premolar; SnapLink passive self-ligating buccal tubes
were bonded for first molars and titanium buccal
tubes were bonded for second molars. The Damon Q
brackets with optional torque values were not used as
‘sets’ otherwise the correct torque for each tooth was
selected. Each tooth was polished, rinsed with water,
dried, etched with 37% phosphoric acid for 30 s, and
rinsed thoroughly with water for a minimum of 5 s
per tooth with a forceful air/water spray. The enamel
was dried with clean, oil-free compressed air to obtain
a uniform, dull, frosty appearance. A very thin coat
of sealant and bond enhancer (Ortho solo 740-0271;
Ormco Corporation) was applied to the prepared
tooth and air thinned. A small amount of light-cured
two-way color change adhesive paste (Grengloo
adhesive 740-0321; Ormco Corporation) was placed
on the orthodontic bracket base. The bracket was
placed on the tooth following the principles suggested
by Andrews, in which the brackets were placed on
the midpoint of the facial axis of the clinical crown,
with the vertical bracket removable positioning gauge
parallel to this axis. Thereafter, it was pressed gently
and the excess adhesive around the bracket was
removed with a clinical probe. Finalized position and
light-curing using conventional LED light was started
within 2 min and was left for 20 s for each bracket and
30 s for every molar tube.
All teeth were bonded and included in the archwire
from the first appointment. Blocked-out teeth were
managed by creating space with open Ni–Ti coil spring,
and the displaced tooth was tied to the archwire with
an elastic thread, a traction hook, or a 0.008” stainless
steel ligature wire. The preloaded crimpable stops of
the Damon CuNiTi archwire were placed on a section
of the archwire where little movement of the archwire
relative to the bracket was expected to occur. Thus, stops
were placed as far as possible from crowded, displaced,
or rotated teeth at either side of a bracket, or at either
end of an interbracket span. Where crowding was
bilateral, stops were placed anterior to the crowding
typically at or near the midline (Fig. 1).
The archwire was inserted into the slot so that it was not
obstructing the slide. Ordinarily, archwire was inserted
and the slides were closed easily with the fingertips.
In cases with severely rotated teeth and archwire that
was severely deflected and difficult to insert into the
bracket slot, a ligature director was used to seat the
archwire. Opening and closing of the bracket slide were
carried out using SpinTek slide opening instrument or
SpinTek slide opening/closing instrument (SpinTek
slide opening/closing instrument 866-4016; Ormco
Corporation) (Fig. 2).
Drop in hooks (Damon Q Drop-in Hooks 242-0114;
Ormco Corporation) were added for any bracket in the
vertical slots for intermaxillary elastic attachment while
Figure 1
a b
(a) Frontal view showing the archwire stops placed at either side
of the maxillary central incisors a bracket and at either side of a
mandibular left central incisor bracket. (b) Frontal view showing the
change in the archwire stops position to be placed at either end of
the maxillary central incisors interbracket span (midline) and between
the mandibular right and left central incisor bracket (midline) after
crowding relief.
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20  Tanta Dental Journal
Figure 2
a b c a
(a) Insertion of the flat end of the SpinTek slide instrument into the
slide and twisting 900 clockwise. (b) The flat end of the SpinTek slide
instrument twisted 900 and slide opened. (c) Positioning the SpinTek
slide instrument on both sides of the bracket and squeezing the
opposing prong of the instrument upward.
progressing through the Damon archwire sequence
regardless of round or rectangular wires. The hook was
inserted in the vertical slot and bended behind the tie
wings, as shown in Fig. 3.
