The Damon Passive Self-Ligating Appliance System

David Birnie
The Damon System (Ormco Corp., 1332 South Lone Hill Ave., Glendora, CA 91740-0000) is a passive self-ligation system that was originally introduced in 1994. Since then, both the bracket and the philosophy behind the system have undergone continuous evolution. If the development of the Edgelok (Ormco Corp.) appliance by Wildman in 1972 and the development of the SPEED (Strite Industries Ltd., 298 Shepherd Ave., Cambridge, Ontario, N3C 1V1 Canada) appliance by Hanson in 1980 marked the start of modern self-ligating appliances, then the Damon System has probably been responsible for a fuller understanding of the inuence of passive self-ligation on orthodontic treatment and the increasing popularity and utilization of the concept. (Semin Orthod 2008;14:19-35.) 2008 Elsevier Inc. All rights reserved.

The Damon Philosophy

full description of the Damon philosophy and treatment techniques are given by Damon.1 The Damon philosophy is based on the principle of using just enough force to initiate tooth movementthe threshold force. The underlying principle behind the threshold force is that it must be low enough to prevent occluding the blood vessels in the periodontal membrane to allow the cells and the necessary biochemical messengers to be transported to the site where bone resorption and apposition will occur and thus permit tooth movement. A passive self-ligation mechanism has the lowest frictional resistance of any ligation system. Thus the forces generated by the archwire are transmitted directly to the teeth and supporting structures without absorption or transformation by the ligature system. The forces generated by elastomeric ligatures can

have unwanted side effects on treatment progress as shown in Figs 1-4. Compared with conventional preadjusted edgewise appliances, it is suggested that the use of passive self-ligation results in a signicant reduction in the:

Consultant Orthodontist, Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, U.K. Address correspondence to David Birnie, BDS (Edin), FDS, DMI, RCSEd, FDS, MOrth, RCSEng, Consultant Orthodontist, Maxillofacial Unit, Queen Alexandra Hospital, Portsmouth, PO6 3LY, U.K. E-mail: [email protected]. 2008 Elsevier Inc. All rights reserved. 1073-8746/08/1401-0$30.00/0 doi:10.1053/j.sodo.2007.12.003

Use of anchorage devices because the frictional resistance generated by ligatures is not present. Srinivas2 has demonstrated that passive self-ligating appliances use less anchorage than conventional appliances. This supports the reduction in the use of anchorage devices experienced by users of passive self-ligation. Use of intraoral expansion auxiliaries such as quadhelices or W-springs because the force of the archwire is not transformed or absorbed by the ligatures and the necessary expansion can be achieved by the force of the archwires. Need for extractions to facilitate orthodontic mechanics because alignment is not hindered by frictional resistance from ligatures and can therefore largely be achieved with small diameter copper nickel titanium archwires. Tooth alignment therefore places minimal stress on the periodontium as it occurs and so the possibility of iatrogenic damage to the periodontium is reduced.

In addition, a passive edgewise self-ligation system provides three key features:

Very low levels of static and dynamic friction, 19

Seminars in Orthodontics, Vol 14, No 1 (March), 2008: pp 19-35

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Figure 1. At the start of treatment. Both upper permanent cuspids are ectopic and palatally positioned. (Color version of gure is available online.)

Figure 3. Palatal view of upper cuspids and traction hooks taken at same visit as Fig 1. (Color version of gure is available online.)

Rigid ligation due to the positive closure of the slot by the gate or slide, and Control of tooth position because there is an edgewise slot of adequate width and depth.

This allows extended intervals between treatment visits, particularly in the early stages of treatment, a reduced number of visits during a course of treatment, and shortened treatment times. Although orthodontics is accepted as inuencing tooth position, alveolar bone, gingival health, and facial appearance, Damon suggests that orthodontic treatment can also affect

speech, airway, and sleep disorders (Damon DH, personal communication, 2005). Although most orthodontists would acknowledge the effect of orthodontic treatment on the rst four items, the last three are more contentious areas that are closely related to soft tissues, their behavior, and their relationship to orthodontic treatment. One of the reasons that these areas are contentious is that they are poorly understood because of the difculty in measuring them and the relative ineffectiveness and unpredictability of treatment strategies designed to inuence them. It is suggested that if the forces applied to the teeth are kept very low, then the lips will restrict anterior movement of the dentition and the tongue may contribute to posterior expansion.

Figure 2. The upper cuspids have been exposed and are sufciently erupted for traction hooks to be placed on them to move the cuspids into the line of the arch. Space has been opened in the arch to accommodate the cuspids. A 0.014 copper nickel titanium wire as been placed using gure of 8 ligatures to maximize archwire engagement and hence tooth control. (Color version of gure is available online.)

Figure 4. One visit after Figs 2 and 3. The friction caused by the elastomeric ligatures has prevented the archwire sliding through the brackets distal to the space. The archwire has therefore expressed itself by proclining the upper incisors resulting in an unwanted overjet. (Color version of gure is available online.)

