Scientific Dental Journal

Original Article

The Effects of Different Bracket Types on Orthodontic Treatment 
Evaluated with the Objective Grading System   

Suli Andryani1, Nazruddin2, Siti Bahirrah2

1 Postgraduate Program in Orthodontics, Faculty of Dentistry, University of North Sumatera – Indonesia
2 Department of Orthodontics, Faculty of Dentistry,University of North Sumatera – Indonesia

‘Corresponding Author: Suli Andryani, Faculty of Dentistry, University of North Sumatera – Indonesia
Email: suli_andryani@yahoo.co.uk
Received date: October 15, 2018. Accepted date: January 7, 2019. Published date: January 31, 2019.
Copyright: ©2019 Andryani S, Nazruddin, Bahirrah S. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided
the original author and sources are credited.
DOI: http://dx.doi.org/10.26912/sdj.v3i1.3634

ABSTRACT

Background: Standard edgewise and preadjusted Roth are two bracket types widely used for orthodontic treatment.
Whether one of these bracket types offers better treatment results than the other requires further evaluation. The
Objective Grading System created by the American Board of Orthodontics (ABO) is one of the most reliable indices used
to evaluate treatment outcomes. Objectives: To determine the effects of using two different bracket types on treatment
outcomes by using the Objective Grading System. Methods: The sample for this study consisted of 64 randomly selected
post-treatment dental casts and panoramic radiographs. Of these samples, 32 were treated with a standard edgewise
bracket, and the others were treated with a preadjusted Roth bracket. Patient samples were included if they had non-
extraction Class I malocclusion (minor crowding < 4 mm for both bracket types, ANB = 2º ± 2º), no history of dental
trauma, complete teeth (except third molars), and no growth or development disturbances. All samples were evaluated
using eight parameters of the Objective Grading System and statistically analyzed using Mann–Whitney and chi-squared
tests. The score range for each tooth in each parameter was 0 – 2. Results: The total score was 19.00 ± 12.00 for the
standard edgewise bracket and 15.00 ± 7.00 for the preadjusted Roth bracket, with no statistically significant differences
between the two bracket types (p = 0.149). There were also no statistically significant differences in the scores of the
eight parameters of the Objective Grading System between these brackets (p > 0.05). The highest score was found for the
buccolingual inclination parameter, and the lowest score was for interproximal contacts. Conclusion: According to the
Objective Grading System, there are no statistically significant differences between the orthodontic treatment outcomes
obtained using a standard edgewise or a preadjusted Roth bracket.

Keywords: brackets, orthodontics, objective grading system

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Background
Fixed orthodontic treatment has progressed quite
significantly, especially in the orthodontic bracket system.
In 1928, Edward H. Angle introduced the edgewise
appliance, which has a rectangular bracket slot and a
rectangular wire that enable control of tooth movement in
three occlusal planes. In the standard edgewise bracket,
the tipping and the torquing of the bracket are 0°, and
there is no in-out design on the bracket base; thus, a
complicated wire bending procedure is required (first-,
second-, and third-order bends) to obtain the desired tooth
movement.1,2
Faced with the above dilemma, in 1970, Andrews
conducted a study and established six keys to normal
occlusion. He introduced the "preadjusted" appliance,
which enabled tipping, torquing, and in-out design in each
bracket for each tooth.3,4 However, some clinicians
modified the system proposed by Andrews and created
their own prescriptions.5,6 The preadjusted Roth bracket
prescription is widely used, including by the Orthodontic
Clinic in the Faculty of Dentistry at University of North
Sumatera, Medan. The use of this preadjusted bracket is
claimed to reduce or eliminate the complex wire bending
procedure, shorten the working time of clinicians, reduce
patient chairtime, and simplify the treatment mechanism
used to achieve ideal tooth inclination, angulation, and in-
out while enabling better treatment outcomes.7,8
A study on the evaluation of the success of
orthodontic treatments is indispensable for identifying and
improving the quality of treatment outcomes. However,
assessment of orthodontic treatments is often solely based
on subjective opinions and clinician experiences, so the
obtained results are invalid and unreliable. Therefore,
several indices have been introduced to evaluate treatment
outcomes more objectively and accurately.9–11
The Objective Grading System proposed by the
American Board of Orthodontics (ABO) in 1999 was
applied in this study to evaluate treatment outcomes using
post-treatment dental casts and panoramic radiographs.
There were eight parameters to be assessed, namely
alignment, marginal ridges, buccolingual inclination,
occlusal contacts, occlusal relationships, overjet,
interproximal contacts, and root angulation.10–13
10
Jain et al. have used the ABO Objective Grading
System to evaluate orthodontic treatment results obtained
using Roth and MBT prescription brackets. They found
significant differences in the total scores between the two
groups; the MBT bracket had a lower total score and
lower scores in the buccolingual inclination and occlusal
contacts parameters. They found that treatment with the
MBT bracket achieved better outcomes.12
The main purpose of the present study was to
determine whether there were statistically significant
differences between the orthodontic treatment outcomes
obtained with the standard edgewise and the preadjusted
Roth brackets based on the ABO Objective Grading
System. This evaluation was conducted by comparing the
scores for each of the eight parameters of the ABO
Objective Grading System, the total scores, and the
success rates of the two types of brackets.
Materials and Methods
This retrospective study collected 64 post-treatment
samples (based on a minimum sample size calculation) in
the form of dental casts and panoramic radiographs from
patients treated with standard edgewise and preadjusted
Roth 0.018-in slot Mini Gamma brackets from SD
Orthodontic, made in the United States of America. These
samples were collected from 2008 to 2017 and were
divided into two equal groups. All samples and medical
record data of patients aged between 18 and 35 years old
with no gender differences were collected randomly by
one operator from the Orthodontics Clinic in the Dental
and Oral Hospital at the Faculty of Dentistry at University
of North Sumatera, Medan. Research ethics approval was
obtained from the Ethics Commission for Health Research
in the Faculty of Medicine at University of North
Sumatera, Medan.
Patient samples were included in this study if they
exhibited non-extraction skeletal Class I malocclusion
(minor crowding < 4 mm for both types of brackets, ANB
angle = 2ᵒ  ± 2ᵒ), no history of dental trauma, complete
teeth except the third molars, and no growth or
development disturbances. In addition, patient samples
exhibiting a bad condition or damaged dental casts and
panoramic radiographs, the use of dental prostheses,
 SCIENTIFIC DENTAL JOURNAL 01 (2019) 09-16

