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International Orthodontics 2019; 17: 621–633

Websites:
www.em-consulte.com
www.sciencedirect.com

Systematic review
Dental and skeletal changes associated with
the Damon system philosophical approach

Hye Jin Nam, Carlos Flores-Mir, Paul W. Major, Giseon Heo, Justin Kim, Manuel O. Lagravère

Available online: 29 August 2019 School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta,
ECHA 5-524, 11405, 87th avenue, Edmonton, Alberta T6G 1C9, Canada

Correspondence:
Manuel O. Lagravère, School of Dentistry, Faculty of Medicine and Dentistry,
University of Alberta, ECHA 5-524, 11405, 87th avenue, Edmonton,
Alberta T6G 1C9, Canada.
manuel@ualberta.ca

Keywords Summary
Damon
Brackets Objective > To compare the skeletal and dentoalveolar changes produced by the Damon system's
Self-ligating treatment philosophy to traditional orthodontic treatment techniques.
Expansion Materials and Methods > An electronic search in four major databases was completed: Cochrane,
Transverse Dimension PubMed, EMBASE, and Google Beta Scholar on October 5th, 2018. Randomized controlled trials,
prospective and retrospective controlled clinical trials were included in this systematic review. The
quality assessment of individual studies was done using two different tools: The Cochrane Risk of
Bias Assessment Tool (RTCs) and The Methodological Index for Non-Randomized Studies (MINORS)
(non-RCTs).
Results > Seven studies were included for this qualitative analysis. Six studies compared the
Damon system to various types of conventional (non self-ligating bracket) system as a comparison
group. One study used a quad helix as a comparison for a few months before a full bonding
appointment with conventional brackets. The majority of studies found an increase in maxillary
inter-canine, inter-premolar, and intermolar distance after the treatment in both the Damon and
comparison groups. Yet, all studies concluded that there is no significant difference in the final
transverse dimension between the two groups. One study also found that the transverse expan-
sion was achieved mainly by tipping movement of posterior dentition, and a decrease in the
posterior buccal bone area was evident in both groups after treatment.
Conclusion > There is not enough evidence to support the claim that the Damon system allows
additional arch expansion with better tipping control than with traditional techniques.
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https://doi.org/10.1016/j.ortho.2019.08.001
© 2019 CEO. Published by Elsevier Masson SAS. All rights reserved.
H.J. Nam, C. Flores-Mir, P.W. Major, G. Heo, J. Kim, M.O. Lagravère
Systematic review

Mots clés Résumé


Damon
Attaches Changements dentaires et squelettiques associés à l'approche philosophique du système
Auto-ligaturant Damon
Expansion
Objectif > Comparer les changements squelettiques et dento-alvéolaires produits par la philos-
Dimension transversale
ophie de traitement du système Damon à ceux produits par les techniques traditionnelles de
traitement orthodontique.
Matériels et méthodes > Une recherche électronique dans quatre grandes bases de données,
Cochrane, PubMed, EMBASE, et Google Beta Scholar, a été effectuée le 5 octobre 2018. Des essais
comparatifs randomisés, des essais cliniques comparatifs prospectifs et rétrospectifs ont été
inclus dans cette revue systématique. L'évaluation de la qualité des études individuelles a été
effectuée à l'aide de deux outils différents: l'outil d'évaluation du risque de biais de Cochrane
(RTCs) et l'indice méthodologique pour les études non randomisées (MINORS) (non-RCTs).
Résultats > Sept études ont été incluses pour cette analyse qualitative. Six études ont comparé le
système Damon à différents types de systèmes conventionnels (non auto-ligaturants) servant de
groupe témoin. Une étude a utilisé, à titre de comparaison, un appareil Quad Helix pendant
quelques mois avant la séance de collage complet d'attaches conventionnelles. La majorité des
études ont constaté une augmentation de la distance intercanine maxillaire, interprémolaire et
intermolaire après traitement, tant dans le groupe Damon que dans le groupe témoin. Mais déjà
toutes les études ont conclu qu'il n'y avait pas de différence significative de la dimension
transversale finale entre les deux groupes. Une étude a également montré que l'expansion
transversale était obtenue principalement au prix d'une version des molaires et qu'une diminu-
tion de l'os vestibulaire dans la zone postérieure était évidente dans les deux groupes après
traitement.
Conclusion > Il n'existe pas assez de preuves scientifiques pour soutenir que l'expansion des
arcades avec le système Damon soit supérieure à celle produite par les systèmes conventionnels,
pas plus qu'un meilleur contrôle de la version molaire n'est démontré.

