by T. Richard Ziehmer, DDS, MSD
From the beginning of time, humans have always
tried to find a better way to do just about anything.
Orthodontics is no different, particularly when it
comes to the endless search for ways to reduce
treatment and appointment times, and avoid the removal of teeth.
Building a better mousetrap
Self-ligating braces are one of the most recent attempts to accomplish all of these. Orthodontic literature is replete with articles addressing self-ligating versus conventional-ligating bracket systems, and investigating whether one offers a superior advantage. While some clinicians have observed that self-ligating brackets afford them shorter treatment times and the ability to avoid extractions,1 the majority of the literature concludes that no differences exist,2, 3 and some even show conventional ligating brackets to be superior.4
So why might some clinicians choose to pay significantly higher fees for a bracket when there's not a clear advantage? No matter where you practice, you've likely encountered patients or parents inquiring as to whether you use self-ligating brackets. Maybe they recently saw an ad touting superior results from a self-ligating bracket. Maybe a friend of theirs started treatment with an orthodontist who conveyed a similar message.
Regardless of the scenario, if potential patients believe that they can have treatment done more quickly and with fewer visits to the orthodontist, and they can avoid extractions, what's not to like—and why wouldn't they seek out doctors who use such systems?
The surprising case study
When I opened my practice in 2007, I chose an active self-ligating bracket system, but within a year had succumbed to the constant marketing and complimentary weekend course from one of the passive self-ligating companies, and made the switch. When it came time for the big order in year three, I decided to go back to a conventional twin bracket—I really hadn't consistently observed any profound advantages with self-ligating brackets and didn't want to continue paying exorbitant amounts of money for a door on a bracket. Two years later when I was in St. Louis for ABO recertification, I made a very interesting observation.
Of the six cases I submitted, four of them were treated with passive self-ligating brackets, one with active self-ligating and one with conventional twin brackets. All cases graded out very well according to ABO standards, and I was awarded another 10 years of certification.
During my first six years of practice and utilizing all three systems, I observed the following: Self-ligating brackets (active or passive) were less time-consuming for wire change appointments, but my staff and I frequently struggled with doors opening properly, especially in adult patients with calculus accumulation in the lower anterior region.
Rotation control seemed easier to achieve with active self-ligating brackets than passive, but conventional twin appeared to be superior to either of the above. I had not found any ascertainable difference between the three when it came to the rate of space closure. When unraveling a crowded arch without extractions, passive and active self-ligating brackets seemed to provide alignment more quickly and with less flaring of the incisors than conventional twin brackets. Arch expansion appeared greatest with passive self-ligating.
Without a doubt, finishing was most efficient in my hands (less wire bending/fewer appointments) with conventional twin and active self-ligating brackets. I had become a great wire bender in trying to finish my passive self-ligating cases! (I know, I know, I didn't position the brackets properly.) These are my own observations, and are not backed up by sound scientific data.
Conclusion
In my quest to determine if bracket
type is predictive of a particular outcome—in this case, a good or bad finish—I can only conclude that it is probably not. All brackets straighten teeth! Earth-shattering, I know…but if you render a proper diagnosis, start treatment at the appropriate time, and patient compliance is good, the case will finish nicely regardless of what bracket you choose.
I have observed great and poor finishes in my own practice with all three types of appliances. I have observed doctors who utilize only passive self-ligating brackets still achieve consistently great results. I have observed the same with doctors limited to active self-ligating and conventional twin. Despite seeing great results with both passive and active self-ligating brackets, I currently utilize a conventional twin bracket. In my hands they consistently give me the most predictable results in the shortest amount of time.
I found no winners or losers when it comes to brackets and bracket systems. What's more important than the type of bracket system you employ in your practice is your consistency of use. Choose a bracket and a system that works for you and stick to it. The more you utilize any of the bracket systems, the more proficient you will be.
In an industry that has become ultra-competitive, it's only natural that we would all try to gain an edge. If you feel you are in a market where all of your competitors are using one of these self-ligating systems and you have to as well in order to be competitive, I suggest you re-evaluate your other systems. The type of bracket system you use should not define your practice!
References
- Prettyman C, Best AM, Lindauer SJ, Tufekci E. Self-Ligating vs. Conventional Brackets as Perceived by Orthodontists. Angle Orthod 2012; 82: 1060-1066.
- Fleming PS, O'Brien K. Self-Ligating Brackets Do Not Increase Treatment Efficiency. Am J Orthod Dentofacial Orthop 2013; 143: 11-19.
- Ong E, McCallum H, Griffin MP, Ho C. Efficiency of Self-Ligating vs. Conventionally Ligated Brackets During Initial Alignment. Am J Orthod Dentofacial Orthop 2010; 138: 138e1-138e7.
- Songra G, Clover M, Atack NE, Ewings P, Sherriff M, Sandy JR, Ireland AJ. Comparative Assessment of Alignment Efficiency and Space Closure of Active and Passive Self-Ligating vs. Conventional Appliances in Adolescents: A Single-Center Randomized Controlled Trial. Am J Orthod Dentofacial Orthop 2014; 145:569-78.
Dr. T. Richard Ziehmer is a board-certified orthodontic specialist practicing in Tucson, Arizona. He’s a proud member of the Pro Ortho Study Group, and the American Association of Orthodontists, and is a diplomate of the American Board of Orthodontics.
|