J Orofac Orthop (2017) 78:121128

DOI 10.1007/s00056-016-0059-8

ORIGINAL ARTICLE

Differences between active and passive self-ligating brackets

for orthodontic treatment
Systematic review and meta-analysis based on randomized clinical trials

Unterschiede zwischen aktiven und passiven selbstligierenden

Brackets bei der kieferorthopadischen Behandlung
Systematisches Review und Metaanalyse auf der Basis randomisierter klinischer
Studien

Xianrui Yang1 Yiruo He1 Tian Chen1 Mengyuan Zhao1 Yinqiu Yan1

Hongzhe Wang1 Ding Bai1

Received: 14 March 2016 / Accepted: 7 September 2016 / Published online: 21 February 2017
Springer-Verlag Berlin Heidelberg 2017

Abstract
Purpose In orthodontic treatment, the effects of differ-
ences in the design between active and passive self-ligating
bracket (ASLB and PSLB, respectively) are usually
neglected. This study investigated differences in effec-
tiveness and efficiency between ASLBs and PSLBs.
Methods To identify randomized, controlled clinical trials
(RCTs) comparing ASLB with PSLB, the electronic data-
bases Medline, Embase, Cochrane Central Register of
Controlled Trials, Chinese Biomedical Literature Database,
China National Knowledge Infrastructure, and Chinese
Medical Journal Database were searched without language
or time limits. Relevant available dental journals and ref-
erence lists from included studies were manually searched
for applicable reports. Meta-analyses were conducted with
the Review Manager program. Two independent reviewers
performed all search processes; disagreements were dis-
cussed with a third reviewer.
Results Eight studies were included in the systematic
review, of which six were included in the meta-analysis
due to the data consistency. Three had a low risk of bias,
Dr.: Ding Bai.
& Ding Bai
baiding@scu.edu.cn
1
Department of Orthodontics, West China School of
Stomatology, Sichuan University, 3rd Section of Renmin
South Road, Chengdu 610041, Sichuan, China
four had an unclear risk of bias, and one had a high risk of
bias. With regard to alignment efficiency, meta-analysis
favors ASLB [mean difference (MD) -10.24 days, 95%
confidence interval (CI) -17.68 to -2.80]. However, the
same analysis does not favor either design in terms of
width change due to treatment for intercanine (MD -0.49
mm, 95% CI -1.10 to 0.13 mm) interfirst premolar (MD
-0.07 mm, 95% CI -0.69, 0.56 mm) intersecond premolar
(MD -0.58 mm, 95% CI -1.25 to 0.08 mm) and inter-
molar (MD 0.10 mm, 95% CI -0.82 to 1.02 mm) width.
Conclusions Based on current clinical evidence from
RCTs, ASLB appears to be more efficient for alignment,
while neither design shows an advantage for width change.
Further research is needed to confirm present results.
Keywords Active self-ligating bracket
Passive self-
ligating bracket
Randomized controlled clinical trial

Efficacy
Alignment
Zusammenfassung
Ziel Bei der kieferorthopadischen Behandlung werden die
Effekte von Unterschieden im Design zwischen aktiv und
passiv selbstligierenden Brackets (ASLB bzw. PSLB) in
der Regel nicht berucksichtigt. Ziel der Studie war die
Erforschung moglicher Unterschiede zwischen ASLB und
PSLB hinsichtlich Effektivitat und Effizienz.
Methoden Um randomisierte kontrollierte klinische Stu-
dien (RCT) zum Vergleich von ASLB und PSLB zu
ermitteln wurde in elektronischen Datenbanken Medline,

