Effects of self-ligating brackets on oral hygiene and discomfort: a systematic review and meta-analysis of randomized controlled clinical trials

Assessment of Motivations, Treatment Risks, and Oral Health in Adults with Fixed Orthodontic Care: A Cross-Sectional Study

Aim: This cross-sectional study aims to investigate the reasons why adults seek orthodontic treatment, their perceived treatment risks, oral hygiene habits, and awareness of oral health. Materials and Methods: This study, which involved 246 adults, used a self-report questionnaire to collect sociodemographic data and examine the participants' understanding of oral health, self-assessment of oral health status, adherence to oral hygiene routines, and use of oral hygiene products. In addition, the reasons for opting for orthodontic treatment, negative associations, and expected outcomes were examined. The collected data were subjected to statistical analysis, including descriptive and regression methods. Results: The results showed that factors such as previous oral health education and regular use of specialized toothbrushes, including rotary toothbrushes, were significantly associated with higher knowledge levels (p < 0.05). However, daily oral hygiene practices were suboptimal, with the low utilization of aids: only 58.9% reported using interdental brushes, and 36.6% used dental floss regularly. Commonly reported dental problems included food debris between teeth (46.3%), tartar (35.4%), and tooth sensitivity to cold (26.4%). The primary motivations for orthodontic treatment were aesthetic improvement (63.8%), enhancements in oral function (49.6%), and addressing psychosocial concerns (42.7%). In contrast, the most frequently mentioned negative aspects associated with fixed orthodontic treatment were aesthetic concerns (30.9%), treatment duration (27.6%), and mouth ulcers (24.0%). Conclusions: Based on the research findings, regular oral hygiene education is recommended for adult patients considering fixed orthodontic therapy, including the use of additional tools such as interdental brushes and floss to improve oral health and reduce the risk of complications during treatment. The importance of chemical compounds in dentifrices and mouthwashes cannot be overstated, as they play a crucial role in addressing various dental issues. In addition, it is crucial to carefully weigh the pros and cons of therapy and to visit a dentist regularly to maintain oral health and monitor progress during treatment.

The Efficacy of Accelerating Orthodontic Tooth Movement by Combining Self-Ligating Brackets With One or More Acceleration Methods: A Systematic Review

This review aimed to evaluate the effectiveness of using one or more acceleration methods with self-ligating brackets to accelerate orthodontic tooth movement in adults and the associated effects of these interventions. An electronic search of the following databases (PubMed, Scopus, Google Scholar, EMBASE) was performed (From January 1990 to November 2021). ClinicalTrials.gov and the International Clinical Trials Registry Platform were also electronically searched to find any unpublished studies and ongoing trials. The selected randomized controlled trials (RCTs) involved adult patients treated using self-ligating brackets combined with one or more acceleration methods compared with self-ligating brackets or conditional brackets alone. The risk of bias was assessed using Cochrane's risk of bias tool. A total of seven RCTs and one controlled clinical trial (CCT) were included in this review. Combining self-ligating brackets with flapless corticotomy, low-level laser therapy (LLLT), and infrared light accelerated orthodontic movement by 43% and 50% for surgical methods, 20-50% for LLLT, and 22% for infrared light. Regarding side effects on periodontal tissues, neither flapless corticotomy nor low-frequency vibrational forces caused any damage. Combining self-ligating brackets and flapless corticotomy, low-level laser, or infrared light effectively accelerated orthodontic movement by 20% to 50 %. In contrast, the combination of self-ligating brackets with vibrational forces did not affect speeding tooth movement. The acceleration methods did not have any side effects on the periodontal tissues, but the available evidence was insufficient. There is a need for further primary research regarding the effectiveness of combining self-ligating brackets with acceleration methods and the possible untoward side effects.

Microbial colonisation associated with conventional and self-ligating brackets: a systematic review

BACKGROUND

Decalcification and gingivitis caused by plaque accumulation around brackets are common iatrogenic effects of fixed appliances. The influence of conventional versus self-ligating bracket design on microbial colonisation is unknown.

OBJECTIVE

To assess the levels of microbial colonisation associated with conventional and self-ligating brackets.