Treatment phases and archwire sequencing were
carried out according to the manufacturer’s instructions
and relative to each case pretreatment malocclusion. In
the presented case, all teeth of the maxillary arch were
bonded and included in the initial archwire in the first
appointment; posterior composite buildup was placed
on the occlusal surface of the mandibular first molars,
followed by bonding of the mandibular teeth and
insertion of the mandibular first archwire in the next
appointment. In the first phase of treatment, a light
Damon CuNiTi archwire measuring 0.013” and/or
0.014” in diameter was used to correct rotations, align
the teeth, and initiate arch development. This phase
lasted nearly 6 months, with appointments at 6-week
intervals (Fig. 4). In the first recall appointment,
archwires were removed, permanent deformations
were checked and replaced with new archwire if
necessary, and original or new archwire was inserted.
The next archwire used was 0.016” followed by 0.018”
Damon CuNiTi archwires. Early light intermaxillary
elastics of 3/16” and 2 oz (Quail 630-0011; Ormco
Corporation) were used. Force was usually begun to
be used in this phase with 0.018” Damon CuNiTi
archwires according to each case canine relation and
midline shift, if present.
In the second phase, two archwires were often used,
followed by CuNiTi archwires. This phase lasted from
3 to 6 months, with appointments at 6-week intervals.
At this stage of treatment the following were carried
out: full correction of all rotations and full alignment
of all teeth were obtained; any space was consolidated
Figure 3
b
(a) Inserting the drop in hook into the vertical slot. (b) Bending the
drop in hook behind the tie wings.
and tooth contact was maintained; and torque control
was initiated, by almost filling the 0.028” slot depth.
The process of space consolidation between teeth
was carried out on rectangular archwires using chain
elastics from molar to molar. If all spaces between
teeth were closed, the teeth were ligated together
under the archwire with 0.008” stainless steel ligature
wire. In patients who began this phase with fairly
well-aligned teeth, a single 0.016 × 0.025” CuNiTi
archwire was used for 3 months. The archwires used
in the third phase were 0.016 × 0.025”, followed by
0.019 × 0.025” preposted stainless steel (Stainless steel
archwire with preposted hooks distal to laterals; Ormco
Corporation). This phase lasted nearly 3–6 months
with appointments at 6-week intervals. In this phase
of treatment, torque control was finished, and correct
anteroposterior, buccolingual, and vertical relationships
were obtained (Fig. 5).
The archwires used in the final phase were
0.019 × 0.025” preposted stainless steel, followed by
0.019 × 0.025” Damon low-friction TMA (Ormco
Corporation) or 0.019 × 0.025” Damon low-friction
TMA only, depending on the final detailing needed.
Final buccolingual, torque, and occlusal adjustments
were carried out in this phase of treatment. This phase
lasted nearly 3 months, with appointments at 6-week
intervals. Debonding was performed using Damon
Q debonding instrument (Damon Q debonding/
repositioning instrument 866-4008; Ormco
Corporation). Remaining adhesive was cleaned by
cooling the adhesive with short blasts of cold air or
water to revert it back to its original green color, and
then removed with low-speed carbide burs, followed
by sandpaper discs and a polishing cup or paste (Fig. 6).
The lingual retainer was fabricated directly in the
patient’s mouth. A flattened braided lingual retainer
wire (Bond-a-Braid #BAB2; Reliance Orthodontic
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Damon system in nonextraction orthodontic cases Sayed et al.  21

Figure 4 on the lingual surface of teeth, from canine to canine,

and then bonded with a small amount of resin. Excess
resin was eliminated from the wire with a high-speed
diamond bur. Vacuum-formed retainers were fabricated
on the final models and patients were instructed to wear
a
them for 6 to 12 months while the soft and hard tissues
remodel around the teeth. The following were recorded
before (T1) and after treatment (T2) to determine
b c
the changes that occurred during treatment. On study
casts, space analysis, arch width, arch depth, curve of
Spee, overjet, overbite, and first molar angulation were
measured. On lateral cephalometric radiographs, the
following measurements were calculated for each lateral
d e cephalogram. The cephalometric measurements were
(a) Frontal, (b) right lateral, (c) left lateral, (d) maxillary occlusal, categorized into skeletal measurements (SNA, SNB,
and (e) mandibular occlusal views showing the first 0.013" Damon ANB, PtV-A, PtV-B, and y-axis), dental measurements
CuNiTi archwire.