123
122
Embase, Cochrane Central Register of Controlled Trials,
Chinese Biomedical Literature Database, China National
Knowledge Infrastructure und Chinese Medical Journal
Database ohne sprachliche oder zeitliche Restriktionen
gesucht. Relevante zur Verfugung stehende zahnarztliche
Periodika und Literaturverzeichnisse von in die Analyse
aufgenommenen Studien wurden manuell durchsucht. Fur
die Metaanalysen wurde die Software Review Manager
(RevMan) eingesetzt. Alle Suchprozesse wurden von 2
unabhangigen Forschern durchgefuhrt, Uneinigkeiten
wurden mit einem dritten Forscher diskutiert.
Ergebnisse In den systematischen Review eingeschlossen
wurden 8 Studien, bedingt durch die Datenkonsistenz
gingen 6 dieser Studien in die Metaanalyse ein. Bei 3
Studien bestand ein geringes Bias-Risiko, bei 4 ein
unklares und bei einer Studie ein hohes Bias-Risiko. Hin-
sichtlich der Alignment-Korrektur wies die Metaanalyse
eine U berlegenheit der ASLB nach [durchschnittliche
Differenz (mean difference, MD) -10,24 Tage; 95%- selection and outcome biases [24]. However, methods and
Konfidenzintervall (KI) -17,68 bis -2,80]. Die gleiche
Analyse zeigte allerdings keinen Vorteil fur eines der
beiden Verfahren hinsichtlich der therapeutischen Brei-
tenanderungen [intercanine Distanz (MD -0,49 mm, 95%-
KI -1,10 bis 0,13 mm), Distanz zwischen ersten Pramola-
ren (MD -0,07 mm, 95%-KI -0,69, 0,56 mm), zweiten
Pramolaren (MD -0,58 mm, 95%-KI -1,25 bis 0,08 mm)
und Molaren (MD 0,10 mm, 95%-KI -0,82 bis 1,02 mm)].
Schlussfolgerungen Auf der Grundlage aktueller klinischer
Evidenz aus RCTs scheinen ASLB fur das initiale Ali-
gnment effizienter zu sein. Fur Korrekturen der Breiten
dagegen erweist sich kein Design als uberlegen. Zur
Bestatigung der vorgestellten Ergebnisse sind weitere
Untersuchungen notwendig.
Schlusselworter Aktives selbstligierendes Bracket

Passives selbstligierendes Bracket
randomisierte
kontrollierte klinische Studie
Wirksamkeit
Alignment
Introduction
In recent years, orthodontic treatment with self-ligating
brackets (SLBs) has gained popularity due to the conve-
nience and claimed clinical superiority [4, 22]. Some
orthodontists believe that full arch wire engagement and
low friction are obtained through the inbuilt metal labial
face of the ligature-less bracket system [10]. Although
comparative advantages between SLBs and conventional
brackets (CBs) continue to be debated, most studies do not
classify SLBs into subdesigns, thus, neglecting differences
in effectiveness and efficiency between different types of
SLBs. There are two main designs, among which the
mechanism of lid closure is the main difference: active
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X. Yang et al.
self-ligating brackets (ASLBs) and passive self-ligating
brackets (PSLBs). ASLBs can apply force on the archwire,
owing to the spring clip, whereas PSLBs do not exert active
force and do not encroach on the slot lumen [20]. Since
different lid configurations may result in various mecha-
nisms during the same treatment procedures, it is necessary
to distinguish if there is any difference in outcomes
between ASLBs and PSLBs.
Due to lack of clinical studies, the claimed clinical
performance and superiority of various bracket designs
currently come from bracket manufactures, whose claims
are usually substantiated by marketing-derived principles
rather than by scientific evidence. Fortunately, an increas-
ing number of studies that focus on the comparison
between active and passive bracket designs have been
published in recent years. Moreover, some recent reports
are randomized controlled clinical trials (RCTs), which are
regarded as being superior, partly because RCTs eliminate
results of RCTs vary, some concluding in favor of ASLBs,
some in favor of PSLBs, while others find no difference
between the two designs [20]. At this point, the controversy
between designs requires that we collect and analyze
available relevant studies.
Therefore, the present systematic review and meta-
analysis gathered all published RCTs that compare ASLBs
with PSLBs, which were analyzed and used in order to
compare results and resolve which self-ligating orthodontic
bracket design is more effective.
Materials and methods
To specify the materials and methods of the present review,
a customized protocol was conducted in advance. Two
independent reviewers carried out the study selection, risk-
of-bias assessment, and data extraction. Any disagreement
between reviewers was resolved by conference with a third
reviewer.
Selection criteria
Participants included in this systematic review and meta-
analysis were patients who underwent orthodontic treat-
ment with active or passive self-ligating brackets. Inter-
vention and control groups received similar orthodontic
procedures. Outcome variables consisted of all applicable
measurements. The primary outcomes included efficiency
of alignment time and effectiveness of transverse dimen-
sional change. The secondary outcomes were treatment
time, periodontal condition, and space closure rate.
Accepted study designs were randomized, controlled
Differences between active and passive self-ligating brackets for orthodontic treatment 123

