POINT/COUNTERPOINT

11

Self-ligating brackets do not increase treatment

efciency
Padhraig S. Fleminga and Kevin OBrienb
London and Manchester, United Kingdom

he Oxford English Dictionary denes efciency

as achieving maximum productivity with minimum wasted effort or expense. Orthodontic
pioneers have continuously sought methods of enhancing treatment efciency by attempting to reduce
the duration of orthodontic treatment and the length
of orthodontic appointments.1 Although mean treatment times of 1 to 2 years are now typical, the drive
to reduce orthodontic treatment duration persists.2,3
Many techniques and appliances, including surgical
techniques,4 vibratory stimulation,5 increased customization of wires and brackets,6 eschewal of integral
treatment phases,7 and routine avoidance of extractions, continue to be proposed with the expressed
aim of furthering this progression. The most high prole of these developments has been self-ligating
brackets.8 Unfortunately, the marketing of selfligating brackets has courted controversy, with some
advocates overly optimistic about the potential effects
and, consequently, overlooking or ignoring the
ndings from clinical research studies.9,10 In this article, we will review the evidence for many of the
claims made by those who promote self-ligating
brackets, even in the face of recently published clinical
research.
CHAIR-SIDE EFFICIENCY AND EASE OF USE

Evidence indicating that self-ligating systems result

in a consistent but modest reduction in chair-side
time compared with conventional appliances is plentiful8,11-15 (Table I). In a meta-analysis,16 results from 2
comparable studies8,15 reported mean time savings of
20 seconds per arch with slide opening compared
a

Clinical senior lecturer/honorary consultant, Barts and The London School of

Medicine and Dentistry, London, United Kingdom.
Professor of orthodontics, School of Dentistry, University of Manchester,
Manchester, United Kingdom.
Reprint requests to: Padhraig S. Fleming, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Institute of Dentistry,
Turner Street, London E1 2AD, United Kingdom; e-mail, padhraig.eming@
gmail.com.
Am J Orthod Dentofacial Orthop 2013;143:10-9
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.10.012

with ligature removal. No signicant time difference

was noted, however, for slide closure and replacement
of ligatures. Proponents have suggested that the saved
time could be used to schedule more patients, increase
efciency, improve patient relations, or allow oral
hygiene reinforcement.11 However, it could also be
suggested that a saving of 40 seconds per patient is insignicant and would not make many operators
change their practice.
EFFICIENCY OF TREATMENT

Early research examining the relationship between

self-ligating brackets and overall treatment time was
observational.17,18 These studies were invariably compromised by the compelling possibilities of selection
bias, observer bias, and confounding, including susceptibility to uncontrolled factors such as varying
operator experience and preference, differing archwires
and sequences, and inconsistent appointment intervals. These studies were most notable for large reported
discrepancies in treatment durations, with mean treatment times for conventional brackets ranging from
23.518 to 3117 months. This inconsistency suggests
that any advantage attributable to bracket type is likely
to be dwarfed by extraneous factors, including the
skills, standards, and ability of the operator. Nevertheless, the enduring message from these studies was that
self-ligating brackets were responsible for signicantly
reducing treatment times and visits without impairing
the occlusal outcomes. This assumption remained unchallenged until more robust prospective research began to emerge 4 years later. This prospective research
was initially restricted to efciency during a snapshot
of treatment, including the efciency of the initial orthodontic alignment19-26 and the rate of orthodontic
space closure27,28; however, prospective studies encompassing treatment in its entirety have been published more recently.
EFFICIENCY OF ARCH ALIGNMENT

A number of prospective studies have investigated

the efciency of initial orthodontic alignment over periods up to 20 weeks.19-26 The results from these trials

