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I would like to know your opinion regarding the Lotus Passive Self Ligating Brackets from Ortho Technology. I will be pleased to hear from you.

Dr. Takreem Rehman
India

Dear Dr. Takreeem Rehman,
 
I am very sorry. I am currently not acquainted with this brand of self-ligating brackets. 
 
As time goes by, more and more companies are seeing the advantages of self-ligating brackets, and are introducing many variations. I have not had the opportunity to try this bracket. 
 
Thank you for your question.
 
Regards,
Michael C. Alpern, DDS, MS

Do you think a passive or active self-ligating bracket is better and why?

W. Keith Harvey, DMD, PC
Mobile, Ala

Dear Dr. Keith Harvey,

The subject of active or passive has degenerated down to marketing. What seems to be lost in the question is "evidence-based knowledge."

I have found that truth is not a word game. Orthodontic brackets interact with orthodontic arch wires. This interaction moves teeth. Therefore, at some point in time the main archwire has to have some contact with the bracket slot. Thus, no bracket system should be labeled "passive" or even "active."

"Interactive" is a more accurate term. Depending on the size and shape of the orthodontic wires and the bracket slot's design, sometimes there is an active relationship between the wire and the bracket, causing tooth movement. Conversely, sometimes the wire and the bracket have achieved the desired tooth movement and a "passive" state exists between the two.

Orthodontic biomechanics requires tooth movement sometimes, and no tooth movement at other times. The key here is CONTROL. I have written about "control" in several articles including, "Gaining Control of Self-ligation" published in Seminars in Orthodontics, Volume 14, No 1, March 2008, pages 73-86. I have also published, "Complete Control" in Orthodontic Products. The AAO library and Orthodontic Products should be able to supply you with copies.

In my mind, orthodontic mechanotherapy requires that we have control of tooth movement. Therefore, sometimes my systems are active and sometimes passive, but mostly they are interactive. All wire-bracket contact occurs with as much control between the archwire's size (and metallurgy) and a correctly manufactured self-ligating bracket with exact corner radius tolerance of the interior walls of the bracket slot as possible.

Michael C. Alpern, DDS, MS

Comparing overall performance combined with pricing, what self-ligating system would you recommend?

Joseph Porter
Baton Rouge, LA

Dear Dr. Porter, 
 
Thank you for your question. I will answer with a brief introduction of the philosophy I use towards all self-ligating brackets.  
 
I regard self-ligating brackets as an additional, advanced component to my existing orthodontic mechanotherapy. In my practice, I place nearly every single wire. In the past, I have permitted my assistants to steel-tie brackets, with me checking the patient before discharging them. Full steel-tying every bracket is labor-intensive and varies based on who is tying the metal ties. If the archwire is not fully engaged into the bracket slot, then full correction does not occur. Steel ties can come loose, trap food, and are often uncomfortable.  And changing upper and lower archwires with each bracket steel-tied takes time. More importantly, each time a ligature wire crosses the archwire, there are two points of friction.  Thus, one steel tie creates four points of significant friction to sliding and other movements. 
 
If a self-ligating bracket has a steel, alloy or titanium spring closing clip, now for the first time, I can have spring-flex in the wire and spring-flex in the closing clip. Depending on the design, some closing clips have a bracket stop to closing. You might want to research my article, "Gaining Control of Self-Ligation," published in the March 2008 (Vol 14, No 1) issue of Seminars in Orthodontics.
 
I have used Speed, Innovation R & C, and American Orthodontics T3. All appear to have a flexible, spring clip. Advantages: 1) Saves time in changing archwires. One example for me is during my afternoon, after-school "observation appointments." How many times during this time have you wanted to slide an existing arch partially out of the molar tubes, make adjustments and reseat the archwire? It takes me less than 3 to 5 minutes to open 4 to 6 brackets, slide the archwire partially out, make adjustments, and re-seat. 
 
If patients floss every tooth every night and maintain a good diet, teeth appear to move faster when there is less friction. Under the correct circumstances, self-ligating brackets can shorten treatment time. However, with poor oral hygiene and no flossing and poor nutrition, self-ligating brackets are no more effective at tooth movement than any bracket.
 
Patients who develop significant calculus (even with dental cleaning every 3 months) can present challenges to self-ligating brackets. Calculus can adhere to the sliding, closing clips of self-ligating brackets. Thus, normal opening may not be possible. We have three cavitrons in our office and use them to open self-ligating brackets that are immovable due to calculus.  There are initial studies in the literature to determine if self-ligating brackets collect more or differing bacteria. Time will illuminate this potential problem.
 
Self-ligating brackets do cost more. However, after 8 to 10 years of using them, all I have to do is have a transfer patient who came in with steel-tie ligatures and steel-tie in one upper and lower archwire, and I am convinced that self-ligating brackets are my future.
 
Your question is which brand would I recommend. I would try 20 cases of differing brackets and see which system you find the most efficient. How easy is it to open and close the clip? Do the clear systems break too easily? The reason for my hesitancy to name a brand and recommend that brand is "technology."  Many companies have significant efforts directed toward improving and innovating self-ligating brackets. 

A good friend of mine always said, "If you quote me, date me."
 
Regards,
Michael C. Alpern, DDS, MS

What are the significant differences and advantages among self-ligating brackets as compared to other bracket systems like straightwire brackets?

Romabel Asaytuno
Manila, Philippines

Dear Dr. Romabel Asaytuno,
 
Thank you for your question.
 
As I understand your question, you would like to know the significant difference and advantages of self-ligating brackets compared to other straightwire bracket systems.
 
