LITHUANIAN UNIVERSITY OF HEALTH SCIENCES ACADEMY OF MEDICINE
FACULTY OF ODONTOLOGY THE CLINIC OF ORTHODONTICS
Elionora Segal
5th Course, group 14DIFFERENCE IN INCISOR POSITION AFTER
ORTHODONTIC TREATMENT WITH
CONVENTIONAL AND SELF-LIGATING BRACKETS
A systematic review
Work supervisor
PhD, Kristina Lopatiene
LITHUANIAN UNIVERSITY OF HEALTH SCIENCES ACADEMY OF MEDICINE
ODONTOLOGY FACULTY THE CLINIC OF ORTHODONTICS
DIFFERENCE IN INCISOR POSITION AFTER ORTHODONTIC TREATMENT WITH CONVENTIONAL AND SELF-LIGATING BRACKETS
A systematic review Student... (signature) Work supervisor ... (signature)
Elionora segal, 5th course, group 14 PhD, Kristina Lopatiene
20....yr... (month, day) 20....yr... (month, day) Reviewer ... Evaluation ... (signature) ... (science degree, full name)
20....yr. ... (month, day) Comments: ... ... ... ... ... ...
EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC
LITERATURE
Evaluation:………. Reviewer: ………
(Scientific degree. name and surname)
Reviewing date: ...
No. MT parts MT evaluation aspects
Compliance with MT requirements and evaluation Yes Partially N o 1 Summary (0.5 point)
Is summary informative and in compliance with
the thesis content and requirements? 0.3 0.1 0
2 Are keywords in compliance with the thesis
essence? 0.2 0.1 0
3 Introduction, aim and tasks (1 point)
Are the novelty, relevance and significance of the
work justified in the introduction of the thesis? 0.4 0.2 0
4 Are the problem, hypothesis, aim and tasks
formed clearly and properly? 0.4 0.2 0
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection criteria of the studies, search methods
and strategy (3.4 points)
Is the protocol of systemic review present? 0.6 0.3 0 7
Were the eligibility criteria of articles for the selected protocol determined (e.g., year, language, publication condition, etc.)
0.4 0.2 0
8
Are all the information sources (databases with dates of coverage, contact with study authors to identify additional studies) described and are the last search day indicated?
0.2 0.1 0
9
Is the electronic search strategy described in such a way that it could be repeated (year of search, the last search day; keywords and their combinations; number of found and selected articles according to the combinations of keywords)?
0.4 0.1 0
10
Is the selection process of studies (screening, eligibility, included in systemic review or, if applicable, included in the meta-analysis) described?
0.4 0.2 0
11
Is the data extraction method from the articles (types of investigations, participants, interventions, analysed factors, indexes) described?
0.4 0.2 0
12
Are all the variables (for which data were sought and any assumptions and simplifications made) listed and defined?
0.4 0.2 0
13
Are the methods, which were used to evaluate the risk of bias of individual studies and how this information is to be used in data synthesis, described?
14 Were the principal summary measures (risk ratio,
difference in means) stated? 0.4 0.2 0
15
Systemization and analysis of
data (2.2 points)
Is the number of studies screened: included upon assessment for eligibility and excluded upon giving the reasons in each stage of exclusion presented?
0.6 0.3 0
16
Are the characteristics of studies presented in the included articles, according to which the data were extracted (e.g., study size, follow-up period, type of respondents) presented?
0.6 0.3 0
17
Are the evaluations of beneficial or harmful outcomes for each study presented? (a) simple summary data for each intervention group; b) effect estimates and confidence intervals)
0.4 0.2 0
18
Are the extracted and systemized data from studies presented in the tables according to individual tasks?
0.6 0.3 0
19
Discussion (1.4 points)
Are the main findings summarized and is their
relevance indicated? 0.4 0.2 0
20 Are the limitations of the performed systemic
review discussed? 0.4 0.2 0
21 Does author
results?
present the interpretation of the
0.4 0.2 0
22
Conclusions (0.5 points)
Do the conclusions reflect the topic, aim and
tasks of the Master’s thesis? 0.2 0.1 0
23 Are the conclusions based on the analysed
material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
25
References (1 point)
Is the references list formed according to the
requirements? 0.4 0.2 0
26
Are the links of the references to the text correct? Are the literature sources cited correctly and
precisely? 0.2 0.1 0
27 Is the scientific level of references suitable for
Master’s thesis? 0.2 0.1 0
28
Do the cited sources not older than 10 years old form at least 70% of sources, and the not older than 5 years – at least 40%?
0.2 0.1 0
Additional sections, which may increase the collected number of points
29 Annexes Do the presented annexes help to understand the
analysed topic? +0.2 +0.1 0
30
Practical recommend-
dations
Are the practical recommendations suggested and
are they related to the received results? +0.4 +0.2 0 31
Were additional methods of data analysis and their results used and described (sensitivity analyses, meta-regression)?
32
Was meta-analysis applied? Are the selected statistical methods indicated? Are the results of each meta-analysis presented?
+2 +1 0
General requirements, non-compliance with which reduce the number of points
33
General requirements
Is the thesis volume sufficient (excluding annexes)?
15-20 pages
(-2 points) <15 pages (-5 points)
34 Is the thesis volume increased
artificially? -2 points -1 point
35 Does the thesis structure satisfy the
requirements of Master’s thesis? -1 point -2 points
36 Is the thesis written in correct
language, scientifically, logically and laconically?
-0.5 point -1 points
37 Are there any grammatical, style or
computer literacy-related mistakes? -2 points -1 points
38 Is text consistent, integral, and are
the volumes of its structural parts balanced?
-0.2 point -0.5 points
39 Amount of plagiarism in the thesis. >20% (not
evaluated) 40
Is the content (names of sections and sub- sections and enumeration of pages) in compliance with the thesis structure and aims?
-0.2 point -0.5 points
41
Are the names of the thesis parts in compliance with the text? Are the titles of sections and sub-sections distinguished logically and correctly?
-0.2 point -0.5 points
42 Are there explanations of the key
terms and abbreviations (if needed)?
-0.2 point -0.5 points 43 Is the quality of the thesis typography (quality of printing,
visual aids, binding) good?
-0.2 point -0.5 points
*In total (maximum 10 points):
*Remark: the amount of collected points may exceed 10 points.