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Figure 5. Start of treatment. Right buccal segment half a unit Class II. Right permanent cuspid in the line of the arch. (Color version of gure is available online.)

Figure 7. End of treatment. Treatment duration, 22 months including time for upper right permanent cuspid to erupt. (Color version of gure is available online.)

This is demonstrated in Figures 5-7 where the right buccal segment has been distalized half a unit to allow eruption and alignment of the upper right permanent cuspid with gentle activation of the coil spring only; during distalization, no increase in overjet occurred. In nonextraction cases, this suggestion means that tooth alignment results in:

Signicant posterior expansion without the need for auxiliary expanders such as rapid maxillary expansion and quadhelices or Wsprings; and Posterior expansion that is not produced by the tipping movements normally expected with expansion achieved by the use of archwires and cross-elastics alone.

Less incisor proclination and less labial protrusion than might be expected with a conventional nonextraction treatment;

Evidence for the Damon Philosophy Archwire Placement and Removal

The speed of archwire ligation and release has been studied by a number of authors3-6 and self-ligating brackets have been shown to take less time and also require less or no chairside assistance. Turnbull and Birnie7 divided the archwires into four different groups in ascending order of size. They found that:

Figure 6. Seven months into active treatment. Space has been opened for the upper right cuspid and the upper right buccal segment has been distalized half a unit by placing an open nickel titanium coil spring one bracket width wider than the interbracket span and replacing at each visit. The overjet is unchanged. (Color version of gure is available online.)

The time taken to ligate archwires decreased with increasing archwire size. This was an unexpected nding; it might be expected that ligation of thicker wires might takes longer because of greater difculty in obtaining full archwire engagement in the bracket. However, the difculty of obtaining full archwire engagement in the bracket with thicker archwires was offset by the tooth alignment produced by earlier archwires. The time taken to open the Damon self-ligating brackets and to remove elastomeric ligatures was almost independent of archwire size.

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Figure 8. Figure showing static friction for passive, active, TipEdge, and conventionally ligated brackets. The value for the passive self-ligating Damon SL bracket was zero except for with the 0.019 0.025 stainless steel archwire. Reprinted with permission of Oxford University Press.8

It took less time to ligate and release an archwire using Damon passive self-ligating brackets than with conventional brackets and elastomeric ligatures.

Effect of Passive Ligation on Friction

Many authors have found that static friction measured in vitro is much less with a passive self-ligating system than with any other type of xed appliance.8-10 The static friction developed by passive self-ligating brackets is almost negligible as is shown in Fig 8. As angulation11 or inclination12 is applied to the bracket, binding occurs although the force generated by this binding is less for self-ligating brackets than for conventional ligation. A further study13 that looked at dynamic friction also suggested that Damon brackets had the lowest frictional resistance of the four bracket types tested: conventional, ceramic, active self-ligating (GAC In-Ovation; GAC International, 355 Knickerbocker Ave., Bohemia, NY 11716) series, and passive self-ligation (Damon2).

Littles Index. This is a surprising nding particularly as other passive ligating systems, such as the Begg technique, were known for their rapid tooth movement.15 It may be accounted for by the experimental design, which although ingenious, did not allow independence between the effects of the conventional and self-ligating brackets. In addition, a then-current but now obsolete archwire sequence (0.014 , 0.016 0.025 copper nickel titanium) was used. Another study16 has shown that more initial alignment in a given time was produced with Damon brackets than with conventional brackets by a factor of 1.7. When the experimental group was subdivided into less crowded and more crowded cases, the less crowded cases aligned 2.5 times faster and the more crowded cases 1.4 times faster. Cash and coworkers17 studied slot dimensions in 11 different bracket types and determined that the Damon2 bracket had a convergent slot with a base dimension that was 17% oversize and a slot opening that was 13% oversize. Bourauel and coworkers18 in a laboratory study found Damon2 brackets less effective in transmitting torque than SPEED or brackets using conventional ligation and attributed this to greater play between bracket and archwire. Pandis and Eliades19 investigated the effectiveness of torque transmission with conventional and self-ligating brackets in extraction and nonextraction cases and found no difference between the two bracket types in their ability to torque upper incisors in either extraction or nonextraction cases.

Length of Treatment
If alignment and space closure can be achieved more quickly with self-ligating brackets due to reduced friction, then treatment times might be shorter using self-ligating brackets. Harradine3 in 2001 and Eberting and coworkers,20 also in 2001, showed reductions in treatment times of 4 and 7 months respectively.

