Original Article

Self-ligating brackets do not reduce discomfort or pain when compared to

conventional orthodontic appliances in Class I patients: a clinical study
Gracia Costa Lopesa; Gilson Kazuo Watinagaa; Antônio Sérgio Guimarãesb; Lidia Audrey Rocha
Valadasc; Juliana Ramacciatod

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ABSTRACT
Objectives: To compare the intensity, location, and short-term impact of the periodontal discomfort/
pain, as well as the related functional parameters of bite force and masticatory efficiency, between
self-ligating and conventional orthodontic appliances.
Materials and Methods: In 20 patients referred for orthodontic treatment, samples were collected
from the gingival sulcus to evaluate the level of substance P using enzyme-linked immunosorbent
assay. Orthodontic devices were randomly bonded, with self-ligating appliances on one side and
conventional brackets on the contralateral side. Pain threshold (PT), maximal bite force (MBF), and
masticatory efficiency (ME) were assessed using standard validated techniques at the beginning of
the treatment and 24 hours post–orthodontic activation with an 0.016-inch nickel-titanium wire.
Results: There were no significant differences (P . .05) in the substance P levels, PT, MBF, and
ME between the self-ligating and conventional orthodontic appliances.
Conclusions: There was no difference between conventional and self-ligating appliances in the
parameters of pain: substance P and pressure. Functional aspects, such as pain, discomfort, and
masticatory efficiency, should not be considered when making a therapeutic decision regarding the
use of self-ligating vs conventional orthodontic appliances. (Angle Orthod. 2023;93:398–402.)
KEY WORDS: Pain; Orthodontic appliances; Self-ligating brackets

INTRODUCTION for the patient and repeated consultations because of

loss of ties, inconsistency in the strength of the
Since the first orthodontic devices were created by
material, and, consequently, lack of control over the
Angle, there has been great advancement in ortho-
dental material.2–4 Therefore, self-ligating brackets
dontic appliances in order to improve and facilitate
were created with the premise that brackets that were
adequate patient care. For many years, brackets were free of elastomeric ties or ligatures would create much
tied to the archwire by elastomeric ties or ligatures,1 but less friction, allowing better dental sliding mechanics
this type of link was shown to have disadvantages and with subsequent higher efficiency.5 To date, however,
limitations, such as the need for longer time in the chair there is little evidence regarding pain in patients with
self-ligating brackets. In general, pain is the most
a
MSc Student, Postgraduate Program in Orthodontics, São negative side effect related to orthodontic treatment2,3
Leopoldo Mandic College of Dentistry, Campinas, Brazil.
b
Professor, Laboratory of Neuroimmune Interface of Pain and is often an argument for lack of patient compli-
Research, São Leopoldo Mandic College of Dentistry, Campi- ance.6 At the basis of this complaint is the main
nas, Brazil. mechanism related to orthodontic movement, the bone
c
Researcher, Department of Preventive Dentistry, College of remodeling process, in which mature bone tissue is
Dentistry, University of Buenos Aires, Buenos Aires, Argentina.
d
Professor, Postgraduate Program in Orthodontics, São removed and new bone tissue is formed. Tooth
Leopoldo Mandic College of Dentistry, Campinas, Brazil. movement is, therefore, initiated as a result of
Corresponding author: Dr Lı́dia Audrey Rocha Valadas, inflammation in the periodontal tissues after the
Researcher, Department of Preventive Dentistry, College of application of orthodontic forces, which underlies such
Dentistry, University of Buenos Aires, Buenos Aires, Argentina
(e-mail: lidiavaladas@gmail.com)
remodeling.7–9 Clinical studies10 indicated that pain is a
major concern in orthodontic patients, one that affects
Accepted: December 2022. Submitted: May 2022.
Published Online: February 27, 2023 their quality of life.
Ó 2023 by The EH Angle Education and Research Foundation, In this context, pain in orthodontic patients with self-
Inc. ligating brackets has not been adequately investigated.

Angle Orthodontist, Vol 93, No 4, 2023 398 DOI: 10.2319/050822-346.1

PAIN AND DISCOMFORT WITH SELF-LIGATING BRACKETS 399

This oversight is not only due to technical constraints similar appearance in order to avoid bias. The
but also to the fact that most of the studies to date have conventional appliances had elastomeric ties without
relied on self-reported data and subjective measures, esthetic discomfort for the patient. Samples for
with consideration of the fact that quantification of pain substance P (SP) level, the pressure-related pain
is inherently biased by individual perception. There- threshold, maximal bite force, and masticatory perfor-
fore, there is a lack of high-quality controlled studies mance were measured at two timepoints: T1 (before
objectively assessing this clinically relevant issue. For the first activation) and T2 (24 hours after the first
this reason, the aim of this study was to investigate the activation). The primary outcome was the pain, and the
differences between self-ligating brackets and conven- secondary outcome was the pressure.
tional brackets in terms of discomfort/pain and the