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have consistently indicated that despite their associated

self-ligating brackets, it does not become apparent in
costs, self-ligating brackets might offer no advantage
the initial alignment phase of treatment. However,
with respect to treatment efciency (Table II).
alleviation of dental irregularity is difcult to measure
For example, in a prospective analysis of 48 particperfectly, most trials have failed to control for individipants, Miles19 compared alignment efciency with
ual metabolic variations, confounding might occur beSmartClip (3M Unitek, Monrovia, Calif) and convencause of baseline imbalances, and the results could
tional twin brackets. SmartClip was found to be no
have been unintentionally biased by inaccurate bracket
more effective at reducing irregularity during the initial
placement. In addition, split-mouth designs might be
stage of treatment than the conventional twin bracket
criticized because of the complexity in handling residligated with elastomeric modules or stainless steel ligual malalignment between the central incisors. Neveratures, with slightly more irregularity remaining after
theless, unless time is saved later in treatment, on the
initial alignment in the group treated with SmartClip;
basis of these prospective studies it seems unlikely
this was attributed to the rotational play allowed by
that self-ligating systems counterbalance their costs
the passive self-ligating system with a 0.014-in alignby resulting in more efcient treatment or better treating nickel-titanium wire. This study was limited by
ment outcomes.
inclusion of both extraction and
RATES OF SPACE
nonextraction subjects and meaCLOSURE AND CANINE
Unfortunately,
the
marketing
of
surement of the labial segments
RETRACTION
only. These ndings were mirself-ligating brackets has courted
22
Rates of space closure
rored by Scott et al in a randomcontroversy, with some advocates
ized controlled trial of Damon
and canine retraction
overly optimistic about their
3 (Ormco Corporation, Orange,
were rst investigated by
potential
effects and, consequently, Miles,27 who considered
Calif) and a conventional appliance in subjects treated with overlooking or ignoring the ndings the rate of orthodontic
space closure in a splitmandibular rst premolar extracfrom clinical research studies.
mouth design negating
tions. In a further clinical investithe inuence of metagation of 58 patients, Miles
bolic variations. No statistical difference was found
et al20 compared efciency of alignment and patient
comfort related to Damon 2 and a conventional twin
between the appliance types. This study had a relabracket in nonextraction subjects, using a splittively small sample size, with 4 of 18 subjects failing
mouth study design. At 10-week and 20-week interto complete the study. Posted archwires were used on
vals, the twin bracket had achieved an irregularity index
both sides; this design meant that the rate of space
score of 0.2 mm lower than that achieved with the Daclosure on each side might also not have been common 2 brackets.
pletely independent of the opposing side. NevertheSimilar ndings were reported by Pandis et al21 in
less, these ndings were reinforced by those of
a controlled clinical trial involving Damon 2 and MicroMezomo et al28 in a split-mouth randomized conArch appliances (Dentsply International Inc, York, Pa),
trolled trial comparing the rates of canine retraction
with no signicant difference overall in the time taken
with either SmartClip or Gemini (3M Unitek) brackets
to align the mandibular arch. The authors of a further
on the canines. Again, no clinically or statistically aprandomized controlled trial reported little difference
preciable difference in the monthly rate of canine
in alignment efciency with an initial aligning wire
retraction was found; the average monthly rate of re(0.016-in nickel-titanium) with SmartClip and Victory
traction was just 0.06 mm more with the self-ligating
systems (3M Unitek) in subjects treated without
brackets. These studies consistently indicate that selfextractions.23 This study of 65 patients involved 3-diligating brackets might have little benet with respect
mensional measurements and encompassed 11 manto treatment efciency.
dibular contact points. Similarly, no difference in the
OVERALL TREATMENT DURATION
rate of alignment could be attributed to ceramic selfRecently, a large retrospective study29 and several
ligating brackets compared with ceramic conventional
randomized controlled trials30-32 investigating the dubrackets in a further randomized controlled trial over
24
ration of orthodontic treatment in its entirety have
10.7 weeks.
Overall, these studies involving 447 participants
been published. The prospective studies were based in
indicate that if any time saving arises from use of
hospital or public health care settings and comprised

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Table I. Comparative studies of chair-side time differences with self-ligating and conventional brackets
Study
Maijer and Smith (1990)11
Shivapuja and Berger (1994)12

Self-ligating
SPEED*
Activa,y Edgelok (Ormco), SPEED

Voudouris (1997)13
Harradine (2001)8
Berger and Byloff (2001)14
Turnbull and Birnie (2007)15

Interactwin (Ormco)
Damon SL
SPEED
Damon 2

Conventional ligation
Elastomerics
Elastomerics
Steel ligatures
Elastomerics
Elastomerics
Elastomerics
Elastomerics

Time savings
7 min
1 min
12 min
2.5 min
25 s
2-3 min
1.5 min

*SPEED System Orthodontics; Strite Industries, Cambridge, Ontario, Canada; yA Company Orthodontics, San Diego, Calif.