SEARCH SOURCES

Three databases were searched for publications from 2009 to 2021.

DATA SELECTION

Randomised controlled trials comparing levels of microbial colonisation before and during treatment with conventional and self-ligating brackets were assessed independently and in duplicate.

DATA EXTRACTION

Data were extracted independently by two authors from the studies that fulfilled the inclusion criteria. Risk of bias assessments were made using the revised Cochrane risk of bias tool for randomized trials. The quality of the included studies was assessed using the Critical Appraisal Skills Programme Checklist.

RESULTS

A total of 11 randomised controlled trials were included in this systematic review. Six of the studies were found to be at low risk of bias and five presented with some concerns. The studies were considered moderate to high quality. Five trials reported no statistically significant difference in microbial colonisation between bracket types. The remaining studies showed mixed results, with some reporting increased colonisation of conventional brackets and others increased colonisation of self-ligating brackets. The heterogeneity of study methods and outcomes precluded meta-analysis.

CONCLUSION

Of the 11 studies included in this systematic review, five found no differences in colonisation between conventional and self-ligating brackets. The remaining studies showed mixed results. The evidence is inconclusive regarding the association between bracket design and levels of microbial colonisation.

Periodontal Health in Patients with Self-Ligating Brackets: A Systematic Review of Clinical Studies

BACKGROUND AND OBJECTIVES

The aim of this systematic review with meta-analysis is to assess the available evidence from human clinical studies of using self-ligating brackets compared to conventional brackets in maintaining periodontal health.

MATERIALS AND METHODS

The protocol details were registered in the PROSPERO database (CRD42022302689). This review was performed under the PRISMA guidelines. The electronic search was performed in PubMed, Scopus, Web of Science and grey literature databases, as well as manual searches to find relevant articles published until January 2022. The inclusion criteria consisted of human clinical studies which reported the use of fixed orthodontic treatment with self-ligating brackets (SLBs) or conventional brackets (CBs) in maintaining periodontal health.

RESULTS

A total of 453 studies were imported into the Covidence Platform from the databases. Of these, six articles met the inclusion criteria. For plaque index, statistical significance was achieved for SLBs compared to CBs (0.31 (95% CI (0.15 to 0.48), p = 0.0001). For gingival index, probing depth and bleeding on probing no statistical significance was achieved. None of the included studies assessed clinical attachment level.

CONCLUSIONS

The present systematic review with meta-analysis was considered to provide relevant data on periodontal health during orthodontic treatment in patients with SLBs in comparison with patients wearing CBs. Our findings indicated that SLBs are not superior to CBs in terms of periodontal health.

An Umbrella Review of Systematic Reviews With or Without Meta-Analysis Assessing Treatment Outcomes and Efficiency of Self-Ligating Brackets

Introduction

Self-ligating bracket systems are popular and seem to demonstrate lesser friction, allowing tooth movement without exerting unwanted forces on surrounding structures. This umbrella review aimed to compare self-ligating and conventional bracket systems for treatment efficiency.

Methods

An electronic search in 8 databases was performed for literature published between January 1, 1990, and October 1, 2021, with manual hand-searching of references of retrieved articles. Quality assessment was performed using the risk of bias in a systematic tool by 2 independent reviewers. Data were extracted using a prepiloted form (Joanna Briggs Institute) for evidence synthesis. Corrected covered area was calculated to quantify study overlaps across systematic reviews with or without meta-analysis.

Results

605 articles were retrieved, of which 16 were selected. Most included studies had a low risk of bias, except for 6 that showed an unclear risk of bias. Data analysis revealed a reduction in lower incisor proclination, bacterial accumulation, and oral malodor using self-ligating appliances.

Conclusions

Self-ligating systems reduce mandibular incisor proclination, bacterial accumulation, external apical root resorption, chairside time, and oral malodor. No other differences could be demonstrated in comparison with conventional appliance systems.

Is there any difference between conventional, passive and active self-ligating brackets? A systematic review and network meta-analysis

AIM

To test the null hypothesis that there was no difference in treatment efficiency between therapies undertaken with conventional (CBs), passive self-ligating (PSLBs) or active self-ligating (ASLBs) brackets.