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related functional parameters of bite force and masti- Gingival Fluid Collection
catory efficiency.
Collection of gingival fluid from the gingival sulcus for
MATERIALS AND METHODS measurement of SP level was performed from the
maxilla according to the Offenbacher method. All teeth
Type of Study were first gently washed with water, and the side of the
procedure was isolated for minimizing salivary con-
This study isw a randomized, controlled clinical
tamination. An endodontic paper cone was then
study comparing conventional and self-ligating brack-
inserted about 1 mm inside the gingival sulcus and
ets.
was kept there for 1 minute. The volume of fluid
absorbed by the paper cone was measured using
Study Subjects
Periotron 8000 (Harco, Periotron 8000, Amityville, NY),
Twenty patients aged 15 to 25 years with good which was calibrated with human serum. All paper
general and oral health, without caries or periodontal cones were stored at a temperature of 308C until they
disease, with permanent dentition, and in whom were processed. The protein concentration was eval-
orthodontic treatment was indicated, were selected to uated using the Bradford method, with bovine serum
be included in this study. Patients with symptoms of albumin used as a standard.
anxiety, depression, or denoted psychological instabil-
ity were excluded. Patients with dentofacial deformities Enzyme-Linked Immunosorbent Assay
or temporomandibular joint disorders and those who
had used psychotropic drugs, anti-inflammatory drugs, The levels of SP were measured using the enzyme-
or antibiotics during a period of 6 months prior the linked immunosorbent assay method (Systems R&D,
beginning of the protocol were also excluded. Among Minneapolis, Minn), according to the manufacturer’s
the females, the orthodontic devices were inserted out instructions.
of the follicular phase of the ovulatory cycle.
To establish the sample size, a difference of 20% Pressure-Related Pain Evaluation
was considered between the means of any of the Periodontal pain evaluation was performed using a
outcome variables (masticatory performance, bite calibrated mechanical algometer (EMG System, Bra-
force, or pressure pain), with a 10% standard deviation. zil), which allowed measurement of the pressure-
Thus, 20 volunteers would be enough to provide a test related pain threshold in each tooth. The circular and
power greater than 90% (with an alpha of 5%, two- flat active tip of the device, measuring 1 cm2, was
tailed test) in a crossover study. surrounded by a finger rubber and was applied cross-
sectionally and longitudinally along the long axis of the
Experimental Design tooth and in the center and at the occlusal surface of
All patients included in the present study had a Class the clinical crowns. The pressure was progressively
I malocclusion and were evaluated by two of the increased, with constant speed controlled by validated
researchers. Straight-wire systems were used, and software, and the patients were asked to notify the
orthodontic devices were randomly bonded with self- operator when they felt the pressure was turning into
ligating (Damon, slot ¼ 0.022 inches; Ormco Yokoha- pain. At that time, the test was immediately stopped.
ma, Japan) brackets on one side and conventional Concomitant with the pain threshold test, the patient
brackets (Spirit, slot ¼ 0.022 inches; Ormco) on the was asked to hold with one hand a mechanical device
contralateral side. The type of treatment for each that measures tooth pressure sensation and to hold
patient was randomized using Microsoft Excel. The with the other hand a sensor indicating the subjective
measurements recorded before bracket insertion were feeling in increase in pressure. The calibrated scale
used as controls. All brackets were metallic with a from zero (absence of pressure) to 10 (pressure

Angle Orthodontist, Vol 93, No 4, 2023

400 LOPES, WATINAGA, GUIMARÃES, VALADAS, RAMACCIATO

Table 1. Mean ( 6Standard Deviation) of Substance P study was approved by the São Leopoldo Mandic
Measurement (ng/mL) in the Gingival Sulcus by Bracket Type and Ethical Committee under project 1.336.037.
Evaluation Timepoint
Conventional Self-Connected RESULTS
Assessments Bracket Bracket
First evaluationa 4.26 (2.64) 5.33 (2.52) Table 1 shows that there was no significant
Second evaluationb 3.69 (2.31) 2.94 (1.46)* difference in the measurement of substance P between
a
Patient without the bracket installed. the two devices (P . .05). However, for the self-ligating
b
Twenty-four hours after the first activation of the 0.16-inch wire brackets, the mean in the second assessment (after 24
orthodontic appliance. hours from the first activation) was significantly lower
* Differs from the measurement performed without the bracket,
than in the first (before the brackets were installed; P ,

