To cite this article: Malik DES, et al.

Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
International Orthodontics 2019; //: ///

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

Systematic review and meta-analysis

Comparison of anchorage loss between
conventional and self-ligating brackets
during canine retraction – A systematic
review and meta-analysis

Durr E. Shahwar Malik, Mubassar Fida, Erum Afzal, Sarah Irfan

Available online: The Aga Khan University Hospital, Department of Surgery, Section of Dentistry, P.O
Box 3500, Stadium Road, Karachi 74800, Pakistan

Correspondence:
Mubassar Fida, The Aga Khan University Hospital, Department of Surgery, Section of
Dentistry, P.O Box 3500, Stadium Road, Karachi 74800, Pakistan.
mubassar.fida@aku.edu

Keywords Summary
Anchorage
Conventional brackets Introduction > Anchorage is defined as the resistance to unwanted tooth movement. In orthodon-
Self-ligating brackets tics, loss of anchorage can be detrimental to treatment. The proponents of orthodontic self-ligating
Canine retraction brackets (SLB) advocate the use of extremely light forces thereby reducing anchorage burden.
Therefore, the aim of this study was to compare anchorage loss during canine retraction between
conventional brackets (CB) and self-ligating brackets.
Methods > An electronic search was conducted on the Cochrane database, Scopus, Web of Science,
PubMed, Dental & Oral Science and CINAHL, along with handsearching Google Scholar and
clinicaltrials.gov. Randomized or non-randomized clinical trials published in the English language
on human subjects were included. Orthodontic patients undergoing canine retraction after
premolar extraction bonded with self-ligating brackets as the intervention and conventional
brackets as the control group in a split mouth design were included. Primary outcome studied
was anchorage loss; secondary outcomes were retraction velocity and total amount of canine
retraction. Two researchers carried out data extraction and study selection independently. The risk
of bias was calculated using the Cochrane's Risk of Bias Assessment tool. The RevMan software was
used for quantitative synthesis of data. Effect estimate of the primary and secondary outcomes
was expressed using weighted mean difference and 95% confidence intervals (CIs). Heterogeneity
of the studies was evaluated using the Cochrane's test for heterogeneity (I2 Test); subgroup and
sensitivity analyses were performed to investigate sources of heterogeneity among the studies.
Results > Results of the literature search across all databases yielded 10,439 hits, out of which five
studies were included in the qualitative synthesis that met the inclusion criteria. Four studies were
randomized control trials (RCTs) where as one was a non-randomized control trial, with 100 sub-
jects included in this systematic review. All studies used a split mouth design. Of the five studies
included, only one reported significant differences between CB and SLB for anchorage loss,
retraction velocity and total amount of canine retraction (P-value
0.001). Four studies were
included in the meta-analysis, which showed no difference in the amount of anchorage between

tome xx > 000 > xx 2019

1

https://doi.org/10.1016/j.ortho.2019.11.002
© 2019 Published by Elsevier Masson SAS on behalf of CEO.

ORTHO-443
 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002

DES. Malik, M. Fida, E. Afzal, S. Irfan

Systematic review and meta-analysis

self-ligating and conventional brackets (weighted mean difference – 0.22; 95% CI [0.82, 0.38];
P = 0.48). Multiple subgroup analyses further revealed there were no significant differences
between the intervention and control groups for all outcomes studied.
Conclusion > This systematic review and meta-analysis found insufficient evidence to suggest a
significant difference in anchorage loss between the CB and SLB groups. The scarcity of current
evidence dictates that further studies are needed to canonically establish the clinical superiority of
one over the other.
Review registration > PROSPERO 2019 CRD42019133217.