CONTENT
ABSTRACT………....page 1
INTRODUCTION……….….page 2-4
SELECTION CRITERIA OF THE STUDIES. SEARCH METHODS AND STRATEGY
……….Page 5-6
SYSTEMIZATION AND ANALYSIS OF DATA…………..……….…page 7-8
1. Evaluation of the incisors torque/inclination in the maxillary arch between conventional and self-ligating brackets after orthodontic treatment………...page 9-13
2. Evaluation of the incisors torque/inclination in the mandibular arch between conventional and self-ligating brackets after orthodontic treatment………page 14-20
DISCUSSION………...page 21-24
CONCLUSIONS……….…..page 25
1
ABSTRACT
Objectives:
The purpose of this systematic literature review was to determine the efficiency ofself-ligating bracket system over conventional bracket system on incisor inclination on the maxillary and mandibular arches after orthodontic treatment.
Material and methods: Relevant literature were identified by searching the PubMed, AJO-DO
and ScienceDirect electronic databases and were been available in full-text version, information search for controlled studies on humans published between January first 2006 till thirty of September 2016. Inclusion criteria were: English language, a study on humans, randomized or nonrandomized controlled clinical studies, assessment of self-ligating and conventional brackets system in incisor inclination on maxillary and mandibular arches after orthodontic treatment. Quality assessment of the included articles was performed.Results: In total 369 scientific publications, articles, clinical trials reviews were identified and
were related to keywords used during the search. Finally, 21 articles were included in the review and eight clinical studies fulfilled all inclusion criteria.Our hypothesis was that self-ligating brackets are more effective than conventional brackets in a comparison between incisor inclination on the maxillary and mandibular arches. The results were not statistically significant according to the level of statistical significance was set at P <0.05. Despite claims about the advantages of self-ligating brackets, evidence of shorter chair time and treatment time are the only significant advantages of this bracket system.
Conclusion: Our hypothesis was rejected due to findings that implied: Evaluating the changes of
incisors torque/inclination on the maxillary arch between conventional and self-ligating brackets after orthodontic treatment the finding suggest that no statistical difference was found between the self-ligating system over the conventional bracket system on the movement of the incisor teeth. Simultaneously after evaluating the changes of incisors torque/inclination in the mandibular arch between conventional and self-ligating brackets after orthodontic treatment the finding suggest overall increase in proclination of the mandibular incisors regardless of bracket type, where no statistical difference was identified after treatment between the conventional and self-ligating bracket groups.INTRODUCTION
Several decades ago the self-ligating brackets were introduced into orthodontics world and have been gaining popularity since then, furthermore, some professional orthodontics believed that they are the most clinically effective and have many advantages compared to conventional brackets. Mainly in these days, there are two main types of brackets for practicing orthodontists: conventional and self-ligating brackets. On one hand, the conventional tie wing bracket, wire ligatures, and elastomeric ligatures have been documented with higher frictional forces, which reach undesirable levels relative to those that are ideal for tooth movement. On the other hand, the self-ligating brackets are considered a ligature with less bracket system and an inbuilt metal labial face, which provides the combination of low friction and full archwire engagement [1].
In fact, the self-ligating brackets can be divided into 2 main categories: active and passive, according to their mechanisms of closure. Active self-ligating brackets have a spring clip that stores energy to press against the archwire for rotation and torque control. On the other hand, passive self-ligating brackets usually have a slide that can be closed which does not encroach on the slot lumen, thus exerting no active force on the archwire.
Self-ligating brackets are proposed to have the potential advantages of producing more physiologically harmonious tooth movement by not overpowering the musculature and interrupting the periodontal vascular supply. Therefore, more alveolar bone generation, greater amounts of expansion, less proclination of anterior teeth, and less need for extractions are claimed to be possible.Other claimed advantages include full and secure wire ligation, better sliding mechanics and possible anchorage conservation, decreased treatment time, longer treatment intervals with fewer appointments, chair time savings, less chair-side assistance and improved ergonomics,better infection control, less patient discomfort, and improved oral hygiene. However, self-ligating brackets have some disadvantages, including higher cost, possible breakage of the clip or the slide, higher profile because of the complicated mechanical design, potentially more occlusal interferences and lip discomfort, and difficulty in finishing due to the incomplete expression of the archwires [2].
Besides in orthodontic treatment, torque control is often required for an ideal interincisal angle, adequate incisor contact, and sagittal adjustment of the dentition in order to achieve an ideal occlusion [3].
In general, the extent of change in the buccolingual inclination of the crowns depends on the wire, torque stiffness, bracket design, the wire/slot play, and the mode of ligation [4]. Therefore, any appliance system that can increase the rate of tooth alignment is a potential clinical advance.
3
These include patient discomfort and loss of tooth root length due to resorption [5]. In fact, the interaction between the bracket of an axially rotated tooth and an archwire produces a moment. This moment influences the inclination of all teeth in a buccal or lingual direction, particularly the incisors. In addition, torque is a moment generated by the torsion of a rectangular wire in the bracket slot. The sources of variation in the expression of torque involve the stiffness of wire alloys, the play between wire and slot, the ligation modes, and the bracket design [6]. The amount of torque is dependent upon the degree of axial rotation of the archwire relative to the bracket slot. The angle at which the wire engages the bracket slot and generates a torque is referred to as the engagement angle. The engagement angle may vary and is dependent upon the size of the rectangular archwire and of the bracket slot. Concluded that the amount of play between the wire and the slot is more important in determining torque than is the design of the bracket. However, bracket width will have a significant effect on torque play. This would require the force of ligation to be sufficient to deform the bracket [7].In clinical orthodontics, the optimal labiolingual inclination of both posterior and anterior teeth is considered essential to establish an esthetic smile line, a proper occlusal relationship, and subsequently long-lasting stability of the orthodontic outcome. Inadequately, inclined incisors result in a dental arch constriction, as it has been evaluated that for every 5 degrees fallacy of anterior inclination a decrease of about 1 mm of the dental arch is to be expected. In particular, the main objective of the current study was to comprehensively investigate the torque efficiency of various archwires combined with diverse bracket systems used in clinical orthodontics [8], as conventional and self- ligating brackets, and the affect of them on incisor and molar teeth inclination. In this particular systematic review, we prefer to focus only on the incisors teeth in the maxillary and mandibular arch, for furthermore evaluation on clinically significant values of the self- ligating brackets over the conventional brackets system.
The dawn of the 21st century in orthodontics has been accompanied by significant development that enhanced the clinical outcome in multiple facets of clinical practice [9]. Years of constant trial and clinical experimentation has led the orthodontic professional to realize that self-ligating appliances with active or passive ligation modes are more suitable and better choice in the manner of fixed appliances. The basic advantages of these brackets involve the elimination of certain utilities or materials such as elastomeric modules along with the process or tools associated with their application [10]. In the recent years through newer techniques such as MBT (McLaughlin Bennet Trevesi) have been able to solve the purpose of perfection in leveling, aligning, with the advantage of the invention of newer self- ligating brackets [11].
