SHORT COMMUNICATION

Self-ligating vs conventional twin brackets during en-masse space closure with sliding mechanics
Peter G. Miles Caloundra, Queensland, Australia Introduction: The aim of this study was to compare the rate of en-masse space closure with sliding mechanics between passive self-ligating SmartClip brackets (3M Unitek, Monrovia, Calif) and conventional twin brackets ligated with stainless steel ligatures. Methods: Nineteen patients including 20 arches participated in this prospective trial with 0.018-in slot brackets. All patients had rst premolar extractions in at least 1 arch, with the second premolar and the rst molar distal to the extraction site bonded with SmartClip brackets on 1 side and conventional twin brackets on the other. The sides were alternated with each consecutive patient. Space closure was achieved on 0.016 0.022-in stainless steel wires with nickel-titanium coil springs activated 6 to 9 mm. The patients were recalled every 5 weeks until 1 side had closed. The distances from the mesial aspect of the canine bracket to the distal aspect of the rst molar bracket were recorded before and after space closure, and an average rate of space closure per month was calculated. Results: Thirteen patients completed the trial (14 arches); the median rates of tooth movement for the SmartClip bracket side (1.1 mm per month) and the conventional twin bracket side (1.2 mm per month) were not signicantly different (P .86). Conclusions: There was no signicant difference in the rate of en-masse space closure between passive SmartClip brackets and conventional twin brackets tied with stainless steel ligatures. (Am J Orthod Dentofacial Orthop 2007;132:223-5)

uring premolar extraction treatment, the orthodontist has several options for space closure. A popular method is en-masse space closure with sliding mechanics and coil springs. Some selfligating brackets are labeled as passive and promoted on the premise that elimination of ligatures reduces friction and allows for faster sliding mechanics. If true, self-ligating brackets could reduce overall treatment time.1 Two retrospective studies of patients treated with Damon SL brackets reported reductions in treatment time of 4 to 6 months and 4 to 7 visits during active treatment.1,2 However, a recent prospective study comparing Damon 2 with conventional twin brackets found that the passive Damon 2 bracket was no better during initial alignment than a conventional bracket ligated with elastomeric modules.3 In a similar study, passive SmartClip brackets were no more efcient during initial alignment with identical wire sequences and crosssections.4 One can then surmise that, if there is a potential
Senior lecturer, University of Queensland Dental School, Brisbane; and private practice, Caloundra, Queensland, Australia. Reprint requests to: Peter G. Miles, 10 Mayes Ave, Caloundra, Queensland 4551, Australia; e-mail, pmiles@beautifulsmiles.com.au. Submitted, revised and accepted, April 2007. 0889-5406/$32.00 Copyright 2007 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2007.04.028

time saving with passive self-ligating brackets that is not during initial alignment, it must be at a later stage of treatment. Perhaps in extraction patients, the reduced normal force of friction with passive self-ligating brackets allows faster sliding mechanics during space closure and therefore reduces treatment time. The aim of this study was to compare the rates of space closure between conventional twin brackets ligated with stainless steel (SS) ligatures and passive self-ligating SmartClip brackets (3M Unitek, Monrovia, Calif).
MATERIAL AND METHODS

Nineteen consecutive patients who met the selection criteria were drawn from the authors private orthodontic practice to obtain 20 arches for comparison. The criteria included extraction of the rst premolars in at least 1 arch, no missing teeth other than third molars, and no asymmetric mechanics or asymmetric elastic wear during space closure. Eligible subjects were assigned to 1 of 2 groups in a split-mouth design with sides alternated with each consecutive subject. All mandibular anterior teeth were bonded with conventional metal 0.018-in MBT prescription brackets (3M Unitek), and the maxillary anterior teeth were bonded with Clarity MBT prescription brackets (3M Unitek). On 1 side, the second
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American Journal of Orthodontics and Dentofacial Orthopedics August 2007

