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Introduction: The aim of this study was to evaluate the effects of self-ligating brackets and conventional
brackets ligated with stainless steel ligatures on dental plaque retention and microbial ora. Methods: Twenty
boys (mean age, 14.2 6 1.5 years) underwent bonding with self-ligating bracket systems and conventional
standard edgewise bracket systems ligated with stainless steel ligatures with a split-mouth design. Clinical
measurements, including plaque index, probing pocket depth, and bleeding on probing, were obtained before
bonding, 1 week after bonding, and 3 months after bonding. Supragingival plaque samples were obtained at
baseline and 3 months after bonding for the detection of bacteria. A quantitative analysis for Streptococcus
mutans, Streptococcus sobrinus, Lactobacillus casei, and Lactobacillus acidophilus was performed using
real-time polymerase chain reaction. The Mann-Whitney U test and the Hotelling T2 multivariate test were
used for statistical comparisons of the groups. Results: The numbers of S mutans, S sobrinus, L casei, and
L acidophilus were not statistically different between self-ligating brackets and conventional brackets ligated
with stainless steel ligatures (P .0.05). The 2 archwire ligation techniques showed no statistically signicant
differences in plaque index, bleeding on probing, and probing pocket depth values of the bonded teeth
(P .0.05). All clinical parameters and the numbers of all microorganisms showed statistically signicant
increases from baseline to 3 months after bonding in both groups (P \0.001). Conclusions: Self-ligating
brackets and conventional brackets ligated with stainless steel ligatures do not differ with regard to dental plaque
retention. (Am J Orthod Dentofacial Orthop 2013;144:260-7)
260
volume of acid-producing bacteria, mainly Streptococcus mutans, Streptococcus sobrinus, and lactobacilli, and metabolization of sugars by these cariogenic
bacteria.5,6 Enamel demineralization, termed white
spot lesions, is a common side effect of orthodontic
treatment. White spot lesions can be seen in
approximately 50% of patients after xed orthodontic
treatment.7-9
Many studies have reported increases in the amounts
of cariogenic microorganisms, including S mutans and
lactobacilli, in the dental plaque and saliva of patients
after the bonding of orthodontic appliances.10-15
During xed orthodontic treatment, gingival
inammation occurs,1,16,17 and the pathologic changes
in patients treated with xed orthodontic appliances
have been reported as mostly gingivitis, gingival
bleeding, gingival enlargement, and increased
periodontal pocket depth.18 The ligation method of
the orthodontic archwires is an additional factor to be
taken into account for microbial dental plaque retention. Elastic and stainless steel ligatures are used to tie
stainless steel wires into the brackets and are often
linked to the risk of dental caries in orthodontic
261
262
S sobrinus
L casei
L acidophilus
Primer- probe
Forward
Reverse
Probe
Forward
Reverse
Probe
Forward
Reverse
Probe
Forward
Reverse
Probe
Sequence
5'-CCGGTGACGGCAAGCTAA-3'
5'-TCATGGAGGCGAGTTGCA-3'
FAM-5'-CTCTGAAAGCCGATCTCAGTTCGGATTG-TAMRA-3'
5'-TTCAAAGCCAAGACCAAGGCTAGT-3'
5'-CCAGCCTGAGATTCAAGCTTGT-3'
FAM-5'-CCTGCTCCAGCGACAAAGGCAGC-TAMRA-3'
5'-CTATAAGTAAGCTTTGATCCGGAGATTT-3'
5'-CTTCCTGCCGGTACTGAGATGT-3'
FAM-5'-ACAAGCTATGAATTCACTATGC-TAMRA-3'
5'-GAAAGAGCCCAAACCAAGTGATT-3'
5'-CTTCCCAGATAATTCAACTATCGCTTA-3'
FAM-5'-TACCACTTTGCAGTCCTACA-TAMRA-3'
232
132
391
263
Table II. Means, standard deviations, and statistical comparisons of the bacterial counts (log 10)
T0
Group
Self-ligating
Steel ligature
Self-ligating
Steel ligature
Self-ligating
Steel ligature
Self-ligating
Steel ligature
S mutans
S sobrinus
L casei
L acidophilus
n
20
20
20
20
20
20
20
20
Mean
4.44
4.55
2.36
2.45
2.99
2.82
2.10
1.79
T2
SD
0.94
1.21
0.33
0.36
0.83
0.74
0.88
0.39
Mean
6.15
6.39
3.05
3.34
4.45
4.23
3.09
2.78
Signicance between
SD
1.05
1.00
0.84
0.67
1.56
1.53
1.03
1.11
T0-T2
0.000
0.000
0.000
0.000
0.000
0.000
0.000
0.000
Table III. Statistical comparisons of the differences in the bacterial counts (log 10) between groups
Self-ligating
Microorganism
S mutans
S sobrinus
L casei
L acidophilus
n
20
20
20
20
Mean
1.72
0.69
1.47
0.99
SD
1.15
0.67
1.34
0.56
Minimum
