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207]

Original Research

“Comparative evaluation of surface modified elastomeric

ligatures for microbial colonization”: An in vivo study

Pavithra Bai M, Anna Cecilia Vaz

Department of Orthodontics
and Dentofacial Orthopedics,
ABSTRACT
P.M.N.M Dental College and
Hospital, Bagalkot,
Karnataka, India
Received : 07-10-13
Review completed : 05-03-14
Accepted : 20-04-15
Introduction: Elastomeric ligatures are observed to reduce chair side time; however, they are also
seen to have greater bacterial adhesion. Polymeric coating utilizing the Metafasix Technology
and the OrthoShield Technology have been introduced in the Super Slick™* and Safe‑T‑Ties™**
by TP Orthodontics, Ortho Organizers, respectively, to reduce bacterial adhesion. While each
of the elastomers has been individually evaluated, no study compares the two elastomers
manufactured by differing technologies together; hence the need for this study was felt. This
in vivo study compared the Super Slick and Safe‑T‑Ties with their unmodified counterparts for
bacterial adhesion.
Materials and Methods: Thirty patients undergoing orthodontic treatment, between 12 and
25 years age group were selected and the modified, and the unmodified elastomers were
randomly placed quadrant wise, on all the premolar brackets. After a period of 4 weeks, the
elastomeric rings were removed and transported for culture on Mitis–Salivarius, Rogosa SL
agar for Streptococcus mutans and Lactobacilli, respectively. The colonies were digitally
counted (HiMedia) after 48 h of incubation at 37°C.
Results: There was a significant difference in the S. mutans and Lactobacilli counts in both surface
modified and unmodified elastomeric modules (P < 0.01). Unmodified elastomeric modules
Mini Stix™*, Hand‑EE‑Lasts™** was associated with higher mean values of colony‑forming
units/millimeter than the surface modified Super Slick™* and Safe‑T‑Ties™** ligatures. When
compared pair‑wise, the surface modified elastomers showed less bacterial accumulations than
the unmodified counterparts for both S. mutans and Lactobacillus, and the differences were
statistically significant.
Conclusion: Technological modifications of the elastomers using the Metafasix or OrthoShield
Technology, is a definite improvement over the regular elastomers with regard to adhesion of
S. mutans and Lactobacilli.
Key words: Elastomeric ligatures, microbial colonization, Safe‑T‑Tie, Super Slick

The development of dental plaque has been associated hygiene.[5,6] Decalcification, white spot lesions, caries, and
with several factors such as maintenance of oral hygiene,[1] inflammatory periodontal disease are some of the commonly
composition of diet,[1,2] fluoride exposure,[3] the quality of recognized consequences of poor oral hygiene, especially
saliva, the composition of the oral micro flora and immune during orthodontic treatment.[7,8] The prevalence of white
factors.[4,5] Fixed or removable orthodontic appliances create spot lesions in patients after orthodontic treatment range
new retention areas[4] and impede the maintenance of oral from 15% to 85%[9] and some studies report a prevalence
of around 50–70%.[10‑13] Decalcification has been shown to
Address for correspondence: occur as early as 4 weeks after bonding.[8]
Dr. Anna Cecilia Vaz
E‑mail: dr.anna.vaz@gmail.com
The method of ligation of orthodontic archwires is one
Access this article online relevant factor that accounts for dental biofilm retention.[4]
Quick Response Code: Website:
Clinicians may use 0.008–0.014 inch stainless steel ligature
www.ijdr.in wire, self‑ligating springs or circular synthetic elastomers
to secure arch wires to brackets.[1-4] In the search for more
practical and efficient orthodontic accessories, elastomeric
rings have been suggested as the material of choice to
DOI: connect stainless steel archwires to brackets instead of
10.4103/0970-9290.159156
metallic ligatures.[4,14,15] Apart from its practical advantages,