Table II. Comparative studies of the rate of initial orthodontic alignment with self-ligating and conventional

brackets
Study
Miles (2005)19

Miles et al (2006)20

Pandis et al (2007)21

Scott et al (2008)22

Fleming et al (2009)23

Miles and
Weyant (2010)24

Ong et al (2010)25

Pandis et al (2011)26

Method
CCT, observed at
10 and 20 weeks

Subjects
48 patients; mean age,
17.1 years; 26 male,
32 female

Interventions
Group 1: 24 patients
with SmartClip
Group 2: 24 patients
with Victory
CCT, split-mouth design,
58 consecutive patients;
Lower appliance with
observed at
mean age, 16.3 years;
Damon 2 or Victory
10 and 20 weeks
18 male, 40 female
brackets in alternate
quadrants
CCT, observed until
54 patients; mean age,
Group 1: 27 patients
alignment achieved
13.7 (SD 1.38) years;
with Damon 2
11 male, 43 female
Group 2: 27 patients
with MicroArch
RCT, observed at 8 weeks
62 patients recruited;
Group 1: 33 patients
and after mandibular
mean age, 16.27
with Damon 3
alignment
(SD 4.47) years; 32 male, Group 2: 29 patients
30 female
with Synthesis
(Ormco)
RCT, observed at 8 weeks
65 patients; mean age,
Group 1: 32 patients
16.28 (SD 2.68) years;
with SmartClip
22 male, 43 female
Group 2: 33 patients
with Victory
RCT, observed at 10.7 weeks 60 patients; 22 male,
Group 1: 30 patients
38 female
with In-Ovation C (Dentsply)
Group 2: 30 patients
with Clarity (3M Unitek)
CCT, observed at
50 patients; 20 male,
Group 1: 40 arches
10 and 20 weeks
30 female
with Damon 3
Group 2: 44 arches
with conventional
brackets (26 Victory,
18 Mini Diamond [Ormco])
RCT, observed at
50 patients; 17 male,
Group 1: 25 arches
10 and 20 weeks
33 female
with Damon 3
Group 2: 25 arches
with MicroArch

Outcomes
Rate of initial alignment
mandibular 3-3

Rate of initial alignment

mandibular 3-3

Time taken (days) to align

mandibular 3-3

Rate of initial alignment

mandibular 3-3
Time taken (days) to
align mandibular arch
in 0.019 3 0.025-in SSW
Rate of initial alignment
mandibular 6-6

Rate of initial alignment

maxillary 3-3

Rate of initial alignment

maxillary and
mandibular 3-3

Rate of initial alignment

mandibular 3-3

CCT, Controlled clinical trial; RCT, randomized controlled trial; 3-3, canine to canine; SSW, stainless steel wire; 6-6, rst molar to rst molar.

a total of 192 participants (Table III). Findings from the

3 prospective studies indicate that treatment with selfligating brackets does not result in shorter treatment
times. Importantly, they also included assessment of
the quality of treatment outcome achieved by using
the peer assessment rating index30,31 or the Index of

Complexity Outcome and Need (ICON) score.32 No statistical difference in treatment outcome was observed
in any trial. These studies, therefore, indicate that
self-ligating brackets are neither advantageous nor
disadvantageous in respect of treatment duration or
outcome.