Mots clés Résumé

Ancrage
Attaches conventionnelles Comparaison de la perte d'ancrage entre les attaches conventionnelles et
Attaches autoligaturantes autoligaturantes – Étude systématique et méta-analyse
Rétraction canine
Introduction > L'ancrage est défini comme une résistance à un mouvement dentaire indésirable.
En orthodontie, une perte d'ancrage peut être un effet négatif du traitement. Les partisans des
attaches autoligaturantes (SLB) prônent l'utilisation de forces extrêmement légères réduisant
ainsi le problème de l'ancrage. Par conséquent, l'objectif de cette étude était de comparer la
perte d'ancrage pendant la rétraction canine entre les attaches conventionnelles (CB) et
autoligaturantes.
Méthodes > Une recherche électronique de la littérature a été effectuée dans les bases de
données Cochrane, Scopus, Web of Science, PubMed, Dental & Oral Science et CINAHL, avec
en parallèle une recherche à la main dans les bases de données Cochrane, Google Scholar et
clinicaltrials.gov. Les essais cliniques randomisés et non randomisés publiés en langue anglaise
sur des êtres humains ont été inclus. Les patients orthodontiques pour qui était indiquée une
rétraction canine après extraction de prémolaires ont été inclus, avec attaches autoligaturantes
pour le groupe interventionnel et conventionnelles pour le groupe témoin selon un design split
mouth. Le critère de jugement principal était la perte d'ancrage, les critères secondaires étaient la
rapidité de rétraction et la quantité totale de rétraction. Deux chercheurs ont extrait les données
et fait la sélection séparément. Le risque de biais a été calculé avec l'outil d'évaluation des risques
de biais Cochrane. Le logiciel RevMan a été utilisé pour la synthèse quantitative des données.
L'effet estimé des critères de jugement principaux et secondaires a été établi selon la différence
moyenne pondérée (DMP), calculée selon un intervalle de confiance (IC) à 95 %. L'hétérogénéité
des études a été calculé en utilisant le test d'hétérogénéité Cochrane (I2 Test) ; les analyses en
sous-groupe et de sensibilité ont été menées pour investiguer les sources d'hétérogénéité entre
les études.
Résultats > L'analyse de la littérature a donné plus de 10 439 titres à partir desquels cinq études
satisfaisant aux critères d'inclusion ont été incluses dans la synthèse qualitative. Quatre études
étaient des essais contrôlés randomisés (RCTs), une n'était pas randomisée, avec un total de
100 patients inclus dans cette étude systématique. Toutes les études étaient des essais cliniques
avec un split mouth design sur les cinq études incluses, seulement une rapportait une différence
significative entre les attaches CB et SLB en ce qui concerne la perte d'ancrage, la vitesse et la
quantité totale de rétraction canine (p-value
0,001). Quatre études ont été incluses dans la
méta-analyse qui n'a montré aucune différence significative de perte d'ancrage entre les deux
groupes d'attaches autoligaturantes et conventionnelles (DMP – 0,22 ; IC95 % [0,82, 0,38] ;
p = 0,48). Les analyses multivariées de sous-groupes n'ont montré aucunes différences signi-
ficatives entre les deux groupes pour tous les paramètres étudiés.
Conclusion > Cette étude systématique/méta-analyse n'a pas trouvé de preuve suffisante pour
signifier une différence significative dans la perte d'ancrage entre les CB et SLB. Ce manque actuel
d'éléments de preuve nécessite d'autres avancées scientifiques pour établir fermement la
supériorité clinique d'une technique par rapport à l'autre.
Review registration > PROSPERO 2019 CRD42019133217.
2