premolar and the rst molar distal to the extraction site were bonded with 0.018-in SmartClip MBT prescription brackets, and the contralateral side was bonded with conventional metal MBT prescription brackets. All patients were told the purpose of the study but were unaware of which side had the SmartClip or the conventional twin brackets. After initial alignment, a 0.016 0.022-in SS archwire was placed with a soldered hook mesially to the canines and then left in place for 5 weeks. The 6 anterior teeth were consolidated with elastic chain, and the archwire ended ush with the distal aspect of the rst molar bracket on each side. After 5 weeks of alignment, 9-mm nickel-titanium (Ni-Ti) medium Sentalloy (150 g) coil springs (GAC International, Bohemia, NY) were placed across the extraction sites from the bracket hook on the rst molar; the spring was activated between 6 and 9 mm and then ligated with an SS ligature to the archwire hook mesial to the canine. The space between the mesial aspect of the canine bracket and the distal aspect of the rst molar bracket was measured intraorally by using a digital caliper (150 mm ECP-015D digiMax caliper, Moore and Wright, Buchs, Switzerland) to the nearest 0.1 mm. Three measurements were taken, and, if there was any discrepancy, the 2 closest were recorded and averaged. The patients were recalled every 5 weeks, excess wire was clipped distal to the molar brackets, the springs were checked for 6 to 9 mm activation, and the spaces were measured until 1 extraction space had closed. The difference between the initial and the nal measurements was calculated to give the total amount of space closure, and this was divided by the number of months to give the rate of space closure in millimeters per month. Because the small sample size makes an assumption of normality difcult, a nonparametric Wilcoxon signed rank test was used to assess the data.
RESULTS

mm for both groups, and the median calculated rates of movement were 1.1 mm per month for SmartClip and 1.2 mm per month for conventional twin brackets. The Wilcoxon signed rank test showed no statistically signicant difference (P .86) between the median rates of space closure (95% CI, 0.29 to 0.20).
DISCUSSION

Nineteen patients were enrolled in the study; 1 subject had both arches involved, for a total of 20 arches. Six subjects were excluded during the study. Two had at least 1 extraction space closed during the initial alignment phase, 1 moved away, 1 had a measurement not recorded, 1 had the anterior elastic chain break resulting in canine drift distally, and 1 had a loose molar bracket during space closure. The nal sample included 13 subjects and 14 arches (8 female, 5 male; median age, 13.1 years; range, 11.8-29.4 years; 11 maxillary arches, 3 mandibular arches). Because the rates of space closure were similar in both arches and also for the only adult patient in the group, the data were pooled. The median space to be closed was 4.9

Previous in-vitro studies of self-ligating brackets clearly showed that passive ligation results in less friction than active ligation.5-7 However, it was assumed that, along with low friction in vitro, come more rapid space closure and reduced treatment time in vivo. The results of this study demonstrate that the rates of space closure were almost identical with the passive SmartClip bracket and the conventional brackets tied with SS ligatures distal to the extraction site. Clinicians can therefore use their preferred bracket type (conventional or passive self-ligating) without it affecting the rate of space closure in extraction patients. SS ligatures were tied normally with no attempt to keep them loose, so this would seem to offer no advantage during en-masse space closure when the teeth are already leveled and aligned. However, if a different method were used such as modules or a chain tied around the bracket, the higher resistance to sliding might impact the rate of space closure. A previous split-mouth study comparing Ni-Ti springs with a stretched elastomeric module showed that springs were superior to the module for en-masse space closure.8 However, no attempt was made to equalize the initial forces applied. The same authors, when comparing 150-g springs (as used in this study) with 200-g springs, found no clinical difference in the rate of space closure.9 A randomized clinical trial of a 22-in slot preadjusted bracket with 0.019 0.025-in SS wires compared active ligatures, power chain, and Ni-Ti springs during space closure.10 The Ni-Ti coil springs (activated no more than 9 mm) were found to achieve the most rapid rate of space closure at 0.81 mm per month. These authors concluded that intermaxillary elastics were not a factor in the rate of space closure. In a split-mouth comparison of elastomeric chain vs Ni-Ti coil springs with a 22-in slot system and 0.019 0.025-in SS wires, no statistically signicant difference was found in another study.11 The elastomeric chain achieved movement of 0.21 mm per week (about 0.9 mm per month), whereas the 9-mm Ni-Ti springs (stretched the whole length of the span) achieved 0.26 mm per week (about 1.1 mm per month); this is similar to the median rate of space closure (1.1-1.2 mm per month) in this study. Although these previous studies used a 22-in slot system, the rates of space closure were less than or similar to the 18-in slot