Introduction to the conventional bracket and the use of ligating ties, it has
Any tooth movement has dynamic effects on bone and soft been claimed that a passive self-ligating bracket, like the
tissue structures surrounding it. With increase force levels, an Damon one, allows a wire to slide through the brackets with
avascular area in the PDL, also known as a hyalinized area, can a lower resistance to sliding resulting in faster level and align-
slow down the tooth movement, and also may increase the risk ment of teeth [2,3]. This philosophical approach also involves
of root resorption and the amount of pain due to chemicals the use of the term "optimal force zone'' which implies that the
released from the ischemic area. If continuous excessive ortho- force applied to teeth should generate an optimal pressure to
dontic force is applied to teeth, it can occlude and cut off blood allow uninterrupted vascular supply to the tooth and its sur-
supply to the periodontal ligament (PDL), and therefore, could rounding system [2,3]. In addition to suggested benefits listed
cause necrosis of the compressed area. Therefore, use of light above, this philosophy argues that the light force produced by
continuous forces are suggested to be critical in achieving the system allows the connective tissue and alveolar bone to
desired movements in orthodontics while minimizing the follow tooth movement, and therefore, more expansion of
unwanted side effects [1]. maxillary arch can be achieved. Also, the applied force is so
The Damon appliance system is one of the multiple self-ligating light that the pressure from lips can minimize unwanted tipping
bracket systems that have been increasingly used by orthodont- of incisors during alignment stage. These two claims suggest
ists. This philosophical approach claims to have many benefits that the need for extraction is reduced when using the Damon
over conventional bracket systems, including less force applied System as additional arch perimeter can be safely gained [2].
on the teeth, reduced amount of pain experienced by patients, The Damon's proposed clinical benefits are heavily marketed to
and higher treatment efficiency [2,3]. The Damon bracket is both orthodontists and patients without high quality evidence.
advertised as "a nearly friction-free'' system [2]. Thus, compared Currently, there is no systemic review on the potential benefits
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Systematic review
of the Damon System over more traditional orthodontic orthodontists to attain maxillary expansion without some of
bracket/archwire system management. In 2011, a limited criti- the negative associated side effects commonly seen in the rapid
cal review on the Damon system was published [4]. Acknowl- expansion appliance such as a tipping movement of posterior
edging their limited search strategy, they concluded that other teeth.
than a possible reduced chair-side time for orthodontists, many
of its claims such as lower pain experience, higher efficiency of
treatment, and better stability after expansion were not clearly Materials and methods
supported by the available literature. Protocol and registration
This review will focus on one of many benefits suggested by the The PROSPERO website was accessed on March 17, 2017, and no
Damon system, which is that a stable clinically meaningful systemic review on the Damon system was registered. A
expansion can be done negating the need for rapid palatal proposal for the systematic review was registered on March
expansion appliances. If this claim is true, it may allow 29, 2017 (registration #: CRD42017059758).

Figure 1
PRISMA Flow Chart for Literature Search.
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Systematic review

Eligibility criteria Results


The PICO model was used to formulate the research questions: Literature search
 population Patients with any type of malocclusion with max-
The detailed study selection process is shown in figure 1. Out of
illary arch crowding; 397 total published articles, 167 duplicate articles were
 intervention Orthodontic treatment following the Damon sys-
removed. From the remaining 230 articles, 217 were later
tem philosophy; excluded after reading the abstract. During the second selection
 comparison: Orthodontic treatment using any conventional
stage, eligibility assessments were done by reading the full-text
bracket/archwire system or any type of maxillary expansion of the remaining 13 articles. At this stage 6 articles [4,7–11] were
appliance; excluded due to reasons stated in the flow chart. Hence the final
 outcome: Maxillary dental and skeletal transverse changes.
number of included articles was 7.
There was no restriction on publication year, length of follow-up,
and treatment duration. The exclusion criteria included edito- Description of studies
rials, review articles, studies that focus on efficiency and speed Methods for analysis
of treatment, dental changes in mandibular arch, biomechanical Tables I and II summarize characteristics of each study. Out of
properties of brackets, and pain related to the Damon system. 7 included studies, only 1 study used 3-dimensional imaging
(CBCT) for the analysis. All other studies used 2-dimensional
Search strategy
imaging such as a lateral cephalometric radiograph and/or a
Two independent researchers completed an electronic search in
posteroanterior radiograph.
four major databases. Cochrane, PubMed, and EMBASE data-
The majority of studies compared the Damon (self-ligating
bases were accessed on October 5th, 2018. Additionally a partial
bracket) system to various types of conventional (non-self-
grey literature was completed by reading the title/abstract of
ligating bracket) system as a comparison group. Only Atik
the first 100 hits on Google Beta Scholar database. The keywords
and Ciger used a quad helix for a few months before a full
used for the electronic search were (Damon and [bracket or
bonding appointment with conventional brackets as comparison
brackets or appliance or system or braces]). The detailed search
group [12]. Out of 7 included studies, 3 studies used Ormco
strategy is outlined in the Appendix 1.
Damon archwires for all patients [12–14]. The remaining 4 stud-
Study selection ies used Ormco Damon archwires for the Damon treatment
In each database result, titles were screened first and then group and various different companies' archwires for the com-
abstracts were reviewed in each article. Details of the selection parison group [15–18].
process are listed in figure 1. Randomized controlled trials, Changes in transverse dimension in each treatment
prospective and retrospective controlled clinical trials were
group.
included in this systematic review.
All studies showed an increase in maxillary transverse dimen-
sion in each treatment group except for one study (table III).
Data collection process and data items
The majority of studies found an increase in maxillary inter-
For each article, the following data were extracted: publication
canine, interfirst premolar, intersecond premolar, and inter-
year, study design, number of intervention groups, sample
molar distance after the treatment in all treatment groups. In
description, malocclusion characteristics, records used for anal-
Damon group, the average increase in maxillary intercanine
ysis, and significant clinical findings. In the case of uncertainty,
distance was 2.25  2.43 mm and intermolar distance was
the author of the article was contacted for clarification.
2.51  1.72 mm (tables IV and V). In their comparison groups
Risk of bias assessment (conventional brackets, quad helix or active self-ligating brack-
The quality assessment of individual studies was done using two ets), the average increase in maxillary intercanine distance
different tools. The Cochrane RTCs was used for randomized was 1.72  1.97 mm and intermolar distance was 2.04
controlled studies, which is divided into a selection, perfor-  1.83 mm (tables IV and V). Only Shook et al. found no
mance, detection, attrition, reporting, and other bias [5]. The statistical difference in intercanine and intermolar distance
MINORS was used for both prospective and retrospective cohort in any of the treatment groups [15]. In addition, Catteneo
studies [6]. et al., using a cone-beam computed tomography (CBCT), found
that the transverse expansion was achieved by tipping move-
Summary measures ment of posterior teeth in either group [16]. Buccal bone
Only qualitative analysis of dental and skeletal changes was remodeling was also measured using a coronal cross-section
possible. Due to the methodological differences and heteroge- generated from the CBCT. Both the Damon and In-Ovation
neity between the included studies a meta-analysis was not bracket system treatment groups showed a decrease in the
considered. buccal bone thickness after the treatment [16]. According to
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TABLE I
Characteristics of included studies.