The aim of this systematic literature review was to determine the efficiency of self-ligating bracket system over conventional bracket system on incisor inclination on the maxillary and mandibular arches after orthodontic treatment.
Our tasks are:
1. To evaluate the changes of incisors torque/inclination on the maxillary arch between conventional and self-ligating brackets after orthodontic treatment.
2. To evaluate the changes of incisors torque/inclination on the mandibular arch between conventional and self-ligating brackets after orthodontic treatment.
5
SELECTION CRITERIA OF THE STUDIES.
SEARCH METHODS AND STRATEGY
The systematic review was conducted according to the protocol of the following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) statement [15].
The systematic literature review is based on a selection of main information source as literature studies from electronic databases that were used during a search in Google web browser.
The keywords that were used in the search are incisor, torque, inclination, conventional brackets, and self-ligating brackets.
Relevant literature was identified by searching the PubMed, AJO-DO and ScienceDirect electronic databases and were been available in full-text version were determined whether to include it the systematic work.
The literature search included assessment of articles from dental journals that were also in the English language, studies that were preformed on humans only and published in the years from January first 2006 tillthirty of September 2016 and included the keywords that were selected. In total 369 scientific publications, articles, clinical trials reviews were identified and were related to keywords used during the search.
Titles and abstracts derived from this broad search were independently screened to eliminate irrelevant publications. The final stage of screening involved reading the full texts to confirm each study's eligibility based on inclusion and exclusion criteria.
Our hypothesis focus questions were to evaluate the self-ligating bracket system over the conventional bracket system on the meaner of torque/inclination of incisor teeth after orthodontic treatment. The following focus question was developed according to the population, intervention, comparison, and outcome (PICOS) study design (Table 1).
Table 1. PICOS table
Description Component
Patients included in the clinical studies that were treated with conventional and self-ligating bracket systems.
Population
Inclination/torque of incisor teeth on the maxillary and mandibular arch. Intervention
Maxillary and mandibular arches with an extraction of teeth, crowding, and expansion of the arch.
Comparison
Statistically significant (p< 0.05) amount of teeth inclination with the self-ligating bracket system over the conventional system.
Outcome
Randomized and non-randomized controlled trials, cohort studies. Study design
To be included in the study all records had to be determined by following inclusion criteria: 1. Patients with performed cephalometric analysis and dental cast evaluation.
2. The position of maxillary and mandibular incisors as inclination or torque before and after orthodontic treatment.
3. Comparison between the self-ligating and conventional brackets. 4. All the study subjects are humans.
5. Years of articles publication were chosen from January first 2006 tillthirty of September 2016.
The exclusion criteria are: 1. In vitro studies.
2. Non- human studies.
3. literature reviews, single case reports, editorials, commentaries.
The majority of studies selected for this literature review were published by:
www.ajodo.org
– American Journal of Orthodontics and Dentofacial Orthopedics
-www.angle.org
-The Angle Orthodontist
-http://ejo.oxfordjournals.org/
European Journal of Orthodontics
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SYSTEMIZATION AND ANALYSIS OF DATA
The articles review and data extraction were performed according to the PRISMA flow diagram (figure 1) [21]. The initial database search displayed 369 results. The preliminary exclusion was done by relevancy; 202 duplicated titles and abstracts were excluded. Of the remaining 167 articles result, 134 were excluded due to not enough information, 33 full-text articles assessed for eligibility.
Finally, 21 articles were included in the review. A flow chart of the selection process is present in Figure 1.
Id en tif icat ion
PubMed, ScienceDirect, AJO-DO database advanced search:
Search terms: " incisor torque" OR "incisor inclination" AND "conventional brackets" OR "self-ligating brackets"
Abstract available. Studies on humans. English language. Dental journals.
Publication dates: January first 2006 till thirty of September 2016. (n= 369)
Filtered
Removed duplicated titles and abstracts
(n=202) Exclusion criteria: -Case reports (n=51) - No access (n=51) -Other reasons (n=100) Title and abstracts were selected according to
relevancy after duplication removal (n= 167)
Filtered
Not enough information (n=134) Exclusion criteria: -study type (n=67)
-reference standard (n=67)
Full text articles assessed for eligibility (n=33)
Filtered
Full text articles excluded duo to general reasons
(n=12) Exclusion criteria: - Unable to obtain assessment (n=12)
Final articles selection (n=21)
Studies on maxillary arch (n=4) Studies on Mandibular arch (n=5)
Mixed study (conventional vs. self-ligating brackets ( n= 12)
Figure 1. PRISMA flow diagram
S cr ee n in g E li gib il ity In clu d ed
Assessment of methodological quality
The quality of all included studies was assessed during the data extraction process and involved evaluating the methodological elements that might influence the outcome of each study (Table 2). The Cochrane hand book for assessing risk of bias [23] was used to assess bias across the studies and to identify papers with intrinsic methodological and design flaws. Based on the information given in each study the potential risk of bias was categorized into: low risk of bias (+), unclear risk of bias (?), or high risk of bias (-).
Table 2. Risk of bias summary
Categories as follows: low risk of bias (+), unclear risk of bias (?), or high risk of bias (-).
Quality assessment
The quality assessment of the included studies revealed an unknown risk of bias (for one or more key domains) for all of the included studies [9-10, 13-14, 16-17, 20, 22].
Random Sequence Generation Allocation Concealment Blinding of Participants and Personnel Blinding of Outcome Assessment Incomplete Outcome Data Selective Reporting Other Sources Bias Prasad et al.[9] ? + + + + - ? Pandis et al. [10] ? ? + + + + + Atik et al. [13] ? ? + + + + + Atik et al. [14] ? ? + + + + + Pandis et al. [16] ? ? + + + + + Pandis et al. [17] ? ? + + + + + Celikoglu et al. [20] ? ? + + + + + Fleming et al. [22] ? ? + + + + +
9
1. EVALUATION OF INCISOR TORQUE/INCLINATION IN THE
MAXILLARY ARCH BETWEEN CONVENTIONAL AND SELF-LIGATING
BRACKETS AFTER ORTHODONTIC TREATMENT.
The included studies in the evidence table of maxillary arch (Table 3) were compared regarding the number of participants, treatment methods of the groups, and main results. The mentioned 3 articles were discussing the changes of incisors position on the maxillary arch after orthodontic treatment with conventional brackets and self-ligating brackets.
Passive self-ligating brackets have been claimed to lead to posterior expansion without prominent labial movement of the incisors. Based on this idea, conventional and passive self-ligating brackets were compared in terms of maxillary arch dimensional changes in several studies.