(U1-SN°, U1-NA°, U1-NA mm, U1-A-Pog°, U1-A-
Pog mm, U1-PtV mm, DU6-PTV mm, L1-MP°, L1-
Figure 5 NB°, L1-NB mm, L1-A-Pog°, L1-A-Pog mm, L1-
PtV mm, DL6-PTV mm, and interincisal angle), and
soft tissue measurements (E Plane-Ls, E Plane-Li,
superior sulcus depth, inferior sulcus depth, nasolabial
a
angle, and mentolabial angle).

Statistical analysis
b c Study model and lateral cephalometric measurements
were recorded and then the data were tabulated. To
assess intraobserver reliability, the measurements were
repeated for all patients after 2 weeks. Dahlberg’s formula
was used for reporting the error between measured and
d e
remeasured data [13]. The coefficient of reliability was
(a) Frontal, (b) right lateral, (c) left lateral, (d) maxillary occlusal,
found to be on average 0.3 and 0.1° with corresponding
and (e) mandibular occlusal views showing 0.016×0.025" preposted P-values of 0.097 and 0.314 for lateral cephalometric
stainless steel archwire. and study model angular measurements, respectively.
In addition, the mean error of the linear measurements
Figure 6 was 0.2 mm (0.135) for the lateral cephalometric and
0.15 mm (0.247) for the study model. Data analysis
was performed using SPSS version 21 (Chicago,
USA). Statistical analysis of the data with different
characteristics was performed with the use of the paired
a
t-test. A two-tailed P-value of 0.05 was considered
statistically significant with a 95% confidence interval,
whereas P-values of 0.001 were considered highly
b c significant with a 99.9% confidence interval.

d e
Post-treatment (a) frontal, (b) right lateral, (c) left lateral, (d) maxillary
occlusal and (e) mandibular occlusal views.
Products Inc., Itasca, Illinois, USA) was bended,
adjusted with pliers, and its adaptation was checked
Results
The current study was performed on 15 patients
(12 female and three male) seeking orthodontic
treatment in the Orthodontic Department, Faculty
of Dentistry, Tanta University, after exclusion of five
patients who decided to finish their treatment early
before completion of follow-up. All study cases had class
I skeletal and molar relationships with moderate arch
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22  Tanta Dental Journal

length deficiency and an acceptable soft tissue facial A significant increase in the maxillary canine and
profile. The patients were treated with a nonextraction molar arch depths and a nonsignificant increase in
approach using the Damon system appliance and the mandibular canine and molar arch depth were
mechanics (Table 1). detected (Table 4). The maxillary and mandibular arch
perimeters increased significantly. However, the curve
The study model analysis showed a nonsignificant change of Spee decreased significantly. The overjet showed
in the canine arch width in both maxilla and mandible. a significant decrease, and the overbite decreased
The maxillary interfirst premolar width showed a nonsignificantly (Table 5).
significant increase, whereas mandibular interfirst
premolar width showed a nonsignificant increase. The skeletal changes in lateral cephalometric
Maxillary and mandibular intersecond premolar width radiographs after treatment with the Damon system
showed a significant increase. In addition, maxillary were not significant (Table 6). The analysis of the dental
and mandibular intermolar width showed a significant
increase (Table 2). A nonsignificant uprighting of the Table 4 Descriptive statistics of study model changes in arch
depth (mm)
maxillary first molars and a significant uprighting of
Minimum Maximum Mean±SD P value
the mandibular first molar axis angle after expansion
T1 max. Cd 5 11 7.92±2.18 0.035*
for the combined right and left first mandibular molars T2 max. Cd 8 12 9.46±1.13
were found (Table 3). T1 mand. Cd 2 8 5.00±1.78 0.068
T2 mand. Cd 5 7 6.08±0.49
Table 1 Demographic and clinical characteristics of the study T1 max. Md 20 32 27.62±3.38 0.028*
sample
T2 max. Md 22 31 28.92±2.36
Minimum Maximum Mean±SD
T1 mand. Md 19 30 24.69±3.07 0.175
Starting age (years) 13 23 17.80±3.688
T2 mand. Md 18 31 25.54±2.99
Treatment time (months) 16 25 20.67±2.160
Number of appointments 11 17 13.8±1.521 *Significant at P<0.05.**Highly significant at P<0.001.
