Self-Ligating Brackets: Theory and Practice: C H A P T e R

S E L F - L I G A T I N G B R A C K E T S : T H E O R Y A N D P R A C T I C E 1 9 7
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6
11
Chapter
Self-ligating brackets: theory and

practice
Nigel Harradine and David Birnie
1 9 8 S E L F - L I G A T I N G B R A C K E T S : T H E O R Y A N D P R A C T I C E
Introduction
Self-ligating brackets have made a major impact in orthodontics in the last seven or so years. There is no
doubt that they add a new dimension to orthodontic treatment and it can be argued that they are more than
just a bracket system facilitating tooth movements that are difficult to achieve with conventional appliances.
It is easy to focus on the absence of ligatures as the raison d'être for self-ligating brackets. A better
description is that they are ligatureless brackets in that they do not use ligatures but require some
procedure to be carried out on the bracket in order to either secure or release the archwire.
It is worth trying to think about the other benefits that current self-ligating brackets may offer and some of
these concepts are encapsulated in an article by Alan Pollard (2003).
Self-ligating brackets have an inbuilt metal labial face which can be opened and closed. Brackets
incorporating their own ligation system have existed for a surprisingly long time in orthodontics - the
Russell Lock edgewise attachment being described by Stolzenberg in 1935. Many designs have been
patented, although only a minority have become commercially available. We have also used self-ligating
Begg brackets in the past.
New designs continue to appear, with three new brackets becoming available in the 1990s and at least
nine new brackets since 2000. This rapidly accelerating activity is in spite of the fact that until recently,
self-ligating brackets had never attracted more than a small percentage of bracket sales. All
manufacturers have come to appreciate the capabilities of these brackets.
We have a fairly wide range of experience with different self-ligating brackets since 1982, having in the
past treated a considerable number of cases with Speed brackets, a few with Mobil-Lock brackets, a large
number with Activa brackets from 1986 to 1995, Damon SL brackets from 1995 to 2000 and TwinLock
brackets on a few cases. Damon SL brackets had tie-wings and a self-ligation slide and superseded
Activa. Damon 2 brackets are a substantial further development of this concept. Damon 3 brackets have a
new slide mechanism and are partially made of composite resin to enhance the aesthetics, whilst Damon
MX brackets have essentially the same slide mechanism bur are all-metal brackets. Brackets made
entirely from composite polymers have also appeared – Oyster and Opal. In-Ovation brackets were
previously known as Interactwin and Sigma before their commercial release in 2000. They have tie-wings
but have an active self-ligation clip. More recently they have been renamed ‘System R’. Adenta LT
brackets are a lingual version of the Time bracket. The 3M Unitek
Bracket Year SmartClip bracket has wire-retaining spring clips added to either
Russell Lock 1935 side of a conventional bracket. This chapter looks first at the
Ormco Edgelok 1972 requirements of an ideal bracket ligation system and the extent to
Forestadent Mobil-Lock 1980 which the current self-ligating brackets meet these requirements.
Orec SPEED 1980
“A” Company Activa 1986
Properties of an ideal ligation system

Adenta Time 1994
“A” Company Damon SL 1996
Ormco TwinLock 1998 We are so used to accepting that tie-wing brackets are the way
Ormco/”A” Co. Damon 2 2000 that ligation is performed, that it is worthwhile considering a list of
Gestenco Oyster 2001 ideal properties of any ligation system. This puts in perspective
GAC In-Ovation 2002 any assessment of the benefits and difficulties with current self-
GAC In-Ovation R 2002 ligating systems. Archwire ligation should:
Adenta Evolution LT 2002
Ultradent Opal 2004 • be secure, robust ligation
SDS Ormco Damon 3 2004
• ensure full bracket engagement of the archwire
2004
•
3M Unitek SmartClip
exhibit low friction between bracket and archwire
SDS Ormco Damon MX 2005
Class One Carrière SLB 2005 • be quick and easy to use
• permit high friction when required
Table 11.1: Self-ligating bracket
designs • assist good oral hygiene
• be comfortable for the patient
Conventional wire and elastomeric ligatures in relation to the requirements

for an ideal ligation system
Secure robust ligation
It is highly desirable that once ligated, the system is very resistant to inadvertent loss of ligation. Wire
ligatures are good in this respect, whilst elastomeric ligatures are much less good, especially if left for too
long without being renewed. The force decay of elastomerics has been well documented (Taloumis et al
1997).
Full bracket engagement

It is a large advantage if the archwire can be fully engaged in the bracket slot and then maintained there
with certainty. Wire ligatures do not stretch to an extent that engagement once achieved at ligation is
subsequently lost, so they can meet this requirement. Elastomerics are again worse in this respect since
they may on occasion exert insufficient force to fully engage even a flexible wire and the subsequent
degradation of their elastic performance may cause a significant loss of full engagement as the elastomeric
stretches. Twin brackets with the ability to ‘figure of 8’ the elastomerics are a significant help in this respect
but certainly not a complete answer.
Quick and easy to use

This is a major weak point of wire ligatures and the principal reason for the enormous decline in their use.
Maijer and Smith (1990), and Shivapuja and Berger (1994) have shown that wire ligation is very slow
compared to elastomerics. In the latter study, the use of wire ligatures added almost 12 minutes to the
time needed to remove and replace two archwires. This is the largest and very understandable reason
why so few wire ligatures are now used.
Low friction
Wire ligatures are again better than elastomerics; producing 30%-50% of the friction forces in the study by
Shivapuja and Berger (1994) but the forces still reach undesirable levels relative to the force levels
considered ideal for tooth movement. Khambay et al (2004), also found that stainless steel ligatures
produced lower frictional forces than elastomerics. Interestingly, the polymeric-coated SuperSlick ligatures
(TP Orthodontics Inc. Indiana) which were designed to reduce friction produced more friction than more
conventional elastomerics. Also, the force normal to the archwire produced by a wire ligature is very
variable (Iwasaki et al 2003) even after training in a standardised method of ligature tying. This force has
also been shown to be more variable for elastomeric ligatures than for passive self-ligation (Thorstenson
and Kusy 2001)
High friction
It is also helpful under some circumstances if the ligation system can ‘lock’ a tooth to the wire to prevent
unwanted movement of that tooth along the wire. When initially placed, an elastomeric in a ‘figure of 8’
configuration increases the friction by a factor of 70-220%. compared to the ‘O’ configuration (Sims et al
1993) which partially meets this requirement.
Easy attachment of elastic chain

Some self-ligating brackets such as Opal and Speed have dispensed with tie-wings. This makes
attachment of elastic chain and if desired, elastomeric ligatures, less convenient or impossible. Most of the
recently developed self-ligating brackets have tie-wings.
Assists good oral hygiene

Elastomerics accumulate plaque more than do tie-wires and fluoride releasing elastomerics have yet to
reach reliably robust performance levels by way of compensation. The ends of wire ligatures are however
an additional obstacle to oral hygiene. An interesting paper by Turkkahraman et al (2005) compared
elastomerics and wire ligatures with respect to various measures of plaque quality and quantity, gingival
index, probing depth and bleeding on probing. The bacteriology results slightly favoured wire ligation, but
not to a significant extent, but the important sign of bleeding on probing was substantially higher with
elastomeric ligation. A current study in the United Kingdom is comparing elastomerics with self-ligation in
this area of potential concern.
Comfortable for the patient

Elastomerics are good in this respect, but wire ligatures require careful tucking in of the ends to avoid soft
tissue trauma and even then can occasionally be displaced between appointments and cause discomfort.
Summary: What is wrong with conventional ligation?

• failure to provide and to maintain full archwire engagement
• high friction
• for elastomerics, the force (and therefore tooth control) decays and they are sometimes lost
• potential impediment to oral hygiene
• wire ligation is very slow
Wire ties are secure, robust, enable full, partial or distant ligation and have lower friction than elastomerics.
Their large drawback is the time required for ligation. Elastomerics are quick but less good in every other
respect. Neither method is ideal nor nearly as good as a molar tube assembly which is universally adopted
as the ‘ligation’ of choice on posterior teeth. It is easy to find examples of the deficiencies of conventional
ligation, but clinicians have become accustomed to tolerating these shortcomings.
Advantages of self-ligating brackets

These advantages apply in principle to all self-ligating brackets although the different makes vary in their
ability to deliver these advantages consistently in practice.
• more certain full archwire engagement

• low friction between bracket and archwire
• less chairside assistance
• faster archwire removal and ligation
Secure, full archwire engagement