Clinical Studies
One of the extrapolations from these in vitro studies might be that the low static and dynamic friction will result in more rapid initial alignment. One clinical study,14 which utilized a split mouth design, found that this did not in fact occur and that there was no difference in the speed of alignment between conventional brackets and Damon2 brackets when measured using

Bracket Design
The bracket design of the Damon bracket has had the following characteristics since its introduction as the Damon SL bracket:

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A passive self-ligating design with conventional tie wings, and A self-ligating gate, with a positive mechanism to keep the gate either open or closed, that opens to allow operator to see into slot.

As the bracket has evolved, the following features have changed:

The bracket has become smaller, with a lower prole and more rounded contours resulting in a bracket that is more comfortable for the patient. As a result of a clearer understanding of bracket function and advances in manufacturing technology, the gate mechanism has become more reliable, and simpler to open and close. The D3 MX bracket has a vertical auxiliary slot.
Figure 10. Damon 3 MX bracket with gate open. Permanent bracket identication is cast into the base of the slot.

The most recent bracket design, the D3 MX, is a highly sophisticated piece of industrial design and is shown in Figs 9 and 10; it is quite unlike the simple drawn and milled standard edgewise brackets of 4 decades ago.

Treatment planning involves ve separate areas.

The Face
Treatment planning should take into account:

Treatment Planning
Treatment planning should be based on etiology, and careful thought about why the presenting malocclusion occurred.

The individuals facial pattern and appearance, and The likely growth, maturation, and aging of the patients face including the inuence of genetic inheritance on their future facial appearance.

The Soft Tissues

The interpretation of soft tissue behavior and its inuence on tooth position and oral function is acknowledged but difcult to quantify in individual cases. The clinician should consider whether soft tissue behavior has been a signicant factor in the development of the malocclusion and, if so, whether it can be modied. This includes consideration of lip position and lip posture, tongue behavior, muscle tone, and mode of breathing.

Dental Factors
Dental factors include:
Figure 9. Damon 3 MX bracket with gate closed.

Space analysis, Arch width analysis, and

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Table 1. Optional Torque Values in the Damon System

Upper Arch U1 High torque Standard torque Low torque 17 12 7 U2 10 8 3 U3 7 0 U4 7 Lower Arch L1 High torque Standard torque Low torque 1 6 L2 1 6 L3 7 0 L4 12 L5 17 L6 28 L7 10 U5 7 U6 18 U7 27

The inclination of labial and buccal segment teeth.

Several decades ago, tooth extraction was necessary to obtain dental alignment because of the relatively unsophisticated appliances available. Technically, it is often no longer necessary, except in a few cases, to extract teeth to obtain alignment or to facilitate orthodontic mechanics. Extractions may be required, however, to optimize facial balance or because of dental or periodontal pathology. In addition, tooth extraction does not necessarily prove a guarantee of posttreatment or postretention stability.

obtain better orthodontic results than those with compromised oral health. Particularly in the preteen and teenage patient, the healthy periodontium seems to have signicant powers of adaptation and regeneration.

Bracket Selection
Obtaining the correct inclination of teeth during orthodontic treatment has always been challenging with orthodontic appliances based on the edgewise system. The Damon System provides several torque options for incisor and cuspid teeth and these are shown in Table 1. In general, the torque selected in each bracket should be designed to over-correct tooth position.

Cephalometry
Cephalometry remains an important tool for the orthodontist, but long and elaborate analyses are unnecessary in most cases. It remains subservient to facial analysis for many measurements. Some parameters (such as upper incisor inclination) can be visualized directly rather than being measured from a lateral skull radiograph. In addition, treatment to mean values (such as for incisor inclination) do not recognize the significant range of biological variability present in the population nor is this strategy a guarantee of treatment stability. The response of the facial tissues to tooth movement, particularly proclination, is unpredictable and so tooth movements planned to achieve favorable, or prevent unfavorable soft tissue movements, should be executed with caution.

High Torque Brackets

Examples of where high torque brackets may be used on upper incisors are as follows:

Extraction cases where treatment mechanics may excessively retrocline the upper incisors; Class II Division 1 malocclusions where treatment mechanics may excessively retrocline the upper incisors; and Class II Division 2 malocclusions.

Examples of where high torque brackets may be used on upper cuspids are as follows:

First premolar extraction cases; and Cases where the crowns of the upper cuspids are palatally tipped.

Standard Torque Brackets Oral Health

Patients with good oral health, excellent oral hygiene, and a normal gingival biotype seem to Standard torque brackets are used where the inclination of the teeth is satisfactory before treatment and the treatment mechanics will not

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adversely affect the inclinations during treatment.

Low Torque Brackets

Examples of where low torque brackets may be used on upper incisors are as follows:

Excessively proclined upper incisors; Isolated upper incisors with palatally positioned roots (eg, upper lateral incisor in the palate); Malocclusions where treatment mechanics may result in excessive upper incisor proclination; Moderate and severe upper arch crowding; and Anterior open bite cases with proclined incisors.