Study group Study design Treatment group Sample (size and Records used for Pretreatment Clinical Characteristics
and year (A, B, vs C) a mean age) analysis
Atik and Ciger RCT A: Quad helix and A: 17 patients Cephalometric, Moderate max/mand crowding, Class I
2014 [12] conventional (14,5  1.2 yrs) Posteroanterior MO with
B: Damon 3MX B: 16 patients radiographs, and maxillary constriction
bracket (14.8  1.0 yrs) dental casts Maxillary crowding (mm):
Group A: 3.5 (2.4–6.0), Group B: 3.5
(2.4–6.2)
Mandibular crowding (mm):
Group A: 3.4 (2.3–4.6), Group B: 3.9
(2.3–5.5)
Atik et al., Prospe-ctive A: Self-ligating A: 15 patients Cephalometric, Moderate max/mand crowding, Class I
2016 [13] Clinical Trial (Nexus) (14.4  1.5 yrs) Posteroanterior MO, non-extraction treatment
B: Conventional B: 15 patients radiographs, and Maxillary crowding (mm):
C: Passive self- (14.4  1.6 yrs) dental casts Group A: 4.0 (0.77), Group B: 3.1 (0.74),
ligating bracket C: 16 patients Group C: 3.9 (1.12)
(14.8  1.0 yrs) Mandibular crowding (mm):
Group A: 4.1 (0.99), Group B: 3.2 (1.12),
Group C: 3.8 (0.93)
Cattaneo et al., RCT A: Damon A: 21 patients Dental casts and Class I, II, and mild Class III MO, non-
2011 [16] B: In-Ovation (16.0  5.7 yrs) CBCT extraction treatment
(active self- B: 20 patients
ligating brackets) (15.0  3.3 yrs)

Fleming et al., RCT A: Damon Q A: 32 patients Cephalometric Any type of MO with maxillary crowding
2013 [14] B: In-Ovation C (18.9  2.9 yrs) radiographs and <6 mm, non-extraction treatment
C: Ovation B: 32 patients dental casts Maxillary crowding (mm):
(conventional) (22.5  8.5 yrs) Group A: 2.3 (2.64), Group B: 2.59 (1.99),
C: 32 patients Group C: 2.56 (2.22)
(18.6  3.4 yrs)
Shook et al., Retrospe-ctive A:Conventional A: 45 patients Digital models Any type of MO, non-extraction
2014 [15] study B: Damon (15.0  3.5 yrs) treatment
B: 39 patients Maxillary crowding (mm):
(15.3  4.1 yrs) Group A: 1.69 (4.17), Group B: 2.41
(3.09),
Tecco et al., Prospe-ctive A:Conventional A: 20 patients Dental casts Any type of MO with low mand plane
2009 [18] Clinical Trial B: Self-ligating B: 20 patients angle, normal OB, mild crowding
(Damon-3MX, Mean age 15.8 yrs
Ormo) (range 14 to 30 yrs)
Vajaria et al., Retrospe-ctive A: Damon A: 27 patients Cephalometric Class I MO with
2011 [17] study B: Conventional B: 16 patients radiographs and maxillary constriction
A mean age not listed dental casts