Max. crowding (mm) 4.0 9.0 6.967±1.8753
Mand. crowding (mm) 2.0 6.0 4.200±1.2790 Table 5 Descriptive statistics of study model changes in arch
perimeter, curve of Spee, overjet, and overbite (mm)
Minimum Maximum Mean±SD P value
Table 2 Descriptive statistics of study model changes in arch T1 max. Ap 63 79 69.46±3.44 0.000**
width (mm)
T2 max. Ap 72 86 76.73±2.74
Minimum Maximum Mean±SD P value T1 mand. Ap 56 70 63.00±2.51 0.000**
T1 max. IC W, 33, 33 39, 38 35.08±2.02, 0.883 T2 mand. Ap 61 74 67.08±2.77
T2 max. IC W 35.09±1.63
T1 Spee 0.5 3 1.62±0.74 0.020*
T1 mand. IC W, 21, 23 30, 29 25.46±2.40, 0.538
T2 Spee 0 2.5 0.94±0.75
T2 mand. IC W 25.77±1.36
T1 overjet 0 5 2.77±2.13 0.017*
T1 max. IPM1 W, 36, 40 43, 47 40.31±2.14, 0.001**
T2 max. IPM1 W 42.58±1.91 T2 overjet 0 2 1.35±0.69
T1 mand. IPM1 W, 31, 32 36, 37 33.62±1.56, 0.146 T1 overbite 0 5 2.12±1.98 0.565
T2 mand. IPM1 W 34.54±1.56 T2 overbite 1 3 1.81±0.56
T1 max. IPM2 W, 40, 45 48, 52 44.08±2.29, 0.000** Ap, arch perimeter; Spee, curve of Spee.*Significant at P<0.05.**Highly
T2 max. IPM2 W 47.35±1.99 significant at P<0.001.
T1 mand. IPM2 W, 31, 36 42, 42 38.38±2.87, 0.038*
T2 mand. IPM2 W 40.00±1.73
Table 6 Descriptive statistics of skeletal measurements after
T1 max. IM1 W, 46, 48 54, 54 49.46±2.50, 0.010* treatment (mm)
T2 max. IM1 W 50.92±1.61
Minimum Maximum Mean±SD t P value
T1 mand. IM1 W, 40, 42 46, 49 42.62±2.22, 0.002*
T2 mand. IM1 W 44.69±2.32 T1 SNA° 75 87 80.38±3.07 1.806 0.096
T2 SNA° 76 87 80.77±2.98
IM1 W, interfirst molar width; IPM1 W, interfirst premolar width;
T1 SNB° 71 83 77.54±3.38 0.000 1.000
IPM2 W, intersecond premolar width; IC W, intercanine width.
*Significant at P<0.05.**Highly significant at P<0.001. T2 SNB° 70 83 77.54±3.48
T1 ANB° 1 4 2.85±1.21 0.562 0.584
T2 ANB° 1 4 2.92±1.04
Table 3 Descriptive statistics of study model changes in
molar angulations (deg.) T1 PtV‑A (mm) 45 52 49.27±2.17 1.585 0.139
Minimum Maximum Mean±SD P value T2 PtV‑A (mm) 45 54 49.73±2.28
T1 max. M1, 150, 155 175, 175 162.77±9.06, 0.109 T1 PtV‑B (mm) 35 54 44.15±4.82 −0.151 0.882
T2 max. M1 166.38±5.69 T2 PtV‑B (mm) 35 51 44.08±4.26
T1 mand. M1, 138, 158 173, 180 160.54±11.57, 0.001** T1 Y‑axis° 55 68 60.19±3.34 0.463 0.652
T2 mand. M1 171.23±7.45 T2 Y‑axis° 56 68 60.38±3.18
*Significant at P<0.05. **Highly significant at P<0.001. Significant at P<0.05.**Highly significant at P<0.001.
