ONLINE ONLY

Active or passive self-ligating brackets? A

randomized controlled trial of comparative
efficiency in resolving maxillary anterior
crowding in adolescents
Nikolaos Pandis,a Argy Polychronopoulou,b and Theodore Eliadesc
Corfu, Athens, and Thessaloniki, Greece
Introduction: Our aim was to compare the time required to complete the alignment of crowded maxillary
anterior teeth (canine to canine) between Damon MX (Ormco, Glendora, Calif) and In-Ovation R (GAC, Central
Islip, NY) self-ligating brackets. Methods: Seventy patients from the first authors office were included in this
randomized controlled trial by using the following inclusion criteria: nonextraction treatment on both arches,
eruption of all maxillary teeth, no spaces in the maxillary arch, no high canines, maxillary irregularity index
greater than 4 mm, and no therapeutic intervention planned involving intermaxillary or other intraoral or extraoral appliances including elastics, maxillary expansion appliances, or headgear. The patients were randomized
into 2 groups: the first received a Damon MX bracket; the second was bonded with an In-Ovation R appliance,
both with a 0.022-in slot. The amount of crowding of the maxillary anterior dentition was assessed by using the
irregularity index. The number of days required to completely alleviate the maxillary anterior crowding in the 2
groups was investigated with statistical methods for survival analysis, and alignment rate ratios for appliance
type and crowding level were calculated with the Cox proportional hazard regression. An analysis of each protocol was performed. Results: No difference in crowding alleviation was found between the 2 bracket systems. Higher irregularity index values were associated with the increased probability of delayed resolving of
crowding. Conclusions: The use of passive or active self-ligating brackets does not seem to affect treatment
duration for alleviating initial crowding. (Am J Orthod Dentofacial Orthop 2010;137:12.e1-12.e6)

he last decade has witnessed unprecedented

progress in the development of new appliances
with alternative ligating features. Passive and
active self-ligating appliances with many ligating mechanisms were introduced to presumably allow for efficient sliding mechanics. This feature was linked with
several presumed effects including lower forces and
moments and higher rates of tooth movement, because
of the reduced friction and absence of binding of ligatures on wire. Nonetheless, for most of these appliances,
there is little evidence about the characteristics and capabilities claimed by the manufacturers, and, in some

Private practice, Corfu, Greece.

Assistant professor, Department of Community and Preventive Dentistry,
School of Dentistry, University of Athens, Athens, Greece.
c
Associate professor, Department of Orthodontics, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.
The authors report no commercial, financial, or proprietary interest in the
products or companies described in this article.
Reprints requests to: Theodore Eliades, 57 Agnoston Hiroon Str, Nea Ionia
GR-14231, Greece; e-mail, teliades@ath.forthnet.gr.
Submitted, June 2009; revised and accepted, August 2009.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.08.019
b

cases, it seems that marketing-derived principles rather

than scientific evidence is used to substantiate their
well-advertised clinical performance. Thus, the resultant turmoil in this specialty has no support in the literature, since most published trials do not show superior
efficiency of self-ligating brackets regardless of type
or ligating mechanism.1-8
The available evidence on the efficiency of selfligating brackets derives from a few prospective and
randomized clinical trials, with most prospective and
randomized controlled trials (RCTs) demonstrating no
difference in treatment duration between conventional
and self-ligating brackets.3-7
Recently, the relatively low validity and reliability
of retrospective studies as opposed to prospective and
especially RCTs have switched investigators interests
to the latter type of studies.9,10 RCTs are preferred because of the elimination of selection and outcome biases
of retrospective studies.11 Currently, there is little evidence from this type of study on the potential differences between passive and active self-ligating
brackets in tooth movement rates.
The purpose of this study was to compare the time
required to complete the alignment of crowded
12.e1

12.e2

Pandis, Polychronopoulou, and Eliades

Table I.

Demographic and clinical characteristics of sample

Demographic characteristics
Age (y)
Sex (%)
Girls
Boys
Clinical characteristics
Crowding (irregularity index, mm)
Angle class (%)
I
II
III

American Journal of Orthodontics and Dentofacial Orthopedics

January 2010

Total (n 5 70)
mean or %

SD

Damon MX (n 5 35)
mean or %

SD

In-Ovation R (n 5 35)
mean or %

SD

P value*

13.8

1.8

13.8

1.8

13.8

1.7

NS

58.6
41.4
7.5

60.0
40.0
2.1

48.6
47.1
4.3

8.0

57.0
43.0
2.1

51.4
42.9
5.7

7.0
45.7
51.4
2.9

NS

2.0

NS
NS

NS, Not significant.