Examples of where low torque brackets may be used on lower incisors are as follows:

Cases where it is necessary to control the proclination of lower incisors, eg; extreme lower labial segment crowding, cases using Class II elastics, and xed Class II correctors attached to the brackets, buccal tubes, or archwires; and Lingually placed lower incisors.

For deep bite cases, cuspid and incisor brackets should be progressively placed slightly more incisally in both arches to aid bite opening. For open bite cases, cuspid and incisor brackets should be placed progressively slightly more gingivally in both arches to aid bite closure. Where teeth have to undergo signicant translation, overangulation of the brackets to exaggerate the root movement in the desired direction will ensure adequate root movement occurs. Examples of malocclusions where this strategy is helpful include the correction of pseudotranspositions, the opening of space for restorative implants, and closure of large spaces such as moving lateral incisors into central incisor spaces. Where teeth have incisal edge damage or are substituting for other teeth, position the brackets to obtain the correct gingival emergence prole and adjust the subsequent incisal edge problem restoratively. Brackets are not inverted to change the torque values as this may make the gates more vulnerable to inadvertent opening, and rarely generates enough torque to completely correct the problem.

The brackets with optional torque values should not be used as sets. The clinician should study the case carefully beforehand and individually select the bracket with the correct torque for each tooth.

Instead, choose a bracket with a torque value that will exaggerate the tooth movement required (such as a low torque bracket for a palatally placed upper lateral incisor). This solves the rst problem, but in most cases, additional torque will need to be placed in the archwire to obtain ideal root position.

Bracket Positioning
Bracket positioning follows the principles suggested by Andrews21 where brackets are placed on the midpoint of the facial axis of the clinical crown with the vertical bracket positioning key (eg, tie wings for D3 and D3 MX brackets) parallel to this axis. The following exceptions to this rule should be noted:

Treatment Phases, Archwire Selection, and Archwire Sequencing Phase 1: Light Round High Technology Wires
This phase of treatment uses 0.013 , 0.014 , or 0.016 copper nickel titanium archwires. The aims of this phase of treatment are to:

Lower cuspid brackets should be positioned 0.5 mm to 1 mm mesial to the facial axis of the clinical crown to prevent the mesial edge of the cuspid tucking behind the distal part of the lower lateral incisor.

Obtain tooth alignment; Level the arches (excluding second molars). Second molars, although bonded from the start of treatment, are not engaged by the initial archwire until the second phase of treatment to prevent the archwire being dislodged from the second molar tubes. The intertube span between rst molar and second molar is

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too large to reliably support small-diameter nickel titanium archwires; Substantially correct all anterior rotations and partially correct posterior rotations; and Initiate arch development by using light enough forces to allow the soft tissues to inuence arch shape.

This phase of treatment normally lasts 10 to 20 weeks and appointment intervals are at 10 weeks.

spontaneously by this stage, particularly when, as is often the case, the crossbite has not included the second molars. Where buccal segment crossbites persist, the use of a 0.016 0.025 preposted stainless steel archwire in the arch where some buccal or lingual tipping is desired, together with the use of a 3/16 (110 g) cross elastic, will assist crossbite correction. The aims of this phase of treatment are to:

Phase 2: High Technology Rectangular Wires

The second molars are normally engaged by the rst archwires in this phase except in patients with anterior open bites. This phase of treatment normally uses two archwires: 0.014 0.025 followed by 0.018 0.025 copper nickel titanium wires. In cases that are well aligned at the start of treatment, these two archwires can occasionally be replaced by a single 0.016 0.025 copper nickel titanium wire. The use of a wire with a 0.025 rst order dimension is critical to obtain tooth alignment by almost completely lling the 0.027 slot depth of a Damon bracket. Where incisor intrusion is required, 0.017 0.025 or 0.019 0.025 copper nickel titanium archwires with preformed curves or reverse curves of Spee can be used in this stage. Additional torque can also be applied at this stage with the use of 0.019 0.025 copper nickel titanium archwire preformed with 20 of torque anteriorly. The aims of this stage of treatment are to:

Maintain the archform developed in the rst two phases, Finish torque control, Consolidate posterior space, and Completely correct anteroposterior, buccolingual, and vertical relationships.

This phase of treatment lasts 8 to 10 weeks with appointments at 10-weekly intervals. Where Class II or Class III elastics are being used, buccal segment correction occurs more quickly if the molar distal to those to which the elastic is placed are temporarily not included in the archwire.

Phase 4: Finishing and Detailing

The stainless steel archwires may be continued in this phase. However, some detailed adjustments to individual teeth may be required, in which case 0.019 0.025 -titanium archwires allow individual adjustments to be made in the archwire to optimize tooth positions. Settling elastics may be used to develop a well-interdigitated occlusion.

Fully correct all rotations and obtain full alignment of all teeth, Consolidate any anterior space and maintain tooth contact, Initiate torque control, Initiate bite opening, and Continue arch development.