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Damon system in nonextraction orthodontic cases Sayed et al.  23

linear measurements showed that the mandibular Table 7 Descriptive statistics of changes in dental linear
measurements (mm)
incisors advanced anteroposteriorly significantly in
Minimum Maximum Mean±SD P value
relation to NB and A-Pog lines. However, there was no
T1 U1‑NA, 1, 5 9, 9.0 4.92±2.36, 0.733
significant difference in the anteroposterior position T2 U1‑NA 4.65±2.66
of the maxillary incisors after Damon treatment. T1 U1‑A.POG, 3, 4 11, 10 7.08±2.47, 0.844
The maxillary first molar distance to PtV decreased T2 U1‑A.POG 7.19±1.71
nonsignificantly; meanwhile, the mandibular first T1 U1‑PTV, 50, 49 60, 61 54.42±3.49, 0.319
T2 U1‑PTV 55.04±3.51
molar distance to PtV increased nonsignificantly
T1 DU6‑PTV, 13, 14 23, 21 17.54±2.41, 0.594
(Table 7). T2 DU6‑PTV 17.35±2.41
T1 L1‑NB, 3, 3 9, 10 5.69±1.92, 0.000**
The analysis of the dental angular measurements T2 L1‑NB 7.31±2.07
showed that the mandibular incisors proclined T1 L1‑A.POG, 1, 1 6, 6 3.27±1.51, 0.028*
significantly; however, the maxillary incisors retroclined T2 L1‑A.POG 4.19±1.70
T1 L1‑PtV, 46, 46 58, 58 50.77±3.95, 0.086
nonsignificantly. There was a nonsignificant decrease
T2 L1‑PtV 51.88±3.50
in the interincisal angle (Table 8). No significant T1 DL6‑PtV, 10, 12 24, 22 17.00±3.74, 0.151
differences were detected with regard to the soft tissue T2 DL6‑PtV 17.62±3.07
measurements (Table 9). *Significant at P<0.05.**Highly significant at P<0.001.

Table 8 Descriptive statistics of changes in dental angular

Case report
measurements (deg.)
The patient presented at 16 years and 5 months with Minimum Maximum Mean±SD P value
9 mm maxillary arch crowding and 3 mm mandibular T1 U1‑SN, 94, 88 113, 111 104.15±6.50, 0.338
arch crowding. Fig. 7 shows the extraoral and intraoral T2 U1‑SN 102.31±7.62
photos before treatment. Fig. 8 shows the patient’s T1 U1‑NA, 15, 9 34, 32 24.23±6.11, 0.316
facial and the dental appearance after the end of active T2 U1‑NA 22.31±6.82
T1 U1‑A.POG, 20, 22 40, 35 29.46±5.83, 0.585
treatment. T2 U1‑A.POG 28.54±3.60
T1 L1‑MP, 85, 89 102, 108 94.85±4.56, 0.028*
T2 L1‑MP 97.00±5.58
T1 L1‑NB, 19, 21 34, 40 27.62±4.31, 0.019*
Discussion T2 L1‑NB 30.38±5.32
The current study is a clinical trial that was performed T1 L1‑A.POG, 18, 19 32, 33 25.31±4.31, 0.065
T2 L1‑A.POG 27.54±4.56
by the same clinician, with strict inclusion criteria of
T1 U1‑L1, 114, 115 142, 136 124.81±8.83, 0.739
the patients; this could improve the reliability of the T2 U1‑L1 124.08±7.35
outcome. The dropout rate in this study was five of
*Significant at P<0.05
20 cases. In the present study, no attempt was made
to compare treatment outcomes of the Damon system Table 9 Descriptive statistics of changes in soft tissue
with conventional bracket system. However it was measurements after treatment
impossible to compare systems which are not allowing Minimum Maximum Mean±SD t P value
for similar treatment modality (i.e. arch widening) T1 E‑Ls (mm), −6, −6 0, −2 −3.50±1.841, −1.633 0.137