tome xx > 000 > xx 2019

 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
Comparison of anchorage loss between conventional and self-ligating brackets during canine retraction – A
systematic review and meta-analysis
Introduction
Development of evermore sophisticated appliances has flooded
orthodontic practices with various bracket systems and philoso-
phies. It is imperative to select an appliance that simplifies
mechanics, reduces treatment duration and elicits an optimal,
physiologic response from the periodontium [1]. This can be
done by using low forces, reducing friction generated between
the bracket and wire, and minimizing areas of hyalinization
during tooth movement. Hence, the ideal appliance should
be one that reduces burden on anchorage and brings about
steady tooth movement [2,3].
A self-ligating bracket is one that has the inherent ability to hold
the wire within the slot by means of a locking mechanism [4]. This
lock converts the bracket into a tube, eliminating the need for
elastomeric ligation. The disagreement between proponents of
conventional and self-ligating brackets stems from the principles
of friction, created as teeth slide along an archwire. Self-ligating
appliances claim they overcome friction, converting the oral
environment into one where tooth movement and tissue adap-
tation takes place under complete physiologic control [5–7]. Slid-
ing mechanics are most commonly used during the initial
alignment and canine retraction phase of orthodontic treatment.
As a tooth is moved along the wire, friction can cause binding
between the slot and wire material, causing force loss. This is
overcome at the expense of anchorage [8–10]. Anchorage loss
during canine retraction with sliding mechanics can be detrimen-
tal to treatment. Use of self-ligating brackets is hypothesized to
minimize friction and the burden on anchorage. Multiple in vitro
and clinical studies have claimed self-ligating brackets generate
less friction during sliding mechanics [11–14]. This finding is highly
dependent on various factors such as the slot size, wire diameter,
type of tooth movement, etc. [1]. In fact, when using full dimen-
sion stainless steel wires, Oz et al. [11] found self-ligating brackets
have a higher coefficient of friction when compared to modified
twin brackets. Therefore, the results have to be interpreted with
caution and cannot be applied to all stages of tooth movement.
The evidence from various systematic reviews studying treat-
ment efficiency with self-ligating versus conventional brackets
has yielded inconclusive results to validate the superiority of one
over the other [15,16]. Outcomes of prospective studies com-
paring anchorage loss during canine retraction with self-ligating
and conventional brackets have been contradictory. A study by
de Almeida et al. [17] showed no significant differences in the
amount of anchorage loss of the maxillary first molars between
self-ligating and conventional bracket systems during space
closure, whereas Juneja et al. [18] found greater anchorage
loss with conventional brackets and statistically significant
reduction in treatment time with self-ligating brackets.
A systematic review evaluating anchorage loss between self-
ligating and conventional brackets found insufficient data to
validate the superiority of one over the other [19]. In spite of
tome xx > 000 > xx 2019
Systematic review and meta-analysis
various studies [20–22] negating the efficacy and clinical supe-
riority of self-ligating brackets, clinicians continue to advocate
their use in lieu of faster chair time, reduced armamentarium,
and claims of deriving a more physiologic response from the
dentoalveolar structures [23]. Hence, recent, high quality ran-
domized control trials should be used to re-evaluate the differ-
ences between the two appliance systems; furthermore, using
an in vivo split mouth design can control for sample differences
and biases commonly introduced in laboratory settings or obser-
vational studies. Therefore, the aim of this systematic review
was to compare in vivo the amount of anchorage loss between
conventional and self-ligating brackets during canine retraction.
Materials and methods
Registration of protocol
The protocol was registered a priori at PROSPERO (Registration #
CRD42019133217) to avoid chances of unplanned duplication
and was followed accordingly while conducting the systematic
review. Guidelines stated as the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) [24] were
strictly followed during all phases of the review which were
updated accordingly to the online PROSPERO registry.
Review question and eligibility criteria
The review question was based according to the PICOS model
stated concisely as "Is there a difference in anchorage loss
during canine retraction between conventional and self-ligating
brackets?'', where the population under study were patients
undergoing canine retraction after premolar extraction using
sliding mechanics, the intervention group included all types