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system used in this study. It would therefore appear that the slot size in conjunction with the appropriate wire size makes minimal clinical difference in the rate of space closure. In addition, the use of the passive SmartClip bracket made no difference to the rate of space closure when compared with the conventional twin bracket ligated with SS ligature. It appears that, once the initial static friction in either system is overcome, the residual force with the 150-g spring is sufcient to produce similar rates of movement. Therefore, the clinical choice of slot size and bracket ligation (passive self-ligating vs SS ligature) for sliding mechanics can be based on practitioner preference. Although self-ligating brackets save time compared with conventional brackets when untying and ligating, once a SS ligature is tied at the initial placement of the SS archwire for space closure, it can be left for the entire duration of space closure without retying.2,12 The time saved for ligation would be greater at wire changes during initial alignment and in the nal detailing stages of treatment. A disadvantage of a slit-mouth design as in this study is the potential for the archwire to slide to 1 side, but it was thought that the soldered posts would prevent or minimize this. The canine could not move if the archwire slid because the 6 anterior teeth were consolidated with elastic chain. If the archwire was to move, it would be expected to be toward the side with less friction; this would affect the measurements if taken from a xed point on the archwire. Because the measurements were taken bracket to bracket, this should not impact the measured changes. It could be argued that the use of conventional brackets and chain in the anterior would increase friction in the system, but, during rst premolar extraction space closure, the archwire slides distally to the extraction site, which is where friction would be critical, so this should not inuence the result. The archwires in this study extended to the rst molars during space closure, and, if extended to the second molars, this might affect the rate of closure. However, because a tube is normally used on second molars even in self-ligating bracket systems, it is unlikely to alter the outcome. With a small sample size, it is possible that a type II error was made and that the null hypothesis was accepted when it should have been rejected (no difference was found when it would have been found with a larger sample with higher power), so a larger sample would be preferable. Because the 95% CI for the differences in the medians ( 0.29 to 0.20 mm) spans either side of zero (indicating no statistically signicant difference) and the range is small (only 0.2-0.3 mm), it is still quite likely

that a larger sample would still nd no clinically signicant difference. Further prospective research with identical wire progressions and mechanics is required to determine whether there is any reduction in overall treatment duration with self-ligating brackets. The ndings of this and previous research with the same wire sequences showed no differences between passive self-ligating brackets and conventional twin brackets during either initial alignment or space closure.3,4 Therefore, any treatment time savings might still be possible during the latter stages of treatment or only in certain types of patients, or there might be no time saving.
CONCLUSIONS

With Ni-Ti coil springs with the wire sequence and bracket prescription as used in this study, there was no difference in the rates of space closure between the passive self-ligating SmartClip bracket and the conventional twin bracket ligated with SS ligatures.
REFERENCES 1. Eberting JJ, Straja SR, Tuncay OC. Treatment time, outcome, and patient satisfaction comparisons of Damon and conventional brackets. Clin Orthod Res 2001;4:228-34. 2. Harradine NWT. Self-ligating brackets and treatment efciency. Clin Orthod Res 2001;4:220-7. 3. Miles PG, Weyant RJ, Rustveld L. A clinical trial of Damon 2 vs. conventional twin brackets during initial alignment. Angle Orthod 2006;76:480-5. 4. Miles PG. SmartClip versus conventional twin brackets for initial alignment: is there a difference? Aust Orthod J 2005;21: 123-7. 5. Pizzoni L, Raunholt G, Melsen B. Frictional forces related to self-ligating brackets. Eur J Orthod 1998;20:283-91. 6. Sims AP, Waters NE, Birnie DJ, Pethybridge RJ. A comparison of the forces required to produce tooth movement in vitro using two self-ligating brackets and a pre-adjusted bracket employing two types of ligation. Eur J Orthod 1993;15:377-85. 7. Shivapuja PK, Berger J. A comparative study of conventional ligation and self-ligation bracket systems. Am J Orthod Dentofacial Orthop 1994;106:472-80. 8. Samuels RH, Rudge SJ, Mair LH. A comparison of the rate of space closure using nickel-titanium spring and an elastomeric module: a clinical study. Am J Orthod Dentofacial Orthop 1993;103:464-7. 9. Samuels RH, Rudge SJ, Mair LH. A clinical study of space closure with nickel-titanium coil spring and an elastic module. Am J Orthod Dentofacial Orthop 1998;114:73-9. 10. Dixon V, Read MJF, OBrien KD, Worthington HV, Mandall NA. A randomized clinical trial to compare three methods of orthodontic space closure. J Orthod 2002;29:31-6. 11. Nightingale C, Jones SP. A clinical investigation of force delivery systems for orthodontic space closure. J Orthod 2003; 30:229-36. 12. Berger J, Byloff FK. The clinical efciency of self-ligated brackets. J Clin Orthod 2001;35:304-8.