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Table III. Summary of average treatment times in comparative studies of self-ligating and conventional brackets
Study
Eberting et al (2001)17
Harradine (2001)18
Hamilton et al (2009)29
*Fleming et al (2010)30
*DiBiase et al (2011)31
*Johannson and Lundstrom (2012)32

n
215
60
762
54
48
90

Treatment time (months)

with self-ligating brackets
25
19.4
15.5
21
24.48
20.4

Self-ligating bracket
Damon SL
Damon SL
In-Ovation
SmartClip
Damon 3
Time 2y

Treatment time (months)

with conventional brackets
31
23.5
15.8
18
23
18.2

*Prospective study; yAmerican Orthodontics, Sheboygan, Wis.

On the basis of this research, it is doubtful whether

a xed appliance system can have a signicant bearing
on the duration of orthodontic treatment or the number of visits required. Moreover, the skill, experience,
and objectives of the treating clinician, in addition to
the dictates of the patient's malocclusion, are likely
to override any potential difference in treatment
efciency due to bracket type.
CONCLUSIONS

In total, 9 randomized controlled trials have been

cited in this summary. There are also 2 published
systematic reviews on self-ligating brackets.16,33 It
is, therefore, reasonable to assert that the question
of whether self-ligating brackets improve treatment
efciency has been particularly well researched in
the context of orthodontic evidence. Furthermore,
the consistency of the ndings from these prospective studies is remarkable, with none nding that
self-ligating brackets translate into enhanced efciency, during either 1 phase of treatment or overall
therapy.
Therefore, despite the preliminary ndings from
retrospective studies, the contention that self-ligating
brackets do not improve treatment efciency is compelling, highlighting the divergence between retrospective research and clinical reality. The efciency of
a course of orthodontic treatment is based on a complex
interaction of parameters including appliance type,
compliance, biologic age, and bone remodeling, with
biologic processes as the ultimate arbiter dictating
the maximum speed of the process. Although technological advances might sound and look alluring, osteoclasts are less easily impressed than clinicians. As our
specialty progresses, further technological advancement and greater intrusion from private companies
with nancial backing are inevitable. It is important
that a degree of introspection occurs and that salutary
lessons are learned when appraising the benets of
new, heavily marketed appliance systems and new

philosophies. We should not fall for the emperor's

new clothes again.
REFERENCES
1. Stolzenberg J. The Russell attachment and its improved advantages. Int J Orthod Dent Child 1935;21:837-40.
2. Turbill EA, Richmond S, Wright JL. The time-factor in orthodontics: what inuences the duration of treatments in the National
Health Service practices? Community Dent Oral Epidemiol
2001;29:62-72.
3. Richmond S, Andrews M. Orthodontic treatment standards in
Norway. Eur J Orthod 1993;15:7-15.
4. Wilcko WM, Wilcko T, Bouquot JE, Ferguson DJ. Rapid orthodontics with alveolar reshaping: two case reports of decrowding.
Int J Periodontics Restorative Dent 2001;21:9-19.
5. AcceleDent. Available at: http://acceledent.com/images/uploads/
AcceleDent1Increases1the1Rate1of1Orthodontic1Tooth1
MovementResults1of1a1RCT1Final1for1Print1November
11412011. Accessed July 5, 2012.
6. Saxe AK, Louie LJ, Mah J. Efciency and effectiveness of SureSmile. World J Orthod 2010;11:16-22.
7. Six Month Smiles. Available at: http://www.6monthsmiles.com.
Accessed July 5, 2012.
8. Damon System. Available at: http://www.damonbraces.com/
choose/index.php. Accessed July 5, 2012.
9. Peck S. So what's new? Arch expansion, again. Angle Orthod
2008;78:574-5.
10. O'Brien K, Sandler J. In the land of no evidence, is the salesman
king? Am J Orthod Dentofacial Orthop 2010;138:247-9.
11. Maijer R, Smith DC. Time saving with self-ligating brackets. J Clin
Orthod 1990;24:29-31.
12. Shivapuja PK, Berger J. A comparative study of conventional
ligation and self-ligation bracket systems. Am J Orthod Dentofacial Orthop 1994;106:472-80.
13. Voudouris JC. Interactive edgewise mechanisms: form and
function comparison with conventional edgewise brackets. Am
J Orthod Dentofacial Orthop 1997;111:119-40.
14. Berger JL, Byloff FK. The clinical efciency of self-ligated
brackets. J Clin Orthod 2001;35:304-8.
15. Turnbull NR, Birnie DJ. Treatment efciency of conventional vs
self-ligating brackets: the effects of archwire size and material.
Am J Orthod Dentofacial Orthop 2007;131:395-9.
16. Chen SSH, Greenlee MG, Kim JE, Smith CL, Huang GJ. Systematic
review of self-ligating brackets. Am J Orthod Dentofacial Orthop
2010;137:726.e1-18.
17. 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.