of self-ligating brackets irrespective of their proprietary names,
whereas any design of conventional brackets using wire or
elastomeric ligatures served as the control. The primary out-
come studied was molar anchorage loss; secondary outcome
measures were retraction velocity of canines and total duration
of retraction or space closure.
Only randomized or non-randomized clinical trials published in
the English language were included in this study. No distinction
was made for either maxillary or mandibular canines. All in vitro
or animal studies, cohorts, case-control, retrospective designs,
reviews, editorials and patents were excluded.
Information sources and search strategy
Electronic and manual searches were conducted on databases
including PubMed, Scopus, Web of Science, Dental & Oral Sci-
ence and CINAHL, along with handsearching Google Scholar,
metaRegister of Controlled Trials, National Institute of Public
Health registry for clinical trials and clinicaltrials.gov. After pre-
liminary screening, the search was refined once again by perus-
ing citations of included articles for any missed data.
No filters on date of publication were placed. The search strategy
used multiple MeSH terms joined by Boolean operatives to
3
 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
DES. Malik, M. Fida, E. Afzal, S. Irfan
Systematic review and meta-analysis
conduct the electronic search. Keywords from relevant studies
were used to conduct the manual search (Appendix 1).
Selection of studies
The search results were exported to Endnote (version X7, Thom-
son Reuters) where screening for eligibility was carried out
independently by two authors. No blinding to study results,
author identity, institute or affiliation was done. Studies were
then systematically eliminated based on titles, abstracts and
study design. When narrowed down, full texts were obtained
and read. All articles that followed the inclusion criteria were
included. Two weeks after preliminary screening, a third author
repeated the selection, which showed excellent agreement for
all studies finalized (ICC = 0.89).
Data collection process and items
Data was extracted and collected on customized data sheets by
two authors. The proforma was split into three parts:
 study characteristics, including authors, year and journal of
publication, study design, number of participants, intervention
and control groups, methods of assessment, use of any aux-
iliaries, and retraction wires;
 patient demographics, such as male to female distribution of
sample and mean age;
 outcome measures studied (Appendix 2).
Risk of bias for individual studies
Two investigators for quality assessment of all included trials used
the Cochrane's risk of bias tool [25]. The guidelines described by
the Cochrane collaboration were used to classify the studies as
high, moderate or low risk of bias. A field that had been fulfilled
and described by the respective authors, such that methods could
be reproduced, was considered to have low risk. Failure to report a
Figure 1
PRISMA flowchart
4
field introduced a high risk of bias. If the authors failed to provide
direct and consistent details with regards to a particular field, it
was considered to have an unclear risk of bias. Any disagreement
was resolved by discussing with a third author. A strict grading
approach was followed where a trial was ascribed a higher risk
status if it failed to satisfy all conferring authors.
Risk of bias across studies
Risk of bias across studies was calculated using the Cochrane's
risk of bias tool for assessment of randomized control trials. All
biases such as publication and reporting biases influencing the
overall systematic review were assessed and the overall result
was presented as the cumulative scores from all studies.
Summary measures and synthesis of results
Mean differences with 95% confidence interval (CI) were used to
express the effect estimate for the primary outcome of anchorage
loss, and secondary outcomes of retraction velocity of canines and
total time duration. The test for heterogeneity (I2 test) was used to
assess the discrepancy in the effect estimate between the studies.
A random effects model was used to control for the heterogeneity
of the sample on the assumption that ethnic variation was present
among the patient population of the various studies. The meta-
analysis was performed for only the randomized control trials
reporting similar outcomes to control the validity and strength
of the results. Subgroup and sensitivity analyses were performed
to analyse extreme heterogeneity of the studies.
Results
Study selection
The electronic search generated 10,439 hits across various data-
bases. To this, eight more studies were added via hand search.
After the removal of duplicate articles, patents and editorials,
tome xx > 000 > xx 2019
 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
Comparison of anchorage loss between conventional and self-ligating brackets during canine retraction – A
systematic review and meta-analysis