180 Indian Journal of Dental Research, 26(2), 2015

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Microbial colonization on surface modified elastomeric ligatures Bai and Vaz
it is evident from the literature review that elastomeric
rings exhibit a greater number of micro‑organisms in the
plaque around the brackets when compared with the steel
ligatures.[4,16]
To reduce the demineralization of the teeth during and
postorthodontic treatment, various plaque control measures
such as the use of chlorhexidine mouthwashes, varnishes or
topical fluoride applications, fluoride releasing composites,
cements were advocated. [17] The fluoride releasing
elastomeric rings have been reported to reduce dental
biofilm formation and improve enamel remineralization
in areas adjacent to the bracket base, which is difficult to
clean.[18‑21] However, not all researchers concurred with the
latter view.[22]
The surface characteristics of the elastomerics have been
altered by companies in recent years using the Metafasix
technology  (Super Slick™*) [23] and the OrthoShield
Orthodontic Antimicrobial Technology (Safe‑T‑Ties™**).[24]
These alterations have been claimed to reduce bacterial
adhesion.[23‑26] Reports in literature with regards to the
efficacy of the Super Slick™* elastomers in reducing microbial
adhesion remains controversial.[27] Literature is scarce[28]
with regard to the utility of the OrthoShield Technology
on elastomers in orthodontics. It was our premise that the
improved technological changes in orthodontic elastomers
did, in fact, alter the surface characteristics and reduced
bacterial adhesion on them. Our null hypothesis, therefore,
stated that surface modified elastomers reduced the bacterial
adhesion on them, but it made no difference as to which
technology was used.
No study to the best of our knowledge was carried out to
comparatively evaluate the two elastomers utilizing differing
technologies to reduce bacterial adhesion. Hence, this study
compared the surface modified Super Slick™*, Safe‑T‑Ties™**
with their unmodified counterparts from the same company,
Mini Stix™*, Hand‑EE‑Lasts™** for bacterial adhesion.
MATERIALS AND METHODS
Thirty patients  (15  males and 15  females) undergoing
orthodontic treatment, aged between 12 and 25  years
were randomly selected from the post graduate clinic
of the Department of Orthodontics, P.M.N.M Dental
College and Hospital, Bagalkot, Karnataka. This
research project was approved by the local Ethical
Committee (PMNMDCH/1816/2011‑12) of the institution.
A written consent was received from the patients who were
willing to be part of the study from the patients themselves
or their parents (or legal representatives).
Patients who were using antimicrobial mouthwashes, or
who had any systemic diseases, were pregnant, had used
antibiotics 3  months prior to the study, or had brackets
Indian Journal of Dental Research, 26(2), 2015
bonded with glass ionomer cements were excluded from
the study. All patients selected were right handed brushers.
They had undergone thorough oral prophylaxis at the start of
the study. They were instructed to use a common dentifrice
and to brush after each meal.
The investigation was designed as a split‑mouth study.
Stainless steel 0.022″ slot MBT brackets were bonded
in both the arches and 0.016‑inch  Nitinol Archwire
(Ortho Organizers)  was placed. In each subject, the
elastomers were randomly assigned to premolars. If the
modified elastomers, one of each type, were assigned to
one quadrant, care was taken to see that the contralateral
side received the unmodified elastomers, one of each type.
Similarly, if the maxillary arch received the modified
elastomers, the mandibular arch of the same side received
the unmodified counterparts. This was carried out for a
total of 240 ligatures [Figure 1]. Patients were recalled after
4 weeks, the ligatures were aseptically and carefully removed
without disturbing the plaque around the brackets. Each
elastomeric ligature with the adhered plaque was individually
transported in a vial containing 10  ml of thioglycolate
medium to which Hemin and Vitamin K (1:1000 dilutions)
were added [Figure 2] to be inoculated on media for culture
of Streptococcus mutans and Lactobacilli.
The samples were inoculated on Mitis–Salivarius agar to
estimate the colonization of S. mutans. A decimal dilution
of the specimen was prepared, and 0.01ml in amount was
spread by a platinum loop over the surface of the complete
medium. The plates were then incubated in CO2 jar at 37°C
for 24 h with 5–10% CO2. One percent potassium tellurite
solution was added to make the medium highly selective for
S. mutans. Cultural characteristics appeared after 18–48 h
at 37°C. Plates were removed from the jar, growth noted,
and organisms identified by Gram staining. To estimate
Lactobacilli, the samples were inoculated on Rogosa SL agar,
which is highly selective for oral Lactobacilli. A  decimal