where arch expansion relies solely on archwires and T2 E‑Ls (mm) −4.30±1.160
bracket interactions. Moreover, with conventional T1 E‑Li (mm), −3, −3 2, 3 −0.30±1.567, −0.231 0.823
T2 E‑Li (mm) −0.40±1.647
brackets, space problems are usually handled T1 SSD (mm), −6, −6 −2.5, −3 −4.65±1.055, 0.156 0.879
differently compared with expansion alone, making T2 SSD (mm) −4.60±1.174
them unsuitable as a control group. The sample T1 ISD (mm), −5, −4 −1, −2 −3.50±1.179, 0.429 0.678
was limited to class I, malocclusions treated with a T2 ISD (mm) −3.40±0.843
nonextraction approach, so that expansion would not T1 nasolabial°, 93, 93 120, 120 110.30±8.166, 0.248 0.809
T2 nasolabial° 110.80±9.739
be compromised with movement of the teeth into
T1 mentolabial°, 115, 118 156, 147 127.20±11.998, 1.208 0.258
the extraction spaces. Another consideration was T2 mentolabial° 130.60±9.559
amounts of initial crowding, which ranged from 4 to
9 mm, because the correction of a small amount of
crowding will have little effect on dental arch form. appliance-related and the effect of growth was
The patients’ ages ranged between 13 and 23 years. It negligible.
was agreed, based on previous studies [14–16], that
the rate of dimensional changes in arch form rapidly The Damon self-ligating appliances possessed certain
declines after the eruption of permanent dentition. handling characteristics such as ease of ligation and
It is therefore reasonable to assume that arch form consistent wire engagement without the undesirable
changes occurring in the present study were primarily force relaxation of elastomeric modules, thereby
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24  Tanta Dental Journal
Figure 7
Pretreatment.
maintaining a constantly active status of engaged wires.
This makes them suitable alternatives to conventional
appliances. This is in agreement with the findings
of Berger [17], Harradine [18], and Turnbull and
Birnie [19]. The mean treatment time in the current
study was nearly similar to those reported in previous
studies [18,20,21]. However, Jil-Agopian [22]
reported a greater treatment time than that in the
current findings. The average number of appointments
required to finish the treatment in the present study is
in accordance with that reported by Harradine [18],
Jil-Agopian [22], and DiBiase et al. [21] However,
Eberting et al. [20] reported a higher number of
appointments. Total treatment time differs from one
case to another, because not only the ligation technique
but also many other factors such as patient cooperation
variables and practitioner skills can influence the
efficiency of treatment [23–27]. Many authors found a
positive effect of the severity of crowding on treatment
duration regardless of the bracket type used [3,28–30].
The study model analysis in the current study revealed
overall transverse expansion, which was mostly evident
Figure 8
Post-treatment.
at the level of the premolars, followed by the molars, with
more expansion in the maxilla than in the mandible.
