The Damon Passive Self-Ligating

Appliance System
David Birnie

The Damon System (Ormco Corp., 1332 South Lone Hill Ave., Glendora, CA
91740-0000) is a passive self-ligation system that was originally introduced
in 1994. Since then, both the bracket and the philosophy behind the system
have undergone continuous evolution. If the development of the Edgelok
(Ormco Corp.) appliance by Wildman in 1972 and the development of the
SPEED (Strite Industries Ltd., 298 Shepherd Ave., Cambridge, Ontario, N3C
1V1 Canada) appliance by Hanson in 1980 marked the start of modern
self-ligating appliances, then the Damon System has probably been responsible
for a fuller understanding of the influence of passive self-ligation on orthodontic
treatment and the increasing popularity and utilization of the concept. (Semin
Orthod 2008;14:19-35.) © 2008 Elsevier Inc. All rights reserved.

The Damon Philosophy have unwanted side effects on treatment

full description of the Damon philosophy
A and treatment techniques are given by
Damon.1 The Damon philosophy is based on the
principle of using just enough force to initiate
tooth movement—the threshold force. The un-
derlying principle behind the threshold force is
that it must be low enough to prevent occluding
the blood vessels in the periodontal membrane
to allow the cells and the necessary biochemical
messengers to be transported to the site where
bone resorption and apposition will occur and
thus permit tooth movement.
A passive self-ligation mechanism has the
lowest frictional resistance of any ligation sys-
tem. Thus the forces generated by the arch-
wire are transmitted directly to the teeth and
supporting structures without absorption or
transformation by the ligature system. The
forces generated by elastomeric ligatures can
Consultant Orthodontist, Maxillofacial Unit, Queen Alexandra
Hospital, Portsmouth, U.K.
Address correspondence to David Birnie, BDS (Edin), FDS,
DMI, RCSEd, FDS, MOrth, RCSEng, Consultant Orthodontist,
Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6
3LY, U.K. E-mail: David.Birnie@porthosp.nhs.uk.
© 2008 Elsevier Inc. All rights reserved.
1073-8746/08/1401-0$30.00/0
doi:10.1053/j.sodo.2007.12.003
progress as shown in Figs 1-4.
Compared with conventional preadjusted
edgewise appliances, it is suggested that the use
of passive self-ligation results in a significant re-
duction in the:
● Use of anchorage devices because the fric-
tional resistance generated by ligatures is not
present. Srinivas2 has demonstrated that pas-
sive self-ligating appliances use less anchorage
than conventional appliances. This supports
the reduction in the use of anchorage devices
experienced by users of passive self-ligation.
● Use of intraoral expansion auxiliaries such as
quadhelices or W-springs because the force of
the archwire is not transformed or absorbed
by the ligatures and the necessary expansion
can be achieved by the force of the archwires.
● Need for extractions to facilitate orthodontic
mechanics because alignment is not hindered
by frictional resistance from ligatures and can
therefore largely be achieved with small diame-
ter copper nickel titanium archwires. Tooth
alignment therefore places minimal stress on
the periodontium as it occurs and so the possi-
bility of iatrogenic damage to the periodontium
is reduced.
In addition, a passive edgewise self-ligation sys-
tem provides three key features:
● Very low levels of static and dynamic friction,