Full engagement is a feature of self-ligation because, if a clip or slide is functioning properly, it is either fully
shut or it is not. Unintentional partial engagement is not possible. There is no problem of decay of the
ligature as with elastic ligatures. However, security of ligation will depend on the clip/slide being robust and
not inadvertently opening. Until recently, this requirement for security of performance was not fully met by
any self-ligation designs. Secure, full archwire engagement maximises the potential long range of action of
modern low modulus wires and minimises the need to regain control of teeth where full engagement is lost
during treatment.
Low friction
Very low friction has been clearly demonstrated and quantified in work by Sims et al (1993, 1994), Berger
(1990) and Shivapuja and Berger (1994) for both Activa and Speed brackets and indeed Edgelok.
Voudouris (1997) has reported greatly reduced friction with Sigma and Interactwin prototypes and with
Damon brackets. The friction is dramatically lower than for elastomeric rings with conventional brackets
and seems to be an inherent characteristic of self-ligating brackets. Thomas et al (1998) confirmed
extremely low friction with Damon brackets compared to both conventional preadjusted and also Tip-Edge
brackets. Kapur et al (1998) found that with NiTi wires the friction per bracket was 41 g with MiniTwin and
conventional ligation and 15 gm with Damon brackets whilst with stainless steel wires, these values were
61 gm and only 3.6 gm respectively. Pizzoni et al (1998) have reported that Damon brackets showed
lower friction than Speed which in turn had less friction than conventional brackets stating that: “In the case
of rectangular wires, the Damon bracket

2.5 was significantly better than any of the
other brackets and should be preferred if
2 sliding mechanics is the technique of
choice”. Meling et al (1997), examining
1.5 the effect of friction on wire stiffness
newtons
concluded that each elastomeric placed

1
in an ‘O’ configuration produces an
average of 50 gm of frictional force. This
0.5
figure is supported by Khambay et al
(2004) using a method which gave zero
0
0.014 NiTi 0.0175 TF 0.016x0.022 0.016x0.022 0.019x0.025
friction for Damon 2 brackets found
SS NiTi SS mean frictional forces ranging between
43 and 98 gm (0.43 and 0.98 newtons)
A Co Damon SL Adenta Time TP TipEdge A Co Std for various elastomeric/archwire
combinations.
Figure 11.1: Data from Thomas et al (1998) showing typically very low
Friction in vivo and with active
friction for self-ligating brackets compared to conventional ligation
wires
It is however, difficult to be certain how
accurately any laboratory simulation of friction reproduces the true in vivo situation where other factors
including variable archwire activation and its consequent binding exist. A study by Loftus et al (1999) found
that in an experiment with a simulated periodontal ligament and with slight tip and rotation of the brackets,
the friction with Damon SL was not significantly less than with conventionally ligated brackets.
Read-Ward et al (1997) reported that the reduction in friction with self-ligation is much less when the wire
is active, but this study also showed the considerable methodological problems in measuring friction with
active wires, the standard deviation of repeated measurements being very high. Sims et al (1994) still
found much lower friction with self-ligating brackets, even at high values of active torque.
Three papers by Thorstenson and Kusy have investigated aspects of this topic. Thorstenson and Kusy
(2001) examined the effects of varying active tip (angulation) on the resistance to sliding. They also found
that angulation beyond the angle at which the archwire first contacts the diagonally opposite corners of the
bracket slot causes a similar rise in resistance to sliding of both self-ligated (Damon SL) and conventional
brackets. However, at all degrees of tip, the Damon brackets produced significantly less resistance to
sliding (Table 11.2). At a realistic angulation of 6 degrees for an 0.018" x 0.025" stainless steel wire, the
difference is probably of clinical significance. The second paper (2002a) compared different self-ligating
brackets for resistance to sliding with active angulations. It quantifies a little more closely the lower
resistance to sliding with passive self-ligation and points out that low resistance to tooth movement can
lead to unanticipated movement as is mentioned later in this chapter. The third paper (2002b), examined
the same factors with wires of different sizes and in the dry state. The increase in friction when larger wires
deflect the clips in active self-ligating brackets is quantified and the scanning electron micrographs of the
different brackets show very clearly the relationship between small and large wires and active clips and
passive slides. Table 11.3 contains data from an abstract of work by Mah (2003), which used an
interesting methodology. A known tipping (angulation) moment was applied to brackets able to tip up to 20
degrees and the resistance to sliding was termed dynamic friction and measured for the four bracket types.
The reduced friction for both types of self-ligating bracket can be seen and the difference between In-
Ovation and Damon 2 was statistically significant. Further details from this study will be of interest, but to
Angulation Damon SL Conventional Minitwin Transcend In-Ovation Damon 2

(degrees) Bracket 6000
0 0 34 379 455 238 99
3.5 0 55
6.0 80 140
Table 11.2: Resistance to sliding (RS). for different bracket Table 11.3: Mean dynamic friction for different brackets with
angulations with a 0.018/0.025 archwire Forces in cN an applied tipping moment on a 0.019/0.025 stainless steel archwire.
Thorstenson and Kusy (2001) Forces probably in cN. Mah et al (2003)
date, no subsequent, fuller details of this work have been traced. The study supports the view that self-
ligation produces less resistance to tooth movement along an archwire in vivo. An interesting study by
Cacciafesta et al (2003) showed that Oyster polycarbonate self-ligating brackets had a much higher friction
than Damon 2 brackets. In fact the mean friction was more than double at 100gm compared to 40 gm for
Damon 2 and indeed was no different from conventional 3M Unitek Victory brackets with elastomeric
ligatures.
Friction in vivo – occlusal and masticatory forces

A further factor has been investigated in studies by Braun et al (1999) and O’Reilly et al (1999) who found
that various vibrations and displacements of a test jig (to mimic intra-oral masticatory forces) can
substantially reduce the friction with conventional ligation. This is a valid line of enquiry and an interesting
finding, but the question then arises as to how accurately these laboratory studies mimic intra-oral
masticatory ‘jiggling’ forces. The full interpretation of laboratory friction studies is clearly difficult and the in
vivo situation will show substantial variation. An impressive study by Iwasaki et al (2003) employed an
intra-oral device to produce a combination of tipping and ligation forces and measured the effect of
chewing gum on the resulting resistance to sliding. They concluded, “these results refute the hypothesis
that masticatory forces consistently and predictably decrease friction”. Measurement of the variables which
influence in-vivo friction will remain a challenge, but progress is being made. Meanwhile, the balance of
the current evidence from studies and from clinical experience is that self-ligation provides very significant
reduction in friction in all dimensions of tooth movement.
The clinical significance of low friction in isolation is hard to estimate and it is more helpful to consider the
combination of low friction and secure archwire engagement which self-ligating brackets provide.
Secure ligation and low friction as a combination

Other bracket types - most notably Begg brackets - have low friction by virtue of an extremely loose fit
between a round archwire and a very narrow bracket, but this is at the cost of making full control of tooth
position correspondingly more difficult. Some brackets with an edgewise slot have incorporated shoulders
to distance the elastomeric from the archwire and thus reduce friction, but this type of design also produces
reduced friction at the expense of reduced control, since the shoulders which hold the ligature away from
the archwire increase the slot depth and reduce the tension in the elastomeric. This reduces the control of
rotations or of labiolingual tooth position. Elastomeric rings cannot provide and sustain sufficient force to
maintain the archwire fully in the slot without also pressing actively on the archwire to an extent which
increases friction. Comparison with a molar tube is helpful in this context, since such an attachment is in
essence a passive self-ligating bracket with the slide permanently closed. If a convertible molar tube is
converted to a bracket by removal of the slot cap or straps, an elastomeric or even a wire ligature can
prove very ineffective at preventing rotation of the tooth if it is moved along the wire or used as a source of
intermaxillary traction. These ligation methods simultaneously increase friction while attempting to retain
full archwire engagement. An article by Matasa (2001), measured and illustrated the reduction in friction,
but the consequent reduced control with such bracket designs which diminish the tight fit of the elastomeric
around the archwire. The investigation into three such ‘low friction’ bracket types by Thorstenson and Kusy
(2003) also found no evidence that bumps in the floor of the archwire slots reduced resistance to sliding.
With tie-wing brackets and conventional ligation, an improvement in friction is usually at the cost of
deterioration in control. The combination of very low friction and very secure full archwire engagement in
an edgewise-type slot is currently only possible with self-ligating brackets (or with molar tubes!) and is likely
to be the most beneficial feature of such brackets. This combination enables a tooth to be slid along an
archwire with lower and more predictable net forces and yet under complete control with almost none of the
undesirable rotation of the tooth resulting from a deformable mode of ligation such as an elastomeric.
Anchorage consequences of low friction and secure full archwire engagement

This combination of properties can in turn conserve anchorage for three reasons:
• with low friction, the net tooth-moving forces are more predictably low and the reciprocal
forces correspondingly smaller.
• lower net forces facilitate release of binding forces between wire and bracket, enhancing
sliding of brackets along a wire.
• individual teeth - for example canines - can be retracted separately along an archwire and
thus potentially reduce the overall anchorage demands by reduction of the root area of teeth
to be moved at any one time, but with none of the potential disadvantages of other methods
of separate canine retraction with conventional brackets e.g.: loss of rotational control.
Following such separate canine retraction, the low friction of self-ligating brackets then
permits the sensible use of sliding mechanics to retract incisors even though there will now
be a minimum of three brackets distal to the remaining space through which archwire sliding
must occur. This applies equally to preservation of anterior anchorage in hypodontia cases.
Alignment of severely irregular teeth

