European Journal of Orthodontics, 2016, 609–614

doi:10.1093/ejo/cjv089
Advance Access publication 3 February 2016

Original article

Three-dimensional digital cast analysis

of the effects produced by a passive self-
ligating system
Megan B. Lineberger1,2, Lorenzo Franchi3,4, Lucia H.S. Cevidanes4,
Luis T. Huanca Ghislanzoni5 and James A. McNamara Jr4,6,7,8
1
Graduate Orthodontic Program, The University of Michigan, Ann Arbor, MI, USA, 2Private Practice, Huntersville,
NC, USA, 3Department of Surgery and Translational Medicine, Division of Orthodontics, The University of Florence,
Italy, 4Department of Orthodontics and Pediatric Dentistry, School of Dentistry, The University of Michigan, Ann
Arbor, MI, USA, 5Department of Biomedical Sciences for Health, Universitá’ degli Studi di Milano, Italy, 6Department
of Cell and Developmental Biology, School of Medicine, The University of Michigan, Ann Arbor, MI, USA, 7Center
for Human Growth and Development, The University of Michigan, Ann Arbor, MI, USA, 8Private Practice, Ann
Arbor, MI, USA

Correspondence to: James A. McNamara, Department of Orthodontics and Pediatric Dentistry, University of Michigan, Ann
Arbor, MI 48109-1078, USA. E-mail: mcnamara@umich.edu

Summary
Aim: To evaluate maxillary and mandibular dental arch changes induced by a passive self-ligating
system by analysing digital dental casts.
Subjects and methods: A sample of 25 growing patients (16 females and 9 males, mean age
12.8 years) treated with passive self-ligating brackets was compared to a sample of 25 untreated
controls (15 females and 10 males, mean age 13.4 years). Sixty three-dimensional points were
digitised on the maxillary and mandibular pre- and post-treatment virtual models to evaluate
differences in the transverse and antero-posterior arch dimensions and in the torque values
of representative anterior and posterior teeth. Statistical comparisons were performed with
independent sample t-tests with Holm-Bonferroni correction for multiple tests.
Results: The greatest increments in arch widths were found at the maxillary and mandibular
premolar level (ranging from 2.0 to 2.2 mm) and they were associated with significant increases
in maxillary and mandibular arch perimeters (2.3 and 2.5 mm, respectively), and in buccal crown
torque of the upper premolars (with adequate torque control of all other teeth).
Conclusions: The passive self-ligating system produced a modest but statistically significant
widening of both maxillary and mandibular dental arches that were associated with significant net
gains in maxillary and mandibular arch perimeters.

Introduction possible to achieve large gains in arch perimeter and transverse

dimension without the use of rapid maxillary expansion (1, 2).
Over the years, the appeal of non-extraction orthodontic treat-
In addition, advocates have credited these brackets with having
ment has created an interest in maxillary expansion as a method
the ability to expand arches and create or move the supporting
of increasing arch perimeter. The use of self-ligating (SL) brack-
tissues, decreasing the need for extractions and increasing overall
ets is a trend in orthodontics that has been gaining in popular-
stability (1, 2).
ity. Proponents of the Damon System®, for example claim it is