The self-ligating systems I have used are all straightwire bracket systems. The primary difference for me is I do not have to use stainless steel ligatures to secure the main archwire to each bracket. For more than 20 years, I primarily used stainless steel ligatures ties, all twisted into pigtails and cut to approximately 2 to 3 mm long. These stainless steel ligatures were labor-intensive and how snugly they were tied to the bracket slot varied as to whether I tied them or a certified orthodontic assistant tied them. 
 
The main problem with steel ligature ties is friction. Each stainless steel ligature crosses the main archwire two times (mesial and distal of each bracket). As each portion of the ligature crosses the main archwire, there are two friction contacts. One friction contact is where the wires cross the incisal edge of the archwire and the second friction contact is at the gingival edge of the archwire. These friction contacts limited sliding mechanics. Also, stainless steel ligatures have almost no elasticity, further limiting sliding mechanics. 
 
The self-ligating brackets I have used all have a flexible closing clip which replaces the stainless steel ligatures. Thus, there is less limitation to sliding mechanics. The self-ligating brackets I have used all have a closing clip stop on the bracket design. Thus, once the closing clip contacts the stop on the bracket—in the correct-sized wire—the closing clip does not touch the main archwire. Most importantly, in the wire sequence I use, the closing clip is sometimes active (seating the wire fully into the bracket slot), and sometimes passive. In a passive situation, the main archwire is seated (producing full 3D tooth-positioning control), yet the main archwire does not contact the closing clip. 

I have published two articles on this technique. One, published in Orthodontic Products, is entitled "Complete Control."  The other was published in the March 2008 (issue Vol 14, No 1) of Seminars in Orthodontics, pages 73-86, published by Elsevier. These two articles more completely and visually explain these advantages. 
 
Another advantage of self-ligating brackets is the time savings in changing maxillary and mandibular archwires. Time is also saved when making small intraoral archwire adjustments. I open the closing clips adjacent to the adjustment bends I plan to make in the archwire. Then, I make the adjustments (without breaking the brackets off the teeth) and efficiently re-close the flexible bracket clips.  
 
In my treatment regimen, I begin using Nickel and Beta Titanium wires (all .018 x .018 in a .018 slot size). Thus, I fill the bracket slot vertically, gaining control for the initial wires. The forces applied to the teeth are light, individualized forces. Because the closing clips and wires are flexible, I postulate that I am using lighter, continuous forces, achieving more rapid tooth movement in a safe manner. 
 
There are disadvantages to ligature-less brackets. They do cost more. However, to me, the time savings (mentioned above) and reduced sliding friction make up for the increased cost. 
 
The self-ligating brackets I use seem to collect slightly more calculus. There are initial studies indicating that slightly more and/or differing types of bacteria collect around these brackets. We try to stress to patients that more rigid oral hygiene is required. In a significant number of adults, their calculus adheres not just to the teeth and the bracket base, but also to the sliding mechanisms of the closing and opening clips. We have found a significant number of patients require a Cavitron to remove the calculus and open the flexible clip. The ultrasonic cavitation of these cleaners also tends to help clean the slots which the closing clip must slide through in order to function. 
 
I have used self-ligating brackets for nearly 10 years. These brackets have not changed my basic treatment philosophy. In spite of the disadvantages and cost, I think they will continue to be more common in orthodontic practices. Innovations in self-ligation will continue to make these brackets part of our future.  
 
Thank you for your question. 
 
Regards, 
Michael C. Alpern, DDS, MS

I have been using the Innovation bracket for several months now. From my reading, I understand that you close extraction spaces in the .018 x .018 Bioforce wire.

Is this correct? If so, how do you control unwanted tipping forces? Thanks for your time.

David Christiansen
Provo, UT

Dear Dr. Christiansen,
 
Thank you for your question.
 
I assume you are using the Innovation brackets in the .018 slot. If that is correct, then I do use the .018 x .018 BioForce with Ion Guard wire in the AccuArch form. BioForce is temperature-sensitive with individual forces from the incisors to the molars. Ion Guard is a special ionic bombardment of the BioForce wire to make the surface very smooth and further reduce friction.
 
To answer your question, I slide onto the main archwire, custom-cut sections of stainless .051 steel tubing in the extraction sites. This tubing is cut to be a total of approximately 3 mm from the mesial and distal abutment teeth. It is important to note the total reduction is 3 mm from abutment teeth. This steel tubing is usually approximately 1-1.5 mm from each abutment tooth. As space closes, the steel tubing slides with the teeth. The steel tubing does not interfere with sliding mechanics, yet it prevents the BioForce wire from causing unwanted tipping movements.
 
I see patients every 5 to 6 weeks. At each appointment, we quickly open the self-ligating brackets, slide the steel tubing off the archwire, and reduce the tubing length by approximately 2 to 3 mm. Once the steel tubing is reduced, we slide it back on the archwire and close the bracket closing clips. This technique permits good control of abutment teeth in space closure, yet the lack of friction also permits rapid and safe space closure. I especially use this in extraction of first molars. The tubing ensures no tipping and also prevents patients from biting on hard food which could force the BioForce wire out of the second molar tubes and into the gingiva.  
 
I purchase this steel tubing from Summit Orthodontics (800-321-9124). The order number is 076-050. One container contains enough tubing to last a long time. 
 
In my hands, we close extraction spaces with Dentsply Glenroe Ultra Slide Elastomeric chain in the "open" design. This chain tends to retain the elasticity for 6 to 8 weeks. 
 
If you are using the .022 slot, then the same size tubing works using a .020 x .020 BioForce wire with Ion Guard in the large AccuArch form. 
 
I hope this clearly answers your question. If you have additional questions, please e-mail me. 
 
Regards, 
Michael C. Alpern, DDS, MS