American Journal of Orthodontics and Dentofacial Orthopedics

January 2013  Vol 143  Issue 1

Counterpoint

18. Harradine NW. Self-ligating brackets and treatment efciency.

Clin Orthod Res 2001;4:220-7.
19. Miles PG. SmartClip versus conventional twin brackets for initial
alignment: is there a difference? Aust Orthod J 2005;21:123-7.
20. Miles PG, Weyant RJ, Rustveld L. A clinical trial of Damon2 vs
conventional twin brackets during initial alignment. Angle
Orthod 2006;76:480-5.
21. Pandis N, Polychronopoulou A, Eliades T. Self-ligating vs
conventional brackets in the treatment of mandibular crowding: a prospective clinical trial of treatment duration and
dental effects. Am J Orthod Dentofacial Orthop 2007;132:
208-15.
22. Scott P, DiBiase AT, Sherriff M, Cobourne MT. Alignment efciency of Damon3 self-ligating and conventional orthodontic
bracket systems: a randomized clinical trial. Am J Orthod Dentofacial Orthop 2008;134:470.e1-8.
23. Fleming PS, DiBiase AT, Sarri G, Lee RT. Efciency of mandibular
arch alignment with 2 preadjusted edgewise appliances. Am J
Orthod Dentofacial Orthop 2009;135:597-602.
24. Miles P, Weyant R. Porcelain brackets during initial alignment:
are self-ligating cosmetic brackets more efcient? Aust Orthod
J 2010;26:21-6.
25. Ong E, McCallum H, Grifn MP, Ho C. Efciency of self-ligating
vs conventionally ligated brackets during initial alignment. Am J
Orthod Dentofacial Orthop 2010;138:e1-7.
26. Pandis N, Polychronopoulou A, Katsaros C, Eliades T. Comparative assessment of conventional and self-ligating appliances on

19

27.

28.

29.

30.

31.

32.

33.

American Journal of Orthodontics and Dentofacial Orthopedics

the effect of mandibular intermolar distance in adolescent nonextraction patients: a single-center randomized controlled trial.
Am J Orthod Dentofacial Orthop 2011;140:e99-105.
Miles PG. Self-ligating vs conventional twin brackets during
en-masse space closure with sliding mechanics. Am J Orthod
Dentofacial Orthop 2007;132:223-5.
Mezomo M, de Lima ES, de Menezes LM, Weissheimer A,
Allgayer S. Maxillary canine retraction with self-ligating and conventional brackets. A randomized clinical trial. Angle Orthod
2011;81:292-7.
Hamilton R, Goonewardene MS, Murray K. Comparison of active
self-ligating brackets and conventional pre-adjusted brackets.
Aust Orthod J 2008;24:102-9.
Fleming PS, DiBiase AT, Lee RT. Randomized clinical trial of
orthodontic treatment efciency with self-ligating and conventional xed orthodontic appliances. Am J Orthod Dentofacial
Orthop 2010;137:738-42.
Di Biase AT, Nasr IH, Scott P, Cobourne MT. Duration of treatment and occlusal outcome using Damon3 self-ligated and conventional orthodontic bracket systems in extraction patients:
a prospective randomized clinical trial. Am J Orthod Dentofacial
Orthop 2011;139:e111-6.
Johannson K, Lundstrom F. Orthodontic treatment efciency
with self-ligating and conventional edgewise twin brackets.
Angle Orthod 2012;82:929-34.
Fleming PS, Johal A. Self-ligating brackets in orthodontics.
A systematic review. Angle Orthod 2010;80:575-84.

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