dilution of the specimen was prepared, and 0.01  ml in
amount was spread by a platinum loop over the surface of the
complete medium. The plate was incubated at 37°C for 48 h
at 5% CO2 in a vacuum anaerobic jar. Cultural characteristics
appeared after 40–48 h at 37°C. Plates were removed from
the jar, growth noted, and organisms identified by Gram
staining [Figure 3].
The number of colonies was counted with a digital
colony counter  (HiMedia). The results were expressed
as colony‑forming units per millimeter  (CFU/ml  ×  103)
and tabulated. All the microbiologic procedures were
performed by an investigator who was blinded to the type
of elastomeric ring being investigated.
Statistical analysis
A pilot study was conducted in first two groups by taking a
convenience sample of 3 each; CFU counts were recorded.
181
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Microbial colonization on surface modified elastomeric ligatures Bai and Vaz
Figure 1: Quadrant wise distribution of ligatures at the time of
placement
Based on the pilot study  (alpha error  =  5%, power of
test  =  90%), the sample size was estimated to 60 in each
group, totaling 240 ligatures (60 × 4 = 240).
The normal distribution of the data was estimated to be
a skewed distribution in all the four groups as calculated
from the Shapiro–Wilk W‑test  (Group  1: W  = 0.93518,
P < 0.00416; Group 2: W = 0.86058, P < 0.00001; Group 3:
W = 0.91862, P < 0.0005; Group 4: W = 0.94109, P < 0.0100).
The data obtained from the study was subjected to statistical
analysis using  SPSS software  (IBM® SPSS® Advanced
Statistics version 20.0). All bacterial counts were considered
at 103 CFU/ml for ease of statistical calculations.
Descriptive statistics
The mean and standard deviation was calculated for each
type of elastomers.
• Comparison of each type of elastomer with respect to
the bacterial count of S. mutans and Lactobacilli was
analyzed nonparametrically using Kruskal–Wallis (H)
one‑way ANOVA test
• Pair‑wise comparisons of the same were done by the
Mann–Whitney U‑test.
Significance for all statistical tests was predetermined
at P  ≤  0.05. The researcher was blinded to the type of
elastomeric ring when analyzing the data.
RESULTS
The mean and standard deviation of bacterial counts in
103 CFU/ml on the four types of elastomers is tabulated
in Table  1 for both S. mutans and Lactobacilli. Analysis
of the data revealed the unmodified elastomeric modules
Mini Stix™*, Hand‑EE‑last™** to be associated with higher
mean values of CFU/ml than the surface modified ligature
modules Super Slick™*, Safe‑T‑Ties™** as illustrated
in Table  1. Kruskal–Wallis, one‑way ANOVA test
when applied to the data showed the difference to
182
Figure 2: Transport medium
be statistically significant for S. mutans  [Table  2] and
Lactobacillus  [Table  3]  (P  <  0.05). When the number of
CFU’s of S. mutans was compared with that of Lactobacillus,
it was noted that the number of CFU’s in S. mutans was
higher than those of Lactobacillus in both surface‑modified
and unmodified elastomeric modules  [Figure  4]. The
micro‑organisms on the surface modified Safe‑T‑Tie™**
utilizing the OrthoShield antimicrobial technology were
seen to be the least while the micro‑organisms on the
Mini Stix™* were seen to be the highest both for S. mutans
as well as for Lactobacillus [Table 1].
Pair‑wise comparison using Mann–Whitney U‑test carried
out between the same company elastomers showed the
pairs to have statistically significant differences (P < 0.05)
with the surface modified elastomers having less bacterial
accumulations than the unmodified elastomers for both
S. mutans [Table 4] and Lactobacillus [Table 5]. When the
pairs of different companies were compared, the unmodified
elastomers showed more bacterial adhesions than the surface
modified elastomers, and these differences were statistically
significant. The CFUs on Safe‑T‑Ties™** were the least, lower
than that of Super Slick™* however, the difference between
them was not statistically significant. Hand‑EE‑last™**
showed statistically significant difference with Mini Stix™*.
DISCUSSION
Plaque is the major etiological factor in the development of
dental caries. The control of plaque is fundamental in the
control of caries and periodontitis. It has been reported that
Lactobacilli and Streptococci species create a low pH oral
environment (pH < 5.5) due to the bacterial byproducts.[29]
S. mutans is strongly associated with the initiation of dental
caries,[30] and Lactobacilli has long been associated with
caries development.[31] Therefore, determination of both
the S. mutans and the Lactobacilli counts was considered
important to determine caries risk in this study. This study
showed the streptococcal counts to be higher than that
Indian Journal of Dental Research, 26(2), 2015
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Microbial colonization on surface modified elastomeric ligatures Bai and Vaz