The other situation in which the combination of low friction and secure full engagement is particularly useful
is in the alignment of very irregular teeth and especially the resolution of severe rotations where the
capacity of the wire to slide through the brackets of the rotated and adjacent teeth significantly facilitates
derotation. This relationship between friction and derotation has been described and quantified by Koenig
and Burstone (1989) and the potential adverse forces shown to be very large. Low friction therefore
permits rapid alignment and more certain space closure, whilst the secure bracket engagement permits full
engagement with severely displaced teeth and full control whilst sliding teeth along an archwire. Modern,
low modulus wires substantially enhance our ability to harness these benefits.
It is this feature which greatly facilitates the alignment of crowded teeth without extractions if this is the
desired treatment goal.
Less chairside assistance and faster ligation/ archwire removal

The original motive when developing the earlier self-ligating brackets was to speed the process of ligation.
For example a paper by Maijer and Smith (1990) demonstrated a fourfold reduction in ligation time with
Speed brackets compared to wire ligation of conventional brackets. Shivapuja and Berger (1994) have
shown similar results but also that the speed advantages compared to elastomeric ligation are less
dramatic (approximately one minute per set of archwires). Voudouris (1997) has also reported a fourfold
reduction in archwire removal/ ligation time with prototype Interactwin brackets. A study by Harradine
(2001) found statistically significant but clinically much more modest savings in ligation/re-ligation time with
Damon SL - an average of 24 seconds per archwire removal and replacement. It should however be
remembered that archwire 'ligation' using self-ligating brackets does not require a chairside assistant to
speed the process, since self-ligating brackets require no passing of elastomeric or wire ligatures to the
operator during ligation. Although we feel
that this is the least significant advantage of
10 self-ligation, it is still perhaps worthwhile.
9
8 Turnbull and Birnie (2006) investigated the
7 difference in time taken to open and close
6 brackets for different archwire groups with
seconds
5 Orthos and Damon 2 brackets. The

4 archwire groups were defined as:
3
2
1
• 0.014”, 0.016” and 0.018”
0
nickel titanium
1 2 3 4 • 0.014” x 0.025”, 0.016” x
Wire group 0.025” and 0.016” x 0.022”
nickel titanium
Damon open Orthos open
• 0.018” x 0.025” and 0.019” x
Damon close Ortho close
0.025” nickel titanium
Figure 11.2: Opening and closing times per bracket for Damon 2 and
• 0.018” x 0.025” and 0.019” x
Orthos brackets for various archwire groups (from Turnbull and Birnie 2006)
0.025” stainless steel
The authors found time savings slightly greater than those of Harradine with Damon 2 brackets being 1
second per bracket for opening brackets and 2 seconds per bracket for closing brackets. It was twice as
quick to close Damon 2 brackets as to ligate Orthos brackets. For both bracket systems, the time taken to
ligate and unligate archwires decreased with increasing archwire size (and correspondingly better tooth
alignment) as shown in Figure 11.2.
SDS Ormco Damon system

Damon SL brackets
These self-ligating brackets became available in 1996. They had a slide which moved vertically on the
labial surface of an otherwise fairly conventional twin tie-wing bracket. The slide clicked into a positive
open or shut position and opened in a downward direction in both jaws to give a full view of the slot. A tiny
U-shaped wire spring lay under the slide and clicked into the two labial ‘bulges’ on the slide to provide
positive open and shut positions. These brackets were a major step forward, but suffered two irritating
problems - the slides inadvertently opened and were prone to breakage. The study by NH (2001)
quantified these problems. In 25 consecutive cases in treatment for more than one year, 31 slides broke
and 11 inadvertently opened between visits. This compared with 15 broken and lost elastomeric ligatures
in 25 consecutive cases treated with conventional brackets. Slide breakage was due to work hardening of
the slide corners. The loss of slide was sometimes due to breakage but was also due to the considerable
overall length of the slide and the play in the slide/bracket contact. These permitted over-opening of the
slide which could pass beyond the stop provided by the underlying U-shaped wire.
Damon 2 System brackets (D2)

The imperfections in the Damon SL led to the development of Damon 2 System brackets which retain the
same vertical slide action and U-shaped spring to control opening and closing, but place the slide within
the shelter of the tiewings. Combined with the metal injection moulding manufacture, which permits closer
tolerances, these developments almost completely eliminated inadvertent slide opening or slide breakage.
Although special and excellent slide-opening tools are provided with these brackets, they can after a little
practice be easily opened and closed with conventional light-wire pliers. A side effect of this design change
has been to reduce the overall size of the bracket to very compact dimensions, which is a significant
advantage - the greater interbracket span giving lower forces - but with the full wire engagement retaining
good control. Scope remained for further improvement in the ease and consistency of opening and closing
the slides. Whilst the slide closure is very secure, the close fit causes the force required to open the slide
to vary. The more recent introduction of metal injection moulded slides has delivered a more consistent
force. These continuing developments are typical of self-ligating brackets and illustrate the considerable
technical demands in manufacturing an ideal bracket. One unique and useful feature of the slides on all
Figure 11.3: The Damon SL bracket Figure 11.4: The Damon 2 bracket Figure 11.5: The Damon 3 bracket
(1996) (2000) (2004). Slide opening is with a tool which
engages the labial aperture. Slide closing is
by finger pressure.
Damon brackets is that they open inferiorly in both arches in order to give an unobstructed view of the slot.
Damon 3 brackets (D3)

These brackets have three major changes from previous Damon brackets.
• a tooth-coloured composite resin base and upper tie-wing which reduces the visual impact of
the bracket
• a completely new vertically-placed chair-shaped spring clip behind the slide. This has
produced a slide which is extremely easy and consistent to open and close. The slide is
closed with finger pressure and has a positive tactile and audible signal when fully closed. It
is opened with a special opening tool resembling a modified blunt dental probe. The
technique is to slide the point of the tool down the V-shaped ramp on the front of the slide
until it engages in the small hole at the base of the slide; pressing inwards while continuing
to press downwards releases the clip.
• a rhomboidal shape of the bracket and slide which facilitates bracket siting
The ease of use of the slide mechanism is a huge improvement over previous versions of the Damon
bracket. Initial problems with bracket retention were addressed by a specific adhesive – Blugloo – which
has an acrylic resin and therefore binds chemically to the bases. The security of the union between the
metal and composite components of the bracket also required further development in the form of additional
retentive metal tags. The robustness of the composite tie-wings in the long-term and in deep bite
malocclusions remains to be evaluated, but the advent of Damon MX brackets greatly diminishes that
issue.
Damon MX brackets
These brackets are all-metal and have essentially the same slide mechanism as D3 with further
refinements. They are designed to be fully compatible with D3. They have a vertical slot behind the
archwire slot into which prefabricated click-in auxiliary hooks can be added to any bracket as required.
Bracket identification
The Damon 2 System has a variety of possible prescriptions for incisors and canines making it a semi-
custom appliance system.
In selecting a semi-custom prescription it is sensible to start with the standard prescription and decide what
departures are necessary from this prescription. The only parameter that varies in the variants of the
Damon System 2 appliance is inclination. Generally, err on the side of overcorrection; so if correcting
retroclined upper incisors, choose a bracket with a higher inclination to try and achieve a measure of over-
correction.
Figure 11.6: The Damon MX Figure 11.7: The Damon MX bracket Figure 11.8: The Damon MX
bracket (2005). Slide closed (2005). Slide open bracket (2005). Bracket ID in slot base
st nd
Upper arch Central Lateral Canine 1 premolar 2 premolar
Colour code Blue Pink Light blue Purple Purple
Damon standard
ID Distogingival dot Distogingival dot Distogingival dot \ Distogingival dot Distogingival dot
/// notches /// notches
Prescription 5°/7° 9°/3° 6°/0° 2°/-7° 2°/-7°
Roth
ID Distogingival dot Distogingival dot Distogingival dot
occlusal tie wing occlusal tie wing occlusal tie wing
dash dash dash
Prescription 5°/12° 9°/8° 6°/-7° 2°/-7° 2°/-7°
Super torque
ID Distogingival dot Distogingival dot
- black - black, notch
Prescription 5°/17° 9°/10° 6°/-7° 2°/-7° 2°/-7°
Damon 6°/7° Distogingival dot /
st nd
Lower arch Central Lateral Canine 1 premolar 2 premolar
Colour code Yellow Yellow Light blue Whhhiiittteee
W
W Red
Damon standard
ID Distogingival dash Distogingival dash Distogingival dash Distogingival dash Distogingival dash
\ // notches /// notches
Prescription 2°/-1° 2°/-1° 5°/0° 2°/-17° 2°/-22°
Damon 5°/7° Distogingival dash
/
Damon 2°/-6° Distogingival dash Distogingival dash
Table 11.3: Bracket identification and prescription variations for the Ormco Damon System appliance
The prescription options that are available together with their identifying characteristics are shown in Table
11.3. The only identification problem is between Damon Standard (2°/-1°) and Damon (2°/-6°) which have
the same identification markings; the two brackets can be distinguished by careful inspection. We routinely
use the prescription with –6° torque.
The Damon 3 System is only available in the standard Damon prescription at the moment and uses
Ormco’s FacePaint colour identification system which is identical to the coloured dots used on Damon 2
System brackets.
Ultradent Opal brackets