MATERIALS AND METHODS

An electronic search was performed in 3 data bases (Pubmed, Web of Science, Cochrane Library) from their origin up to January 2019. Additional references were hand searched. Search was strictly restricted to randomized controlled trials (RCTs) and split-mouth design studies (SMDs). RCTs and SMDs were initially processed separately and subsequently combined in a network meta-analysis. The following variables were evaluated: treatment duration, number of visits, occlusal outcomes, alignment rate, transverse arch dimensional changes, incisor position modification, rate of space closure, anchorage loss, bond failure, root resorption, perception of discomfort during the initial phase of alignment, time to ligate in or to untie an archwire, periodontal variables, quality of life.

RESULTS

On 229 papers, 30 RCTs and 9 SMDs were finally included in this study. Out of 85 comparisons, 16 only revealed statistically significant differences. It was quicker to untie and ligate an 0.014 NiTi arch from/in 6 ASLBs anterior ceramic brackets compared to 6 ceramic CBs. It was also more painful to insert and remove an 0.019×0.025 SS wire in/from PSLB's brackets compared to CB's attachments. Compared to conventional brackets, there was less maxillary incisor proclination with PSLBs in non-extraction cases. Moreover, there was less bleeding on probing 4-5 weeks after bonding with PSLBs compared to CBs brackets. The only significant difference between ASLBs and PSLBs was that alignment was 10 days faster with active self-ligating braces compared with passive self-ligating braces even if treatment duration between ASLBs and PSLBs was not significantly different. The network meta-analysis revealed that IMPA was greater in extractions cases with CBs compared with both ASLBs (+2,5°) and PSLBs (+1,6°).

CONCLUSIONS

The vast majority of the studied variables did not show any significant differences between the three types of brackets. The most significant findings were that it was quicker to insert and remove archwires from ASLBs compared to CBs, and it was more painful to insert and remove an 0.019×0.025" stainless steel wire in/from PSLBs compared to CBs. The major difference between ASLBs and PSLBs was that alignment was 10 days faster with active self-ligating braces compared with passive self-ligating braces even if treatment duration between ASLBs and PSLBs was not significantly different. Most of the claims put forward by the suppliers were not substantiated by our network meta-analysis.

The effect of ligation methods on biofilm formation in patients undergoing multi-bracketed fixed orthodontic therapy - A systematic review

BACKGROUND

Many modifications to fixed orthodontic appliances have been introduced to manage biofilm formation. The aim of this review was to investigate elastomeric ligation in comparison with stainless steel ligation and self-ligation with regard to microbiological and clinical indicators of biofilm formation in patients wearing multi-bracketed fixed orthodontic appliances.

METHODS

The MEDLINE and the EMBASE databases were searched up to February 2021 and supplemented by additional manual searches of bibliographies. Parallel-group and split-mouth randomized controlled trials (RCTs) comparing different ligation methods were identified. The Cochrane Risk of Bias-2 tool was applied to assess the quality of evidence.

RESULTS

A total of 11 RCTs were included in this review. Nine RCTs compared self-ligation and elastomeric ligation; two compared elastomeric ligation and stainless steel ligation. The included studies had either some concerns or were at a high risk of bias. Qualitative assessment of the studies identified that there were no significant differences in biofilm formation between elastomeric ligation and self-ligation, but that stainless steel ligation was less susceptible to biofilm formation than elastomeric ligation.

CONCLUSIONS

There were no significant differences between self-ligation and elastomeric ligation for biofilm formation in patients wearing multi-bracketed fixed orthodontic appliances. Stainless steel ligation may accumulate less biofilm than elastomeric ligation; however, the clinical significance of the difference could not be evaluated. Further high-quality studies are required in order to determine which ligation method is better for managing biofilm formation in patients wearing multi-bracketed fixed orthodontic appliances.

Systematic reviews in orthodontics: Impact of the PRISMA for Abstracts checklist on completeness of reporting

INTRODUCTION

This study evaluated and compared the completeness of reporting of abstracts of orthodontics systematic reviews before and after the publication of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Abstracts Checklist (PRISMA-A).