Managing Severely Displaced or Rotated Teeth

Severely displaced teeth are managed by creating space for the teeth with open coil spring; this should be done with low forces and the coil spring should be no longer than the width of the space plus a bracket width (approximately 3 mm). A traction hook is bonded to the displaced tooth. The displaced tooth is tied to the archwire with elastic thread. Two types of traction hook are used:

The duration of this phase of treatment is 20 to 30 weeks. The rst archwire is left in place for 8 to 10 weeks and the second for 4 to 6 weeks.

Phase 3: Major Mechanics

The archwires used in this phase are 0.019 0.025 preposted stainless steel archwires. Many buccal segment crossbites will have corrected

A very thin wire loop traction hook on a bondable base. This is demonstrated in Figs 11 and 12 and used where there is very little space for the displaced tooth or on rotated teeth some distance from the line of the arch. It is positioned so that the lumen of the hook will allow the archwire to pass through it as the tooth ap-

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Figure 11. This patient has an upper left palatal cuspid that is rotated mesially. A traction hook has been placed on the mesial edge of the tooth to maximize derotation as the tooth moves to wards the line of the arch. The bracket system is Damon2 (D2) and the archwire 0.014 copper nickel titanium. A length of coil spring one bracket width wider than the space has been placed and the tooth attached to the archwire with elastomeric thread. (Color version of gure is available online.)

Figure 13. The upper left lateral incisor has a broad traction hook in place with the 0.014 copper nickel titanium archwire running through its lumen. There is insufcient room to place a full-sized bracket. The broader traction hook gives some rotational control and is usually replaced with a normal passive selfligating bracket after one visit. (Color version of gure is available online.)

proaches the line of the arch. Its minimal mesiodistal width maximizes interbracket span although provides no intrinsic rotational control. A broader eyelet or traction hook (part no: DB22-0450; DB Orthodontics Limited, Ryeeld Way, Silsden, Keighley, West Yorkshire,

BD20 0EF U.K.) used where greater space is available but insufcient to place a self-ligating bracket in its correct position as shown in Figure 13. This type of traction hook is oriented in the same way as the other type of traction hook but has the advantage of giving some rotational control. If the tooth is rotated, then two strategies may be used:

Figure 12. Two visits after that of Fig 11. At the previous visit, the 0.014 copper nickel titanium (CuNiTi) archwire was put through the lumen of the bracket. All the movement of the upper left cuspid has been achieved with a traction hook and a 0.014 CuNiTi archwire in two visits. The D2 bracket was placed at this visit. (Color version of gure is available online.)

If the tooth is so displaced from the archwire that it is not possible to engage the traction hook directly with the archwire, the traction hook is attached to the archwire with elastic thread and positioned so as to maximize correction of the tooths position as it moves toward the arch. If the traction hook can be directly engaged with the archwire, then elastomeric chain is placed over the archwire, mesial or distal to the traction hook depending on the direction of rotation required and then attached to a bracket that has the archwire fully engaged so as to provide a very light derotation couple. This technique is particularly useful for rotated lower incisors and rotated premolars where initial placement of a full-sized bracket in the correct position is impossible.

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Stops can also be used to prevent tooth movement. Examples of this are as follows:

Placement of the stops distal to the cuspids maintains consolidation of the anterior segment. Placement of stops at either end of an interbracket span can maintain space for an unerupted or prosthetic tooth. Placement of stops immediately mesial to upper second molars in rst molar extraction cases will maintain arch length to allow the resolution of anterior crowding.

Figure 14. A Damon splint and tongue trainer. (Color version of gure is available online.)

Archwire Stops
Passive self-ligating brackets have extremely low levels of friction between archwire and bracket. Archwires are free to swivel to mesiodistally and, if allowed to do so, cause wire pokes distal to the terminal buccal attachments. The archwires therefore need to be stabilized using archwire stops to prevent irritation to the buccal mucosa. Originally, a single stop was placed in a short interbracket span, such as between lower incisors or between upper rst and second premolars. Stops could be made of composite, soft split stainless steel tube, or stainless steel tube placed over the archwire before insertion. Many high technology archwires now come with two stops preloaded on to the archwires and the following recommendations for the use of stops are given:

Stops are not required on preposted archwires as the posts act as stops; careful selection of the size, however, can mean that the posts can have a secondary function such as maintaining the consolidation of anterior space.