Seminars in Orthodontics, Vol 14, No 1 (March), 2008: pp 19-35 19

20
Figure 1. At the start of treatment. Both upper per-
manent cuspids are ectopic and palatally positioned.
(Color version of figure is available online.)
● Rigid ligation due to the positive closure of
the slot by the gate or slide, and
● Control of tooth position because there is an
edgewise slot of adequate width and depth.
This allows extended intervals between treat-
ment visits, particularly in the early stages of
treatment, a reduced number of visits during a
course of treatment, and shortened treatment
times.
Although orthodontics is accepted as influ-
encing tooth position, alveolar bone, gingival
health, and facial appearance, Damon suggests
that orthodontic treatment can also affect
Figure 2. The upper cuspids have been exposed and
are sufficiently erupted for traction hooks to be
placed on them to move the cuspids into the line of
the arch. Space has been opened in the arch to ac-
commodate the cuspids. A 0.014⬙ copper nickel tita-
nium wire as been placed using figure of 8 ligatures to
maximize archwire engagement and hence tooth con-
trol. (Color version of figure is available online.)
D. Birnie
Figure 3. Palatal view of upper cuspids and traction
hooks taken at same visit as Fig 1. (Color version of
figure is available online.)
speech, airway, and sleep disorders (Damon DH,
personal communication, 2005). Although most
orthodontists would acknowledge the effect of
orthodontic treatment on the first four items,
the last three are more contentious areas that
are closely related to soft tissues, their behavior,
and their relationship to orthodontic treatment.
One of the reasons that these areas are conten-
tious is that they are poorly understood because
of the difficulty in measuring them and the rel-
ative ineffectiveness and unpredictability of
treatment strategies designed to influence them.
It is suggested that if the forces applied to the
teeth are kept very low, then the lips will restrict
anterior movement of the dentition and the
tongue may contribute to posterior expansion.
Figure 4. One visit after Figs 2 and 3. The friction
caused by the elastomeric ligatures has prevented the
archwire sliding through the brackets distal to the space.
The archwire has therefore expressed itself by proclin-
ing the upper incisors resulting in an unwanted overjet.
(Color version of figure is available online.)
 Damon Passive System
Figure 5. Start of treatment. Right buccal segment
half a unit Class II. Right permanent cuspid in the line
of the arch. (Color version of figure is available on-
line.)
This is demonstrated in Figures 5-7 where
the right buccal segment has been distalized half
a unit to allow eruption and alignment of the
upper right permanent cuspid with gentle acti-
vation of the coil spring only; during distaliza-
tion, no increase in overjet occurred. In nonex-
traction cases, this suggestion means that tooth
alignment results in:
● Less incisor proclination and less labial pro-
trusion than might be expected with a conven-
tional nonextraction treatment;
Figure 6. Seven months into active treatment. Space
has been opened for the upper right cuspid and the
upper right buccal segment has been distalized half a
unit by placing an open nickel titanium coil spring
one bracket width wider than the interbracket span
and replacing at each visit. The overjet is unchanged.
(Color version of figure is available online.)
21
Figure 7. End of treatment. Treatment duration, 22
months including time for upper right permanent
cuspid to erupt. (Color version of figure is available
online.)
● Significant posterior expansion without the
need for auxiliary expanders such as rapid
maxillary expansion and quadhelices or W-
springs; and
● Posterior expansion that is not produced by
the tipping movements normally expected
with expansion achieved by the use of arch-
wires and cross-elastics alone.
Evidence for the Damon Philosophy
Archwire Placement and Removal
The speed of archwire ligation and release has
been studied by a number of authors3-6 and
self-ligating brackets have been shown to take
less time and also require less or no chairside
assistance. Turnbull and Birnie7 divided the
archwires into four different groups in ascend-
ing order of size. They found that:
● The time taken to ligate archwires decreased
with increasing archwire size. This was an un-
expected finding; it might be expected that
ligation of thicker wires might takes longer
because of greater difficulty in obtaining full
archwire engagement in the bracket. How-
ever, the difficulty of obtaining full archwire
engagement in the bracket with thicker arch-
wires was offset by the tooth alignment pro-
duced by earlier archwires.
● The time taken to open the Damon self-ligat-
ing brackets and to remove elastomeric liga-
tures was almost independent of archwire size.
22
Figure 8. Figure showing static friction for passive,
active, TipEdge, and conventionally ligated brackets.
The value for the passive self-ligating Damon SL
bracket was zero except for with the 0.019⬙ ⫻ 0.025⬙
stainless steel archwire. Reprinted with permission of
Oxford University Press.8
● It took less time to ligate and release an arch-
wire using Damon passive self-ligating brackets
than with conventional brackets and elasto-
meric ligatures.
Effect of Passive Ligation on Friction
Many authors have found that static friction
measured in vitro is much less with a passive
self-ligating system than with any other type of
fixed appliance.8-10 The static friction developed
by passive self-ligating brackets is almost negligi-
ble as is shown in Fig 8. As angulation11 or
inclination12 is applied to the bracket, binding
occurs although the force generated by this
binding is less for self-ligating brackets than for
conventional ligation. A further study13 that
looked at dynamic friction also suggested that
Damon brackets had the lowest frictional resis-
tance of the four bracket types tested: conven-
tional, ceramic, active self-ligating (GAC In-Ova-
tion; GAC International, 355 Knickerbocker
Ave., Bohemia, NY 11716) series, and passive
self-ligation (Damon2).
Clinical Studies
One of the extrapolations from these in vitro
studies might be that the low static and dynamic
friction will result in more rapid initial align-
ment. One clinical study,14 which utilized a split
mouth design, found that this did not in fact
occur and that there was no difference in the
speed of alignment between conventional brack-
ets and Damon2 brackets when measured using
D. Birnie
Little’s Index. This is a surprising finding partic-
ularly as other passive ligating systems, such as
the Begg technique, were known for their rapid
tooth movement.15 It may be accounted for by
the experimental design, which although inge-
nious, did not allow independence between the
effects of the conventional and self-ligating
brackets. In addition, a then-current but now
obsolete archwire sequence (0.014⬙, 0.016⬙⫻
0.025⬙ copper nickel titanium) was used.
Another study16 has shown that more initial
alignment in a given time was produced with
Damon brackets than with conventional brack-
ets by a factor of 1.7. When the experimental
group was subdivided into less crowded and
more crowded cases, the less crowded cases
aligned 2.5 times faster and the more crowded
cases 1.4 times faster.
Cash and coworkers17 studied slot dimensions
in 11 different bracket types and determined
that the Damon2 bracket had a convergent slot
with a base dimension that was 17% oversize and
a slot opening that was 13% oversize. Bourauel
and coworkers18 in a laboratory study found
Damon2 brackets less effective in transmitting
torque than SPEED or brackets using conven-
tional ligation and attributed this to greater play
between bracket and archwire. Pandis and Elia-
des19 investigated the effectiveness of torque
transmission with conventional and self-ligating
brackets in extraction and nonextraction cases
and found no difference between the two
bracket types in their ability to torque upper
incisors in either extraction or nonextraction
cases.
Length of Treatment
If alignment and space closure can be achieved
more quickly with self-ligating brackets due to
reduced friction, then treatment times might be
shorter using self-ligating brackets. Harradine3
in 2001 and Eberting and coworkers,20 also in
2001, showed reductions in treatment times of 4
and 7 months respectively.
Bracket Design
The bracket design of the Damon bracket has
had the following characteristics since its intro-
duction as the Damon SL bracket:
 Damon Passive System 23