According to Atik et al. [13] the changes of incisors inclination on the maxillary arch after orthodontic treatment with conventional brackets and self-ligating brackets can be compared to a total of 46 participants with class I malocclusion and moderate crowding chosen for the study, subjects main age 14-16, that divided into 3 groups. The groups were treated by: group I- active self-ligating bracket, group II - conventional bracket, group III- passive self-ligating bracket. All the groups were using the same Damon archwire material from copper-nickel-titanium (Cu-NiTi) and stainless steel (SS), all groups were using the same bracket slot size and same sizes of archwire sequences.Incisor inclination: before treatment in group I the U1-NA (24.13°, 4.49 mm), group II NA (24.95°, 5.53 mm), group III NA (23.17°, 5.12 mm), after treatment in group I the U1-NA (28.02°, 5.92 mm), group II U1-U1-NA (28.23°, 6.56 mm), group III U1-U1-NA (26.93°, 6.22 mm). The results were not statistically significant, no difference found in the measurements among all groups, but according to the lateral cephalometric measurements, the changes in the labiolingual inclination for maxillary arch were significant in all bracket systems.
Non-extraction treatment of crowded maxillary dental arch without distal movement of the arches requires an increase not only in transverse dimension but also in incisor proclination. Maxillary incisor inclination changes were the same in all groups.
In this particular study, the expansion of the maxillary arch with a quad-helix appliance was used, followed by conventional brackets in patients with dentally constricted maxillary arch with regard to the incisor position. This can be seen in Atik et al. [14], a total of 33 participants with class I malocclusion, subjects main age 14.5, which divided into 2 groups. The group's were treated by: group I- conventional bracket, group II - passive self-ligating bracket. In group I: a quad-helix appliance was applied before the bonding of the brackets, on other hand in group II the quad-helix
appliance was not applied before the bonding of the brackets. All groups were using the same bracket slot size and archwire sequences. Incisor inclination: before treatment in conventional system the U1-NA (22.82±6.28°, 5.12±2.06 mm) and on the self-ligating U1-NA (23.17±7.47°, 5.12±2.60 mm), after treatment in conventional system the U1-NA (25.44±5.02°, 5.88±2.42 mm) and on the self-ligating U1-NA (26.93±5.37°, 6.22±1.94 mm). The results were not statistically significant, the conventional and self-ligating bracket system were found to be similar with regard to incisor position.
In this case in particular the participants were treated with extractions prior to the placement of the brackets systems, Insufficiently inclined incisors preclude the distal movement of the anterior maxillary dentition, and deprive the dental arch from arch space; it has been shown that on average, a 5° anterior inclination, generates 1 mm of arch length. This can be seen in Pandis et al. [16] a total of 105 participants, half were treated without extractions and the other half were treated with extractions of maxillary first premolar on each side of the arch, subjects main age 16, the 2 groups were subdivided into two samples each and received the same archwire sequence for both groups; group I- half of the extraction and non-extraction cases were treated with conventional bracket, group II - other half of the extraction and non-extraction cases were treated with self-ligating bracket. Incisor inclination: before treatment in ligating/non-extraction U1-NA ( 24.8°), self-ligating/ extraction U1-NA ( 22.8°) , conventional/non-extraction U1-NA (24.40°), conventional/ extraction U1-NA (22.1°), after treatment in ligating/non-extraction U1-NA (4.3°), self-ligating/ extraction U1-NA (6.9°) , conventional/non-extraction U1-NA (5.6°), conventional/ extraction U1-NA (6.2°). The results were not statistically significant, a lack of effect of ligation mode on the maxillary incisor buccolingual inclination was found of extractions or bracket interaction, the use of different brackets and associated mechanotherapy seems to have no effect on altering the torque of the maxillary incisor.
In summary all the articles were discussing on incisor inclination after orthodontic treatment on the maxillary arch with conventional and self-ligating bracket system, the total amount of participants were in: Atik et al. [13] - 46 participants, Atik et al. [14] - 33 participants and in Pandis et al. [16]- 105 participants . The main age was in: Atik et al. [13] - 14-16 years, Atik et al. [14] - 14.5 years and in Pandis et al. [16]- 16 years. The groups division and duration of treatment time were in: Atik et al. [13] - divided into 3 groups. The groups were treated by: group I- active self-ligating bracket along with 8.2-22.4 month of treatment, group II - conventional bracket along with 11-25 month of treatment, group III- passive self-ligating bracket along with 10-22 month of treatment.
11
Atik et al. [14] - divided into 2 groups. The groups were treated by: group I- conventional bracket along with 10-23 month of treatment, group II - passive self-ligating bracket along with 10-22 month of treatment, and in Pandis et al. [16]- the groups divided into two samples with conventional and self-ligating bracket but the duration time of the treatment was not indicated. Mainly in all studies as Atik et al. [13, 14] and Pandis et al. [16] the final archwire that was used in order to align the teeth and the dental arch was 0.019 × 0.025 in Damon arch form stainless steel. Additionally in Atik et al. [13, 14] and Pandis et al. [16] all the cephalometric radiographs and dental cast models were measuring the incisor inclination by degrees and millimeters in the angle of U1-NA, as well as all the changes in arch were measured by digital caliper from dental study casts that were taken at pretreatment (T0) and post-treatment (T1), of each subject were digitally traced using Quick Ceph Studio software(Quick Ceph Systems, San Diego, Calif).The results in all the 3 articles: Atik et al. [13], Atik et al. [14] and in Pandis et al. [16] were similar with no statistical difference between the conventional and self-ligating bracket system on the movement of the incisor.
Table 3.Evidence Table of maxillary arch Author/Ye ar Level of Evidence/ Study Design/ Participants/ Inclusion Criteria Intervention and Control Groups Treated with Outcome Measures Archwire Results Atik et al. [13] 2016 Level II NRS Group I : N = 15 3 Male, 12 Female M age = 14.4 ± 1.5 yr Group II: N =15 6 Male, 9 Female M age = 14.4 ± 1.6 yr Group III: N = 16 0 Male, 16 Female M age = 14.8± 1.0 yr Inclusion Criteria: between 13 and 17 years of age at the start of the treatment, past the pubertal growth spurt, with moderate maxillary and mandibular crowding and a Class I malocclusion, and non-extraction treatment .