Anteroposterior Correction Class II Malocclusion

Anteroposterior correction of Class II malocclusion is often achieved before xed appliance treatment using some form of functional appliance. If not, then Class II correction can be achieved during treatment using either class elastics or a xed Class II corrector such as a Herbst appliance attached to the archwires. The Herbst appliance is a more effective class corrector than Class II elastics and so is used where more facial and dental correction is required. The Herbst appliance is fabricated to t on to the archwire directly. Its use is facilitated by the use of self-ligating upper rst molar tubes. A TP Flip-Lock Herbst kit (TP Orthodontics Inc, 100 Center Plaza, Laporte, IN 46350) is required together with some thick-walled 0.022 0.028 Inconel (trademark of Special Metals Corporation, Huntington, WV) rectangular tubing (OSCAR Inc., 11793 Technology Dr., Fisher, IN 46038). The stages of fabrication and tting are as follows:

To stop the archwire swiveling, stops are placed either side of a bracket or at either end of an interbracket span. Stops should be placed on a section of the archwire where little movement of the archwire relative to the bracket is expected to occur. Thus stops should be placed as far as possible from crowded, displaced, or rotated teeth. Where crowding is bilateral, stops should be placed anterior to the crowding. Stops should be placed where they are unobtrusive and not easily seen. This normally means in the lower incisor region and in the upper second premolar region. Stops placed also help to identify the archwire once it is removed from the mouth.

Sections of the Inconel tubing are welded and soldered to the underside of the Herbst axles ( 4) so that the Inconel tubing is ush on one side of the axle and projects 2 mm on the other side. The patient should be in 0.019 0.025 preposted stainless steel archwires.

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Figure 15. Extraoral photographs at the start of treatment aged 14 years 0 months. Note relatively immature facial appearance. (Color version of gure is available online.)

Figure 16. Intraoral photographs at the start of treatment. There is moderate crowding in the upper arch and severe crowding in the lower arch. The clinical crown of the lower right central incisor is longer than on the adjacent teeth. There is a left buccal segment crossbite. (Color version of gure is available online.)

The Herbst axles are placed on the archwires. In the upper arch, the 2-mm Inconel tube projection should face anteriorly, and in the lower arch posteriorly. This is to maximize the distance between the axles.

In the upper arch, the Herbst axles are placed between the upper rst and second molars. In the lower arch, the Herbst axles are placed between the lower cuspids and the lower rst premolars. The Inconel tube should be an

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D. Birnie

the buccal mucosa. The cylinder is engaged rst on the upper axles, the piston inserted into the cylinder and then attached to the lower axle. The integrity of each buccal segment is maintained by a wire ligature or elastomeric link running from the hook on the second molar to the archwire post. The Herbst is activated 2 mm at each visit by placing split tube spacers (TP Orthodontics Inc.) over the piston until a full edge-to-edge occlusion is achieved.

Once a full edge-to-edge occlusion has been achieved, the Herbst appliance is left in place for a further 6 months.

Retention
Retention is normally with a xed solid 0.026 stainless steel wire retainer from the lingual surface of lower cuspid to lower cuspid. The wire is only bonded to the lingual surfaces of the lower cuspids, which are lightly sandblasted before etching. The ends of the wire are attened, contoured, and sandblasted to maximize retention. In the upper arch, a braided retainer wire (Reliance Orthodontic Products, PO Box 678, Itasca, IL 60143) is bonded to the palatal surfaces of the four upper incisors ensuring that it does not interfere with the lower incisors. Upper and lower

Figure 17. Cephalometric radiograph at the start of treatment.

exact but not tight t between the intertube/ interbracket space. The Herbst piston/cylinder assembly is then cut to provide approximately 4 to 6 mm of initial protrusion. The piston should be trimmed so that it does not protrude more than 3 mm out of the back of the cylinder in the closed position so as to avoid irritation to

Figure 18. Treatment progress approximately 7 months into treatment. Alignment has been achieved in the upper arch. (Color version of gure is available online.)

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Figure 19. Treatment progress 15 months into treatment. Alignment within the arches has been achieved although some spacing persists in the upper arch and should have been consolidated and tooth contact maintained with a continuous wire tie or stops distal to the upper cuspids. (Color version of gure is available online.)

vacuum formed retainers are used in addition on a nighttime-only basis. For patients who have had correction of a Class II skeletal pattern, a Damon splint and tongue trainer is used to maintain Class II correction over the long term. This is shown in Fig 14.

Summary
Passive self-ligation offers the most direct transmission of force from archwire to tooth with very low friction, secure ligation, and ex-

cellent control of tooth position. All contemporary modalities of orthodontic treatment can achieve tooth alignment; passive self-ligation, however, does achieve results effectively, efciently, and in a manner that corresponds with patient values. In addition, practitioners experienced with the technique perceive that additional, unexpected patient benets occur that are not traditionally associated with conventional orthodontic treatment. However, these need further evaluation to understand and substantiate them. Mastering self-ligation

Figure 20. Patient at 25 months into treatment. The second molars were bonded 16 months into treatment and crossbite correction has occurred spontaneously without the need for auxiliary appliances such as a quadhelix appliance or cross elastics. (Color version of gure is available online.)