This is one of two currently available brackets which are entirely non-metallic. We have used Opal
brackets on a significant number of patients. They were designed and developed by Professor Norbert
Abels. The material has to meet the difficult challenge of being sufficiently rigid to function as an effective
bracket slot, transmitting the forces as intended, whilst also being sufficiently flexible in the hinge area to
open and close. The OPAL design is rather ingenious in this respect but care must be taken not to fatigue-
fracture the thin hinge part of the bracket by repeated full opening of the cap. Also the cap has to be
sufficiently robust to withstand the sharpness of the opening tool and the bond strength needs to withstand
the leverage of the initial opening of the cap. The brackets, like most resin brackets, are perhaps best
suited to short courses of treatment where these problems of longevity are less of an issue. There are no
tie-wings, so elastic chain is placed in the auxiliary slot prior to closing the cap.
The other polycarbonate self-ligating bracket is the Oyster, made by Gestenco. An interesting study by
Cacciafesta et al (2003) showed that Oyster brackets had a much higher friction than Damon 2 brackets
and were indeed no different from conventional 3M Unitek Victory brackets with elastomeric ligatures. This
indicates that the lower friction inherent in passive self-ligation counteracts the known higher friction for
Figure 11.9: The Ultradent Opal bracket. The hinge is on the Figure 11.10: The Opal bracket with hinge open
right and the potential auxiliary slot on the left next to the point of
application of the opening tool.
polycarbonate brackets and makes Oyster brackets equivalent to conventional stainless steel brackets in
this respect. We have not used Oyster brackets.
GAC In-Ovation brackets

These brackets have more recently been re-branded as “System R”. These are very similar to the SPEED
bracket in conception and design, but are of a twin configuration. They are a good, robust design and no
inadvertent opening or slide breakage has been personally experienced or reported. The slides are very
easily closed once the wire is fully engaged. Some relatively minor disadvantages are apparent in bracket
handling:
• some brackets are hard to open. This is unpredictable, but more common in the lower arch
where the gingival end of the spring clip is difficult to visualise. Excess composite to the
gingival of lower brackets can be hard to see and may hinder opening. The Opin R version
(Figure 11.12) should alleviate this problem.
• these brackets are extremely easy to close
inadvertently before the archwire is in
position and the downward direction of
closure makes this more likely in the lower
arch.
• the security of closure of the flexible clip
can be overcome by some rectangular
nickel-titanium wires, which can cause
spontaneous opening of the clip. This
applies more to the narrower R versions of
the bracket with their narrower slides.
• it is possible - as with the Damon 2 bracket
slides - to incompletely open the clip and
Figure 11.11: The Figure 11.12: The discover the need for the final fraction of
GAC In-Ovation bracket more recent Opin R version opening through difficulty with removing a
of the GAC In-Ovation thicker archwire.
bracket permits opening of
the clip using a probe in the • when using wire-ligature underties to
labial notch arrowed maintain space closure or lacebacks
across extraction spaces, the spring clips
are a real nuisance in competing for the space behind the tie-wing.
In 2002, narrower brackets for the anterior teeth became available – In-Ovation R (Reduced). This
narrower width is welcome in terms of greater inter-bracket span. In-Ovation brackets have an active clip
and this is discussed in the next section.
Bracket identification
The GAC In-Ovation bracket system uses an active clip. It uses the same colour identification system as
the Ormco Damon System 2 but is only available in
the Roth prescription.
3M Unitek SmartClip brackets

This bracket which became available in 2004 is a
conventional bracket with additional nickel-titanium
spring clips mesial and distal to the tie-wings (Figure
11.13). It is a passive self-ligation system. It is still
too early to comment in depth from our clinical
experience with this bracket, but the following points
Figure 11.13: 3M Unitek SmartClip bracket are pertinent.
• the insertion of small diameter archwires is easy.

• removal of archwires with the special tool needs a little practice but is easy with small
diameter wires
• the spring clip has to cope with providing easy insertion and also no inadvertent loss of
ligation for both small flexible and large stiff archwires. This is a testing requirement. Other
spring clips (such as on SPEED brackets) with their vertical action have a rigid bracket
component to assist the spring in resisting loss of ligation. The spring on the SmartClip has
to cover the wide range of requirements for different wire sizes with one shape and stiffness
of spring unaided by a rigid component.
• removal of larger, stiffer wires means overcoming an advertised 2 kilograms of force per
bracket with a labially directed force. The question arises as to how comfortable and easy
this will prove, especially if the teeth on either side of that bracket are also engaged on the
archwire. This force seems high to the operator and to the patient and recently the
manufacturers have responded by introducing a more flexible clip. This should permit easier
removal of thicker archwires, but may make spontaneous clip opening more frequent – time
will tell.
• the effective width of the bracket is wider than for most other self-ligating brackets which
have taken advantage of the more secure, full ligation of self-ligating brackets to reduce
bracket width, thus lowering forces with no loss of tooth control. The wider SmartClip
brackets reduce the inter-bracket span and would be expected to provide higher forces.
Active clip or passive slide?

This is an issue which has attracted heated debate (Matasa 1996). It is therefore worth a detailed
consideration.
Speed and In-Ovation brackets both have a sliding spring clip, which encroaches on the slot from the labial
aspect, potentially placing an active force on the archwire. Time brackets have a similar clip but for closure
it rotates round a tie-wing rather than slides into place. These three brackets all have potentially active
clips. In contrast, Damon brackets have a slide which opens and closes vertically and creates a passive
labial surface to the slot with no intention or ability to invade the slot and store force by deflection of a metal
clip. Smartclip is also a passive system.
The intended benefit of storing some of the force in the clip as well as in the wire is that in general terms a
given wire will have its range of labiolingual action extended and produce more alignment than would a
passive slide with the same wire. This needs more detailed consideration. It is perhaps helpful to think of
the situation with three different wire sizes.
• with thin aligning wires smaller then 0.018" diameter

The potentially active clip will be passive and irrelevant unless the tooth (or part of the tooth
if it is rotated) is sufficiently lingually placed in relation to a neighbouring tooth that the wire
touches the clip. In that situation, a higher total force will usually be applied to the tooth in
comparison to a passive clip. Even if there is no significant clip deflection there is still a
force on the wire which would not exist with a passive clip because the active clip effectively
reduces the slot depth from 0.027" (the depth of a Damon slot) to approximately 0.018",
either immediately - if the clip is not deflected - or as the wire goes passive if it is deflected.
This additional force is unlikely to be detrimental with modern low modulus wires but should
be borne in mind. For teeth which were initially placed lingual to their neighbours, the active
clip can bring the tooth more labially (up to a maximum of 0.027 - 0.018 = 0.009 inches) with
a given wire. These figures are slightly complicated by the fact that the active clip does not
reduce the slot depth to the same extent over the whole height of the slot - the clip on
Speed, Time and In-Ovation brackets impinges into the slot more at the gingival end than at
the occlusal. This is well visualised in the illustrations in Thorstenson and Kusy (2002b).
This asymmetry would make a difference with small diameter wires depending on the
relative vertical positions if neighbouring teeth. The effect of having an active clip at this
early stage of treatment can be thought of as having a potentially shallower bracket slot.
This will frequently produce higher forces with a given wire but a potential maximum extra
0.009" of labial movement of some teeth for a given small diameter wire. This figure is
approximate for the reasons given above.
• for wires > 0.018" diameter
The active clip will place a continuous lingual force on the wire even when the wire has gone
passive. On teeth which are in whole or in part lingual to a neighbouring tooth, the active
clip will again bring the tooth (or part of the tooth if rotated) slightly more labial than would
have been the case with a passive clip at 0.027" slot depth. The maximum difference will be
the difference between the labiolingual dimension of the wire and 0.027". For a typical
0.016" x 0.022" intermediate wire, this would give a maximum difference of 0.005". 0.016" x
0.025" or 0.014” x 0.025” nickel titanium wires are recommended as the intermediate
aligning wire for Damon and this wire reduces this potential difference to 0.002". Lingually
placed teeth would have a slightly higher initial force with an active clip and wires of this
intermediate size. With an active clip, an active
lingually-directed force will remain on the wire
even when it is passive
• with thick rectangular wires
An active clip will probably make a labiolingual
difference in tooth position of 0.002" or less which
is very small. The suggestion that continued
lingually-directed force on the wire from an active
clip (or from a conventional ligature) will cause
additional torque from an undersized wire is
interesting and probably reflects a degree of
misunderstanding about the generation of torque
Figure 11.14: Diagram of a SPEED bracket in an edgewise slot. Figure 11.14 shows that
with conventional and bevelled rectangular wires, whatever the orientation or shape of the
both showing the reduced gingival slot wall depth rectangular wire, the clip in fact places a
and consequent reduction in torquing ability in one diagonally directed lingual force on the wire which
direction. Torque rails on some brackets with a
correspondingly narrower clip are intended to does not contribute to any third order interaction
address this issue. Selective use of significantly between the wire corners and the walls of the
higher palatal root torque values would be sensible bracket slot - which is the origin of torquing force.
in upper incisor brackets In fact, the need for an active clip to invade the
slot reduces the available depth of one side of the slot and this means the rectangular wire is
not fully engaged. This increases the ‘slop’ between the rectangular wire and the slot and
also reduces the moment arm of the torquing mechanism. Errors in torque can appear as
errors in height or as labiolingual contact point errors. SPEED brackets have recently
addressed this problem on upper incisors by extending the gingival walls of the slot either
side of the clip as “torquing rails”. This should indeed restore the torquing effectiveness, but
at the cost of a reduced mesiodistal width of the clip and therefore reduced rotational control
in a bracket which is already narrow. In-Ovation brackets have a small central portion of the
slot wall which is at the full slot depth and provides full torquing capacity on that section.
Another possible response to this potential problem is to place higher torque values in the
direction of the inefficiency in torquing – the problem only existing in one direction for a given
bracket. This would need to be selectively applied to prevent certain teeth being
overtorqued in the opposite direction.
Overall advantages or disadvantages of an active clip