Group I: 0.022-in Nexus active
self-ligating bracket (Ormco, Orange, Calif) Group II: 0.022-in Roth prescription bracket (Forestadent,
Pforzheim, Germany) Group III: 0.022-in Damon 3MX passive self-ligating appliance system (Ormco/A Company,San Diego, Calif) In all groups, Ormco archwires were sequentially used: 0.014-, 0.018-, 0.014 ×0.025-, and 0.017 × 0.025-in Damon arch form copper-nickel-titanium (35°C), followed by 0.017 ×0.025-in and 0.019 × 0.025-in Damon arch form stainless steel archwires.
No differences were found in terms of maxillary arch dimensional changes in incisor inclination in active self-ligating, passive self-ligating, and conventional brackets used with broad archwires. The results were not statistically significant. Atik et al. [14] 2014 Level II NRS Group I : N = 17 0 male, 17 female M age= 14.5 ± 1.2 yr Group II: N = 16 0 male, 16 female M age= 14.8 ± 1.0 yr Inclusion Criteria: between 13 and 17 years of age at the start of the treatment, moderate maxillary and mandibular crowding, a Class I malocclusion, and a dentally constricted Maxillary arch. Group I : 0.022-inch Roth bracket system (Forestadent,
Pforzheim, Germany) Group II: 0.022-inch Damon 3MX appliance system
(Ormco/A Company, San Diego, Calif).
Group I : 0.014-inch, 0.018-inch copper nickel-titanium (Cu-NiTi; Ormco) and 0.014×0.025-inch, 0.017 × 0.025-inch Cu-NiTi archwires was used, followed by 0.017 × 0.025-inch and 0.019 × 0.025-inch stainless steel (SS; Ormco) archwires. Group II: 0.014-inch, 0.018-0.014-inch, 0.014 ×0.025-inch, and 0.017 × 0.025- inch Maxillary incisor proclination changes were the same between the two groups. The results were not statistically significant.
13
Cu-NiTi,followed by 0.017 × 0.025-inch and 0.019×0.025-inch Damon arch form SS archwires. Pandis et al. [16] 2006 Level II NRS N = 105 36 male 69 female 51 with extractions 54 no extractions M age = 16 yr Inclusion Criteria: no contributory medical history, absence of trauma in the maxillary anterior teeth, no oral habits reported, irregularity index not higher than 4 (in the non-extraction group); minor or no spacing in the maxillary arch (non-extraction group); and no use of class II elastics or other auxiliary or utility during treatment. Similar criteria were used for the extraction group, where the two maxillary first premolars were removed.
half of the extraction and non-extraction cases were treated with a conventional 0.022 in, Roth prescription, edgewise bracket (Microarch, GAC, Bohemia, NY, USA), whereas the remaining received a self-ligating bracket of identical slot size and prescription (12° and 8° of torque for
maxillary central and lateral incisors, respectively) appliance
(Damon2;ORMCO, Glendora, CA, USA)
Arch wire sequence for the non-extraction group consisted of an initial arch wire of 0.014 or 0.016-in NiTi (ORMCO), where applicable, finishing with a 0.019 × 0.025 stainless steel, for both bracket groups. For the extraction group, arch wire sequence included the above-mentioned wires with the addition of the incisors-retracting arch wires, which consisted of a 0.019 × 0.025 NiTi reverse curve of Spee and elastomeric chain, finishing with a 0.019 × 0.025 stainless steel in both groups No statistically Significant effect of extractions or bracket is shown, whereas the interaction term is also insignificant. Thus, the use of different brackets and associated mechanotherapy seems to have no effect on altering the torque of the maxillary incisor.
2. EVALUATION OF INCISOR TORQUE/INCLINATION IN THE
MANDIBULAR ARCH BETWEEN CONVENTIONAL AND SELF-LIGATING
BRACKETS AFTER ORTHODONTIC TREATMENT.
The included studies in the evidence table of mandibular arch (Table 4) were compared regarding the number of participants, treatment methods of the groups, and main results. The mentioned 5 articles were discussing the changes of incisors position on the mandibular arch after orthodontic treatment with conventional brackets and self-ligating brackets.
Over all decrowding can take place by incisor proclination, but this would mean a round trip treatment for the incisors. It would be advantageous to have the decrowding with no or minimal proclination, as this would lead to a lesser amount of incisor retraction during next stage of treatment. The different methods of engaging the wire, the single verses twin bracket design, as well as different bracket dimensions may affect their ability to align teeth. As Prasad et al. [9] have indicated subjects eligible for the study required extraction on the first pre-molar basis and lower anterior crowding discrepancy. A total of 20 participants, subjects main age 14-22, that divided into 2 groups. The groups were treated by: group I- conventional bracket, group II- self-ligating bracket. All groups were using the same bracket slot size and archwire sequences. The results were statistically significant in both the groups; both the groups' cases showed a high degree of proclination during decrowding, the mean change in the Incisor mandibular plane angle (IMPA) in Group-I and Group-II, with p< 0.0001.
In particular, this study was focusing on the amount of crowding and irregularity assessment of the mandibular anterior dentition, mandibular crowding mainly was selected as a model for examining the efficiency of brackets because correction of this discrepancy largely depends on the “free play” or clearance of the archwire inside the slot walls. According to Pandis et al. [10] a total of 54 participants, subjects main age 14 that divided into 2 groups. The groups were treated by: group I- conventional bracket, group II- self-ligating bracket, both groups were using the same bracket slot size but different sizes of archwire sequences. The results of this study suggest that, overall, self -ligating brackets are not more efficient in terms of treatment time required to resolve severe anterior mandibular crowding than conventional appliances. However, moderate crowding was alleviated about 2.7 times faster with self- ligating brackets than with conventional appliances. This difference might be because of the substantially greater free play of the self-ligating appliances, an effect that facilitates undisturbed labial movement of the crown. Incisor inclination: before treatment in
15
conventional system the L1-NB (32.37°) and on the self-ligating L1-NB (33.18). The results of the assessment of mandibular incisor position resulted in an overall significant proclination of the mandibular incisors regardless of bracket type, whereas no difference for incisor position between bracket groups was identified.Multivariate linear regression was used to examine the effect of the bracket system on arch width or lower incisor inclination adjusting for the confounding effect of demographic and clinical characteristics. In fact, according to Pandis et al. [17] non- extraction treatment in the mandibular arch was indicated compared to previous findings. A total of 54 participants, subjects main age 13.5-15, that divided into 2 groups. The groups were treated by: group I- conventional bracket, group II – self-ligating bracket. Both groups were using the same bracket slot size but different sizes of archwire sequences. incisor inclination: before treatment in conventional system the L1-NB (25.00±5.5°) and on the self-ligating L1-NB (25.4±6.3°), after treatment in conventional system the L1-NB (30.7±5.5°) and on the self-ligating L1-NB (29.3±6.3°).The results showed an overall increase in the proclination of the mandibular incisors associated with alleviation of crowding for both bracket groups; no difference was found between self-ligating and conventional brackets with respect to this parameter at the end of orthodontic treatment. Overall the results were not statistically significant.