of Lactobacillus during the 4‑week period of study. As

Streptococcus is strongly associated with the initiation of
dental caries, it is postulated that the risk of demineralization
is high.

The material used for ligation of orthodontic archwires

alters the bacterial colonization in the areas adjacent
to the brackets. [4,10,16,17,32] Forsberg et  al. [4] found that
most patients had a higher bacterial count on teeth
ligated with conventional elastomers than on teeth
ligated with steel ligatures. On the other hand,
Türkkahraman et  al . [17] and Sukontapatipark et  al . [32]
found no significant differences  (P  >  0.05) between the
two materials when evaluated for microbial colonization.

250
217.48

200
179.41

Mean +/- SD CFU/ml

150
124.05 122.65
97.97 92.17
100 81.25 80.3

50

0
Coated Super Non-Coated Mini Coated Safe-T- Non-Coated
Slick* Stix* Tie** Handeelast**

Streptococcus mutans Lactobacillus

Figure 4: Comparison of Streptococcus mutans and Lactobacillus

Figure 3: Culture plates and Gram staining of the colonies counts in four elastomeric groups in ×103 CFU/ml

Table 1: Bacterial counts in ×103 CFU/ml

Organisms Summary Surface modified super slick™* Mini Stix™* Surface modified safe‑T‑Tie™** Hand‑EE‑last™**
Streptococcus mutans Means 124.05 217.48 122.65 179.41
SD 12.24 17.05 16.70 14.04
Lactobacillus Means 81.25 97.97 80.30 92.17
SD 09.37 07.88 12.67 15.21
SD=Standard deviation, CFU=Colony‑forming units

Table 2: Comparison of four types of elastomers with respect to bacterial counts in ×103 CFU/ml of Streptococcus mutans by
Kruskal–Wallis one‑way ANOVA by ranks
Elastomers Sum of ranks Median Kruskal–Wallis P Significance
Surface modified super slick™* 3776.5 125.00 195.9534 0.0000* Significant
Mini Stix™* 12424 224.00
Surface modified safe‑T‑Tie™** 3512 124.00
Hand‑EE‑last™** 9207.5 180.00
CFU=Colony‑forming units, *P≤0.05

Table 3: Comparison of 4 types of elastomers with respect to bacterial counts in ×103 CFU/ml of Lactobacillus by
Kruskal–Wallis one‑way ANOVA by ranks
Elastomers Sum of ranks Median Kruskal–Wallis H P Significance
Surface modified super slick™* 4718 82.00 93.1944 0.0000* Significant
Mini Stix™* 11101.5 98.50
Surface modified safe‑T‑Tie™** 5025.5 87.00
Hand‑EE‑last™** 8075 89.00
CFU=Colony‑forming units, *P≤0.05

Indian Journal of Dental Research, 26(2), 2015 183

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Microbial colonization on surface modified elastomeric ligatures Bai and Vaz

Table 4: Pair‑wise comparison of four types of elastomers with respect to bacterial counts in ×103 CFU/ml of Streptococcus
mutans by Mann–Whitney U‑test
Elastomers Sum of ranks U Z P Significance
Surface modified super slick™* 1830 0 −9.4475 0.0000* Significant
Mini Stix™* 5430
Surface modified safe‑T‑Tie™** 1858.5 28.5 −9.298 0.0000* Significant
Hand‑EE‑last™** 5401.5
Surface modified super slick™* 3776.5 1653.5 −0.7689 0.4419 Nonsignificant
Surface modified safe‑T‑Tie™** 3483.5
Mini Stix™* 5224 206 −8.3663 0.0000* Significant
Hand‑EE‑last™** 2036
CFU=Colony‑forming units, *P≤0.05

Table 5: Pair‑wise comparison of 4 types of elastomers with respect to bacterial counts in ×103 CFU/ml of Lactobacillus by
Mann–Whitney U‑test
Elastomers Sum of ranks U Z P Significance
Surface modified super slick™* 2115.5 285.5 −7.9491 0.0000* Significant
Mini Stix™* 5144.5
Surface modified safe‑T‑Tie™** 2810 980 −4.3039 0.0000* Significant
Hand‑EE‑last™** 4450
Surface modified super slick™* 3572 1742 −0.3044 0.7608 Nonsignificant
Surface modified safe‑T‑Tie™** 3688
Mini Stix™* 4544.5 885.5 −4.7999 0.0000* Significant
Hand‑EE‑last ™** 2715.5
CFU=Colony‑forming units, *P≤0.05