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Figure 21. Patient at 12 months after the end of active treatment and 1 year into retention. The clinical crown height of the lower incisors has normalized. The crowding has been resolved. The patient has direct bonded xed retainers and vacuum formed retainers that have been worn in the evenings and at night only. (Color version of gure is available online.)

is challenging, however, and it is not a technique that requires less clinical judgment or prociency. Effective health care interventions must have an evidence base; that evidence base is a combination of clinically relevant research, clinical expertise, and patient values.22 For passive self-ligation, the clinically relevant research base is small because interest in the subject has only commenced relatively recently, but is growing steadily; clinical expertise has allowed the technique to evolve and mature and its exibility allows it to respond to patients needs and preferences.

occur during his teenage years. He has a left unilateral crossbite. The lower right central incisor has a long clinical crown (see Figs 15-17). All permanent teeth were present on the dental pantomogram except for the upper third molars. His oral hygiene was good although still capable of improvement.

Case Presentation
This case is presented because it is challenging and controversial. It was treated by the author shortly after changing over completely to passive self-ligation in 2001. There are many possible ways of treating it. Important questions, however, are:

What caused the malocclusion? What treatment would provide the best optimization of facial appearance, smile esthetics, oral health, and stability?

Patient 09038801 presented at 14 years 0 months with moderate upper arch crowding and severe lower arch crowding. His facial appearance was prepubescent, he did not seem to have entered his pubertal growth spurt, and it was thought that signicant nasal tip and chin growth would

Figure 22. The posttreatment cephalometric radiograph.

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Table 2. Cephalometric and Study Cast Values at the Start of Treatment and Four Months after the End of Active Treatment (First Retainer Check)
Units Skeletal measurements SNA SNB ANB SN-maxillary plane Maxillary-mandibular plane LAFH UAFH LAFH/TAFH % LPFH UPFH PFH Wits appraisal Teeth Overjet Overbite UI-Maxillary plane LI-Mandibular plane Interincisal angle L1-Apo L1-Facial plane Soft tissue Upper lip to E-plane Lower lip to E-plane Nasolabial angle Chin thickness B-NPo L1-Mandibular plane Lower study cast Inter cuspid width Inter rst bicuspid width Inter second bicuspid width Inter rst molar width Inter second molar width Upper study cast Inter cuspid width Inter rst bicuspid width Inter second bicuspid width Inter rst molar width Inter second molar width degrees degrees degrees degrees degrees mm mm percent mm mm mm mm mm mm degrees degrees degrees mm mm mm mm degrees mm mm mm mm mm mm mm mm mm mm mm mm mm 18 March 2002 83.4 77.9 5.6 4.2 27.8 55.2 50.2 55.1 24.3 45.0 69.4 3.0 7.6 3.2 113.9 87.4 131.0 0.2 3.0 1.3 1.3 114.4 10.6 1.1 34.6 19.2 29.6 38.2 49.6 52.2 31.4 39.0 41.0 47.0 52.3 11 March 2005 83.0 77.3 5.7 5.6 28.2 62.1 54.7 56.7 27.8 47.5 75.3 4.4 2.8 1.3 114.9 97.5 119.3 3.4 6.1 5.1 0.2 121.7 9.5 2.4 39.5 29.4 38.1 43.8 50.7 55.9 38.4 46.4 51.1 55.1 58.1 Difference 0.4 0.6 0.1 1.4 0.4 6.9 4.5 1.6 3.5 2.5 5.9 1.4 4.8 1.9 1.0 10.1 11.7 3.2 3.1 3.8 1.5 7.3 1.1 1.3 4.9 10.2 8.5 5.6 1.1 3.7 7.0 7.4 10.1 8.1 5.8

SNA, Sella-Nasion-A point; SND, Sella-Nasion-B point; ANB, A point-Nasion-B point; LAFN, lower anterior facial height; UAFH, upper anterior facial height; LAFH/TAFH%, lower anterior facial height as a percentage of total anterior facial height; LPFH, lower posterior facial height; UPFH, upper posterior facial height; UI, upper incisor; LI, lower incisor; Apo, A Point-Pogonion; E-plane, Ricketts esthetic plane; B-NPo, B-Point-Nasion-Pogonion.

Figure 18 shows treatment progress after 7 months of treatment. Alignment has been achieved in the upper arch, but there is still insufcient space for the lower left lateral incisor. No crossbite correction has yet taken place; note that the right second molars, which are just visible, are not in crossbite. Figure 19 shows 15 months into treatment. Alignment within the arches has been achieved, but crossbite correction has not yet taken place. Once alignment of the upper labial segment had been obtained, the consolidation should have

been maintained with a continuous tie or stops distal to both upper cuspids. Figure 20 shows 25 months into treatment. The second molars were bonded 16 months into treatment, and crossbite correction then occurred spontaneously without the need for auxiliary appliances or cross elastics. Once stainless steel archwires were placed, the upper archwire was expanded and the lower contracted to ensure maximal correction. Figure 21 shows 12 months after the end of active treatment and 1 year into retention. The

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D. Birnie

Figure 23. Extraoral photographs taken 12 months after the end of active treatment showing that signicant facial maturation has taken place. Nasal growth has taken place and the hyoid bone is now much more prominent. (Color version of gure is available online.)