clinical trials (RCT), quasi-RCT, and split-mouth ran- Results

domized clinical studies.
Inclusion process
Search strategy
After a careful search, 112 studies were identified, while 98
Electronic databases, including Medline (via PubMed), remained for screening after removing duplicate publica-
Cochrane Central Register of Controlled Trials (CEN- tions, from which 21 full texts were retrieved for further
TRAL), EMBASE (via OVID), Chinese Biomedical Liter- consideration. Applying terms of eligibility, eight studies
ature Database, China National Knowledge Infrastructure met the inclusion criteria, of which only six could be used
and Chinese Medical Journal Database were searched in the meta-analysis due to the result inconsistency when
without language limitation, and an updated search was analyzing their detailed data (Fig. 1).
conducted in February of 2016. Relevant available dental
journals were manually searched and the reference lists from Description of included studies
all included studies were checked for applicable reports.
The search strategy combined MeSH terms with free All the included studies were RCTs, published in the past
text words, and Cochrane Highly Sensitive Search Strategy 5 years, and which compared different orthodontic brack-
was used to identify randomized trials. Search terms ets, four comparing active with passive design, and three
included active, passive, self-ligating, orthodon- comparing active, passive, and conventional brackets. The
tic, and brackets. To collect all potentially eligible remaining study concerned five different ligation methods,
studies, all discovered titles and abstracts were scanned, including elastomeric, stainless steel, Leone slide, passive,
then full texts were obtained for further consideration. and active ligature. Here, only the data comparing ASLB
with PSLB were extracted for analysis (Table 1).
Risk-of-bias assessment
Risk-of-bias assessment
Six domains were considered as criteria to assess risk of
bias, including sequence generation, allocation conceal- Three studies were organized and conducted well, plus
ment, blinding of outcome assessor, incomplete outcome, were evaluated as having low risk of bias. Four studies
selective data reporting, and other bias. A study was con- were grouped as unclear risk of bias mainly due to the lack
sidered low risk of bias if all domains were assessed as of a sequence generation description. Only one study was
low risk, moderate risk of bias if any domain was considered as high risk of bias because the follow-up lost
considered as unclear risk, and high risk of bias if any situation was not well explained or managed (Table 2).
domain was assessed as high risk [7].
Efficiency differences in alignment time
Data analysis
Three studies [15, 19, 21] reported an advantage for ASLB
A data extraction form was developed with details of on initial alignment efficiency, compared to PSLB, while
included studies, such as study identification, demographic
data, self-ligating brands, and all relevant outcomes.
Qualitative data were described, while quantitative data
were analyzed using the program Review Manager 5.3
(Nordic Cochrane Centre, Cochrane Collaboration,
Copenhagen, Denmark). To determine the statistical
heterogeneity of collected data, we performed a v2 test with
10% level of significance. The I2 statistic was adopted to
quantify the effect of statistical heterogeneity. The random-
effect model was applied when I2 [ 50% (P B 0.10),
otherwise, the fixed-effect model was adopted. In some
cases subgroup analysis was applied when high hetero-
geneity existed. Odds ratio (OR) together with the 95%
confidence interval (CI) was applied to dichotomous data,
while mean difference (MD) and 95% CI were used for
continuous data. Statistical significance was set at P \ 0.05 Fig. 1 Flow diagram used to identify studies
(two-tailed z tests). Abb. 1 Flussdiagramm zur Identifikation der Studien

123
124 X. Yang et al.