The actual clinical consequences of having a potentially active clip impinging into the slot are perhaps
harder to assess than a first thought suggests. It is probable that with an active clip, initial alignment is
more complete for a wire of given size to an extent which is potentially clinically useful. However, the
increased clearance between a given wire and a passive slide will generate lower forces and may facilitate
dissipation of binding forces and the ability of teeth to push each other aside as they align.
With modern low modulus wires it is possible to subsequently insert thicker wires into a bracket with a
passive clip and arrive at the working archwire size after the same number of visits – ie: to store all the
force in the wire rather than dividing it between wire and clip. The relative stiffness of archwires and the
spring clip is not well documented. If it is assumed that the spring clip has the same stiffness as the thicker
nickel titanium wire, then both mechanism would produce the same labiolingual aligning force.
Once in the thick working archwire, the potential disadvantages of an active clip are increased friction and
potentially reduced torquing capacity in one direction. To put the friction levels in context, these higher
friction forces are still much lower than those found with elastomeric ligatures on a conventional tie-wing
bracket. All other factors being equal, higher friction is a disadvantage, but again it is hard to assess the
loss of clinical performance which arises from this level of increased friction. Finally, there are the
questions of robustness, security of ligation and ease of use. Is a clip, which is designed to flex, more
prone to breakage or permanent deformation or to inadvertent opening or closing? This question has not
been formally investigated.
Aging
Eliades and Bourauel (2005) have mentioned the possibility of the clips on active self-ligating appliances
aging as a result of repeated activations within the oral environment thus reducing the pressure applied to
the archwire. Both nickel-titanium and stainless steel alloys undergo significant reduction in their force
delivery characteristics as a result of intraoral exposure.
In fact a similar argument can be levelled against passive self-ligating appliances which may be subject to
wear of the indent that holds the clip shut as a result of repeated opening and closing.
There is little direct evidence to support either of these hypotheses but both remain possibilities.
Conclusion
The question of active clip or passive slide may not be the most fundamental aspect of self-ligation, but it is
clear that lower force levels are achieved with passive self-ligation. This issue may also be related,
through associated design features, to other factors such as security of ligation or ease of use. Although
the different effects can be elucidated, it is hard to weigh the extent to which the differences between active
and passive affect clinical performance. However, it is hoped that this section of the chapter usefully
informs a consideration of the claims made in this context.
Clinical tips when using self-ligating

brackets
These tips apply in varying degrees to all self-ligating brackets.
Further clinical tips in the review article by NH (2003).
Changing treatment mechanics

It is useful to briefly list some of the ways that treatment can be
changed to take advantage of the combination of low friction
and full, secure bracket engagement.
Figure 11.15:
Longer appointment intervals
TP Traction Hook used to bring
upper lateral incisor into the line of the arch while
The ability to ensure full and secure wire engagement of
space opening is occurring. The low friction facilitates
space opening. modern, low modulus wires makes an extension of the interval
between appointments a logical step. Eight to ten-week
intervals are usually appropriate. This is a clear advantage for operator and patient.
More traction on lighter wires

The increased effectiveness of light forces and the decreased loss of control combine to enable more
mesiodistal tooth movement to be sensible on lighter, more flexible wires. Compressed coil springs to
move teeth apart can appropriately be placed from the first visit in many instances.
Separate movement of individual teeth

The control of rotation during traction on an individual tooth makes this option much more attractive when
required. This can conserve anchorage in a variety of situations without a penalty in loss of tooth control or
disproportionate lengthening of the treatment.
Parallel processing
These mechanical features make it sensible in some malocclusions to retract separately canines to a class
1 relationship whilst simultaneously reducing the overbite. By the time the overbite reduction permits upper
incisor retraction, the canines are already class 1, but in good rotational control and the case is further
advanced with anchorage conserved.
Squeezing teeth into alignment

Crowded teeth seem to align more rapidly. If the clinician wishes to align crowded teeth without making
space with extractions, these brackets facilitate the alignment. Some clinicians, for example Dwight
Damon, have exploited this capacity to an impressive extent. Very interestingly, randomised prospective
studies by Peter Miles (personal communication) in press with the Angle Orthodontist have shown no
measurable increase in initial alignment at 10 and 20 weeks comparing both Damon 2 and Smartclip
brackets with conventional ligation. Perhaps, the cases were not sufficiently irregular to show a difference,
perhaps the clinical impression of faster alignment is incorrect, perhaps it is better control of alignment in
the later stages that is more significant in potential reduction of treatment duration. Time and further study
will tell.
Bracket placement and bond-up

Bracket placement as always is critical to the long-term success of the treatment. It is felt that normally,
both maxillary and mandibular arches should be bonded at the same time and that bonding should include
second molar to second molar in each arch. It is routinely possible to take records (photographs and study
models), bond second molar to second molar in each arch and place upper and lower archwires in 60
minutes.
For teeth that are well displaced from the archwire or where there is insufficient space to place a bracket in
an ideal position, it is helpful to use a TP Traction Hook 224-011 to gain some early control of these teeth;
this can be used to either tie the tooth to the archwire with Power Tube (normally with a space opening coil
spring) or to pass through the archwire through the lumen of the traction hook to facilitate early alignment
of the tooth. For rotated teeth, it is useful to offset the traction hook so that it is on the part of the crown
furthest from the line of the arch to gain some spontaneous derotation.
Ormco Damon 2 System

Bracket placement is initially a little tricky and takes some getting used to. This is because all the Damon
System 2 bracket bodies are rectangular but the edges of the pad are shaped to give the orthodontist the
siting cues. The consequence of this is that it is sometimes possible to place the brackets so that the tip is
not fully expressed. Damon 3 and Damon MX are rhomboidal brackets.
Opening and closing

There are three components to handling archwires with self-ligation – locating the archwire in the slot,
closing the slide or clip and opening the slide or clip.
Vision
In order to close and open the doors or clips easily, it is
necessary to be able to see clearly whether the archwire is
fully seated in the slot or not. Most problems in closing the
doors are due to failure to fully locate the archwire in the slot.
It is strongly recommended that operators work under mild
magnification (1.5 to 3 times) in order to visualise the
relationship between the archwire and the slot. Magnifying
loupes do not need to be expensive or elaborate. We have
experience of Donegan Optical Company’s OptiVisor
(extremely practical but not very elegant! Guide price £40.00),
the Edroy Products Opticaid (practical, fits existing glasses,
guide price £25.00) and NuView’s Voroscope MXL (variety of
magnification and excellent light source, approximately
£400.00). The Voroscope now comes with an LED light which
Figure 11.16: The NuView Voroscope MXL extends the (rechargeable) battery life considerably and has a
slightly bluish white light.
Locating the archwire in the slot

With self-ligating brackets it is much more important to fully engage the wire before clip closure rather than
attempt to close the clip and simultaneously engage the wire (with SmartClip brackets, this separation of
engagement and closure is not possible). There are three reasons why an archwire does not seat in the
slot:
• there is something in the slot preventing the archwire seating