Figure 24. Superimposition of the start and nish cephalometric tracings. The amount of nasal growth relative to lip growth is demonstrated. The upper incisors have retained their inclination, but there has been proclination of the lower incisors. (Color version of gure is available online.)

Damon Passive System

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clinical crown heights of the lower incisors have equalized. In addition to the xed retainers, the patient wears vacuum formed retainers in the evenings and at night. Figure 22 shows the posttreatment cephalometric radiograph. Table 2 shows the cephalometric values at the start of treatment and at the rst retainer check four months after the end of active treatment. Figure 23 shows the patients facial appearance 12 months after the end of active treatment. Signicant maturation of the face has taken place including nasal tip growth and development of the hyoid bone. The patient has changed from a young boy to a young man. Figure 24 shows the superimposition of start and nish cephalometric tracings. Note nasal tip growth relative to lip growth. Upper incisor torque has not increased, but there has been some proclination of the lower incisors.

References
1. Damon DH: Treatment of the face with biocompatible orthodontics, in Graber TM, Vanarsdall RL, Vig KWL (eds): Orthodontics: Current Principles and Techniques. St Louis, Elsevier Mosby, 2005, pp 753-831 2. Srinivas S: Comparison of canine retraction with selfligated and conventional ligated bracketsa clinical study. Thesis in fulllment of postgraduate degree, Tamilnadu University, Chennai, India, 2003 3. Harradine NWT: Self-ligating brackets and treatment efciency. Clin Orthod Res 4:220-227, 2001 4. Maijer R, Smith DC: Time saving with self-ligating brackets. J Clin Orthod 24:29-31, 1990 5. Shivapuja PK, Berger J: A comparative study of conventional ligation and self-ligation bracket systems. Am J Orthod Dentofacial Orthop 106:472-480, 1994 6. Voudouris JC: Interactive edgewise mechanisms: form and function comparison with conventional edgewise brackets. Am J Orthod Dentofacial Orthop 111:119-140, 1997 7. Turnbull NR, Birnie DJ: Treatment efciency of conventional versus self-ligating brackets: the effects of archwire size and material. Am J Orthod Dentofacial Orthop 131:395-399, 2007 8. Thomas S, Birnie DJ, Sherriff M: 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. Eur J Orthod 20:589-596, 1998

9. Pizzoni L, Raunholt G, Melsen B: Frictional forces related to self-ligating brackets. Eur J Orthod 20:283291, 1998 10. Khambay B, Millett D, Mc Hugh S: Evaluation of methods of archwire ligation on frictional resistance. Eur J Orthod 26:327-332, 2004 11. Thorstenson BS, Kusy RP: Comparison of resistance to sliding between different self-ligating brackets with second-order angulation in the dry and saliva states. Am J Orthod Dentofacial Orthop 121:472-782, 2002 12. Sims APT, Waters NE, Birnie DJ: 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. Br J Orthod 21:367-373, 1994 13. Mah E, Bagby MD, Ngan PW, et al: Investigation of frictional resistance on orthodontic brackets when subjected to variable moments [abstract]. Am J Orthod Dentofacial Orthop 123:A1, 2003 14. Miles PG, Weyant RJ, Rustveld L: A clinical trial of Damon 2 vs conventional brackets during initial alignment. Angle Orthod 76:480-485, 2006 15. Venezia AJ: Pure Begg and edgewise arch treatments: comparison of results. Angle Orthod 43:289-300, 1973 16. Pandis N, Polychronopoulou A, Eliades T: Self-ligating vs conventional edgewise brackets in the treatment of mandibular crowding. Am J Orthod Dentofacial Orthop 132:208-215, 2007 17. Cash AC, Good SA, MacDonald F: An evaluation of slot sizes in orthodontic bracketsare standards as expected? Angle Orthod 74:450-453, 2004 18. Bourauel C, Morina E, Eliades T: Torque capacity of self-ligating brackets compared with standard edgewise brackets. Abstracts of Lectures and Posters [abstract 115]. Amsterdam, European Orthodontic Society, 2005 19. Pandis N, Strigon S, Eliades T: Maxillary incisor torque with conventional and self-ligating brackets: a prospective clinical trial Orthod Clin Res 9:193-198, 2006 20. Eberting JJ, Straja SR, Tuncay OC: Treatment time, outcome and patient satisfaction comparisons of Damon and conventional brackets. Clin Orthod Res 4:228-234, 2001 21. Andrews LF. Straight-Wire: The concept and the appliance. San Diego: LA Wells and Co, 1989 22. Committee on Quality of Health Care in America, Institute of Medicine: Improving the 21st century healthcare system, in Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, National Academy Press, 2001, pp 39-60