*P value for comparison of group means by t test or differences in proportions by chi-square test and Fisher exact test.

maxillary anterior teeth (canine to canine) between passive and active self-ligating brackets.
MATERIAL AND METHODS

Seventy patients were included in this RCT, selected

from a large pool of patients from the first authors office. The following inclusion criteria were used: nonextraction treatment in both arches, eruption of all
maxillary teeth, no spaces in the maxillary arch, no
high canines, maxillary irregularity index greater
than 4 mm, and no therapeutic intervention planned
involving intermaxillary or other intraoral or extraoral
appliances including elastics, maxillary expansion appliances, or headgear. The patients were selected and
treated between March 2007 and May 2009. Their demographics are shown in Table I.
The active self-ligating group was bonded with the
Roth prescription In-Ovation R bracket (GAC, Central
Islip, NY), and the passive self-ligating group received
the high-torque version of the Damon MX (Ormco,
Glendora, Calif), both with a 0.022-in slot. All first and
second (when present) molars were bonded with Speed
bondable tubes (Speed System Orthodontics, Cambridge,
Ontario, Canada). Bracket bonding, archwire placement,
and treatment were performed by the first author.
The amount of crowding of the maxillary anterior
dentition was assessed by using the irregularity index
described by Little.12 Measurements were made twice
on the initial casts by the first author with a digital caliper (Digimatic NTD12-6C, Mitutoyo, Tokyo, Japan).
Archwire sequence was the same for both treatment
groups: 0.014-in Damon arch form copper-nickel-titanium 35 C (Ormco), followed by a 0.016 3 0.025-in Damon arch form copper-nickel-titanium 35 C (Ormco).
Seventy patients (mean age, 13.8 years) were randomized to either an active or a passive self-ligating

appliance. Randomization was accomplished by generating random permuted blocks of variable size; this
ensured equal patient distribution between the 2 trial
arms. Numbered, opaque, sealed envelopes were prepared before the trial containing the treatment allocation
card. After patient selection, the secretary of the practice was responsible for opening the next envelope in
sequence.
Based on previous research, it was assumed that
a hazard ratio larger than 2 between the bracket groups
would be an important clinical finding.6 Sample size
was calculated. Based on this assumption, the required
sample size was calculated at 66 (a 5 0.05, power 5
80%), and it was decided to include 70 subjects in
case of any losses.
The date (T1) that each patient was bonded was recorded. All patients were followed monthly. Complete alleviation of crowding was judged clinically by the first
author. On visual inspection of correction of proximal
contacts, the patient was considered complete, and the
alignment date (T2) was determined and recorded on
the spreadsheet. Only the alignment of the 6 maxillary anterior teeth was evaluated. In other words, we considered
that a patient had reached the T2 stage if the 6 maxillary
anterior teeth were aligned, regardless of possible irregularities in posterior segments. The time to alignment (T2
T1) for each patient was calculated in days. Blinding of
outcome assessment was not feasible for this study. To assess the reliability of the method, the irregularity index
was remeasured a month later in 20 models, selected randomly, and good agreement was found between the first
and the second measurement (ICC .0.95).
Statistical analysis

Demographic and clinical characteristics were investigated with conventional descriptive statistics.

Pandis, Polychronopoulou, and Eliades

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 137, Number 1

12.e3

Assessed for eligibility

(n= 148)

Excluded:
(n= 78)
Enrollment

Not meeting inclusion criteria

(n=67)
Other reasons
(n= 11)

Randomization

Allocated to Damon group

(n=35)
Received allocated intervention
(n=35)

Allocation

Allocated to In -Ovation R gr oup

(n=35)
Received allocated interv ention
(n=35)

Discontinued intervention
(n= 2)
Poor compliance

Follow-Up

Discontinued intervention
(n= 2)
Poor compliance

Analyzed
(n= 33)
Per protocol

Analysis

Analyzed
(n= 33)
Per protocol

Fig 1. CONSORT flowchart of the study.

Comparisons of these between the 2 appliance groups

were conducted with t tests or chi-square tests, depending on the characteristic (parametric or nonparametric). Treatment durationthe time required to
resolve crowding in both appliance groupswas investigated with statistical methods for survival analysis; alignment rate ratios for appliance type and
crowding level were calculated with the Cox proportional-hazards regression. A 2-tailed P value of 0.05
was considered statistically significant with a 95%
confidence interval.
RESULTS

Figure 1 is the CONSORT flowchart. Table I shows

the distribution of demographic variables of the groups
including age, sex, irregularity index, and Angle classification. There was no discrimination with respect to

these factors between the 2 groups, validating the random assignment of appliances to each group. Four patients were excluded from the statistical analysis
because of poor compliance, and the statistical analysis
was conducted per protocol, since loss to follow-up was
not associated with type of treatment.
In Table II, the results of the treatment time to alignment are shown for the 2 bracket groups; no statistical
significance was found.
The results of the Cox proportional-hazards model
are given in Table III. The In-Ovation R appliance had
a 1.4 hazard ratio over the Damon MX bracket; this implied that the former had a 1.4 times higher probability
of alleviating crowding earlier than the latter, but this
effect did not reach statistical significance. On the contrary, higher irregularity index values were associated
with increased probability of delayed resolving of
crowding (P \0.05).