Most of the transverse expansion was observed at the
level of the premolars, which could highlight how the
Damon appliance achieves its crowding relief. This
finding is in accordance with that of Mikulencak [11],
who found a clinically and statistically significant
change in arch width dimension in the molar and
premolar areas after treatment. A significant change
was not seen in the canine area. Al-Sanea [4],
Jackson [5], Ehsani [6], Vajaria et al. [9], and Fleming
et al. [10] found a statistically significant expansion
in all measurements in both arches, with most of the
expansion occurring at the premolars. These were in
partial agreement with the current study. In contrast,
2 mm expansion in the posterior segment of the arch
yields a minimum increase in arch perimeter length,
less than 1 mm [31], whereas an intercanine width
increase provides more favorable space gain, albeit
showing a higher probability of relapse compared with
expansion in the molar region. Meanwhile, another
study [32] reported that limiting mandibular canine
expansion to 1 mm or less resulted in greater stability
in the long run. The present study verified Damon’s
philosophy that the intercanine width is maintained
with treatment, as arch length is gained with transverse
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Damon system in nonextraction orthodontic cases Sayed et al.   25
expansion of the posterior teeth [1]. This could support
the stability concerns, as the available relapse data
showed that premolar expansion and maintaining
the intercanine width is advantageous for stability
purposes, as expanded intercanine widths tend to
decrease toward pretreatment values [33–37].
The increases in transverse dimensions and the larger
amount of expansion reported at the second premolar
and first molar could be explained by the use of the
Damon CuNiTi broad archwire shape, which are
wider than conventional archwires, particularly in the
buccal segments distal to the first premolar. This could
make some doubts about the concept of physiologically
determined tooth position and ‘development of the
arch’ determined by the body and not by the clinician or
the system applied alleged by Damon [38]. Therefore,
in the present study, the amount of expansion seemed
to be correlated with the use of broad-shaped
archwires and should not be assigned to the bracket
type per se, which was supported by the findings of
many studies [3,9,30,39–41]. However, according to
this logic, it would be expected that the amount of
mandibular expansion would be similar to the maxillary
after treatment, especially that the same archwires
were used in both the maxilla and the mandible,
but this was not observed, possibly because of the
bone biology of the mandible. Sandström et al [42]
suggested that buccal expansion in the mandibular
arch is highly unpredictable and can be influenced by
various factors, including anatomy of the underlying
structures, inclination of the molars, and architecture
of the oral musculature. The results of the study model
analysis revealed that the molar expansion using the
Damon system produced a small amount of molar
palatal uprighting in the maxilla and a more significant
degree of buccal uprighting in the mandible. This is in
accordance with the previous results observed in a study
by Mikulencak [11], which showed that the maxillary
arch expansion using the Damon system produced a
0.5° palatal uprighting of the maxillary molars during
treatment.
In relation to the nonextraction approach, control
of labiolingual inclination of the incisors has been
considered of paramount importance for a successful
orthodontic treatment, as lack of control may result in
undesirable flaring [43]. The present study exhibited
a nonsignificant change neither in the position nor
in the angulation of the maxillary incisors, whereas
the mandibular incisors advanced and proclined
significantly as indicated by means of cephalometric
analysis and supported by the increase in the canine
and molar arch depth, which at the canines had the
greatest change, indicating greater anteroposterior
expansion on average in the anterior part of the arch.
The increased arch depth in the current study is in
accordance with that reported by Al-Sanea [4], who
attributed this increase to the incisor advancement.
Even though the maxillary incisors were advanced
nonsignificantly, they exhibited a nonsignificant
retroclination – that is, the angles decreased and the
distances increased. It was probably due to labial root
torque rather than backward movement of the incisal
tip because of the good torque control. In contrast,
the mandibular incisors were advanced and proclined
significantly. These findings were reflected on the
significant decrease in the overjet. These findings
were supported by Jung et al. [44], who found that
the amount of upper lip closing force was related to
the upper incisor angulation in class I malocclusions,
and the upper lip force was greater than the lower
lip force in class I and II malocclusions. This could
explain why the upper incisors were not as proclined
and advanced as the lowers. As all participants began
treatment with class I skeletal and dental relationships,
the class II elastics were used as a routine part of
treatment in this study to correct canine relation and
any class II tendencies in the dental arches and provide
optimal interdigitation of posterior teeth. The force
and duration of the class II elastics were considered
minimal in this study; however, class II elastics are
known to cause lower incisor proclination [45,46].