● A passive self-ligating design with conventional

tie wings, and
● A self-ligating gate, with a positive mechanism
to keep the gate either open or closed, that
opens to allow operator to see into slot.
As the bracket has evolved, the following fea-
tures have changed:
● The bracket has become smaller, with a lower
profile and more rounded contours resulting
in a bracket that is more comfortable for the
patient.
● As a result of a clearer understanding of
bracket function and advances in manufactur-
ing technology, the gate mechanism has be-
come more reliable, and simpler to open and
close.
● The D3 MX bracket has a vertical auxiliary Figure 10. Damon 3 MX bracket with gate open.
Permanent bracket identification is cast into the base
slot. of the slot.
The most recent bracket design, the D3 MX, is a
highly sophisticated piece of industrial design
Treatment planning involves five separate ar-
and is shown in Figs 9 and 10; it is quite unlike
eas.
the simple drawn and milled standard edgewise
brackets of 4 decades ago.
The Face
Treatment planning should take into account:
Treatment Planning
● The individual’s facial pattern and appear-
Treatment planning should be based on etiol-
ance, and
ogy, and careful thought about why the pre-
● The likely growth, maturation, and aging of
senting malocclusion occurred.
the patient’s face including the influence of
genetic inheritance on their future facial
appearance.

The Soft Tissues

The interpretation of soft tissue behavior and its
influence on tooth position and oral function is
acknowledged but difficult to quantify in individ-
ual cases. The clinician should consider whether
soft tissue behavior has been a significant factor
in the development of the malocclusion and, if
so, whether it can be modified. This includes
consideration of lip position and lip posture,
tongue behavior, muscle tone, and mode of
breathing.

Dental Factors
Dental factors include:
● Space analysis,
Figure 9. Damon 3 MX bracket with gate closed. ● Arch width analysis, and
24 D. Birnie