METHODS

Abstracts of systematic reviews and meta-analyses in orthodontics published in PubMed, Latin American and Caribbean Health Sciences Literature, and the Cochrane Database of Systematic Reviews databases before March 23, 2018, that met the predefined inclusion and exclusion criteria, were evaluated using the 12 items of PRISMA-A, scoring each item from 0 to 2. Abstracts were classified into 2 groups: before and after publication of the PRISMA-A checklist. Three calibrated evaluators (intraclass correlation coefficient and kappa > 0.8) assessed the scores for compliance with the checklist. The number of authors, country of affiliation of the first author, performance of meta-analysis, and topic of the article were recorded. A regression analysis was performed to assess the associations between abstract characteristics and the PRISMA-A scores.

RESULTS

Of 1034 abstracts evaluated, 389 were included in the analysis. The mean PRISMA-A score was 53.39 (95% CI, 51.83-54.96). The overall score for studies published after the publication of the checklist was significantly higher than for studies published before (P ≤ 0.0001). The components returning significantly higher scores after publication of PRISMA-A were title (P = 0.024), information from databases (P = 0.026), risk of bias (P ≤ 0.0001), included studies (P ≤ 0.0001), synthesis of results (P ≤ 0.0001), interpretation of results (P = 0.035), financing and conflict of interest (P ≤ 0.0001), and registration (P ≤ 0.0001). These results showed the positive effect of PRISMA-A had on the quality of reporting of orthodontics systematic reviews. Nevertheless, the poor adherence revealed that there is still need for improvement in the quality of abstract reporting.

CONCLUSIONS

The quality of reporting of abstracts of orthodontic systematic reviews and meta-analyses increased after the introduction of PRISMA-A.

Clinical and Salivary Findings in Patients with Metal and Crystalline Conventional and Self-Ligating Orthodontic Brackets

Aim

Data regarding different types of orthodontic brackets and ligation and various clinical and salivary findings are scarce. Therefore, the aim of this study was to compare clinical and salivary findings in patients with different types of fixed orthodontic appliances.

Subjects and methods

Decayed, missing and filled teeth index (DMFT) and plaque index, salivary flow rate, salivary pH and prevalence of white spot lesions were determined in 83 patients with different types of orthodontic brackets and ligation (metal passive self-ligating brackets, conventional metal brackets, mono-crystal brackets and polycrystalline active self-ligating brackets), before and six months after the beginning of fixed orthodontic treatment. The patients were recruited in a private dental office, in the period of two years. The group comprised 83 patients (mean age: 15.14 ± 1.66 years), including 52 women (mean age: 15.08 ± 1.68) and 31 men (15.24 ± 1.64). Statistical analysis was performed by use of dependent and independent samples t-test as well as one way ANOVA, Wilcoxon signed rank test and the Kruskal Wallis test. P-values below 0.05 (p<0.05) were considered significant.

Results

DMFT and salivary flow have shown a significant increase, while salivary pH has shown a significant decrease in the observed time interval, in all patients irrespective of type of brackets and ligation. Among patients with different bracket material, no significant differences were found in any of the observed parameters.

Conclusion

Although salivary flow rate is increased in patients with fixed orthodontic appliances which can have caries-protective effect, DMFT also increases and salivary pH decreases six months after the beginning of the treatment independently of bracket material or ligation type. All patients should receive instructions for precise oral hygiene and dietary habits before the beginning of fixed orthodontic therapy and at every dental check-up.

Effectiveness, efficiency and adverse effects of using direct or indirect bonding technique in orthodontic patients: a systematic review and meta-analysis

Background

The direct and indirect bonding techniques are commonly used in orthodontic treatment. The differences of the two techniques deserve evidence-based study.

Materials and methods

Randomized controlled trials (RCTs), wherein direct and indirect bonding techniques were used in orthodontic patients were considered. The MEDLINE, EMBASE, CENTRAL and Web of Science databases were searched to identify relevant articles published up to December 2018. Grey literature was also searched. Two authors performed data extraction independently and in duplicate using the data collection form. The included trials were assessed using the Cochrane risk of bias assessment tool.