• the archwire is not sufficiently deflected (but can be) to seat fully in the slot
• the archwire cannot be deflected (too stiff) to seat fully in the slot
Plaque or food debris in the slot can be sufficient to prevent the archwire seating fully in the slot; it is
suggested that at each visit after the removal of the archwires, patients are given a disposable pre-pasted
toothbrush (e.g.: Plak Smacker Pre-Pasted Disposable) to clean their teeth with before the new archwire is
placed. This both emphasises the importance of good oral hygiene and ensures that the slots are brushed
clean. If this is not possible, then blowing out the slots and tubes with a 3-in-1 syringe will achieve the
same effect. Occasionally, some calcified material will be found in the slot and this needs to be removed
by the orthodontist.
Key Point:
If you cannot see that the archwire is fully seated in the slot then the door will not close; either remove
any debris from the archwire slot, deflect the archwire further or choose a less stiff archwire
Tools
If the wire is passive labiolingually, a tool is not required. Finger pressure is often sufficient to engage early
aligning wires. However, if archwire engagement and clip/slide closure is difficult for a particular tooth,
several practical tools and techniques are worth knowing.
• for Damon 2 brackets: where a tooth is significantly displaced from the line of the arch, it
may help to half-close the door, tuck the archwire behind the half-closed door and then fully
close the door.
• for all bracket types, the wire can be held into the slot with a variety of tools or instruments.
Simple tools such as an amalgam plugger, ligature tucker, or Mitchell's trimmer may suffice.
However, these only push on one side of the bracket and may fail to fully engage the wire
across the whole width of the slot. The Cool Tool (see below) is excellent and pushes on
both sides of the bracket.
• whereas engagement of an irregular tooth with an elastomeric ligature can involve
considerable pulling on the tooth, with a self-ligating bracket, a pushing force is required.
Reduction of a pulling force on the tooth when placing an elastomeric is difficult, but it is easy
to reduce the net push on the tooth when engaging a wire in a self-ligating bracket – use a
labiolingual “squeeze technique”. As you push from the labial (e.g. with a Cool Tool), also
push the tooth from the lingual/palatal with a thumb of the same hand. The net force on the
tooth is greatly reduced and the wire is fully engaged more easily and comfortably
• if the tooth is very rotated and one end of the slot is too close to the adjacent tooth for an
instrument to be used to seat the wire, dental floss or a ligature wire looped over the
archwire can be used to fully engage the wire on that side
• another occasionally useful manoeuvre on a very rotated or displaced tooth with any self-
ligating bracket, is to first close the clip or slide and then thread the aligning wire through the
closed bracket before engaging the other brackets i.e.: to first convert it to a ‘molar’ tube!
• once the wire is fully engaged, In-Ovation brackets, Damon 3 and Damon MX brackets and
Speed brackets can be closed with a finger. Damon 2 brackets can be closed with ordinary
light-wire or bird beak pliers
• American Orthodontics/Adenta Time brackets are opened with a probe or other fairly sharp
instrument such as a Mitchell’s trimmer using the hole in the clip. Speed brackets and In-
Ovation (System R) brackets can be opened by vertical pressure on the tail of the clip
behind the bracket (eg: with a Mitchell’s trimmer) or can be opened via the hole/notch in the
labial surface of the clip (e.g. with a probe).
THE COOL TOOL
The Cool Tool is a specific tool which is rather akin to a

torquing key. Dwight Damon has developed this instrument
for engagement of wires, via balanced pressure on both
sides of the bracket. GAC has more recently developed the
R tool, which resembles a double ligature tucker and works
in the same way. These specific tools work very well and
can reassure the clinician that slide closure is not being
attempted over an incompletely seated wire. They can also
assist cheek/lip retraction during slide closure and such a
Figure 11.17: he Cool Tool facilitates archwire tool is firmly recommended as a routine part of slide closure
engagement when necessary. on teeth where the wire requires lingual pressure for full
engagement. With thermally active wires, it is theoretically
Plier/Tool Locating archwire in slot Closing door Opening door

Damon Cool Tool
Damon double-ended tweezer
Damon closing pliers

RDK Kasso D2 plier
Non specialist plier
Table 11.4: The relative effectiveness of different tools in locating the archwire in the slot, closing and opening the doors in the Damon
System 2 appliance
easier to insert a wire in some awkward teeth if the Cool Tool is kept in the freezer (as its name suggests).
ORMCO DAMON 2 SYSTEM
The Damon 2 system is unusual in always requiring an instrument to close the slide. Other brackets can be
closed by finger pressure unless there is no space for the finger around a tool being used to fully engage
the archwire, in which case any slim instrument can serve instead of the finger.
It can be seen from Table 11.4:, that there is no single tool that performs all three actions required to close
the doors at the highest level. The best all-round tool was the Damon double-ended tweezer which is very
good at locating the archwire and reasonably good at opening and closing the doors. It is important to hold
this tool at right angles to the bracket to ensure that it opens and closes the slide without slipping. The
door slide was modified in 2004 to have a slightly thicker ‘lip’ that facilitates the use of the double-ended
tweezer. For closing the doors, it is helpful to use it with a ‘two-handed approach. For example, to close a
lower central incisor bracket, hold the tweezer in the right hand and use it to locate the archwire in the slot;
place the thumb of the left hand behind the tooth to support it and then use the index finger of the left hand
to close the door while the right hand uses the tweezer to press the archwire into the slot. It requires a
modest amount of force to close the doors and applying the force close to the end of the tweezer makes
closure much easier than attempting to do it in a rather daintier fashion! Unfortunately, manufacture of the
tweezer has now been discontinued as it has proved very useful for engaging and closing D3 and D3 MX
brackets!
The Damon closing plier resembles modified distal end cutters. It is excellent for closing the doors but less
good for opening the doors in the lower premolar regions. They work better if there is a slight downward
rotation to the opening movement.
The RDK Kasso D2 plier is slightly more difficult to use than the Damon closing plier but opens and closes
the doors without difficulty. These pliers may be recommended for all first-time users since they make all
slides very easy to open. Importantly, no downward rotation is required
when using these pliers. For more experienced users, the recent
redesign of the lower second premolar brackets has made opening and
closing easier with the standard Damon pliers.
Finally it should be said that the doors can be opened and closed with
almost any plier (bird-beaks, light-wire pliers, Weingart utility pliers)
although this is marginally more difficult than using a specialist plier.
DAMON 3 AND DAMON MX
The opening and closing of these Damon brackets is much easier than
with the Damon 2 System. The brackets can be closed with finger
pressure and a simple tool resembling a modified probe is used to
open the bracket. It is as easy as that!
Figure 11.18: RDK Specialties
Kasso D2 plier
Archwires
Biting out
Initial placement
When placing the initial archwires, do not include the second molars. The patient will frequently bite an
0.014" archwire out of the second molar tubes; it is better to terminate the archwires at the first molars for
the first visit and then pick up the second molars on the first nickel titanium rectangular archwires (0.014" x
0.025" or 0.016" x 0.025").
Long unsupported spans

• use tie-backs with flexible wires over extraction sites to lessen the effects of occlusal forces
on unprotected spans of wire
• use small tubes bonded to deciduous teeth to reduce the length of the span
• support the wire with lengths of hard tubing just shorter than the unsupported space to allow
for tooth movement
Prevention of ‘swivelling’
Low friction increases wire displacement. Ironically, the problems of wire displacement resulting from low
friction are perhaps the most convincing and immediate clinical evidence that the low friction found in
laboratory studies is readily apparent in vivo. Even with very irregular teeth, the very low friction with self-
ligating brackets, especially in bracket systems that use a passive slide, enables aligning archwires to slip
through the brackets and an archwire end to protrude. This is clearly a potential nuisance. Steps to
prevent this can include:
• small sections of stainless steel tube crimped onto the archwire. This is quick, easy,
versatile and recommended. 0.5 mm tubing (approx. 0.020" internal diameter) is a good
size for smaller diameter wires. With larger wires, 0.7 mm tubing is required, but a crimp-on
hook may be a better option since it is harder to crimp tubing securely onto the flat surface of
a rectangular wire. Stops are usually placed in the lower anterior region and in the upper
premolar region and should normally be placed anterior to the crowding – one is usually
sufficient unless there are very long interbracket spans (such as partial fixed appliances in
the mixed dentition) when one either side of a bracket may be required. It is recommended
that the stop is not placed on a significantly active part of the archwire. This would diminish
the range of action of the wire where it is most needed
• placing a crimpable split stop on the archwire. Two sizes are available – 0.016" and 0.022"
and are available from manufacturers such as 3M Unitek and Orec Speed.
• Damon archwires are now available with small sections of steel tube already loaded and
temporarily fixed in the midline by wax. This stop can be moved to the desired position and
crimped. This is very convenient.
• flowable composite (e.g. Kerr Revolution 2) can be bonded to the archwire. The archwire
must be dry.
• thorough turning in the ends of flexible archwires. An interesting innovation in this respect is
the Bendistal plier described by Khouri (1998). This is designed to place an effective distal
end bend in a superelastic wire without the need for over-bending which can be difficult and
uncomfortable and also risks the loss of a bonded molar tube
• selective locking of individual brackets to the archwire with elastomerics can be helpful in
those designs which have a full conventional tie-wing assembly
• small V-shaped notches in the midline of flexible wires can also limit the scope for wire
swivelling. These are commercially available or can be bent into nickel-titanium wires with
triple beak pliers. Pre-notched wires are usually more expensive. Sometimes in the lower
arch the notches are too large for the available inter-bracket span. Also, some notches can
creep into the adjacent bracket and cause irregularity of that tooth. For these reasons, this
particular method is not personally recommended
Archwire Sequence
Ormco Damon brackets systems
Archwire sequencing is a little different with self-ligating brackets principally because of their excellent
control between bracket and archwire. It is important to give each archwire time to work out fully and so
treatment intervals of 8-10 weeks are suggested. For patients with very irregular teeth, it may be
necessary to continue the initial archwire for more than one visit; the emphasis is on light forces and giving
the archwires the time to fully express their potential aligning capacity.
The primary archwire sequence is as follows:
• 0.014" nickel titanium superelastic