12.e4

Pandis, Polychronopoulou, and Eliades

Table II.

American Journal of Orthodontics and Dentofacial Orthopedics

January 2010

Treatment time to alignment by wire system and crowding severity

Wire system
Damon MX
In-Ovation R
Total

Total

Mean time to alignment (d)

Minimum (d)

Median (d)

Maximum (d)

P value*

33
33
66

107.1
95.0
101.0

56
54
54

99
92
95.5

175
161
175

NS

NS, Not significant.

*P value based on the log-rank test for equality of survivor functions.
Table III.

Alignment rate ratios derived from the Cox proportional-hazards regression

Predictor
Bracket system
Damon MX
In-Ovation R
Crowding
Irregularity index (mm)

Adjusted hazard ratio*

95% CI

P value

Baseline
1.46

0.85-2.51

NS

0.73

0.64-0.84

\0.05

NS, Not significant.

*Hazard ratios adjusted for demographic characteristics and Angle class.

1.00

Kaplan-Meier survival estimates

0.25

The results of this study emphasize the clinical irrelevance of the typical in-vitro assessment of friction protocols in many studies during the past decade. A number
of factors related to the oversimplicity of experimental
configurations and the overwhelming number of assumptions in the experimental design have deprived
ex-vivo friction assessment of clinical relevance and
scientific soundness. These briefly include the rate of
wire sliding onto slot walls, application of forces on
wire, lack of intraoral aging of materials, and study of
variables with little or no relevance to the actual clinical
situation.13-19 A recent critical review of this topic clarified several misconceptions of the study of static and
kinetic friction and their clinical applicability, suggesting that the importance of this parameter has been overestimated in relevant research.20
Small differences in the torque prescriptions between the 2 brackets were not expected to influence
the outcome because these were outweighed by the
large free play that was more than 2 times higher than
the torque differences in a conventional bracket.21
Registration of the irregularity index changes in this
study was performed at the end of treatment because the
rate of correction was unknown; therefore, changes registered at a certain time during therapy might not hold
for the entire treatment. The use of monthly monitoring

0.00

DISCUSSION

0.50

0.75

Figure 2 depicts the Kaplan-Meier survival curves

for the 2 bracket groups; lack of separation implies no
statistically significant difference.

50

100

analysis time

bracket = Damon

150

200

bracket = In-Ovation R

Fig 2. Kaplan-Meier survival curves for the 2 appliances

used in the study, indicating lack of separation; this
implies no significant effect on treatment duration.

intervals was not a bias because this method was applied

to both bracket groups.
The results of this RCT with the body of evidence on
this issue suggest that the bracket-archwire free play
might not be the most critical factor in altering the tooth
movement rate. The large clearance in self-ligating over
conventional brackets and the presumed lower binding
of Damon MX relative to the In-Ovation R appliance
might be eliminated as archwires of larger cross sections
are gradually placed in the bracket slot.22,23 The clinician might empirically appreciate the free play with
self-ligating brackets, especially in patients with extreme tooth malalignment, when complete engagement
of certain diameters of nickel-titanium wire might not

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 137, Number 1

be feasible with conventional brackets. This situation,

however, changes drastically as treatment progresses
and wires of higher stiffness are engaged in the bracket.
Correction of rotations and achievement of proper buccolingual crown inclination (torque), which are frequently required in mandibular and maxillary anterior
teeth, respectively, necessitate a couple of forces. This
assumes the formation of contacts of wire inside the
bracket slot walls, and thus the major advantage of
self-ligating bracketsfree playis eliminated as the
crowns gradually attain their proper spatial orientation.
Especially for torque application, self-ligating brackets
lose more torque compared with conventional
brackets,24,25 whereas a clinical trial showed that these
brackets can achieve comparable torque transmission
only with reverse curve of Spee archwires.26 Alternatively, torquing auxiliaries, higher torque prescription
brackets, or pretorqued wires can be used to counteract
the greater torque loss from greater free play.
These results agree with several studies that found
no difference in treatment duration in canine retraction27-29 and crowding alleviation between conventional
and various self-ligating brackets.4-8 Regardless of the
type of movement and ligation mechanism of self-ligating brackets, the results of these trials are consistent
with a lack of treatment duration differences.
For the active self-ligating bracket, the clip should
theoretically prevent this by applying a force on the
wire; however, the relaxation of clip for the In-Ovation
R bracket reported previously contributes to the lack
of consistent engagement of the wire throughout
treatment.30
CONCLUSIONS

The results of this RCT suggest that active and passive self-ligating brackets have no difference in treatment duration in the correction of maxillary anterior
crowding, in contrast to the extent of crowding, which
had an effect on the duration of treatment.
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