© The Author 2016. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
609
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610
To date, there have been few studies looking at the effects of
Damon® brackets on transverse maxillary arch width. Tecco et al.
(3) measured the maxillary transverse changes on dental casts after
12 months of treatment (at the end of the leveling and aligning phase
of treatment) with Damon® brackets and conventional preadjusted
brackets. Similar increases in the transverse measurements were found
in the two groups. Vajaria et al. (4) compared the transverse changes
produced by the Damon System® and a conventional bracket sys-
tem by using scanned dental casts. They reported that the change in
maxillary intermolar width in the Damon® group (2.8 mm) was sig-
nificantly greater than in the conventionally ligated group (0.6 mm).
Pandis et al. (5) conducted a similar study focusing only on mandibu-
lar measurements.
By using CBCT-scans and digital models, Cattaneo et al. (6)
assessed transverse maxillary dentoalveolar changes in patients
treated with active (In-Ovation R®) and passive (Damon 3 MX®)
self-ligating brackets. Expansion of the maxillary arch was achieved
by buccal tipping, with no significant differences in the amount of buc-
colingual inclination of the posterior teeth between the two groups.
Fleming et al. (7) performed a multicenter, randomised con-
trolled trial to compare maxillary arch dimensional and inclination
changes after the alignment phase with self-ligating (Damon Q® and
In-Ovation C®) and conventionally ligated brackets. No significant
differences in maxillary arch transverse changes were found among
the three groups.
Recently, Basciftci et al. (8) by using digital dental casts found
that the Damon 3® appliance was able to produce significant expan-
sion of both dental arches (3.2 and 1.9 mm measured at the maxil-
lary and mandibular molars, respectively) that remained stable in the
long-term (2 years after treatment). However, no comparisons with
untreated controls were performed in this study.
No study has evaluated the transverse maxillary and mandibular
arch changes produced by a passive self-ligating system versus an
untreated control sample by using digital dental casts. The current
controlled study, therefore, was performed to evaluate maxillary and
mandibular arch changes induced by a passive self-ligating appliance
by using digital dental casts.
Subjects and methods
Subjects
This retrospective study was performed on patients from one pro-
vider who used the Damon® 3MX System (0.022″ slot). The provider
graduated from an accredited orthodontic program and had at least
5 years of experience with the treatment modality. Records collected
included pre-treatment (T1) and post-treatment (T2) dental casts.
Inclusion/exclusion criteria for this study
required that:
1. Patients presented with a full natural permanent dentition
(excluding third molars) without any prosthetic rehabilitation
(e.g. implants, removable prosthetics).
2. All patients were treated with a non-extraction protocol without
undergoing phase I treatment.
3. Patients with an Angle classification of unilateral or bilateral full
cusp Class II or Class III were excluded.
4. Patients having any systemic diseases, craniofacial syndrome, and
those determined to need corrective jaw surgery were excluded.
5. Patients who were debonded ‘early’ for any reason (including poor
compliance and poor hygiene) were excluded.
6. Patients with incomplete or poor records were excluded.
European Journal of Orthodontics, 2016, Vol. 38, No. 6
Patients included in the treated group (25 patients, 16 females and
9 males) were treated consecutively with a non-extraction protocol.
At T1, 23 patients of the treated group presented with an Angle
Class I malocclusion and two patients showed an Angle Class II
end-on malocclusion. Mean age at T1 was 12.8 ± 1.0 years, mean
age at T2 was 14.4 ± 1.0 years, and the average T1–T2 interval was
1.6 ± 0.4 years.
The typical wire sequence followed included an initial 0.014″
Damon Copper Ni-Ti® (left in place an average of 12 weeks) fol-
lowed by a 0.014 × 0.025″ Damon Copper Ni-Ti® (12–18 weeks).
The practitioner then advanced to a 0.019 × 0.025″ TMA archwire
in the maxillary arch and a 0.016 × 0.025″ stainless steel arch-
wire in the mandibular arch (12 weeks). The finishing wire in the
maxillary arch was a 0.019 × 0.025″ SS and a 0.016 × 0.025″ SS in
the mandibular arch. Both TMA and SS rectangular wires were
coordinated to the Damon arch form. Variations in wire sequence
were used occasionally, depending on the severity of crowding.
No adjuncts other than intermaxillary elastics were used during
treatment.
The dental casts of a control sample of 25 untreated subjects
(15 females, 10 males) in the permanent dentition were evalu-
ated. The control sample was matched to the treatment sample
according to age, dentition stage, gender and Angle classifica-
tion at T1. At T1, 21 subjects of the control group presented
with an Angle Class I malocclusion and 4 subjects showed
an Angle Class II end-on malocclusion. Mean age at T1 was
13.4 ± 0.9 years, mean age at T2 was 15.1 ± 0.8 years, and the
average T1–T2 interval was 1.7 ± 0.5 years. The control data
were derived from the University of Michigan Elementary and
Secondary School Growth Study (9).
This study received exemption from IRB review from the Medical
School Institutional Review Board of the University of Michigan
(HUM00066040).
Dental cast three-dimensional analysis
All of the collected stone study models were converted to digital