Reported that self-ligating brackets are no more efficient than conventional brackets for anterior alignment or passive extraction space closure in the mandibular arch during the first 20 weeks. The ideal alignment procedure would involve slight incisor proclination and inter-canine expansion but a considerable inter-molar expansion, which is important for long-term stability. Along with the previous study findings, can be seen similar outcomes on incisors proclination, it can be evaluated according to Celikoglu et al. [20] a total 46 participants, subjects main age 14.5-18, which divided into 2 groups. The groups were treated by: group I- self-ligating bracket, group II -conventional bracket, both groups used the same types of brackets slots along with standardized archwire sequence. Incisor inclination: before treatment in conventional system the L1-NB (24.7±7.01°, 5.36±4.33 mm) and on the self-ligating L1-NB (24.77±6.80°, 5.35±4.91 mm), after treatment in conventional system the L1-NB (5.44±3.13°, 0.56±4.26 mm) and on the self-ligating L1-NB (5.03±5.37°, 0.80±3.93 mm). The results show similar effectiveness for initial mandibular alignment. The mandibular incisors were significantly proclined (p < 0.001), but their position did not significantly change in both the groups.
The amount of crowding alleviated during treatment also influenced both angular and linear changes of the mandibular incisors. Typical changes involve an increase in arch perimeter caused by incisor advancement and transverse expansion. This can be evaluated by Fleming et al. [22], a total of 60 participants, subjects main age 16 that divided into 2 groups. The groups were treated by: group I- conventional bracket, group II – self-ligating bracket, both groups were using the same bracket slot size but different sizes of archwire sequences. Analysis of covariance (ANCOVA) allowed comparison of the effect of the 2 bracket systems on mandibular incisor inclination changes and mandibular transverse dimensional changes between the 2 groups. Incisor inclination: before treatment in conventional system the L1-NB (90.11°) and on the self-ligating L1-NB (91.8°), after treatment in conventional system the L1-NB (94.43°) and on the self-ligating L1-NB (96.21°). The level of statistical significance was set at P <0.05. The results were not statistically significant between malocclusion classification and the outcomes of interest: incisor proclination (P = 0.412), linear advancement of the incisors (P = 0.12), There were a statistically significant association between the pretreatment scores for incisor inclination and transverse changes and increases in their respective scores, with less proclination likely when the mandibular incisors were at a higher angle initially and less transverse increase likely in wider arches. Baseline differences in pretreatment scores for mandibular incisor inclination influenced inclination changes (P = 0.044). In conclusion mandibular arch alignment and leveling resulted in transverse expansion and incisor proclination irrespective of the appliance system used.
In summary all the articles were discussing on incisor inclination after orthodontic treatment on the mandibular arch with conventional and self-ligating bracket system, the total amount of participants were in: Prasad et al. [9] - 20 participants
,
Pandis et al. [10] - 54 participants, Pandis et al. [17]-54 participants, Celikoglu et al. [20] - 46 participants and in Fleming et al. [22] - 60 participants. The main age was in: Prasad et al. [9]
-
14-22 years,
Pandis et al. [10] - 14 years, Pandis et al. [17] -13.5-15 years, Celikoglu et al. [20] - 14.5-18 yearsand in
Fleming et al. [22]- 16 years. The groups division and duration of treatment time were in: Prasad et al. [9] divided into 2 groups. The groups were treated by: group I- conventional bracket, group II- self-ligating bracket and their duration of treatment time was from1-70 days, Pandis et al. [10] divided into 2 groups. The groups were treated by: group I- conventional bracket along with 114 days of treatment time, group II- self-ligating bracket along with 91 days of treatment time, Pandis et al. [17] divided into 2 groups. The groups were treated by: group I- conventional bracket, group II – self-ligating bracket and in both groups the treatment duration were4-8 weeks, Celikoglu et al. [20] divided into 2 groups. The17
groups the treatment duration were 8-16 weeks, Fleming et al. [22] divided into 2 groups. The groups were treated by: group I- conventional bracket, group II – self-ligating bracket and in both groups the treatment duration were 1-30 weeks. Moreover in all the studies as Prasad et al. [9], Pandis et al. [10 ,17],
Celikoglu et al. [20] and in Fleming et al. [22] all the final archwire that was used in order to align the teeth and dental arch were different from each other in their size and type. In all the studies as Prasad et al. [9], Pandis et al. [10 ,17],
Celikoglu et al. [20] and in Fleming et al. [22] all the cephalometric radiographs and dental cast models were measuring the incisor inclination by degrees and millimeters of the angle L1-NB , as well as all the changes in arch were measured by digital caliper from dental study casts that were taken by digitally traced using Quick Ceph Studio software(Quick Ceph Systems, San Diego, Calif).Additionally in Pandis et al. [10] and Pandis et al. [17] in order to assess intraexaminar reliability, 8 plaster models and 8 cephalometric radiographs were used as well as angular measurements of pretreatment (T0) and post-treatment (T1) of all the patients. Compared in Celikoglu et al. [20] were used 15 randomly selected patients and in Fleming et al. [22] were used 20 randomly selected radiographs and pairs of models. The result shows a statistically significant increase according to Prasad et al. [9] and Pandis et al. [10] but not for specific group of bracket system, also increase in proclination of incisor according Pandis et al. [17, Celikoglu et al. [20] and in Fleming et al. [22] but they are not statistically significant.Table 4.Evidence Tables of Mandibular arch Author/Year Level of Evidence/ Study Design/ Participants/ Inclusion Criteria Intervention and Control Groups Treated with Outcome Measures Archwire Results Prasad et al. [9] 2011 Level II NRS Group I : N = 10 5 male, 5 female M age= 14-22 yr Group II: N = 10 5 male, 5 female M age= 14-22 yr Inclusion Criteria: in the mandibular arch, were in the permanent dentition, had lower anterior crowding discrepancy from 5to 7 (According to Little’s Index), with no or mild proclination
.
Group I: had the lower arch bonded with conventional 0.022 inch 3M Gemini series MBT prescription brackets (3M/Unitek, Monrovia, CA, USA)
Group II: had the lower arc bonded with 0.022 inch. Smart clip MBT prescription brackets (3M/Unitek, Monrovia, CA, USA).