Table 1. Optional Torque Values in the Damon System

Upper Arch
U1 U2 U3 U4 U5 U6 U7

High torque ⫹17° ⫹10° ⫹7°

Standard torque ⫹12° ⫹8° 0° ⫺7° ⫺7° ⫺18° ⫺27°
Low torque ⫹7° ⫹3°

Lower Arch
L1 L2 L3 L4 L5 L6 L7

High torque ⫹7°

Standard torque ⫺1° ⫺1° 0° ⫺12° ⫺17° ⫺28° ⫺10°
Low torque ⫺6° ⫺6°

● The inclination of labial and buccal segment
teeth.
Several decades ago, tooth extraction was neces-
sary to obtain dental alignment because of the
relatively unsophisticated appliances available.
Technically, it is often no longer necessary, ex-
cept in a few cases, to extract teeth to obtain
alignment or to facilitate orthodontic mechan-
ics. Extractions may be required, however, to
optimize facial balance or because of dental or
periodontal pathology. In addition, tooth extrac-
tion does not necessarily prove a guarantee of
posttreatment or postretention stability.
Cephalometry
Cephalometry remains an important tool for the
orthodontist, but long and elaborate analyses
are unnecessary in most cases. It remains subser-
vient to facial analysis for many measurements.
Some parameters (such as upper incisor inclina-
tion) can be visualized directly rather than being
measured from a lateral skull radiograph. In
addition, treatment to mean values (such as for
incisor inclination) do not recognize the signif-
icant range of biological variability present in
the population nor is this strategy a guarantee of
treatment stability.
The response of the facial tissues to tooth
movement, particularly proclination, is unpre-
dictable and so tooth movements planned to
achieve favorable, or prevent unfavorable soft
tissue movements, should be executed with
caution.
Oral Health
Patients with good oral health, excellent oral
hygiene, and a normal gingival biotype seem to
obtain better orthodontic results than those with
compromised oral health. Particularly in the
preteen and teenage patient, the healthy peri-
odontium seems to have significant powers of
adaptation and regeneration.
Bracket Selection
Obtaining the correct inclination of teeth during
orthodontic treatment has always been challeng-
ing with orthodontic appliances based on the
edgewise system. The Damon System provides sev-
eral torque options for incisor and cuspid teeth
and these are shown in Table 1. In general, the
torque selected in each bracket should be de-
signed to over-correct tooth position.
High Torque Brackets
Examples of where high torque brackets may be
used on upper incisors are as follows:
● Extraction cases where treatment mechanics
may excessively retrocline the upper incisors;
● Class II Division 1 malocclusions where treat-
ment mechanics may excessively retrocline the
upper incisors; and
● Class II Division 2 malocclusions.
Examples of where high torque brackets may be
used on upper cuspids are as follows:
● First premolar extraction cases; and
● Cases where the crowns of the upper cuspids
are palatally tipped.
Standard Torque Brackets
Standard torque brackets are used where the
inclination of the teeth is satisfactory before
treatment and the treatment mechanics will not
 Damon Passive System
adversely affect the inclinations during treat-
ment.
Low Torque Brackets
Examples of where low torque brackets may be
used on upper incisors are as follows:
● Excessively proclined upper incisors;
● Isolated upper incisors with palatally posi-
tioned roots (eg, upper lateral incisor in the
palate);
● Malocclusions where treatment mechanics
may result in excessive upper incisor proclina-
tion;
● Moderate and severe upper arch crowding;
and
● Anterior open bite cases with proclined
incisors.
Examples of where low torque brackets may be
used on lower incisors are as follows:
● Cases where it is necessary to control the pro-
clination of lower incisors, eg; extreme lower
labial segment crowding, cases using Class II
elastics, and fixed Class II correctors attached
to the brackets, buccal tubes, or archwires;
and
● Lingually placed lower incisors.
The brackets with optional torque values should
not be used as “sets.” The clinician should study
the case carefully beforehand and individually
select the bracket with the correct torque for
each tooth.
Bracket Positioning
Bracket positioning follows the principles sug-
gested by Andrews21 where brackets are placed
on the midpoint of the facial axis of the clinical
crown with the vertical bracket positioning key
(eg, tie wings for D3 and D3 MX brackets) par-
allel to this axis.
The following exceptions to this rule should
be noted:
● Lower cuspid brackets should be positioned
0.5 mm to 1 mm mesial to the facial axis of the
clinical crown to prevent the mesial edge of
the cuspid tucking behind the distal part of
the lower lateral incisor.
25
● For deep bite cases, cuspid and incisor brackets
should be progressively placed slightly more in-
cisally in both arches to aid bite opening.
● For open bite cases, cuspid and incisor brackets
should be placed progressively slightly more gin-
givally in both arches to aid bite closure.
● Where teeth have to undergo significant trans-
lation, overangulation of the brackets to exag-
gerate the root movement in the desired di-
rection will ensure adequate root movement
occurs. Examples of malocclusions where this
strategy is helpful include the correction of
pseudotranspositions, the opening of space
for restorative implants, and closure of large
spaces such as moving lateral incisors into cen-
tral incisor spaces.
● Where teeth have incisal edge damage or are
substituting for other teeth, position the
brackets to obtain the correct gingival emer-
gence profile and adjust the subsequent in-
cisal edge problem restoratively.