GRADE, the overall quality of evidence supporting this out- Only one study found a greater maxillary incisor proclination in a
come is moderate (table VI). Damon treatment group [17]. According to GRADE, the overall
quality of evidence supporting this outcome is low (table VI).
Changes in inclination of anterior teeth
4 out of 7 included studies compared the axial inclination of Comparison between the treatment groups
anterior teeth before and after the treatment (table III). The All studies concluded that there is no significant difference in the
majority of studies showed a proclination of maxillary incisor final transverse dimension between the Damon and the con-
teeth after the treatment in all treatment groups [12–14]. In the ventional bracket system (table VIII). Yet, there were some
Damon group, the average proclination of maxillary incisor minor differences between included studies. Atik and Ciger
(based on U1-SN8) was 3.50  5.528, while in their comparison found a greater increase in maxillary molar inclination in the
groups, the average proclination was 3.13  4.318 (table VII). Damon treatment group [12]. Also, Vajaria et al. found a greater
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Systematic review

TABLE II
Characteristics of included studies.

Study group and year Treatment group Treatment sequence (Archwire progression protocol)
(A, B, vs C)
Atik and Ciger A: Quad helix and conventional Group A: Quad helix used until lingual cusps of max first molars contacts with
2014 [12] B: Damon 3MX bracket buccal cusps of mand first molars. Then, a sequence of Ormco 0.014 Cu-NiTi, 0.018
Cu-NiTi, 0.014  0.025 Cu-NiTi, 0.017  0.025 Cu-NiTi, 0.017  0.025 SS, and
0.019  0.025 SS archwires were used.
Group B: A sequence of Damon arch form 0.014 Cu-NiTi, 0.018 Cu-NiTi,
0.014  0.025 Cu-NiTi, 0.017  0.025 Cu-NiTi, 0.017  0.025 SS, and 0.019  0.025
SS archwires were used.
Atik et al., A: Self-ligating (Nexus) All groups were treated with a sequence of Damon arch form 0.014 Cu-NiTi, 0.018
2016 [13] B: Conventional Cu-NiTi, 0.014  0.025 Cu-NiTi, 0.017  0.025 Cu-NiTi, 0.017  0.025 SS, and
C: Passive self-ligating bracket 0.019  0.025 SS archwires.
Cattaneo et al., A: Damon Group A: Archwire selection based on the Damon Work-book protocol
2011 [16] B: In-Ovation (active self-ligating Group B: Treatment protocol based on GAC recommendation
brackets)
Fleming et al., A: Damon Q All groups were treated with a sequence of Damon arch form 0.013 Cu-NiTi, 0.014
2013 [14] B: In-Ovation C Cu-NiTi, 0.014  0.025 Cu-NiTi, 0.018  0.025 Cu-NiTi, and 0.019  0.025 SS
C: Ovation (conventional) archwires.
Shook et al., A:Conventional Group A: A sequence of 0.014 Cu-NiTi, 0.018 Cu-NiTi, 0.018  0.025 SS OrthoForm
2014 [15] B: Damon III Ovoid arch forms (3 M Unitek) were customized to arch shape
Group B: A sequence of Damon arch form 0.014 Cu-NiTi to 0.018  0.025 Cu-NiTi
archwires were used
Tecco et al., A:Conventional Group A: A sequence of 3 M Unitek 0.016 Cu-NiTi followed by 0.019  0.025 Cu-
2009 [18] B: Self-ligating (Damon-3MX, Ormo) NiTi (OrthoForm II), non-specified rectangular archwires were used
Group B: A sequence of Ormco 0.014 Cu-NiTi, 0.016 Cu-NiTi, 0.016  0.025 Cu-NiTi,
and non-specified rectangular archwires were used
Vajaria et al., A: Damon Group A: A sequence of Damon arch form 0.012 to 0.014 Cu-NiTi, 0.016 Cu-NiTi,
2011 [17] B: Conventional 0.014  0.025 Cu-NiTi, 0.018  0.025 Cu-NiTi, and 0.019  0.025 SS or TMA
archwires were used.
Group B: A sequence of Ormo 0.013 Cu-Niti, 0.014 Cu-Niti, Highland Metals 0.016
Cu-Niti, Oscar 0.016 SS, Rocky Mountain 0.016  0.022 SS archwires were
customized to arch shape

TABLE III
Qualitative and quantitative summary of the individual study results (Skeletal and dental changes within the group).