Another reason that could possibly contribute to
lower incisor advancement was the correction of the
deep curve of Spee, which was leveled and decreased
significantly with continuous archwires that were
not cinched back during the treatment. It is clear
in the current study that the incisor advancement
and transverse expansion had all been shown to
significantly increase the maxillary and the mandibular
arch perimeter, which in turn resulted in the alignment
of teeth and alleviation of crowding. The amount of
maxillary incisor advancement could be considered
clinically acceptable. Although the mandibular
incisors’ value could be of clinical significance when
maintaining lower incisor position during orthodontic
therapy, it causes protrusion of the lower lip and an
arguably unstable result. Little [37] demonstrated
a tendency for mandibular incisors to upright in
retention, causing lower incisor recrowding, but there
is a possibility that proclined mandibular incisors
retained with a fixed bonded appliance for long periods
of time. The maxillary incisor findings were compatible
with those of Vajaria et al. [9], who found that the
upper incisor position and angulation were not altered
significantly. However, other authors [10] reported
different findings. They found a mean increase in
maxillary incisor inclination of 1.12° for the Damon Q
group, which was mainly because the measurements of
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26  Tanta Dental Journal
that study were taken at the end of alignment and not
after finishing the treatment. Hence, the performance
of the stainless steel larger cross-section rectangular
wires to obtain accepted inclination of the teeth was
not reached. Mandibular incisor proclination and
advancement are common findings in studies that
analyze alleviation of crowding during treatment with
the Damon system [3,6–9]. Limitation of the lower
incisor advancement and proclination accompanied
with self-ligating brackets could be carried out by
performing interproximal reduction as a result of broad
contacts and space gained [47], which was not carried
out in this study. Moreover, individual patient variation
needs to be considered when planning treatment.
Therefore, the necessity of archwire bending to adjust
the final torque may not be eliminated entirely [48].
Alternatively, torquing auxiliaries and higher torque
prescription brackets can be used to counteract the
greater torque loss [7].
The results of the present study revealed that there was
no effect on the sagittal position of the maxilla and the
mandible. There was a nonsignificant increase in the
SNA angle and PtV-A distance. These observations
might suggest that A point was advanced a little
anteriorly in competence with the labial root torque
of the maxillary incisors. For the mandible, SNB angle
did not change. However, there was a nonsignificant
decrease in the PtV-B distance. The significant
proclination of the mandibular incisors yielded posterior
displacement of B point. A nonsignificant increase
in the y-axis angle was detected, contributing to the
decrease of the overbite. This overbite reduction could
be due to the use of intermaxillary elastics, resulting
in slight extrusion of the molars associated with the
clockwise mandibular rotation. In this study, despite
the minimal soft tissue changes after the treatments,
it was found that nonextraction therapy with Damon
appliances did not cause protrusive profiles and had
no adverse effects on facial profiles. Patients had
well-balanced and desirable facial esthetics with all
profile measurements within normal limits.
Conclusion
On the basis of the results obtained after correction
of arch crowding with Damon system appliances and
mechanics, the conclusion of the current study can be
summarized as follows: arch perimeter was gained by
the increase in both arch width and arch depth. Only
the mandibular incisors were advanced and proclined
significantly, contradicting Damon’s lip bumper theory.
(1) The overall transverse expansion was mostly evident
at the level of the premolars, followed by the molars,
with more expansion in the maxilla compared with
the mandible, verifying Damon’s philosophy that the
intercanine width is maintained
(2) The expansion produced a small amount of uprighting
in the maxillary molars and a more significant degree
in the mandibular molars.
Damon appliance cannot rescue extraction cases.
Straight soft tissue profile and upright incisor position
are prerequisite for nonextraction treatment. Moreover,
a harmonious chin and lip position is the key leading
to the successful nonextraction treatment with Damon
appliance.
Declaration of patient consent
The authors certify that they have obtained all
appropriate patient consent forms. In the form the
patient(s) has/have given his/her/their consent for his/
her/their images and other clinical information to be
reported in the journal. The patients understand that
their names and initials will not be published and
due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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