format using the 3Shape R700 model scanner (ESM Digital Solution
Ltd, Dublin, Ireland).
Sixty points were digitised by the same operator (M.B.L.) on the
maxillary and mandibular pre- and post-treatment models accord-
ing to the protocol described by Huanca Ghislanzoni et al. (10)
using VAM software (Vectra, Canfield Scientific, Fairfield, New
Jersy, USA).
Maxillary and mandibular transverse arch widths were measured
for the canines, first premolars, second premolars and first perma-
nent molars by using transverse lingual distances (Figure 1). Values
were recorded as the distance between two lingual points placed at
the point of greatest convexity along the lingual gingival cervical
margin for canines and premolars. For first permanent molars, the
points were digitised at the point of intersection of the cervical gingi-
val margin with the cervical extension of the lingual developmental
groove (10, 11).
Arch perimeter (Figure 2) was measured in six segments (three
per quadrant) extending from the mesial point of first molars to the
mesial point of first premolars, from the mesial point of the first pre-
molars to the distal point of lateral incisors, and from the distal point
of lateral incisors to the mesial contact point of the central incisors.
Arch perimeter then was calculated by summing the segments, as
described by Fisk (12).
Arch depth (Figure 2) was determined by measuring the length
of a perpendicular line constructed from the mesial contact point of
M. B. Lineberger et al.
Figure 1. Transverse arch widths were measured as the intercanine,
interpremolar (first and second), and intermolar (first) lingual distances.
Figure 2. Arch perimeter (sum of six segments represented as continuous
lines) and arch depth (dashed line).
the central incisors to a line connecting the mesial points of the first
molars. The mesial contact point of the central incisors was calculated
as the midpoint between the mesial points of the central incisors.
The angular inclination of the facial axis of the clinical crown
(FACC) on a reference plane (best fit plane between the lingual
points of all the teeth from molar to molar) was calculated (10).
An individual tooth co-ordinate system, which follows each tooth,
was used to calculate the torque through trigonometry (labiolingual
inclination of the FACCs). A positive or negative sign was associ-
ated to the angle according to the same convention used for the
bracket prescription. In that no statistically significant differences
were found between right and left side for either torque values at
T1 or T2–T1 changes in torque values for each tooth, the average
torque values between right and left side for each tooth was used for
statistical analysis (Figure 3).
Finally, the degree of anterior crowding was evaluated with the
Little’s Irregularity Index.
611
Figure 3. Illustration showing the angle of crown torque of a lower molar. S
represents the occlusal limit of the FACC (sulcus); B represents the gingival
limit of the FACC. The green line represents the reference plane (almost
parallel to the occlusal plane) and the red line represents a perpendicular to
the reference plane. α is the angle of inclination of the FACC on the reference
plane. According to definition of torque of bracket prescriptions α value
minus 90 degrees is the torque value when FACC is inclined lingually, and
90 degrees minus α value is the torque value when FACC is inclined buccally
(i.e. upper incisors).
Method error and statistical analysis
To test the validity of the virtual analysis, a validation study was
performed (10). This validation study demonstrated that the digital
analysis used in this investigation has adequate reproducibility. 25
maxillary and mandibular dental casts were digitised twice by the
same operator (M.B.L.) A t-test for paired samples was performed
to assess systematic errors while the method of moments’ estima-
tor was used to assess the random error (13). No systematic error
was found. The average random error for the linear measurements
was 0.4 mm (±0.2 mm) in the maxilla and 0.1 mm (±0.1 mm) in the
mandible.
Normal distribution of data for the maxillary and mandibular
dental cast variables at T1, and for the T2–T1 changes was assessed
through Shapiro–Wilk tests. Therefore, statistical comparisons
between the treated and control groups for the dental cast measure-
ments at T1 (starting forms) and on the T2–T1 changes were per-
formed by means of independent sample t-tests (SPSS version 12.0,
SPSS Inc., Chicago, Illinois, USA) with Holm-Bonferroni correction
for multiple tests (t-tests performed on a set of 23 measurements)
(14).
For a sample size of 25 subjects in each group, an effect size of
0.87 for maxillary intermolar arch width measured at lingual points
(derived from a pilot study performed on 10 subjects comparing
Damon® versus control groups) (10), and an alpha level of 0.05,
the power of the study for the independent sample t-test was 0.854
(SigmaStat version 3.1, Systat Software, Point Richmond, California,
USA).
Results
As for the starting forms (Table 1), no significant differences between
treated and control groups were found for any of the measurements.
When the T2–T1 changes (Table 2) were compared, modest but
statistically significant between-group differences were found for
all the maxillary and mandibular arch width measurements, with
the exception of the maxillary intercanine arch width. In particular,
mandibular intercanine width increased by 1.7 mm in the treated
group with respect to the control sample. The treated group showed
612 European Journal of Orthodontics, 2016, Vol. 38, No. 6