dentofacial anomalies (e.g. cleft lip and palate), and/or

congenitally missing teeth were excluded from this study.
Each sample was evaluated using the eight parameters
of the ABO Objective Grading System according to the
standard measurement using special measurement tools,
such as the ABO measuring gauge (Fig. 1). Seven
parameters of the ABO Objective Grading System—
namely alignment, marginal ridges, buccolingual
inclination, occlusal contacts, occlusal relationships,
overjet, and interproximal contacts were evaluated using
the dental casts of the patients, whereas the root
angulation parameter was evaluated using the panoramic
radiographs of the patients. The score range of each tooth
in each parameter was 0 – 2. A score of 0 indicated a good
occlusion and alignment, whereas a score of 1 or 2
indicated deviation from the norm. The treatment was
declared successful when the measurement score for each
sample was ≤ 27. The measurement was taken twice by an
operator, and an intra-rater reliability test was performed.
Furthermore, the Kolmogorov Smirnov test was also used
to evaluate the normality of the measurement data. The
study was continued by measuring the statistical
differences in each of the eight parameters and the total
scores between both types of brackets using the Mann–
Whitney test with a significant p-value of < 0.05. The
statistical difference in the treatment success rates
between both types of the brackets was obtained from the
results of the chi-squared test.
Result
The intra-rater reliability test showed that the results
of the first and second data measurements were consistent,
with an alpha value > 0.8. Thus, data were collected from
one of the measurement results. The Kolmogorov–
Smirnov test showed that the measurement results of the
two types of bracket samples were not normally
distributed (p < 0.05). The data were analyzed using the
Mann–Whitney test. The significance value used was <
0.05. The total scores of the standard edgewise and
preadjusted Roth brackets are shown in Table 1. There
was no statistically significant difference in the total
scores between the two types of brackets (p =
0.149; p > 0.05). Table 2 compares the measurement
scores for the eight parameters of the ABO Objective
Grading System between the two types of brackets. Based
on the Mann–Whitney results, there were no statistically
significant differences between the brackets, with p >
0.05. The differences in the median values of the eight
parameters between the two brackets can be seen in Fig. 2.
The rates of successful treatment for both bracket types
are shown in Table 3. The successful treatment (defined as
a score of < 27 for each sample) rate for the standard
edgewise bracket was 75% and for the preadjusted Roth
bracket was 81.2%. Thus, there was no statistically
significant difference between the success rates of the two
bracket types (p = 0.762; p > 0.05).