Study group Treatment group Records time Main Statistically Significant Findings (Changes within the group from T0-T1)
and year (A, B, vs C) point
Atik and Ciger A: Quad helix and T0: before tx Group A
2014 [12] Conventional bracket T1: after tx Decrease in OJ ( 1.05  1.37 mm), Increase in intercanine (2.02  1.67 mm), interfirst
B: Damon 3MX (13.2-15.3 premolar (5.72  1.70 mm), intersecond premolar (5.04  2.15 mm), intermolar (3.83
bracket months)  1.57 mm) widths
Increase in max incisor proclination (U1-SN8: 1.95  4.648)
Group B
Decrease in OJ ( 1.16  1.77 mm), Increase in intercanine (2.53  2.16 mm), interfirst
premolar (5.06  2.41 mm), intersecond premolar (4.90  2.55 mm), intermolar (3.43
 1.80 mm) widths
Increase in max incisor proclination (U1-SN8: 3.68  3.648)
Atik et al., A: Self-ligating T0: before tx Group A
2016 [13] (Nexus) T1: after tx Increase in intercanine (2.03  1.33 mm), interfirst premolar (4.03  1.53 mm),
B: Conventional (13.2–14.6 intersecond premolar (3.52  1.21 mm), intermolar (2.34  1.14 mm) widths
C: Passive self- months) Increase in max incisor proclination (U1-SN8: 4.00  4.428)
ligating bracket
(Damon)
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TABLE III (Continued).

Study group Treatment group Records time Main Statistically Significant Findings (Changes within the group from T0-T1)
and year (A, B, vs C) point
Group B
Increase in intercanine (2.02 W 0.95 mm), interfirst premolar (4.05 W 1.75 mm),
intersecond premolar (3.23 W 0.94 mm), intermolar (2.61 W 2.13 mm) widths
Increase in max incisor proclination (U1-SN-: 3.06 W 2.44-)
Group C
Increase in intercanine (2.53 W 2.16 mm), interfirst premolar (5.07 W 2.41 mm),
intersecond premolar (4.9 W 2.55 mm), intermolar (3.43 W 1.80 mm) widths
Increase in max incisor proclination (U1-SN-: 3.68 W 3.64-)
Cattaneo A: Damon T0: before tx Group A
et al., 2011 B: In-Ovation (active T1: after tx Increase in intercanine (1.4 W 1.7 mm), interfirst premolar (4.3 W 1.6 mm), intersecond
[16] self-ligating (21.1–22.4 premolar (4.0 W 1.9 mm), intermolar (1.9 W 1.2 mm) widths
brackets) months) Increase in buccal inclination of first premolar (11.7 W 9.7-)
Increase in buccal inclination of second premolar (13.5 W 8.1-)
Group B
Increase in intercanine (0.7 W 1.7 mm), interfirst premolar (4.5 W 1.6 mm), intersecond
premolar (3.3 W 1.8 mm), intermolar (1.3 W 1.3 mm) widths
Increase in buccal inclination of first premolar (11.8 W 12.4-)
Increase in buccal inclination of second premolar (13.0 W 9.1-)
Fleming et al., A: Damon Q T0: before tx Group A
2013 [14] B: In-Ovation C T1: after tx Increase in intercanine (1.97 W 2.16 mm), interfirst premolar (4.51 W 2.68 mm),
C: Ovation (Minimum of intersecond premolar (3.96 W 2.51 mm), intermolar (1.22 W 2.26 mm) widths
(conventional) 8.5 months) Increase in max incisor proclination (1.12 W 3.88-)
Group B
Increase in intercanine (1.78 W 2.21 mm), interfirst premolar (3.75 W 2.31 mm),
intersecond premolar (3.78 W 1.91 mm), intermolar (1.82 W 1.59 mm) widths
Increase in max incisor proclination (3.25 W 6.89-)
Group C
Increase in intercanine (0.88 W 2.18 mm), interfirst premolar (3.7 W 3.19 mm),
intersecond premolar (3.59 W 2.80 mm), intermolar (1.41 W 2.08 mm) widths
Increase in max incisor proclination (2.84 W 5.68-)
Shook et al., A:Conventional T0: before tx Group A
2014 [15] B: Damon T1: after tx No significant difference in intercanine (0.10 mm) and intermolar (0.53 mm) width
(Mean of 25.6
months)
Group B
No significant difference in intercanine (S0.29 mm) and intermolar (0.86 mm) width
Tecco et al., A:Conventional T0: before tx Group A
2009 [18] B: Self-ligating T1: 12 months Increase in intercanine (2.6 W 2.4 mm), interfirst premolar (4.3 W 2.1 mm), intersecond
(Damon-3MX, Ormo) into tx premolar (4.1 W 2.1 mm), intermolar (2.4 W 2.0 mm) widths
Group B
Increase in intercanine (3.3 W 2.6 mm), interfirst premolar (4.4 W 2.5 mm), intersecond
premolar (4.2 W1.8 mm), intermolar (2.3 W 1.5 mm) widths
Vajaria et al., A: Damon T0: before tx Group A
2011 [17] B: Conventional T1: after tx (not Increase in intercanine (1.74 W 3.44 mm), interfirst premolar (2.87 W 3.03 mm),
specified) intersecond premolar (2.77 W 3.19 mm), intermolar (2.79 W 1.60 mm) widths
Increase in max incisor proclination (U1-SN-: 3.13 W 8.05-)
Group B
Increase in intercanine (1.72 W 2.72 mm), interfirst premolar (3.44 W 1.80 mm),
intersecond premolar (2.87 W 2.41 mm), intermolar (0.60 W 2.42 mm) widths
Increase in max incisor proclination (U1-SN-: 3.50 W 5.22-)
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TABLE IV
Averaged Dental Expansion (Maxillary intercanine distance in mm).