Tab. 1 Detail information of included studies

Tab. 1 Detaillierte Angaben zu den in die Analyse aufgenommenen Studien
Study Study Setting Extraction Brand of Patients Brand of Patients Main results
design ASLBs PSLBs

Othman 3-arm Malaysia Not In-Ovation R 20 (11F, 9M), Damon 20 Quality of life
[14] mention 18.9 years 3MX (8F,12M)17.6 years
Reddy [19] 5-arm India 34,44 In-Ovation R 10 (5F, 5M), SmartClip 9 Alignment efficiency
16.76 years (4M,5F)16.67 years Passive space closure
Upper incisor
inclination
Songra [21] 3-arm UK 14,24,34,44 In-Ovation R 38 (26F, Damon 42 (25F, 14.2 years; Alignment efficiency,
13.8 years; 3MX 17M, 14.3 years) Space closure
12M,
14.1 years)
Ying [25] 2-arm China No Quick 10 (6F, Damon 9 (5F,4M),17.4 years Maxillary and
4M),17.9 years mandibular width
change inclination
Cattaneo [2] 2-arm Denmark No In-Ovation R 20, 14.4 years Damon 26,15.5 years Lower teeth
3MX inclination
Fleming [5] 3-arm UK No In-Ovation C 32 (18F, 14M), Damon Q 32 (18F,14M), Maxillary width
22.5 years 18.9 years change
Upper inclination
Cattaneo [1] 2-arm Italy No In-Ovation R 32,15.0 years Damon 32,16.0 years Maxillary width
4MX change
Upper inclination
Pandis [15] 2-arm Greece No In-Ovation R 35 (20F, 15M), Damon 35 (21F,14M), Alignment efficiency
13.8 years MX 13.8 years
M male, F female

Tab. 2 Risk of bias assessment according to Cochrane handbook tools for randomized control clinical trials evaluation
Tab. 2 Bestimmung des Bias-Risikos gema den Cochrane-Tools fur die Evaluierung randomisierter kontrollierter klinischer Studien
Study Sequence generation Allocation concealment Blinding Incomplete outcome Selective data reporting Other bias Total

Reddy [19] L L L L L L L
Pandis [15] L L L L L L L
Songra [21] U L L L L L U
Fleming [5] L L L L L L L
Cattaneo [2] U U L L L U U
Othman [14] L L U L L U U
Cattaneo [1] L U L H L U H
Ying [25] U U U L L U U
L low risk of bias, U unclear risk of bias, H high risk of bias

one study [19] supported the active type for superior
results, and the other two [15, 21] did not indicate a dif-
ference in alignment efficiency between the two designs.
However, when using all the results in the meta-analysis,
ASLB showed superior results for initial alignment (MD:
-10.24 days, 95% CI -17.68 to -2.80 days) with statis-
tical difference and without heterogeneity (Fig. 2).
Comparison of transverse dimensional change
effectiveness
Transverse dimensional changes were calculated in three
studies [1, 5, 25] for which results showed no difference
between ASLB and PSLB. The meta-analysis also indi-
cated no significant difference in width change for