Systematic review and meta-analysis

TABLE I
Study characteristics.

# Author & year of publication Journal Study design Age (years) Gender Follow-up Sample
contribution

1. Monini 2017 Clinical and Oral Investigations Split mouth RCT 23.32  5.08 M=9 13 months 25
F = 16
2. Hassan 2016 Journal of Contemporary Dental Practice Split mouth RCT 20.99  2.36 M=4 12 weeks 15
F = 11
3. Monini 2014 The Angle Orthodontist Split mouth RCT 23.32  5.08 M=9 13 months 25
F = 16
4. Reddy 2014 APOS Trends in Orthodontics Split mouth N-RCT 16–26 M = 10 12 weeks 20
(Mean = 20) F = 10
5. Mezomo 2011 The Angle Orthodontist Split mouth RCT 12–26 M=5 12 weeks 15
(Mean = 15) F = 10

RCT: randomized control trial; N-RCT: non-randomized control trial; M: males; F: females.

TABLE II
Outcomes and methods of assessment.

# Author Intervention Control Outcomes studied Assessment Teeth Force Wire Auxiliaries
00
1. Monini In-Ovation SLB Ovation CB Anchorage loss Oblique lateral Mandibular canines NiTi springs 0.020 Omega loops
2017 Retraction velocity cephalogram 100 g stainless steel
Total retraction
2. Hassan Damon-Q SLB Mini Master CB Anchorage loss Dental casts Maxillary canines Sentalloy spring 0.019  0.02500 Transpalatal
2016 Retraction velocity 150 g stainless steel arch
Total retraction
3. Monini In-Ovation SLB Ovation CB Anchorage loss Oblique lateral Maxillary canines NiTi springs 0.02000 Omega loops
2014 Retraction velocity cephalogram 100 g stainless steel
Total retraction
4. Reddy Smart Clip SLB 3M India CB Anchorage loss Dental casts Maxillary canines NiTi springs 0.019  0.02500 Transpalatal
2014 Retraction velocity 150 g stainless steel arch

5. Mezomo Smart Clip SLB Gemini CB Anchorage loss Dental casts Maxillary canines Elastic chain 0.01800 stainless steel None
2011 Retraction velocity 150 g
Total retraction

SLB: self-ligating brackets; CB: conventional brackets.

Figure 2
Risk of bias within studies
5

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 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002

DES. Malik, M. Fida, E. Afzal, S. Irfan

Systematic review and meta-analysis

the studies were systematically eliminated based on title, fol-
lowed by abstracts, study designs, and unmatched objectives.
Full text was retrieved for all articles that appeared to meet the
inclusion criteria and further scrutinized. All prospective cohorts,
case-control and retrospective studies were excluded. This
finally gave us a total of five studies to be included in the
systematic review and where applicable, the meta-analysis.
Four out of the five studies were randomized control trials
(RCTs), whereas one was a non-randomized control trial (N-
RCT) (figure 1).

Figure 3
Risk of bias across studies

TABLE III
Results of individual studies.

# Author SLB CB P-value

(mean W SD) (mean W SD)
Anchorage loss (millimeters)
1. Monini 2017 1.28  1.10 1.24  1.36 0.919

2. Hassan 2016 0.27  0.12 1.15  0.40 < 0.001**

3. Monini 2014 1.28  0.87 1.30  0.86 0.880

4. Mezomo 2011 0.66  0.25 0.59  0.25 0.157

Median and IQR

5. Reddy 2014 0.14 (0.3, 0.1) > 0.05

Retraction velocity (millimeters/month)

1. Monini 2017 0.71  0.29 0.72  0.26 0.965

2. Hassan 2016 1.02  0.13 0.71  0.10 < 0.001**

3. Monini 2014 0.54  0.13 0.60  0.20 0.069

4. Mezomo 2011 0.90  0.29 0.84  0.21 0.354

Reddy 2014 0.89  0.25 0.87  0.21 0.804

Total amount of space closure (millimeters)

1. Monini 2017 6.92  1.66 6.97  1.81 0.924

2. Hassan 2016 3.06  0.38 2.12  0.30 < 0.001**

3. Monini 2014 7.16  1.50 7.51  1.46 0.187

4. Mezomo 2011 2.68  0.86 2.53  0.62 0.354

SLB: self-ligating brackets; CB: conventional brackets; SD: standard deviation; **: statistically significant findings.
6

tome xx > 000 > xx 2019

 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
Comparison of anchorage loss between conventional and self-ligating brackets during canine retraction – A
systematic review and meta-analysis