Table 1. Descriptive statistics and statistical comparisons of the starting forms (T1) between treated and control groups.

Treated group Control group Statistical comparisons

Measurements Mean SD Mean SD Diff P

Maxillary arch linear measurements (mm)

Intercanine width 26.5 2.1 25.0 1.6 1.5 NS
Interpremolar (1st) width 25.3 1.4 26.1 1.1 −0.8 NS
Interpremolar (2nd) width 29.8 1.3 30.5 1.2 −0.7 NS
Intermolar width 33.4 1.3 34.0 1.4 −0.6 NS
Maxillary arch perimeter 78.3 4.4 78.3 2.4 0.0 NS
Maxillary arch depth 29.4 2.7 29.4 1.4 0.0 NS
Maxillary teeth angular measurements (deg)
Central incisor torque 2.1 8.6 1.9 5.6 −0.2 NS
Canine torque −8.2 8.2 −7.0 5.4 −1.2 NS
Premolar (1st) torque −16.9 5.0 −15.7 5.0 −1.2 NS
Premolar (2nd) torque −20.4 5.7 −17.7 4.0 −2.7 NS
First molar torque −17.6 5.6 −17.4 4.7 −0.2 NS
Mandibular arch linear measurements (mm)
Intercanine width 20.1 1.3 19.5 1.5 0.6 NS
Interpremolar (1st) width 24.6 1.5 25.0 1.4 −0.4 NS
Interpremolar (2nd) width 28.3 1.5 28.4 1.6 −0.1 NS
Intermolar width 31.5 1.6 31.7 2.0 −0.2 NS
Mandibular arch perimeter 66.9 4.8 66.7 2.4 0.2 NS
Mandibular arch depth 24.4 2.5 24.4 1.6 0.0 NS
Mandibular teeth angular measurements (deg)
Central incisor torque −4.4 8.0 4.2 6.8 −0.2 NS
Canine torque −16.2 6.8 −15.7 4.4 −0.5 NS
Premolar (1st) torque −24.3 5.2 −23.5 4.1 −0.8 NS
Premolar (2nd) torque −34.1 5.3 −33.1 4.8 −1.0 NS
First molar torque −41.5 4.8 −41.0 3.7 −0.5 NS
Little’s irregularity index (mm) 6.0 3.4 6.8 2.6 −0.8 NS

NS, not significant.