123
Differences between active and passive self-ligating brackets for orthodontic treatment
Fig. 2 Meta-analysis and Forest plot of time (days) to alignment
comparing active with passive self-ligating brackets
Abb. 2 Zeit (Tage) bis zum Alignment bei Behandlung mit aktiven
Fig. 3 Meta-analysis and Forest plot of intercanine width (mm)
change comparing active with passive self-ligating brackets
Abb. 3 Veranderung der Eckzahnbreite (mm) nach Behandlung mit
Fig. 4 Meta-analysis and Forest plot of interfirst premolars width
(mm) change comparing active with passive self-ligating brackets
Abb. 4 Veranderung der Breite (mm) im Bereich der ersten
maxillary intercanine (MD: -0.49, 95% CI -1.10, -0.13),
interfirst premolar (MD: -0.07, 95% CI -0.69, 0.56),
intersecond premolar (MD: -0.58, 95% CI -1.25, 0.08),
and intermolar (MD: 0.10, 95% CI -0.82, 1.02) width
ranges. However, results demonstrated a tendency (without
heterogeneity) to favor PSLB for width changes expanding
maxillary intercanine and intersecond premolar width
(Figs. 3, 4, 5, 6).
Other comparisons
Other measurements, such as space closure rate, tooth
inclination, and oral-health-related quality of life, were also
reported from included studies; however, these could be
neither extracted nor used for quantitative analysis. Only
one study [21] concerned space closure rate, which repor-
ted no difference between ASLB and PSLB. Six studies
[1, 2, 5, 19, 25] recorded changed in tooth inclination, three
[2, 19, 25] of which calculated mandibular incisal torque
125
vs. passiven selbstligierenden Brackets im Vergleich, Metaanalyse
und Forest-Plot
aktiven vs. passiven selbstligierenden Brackets im Vergleich, Meta-
analyse und Forest-Plot
Pramolaren nach Behandlung mit aktiven vs. passiven selbstligieren-
den Brackets im Vergleich, Metaanalyse und Forest-Plot
change, while the other three [1, 5, 25] were concerned
about maxillary incisors. However, inclination change is
difficult to assess, since it depends on the individual situ-
ation, which is expected to be different between PSLB and
ASLB in torque control. In addition, one study [14]
investigated the evaluation of oral-health-related quality of
life and claimed that no bracket system could be considered
as superior.
Discussion
Claims have been made of SLBs superiority in reducing
overall treatment time and friction, as well as improving
oral hygiene and esthetics [6, 9, 23]. Although some studies
do not find significantly different outcomes for self-ligating
brackets and conventional ones, current studies neglect
potential differences between passive and active design
types [1113, 16]. Because differences in bracket design
may influence orthodontic treatment outcomes, design type
123
126
Fig. 5 Meta-analysis and Forest plot of intersecond premolars width
(mm) change comparing active with passive self-ligating brackets
Abb. 5 Veranderung der Breite (mm) im Bereich der zweiten
Fig. 6 Meta-analysis and Forest plot of intermolar width (mm)
change comparing active with passive self-ligating brackets
Abb. 6 Veranderung der intermolaren Breite (mm) nach Behandlung
merits attention. The present meta-analysis favors ASLB in
terms of alignment efficiency, which might be explained by
force stored by the wire and the active clip, thus, increasing
labiolingual action range and consequently providing more
effect on alignment than a passive clip would do with the
same wire. The preceding is particularly true for a lingually
or labially displaced tooth. Higher total force will be
applied to the tooth by an active spring clip in comparison
to a passive design, a phenomenon that probably takes
place with high modulus wires, which have large deflec-
tions and are likely to allow a super-elastic wire to deliver
its force so as to improve alignment efficiency [18].
However, many other factors may influence the alignment
rate and affect the reliability of results, such as interbracket
span, arch wire sequences, bracket slot dimension, and
various frictional forces [21]. As presented in this meta-
analysis, many factors may have affected analytical results
for alignment efficiency. For example, two studies [19, 21]
included extraction cases, while another [15] did not
involve extraction. Moreover, some researchers found that
differences in bracket width may also influence alignment
efficiency: when compared with wider brackets, narrow
designs produce higher moments which lead to higher
forces at the edge of bracket slot [15]. The present meta-
analysis includes the same active bracket brand, In-Ovation
R, while including different passive bracket brands, which
is also a form of bias. Therefore, present results should be
explained and applied with caution.
As for expanding the transverse dimension, some authors
believe PSLB such as the Damon type can produce specific,
uniquely stable arch width changes [3], especially for
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X. Yang et al.
Pramolaren nach Behandlung mit aktiven vs. passiven selbstligieren-
den Brackets im Vergleich, Metaanalyse und Forest-Plot
mit aktiven vs. passiven selbstligierenden Brackets im Vergleich,
Metaanalyse und Forest-Plot
intermolar expansion without incisors labial movement and