● Brackets are not inverted to change the torque
values as this may make the gates more vulner-
able to inadvertent opening, and rarely gen-
erates enough torque to completely correct
the problem.
Instead, choose a bracket with a torque value
that will exaggerate the tooth movement re-
quired (such as a low torque bracket for a pala-
tally placed upper lateral incisor). This solves
the first problem, but in most cases, additional
torque will need to be placed in the archwire to
obtain ideal root position.
Treatment Phases, Archwire Selection,
and Archwire Sequencing
Phase 1: Light Round High Technology Wires
This phase of treatment uses 0.013⬙, 0.014⬙, or
0.016⬙ copper nickel titanium archwires. The
aims of this phase of treatment are to:
● Obtain tooth alignment;
● Level the arches (excluding second molars).
Second molars, although bonded from the
start of treatment, are not engaged by the
initial archwire until the second phase of treat-
ment to prevent the archwire being dislodged
from the second molar tubes. The intertube
span between first molar and second molar is
26
too large to reliably support small-diameter
nickel titanium archwires;
● Substantially correct all anterior rotations and
partially correct posterior rotations; and
● Initiate arch development by using light
enough forces to allow the soft tissues to in-
fluence arch shape.
This phase of treatment normally lasts 10 to 20
weeks and appointment intervals are at 10
weeks.
Phase 2: High Technology Rectangular Wires
The second molars are normally engaged by
the first archwires in this phase except in pa-
tients with anterior open bites. This phase of
treatment normally uses two archwires: 0.014⬙
⫻ 0.025⬙ followed by 0.018⬙ ⫻ 0.025⬙ copper
nickel titanium wires. In cases that are well
aligned at the start of treatment, these two
archwires can occasionally be replaced by a
single 0.016⬙ ⫻ 0.025⬙ copper nickel titanium
wire. The use of a wire with a 0.025⬙ first order
dimension is critical to obtain tooth alignment
by almost completely filling the 0.027⬙ slot
depth of a Damon bracket.
Where incisor intrusion is required, 0.017⬙ ⫻
0.025⬙ or 0.019⬙ ⫻ 0.025⬙ copper nickel titanium
archwires with preformed curves or reverse
curves of Spee can be used in this stage. Addi-
tional torque can also be applied at this stage
with the use of 0.019⬙ ⫻ 0.025⬙ copper nickel
titanium archwire preformed with 20° of torque
anteriorly.
The aims of this stage of treatment are to:
● Fully correct all rotations and obtain full align-
ment of all teeth,
● Consolidate any anterior space and maintain
tooth contact,
● Initiate torque control,
● Initiate bite opening, and
● Continue arch development.
The duration of this phase of treatment is 20 to
30 weeks. The first archwire is left in place for 8
to 10 weeks and the second for 4 to 6 weeks.
Phase 3: Major Mechanics
The archwires used in this phase are 0.019⬙ ⫻
0.025⬙ preposted stainless steel archwires. Many
buccal segment crossbites will have corrected
D. Birnie
spontaneously by this stage, particularly when, as
is often the case, the crossbite has not included
the second molars. Where buccal segment cross-
bites persist, the use of a 0.016⬙ ⫻ 0.025⬙ pre-
posted stainless steel archwire in the arch where
some buccal or lingual tipping is desired, to-
gether with the use of a 3/16⬙ (110 g) cross
elastic, will assist crossbite correction.
The aims of this phase of treatment are to:
● Maintain the archform developed in the first
two phases,
● Finish torque control,
● Consolidate posterior space, and
● Completely correct anteroposterior, buccolin-
gual, and vertical relationships.
This phase of treatment lasts 8 to 10 weeks with
appointments at 10-weekly intervals. Where
Class II or Class III elastics are being used, buc-
cal segment correction occurs more quickly if
the molar distal to those to which the elastic is
placed are temporarily not included in the arch-
wire.
Phase 4: Finishing and Detailing
The stainless steel archwires may be continued
in this phase. However, some detailed adjust-
ments to individual teeth may be required, in
which case 0.019⬙ ⫻ 0.025⬙ ß-titanium archwires
allow individual adjustments to be made in the
archwire to optimize tooth positions. Settling
elastics may be used to develop a well-interdigi-
tated occlusion.
Managing Severely Displaced or Rotated Teeth
Severely displaced teeth are managed by creating
space for the teeth with open coil spring; this
should be done with low forces and the coil spring
should be no longer than the width of the space
plus a bracket width (approximately 3 mm). A
traction hook is bonded to the displaced tooth.
The displaced tooth is tied to the archwire with
elastic thread. Two types of traction hook are used:
● A very thin wire loop traction hook on a bond-
able base. This is demonstrated in Figs 11 and 12
and used where there is very little space for the
displaced tooth or on rotated teeth some dis-
tance from the line of the arch. It is positioned
so that the lumen of the hook will allow the
archwire to pass through it as the tooth ap-
 Damon Passive System
Figure 11. This patient has an upper left palatal cus-
pid that is rotated mesially. A traction hook has been
placed on the mesial edge of the tooth to maximize
derotation as the tooth moves to wards the line of the
arch. The bracket system is Damon2 (D2) and the
archwire 0.014⬙ copper nickel titanium. A length of
coil spring one bracket width wider than the space has
been placed and the tooth attached to the archwire
with elastomeric thread. (Color version of figure is
available online.)
proaches the line of the arch. Its minimal
mesiodistal width maximizes interbracket
span although provides no intrinsic rotational