• 0.014" x 0.025" nickel titanium superelastic
o consider an OPG once this wire has been in place for one visit to check root
angulations
• 0.019" x 0.025" nickel titanium superelastic
• 0.019" x 0.025" stainless steel
Where teeth are significantly displaced from the archwire and there is insufficient space to accommodate
them in the dental arch, space should be made using an open nickel titanium coil spring. The coil spring
should be approximately one bracket width wider than the space in which it is going to fit for normal
interbracket spans. At the same time, a narrow attachment, such as a TP Traction Hook, should be
bonded to the displaced tooth and tied on to the archwire with elastic thread (e.g.: PowerTube). This
prevents proclination of the teeth during space opening by placing a lingual or palatal restraining force on
the arch wire and speeds up the alignment process. Once sufficient space is available and the displaced
tooth is close to the line of the arch, an initial aligning archwire can be placed through the traction hook to
bring the displaced tooth into the arch prior to replacing the traction hook with a self-ligating bracket. Once
tooth alignment has been achieved, a continuous wire ligature can be used to prevent space opening up in
the labial segments.
Secondary archwires and wires are as follows:
• 0.016" x 0.025" nickel titanium superelastic archwire

o this archwire is useful in cases with less irregularity as the next archwire step from the
initial 0.014" nickel titanium superelastic archwire
• straight lengths of 0.014" x 0.025" or 0.019" x 0.025" nickel titanium superelastic archwire
o used for crossbite correction requiring arch expansion. Evidence on effectiveness
required.
• 0.019" x 0.025" RCOS (reverse curve of Spee) nickel titanium superelastic archwire
o used for managing deep overbites in both the upper and lower arches
• 0.019" x 0.025" RCOS nickel titanium superelastic torqued (SET) archwire
o used where additional torque is required
• 0.019" x 0.025" TMA
o useful for individual tooth movements at the end of treatment where archwire bends are
required, especially for inclination (torque) adjustments. Consider using low friction
variants if space closure required on this archwire
• 0.021" x 0.025" TMA
o used if full expression of bracket prescription is required; however not always as
effective as one might think and may require other solutions
Distal ends
There is no need to turn down the distal ends of the archwires as the wires are already stopped by the
crimpable stop. In addition, turning down archwires distal to second molars is a frequent source of soft
tissue trauma. Archwires should be cut flush with the distal end of the tube on the terminal molar. We
experience no debonding of molar tubes when using distal end cutters and this may be partially due to
taking care that the plane of the distal end cutters is the same as the archwire plane i.e.: the plane of the
archwire bisects the joint of the distal end cutters. This prevents torquing forces being placed on the wire
at the moment of cutting. In the upper arch, this necessitates lifting one's elbow up considerably to align
the distal end cutters with the plane of the archwire.
When cutting stainless steel archwires prior to insertion in the mouth, cut the wire at an angle to provide a
tapered end for insertion into the first and second molar tubes. In extreme cases, gentle reduction of the
terminal portion of the wire with a green stone may facilitate insertion into the molar tubes.
Archform
The Damon archform does not distinguish between upper and lower archforms. The argument is that as
the upper arch is a little forward of the lower arch and that this provides the differential size requirement
required; in practice this seems to work satisfactorily. The Damon archform provides expansion in the
premolar and molar regions but not in the intercanine region. Customisation of archform cannot obviously
take place until the working archwires stage.
Elastics
Most self-ligating brackets, such as Damon brackets, have sufficiently large tie wings to easily
accommodate two links of elastomeric chain, allow the wire ligation of blocks of teeth or accept elastics to
settle in the occlusion in the final phases of treatment. Possible configurations of elastics are shown in
Figures 11.19 to 11.24. Damon MX brackets permit the instant placement of a ball-ended hook on any
tooth. Speed brackets and Opal brackets have no tie-wings
Debonding
Self-ligating brackets are more rigid than conventional siamese brackets because of the engineering
requirements of the body of the bracket and the need to provide a rigid housing for the clip or door. This
means that at debonding, bracket removal does not occur by failure of the bracket adhesive interface by
Figure 11.19: Class 2 elastics; cutting Figure 11.20: Class 3 elastics; cutting Figure 11.21: Posterior V elastics are
distal to the lower first molars speeds up the distal to the upper first molars speeds up the used to develop interdigitation in the buccal
rate of correction rate of correction segments
Figure 11.22: An anterior trapezoidal Figure 11.23: A Kobayashi ligature Figure 11.24: Triangular elastics or
elastics is used to close down anterior open placed on one of the lower central incisor Schudy elastics can be used to develop
bites brackets makes it more comfortable to wear buccal segment interdigitation in the last few
an anterior cross elastic weeks of treatment
deformation of the bracket but by direct failure of the bracket adhesive interface, cohesive failure of the
adhesive, direct failure of the adhesive enamel interface or a combination of any of these.
The risk of enamel fracture has always been present with stainless steel and ceramic brackets, particularly
in teeth where the integrity of the crown is compromised. The risk of enamel fracture is now increased by:
• brackets with a rigid, non-deformable body structure

• the higher bond strengths delivered by adhesion enhancers and improved adhesives (3M
Unitek have recently issued a warning that 3M Adper Prompt L-Pop Self Etch is unsuitable
for orthodontic use because of the high bond strengths generated)
The best way to debond Damon 2 System brackets is by squeezing two tiewings only with a conventional
debonding plier. The bracket will silently ‘float’ off the adhesive.
Retention
2|2
Dr Dwight Damon uses upper and lower clear overlay retainers as well as a bonded upper retainer
and a bonded lower retainer. The upper retainer is made from 0.016" x 0.022" Reliance Hilgers Bond-
3|3
a-Braid which is a flat braided archwire. That is placed flat on the cingulae of the upper incisors to prevent
spontaneous debonding.
In the lower arch, a 0.025" single strand stainless steel wire is bonded to the lingual surface of the lower
canines only; the ends of the retainer are sandblasted to aid retention.
Clear overlay retainers are used in addition on a night time only basis. Also the chapter on Stability and
Retention
Cost and treatment efficiency

Currently available self-ligating brackets are more expensive than most good quality tie-wing brackets. A
modest balancing factor is the cost of elastic ligatures which are, of course not required. However this
significant extra cost must be measured against savings in time - an expensive commodity. If self-ligating
brackets save any appreciable chairside time as the studies by Maijer and Smith (1990) and Shivapuja and
Berger (1994) suggest, this would provide an offsetting saving.
The study of treatment efficiency (Harradine 2001) using matched pairs of cases found the following:
• a very modest average time saving from a reduction in archwire placement/removal of 24