Source Comparison Groups Damon Groups

Mean STDEV Variance Mean STDEV Variance

Atik and Ciger 2014 [12] 2.02 1.67 2.79 2.53 2.16 4.67
Atik et al., 2016 [13] 2.03 1.33 1.77 2.53 2.16 4.67
Atik et al., 2016 [13] 2.02 0.95 0.90
Cattaneo et al., 2011 [16] 0.70 1.70 2.89 1.40 1.70 2.89
Fleming et al., 2013 [14] 1.78 2.21 4.88 1.97 2.16 4.67
Fleming et al., 2013 [14] 0.88 2.18 4.75
Tecco et al., 2009 [18] 2.60 2.40 5.76 3.30 2.60 6.76
Vajaria et al., 2011 [17] 1.72 2.72 7.40 1.74 3.44 11.83
Average 1.72 1.97 3.89 2.25 2.43 5.91

*Shook et al., 2014 [15] was not included since the STDEV was not reported with the average value.

TABLE V
Averaged Dental Expansion (Maxillary intermolar distance in mm).

Source Comparison Groups Damon Groups

Mean STDEV Variance Mean STDEV Variance

Atik and Ciger 2014 [12] 3.83 1.57 2.46 3.43 1.80 3.24
Atik et al., 2016 [13] 2.34 1.14 1.30 3.43 1.80 3.24
Atik et al., 2016 [13] 2.61 2.13 4.54
Cattaneo et al., 2011 [16 1.30 1.30 1.69 1.90 1.20 1.44
Fleming et al., 2013 [14] 1.82 1.59 2.53 1.22 2.26 5.11
Fleming et al., 2013 [14] 1.41 2.08 4.33
Tecco et al., 2009 [18] 2.40 2.00 4.00 2.30 1.50 2.25
Vajaria et al., 2011 [17] 0.60 2.42 5.86 2.79 1.60 2.56
Average 2.04 1.83 3.34 2.51 1.72 2.97

*Shook et al., 2014 [15] was not included since the STDEV was not reported with the average value.

TABLE VI
GRADE's summary of findings for randomized controlled trials. Dental Changes Associated with the Damon System Compared to a
Conventional Bracket System or an Expansion Appliance. A qualitative descriptive analysis of the results was performed; meta-analysis
was not performed due to differences in methodology.

Population: Patients with any type of malocclusion with maxillary arch crowding, Intervention Orthodontic treatment following the Damon system philosophy, Comparison: Orthodontic
treatment using any conventional bracket/archwire system or any type of maxillary expansion appliance, Outcome: Maxillary dental and skeletal changes.

Outcomes Number of studies/ Number of participants Certainty of the


study design evidence(GRADE)

Maxillary Intercanine Distance assessed with: Dental casts, PA ceph, CBCT follow up: mean 14.3 months 3 RCTs 67 in Damon group *
101 in comparison group Moderatea
Maxillary Intermolar Distance assessed with: Dental casts, PA ceph, CBCT follow up: mean 14.3 months 3 RCTs 67 in Damon group *
101 in comparison group Moderatea
Maxillary Incisor Proclination assessed with: Cephalometric Radiograph follow up: mean 10.9 months 2 RCTs 48 in Damon group **
81 in comparison group Lowa,b
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect
Moderate certainty: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different
Low certainty: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect
Very low certainty: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

a
Need bigger sample size. Total number of participants is less than 400.
b
One out of two studies have unclear risk of bias.
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Systematic review
TABLE VII
Averaged Maxillary Intercanine Proclination (Based on U1-SN, unit in-).

Source Comparison Groups Damon Groups

Mean STDEV Variance Mean STDEV Variance

Atik and Ciger 2014 [12] 1.95 4.64 21.53 3.68 3.64 13.25
Atik et al., 2016 [13] 4.00 4.42 19.54 3.68 3.64 13.25
Atik et al., 2016 [13] 3.06 2.44 5.95
Vajaria et al., 2011 [17] 3.50 5.22 27.25 3.13 8.05 64.80
Average 3.13 4.31 18.57 3.50 5.52 30.43

* Fleming et al., 2013 [14] was not included since reference plane was not specified.

increase in maxillary intermolar width after treatment in the study was assessed as a low risk of bias. Two other RCT studies
Damon group [17]. However, all other measurements (maxillary were assessed as an unclear risk of bias since the detailed
intercanine, interfirst premolar, and intersecond premolar process of allocation was not clearly stated in the methods
widths) showed no significant difference between groups [17]. section.
 MINORS was used to analyse prospective clinical trials and
Risk of bias of included studies retrospective cohort studies included in this review (table IX).
 Cochrane bias tool was used to analyse three randomized Two studies were assessed as a medium risk of bias. Two
controlled trials (RCT) included in this study (figure 2). One remaining studies were assessed as a high risk of bias mainly

TABLE VIII
Qualitative summary of the individual study results. (Skeletal and dental changes between the group).

