Self-ligating brackets increase

treatment
efficiency

CONTENT

Introduction
SECURE, FULL ARCHWIRE ENGAGEMENT
FASTER LIGATION AND ARCHWIRE REMOVAL
LOWER RESISTANCE TO SLIDING
MORE RAPID TREATMENT
IS TREATMENT LESS PAINFUL WITH
SELFLIGATION?
CONCLUSIONS

Introduction
Since an early stage in the development of self-ligating brackets,
authors have proposed advantages in relation to treatment
efficiency.
Increased efficiency can be defined as achieving a result that is as
good or better, with an increase in factors that are valued by the
provider or the recipient of a service.
In orthodontic treatment, these factors could include fewer
appointments, shorter appointments, more comfortable treatment,
practical procedures that are technically easier for the clinician or
the patient, less need for extractions, and less pain or anxiety for the
patient.
There could also be factors relating to outcome, such as less
decalcification or root resorption, and more certain or better results.

 All of these have been proposed by some authors in

relation to self-ligation.
The core assets of self-ligation, which form the basis of
any such proposal, can be summarized as follows:
secure, full archwire engagement; lower resistance to
sliding between bracket and archwire; faster ligation and
archwire removal; and less need for chair-side assistance.

SECURE, FULL ARCHWIRE

ENGAGEMENT
Absolute security of archwire engagement as provided by
a molar tube would inherently reduce treatment
inefficiencies compared with conventional ligation.
Although the potential for decay or loss of elastomeric
ligatures is well known, only decay has been extensively
investigated.
One study did quantify the loss of elastomeric ligatures,
finding 15 lost ligatures in 25 consecutively seen patients
in a 12-month treatment period.

 Some early self-ligating brackets did not deliver the

secure engagement of a molar tube, but today most selfligating brackets have mechanisms to deliver this
advantage and would by definition ensure full
engagement of all archwires andeliminate the need to
regain control of the teeth when full engagement is lost.
In a recent study of canine retraction with 0.018-in
stainless steel wires, selfligating brackets were found to
give better rotational control of the canine than
conventionally ligated brackets.
Furthermore, 80% of the canines rotatedmore than 10
with conventional brackets, as opposed to 33% with selfligating brackets, over the 12-week period.

FASTER LIGATION AND ARCHWIRE

REMOVAL
The original motive when developing self-ligating
brackets was to speed the process of archwire ligation.
Several authors have shown self-ligating brackets to
be better in this respect, with savings of up to 9
minutes per visit compared with wire ligation and
approximately 2 minutes compared with elastomeric
ligation.
In these studies, unassisted archwire ligation with selfligating brackets was compared with conventional
ligation performed with a chairside assistant to speed
the process.

 It is probable that many of the more recent bracket types

would show greater time savings for archwire changes
because the mechanisms have become significantly easier
to use.
Interestingly, almost no recent studies with these newer
brackets have emerged, probably because the speed and
ease of use of the more modern self-ligating brackets is
now taken for granted.

LOWER RESISTANCE TO SLIDING

When drawing wires through well-aligned
brackets,friction is the only source of resistance to
sliding, and friction has consistently been measured as
much lower in self-ligating brackets than in
conventionally ligated brackets.
Studies typically report values of almost zero with selfligating brackets and values from 43 to 98 g per bracket
for various elastomeric-archwire combinations.
The obvious next requirement was to investigate
resistance to sliding with active archwires, where
binding is an important contributor; this has been
thoroughly investigated, particularly by Thorstenson
and Kusy.

 These authors examined the effects of varying active tip

(angulation) on the resulting resistance to sliding (Table).

 They calculated that for an 0.018 3 0.025-in stainless steel

archwire, an activation of 6 was clinically the most
relevant, since beyond that angle uprighting forces from
the archwire would limit further tipping and cause the
tooth to walk along the archwire in a series of binding
and releasing movements around this angle.
At this angulation of 6, the difference in resistance to
sliding is 60 g per bracket.Fig 10 in Thorstenson and
Kusy's paper, which illustrates these data, shows
clinically relevant illustrations showing that in terms of
sliding with second order angulation, this bracket is
superior to the conventional bracket.

 Interpretation of this important point can vary widely,

even when the same research is being quoted.
For example, Brauchlietal correctly quoted data from
Thorstenson and Kusy to the effect that for an 0.018 X
0.025 in wire and a self-ligating bracket with angulations
of 7 between the archwire and slot, more than 94% of the
[resistance to sliding] is caused by binding.
However, this has been taken to imply that the
contribution to resistance to sliding from the lowered
friction of self-ligating brackets is therefore irrelevant
when archwire activation causes binding.
In fact, it is the low friction with selfligating brackets that
makes any binding component such a high percentage of
the overall resistance to sliding.

 If the friction is zero and it is usually close to zero with

self-ligating brackets the binding component will
correspondingly constitute 100% of the resistance to
sliding.
Pliskaetal also found that at high angles of tip, the
reduction in friction with self-ligating brackets is
drowned by the high binding, but at lower and clinically
more relevant levels of activation, reductions in resistance
to sliding averaging 40 g were found with self-ligating
brackets.
Studies of aligning wires placed in irregularly aligned
brackets have also shown large reductions in resistance to
sliding with selfligating brackets in all 3 planes of space.