seconds per arch
• a mean reduction of four months in treatment time (from 23.5 to 19.4 months)
• a mean reduction of four visits during active treatment. (from 16 to 12).
• the same reduction in PAR scores for matched cases
This finding of a mean reduction of four months in treatment time using Damon SL brackets was also
reported by Dr Bob Fry in a presentation at the AAO Annual Session in Toronto 2001. He had converted
one of his two offices to Damon SL. The office management software subsequently revealed that his
treatment times reduced by an average of four months compared to his other office where he had, for the
time being, stayed with conventional ligation. A study by Eberting et al (2001) of intra-practitioner
differences in three practices found an average reduction in treatment time of 7 months (from 30 to 25) and
7 visits (from 28 to 21) for Damon SL cases compared to conventional ligation. The final average ABO
occlusal regularity score was higher (better) for the Damon cases. These three reports support a view of
clinically significant improvements in treatment efficiency with passive self-ligating brackets. The more
recent bracket types would be expected to show still better treatment efficiency. More evidence is required
and random controlled trials are currently comparing treatment times in conventional and self-ligating
brackets.
Reflection
Currently available self-ligating brackets offer the very valuable combination of extremely low friction and
secure full bracket engagement and deliver much of the potential advantages of this type of bracket.
Some recent bracket types have excellent handling characteristics for opening and closing the slide.
These developments offer the possibility of a significant reduction in average treatment times and also in
anchorage requirements in cases requiring large tooth movements. An additional area of development has
been the introduction of more aesthetic self-ligating brackets. Whilst further refinements are desirable and
further studies essential, current brackets are able to deliver measurable benefit with excellent robustness
and ease of use.
It is probably true to say that if the self-ligating appliance is viewed just as another bracket system then the
orthodontist will not get the best out of it. The combination of minimal friction, low forces and extended
time between adjustment visits allows tooth movements to occur which can be argued are technically not
possible with conventional bracket systems. The orthodontist is technically able to more easily treat many
cases without extraction that previously would have required extractions for the technical success of
treatment (compare the management of a mildly crowded class 2 division i case with four first premolar
extractions to reduce the overjet and establish a class 1 molar relationship and the management of the
same case with a functional appliance, no extractions and upper and lower fixed appliances).
Non-extraction treatment has two potential disadvantages: damage to the periodontium in the form of bony
dehiscences and gingival recession and increased potential for relapse. Both of these need continuing
investigation before we fully understand the balance to be achieved between the possibilities of technical
achievement and the biologic limitations of periodontal health and occlusal stability.
In the meantime, we are enormously enthusiastic about this high technology development in orthodontics
and it has been the mainstay of our clinical practice since 2001.
References
Berger JL (1990)
The influence of the SPEED bracket’s self-ligating design on force levels in tooth movement: a comparative in
vitro study
American Journal of Orthodontics and Dentofacial Orthopaedics 97: 219-28
Berger JL (1994)
The SPEED appliance: A 14 year update on this unique self-ligating orthodontic mechanism
Braun S, Bluestein M, Moore BK and Benson G (1999)
Friction in Perspective
Cacciafesta V, Sfondrini MF, Ricciardi A, Scribanti A, Klersy C, Auriccio F (2003)
Evaluation of friction of stainless steel and esthetic self-ligating brackets in various bracket-archwire
combinations
Damon DH (1998)
The rationale, evolution and clinical application of the self-ligating bracket
Clinical Orthodontics and Research 1: 52-61
Damon DH (1998)
The Damon low friction bracket: a biologically compatible straight-wire system
Journal of Clinical Orthodontics 32:670-80
Damon2 Videoconference DVD
Damon System: The Workbook
(only available to participants on Damon Courses)
Eberting JJ, Straja SR, and Tuncay OC (2001)
Treatment time, outcome and patient satisfaction comparisons of Damon and conventional brackets
Eliades T and Bourauel C (2005)
Intraoral aging of orthodontic materials: the picture we miss and its clinical relevance
Harradine NWT (2001)
Self-ligating brackets and treatment efficiency
Harradine NWT (2003)
Self-ligating brackets: where are we now?
Journal of Orthodontics 30: 262-273
Harradine NWT and Birnie DJ (1996)
The clinical use of Activa self-ligating brackets
Iwasaki LR, Beatty MW, Randall CJ and Nickel JC (2003)
Clinical ligation forces and intraoral friction during sliding on a stainless steel archwire
Khambay B, Millett D, Mc Hugh S (2004)
Evaluation of methods of archwire ligation on frictional resistance
European Journal of Orthodontics 26: 327-332
Kapur R, Sinha PK and Nanda RS (1998)
Frictional resistance of the Damon SL bracket
Journal of Clinical Orthodontics 32: 485-489
Khouri SA (1998)
The Bendistal pliers: A solution for distal end bending of superelastic wires
Koenig HA and Burstone CJ (1989)
Force systems from an ideal arch – large deflection considerations
Angle Orthodontist 59:11-16
Loftus BP, Ârtun J, Nicholls JI, Alonzo TA, and Stoner JA (1999)
Evaluation of friction during sliding tooth movement in various bracket-archwire combinations.
Mah E, Bagby M, Ngan P, Durkee M (2003)
Investigation of frictional resistance on orthodontic brackets when subjected to variable moments
American Journal of Orthodontics and Dentofacial Orthopaedics 123: (abstract) A1
Maijer R and Smith DC (1990)
Time saving with self-ligating brackets
Matasa CG (1996)
Self-engaging brackets: passive vs. active.
The Orthodontic Materials Insider 9: 5-11
Matasa CG (2001)
Brackets’ shape influences friction
The Orthodontic Materials Insider 13: 2-5
Meling TR, Ødegaard J, Holthe K, and Segner D (1997)
The effect of friction on the bending stiffness of orthodontic beams: A theoretical and in vitro study.
O’Reilly D, Dowling PA, Lagerstrom L and Swartz ML (1999)
An ex-vivo investigation into the effect of bracket displacement on resistance to sliding
British Journal of Orthodontics 26: 219-227
Pizzoni L, Raunholt G and Melsen B (1998)

Frictional forces related to self-ligating brackets.
Pollard AP (2003)
Capturing the essence of the Damon approach
Clinical Impressions 12 (2): 4-12
Read-Ward GE Jones SP, and Davies EH (1997)
A comparison of self-ligating and conventional orthodontic bracket systems
Shivapuja PK and Berger J (1994)
A comparative study of conventional ligation and self-ligation bracket systems
Sims APT, Waters NE, Birnie DJ and Pethybridge RJ (1993)
A comparison of the forces required to produce tooth movement in vitro using two self-ligating brackets and a
pre-adjusted bracket employing two types of ligation
European Journal of Orthodontics: 15: 377-385
Sims APT, Waters NE, and Birnie DJ (1994)
A comparison of the forces required to produce tooth movement ex vivo through three types of preadjusted
brackets when subjected to determined tip or torque values
Stolzenberg J (1935)
The Russell attachment and its improved advantages
International Journal Orthodontics and Dentistry in Children 21: 837-840
Taloumis LJ, Smith TM, Hondrum SO and Lorton L (1997)
Force decay and deformation of orthodontic elastomeric ligatures
Thomas S, Birnie DJ and Sherriff M (1998)
A comparative in vitro study of the frictional characteristics of two types of self ligating brackets and two types of
preadjusted edgewise brackets tied with elastomeric ligatures
Thorstenson BS and Kusy RP (2001)
Resistance to sliding of self-ligating brackets versus conventional stainless steel twin brackets with second-order
angulation in the dry and wet (saliva) states
Thorstenson BS and Kusy RP (2002a)
Comparison of resistance to sliding between different self-ligating brackets with second-order angulation in the
dry and saliva states
Thorstenson BS and Kusy RP (2002b)
Effect of archwire size and material on the resistance to sliding of self-ligating brackets with second-order
angulation in the dry state
Thorstenson BS and Kusy RP (2003)
Effects of ligation type and method on the resistance to sliding of novel orthodontic brackets with second-order
angulation in the wet and dry state
Angle Orthodontist 73: 418-430
Turkkahraman H, Sayin MO, Bozkurt FY, Yetkin Z. Kaya S, Suleyman O (2005)
Archwire ligation techniques, microbial colonization, and periodontal status in orthodontically treated cases
Angle Orthodontist 75: 231-236
Turnbull NR and Birnie DJ (2006)
Treatment efficiency of conventional versus self-ligating brackets: the effects of archwire size & material.
American Journal of Orthodontics and Dentofacial Orthopaedics (in press)
Voudouris JC (1997)
Interactive edgewise mechanisms: Form and function comparison with conventional edgewise brackets
Wildman AJ (1972)
Round table - the Edgelok bracket
Wildman AJ (1998)
The Wildman TwinLock bracket
Clinical Impressions
published by Ormco Corporation 7 (2): 2-5

Self-Ligating Brackets: Theory and Practice: C H A P T e R

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S E L F - L I G A T I N G B R A C K E T S : T H E O R Y A N D P R A C T I C E 1 9 7

Self-ligating brackets: theory and

Properties of an ideal ligation system

• be comfortable for the patient

Conventional wire and elastomeric ligatures in relation to the requirements

Full bracket engagement

Quick and easy to use

Easy attachment of elastic chain

Assists good oral hygiene

Comfortable for the patient

Summary: What is wrong with conventional ligation?

Advantages of self-ligating brackets

• more certain full archwire engagement

Secure, full archwire engagement

of rectangular wires, the Damon bracket

concluded that each elastomeric placed

Angulation Damon SL Conventional Minitwin Transcend In-Ovation Damon 2

Friction in vivo – occlusal and masticatory forces

Secure ligation and low friction as a combination

Anchorage consequences of low friction and secure full archwire engagement

Alignment of severely irregular teeth

Less chairside assistance and faster ligation/ archwire removal

5 Orthos and Damon 2 brackets. The

SDS Ormco Damon system

Damon 2 System brackets (D2)

Damon 3 brackets (D3)

Ultradent Opal brackets

GAC In-Ovation brackets

3M Unitek SmartClip brackets

• the insertion of small diameter archwires is easy.

Active clip or passive slide?

• with thin aligning wires smaller then 0.018" diameter

Overall advantages or disadvantages of an active clip

Clinical tips when using self-ligating

Changing treatment mechanics

More traction on lighter wires

Separate movement of individual teeth

Squeezing teeth into alignment

Bracket placement and bond-up

Ormco Damon 2 System

Opening and closing

Locating the archwire in the slot

• there is something in the slot preventing the archwire seating

THE COOL TOOL

The Cool Tool is a specific tool which is rather akin to a

Plier/Tool Locating archwire in slot Closing door Opening door

Damon closing pliers

Non specialist plier

ORMCO DAMON 2 SYSTEM

DAMON 3 AND DAMON MX

Long unsupported spans

The primary archwire sequence is as follows:

• 0.014" nickel titanium superelastic

Secondary archwires and wires are as follows:

• 0.016" x 0.025" nickel titanium superelastic archwire

• brackets with a rigid, non-deformable body structure

Cost and treatment efficiency

• a very modest average time saving from a reduction in archwire placement/removal of 24

Pizzoni L, Raunholt G and Melsen B (1998)

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