Study group and year Treatment group Records time point Statistically Significant Findings (Changes between
(A, B, vs C) the group from T0 –T1)

Atik and Ciger 2014 [12] A: Quad helix and T0: before tx No difference between groups in transverse
Conventional bracket T1: after tx (13.2–15.3 months) dimension
B: Damon 3MX bracket Greater increase in max molar inclination in group B
Atik et al., 2016 [13] A: Self-ligating T0: before tx No difference between groups in transverse
B: Conventional T1: after tx dimension
C: Passive self-ligating (13.2–14.6 months)
bracket
Cattaneo et al., 2011 [16] A: Damon T0: before tx No significant difference in inter-premolar bucco-
B: In-Ovation (active self- T1: after tx lingual inclination between two groups
ligating brackets) (21.1–22.4 months) Bone area decrease 20% in Damon, 14% in In-
Ovation group
Fleming et al., 2013 [14] A: Damon Q T0: before tx No significant difference in transverse dimension,
B: In-Ovation C T1: after tx incisal and molar inclination between three groups
C: Ovation (conventional) (Minimum of 8.5 months)
Shook et al., 2014 [15] A:Conventional T0: before tx No difference between groups in transverse
B: Damon T1: after tx dimension
(Mean of 25.6 months)
Tecco et al., 2009 [18] A:Conventional T0: before tx No difference between groups in transverse
B: Self-ligating (Damon- T1: 12 months into tx dimension
3MX, Ormo)
Vajaria et al., 2011 [17] A: Damon T0: before tx No difference between groups in transverse
B: Conventional T1: after tx (not specified) dimension
Greater increase in maxillary intermolar width in
group A
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H.J. Nam, C. Flores-Mir, P.W. Major, G. Heo, J. Kim, M.O. Lagravère
Systematic review

Figure 2
Cochrane Bias Tool Summary Chart. The plus sign indicates a low risk of bias. The question mark indicates unclear risk of bias. The
minus sign indicates a high risk of bias.
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Dental and skeletal changes associated with the Damon system philosophical approach

Systematic review
due to inadequate reporting of characteristics of treatment
equivalence statistical Score
Adequate Total

Score 0 (not reported), 1 (reported but inadequate), or 2 (reported and adequate). The ideal total score is 16 for non-comparative studies and 24 for comparative studies. Total score of 24 indicates a low risk of bias. A score between 20–
20

20

18

17
analyses groups.

Discussion
The Damon system, one of the perceived leading self-ligating
2

2
bracket systems, has been widely used by many orthodontists.
of groups
Prospective An adequate Contemporary Baseline

Some clinicians may see less of a need for extraction with the
Damon system because of its claim that a light force and a low
2

1 friction mechanic allow a clinically stable arch expansion [6].


Our systematic review revealed 7 articles suitable for the dis-
cussion in this paper. Based on the Cochrane RoB and MINORS
calculation control group groups

tools, only 1 study had a low risk of bias, 2 studies presented a


medium risk of bias, and the remaining 4 studies had either a
2

high risk of bias or an unclear risk of bias. The most common


sources of bias resulted from the inadequate description of the
treatment group and/or from the inadequate randomization/
blinding of the procedures [12,16]. Due to the nature of this
2

clinical intervention, a perfect double-blinded randomized clini-


study size

cal trial may be difficult to achieve. The bracket design and


of the

archwires can be easily identified amongst clinicians, and there-


fore, multiple blinding is unfeasible. It was decided to also
0

0
follow-up

include high quality prospective cohort studies in this review.


less than
Loss to

This was with the idea of increasing the number of studies to


5%

synthesize and have conclusions based on more treated


2

patients. The drawback is the risk of bias increases automatically


of the study
appropriate
Follow-up

under this approach. Because of that, findings from the included


period

articles should be analysed with caution.


The majority of studies showed that there was a significant
2

2
of the study

increase in transverse dimension in each group after the com-


appropriate to assessment
Unbiased

endpoint

pletion of treatment (table III). However, one study did not find a
significant increase in maxillary intercanine and intermolar
0

dimension in both treatment groups [15]. In contrast to other


studies where most cases were finished with a rectangular
24 indicates a medium risk of bias. A score below 20 indicates a high risk of bias.
the aim of
Methodological Index for Non-Randomized Studies (MINORS).

stainless steel (SS) or TMA archwire, their Damon treatment


Inclusion of Prospective Endpoints

the study

cases were finished with copper Niti archwires [15]. Also, even
in a conventional treatment group, their final few archwires
2

were customized to the patient's existing arch shape [15]. In


stated aim consecutive collection

addition, all studies showed an increase in maxillary incisor


of data

proclination after the treatment (table III). This finding is incon-


sistent with the "lip bumper'' claim by the Damon group where a
2

low pressure from the Damon archwire system and the resting
patients

lip pressure mitigate the tendency for incisor proclination [19].