 Three of these articles specifically measured the other side of

the equation the net residual aligning force available to act on
the displaced tooth after the losses from resistance to sliding.
Typically in these studies, a bracket displaced by 4 mm from
its neighbors has no residual aligning force with conventional
ligation but 80 g of aligning force with self-ligating brackets.
Petersonetal showed that artificial aging of elastics reduced
this differential, but Matasa demonstrated the consequent
trade-off for elastomerics with the loss of ligating force

available for tooth control. Interestingly, these laboratory

results were similar to an invivo study by Crawfordetal,
who commented that the results of our in situ study
concur with those of the best outcomes from the
laboratory studies.

 Welldesigned in-vitro studies may indeed give a good

insight into in-vivo conditions.
In a systematic review of this question, the authors
concluded that the case is proven for lower resistance to
sliding with selfligation with round wires, but not for the
larger rectangular wires where more evidence is still
required.
An interesting facet of the study selection for this review as
that 2 of the seminal articles by Thorstenson and Kusy
referred to above were not mentioned.
Lower resistance to sliding in clinical use seems probable, as
does the effectiveness of lighter applied forces, since less
force for the desired tooth movement is eaten up as
resistance to sliding.

MORE RAPID TREATMENT

Several consecutive case series studies found that

treatment with self-ligating brackets was quicker, required
fewer visits, and resulted in as good or better final
alignment and occlusion than treatment with conventional
appliances.
However, other similar studies and all randomized
controlled studies to date have found no difference in
these parameters between self-ligating and conventional
brackets in various parts of the treatment process.
Two recent systematic reviews have understandably
concluded that there is insufficient evidence to support
the view that treatment with self-ligating brackets results
in fewer visits or shorter treatment.

 It seems probable that self-ligating brackets, by

themselves, do not confer a blanket advantage of
reduction in duration of treatment and that randomized
controlled trials with a general case mix when the bracket
type is the only tested variable and all other treatment
mechanics are identical will continue to find no difference
in average treatment duration.
It is possible that in certain patients and with archwires
and reappointment intervals customized to match the
biomechanical differences of lower resistance to sliding
and better ligation control, self-ligation might reduce
treatment duration.
.

 However, no randomized controlled trial has succeeded in

supporting the view that fully preadjusted straight-wire
brackets are superior to plain edgewise brackets, although
their superior efficiency is universally assumed and
adopted.
Similarly, after several decades of use, only 1 recent study
has succeeded in supporting the view that nickel-titanium
aligning archwires are more effective than multistrand
stainless steeland then, only with Begg brackets, not
with preadjusted edgewise brackets.

IS TREATMENT LESS PAINFUL

WITH SELFLIGATION?
The notion that treatment with self-ligating brackets is less
painful has 2 possible explanations the forces on the teeth are
lower because lighter archwires can be used with equal
effectiveness, and the teeth move more readily in response to
the applied forces because of decreased resistance to sliding.
However, although it is probable that lower applied forces
will be more effective with self-ligation because less force
will be lost through resistance to sliding, lower net forces are
certainly not inevitable and, with selfligating brackets, are
correspondingly more sensitive to the choice of archwire .

 Three studies found that patients reported lower pain

levels with various self-ligating brackets34,47,48; 2
others found no difference. 48,49 The authors of a
systematic review concluded that the balance of
evidence from the 3 published randomized controlled
trials on this topic just favor a reduction of pain
during alignment with self-ligation.
An interesting split-mouth study examined the
question via a different measure of painthe level of
the neuropeptidase substance P in gingival crevicular
fluid, which is a marker of inflammation and
associated pain resulting from orthodontic forces.

 These authors found that treatment with self-ligating

brackets significantly lowered the levels of this
marker of pain and inflammation when compared
with conventional ligation at 24 hours after archwire
placement. At the least, there is reason to believe that
lower resistance to sliding and the use of lighter but
still effective archwires might be less painful for our
patients.

DOES THE REDUCTION IN

RESISTANCE TO
SLIDING LEAD TO A DIFFERENT
PATTERN OF
TOOTH MOVEMENT?

Investigators using 2 sophisticated systems for measuring

forces and moments in the laboratory have in almost all
instances shown distinctly different force distributions with
self-ligating brackets compared with conventional brackets
in various simulated malocclusions; this suggests that
correspondingly different patterns of in-vivo tooth
movement can be expected.
One such pattern is a reduction in undesirable buccally
directed force, which in turn has led to the hypothesis that
incisor flaring can be reduced with a consequently
increased distal or buccal movement of the teeth .

 As yet, no invivo studies have supported these

hypotheses, but it would be surprising if these marked
differences in force distribution had no clinical
consequences.

CONCLUSIONS
Some of the enthusiastic claims on behalf of selfligation ran
ahead of the evidence to firmly support them. In this respect,
self-ligation is not alone in orthodontics. Functional
appliances continue to be justifiably popular as effective and
efficient means of correcting many Class II malocclusions,
although the original hope and proposal that they would
produce a reliable and significant enhancement of mandibular
growth has been shown to be unfounded.
For self-ligation, the core features of security of
ligation, lower resistance to sliding, and more
rapid and convenient archwire changes remain
and are increasingly supported by good studies.