For both groups 0.014
inch copper NiTi wire (ORMCO Glendora, CA, USA) as initial wire for leveling and aligning followed by 16 inch copper & NiTi 16 X 22 inch copper NiTi.
the mean change in the Incisor mandibular plane angle (IMPA) in Group-I &Group-II, with p< 0.0001, was statistically significant in both the groups, i.e. both the Groups cases showed a high degree of proclination during decrowding. Pandis et al. [10] 2007 Level II NRS Group I : N = 27 26% male,74% female M age= 14 yr Group II: N = 27 15% male, 85% female M age= 13.5 yr Inclusion Criteria: Non-extraction treatment on the mandibular or maxillary arches, eruption of all mandibular teeth, no spaces in the mandibular arch, mandibular irregularity index greater than 2; and no therapeutic intervention planned involving inter maxillary or other intraoral or extra oral appliances including elastics, lip bumpers, maxillary expansion
Group I: conventional edgewise group was bonded with
the Roth
prescription, 0.0.22-in slot (Microarch, GAC,
Central Islip, NY). Group II:
Self-ligating group received the low-incisor torque version of the Damon 2, 0.022-in slot, appliance (Ormco, Glendora, Calif). Group I: 0.016-in copper-Ni-Ti (Cu-copper-Ni-Ti) 35°C (Ormco) ligated mainly with elastics, followed by a 0.020-in medium Sentalloy archwire (GAC) ligated with elastics. Group II: 0.014-in Cu-Ni-Ti Damon (Ormco) and0.014 ×0.025-in Cu-Ni-Ti Damon (Ormco). There was an overall increase in the proclination of the mandibular incisors associated with crowding correction in both bracket groups; no difference was identified between Damon 2 and conventional Brackets for this parameter.
19
headgear. Pandis et al [17] 2010 Level II NRS Group I : N = 27 7 Male, 20 Female M age = 13.9 ± 1.4 yr Group II: N =27 4 Male, 23 Female M age = 13.6 ± 1.4 yr Inclusion Criteria: Non extraction treatment in the mandibular and maxillary arches; eruption of all mandibular teeth; no spaces in the mandibular arch; mandibular irregularity index greater than 2 mm; and no adjunct therapeuticintervention involving lip bumpers, maxillary expansion appliances, or headgear.
Group I: conventional edgewise group was bonded with the Roth prescription, 0.022 inch slot,
(Microarch; GAC, Central Islip, New York, USA)
-self Group II: ligating group received the low-incisor torque version of the Damon2, 0.022 inch slot appliances (Ormco, Glendora, California, USA) Group I: Archwire sequence was in most cases 0.016 inch CuNiTi 35°C (Ormco) ligated mainly with elastics and followed by a 0.020 inch medium Sentalloy archwire (GAC), 0.020 inch, and 0.018 × 0.025 inch stainless steel ligated with elastics Group II: archwire sequence involved a 0.014 inch CuNiTi Damon (Ormco) and 0.014 × 0.025 inch CuNiTi Damon (Ormco) and 0.016 × 0.025 inch stainless steel adapted to the dental archform. There was an overall increase in the proclination of the mandibular incisors associated with alleviation of crowding
for both bracket groups; no difference was found between self-ligating and conventional brackets with respect to this parameter at the end of orthodontic treatment.
The results were not statistically significant. Celikoglu et al. [20] 2015 Level I RCT Group I : N = 22 17 male, 5 female M age= 15.4± 2.5yr Group II: N = 24 18 male, 6 female M age= 14.6 ± 2.0 yr Inclusion Criteria: (1) Skeletal Class I malocclusion (0o < ANB angle [the angle between Nasion-A point line and Nasion-B point line] < 4o and overjet within 2−4 mm); (2) permanent dentition; (3) non-extraction treatment of
In both groups both types of brackets (0.022-inch slot) were bonded to all the teeth between the mandibular first molars by using Transbond XT (3M Unitek). 0.014- inch round heat-activated nickel-titanium archwire (3M Unitek) for 8 weeks and 0.016-inch round heat-activated nickel-titanium archwire (3M Unitek) up to 16 weeks. The mandibular incisors were significantly proclined (p < 0.001), but their position did not significantly change in both the groups. SmartClip self-ligating and conventional brackets have similar effectiveness for initial mandibular alignment.
the mandibular arch in patients aged 12−18 years; and (4) over 3-mm irregularity in the mandibular anterior region. Fleming et al [22] 2009 Level I RCT Group I : N = 31 8 male, 23 female M age= 16 yr Group II: N = 29 13 male, 16 female M age= 16 yr Inclusion Criteria: Subjects eligible for the study were aged between 11 and 21 years who required treatment with fixed appliances on a non-extraction basis in the mandibular arch, were in the permanent dentition, had mild mandibular incisor crowding, and had study models and lateral cephalograms taken not more than 1 month before placement of the mandibular appliance. Self-ligating pre-adjusted edgewise brackets or conventional pre-adjusted edgewise brackets
with MBT values for tip and torque and a 0.022-in slot
were placed in either group according to the random allocation. Standard archwire sequence (016-in round, .017 × .025-in rectangular. 019 × .025-in rectangular martensitic active nickel-titanium alloys [3M Unitek], and .019 × .025-in stainless steel) was used in all subjects There was a statistically significant association between the pretreatment scores for incisor inclination and transverse changes and increases in their respective scores, with less proclination likely when the mandibular incisors were at a higher angle initially and less transverse increase likely in wider arches. Baseline differences in pretreatment scores for mandibular incisor inclination influenced inclination changes (P= 0.044).
21
DISCUSSION
Our hypothesis was that self-ligating brackets are more effective than conventional brackets in a comparison between incisor inclination on the maxillary and mandibular arches. Several retrospectives and prospective in‑vivo studies have compared the efficiency of self-ligating and conventional brackets during various stages of treatment, reporting no significant differences in initial alignment. These bracket systems differ with respect to clip properties, wire types, and sequences [1, 13] as well as in treatment time interval, chair appointments, patient comfort and cost of the bracket system.
They are also potentially biased, despite apparent matching, as there are many uncontrolled factors which may affect the outcome, such as: operator experience, a different type of archwires, altered archwire sequence, and different appointment intervals. Years of constant trial and clinical experimentation has led the orthodontic professional to realize that the probable answer to efficient decrowding lies in a fine tuned bracket system, one that could do away with the need to utilize conventional ligating methods. This viewpoint laid the foundation for the birth of self-Ligating bracket system. [9]
In some clinical studies as Pandis et al. [10, 17] and Celikoglu et al. [20] were found that increase in the proclination of the mandibular incisor associated with alleviation of crowding for both bracket groups, however, no difference were identified between the conventional and self- ligating bracket groups on initial alignment. The other factors that can influence the treatment of a crowded dental arch on a non-extraction basis, are supported by Fleming et al. [22], without tooth size reduction, requires an increase in the arch perimeter to allow resolution of crowding and achievement of optimum arch alignment and leveling. Without active distal movement, changes typically involve both transverse expansion and proclination. The nature and magnitude of these arch dimensional changes have implications for long-term stability.