that this cannot be achieved by ASLB due to encroachment by
the clip on the archwires. Although a tendency to support
PSLB for expanding maxillary intercanine and intersecond
premolar width was shown in the present meta-analysis, there
was no statistical difference. All the included studies adopted
the Damon type as the bracket brand representing the passive
group, while they used different active brands. As well, all
included studies concerned tooth inclination, since transverse
dimensional expansion of the arch was at times achieved by
buccal tipping, which is not a real arch width change. More-
over, width expansion may cause a change in incisor incli-
nation, which is difficult to control. Thus, many factors need to
be considered when expanding in the transverse dimension.
Besides the efficiency of alignment time and effective-
ness of transverse dimensional change, some RCTs payed
attention to the difference in other aspects between ASLB
and PSLB, such as tooth inclination, life quality, and space
closure rate. However, none of them showed any signifi-
cant difference. Songra et al. [21] conducted a 3-arm par-
allel design studying extraction space closure comparing
not only active and passive self-ligating brackets but also
conventional appliances. They found no difference
between those three designs. Moreover, different
orthodontic brackets may differently affect patients
physical, social, and psychological well-being for non-
treatment reasons involving the patients understanding of
the potential benefits and drawbacks of treatment [8].
Although patients are not likely able to distinguish between
passive and active designs, orthodontists have a need to be
clear about the differences.
Differences between active and passive self-ligating brackets for orthodontic treatment
In addition to the comparison between ASLB and PSLB,
four included studies also considered the difference of
conventional brackets compared to self-ligating brackets
[5, 14, 19, 21]. Even though many published studies
compared CB with SLB, they did not classify SLB into
active and passive designs. Moreover, they have not
reached to a conclusion regarding which design is better.
Three studies adopted 3-parallel arm design, including
ASLB, PSLB, and CB [5, 14, 21]. One concerned oral
health-related quality of life, concluding that no bracket
system was superior [14]. One considered the efficiency of
initial alignment and space closure in adolescents, finding
that CB was more effective for initial alignment than
ASLB or PSLB, while all the three designs were similar for
space closure [21]. The final study compared maxillary
width change and inclination of upper teeth of the three
designs, showing that CB and SLB did not differ in arch
dimensional or inclination changes [5]. There was another
study [19] evaluating five ligation methods, including
conventional, active and passive ligation. It claimed SLBs
are more efficient than conventional ligation brackets for
initial leveling and alignment. However, these data could
not be used in the meta-analysis due to various hetero-
geneities. Since there are no convincing results on which
design is better, orthodontists should make their own
judgement based on current evidence and clinical experi-
ence when choosing brackets for patients.
Although this systematic review and meta-analysis fol-
lowed the instructions of the Cochrane Handbook carefully
and only included high-level evidence from RCTs, some
potential biases and limitations were not avoided. First, the
sample size is not ideal, due to the limited number of published
studies. Since small sample size leads to random error, we
have used several studies in the meta-analysis to enlarge the
sample size. Second, we have included clinical trials, which
usually have confounding factors that cannot be avoided, such
as different modalities and methods for various malocclu-
sions, inadequate sample equivalence assessment before
treatment, ill-defined selection criteria, and various bracket
brands [16, 17]. To reduce interindividual variation, a patient-
specific analysis is required, since individual factors may
affect the outcome, such as pretreatment tooth inclination and
occlusion. Thus, future high-quality studies are needed. Third,
selection bias always exists in systematic reviews; so, we have
searched the databases electronically and manually in order to
restrict such bias as much as possible.
Conclusions
Based on current evidence from RCTs, ASLB shows
advantages for initial alignment. Results do not support
advantage for PSLB or ASLB for transverse dimensional
127
expansion. In the future, high quality studies with larger
sample sizes and lower heterogeneity are needed for more
conclusive results. Orthodontists are advised to carefully
consider the differences between bracket designs in clinical
use.
Compliance with ethical guidelines
Conflict of interest X Yang, Y. He, T. Chen, M. Zhao, Y. Yan, H.
Wang, and D. Bai declare that they have no conflict of interest.
This article does not contain any studies with human participants or
animals performed by any of the authors.
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