Systematic review and meta-analysis

Study characteristics
A total number of 100 patients were included in this systematic
review across the five studies. All studies followed a split mouth
design; therefore, the number of teeth observed is doubled.
Both trials by da Costa Monini et al. [26,27] had the highest
number of participants and teeth observed, followed by Reddy
et al. [28]. Least contribution was made by Mezomo et al. [29]
and Hassan et al. [30] with 15 patients in each RCT, respectively.
The assessment methods were either lateral cephalograms for
two of the studies, or dental casts. However, all parameters
were expressed in comparative units of measurement. The
follow-up ranged from 12 weeks minimum to maximum fol-
low-up of 13 months (table I).
Four out of the five studies evaluated maxillary canines,
whereas one was on mandibular canines. Anchorage was rein-
forced using various auxiliaries in four studies. Canines were
retracted using a force ranging from 100–150 grams using either
Nickel-Titanium (NiTi) springs, Sentalloy springs or elastic chains.
All studies used stainless steel wires; two studies used a rect-
angular, and three reported using a round wire during the
retraction phase (table II).
Risk of bias within studies
All studies showed the highest risk of bias for blinding of par-
ticipants and allocation concealment. Both studies by da Costa

Figure 4
Forest plot depicting mean difference between conventional brackets and self-ligating brackets for anchorage loss

Figure 5
Forest plot depicting mean difference between conventional brackets and self-ligating brackets for retraction velocity

Figure 6
Forest plot depicting mean difference between conventional brackets and self-ligating brackets for amount of total retraction
7

tome xx > 000 > xx 2019

 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002

DES. Malik, M. Fida, E. Afzal, S. Irfan

Systematic review and meta-analysis

Monini et al. [26,27] showed low risk of bias for all other fields,
whereas other studies showed high to unclear risk (figure 2).
Risk of bias across studies
Four out of the five studies included were randomized control
trials, with only one study showing unclear random sequence
generation; therefore, risk of bias for randomization was quite
low. Similarly, lowest risk of bias was seen for reporting incom-
plete outcome data. Allocation concealment and blinding of
participants to intervention were not done in any of the included
trials; however, the absence of these does not directly influence
the outcomes assessed as those were objective measurements
independent of patient control. Blinding of outcome assessors
was done for two studies, which also showed low risk for other
sources of bias [26,27]. Three trials showed unclear risk for other
sources of bias, which was a result of lack of reporting how those
factors were controlled [28–30]. The systematic review aimed to
minimize recall bias by including only studies that were pro-
spective clinical trials (figure 3).
Results of individual studies
For all parameters studied, only Hassan et al. [30] found sta-
tistically significant differences between the intervention and
control groups. For amount of anchorage loss, Hassan et al. [30]
found a statistically significant difference in the amount of
mesial movement of molars between SLB and CB, with greater
movement seen on the side with CB (P < 0.001). Similarly, when
comparing retraction velocity of canines, they found a statisti-
cally significant difference between the two sides, with great
velocity recorded with SLB (P < 0.001). The total amount of
space closure also showed statistically significant differences
between the groups with more tooth movement seen with SLB
(P < 0.001). All studies reported anchorage loss and retraction
velocity. Only four studies reported total amount of movement
(table III).
Synthesis of results
The test of heterogeneity (I2) showed values of greater than
90% for all parameters under study; therefore, a random effect

Figure 7
Forest plot of subgroup comparison: conventional brackets and self-ligating brackets, outcome: 1. Anchorage loss
8

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 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
Comparison of anchorage loss between conventional and self-ligating brackets during canine retraction – A
systematic review and meta-analysis