C
A
D D

Figure 1. ABO measuring gauge. Part A is used to measure discrepancies in alignment, overjet,
occlusal contacts, interproximal contacts, and occlusal relationships, part B to measure
discrepancies in the buccolingual inclination of mandibular posterior teeth, part C to measure
discrepancies in marginal ridges, and part D to measure discrepancies in the buccolingual
inclination of the maxillary posterior teeth.

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Table 1. Differences in the total scores between samples treated with standard edgewise and
preadjusted Roth brackets

Total Score
Variable Bracket Type Interquartile p-value
Median
Range

Standard Edgewise 19.00 12

Score .149
Preadjusted Roth 15.00 7

Table 2. Differences in the median and interquartile ranges of each parameter between samples
treated with standard edgewise and preadjusted Roth brackets

Variable Bracket Type Median+Interquartile p-value

Range

Standard Edgewise 3.00+2

Alignment .353
Preadjusted Roth 2.00+2

Standard Edgewise 2.00+2

Marginal ridges .608
Preadjusted Roth 2.00+2

Buccolingual Standard Edgewise 4.50+3

.051
inclination Preadjusted Roth 4.00+3

Standard Edgewise 2.00+2

Overjet .596
Preadjusted Roth 2.00+2

Standard Edgewise 2.00+1

Occlusal contacts .554
Preadjusted Roth 2.50+3

Standard Edgewise 1.00+3

Occlusal relationships .551
Preadjusted Roth 2.00+2

Standard Edgewise .00+1

Interproximal contacts .211
Preadjusted Roth .00+0

Standard Edgewise 2.00+2

Root angulation .599
Preadjusted Roth 1.00+2

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 SCIENTIFIC DENTAL JOURNAL 01 (2019) 09-16

Median score

8 parameters 8 parameters Objective

Objective Grading Grading System of
System of preadjusted edgewise brackets
Roth brackets

Figure 2. Differences in median scores of eight parameters between samples treated with standard
edgewise and preadjusted Roth brackets according to the Objective Grading System

Table 3. Differences in treatment success rates between samples treated with standard edgewise and
preadjusted Roth brackets

Bracket Type
Treatment Results p-value
Standard Edgewise Preadjusted Roth

Success 24 (75.0%) 26 (81.2%)

Fail 8 (25.0%) 6 (18.8%) .762

Total 32 (100%) 32 (100%)

Discussion
Since the introduction of the standard edgewise
bracket by Angle, new advances have occurred in the
invention of orthodontic brackets. The recently developed
preadjusted bracket is a modification of the standard
edgewise bracket designed to overcome the shortcomings
of the standard edgewise bracket. The preadjusted
bracket has tipping and torquing prescriptions and an in-
out design so that it can simplify the treatment
mechanism, reduce patient chair time, and facilitate the
achievement of better treatment results.7,8,14,15
There are several indices used to assess treatment
success, one of which is the Objective Grading System
from the ABO. The ABO established eight parameters to
evaluate treatment outcomes. Seven parameters—namely
alignment, marginal ridges, buccolingual inclination,
overjet, occlusal contacts, occlusal relationships, and
interproximal contacts are measured from post-treatment
dental casts, whereas the root angulation parameter is
measured from the post-treatment panoramic radiographs.
Treatment is considered successful if the total score of
the eight parameters for each sample is ≤ 27.11–13,16,17
This retrospective study aimed to determine whether
different bracket types—the standard edgewise and
preadjusted Roth brackets had significantly different