Elastomeric ligatures with modified surface characteristics
that are claimed to control bacterial development on their
surfaces have been introduced in recent years.[23‑25] These
elastomeric modules are produced by different technologies,
the Metafasix technology[23] and the OrthoShield Orthodontic
Antimicrobial Technology.[24] The Metafasix technology™*
uses a water‑insoluble, hydrogel‑polymer coating which
transforms the polyurethane‑based elastomeric surface,
when moistened, into a highly smooth surface which, as
claimed by the company, reduces bacterial adhesion.[24] On
the other hand, OrthoShield Orthodontic Antimicrobial
Technology™** makes use of the antimicrobial characteristics
of naturally occurring silver; silver has an ability to
destabilize the bacterial cell wall, interrupt cell metabolism
and inhibit reproduction. The silver is embedded in a porous
ceramic that controls the silver’s release to the surface of
the elastomeric ring thus providing a durable antimicrobial
solution for a period of 30 days.[24,25]
This study investigated the microbial colonization on the
surface modified elastomers; Super Slick™*, Safe‑T‑Ties™**
along with the unmodified Mini Stix™*, Hand‑EE‑last™**
for both S. mutans and Lactobacilli. From the results of this
study, it is evident that the plaque around the brackets ligated
with unmodified elastomeric ligatures contained higher
number of bacterial colonies with respect to both S. mutans
and Lactobacilli when compared with the surface modified
Super Slick™*, Safe‑T‑Tie™** elastomers. This indicated that
surface modification of the elastomers, both by Metafasix
technology and the OrthoShield Orthodontic Antimicrobial
Technology, reduces the accumulation of bacteria on the
elastomers. Safe‑T‑Tie™** showed lower bacterial counts than
Super Slick™*, both for S. mutans and Lactobacillus, however,
the differences were not statistically significant (P > 0.05),
thus indicating that both surface‑modified elastomeric
modules irrespective of technology used to modify its surface,
reduces bacterial adhesion.
This study contradicts the lone study of Magno et al.[27] on
the Super Slick™* and the lone study of Kim, et  al.[28]
on the Silver ion releasing elastomers Safe‑T‑Ties™**.
Magno et  al.[27] showed statistically higher number of
S. mutans on Coated Super Slick ties™* when compared
to conventional elastomers. However, the dissimilarities in
study design, type and period of evaluation, scoring system,
type of microbiological test, and host resistant factors in the
patient population could be responsible for the differences
seen in the results of our study with that of Magno et al.[27]
and that of Kim, et al.[28] Clinically, Corbette,[26] has reported
an observation when he used the Safe‑T‑Ties. There
has been no study comparing the different technologies
together to the best of our knowledge and hence direct
comparison with similar studies is difficult.
Surface modification by coating the elastomers using the
Metafasix Technology[23] or using the AgION Antimicrobial
Technology [24] could thus be a useful technological
advancement. This study supports our premise and
favoured our null hypothesis. The surface modification
reduces the colonization of micro‑organisms: S. mutans
and Lactobacillus, related to both caries initiation and
progression.
Limitations of this study
This study evaluated the adherence of two micro‑organisms
to the elastomeric ligatures namely S. mutans and

184 Indian Journal of Dental Research, 26(2), 2015

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Microbial colonization on surface modified elastomeric ligatures Bai and Vaz
Lactobaccillus. Periodontal pathogens such as Actinobacillus
actinomycetemcomitans and Tannerella forsythia have also
been significantly associated with gingival inflammation
during orthodontic therapy however, including these
micro-organisms was beyond the scope of this study.[16] As
furtherance to this study, the microbial spectrum could be
widened.
This study estimated the bacterial adhesion on the
respective ligatures. Estimation of altered microflora in
and around the environment of the ligature is a limitation
in this study and could be pursued utilizing improved
technologies, DNA isolation, and polymerase chain
reactions.
CONCLUSION
Contemporary surface modified elastomeric ligatures
show superior qualities with respect to bacterial adhesion
when compared with their unmodified counterparts.
Technological modifications of the elastomers using the
Metafasix* or OrthoShield** Technology is a definite
improvement over the regular elastomers with regard to
adhesion of Streptococuus mutans and Lactobacilli.
End notes: ™* ‑ TP Orthodontics; ™** ‑ Ortho Organisers.
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How to cite this article: Bai MP, Vaz AC. "Comparative evaluation of surface
modified elastomeric ligatures for microbial colonization": An in vivo study.
Indian J Dent Res 2015;26:180-5.
Source of Support: We acknowledge the support from Ortho Organisers for
providing us with free samples, Dr. (Prof) Kishore Bhatt, Microbiologist who
carried out the microbiological investigation in our study, and Mr. S Javali,
Statiscian for guiding us through the data analysis, Conflict of Interest: None
declared.
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