Systematic review and meta-analysis

model was used to control for the sample heterogeneity in the
meta-analysis. Only the RCTs by da Costa Monini et al. [26,27],
Mezomo et al. [29] and Hassan et al. [30] were included in the
pooled analysis.
The primary outcome studied was amount of molar anchorage
loss. The results of the meta-analysis show no statistically
significant difference between the amount of anchorage loss
seen between SLB and CB during canine retraction (weighted
mean difference – 0.22; 95% CI [0.82, 0.38]; Z = 0.71;
P = 0.48) (figure 4).
Similarly, there was no statistically significant differences for the
secondary outcomes. For retraction velocity of canines, the
overall effect size failed to demonstrate a difference between
the intervention and control groups (weighted mean difference
0.05; 95% CI [0.21, 0.30]; Z = 0.36; P = 0.72) (figure 5).
For total amount of space closure between SLB and CB, no
statistically significant difference was found between the two
groups (weighted mean difference 1.39; 95% CI [0.40, 3.18];
Z = 1.52; P = 0.13) (figure 6). The potential cause of sample
heterogeneity was further explored by carrying out multiple
subgroup and sensitivity analyses for the primary and secondary
outcomes. The following subgroups were considered: maxillary
canines only, retraction on round wires, retraction force delivery
of 100 grams, and retraction force delivery of 150 grams (fig-
ures 7–9). The results of the subgroup analyses were statistically
insignificant for primary outcome of anchorage loss (P = 0.75)
and the total amount of canine retraction (P = 0.82); however,
when testing for subgroup differences for retraction velocity of
canines, statistically significant differences were found
(P < 0.001). This was further investigated by a sensitivity analy-
sis (figure 10), which was carried out by systematically exclud-
ing one study at a time and measuring its effect on the overall
risk estimate; the results of the sensitivity analysis showed the
RCT by Hassan et al. [30] contributed significantly to the amount
of heterogeneity in the sample which was fully eliminated by
excluding it from the pooled analyses (P = 0.49).

Figure 8
Forest plot of subgroup comparison: conventional brackets and self-ligating brackets, outcome: retraction velocity
9

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 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002

DES. Malik, M. Fida, E. Afzal, S. Irfan

Systematic review and meta-analysis

Figure 9
Forest plot of subgroup comparison: conventional brackets and self-ligating brackets, outcome: amount of total retraction

Figure 10
Sensitivity analysis

when compared to conventional brackets [27–29]. Celar et al.

Discussion
The aim of any systematic review is to critically appraise the
highest quality of evidence available in literature, extrapolate
results and make recommendations in service of evidence
based practice. Several authors have reported the efficacy,
comfort and success of treatment with self-ligating brackets
10
[31] evaluated the pain levels and found no statistically signifi-
cant difference in perceived pain between the two SLB and CB
groups. Similarly, Folco et al. [32] and Pejda et al. [33] found no
difference in the gingival or periodontal outcomes in patients
undergoing treatment in with either bracket systems. However,
the amount of anchorage loss during canine retraction is not