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under the same bracket conditions (P , .05).
.05).
becoming a pain sensation) indicated the range of There was also no significant difference between the
sensations. Measurements were performed on premo- conventional or self-ligating brackets with regard to the
time required to reach pain, as measured by the
lars and incisors on both sides. Importantly, for this
algometer (P . .05), as shown in Table 2. It was also
analysis it was required that the patient’s head rested
noted that with both brackets there was a significant
in a specific support, with the orbitomeatal plane
decrease in the time required to reach pain in the
parallel to the floor, and that the hand holding the
second assessment compared to the first, both in the
sensor was placed at the opposite side of the
incisor and premolar regions (P , .05).
evaluation in order to avoid head displacement.
Similar results were observed for pressure measure-
ments by the algometer (Table 3). There was no
Statistical Analysis
significant difference between the brackets (P . .05),
First, descriptive and exploratory data analyses were and both brackets showed a significant decrease in
performed. An exploratory analysis of substance P pressure threshold (P , .05).
data indicated the presence of four outliers (outliers)
that were not considered in the analysis. Then, the DISCUSSION
mixed-model methodology for repeated measures over
Technological innovations are often introduced in the
time with split mouth was applied. The other variables
orthodontic market. Among them, self-ligating appli-
did not meet the assumptions of the analysis of
ances stand out, as they have been claimed11 to
variance and were analyzed by generalized linear
shorten treatment time because of their characteristic
models for repeated measures over time, with a split
of low friction, which facilitates the onset of tooth
mouth. Analyses were performed using the R program,
movement by decreasing the initial resistance to
considering a significance level of 5%.
movement. However, there is a lack of evidence
regarding objective measures in the evaluation. There-
Ethical Standards
fore, the present study was designed to compare self-
The risk-benefit ratio was not compromised in this ligating to conventional appliances with regard to the
study because orthodontic treatment, when indicated, pain and discomfort associated with them both.
is important for the patients’ functioning and wellbeing. Different methods have been used to measure the
All participants signed an informed consent form. The level of pain in orthodontic patients, including tradition-

Table 2. Mean (6Standard Deviation) of the Time to Reach Pain by the Algometer (kpa) by Bracket Type, Location, and Evaluation
Type of Bracket
Measure Tooth Evaluation Conventional Self-Connected
Cross-sectional Incisor First evaluationa 10,831.80 (2162.40) 11,384.55 (10,501.23)
Second evaluationb 4982.85 (3880.28)* 4470.20 (2501.03)*
Premolar First evaluationa 16,725.90 (7615.98) 14,505.95 (8619.65)
Second evaluationb 7181.88 (4764.11) * 7863.43 (5179.44)*
Longitudinal Incisor First evaluationa 13,471.51 (8750.90) 18,474.90 (11,759.56)
Second evaluationb 6960.80 (4637.89)* 8556.55 (6311.84)*
Premolar First evaluationa 17,271.10 (10,268.39) 21,305.65 (14,119.29)
Second evaluationb 10,925.35 (5419.43)* 9394.96 (5630.82)*
a
Patient without the bracket installed.
b
Twenty-four hours after the first activation of the orthodontic appliance with 0.16-inch wire. There was no significant difference between
brackets (P . .05).
* Differs from the measurement performed without the bracket, under the same bracket conditions (P , .05).

Angle Orthodontist, Vol 93, No 4, 2023

PAIN AND DISCOMFORT WITH SELF-LIGATING BRACKETS 401

Table 3. Mean (6Standard Deviation) of the Pressure Measurements by the Algometer (kgf) by Bracket Type, Location, and Evaluation
Type of Bracket
Measure Tooth Evaluation Conventional Self-Connected
Cross-sectional Incisor First evaluation a
35,838 (315.26) 351.13 (269.85)
Second evaluationb 159.25 (92.38)* 146.41 (67.44)*
Premolar First evaluationa 500.68 (205.26) 469.57 (262.42)
Second evaluationb 249.90 (149.80)* 253.82 (161.67)*
Longitudinal Incisor First evaluationa 488.55 (268.89) 611.52 (401.44)
Second evaluationb 247.56 (153.32)* 304.48 (221.04)*
Premolar First evaluationa 597.90 (370.89) 696.95 (460.84)
Second evaluationb 358.98 (201.40)* 325.57 (180.59)*

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a
Patient without the bracket installed.
b
Twenty-four hours after the first activation of the orthodontic appliance with 0.16-inch wire. There was no significant difference between
brackets (P . .05).
* Differs from the measurement performed without the bracket, under the same bracket conditions (P , .05).