control.
● A broader eyelet or traction hook (part no:
DB22-0450; DB Orthodontics Limited, Rye-
field Way, Silsden, Keighley, West Yorkshire,
Figure 12. Two visits after that of Fig 11. At the previous
visit, the 0.014⬙ copper nickel titanium (CuNiTi) arch-
wire was put through the lumen of the bracket. All the
movement of the upper left cuspid has been achieved
with a traction hook and a 0.014⬙ CuNiTi archwire in
two visits. The D2 bracket was placed at this visit. (Color
version of figure is available online.)
27
Figure 13. The upper left lateral incisor has a broad
traction hook in place with the 0.014⬙ copper nickel
titanium archwire running through its lumen. There
is insufficient room to place a full-sized bracket. The
broader traction hook gives some rotational control
and is usually replaced with a normal passive self-
ligating bracket after one visit. (Color version of fig-
ure is available online.)
BD20 0EF U.K.) used where greater space is
available but insufficient to place a self-ligat-
ing bracket in its correct position as shown in
Figure 13. This type of traction hook is ori-
ented in the same way as the other type of
traction hook but has the advantage of giving
some rotational control.
If the tooth is rotated, then two strategies may be
used:
● If the tooth is so displaced from the archwire
that it is not possible to engage the traction
hook directly with the archwire, the traction
hook is attached to the archwire with elastic
thread and positioned so as to maximize cor-
rection of the tooth’s position as it moves
toward the arch.
● If the traction hook can be directly engaged
with the archwire, then elastomeric chain is
placed over the archwire, mesial or distal to
the traction hook depending on the direction
of rotation required and then attached to a
bracket that has the archwire fully engaged so
as to provide a very light derotation couple.
This technique is particularly useful for ro-
tated lower incisors and rotated premolars
where initial placement of a full-sized bracket
in the correct position is impossible.
28
Figure 14. A Damon splint and tongue trainer.
(Color version of figure is available online.)
Archwire Stops
Passive self-ligating brackets have extremely
low levels of friction between archwire and
bracket. Archwires are free to swivel to mesio-
distally and, if allowed to do so, cause “wire
pokes” distal to the terminal buccal attach-
ments. The archwires therefore need to be
stabilized using archwire stops to prevent irri-
tation to the buccal mucosa. Originally, a sin-
gle stop was placed in a short interbracket
span, such as between lower incisors or be-
tween upper first and second premolars. Stops
could be made of composite, soft split stainless
steel tube, or stainless steel tube placed over
the archwire before insertion.
Many high technology archwires now come
with two stops preloaded on to the archwires and
the following recommendations for the use of
stops are given:
● To stop the archwire swiveling, stops are
placed either side of a bracket or at either end
of an interbracket span.
● Stops should be placed on a section of the
archwire where little movement of the arch-
wire relative to the bracket is expected to oc-
cur. Thus stops should be placed as far as
possible from crowded, displaced, or rotated
teeth. Where crowding is bilateral, stops
should be placed anterior to the crowding.
● Stops should be placed where they are unob-
trusive and not easily seen. This normally
means in the lower incisor region and in the
upper second premolar region. Stops placed
also help to identify the archwire once it is
removed from the mouth.
D. Birnie
Stops can also be used to prevent tooth move-
ment. Examples of this are as follows:
● Placement of the stops distal to the cuspids
maintains consolidation of the anterior seg-
ment.
● Placement of stops at either end of an inter-
bracket span can maintain space for an une-
rupted or prosthetic tooth.
● Placement of stops immediately mesial to up-
per second molars in first molar extraction
cases will maintain arch length to allow the
resolution of anterior crowding.
Stops are not required on preposted archwires
as the posts act as stops; careful selection of the
size, however, can mean that the posts can have
a secondary function such as maintaining the
consolidation of anterior space.
Anteroposterior Correction
Class II Malocclusion
Anteroposterior correction of Class II malocclu-
sion is often achieved before fixed appliance
treatment using some form of functional appli-
ance. If not, then Class II correction can be
achieved during treatment using either class
elastics or a fixed Class II corrector such as a
Herbst appliance attached to the archwires.
The Herbst appliance is a more effective class
corrector than Class II elastics and so is used
where more facial and dental correction is re-
quired.
The Herbst appliance is fabricated to fit on to
the archwire directly. Its use is facilitated by the
use of self-ligating upper first molar tubes. A TP
Flip-Lock Herbst kit (TP Orthodontics Inc, 100
Center Plaza, Laporte, IN 46350) is required
together with some thick-walled 0.022⬙ ⫻ 0.028⬙
Inconel (trademark of Special Metals Corpo-
ration, Huntington, WV) rectangular tubing
(OSCAR Inc., 11793 Technology Dr., Fisher, IN
46038). The stages of fabrication and fitting are
as follows:
● Sections of the Inconel tubing are welded and
soldered to the underside of the Herbst axles
(⫻4) so that the Inconel tubing is flush on
one side of the axle and projects 2 mm on the
other side.
● The patient should be in 0.019 ⫻ 0.025⬙ pre-
posted stainless steel archwires.
 Damon Passive System 29