The results of Atik et al. [13, 14] are not in agreement with a recent clinical investigation, mainly no differences were found in terms of maxillary arch dimensional changes in incisor inclination between conventional and self-ligating bracket groups with broad archwires.
Recently, expansion of dental arches by means of self-ligating brackets and broader superelastic archwires has become an issue. On the basis of this idea, conventional and self-ligating brackets have been compared regarding maxillary dentoalveolar expansion in several studies. Only one study employed a rapid maxillary expansion appliance before straight wire mechanics in the conventional bracket group.
This is particularly important with a treatment of patients with an ethnic background other than Caucasian, where significant variations apply to soft-tissue, lip posture, tooth morphology and crown spatial orientation relative to norms derived from Caucasians. Furthermore, the highly individual variability of torque has been noted by a study, which reported the variation of torque with age in the same population, thus introducing a variable, which if not weighted in both populations, may complicate the extrapolation of conclusions on relevant research. Despite the presentation of much empirical and anecdotal evidence, no documented evidence exists on the manufacturers claims on the efficiency of self-ligating brackets in both, space closure and torque control. Combining the findings in this particular study, Pandis et al. [16] found that different brackets and associated mechanotherapy seem to have no effect on alerting the torque of the incisors along with no statistically significant effect were demonstrated.
The main advantages of the self-ligating bracket system include increased patient comfort due to the absence of ligatures, improved oral hygiene, less chair time and shorter overall treatment time. Despite all the advantages of Self-ligating brackets, they have some notable disadvantages including the difficulty of archwire insertion on rotated teeth, difficulty with the full expression of torque, frequent failure of the clips, disengaging of rectangular archwires, and increased discomfort during archwire insertion and removal. Clinicians should, therefore, consider the cost of these systems and their assumed advantages [1, 20] .Even though this hypothesis has been disputed; there is a possibility that proclined incisors retained with a fixed bonded appliance for long periods of time may predispose to attachment loss. Investigations, which rejected the involvement of incisor proclination in recession, did not consider the presence of a bonded appliance on the proclined teeth for long periods of time as in the case of fixed retention, which is usually advocated following correction of crowding. This factor may differentiate the effect of proclination, potentially inflicting additional changes in the periodontium [17]. However, the results in the literature do not provide a clear comparison of these bracket systems in terms of arch width and incisor and molar inclinations because different archwire types and sequences are used in each system [13].
This investigation has shown that in the sample investigated, the self-ligating system was no more clinically effective than a conventional appliance during the alignment phase of orthodontic treatment [5].
As opposed to our investigation of the dental incisors, in fact were found high significant difference noted between groups an increase in mandibular intermolar width in the sample treated with self-ligating brackets [25], according to Pandis et al. [17] whereas intermolar width was found to increase approximately 2.4 mm in the self- ligating compared with 1mm in the conventional bracket group (p< 0.5), Similar findings was found also in Pandis et al. [10].
23
Incisor inclination during initial alignment was significantly influenced by the bracket system with self-ligating brackets resulting in significantly lesser incisor proclination. The results suggest that conventional appliances resolve crowding more through an incisor proclination while self-ligating brackets relieve crowding by facilitating more passive space closure. This phenomenon with self-ligating brackets would help in preventing the torque loss during the initial alignment, prevent round tripping of the anterior teeth, thus minimizing root resorption and would greatly minimize the effective anchorage loss during the overall treatment time of an individual [1]. The results of this study by Prasad et al. [9] are not in agreement with a recent clinical investigation. Because of the complexity of the experimental configuration, there have been only small studies of torque expression until now, and numeric analyses have not been carried out for torque expression in various bracket-archwire combinations [5]. Furthermore, Arch wires tend to retain their normal shape. They are also made of materials activated by body heat to increase stiffness. When it is activated by the heat of the mouth which is 20-25° above room temperature, its desire to remain straight provides the forces necessary to get the biomechanical process of bone remodeling to begin and continue. The solid wires which come later are made of a nickel-titanium alloy and while so flexible, once activated by body heat becomes quite stiff.As seen in
Atik et al. [13 ,14] and Pandis et al. [16] the final archwire that was used in order to align the teeth and dental arch were 0.019 × 0.025 in Damon arch form stainless steel. Despite previous studies ,in this particular studies as Prasad et al. [9],
Pandis et al. [10 ,17],
Celikoglu et al. [20] and inFleming et al. [22] all the final archwire that was used in order to align the teeth and dental arch were different from each other in their size and their types this can affect the torque of the teeth and the final outcome.In this particular systematic review, we didn’t evaluate the period of treatment time along with particular self-ligating bracket system moreover different tooth sample as canine, pre-molar and molar.
For the next study, more researches must be performed due to limited number of literature list of studies on the performance of self-ligating brackets, of which even fewer satisfy the criteria of a prospective trial and none that of a randomized clinical trial. Currently, there is a lack of evidence derived from prospective clinical trials on the performance of self-ligating brackets as it relates to the transmission of torque [16].
This study showed relatively short-term outcomes. Therefore, prospective randomized clinical trials of long-term irregularity correction and transversal effects of both bracket types are warranted [20].
In the future, some trails can evaluate the following factors: conduct a clinical trial of comparison between the self-ligating and conventional bracket system that would help practitioners identify the strengths and limitations of the systems and the information gained would be a valuable tool in patient selection.
The study could have been improved by eliminating as many differences as possible between the two samples, for example, it would be ideal to have the same manufacturer and slot size utilized in both samples. Studies have been done that examine the mandibular arch only, but more studies with large sample sizes are needed that analyze both arches [25]. Furthermore in the future study can be an increase in the number of participants as well as their age for further investigation.
25
CONCLUSIONS
Our hypothesis was rejected due to findings that implied:
1. Evaluating the changes of incisors torque/inclination on the maxillary arch between conventional and self-ligating brackets after orthodontic treatment the finding suggest that no statistical difference was found between the self-ligating system over the conventional bracket system on the movement of the incisor teeth.
2. Simultaneously after evaluating the changes of incisors torque/inclination in the mandibular arch between conventional and self-ligating brackets after orthodontic treatment the finding suggest overall increase in proclination of the mandibular incisors regardless of bracket type, where no statistical difference was identified after treatment between the conventional and self-ligating bracket groups.
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