significantly greater increments of interpremolar arch widths both in
the maxilla and in the mandible (ranging from 2.0 to 2.2 mm) when
compared to the control sample. Both the maxillary and mandibu-
lar intermolar widths exhibited significantly greater increases in the
treated versus the control samples (0.9 and 1.2 mm, respectively).
The T2–T1 increments in the treated group for both maxillary
and mandibular arch perimeters were significantly greater than the
control group (2.3 and 2.5 mm, respectively). No significant changes
were recorded for maxillary and mandibular arch depths.
Both the maxillary first and second premolars in the treated
group exhibited significant greater increments in buccal torque
values with respect to the control group (4.6 and 3.9 degrees,
respectively; Table 2). No other maxillary teeth showed significant
changes in torque values, including the maxillary central incisors
and canines. In the mandibular arch no significant changes in torque
values were found, including the mandibular central incisors. A sig-
nificant improvement in the amount of anterior crowding (4.9 mm)
was recorded in the treated sample.
Discussion
The results of the present study showed that treatment with a self-
ligating system has a potential for producing a modest but statisti-
cally significant widening of the maxillary and mandibular dental
arches with respect to a matched control sample (Table 2). The trans-
verse increments were greater at the first and second premolar levels
in the Damon® group in comparison to controls, with arch widen-
ing at the first and second premolars similar in the upper (2.0 and
2.2 mm, respectively; Table 2) and lower arches (2.0 and 1.9 mm,
respectively). This finding can be explained by two ways: first,
the maxillary and mandibular arch forms and sizes of the Damon
System® are the same, and, second, the arch form is wider in the pre-
molar area to prevent the ‘dark corner syndrome’ when smiling (2).
It is interesting to note that only the mandibular intercanine width
showed a significant increase (1.7 mm) while no significant change
was recorded in the maxillary intercanine width (0.1 mm). This
result can be explained by the fact that some of the treated patients
presented with buccally displaced maxillary canines at T1 (maxil-
lary intercanine width 1.5 mm greater than controls, Table 1) and,
therefore, they required a reduction in maxillary intercanine width.
No previous study has evaluated dental arch changes on digital
dental casts following treatment with a passive self-ligating system
with respect to matched untreated controls. While Tecco et al. (3)
and Fleming et al. (7) measured the maxillary transverse changes
on dental casts at the end of the levelling and aligning phase of
treatment, only Vajaria et al. (4) reported transverse changes when
comparing pre- and post-treatment digital dental casts. The T1–T2
increments in maxillary (from 0.9 to 2.2 mm) and mandibular (from
1.2 to 2.0 mm) intermolar and interpremolar widths found in the
current investigation were smaller than those reported by Vajaria
et al. (4) (from 2.8 to 2.9 mm, and from 2.2 to 4.4 mm, respectively),
even though the archwire sequencing was similar in the two studies.
These differences in findings could be attributed at least in part
to the fact that Vajaria et al. (4) evaluated the changes in maxillary
transverse width by using points located more buccally on the tooth
crowns (cusp tips of the canine and central occlusal pits of premolars
M. B. Lineberger et al. 613

Table 2. Descriptive statistics and statistical comparisons of changes during the T1–T2 interval between treated and control groups.

Treated group Control group Statistical comparisons

Measurements Mean SD Mean SD Diff P

Maxillary arch linear measurements (mm)

Intercanine width −0.6 1.9 −0.7 1.2 0.1 NS
Interpremolar (1st) width 2.2 1.4 0.0 0.4 2.2 **
Interpremolar (2nd) width 2.0 1.3 0.0 0.5 2.0 **
Intermolar width 0.9 1.1 0.0 0.7 0.9 *
Maxillary arch perimeter 1.7 3.4 −0.6 0.7 2.3 *
Maxillary arch depth −0.6 2.0 −0.6 0.4 0.0 NS
Maxillary teeth angular measurements (deg)
Central incisor torque 1.3 8.5 −0.4 1.8 1.7 NS
Canine torque 3.2 5.5 0.9 2.7 2.3 NS
Premolar (1st) torque 5.8 4.6 1.2 1.9 4.6 **
Premolar (2nd) torque 5.1 4.5 1.2 2.2 3.9 **
First molar torque −0.8 4.2 1.0 3.1 −1.8 NS
Mandibular arch linear measurements (mm)
Intercanine width 1.5 1.3 −0.2 0.6 1.7 **
Interpremolar (1st) width 2.0 1.4 0.0 0.3 2.0 **
Interpremolar (2nd) width 1.9 1.4 −0.1 0.5 2.0 **
Intermolar width 1.3 1.3 0.1 0.4 1.2 **
Mandibular arch perimeter 1.9 2.9 −0.6 0.9 2.5 **
Mandibular arch depth −0.3 1.8 −0.4 0.5 0.1 NS
Mandibular teeth angular measurements (deg)
Central incisor torque −0.1 6.8 0.4 1.6 −0.5 NS
Canine torque 2.5 5.9 1.6 2.5 0.9 NS
Premolar (1st) torque 2.4 4.2 1.5 1.6 0.9 NS
Premolar (2nd) torque 3.6 7.3 1.8 2.4 1.8 NS
First molar torque 1.7 5.8 1.4 2.6 0.3 NS
Little’s irregularity index (mm) −4.9 3.5 0.0 0.8 4.9 **

NS, not significant.