Since all treatment groups had some level of initial crowding to
2

start, the crowding was partially resolved by a proclination of


incisors. However, one must note that none of the included
A clearly

studies reported or analyzed a torque prescription of each


bracket system. When a full-size archwire is engaged in a
2

bracket, a specific torque prescription can influence the final


Vajaria et al.,
Shook et al.,

Tecco et al.,

axial inclination of teeth regardless of treatment mechanics.


Atik et al.,
TABLE IX

Next, the comparison between the Damon and the non-Damon


2016

2014

2009

2011

system groups showed a similar finding. All studies showed no


significant difference in the final transverse dimension between
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H.J. Nam, C. Flores-Mir, P.W. Major, G. Heo, J. Kim, M.O. Lagravère
Systematic review

the two treatment groups in their intercanine, interpremolar, Conclusion


and intermolar distances (table VIII) Half of the included studies There is not enough evidence to clearly support the claim that
used the Damon arch form archwires for all patients while the the Damon system allows additional arch expansion with better
rest of studies used archwires from different companies. Irre- tipping control than with traditional techniques.
spective of different arch form shapes by various companies, all In Damon group, the average increase in maxillary intercanine
studies showed similar result. Yet, one study found that the distance was 2.25  2.43 mm, intermolar distance was 2.51
intermolar distance was wider in the Damon group [17]. This  1.72 mm, and the proclination of maxillary incisor (based on
could be attributed to the fact that their Damon group was U1-SN8) was 3.50  5.528. In their comparison groups (conven-
finished with 0.019  0.025 SS or TMA standard Damon arch- tional brackets, quad helix or active self-ligating brackets), the
wires while their conventional bracket group was finished with average increase in maxillary intercanine distance was 1.72
0.016  0.022 SS archwires customized to the patient's original  1.97 mm, intermolar distance was 2.04  1.83 mm and the
arch shape [17]. average proclination was 3.13  4.318. The averaged numerical
The main component of the Damon philosophy is that the light values in the comparison group should be interpreted with
force on dentition will induce remodelling of the bone in the caution since various expansion protocols (types of brackets,
direction of tooth movement [19]. Despite its popular claim, archwire selection) were used in each literature.
there is only one study that investigated the thickness of bone Regardless of different intervention methods in comparison
after the treatment, and it failed to show any bone growth after groups, available limited evidence does not appear to show
the treatment based on the CBCT analysis [16]. Although CBCT is clinical meaningful differences in the Damon dental transverse
currently the gold standard for assessing the alveolar bone dimension when compared to other treatment approaches.
around the dentition, it has a few limitations. First, the size
of voxel (resolution) and the partial volume average effect of Disclosure of interest: the authors declare that they have no competing
CBCT can influence the accuracy in the measurement of alveolar interest.
bone thickness [20,21]. Furthermore, an immediate and post-
retention study of an expansion appliance showed that the
thickness of alveolar bone was reduced right after the treatment Appendix 1
completion, but the thickness was increased after 6 months of Search strategy for Cochrane Review database
retention period [22]. Thus, there is a need for a long-term post 1. Under "Title, Abstract, Keywords'' tab
retention study to investigate the possible late bone remodeling 2. Damon as a search term
process [22]. Search strategy for Pubmed database
1. Damon[Title/Abstract] AND
Limitations
2. (bracket[Title/Abstract] OR brackets[Title/
A few limitations existed in this review. The majority of included
studies had a low to medium risk of bias. Although most studies
Abstract] OR appliance[Title/Abstract] OR
had consistent findings across the studies, a definite clinical rec-
system[Title/Abstract] OR braces[Title/
ommendation cannot be made due to a low number of high
Abstract])
quality studies. Moreover, some studies did not report the level of
Search strategy for EMBASE database
1. Damon.mp. [mp=title, abstract, heading word,
maxillary arch crowding and/or constriction in the beginning of
treatment. These two factors can influence the final stability/
drug trade name, original title, device
amount of expansion at the end of the treatment. Lastly, although
manufacturer, drug manufacturer, device trade
interventions were done mainly in adolescent patients, the age
name, keyword, floating subheading]
2. (bracket or brackets or appliance or system or
range across all the studies combined was from 11 to 31 years old.
In growing child, high proliferative activities in tooth-supporting
braces).mp. [mp=title, abstract, heading word,
tissues are known to move tooth faster than in adults [23,24].
drug trade name, original title, device
Since the biological response from the orthodontic treatment can
manufacturer, drug manufacturer, device trade
vary with age, further studies are required with more attention
name, keyword, floating subheading]
3. 1 and 2
paid to the heterogeneity of treatment groups.
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Dental and skeletal changes associated with the Damon system philosophical approach

Systematic review
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