Figure 15. Extraoral photographs at the start of treatment aged 14 years 0 months. Note relatively immature
facial appearance. (Color version of figure is available online.)

Figure 16. Intraoral photographs at

the start of treatment. There is mod-
erate crowding in the upper arch and
severe crowding in the lower arch.
The clinical crown of the lower right
central incisor is longer than on the
adjacent teeth. There is a left buccal
segment crossbite. (Color version of
figure is available online.)

● The Herbst axles are placed on the archwires.
In the upper arch, the 2-mm Inconel tube
projection should face anteriorly, and in the
lower arch posteriorly. This is to maximize the
distance between the axles.
● In the upper arch, the Herbst axles are placed
between the upper first and second molars. In
the lower arch, the Herbst axles are placed
between the lower cuspids and the lower first
premolars. The Inconel tube should be an
30 D. Birnie
Figure 17. Cephalometric radiograph at the start of
treatment.
exact but not tight fit between the intertube/
interbracket space.
● The Herbst piston/cylinder assembly is then
cut to provide approximately 4 to 6 mm of
initial protrusion. The piston should be
trimmed so that it does not protrude more
than 3 mm out of the back of the cylinder in
the closed position so as to avoid irritation to
the buccal mucosa. The cylinder is engaged
first on the upper axles, the piston inserted
into the cylinder and then attached to the
lower axle.
● The integrity of each buccal segment is main-
tained by a wire ligature or elastomeric link
running from the hook on the second molar
to the archwire post.
● The Herbst is activated 2 mm at each visit by
placing split tube spacers (TP Orthodontics
Inc.) over the piston until a full edge-to-edge
occlusion is achieved.
Once a full edge-to-edge occlusion has been
achieved, the Herbst appliance is left in place for
a further 6 months.
Retention
Retention is normally with a fixed solid 0.026⬙
stainless steel wire retainer from the lingual
surface of lower cuspid to lower cuspid. The
wire is only bonded to the lingual surfaces of
the lower cuspids, which are lightly sand-
blasted before etching. The ends of the wire
are flattened, contoured, and sandblasted to
maximize retention. In the upper arch, a
braided retainer wire (Reliance Orthodontic
Products, PO Box 678, Itasca, IL 60143) is
bonded to the palatal surfaces of the four
upper incisors ensuring that it does not inter-
fere with the lower incisors. Upper and lower
Figure 18. Treatment progress ap-
proximately 7 months into treat-
ment. Alignment has been achieved
in the upper arch. (Color version of
figure is available online.)
 Damon Passive System
vacuum formed retainers are used in addition
on a nighttime-only basis.
For patients who have had correction of a Class
II skeletal pattern, a Damon splint and tongue
trainer is used to maintain Class II correction over
the long term. This is shown in Fig 14.
Summary
Passive self-ligation offers the most direct
transmission of force from archwire to tooth
with very low friction, secure ligation, and ex-
31
Figure 19. Treatment progress 15
months into treatment. Alignment
within the arches has been achieved
although some spacing persists in
the upper arch and should have
been consolidated and tooth con-
tact maintained with a continuous
wire tie or stops distal to the upper
cuspids. (Color version of figure is
available online.)
cellent control of tooth position. All contem-
porary modalities of orthodontic treatment
can achieve tooth alignment; passive self-liga-
tion, however, does achieve results effectively,
efficiently, and in a manner that corresponds
with patient values. In addition, practitioners
experienced with the technique perceive that
additional, unexpected patient benefits occur
that are not traditionally associated with con-
ventional orthodontic treatment. However,
these need further evaluation to understand
and substantiate them. Mastering self-ligation
Figure 20. Patient at 25 months
into treatment. The second molars
were bonded 16 months into treat-
ment and crossbite correction has
occurred spontaneously without the
need for auxiliary appliances such
as a quadhelix appliance or cross
elastics. (Color version of figure is
available online.)
32 D. Birnie

Figure 21. Patient at 12 months af-

ter the end of active treatment and
1 year into retention. The clinical
crown height of the lower incisors
has normalized. The crowding has
been resolved. The patient has di-
rect bonded fixed retainers and vac-
uum formed retainers that have
been worn in the evenings and at
night only. (Color version of figure
is available online.)

is challenging, however, and it is not a tech- occur during his teenage years. He has a left
nique that requires less clinical judgment or unilateral crossbite. The lower right central in-
proficiency. Effective health care interventions cisor has a long clinical crown (see Figs 15-17).
must have an evidence base; that evidence All permanent teeth were present on the dental
base is a combination of clinically relevant pantomogram except for the upper third mo-
research, clinical expertise, and patient val- lars. His oral hygiene was good although still
ues.22 For passive self-ligation, the clinically capable of improvement.
relevant research base is small because interest
in the subject has only commenced relatively
recently, but is growing steadily; clinical exper-
tise has allowed the technique to evolve and
mature and its flexibility allows it to respond
to patients’ needs and preferences.

Case Presentation
This case is presented because it is challenging and
controversial. It was treated by the author shortly
after changing over completely to passive self-liga-
tion in 2001. There are many possible ways of
treating it. Important questions, however, are:
● What caused the malocclusion?
● What treatment would provide the best opti-
mization of facial appearance, smile esthetics,
oral health, and stability?
Patient 09038801 presented at 14 years 0 months
with moderate upper arch crowding and severe
lower arch crowding. His facial appearance was
prepubescent, he did not seem to have entered
his pubertal growth spurt, and it was thought Figure 22. The posttreatment cephalometric radio-
that significant nasal tip and chin growth would graph.
 Damon Passive System 33

Table 2. Cephalometric and Study Cast Values at the Start of Treatment and Four Months after the End of
Active Treatment (First Retainer Check)
Units 18 March 2002 11 March 2005 Difference