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effects on the orthodontic treatment performed. In
addition, this study evaluated the success of orthodontic
treatment outcomes, the differences in ABO total scores,
and the individual scores of the eight parameters of the
ABO Objective Grading System in non-extraction Class I
malocclusion cases treated with the two different bracket
types.
For the standard edgewise bracket, 24 out of 32
samples (75%) had a score ≤ 27, which was categorized as
successful. For the preadjusted Roth bracket, 26 out of 32
samples (81.2%) had a score ≤ 27, which was categorized
as successful. It can be concluded that the treatment of
non-extraction Class I malocclusions was equally
successful using standard edgewise and preadjusted Roth
brackets, and there was no statistically significant
difference between the treatment success rates of the two
types of brackets.
The total score of treatment outcomes for Class I non-
extraction malocclusion using the standard edgewise
bracket was 19.00 ± 12, whereas the total score of
treatment using the preadjusted Roth bracket was 15.00 ±
7. These results indicate that the treatment score obtained
using the standard edgewise bracket was higher than that
obtained using the preadjusted Roth bracket, although the
difference was not statistically significant. This is in line
with astudy by Kattner and Schneider, which compared
the treatment results of both types of brackets using two
treatment outcome evaluation indices, namely the Ideal
Tooth Relationship Index (ITRI) and Andrews' six keys to
normal occlusion. The study results showed no statistically
significant difference between the total scores of ITRI
obtained using the two types of brackets.12
In this study, statistical analysis was used to compare
eight parameters of the ABO Objective Grading System
between the two types of brackets, and no statistically
significant differences were found. This is slightly
different from the results of a study conducted by Kattner
and Schneider, which stated that the angulation and
inclination of maxillary posterior teeth were superior after
the use of preadjusted Roth brackets.12 Similarly, Soltaniet
al. examined orthodontic treatment outcomes using the
standard edgewise bracket and the MBT bracket. They
found a significant difference in the buccolingual
inclination parameters between the two brackets; the MBT
prescription resulted in a superior buccolingual inclination
14
due to the design of the torque in the bracket, which
created a more symmetrical and precise inclination.7
In this study, no significant difference was found in
the buccolingual inclination parameters between the two
types of brackets. This result is in line with a study
conducted by Ugur and Yukay that did not find any
statistically significant differences between the torque
values of cases treated with standard edgewise and
preadjusted Roth brackets.12 This may be due to the use of
non-full-size finishing wire (rectangular wire with a size
of 0.016 in x 0.022 in) in the 0.018-in bracket slot, which
would have prevented the torque in the preadjusted Roth
bracket from being fully expressed. Another possibility
might be the lack of precision in the preadjusted bracket
manufacturing process, resulting in improper design of the
tip and torque.18–20 A study by Awasthi et al. on three
preadjusted bracket products showed that none of the
products had precise tip and torque values.18 Furthermore,
the modifications made with wire bending to torque
certain teeth using standard edgewise brackets can also
affect the score for the buccolingual inclination parameter.
The buccolingual inclination parameter had the
highest score in this study, with 4.50 for the standard
edgewise bracket and 4.00 for the preadjusted Roth
bracket. Yang-Powers et al. (2002, cited in Mislik et al.11)
and Norena et al.8 reported similar results. This is because
of the difficulty in controlling torque in the posterior teeth.
Moreover, discrepancies in the posterior segment are more
difficult to monitor and correct than those in the anterior
segment.8,11,13 The exclusion of the second molar tooth in
this study was enough to influence the score of the
buccolingual inclination parameter. The use of non-full-
sized wire, less precise bracket manufacturing in the
preadjusted Roth bracket, and the lack or inadequacy of
torquing wire in the standard edgewise bracket also
influenced the total score of the buccolingual inclination
parameter.18,19
Interproximal contact is the parameter with the lowest
score in this study. This result is in accordance with
studies conducted by Jain et al.12 and Mislik et al.11 These
studies suggest that it is relatively easy for orthodontists to
identify and correct the closure of interproximal
spaces.11,13 Based on the measurement data, eight
parameters of the ABO Objective Grading System had a
higher score in the standard edgewise bracket than in the
 SCIENTIFIC DENTAL JOURNAL 01 (2019) 09-16
preadjusted Roth bracket. This result may be due to the
prescriptions of tip, torque, and in-out in the preadjusted
bracket design, which can facilitate tooth angulation,
inclination, and interdigitation.
In this study, the second molar tooth,which was not
included in the treatment, increased the ABO Objective
Grading System score, especially the score of the
buccolingual inclination parameter. Norena et al.8 and Jain
et al.12 reported similar results. This may be because the
second molar tooth is often not monitored or is even
ignored by clinicians and patients because the tooth is in
the back of the mouth and therefore does not affect the
patient's aesthetics; thus, this tooth is usually not included
in orthodontic treatment.9,11,13
According to the results of this study and the
Objective Grading System, there was no statistically
significant difference between the orthodontic treatment
outcomes obtained using the standard edgewise bracket
and the preadjusted Roth bracket.
Conclusion
This study showed that the orthodontic treatment
outcomes of non-extraction skeletal Class I malocclusions
treated with standard edgewise and preadjusted Roth
brackets showed similar results, with no statistically
significant differences between the results obtained with
these bracket types based on the Objective Grading
System.
Acknowledgement
The authors would like to thank the Faculty of
Dentistry at University of North Sumatera—especially the
Orthodontics Department—for their support during this
study. The support and caring of the authors‘ families and
Dr. Chihargo were invaluable. The authors would also like
to thank Dr. Pan Li Ting for helping find the measurement
gauge.
Conflicts of Interest
The authors declare that there are no conflicts of
interest.
15
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