Results

Of the 1557 studies screened, 42 full articles were scrutinized and assessed for eligibility. Eight RCTs (247 participants) were finally included for the analyses. The qualitative synthesis showed that no significant difference existed in the accuracy of bracket placement and oral hygiene status between the two bonding techniques. The indirect bonding was found to involve less chairside time but more total working time compared with the direct bonding. The meta-analysis on bond failure rate demonstrated no significant difference between the direct and indirect bonding (RR = 1.13, 95% CI = 0.78–1.64, I² = 22%, P = 0.50). Consistent results were obtained in the subgroup analyses and sensitivity analyses.

Conclusion

Weak evidence suggested that the direct and indirect bonding techniques had no significant difference in bracket placement accuracy, oral hygiene status and bond failure rate, for bonding orthodontic brackets. The indirect bonding might require less chairside time but more total working time in comparison with the direct bonding technique. High-quality well-designed randomized controlled trials are needed before a conclusive recommendation could be made.

Electronic supplementary material

The online version of this article (10.1186/s12903-019-0831-4) contains supplementary material, which is available to authorized users.

[Oral and periodontal hygiene in orthodontic patients]

INTRODUCTION

Orthodontic appliances promote dental plaque retention and make tooth-brushing less easy. They result in both quantitative and qualitative changes in dental plaque, exposing orthodontic patients to dental caries and periodontal diseases.

MATERIALS AND METHODS

The authors explain the effects of orthodontic treatments on dental plaque and the occurrence of dental and periodontal problems; they emphasize the role of pathogenic bacteria and highlight the need for efficient (both individual and professional) control of dental plaque.

DISCUSSION

Therefore, orthodontists have to educate their patients on oral and periodontal hygiene in order to control this bacterial factor and to avoid the occurrence of dental and/or periodontal complications.

Effects of fixed orthodontic brackets on oral malodor: A systematic review and meta-analysis according to the preferred reporting items for systematic reviews and meta-analyses guidelines

BACKGROUND

This systematic review and meta-analysis aimed to identify whether there is any relationship between fixed orthodontic appliances and malodor, and if self-ligating brackets (SLBs) prevent malodor better than conventional brackets (CBs).

METHODS

The electronic databases PubMed, Ovid, EMBASE, and the Cochrane Library were searched from inception to September 2016; a manual search was also performed. Randomized controlled and clinical controlled trials, in which experimental groups received fixed orthodontic therapy and malodor was measured, were included. Patients treated with fixed orthodontic brackets were compared with those without any treatment, and SLB systems were compared with CB systems. Two reviewers independently selected potentially relevant studies, evaluated the risk for bias, extracted essential data, and synthesized findings using Review Manager version 5.3 (Copenhagen: The. Nordic Cochrane Centre, The Cochrane Collaboration, 2014).

RESULTS

Four studies, involving a total of 152 participants, met the inclusion criteria. Fixed orthodontic appliances caused malodor from the initial visit to 2 to 3 months, but was only significant after the first week (mean difference 20.24 [95% confidence interval [CI]11.75-28.74]; P < .00001). Plaque index, gingival index, and periodontal pocket depths demonstrated no statistical differences between the SLB and CB groups after the first week. However, SLBs significantly controlled malodor better than CBs after the first week (mean difference 4.32 [95% CI 6.02 to 2.61]; P < .00001). The quality of the included studies was relatively low and relevant research in this field is quite scarce.

CONCLUSIONS

Although the evidence base was relatively weak, fixed orthodontic treatment appeared to be a risk factor for malodor, independent of periodontal changes, and SLB systems controlled malodor better than CB systems.

Self-ligating Brackets May Not Have Clinical Advantages Over Conventional Brackets for the Periodontal Health of Adolescent Orthodontic Patients

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The effect of bracket ligation on the periodontal status of adolescents undergoing orthodontic treatment. A systematic review and meta-analysis. Arnold S, Koletsi D, Patcas R, Eliades T. J Dent 2016; 54:13-24.

SOURCE OF FUNDING

The authors did not report any funding source information for the study TYPE OF STUDY/DESIGN: Systematic review with meta-analysis of data.