tome xx > 000 > xx 2019

 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
Comparison of anchorage loss between conventional and self-ligating brackets during canine retraction – A
systematic review and meta-analysis
well documented. Therefore, following strict inclusion criteria,
this systematic review analysed four RCTs and one N-RCT to
answer the review question.
The drawback of tailoring the criteria to include only prospective
clinical trials was that a limited number of studies were avail-
able; however, this study design reduced the inherent risk of
bias and thereby increased the validity of the results. In our
systematic review, we found the highest risk of bias for blinding
of participants and allocation concealment. Blinding of partici-
pants is not always possible in an orthodontic population [34].
Anchorage loss, retraction velocity and the total amount of
retraction are objective variables independent of patient control.
It can therefore be hypothesized that lack of blinding and
allocation concealment would not ultimately influence the
results.
In this systematic review, only Hassan et al. [30] reported a
statistically significant difference between self-ligating and con-
ventional brackets for all outcomes assessed. However, the
results of the sensitivity analysis showed this study contributed
highly to the sample heterogeneity of the pooled synthesis.
They evaluated the parameters manually on dental casts, which
was also the method described by two other studies. Further-
more, the retraction wire, amount of force and use of a trans-
palatal arch as described in their study paralleled exactly the
mechanics employed by Reddy et al. [28]. Theoretically, lower
friction with self-ligating brackets is a result of light round wires
moving freely in the tube like slots [13]. However, when using
wires of larger diameter that fully engage the slot, there is little
difference in friction to be expected between the two types of
brackets [31].
The length of follow-up between the studies ranged from
12 weeks to 13 months. Although statistically insignificant dif-
ferences were found between the groups irrespective of dura-
tion, a recommendation for longer follow-ups could allow more
precise assessment of tooth movement in extraction cases.
Another consideration, when evaluating total amount of tooth
movement and retraction velocity, is the distinction between
tipping and bodily movement. Teeth may only tip when using
lighter wires, giving the illusion of faster movement. Therefore,
adequate amount of time for tooth uprighting must be given
before making final assessment of velocity and amount of space
closure [35]. Conversely, when teeth tip, they move freely only
till the point where second order angulation causes binding of
the wire with the bracket slot; this in turn can slow down tooth
movement, independent of bracket type [36].
The split mouth nature of the included trials minimized sample
heterogeneity and patient dependent factors such as oral envi-
ronment, salivary states, masticatory forces and bone quality.
This further reinforces that tooth movement may not be influ-
enced by bracket type but patient variation. When grouped into
"slow'' versus "fast'' movers, da Costa Monini [27] found a
statistically significant difference between the two types with
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Systematic review and meta-analysis
retraction rate of 0.26 mm/month greater for "fast'' movers.
Therefore, it can be inferred that the rate of tooth movement is
predicated on patient variation and differential osteology of the
jaws over the bracket type when all other factors are controlled.
Fleming et al. [37] in their study investigating efficacy, visits and
duration of treatment with conventional VictoryTM versus self-
ligating SmartClipTM brackets found treatment with the SLB
group was actually 3 months longer, with no statistically signifi-
cant differences in treatment efficacy. Moreover, Arnold et al.
[38] in their systematic review on the periodontal outcomes in
adolescents using different ligation methods concluded that
neither systems can be considered clinically superior to the
other in terms of promoting oral hygiene. They found periodon-
tal status and maintenance to be predicated on effective brush-
ing regardless of the ligation system used. Therefore, in light of
current evidence, it can be rationalized that the continued
optimism and demand for treatment with self-ligating brackets
should be considered preferential and based on personal clinical
experiences.
The meta-analysis failed to establish a statistically significant
difference between the intervention and control groups. As
results from only one trial suggested a difference in anchorage
loss, retraction velocity and total amount of space closure, the
overall effect size was not moved to favour self-ligating brack-
ets. Secondarily, this can be attributed to the limited sample size
of the study which failed to make a sizeable impact on the
results of the meta-analysis.
Limitations
A limited number of randomized control trials are available
reporting the specific outcomes evaluated in this systematic
review. The sample size in individual studies was small which
may have failed to demonstrate a statistically significant differ-
ence between the two bracket types. Furthermore, the mean
follow-up time was inadequate to differentiate between tipping
movements and total time required to upright the retracted
tooth. Although no filters with respect to date or language were
used when conducting the search, there is always a possibility of
missed articles and publication bias.
Recommendations
Well executed randomized control trials with larger sample size
and longer duration of follow-up should be carried out to
categorically establish whether or not a distinction exists
between the two types of bracket systems.
Conclusion
The results of this systematic review and meta-analysis failed to
find a significant difference between self-ligating and conven-
tional brackets when studying anchorage loss, retraction veloc-
ity or total amount of space closure. Based on these findings, we
conclude that the choice of bracket system should be made on
the cost-benefit analysis and individual goals of treatment.
11
 To cite this article: Malik DES, et al. Comparison of anchorage loss between conventional and self-ligating brackets during canine
retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002

DES. Malik, M. Fida, E. Afzal, S. Irfan

Systematic review and meta-analysis

Acknowledgments: The authors would like to thank Mr. Khawaja Mustafa Disclosure of interest: the authors declare that they have no competing
for his help in conducting the literature search and Dr. Meisha Gul for her interest.
guidance with statistical analyses.

Author contributions: study selection and data extraction were performed

individually by the first and third authors (DSM and EA). Study selection Supplementary data
was repeated by the last author. First and last author (DSM and SI) carried Supplementary data associated with this article
out risk of bias assessment and data analysis. Disagreements were
resolved by discussion with the remaining authors. All authors read and can be found, in the online version, at https://
approved the final manuscript. doi.org/10.1016/j.ortho.2019.11.002.
none.

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retraction – A systematic review and meta-analysis. International Orthodontics (2019), https://doi.org/10.1016/j.
ortho.2019.11.002
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systematic review and meta-analysis

Systematic review and meta-analysis

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