*P < 0.01; **P < 0.001.

and molars) than the lingual points used here. Mandibular inter-
molar width change (1.7 mm) reported by Pandis et al. (5) was
slightly greater than our findings (1.2 mm), once again because
it was measured as the transverse distance between the central
grooves of the mandibular molars that are located more buccally
to the lingual points used in the current study. The same reasoning
also can explain the greater increases in maxillary and mandibular
arch widths following treatment with the Damon 3MX® appliance
reported recently by Basciftci et al. (8) with respect to the current
investigation.
Another interesting result of the present study was that no sig-
nificant changes were found for either maxillary or mandibular
arch depths. This finding may reflect a lack of proclination of the
maxillary and mandibular incisors, which was supported also by the
non-significant changes in the torque of the central incisors of both
arches with respect to untreated controls. We can hypothesise that
the significant expansion in the mandibular posterior region, par-
ticularly at the premolar level, produced by the Damon arch form
contributed to the significant improvement in the amount of anterior
crowding.
A novel feature of the current investigation was the assessment
of changes in torque values in the posterior arch segments (from the
canine to the first permanent molar). The analysis of torque changes
in combination with changes in transverse arch widths allows a bet-
ter understanding of the expansion effects produced by the Damon
System®. Significant increases in buccal crown torque were found
in the maxillary first and second premolars (4.6 and 3.9 degrees,
respectively) with respect to the untreated controls, while no signifi-
cant changes were found for the maxillary central incisor, canine, first
permanent molar and for any of the mandibular teeth. Importantly,
the patients treated with Damon presented no significant changes in
both upper and lower incisors torque. With regard to the increase in
transverse dimensions in the patient group, the amount of increase
in transverse arch width at the premolars was similar in both arches.
The maxillary and mandibular buccal torque changes in the pre-
molars were slightly different (approximately 3 degrees more buccal
torque changes in the maxillary premolars) may be explained by the
differences in torque values between the maxillary and mandibular
premolar bracket prescriptions (−7 degrees for both maxillary first
and second premolars, −12 degrees for the mandibular first premolar,
and −17 degrees for the mandibular second premolar). Consequently,
the mandibular premolars showed a ‘more bodily’ buccal crown
movement with respect to the maxillary premolars.
The buccal inclination of the crowns of the maxillary premolars
as measured with CBCTs was reported as an effect of the Damon®
appliance by Cattaneo et al. (6) The values reported in the study by
Cattaneo et al. (6) (11.7 and 13.5 degrees for the first and second
premolars, respectively) were higher than those found in the current
investigation. This difference may be explained by the fact that in the
CBCT study (6), the authors evaluated torque changes by measuring
the changes in the inclination of the premolar axis (passing through
the root apex and the central fossa of the crown), while in the pre-
sent investigation only changes in crown torque as read through the
FACC were assessed.
614
Conclusions
The current study compared the treatment effects of a passive self-
ligating system versus an untreated control sample by using digital
dental cast analysis. The findings of this study were as follows:
1. The passive self-ligating system produced a modest but statis-
tically significant widening of both maxillary and mandibular
dental arches in the posterior regions with the exception of the
maxillary intercanine width. These increases in arch widths were
associated with modest significant net gains in maxillary and
mandibular arch perimeters (about 2.5 mm).
2. No significant changes in crown torque were detected for any
teeth with the exception of the maxillary premolars that exhib-
ited a significant increase in buccal crown torque.
Acknowledgements
The authors would like to thank Dr. Bill Dischinger for providing the treated cases
used in this study. This research was supported in part by funds made available
through the Thomas M. and Doris Graber Endowed Professorship, Department
of Orthodontics and Pediatric Dentistry, The University of Michigan.
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