0.03
0.16
0.09
0.18
Steel ligature
Maximum
3.26
2.52
4.82
1.88
Mean
1.84
0.89
1.41
0.99
SD
1.37
0.65
1.25
1.01
Intergroup comparison
Minimum
0.06
0.15
0.04
0.17
Maximum
4.19
2.97
4.4
4.24
P value
0.787
0.104
0.978
0.386
264
Table IV. Means, standard deviations, and statistical comparisons of the periodontal measurements
T0
Plaque index
Bleeding on probing
Probing pocket depth
Group
Self-ligating
Steel ligature
Self-ligating
Steel ligature
Self-ligating
Steel ligature
n
20
20
20
20
20
20
Mean
1.11
1.11
48.17
51.83
2.00
2.02
T1
SD
0.30
0.25
16.31
14.37
0.43
0.37
Mean
1.94
2.09
68.50
68.33
2.44
2.40
T2
SD
0.30
0.31
13.83
14.24
0.44
0.51
Mean
2.27
2.48
86.00
89.83
2.73
2.71
Signicance between
SD
0.34
0.26
7.30
7.05
0.49
0.48
T0-T1
0.000
0.000
0.000
0.000
0.000
0.000
T1-T2
0.000
0.000
0.000
0.000
0.000
0.001
T0-T2
0.000
0.000
0.000
0.000
0.000
0.000
T0, Before bonding; T1, 1 week after bonding; T2, 3 months after bonding.
Table V. Statistical comparison of the difference in the clinical periodontal measurements between groups
Self-ligating
Clinical periodontal index
Plaque index
Bleeding on probing
Probing pocket depth
n
20
20
20
Mean
1.16
37.84
0.72
SD
0.38
15.87
0.31
Minimum
0.43
0.00
0.06
Steel ligature
Maximum
2.03
60.00
1.23
Mean
1.37
38.00
0.68
SD
0.34
14.53
0.32
Minimum
0.76
13.33
0.07
Intergroup comparison
Maximum
1.96
63.33
1.20
P value (T0-T2)
0.091
0.871
0.882
effects of self-ligating brackets on oral hygiene. However, to our knowledge, no studies have compared the differences in retention of microbial dental plaque between
self-ligating brackets and stainless steel ligatures; it is
necessary to compare the 2 ligation systems, as
mentioned by Pellegrini et al.31
Forsberg et al13 evaluated microbial colonization in
12 patients undergoing xed orthodontic treatment
and found that the numbers of S mutans and lactobacilli
in the saliva increased signicantly after the insertion of
xed appliances, and that the maxillary lateral incisors
ligated to the archwires with elastomeric rings had
more bacteria in the plaque than did the incisors ligated
with steel ligatures. They recommended avoiding the use
of elastomeric rings in patients with poor oral hygiene
because elastomeric rings can signicantly increase the
microbial accumulation on the tooth surfaces adjacent
to the brackets, leading to a predisposition for the development of dental caries and gingivitis. In contrast,
Sukontapatipark et al28 used scanning electron microscopy to evaluate the effect of elastomeric rings and steel
ligatures on bacterial colonization at 1, 2, and 3 weeks
after bonding and reported that the ligation method
did not appear to inuence the bacterial morphotypes
on either the composite or the enamel surface. However,
an archwire was not used because the study design
included only 1 bonded tooth in each quadrant. Similarly, Turkkahraman et al29 reported that the differences
between elastomeric rings and steel ligatures were not
signicant and could be ignored. They also reported
that teeth ligated with elastomeric rings were more
prone to bleeding; therefore, elastomeric rings were
not recommended for patients with poor oral hygiene,
as stated by Forsberg et al.13 However, this experimental
design was different from that used by Forsberg et al. In
addition, Pellegrini et al31 compared self-ligating and
elastomeric orthodontic brackets in terms of plaque
retention using adenosine triphosphate-driven bioluminescence and reported that in most patients, teeth
bonded with self-ligating attachments had fewer bacteria in the plaque than did teeth bonded with elastomeric
brackets at 1 and 5 weeks after the bonding. In contrast,
Pandis et al32 investigated the effect of bracket type on
the levels of S mutans and total bacterial counts in
whole saliva of orthodontic patients 2 to 3 months after
appliance bonding and found no difference between
conventional brackets ligated with elastomeric rings
and self-ligating brackets. In our study, a steel ligature
was used instead of an elastomeric ring because an elastomeric ring has been clearly shown to cause more
plaque accumulation in several studies. In an in-vitro
study, Garcez et al33 evaluated biolm retention around
orthodontic brackets involved in the 3 ligation methods
265
266
2.
3.
4.
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