al surveys with pretested questionnaires, the Visual control group, but there was no significant difference in
Analog Scale (VAS) classification,12 the McGill pain the SP values between the self-ligating and the
questionnaire,13 the Verbal Rating Scale,14 and mea- conventional devices. This was contrary to the findings
surement of SP levels in periodontal ligament fluid and of Yamaguchi et al.,22 who found significantly higher
using algometers.15 To reduce these pain variables, mean SP values for teeth undergoing orthodontic
pain evaluation in this study was performed based on movement than those in controls. Although the SP
the SP values, algometer test, and bite force mea- concentration in teeth with self-ligating brackets in that
surements. study was significantly lower than that in teeth with
Zheng et al.16 analyzed patients undergoing fixed conventional brackets, the SP levels had returned to
orthodontic treatment. Patients were interviewed after baseline levels after approximately 168 hours. Based
appliance activation to assess their perception of pain on this finding, the authors suggested that SP
and discomfort in different locations during different participated in a complex network of mediators that
activities using a VAS. All patients experienced some regulate inflammation, and that the Damon system is
pain or discomfort. According to a review by Bergius et useful for reducing inflammation and pain resulting
al.,17 a high rate of orthodontic patients report pain from orthodontic forces. Peck23 discussed the purport-
during orthodontic treatment; however, it is commonly ed advantages of the Damon self-ligating system.
observed that the pain does not develop until up to 2 According to Tecco et al.,24 patients treated with
hours after the placement of the appliance, and when it conventional brackets reported significantly more
does appear, it usually subsides within approximately 3 ‘‘constant’’ pain than did those treated with self-ligating
days. Erdinç and Dinçer18 reported that pain perception brackets, who complained of ‘‘chewing/biting’’ pain.
during orthodontic treatment with fixed brackets peak- Algometry is the most commonly used means for
ed at 24 hours and decreased on the third day, assessing the pain threshold for pressure.25
suggesting that the pain perception may be linked to When self-ligating brackets were developed, even
SP release. The late pain develops a few hours later though they represented a more expensive and
and is caused by increased sensitivity of the nerve complicated technique, much was considered about
fibers to harmful stimuli, such as prostaglandins, the advantage of generating lower forces and, conse-
histamines, and SP, a neuropeptide released by quently, the assumption that they would result in less
nociceptors in the damaged tissue region, which also pain caused by tooth movement. However, the findings
plays a role in increasing the rate of nerve dam- of the current study reported data similar to those
age.8,15,19 In the present study, pain was present in all associated with conventional brackets.
patients after orthodontic activation and during the In this study, there was no significant difference
evaluation of pain and SP level. between the sides with conventional or self-ligating
Yamaguchi et al.20 and Park et al.21 found that SP appliances in terms of the time required to reach
levels in the periodontal ligament were significantly painful levels, as measured by the algometer. It was
elevated during orthodontic movement in inflammatory also noted that there was a significant decrease in the
response to mechanical force. In the present study, the time required to reach pain thresholds in the second
mean SP values 24 hours after orthodontic appliance evaluation compared to the first with both appliances,
activation were significantly lower (inversely propor- both in the incisor and premolar regions. One limitation
tional values  lower values plus SP) than those in the of this study was that both types of brackets were

Angle Orthodontist, Vol 93, No 4, 2023

402 LOPES, WATINAGA, GUIMARÃES, VALADAS, RAMACCIATO

bonded in the same dental arch, with the same wire 11. Chen SS, Greenlee GM, Kim JE, Smith CL, Huang GJ.
passing through both, and there may have possibly Systematic review of self-ligating brackets. Am J Orthod
Dentofacial Orthop. 2010;137:726–727.
been differences in the force released.
12. Karobari MI, Assiry AA, Mirza MB, et al. Comparative
evaluation of different numerical pain scales used for pain
CONCLUSIONS estimation during debonding of orthodontic brackets. Int J
Dent. 2021;2021:6625126.
 There was no difference between conventional and
13. Sandhu SS. Validating the factor structure and testing
self-ligating appliances in the parameters of pain, measurement invariance of modified Short-Form McGill
substance P, and pressure. Pain Questionnaire (Ortho-SF-MPQ) for orthodontic pain
 The results of this study suggest that functional assessment. J Orthod. 2017;44:34–43.
aspects, such as pain and discomfort, should not be 14. Talnia S, Fry RR, Sharma A, Patidar DC, Goyal S, Gandhi

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considered when making a therapeutic decision G. Efficacy of crodermal diclofenac patch as an analgesic
following premolar extractions in orthodontic patients. Ann
regarding the use of self-ligating vs conventional
Maxillofac Surg. 2020;10:37–41.
orthodontic appliances. 15. Kaya Y, Alkan Ö, Kömüroglu AU, Keskin S. Effects of
ibuprofen and low-level laser therapy on orthodontic pain by
means of the analysis of interleukin 1-beta and substance P
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