Skeletal measurements
SNA degrees 83.4 83.0 ⫺0.4
SNB degrees 77.9 77.3 ⫺0.6
ANB degrees 5.6 5.7 0.1
SN-maxillary plane degrees 4.2 5.6 1.4
Maxillary-mandibular plane degrees 27.8 28.2 0.4
LAFH mm 55.2 62.1 6.9
UAFH mm 50.2 54.7 4.5
LAFH/TAFH % percent 55.1 56.7 1.6
LPFH mm 24.3 27.8 3.5
UPFH mm 45.0 47.5 2.5
PFH mm 69.4 75.3 5.9
Wits appraisal mm 3.0 4.4 1.4
Teeth
Overjet mm 7.6 2.8 ⫺4.8
Overbite mm 3.2 1.3 ⫺1.9
UI-Maxillary plane degrees 113.9 114.9 1.0
LI-Mandibular plane degrees 87.4 97.5 10.1
Interincisal angle degrees 131.0 119.3 ⫺11.7
L1-Apo mm 0.2 3.4 3.2
L1-Facial plane mm 3.0 6.1 3.1
Soft tissue
Upper lip to E-plane mm ⫺1.3 ⫺5.1 ⫺3.8
Lower lip to E-plane mm 1.3 ⫺0.2 ⫺1.5
Nasolabial angle degrees 114.4 121.7 7.3
Chin thickness mm 10.6 9.5 ⫺1.1
B-NPo mm ⫺1.1 ⫺2.4 ⫺1.3
L1-Mandibular plane mm 34.6 39.5 4.9
Lower study cast
Inter cuspid width mm 19.2 29.4 10.2
Inter first bicuspid width mm 29.6 38.1 8.5
Inter second bicuspid width mm 38.2 43.8 5.6
Inter first molar width mm 49.6 50.7 1.1
Inter second molar width mm 52.2 55.9 3.7
Upper study cast
Inter cuspid width mm 31.4 38.4 7.0
Inter first bicuspid width mm 39.0 46.4 7.4
Inter second bicuspid width mm 41.0 51.1 10.1
Inter first molar width mm 47.0 55.1 8.1
Inter second molar width mm 52.3 58.1 5.8

SNA, Sella-Nasion-A point; SND, Sella-Nasion-B point; ANB, A point-Nasion-B point; LAFN, lower anterior facial height; UAFH,
upper anterior facial height; LAFH/TAFH%, lower anterior facial height as a percentage of total anterior facial height; LPFH,
lower posterior facial height; UPFH, upper posterior facial height; UI, upper incisor; LI, lower incisor; Apo, A Point-Pogonion;
E-plane, Rickett’s esthetic plane; B-NPo, B-Point-Nasion-Pogonion.

Figure 18 shows treatment progress after 7
months of treatment. Alignment has been
achieved in the upper arch, but there is still
insufficient space for the lower left lateral inci-
sor. No crossbite correction has yet taken place;
note that the right second molars, which are just
visible, are not in crossbite.
Figure 19 shows 15 months into treatment.
Alignment within the arches has been achieved,
but crossbite correction has not yet taken place.
Once alignment of the upper labial segment had
been obtained, the consolidation should have
been maintained with a continuous tie or stops
distal to both upper cuspids.
Figure 20 shows 25 months into treatment.
The second molars were bonded 16 months into
treatment, and crossbite correction then oc-
curred spontaneously without the need for aux-
iliary appliances or cross elastics. Once stainless
steel archwires were placed, the upper archwire
was expanded and the lower contracted to en-
sure maximal correction.
Figure 21 shows 12 months after the end of
active treatment and 1 year into retention. The
34 D. Birnie

Figure 23. Extraoral photographs taken 12 months after the end of active treatment showing that significant
facial maturation has taken place. Nasal growth has taken place and the hyoid bone is now much more
prominent. (Color version of figure is available online.)

Figure 24. Superimposition of the start and finish cephalometric tracings. The amount of nasal growth relative
to lip growth is demonstrated. The upper incisors have retained their inclination, but there has been proclina-
tion of the lower incisors. (Color version of figure is available online.)
 Damon Passive System
clinical crown heights of the lower incisors have
equalized. In addition to the fixed retainers, the
patient wears vacuum formed retainers in the
evenings and at night.
Figure 22 shows the posttreatment cephalo-
metric radiograph. Table 2 shows the cephalo-
metric values at the start of treatment and at the
first retainer check four months after the end of
active treatment.
Figure 23 shows the patient’s facial appearance
12 months after the end of active treatment. Sig-
nificant maturation of the face has taken place
including nasal tip growth and development of the
hyoid bone. The patient has changed from a
young boy to a young man.
Figure 24 shows the superimposition of start
and finish cephalometric tracings. Note nasal tip
growth relative to lip growth. Upper incisor
torque has not increased, but there has been
some proclination of the lower incisors.
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