Digitally positioned brackets - are they any better?

In orthodontics, the current trend is to find ways to accelerate treatment with many appliances making these claims, even in the naming of their appliance or technique (Fast, Quick, Rapid, Speed, 6-month, etc.). There is substantial evidence now to demonstrate that simply changing to a different type of bracket makes no difference – it is the skill of the operator that is most important, otherwise the patient may be accepting a compromise. For example; if treating only in round wires then the roots are not rotated, tipped or especially torqued into their best and most stable positions or the occlusion or overjet not addressed.

To overcome this, some companies have suggested that digitally positioned brackets are the answer as they reduce variability and take into account a lot of the skill and variation of the operator. Systems such as Insignia, SureSmile and even Invisalign are examples of these in orthodontics. However, there is a lot of biological variation with individual patients varying in response as well as appliances do not deliver 100% of what is built into them which is why detailing/finishing is required (the fiddly part of orthodontics). Previous retrospective studies have suggested that digitally customised appliances did deliver faster treatment but these had the same flaws as the self-ligating bracket and vibration appliance studies in that there is a high risk of bias and potential confounding variables that can influence the result beyond just the appliance (the later RCTs found no difference). This is why blinded, RCT’s are considered the gold standard – but also take more time and cost to conduct. However, an RCT was just published online in the Journal of Dental Research (considered the top journal in dentistry in terms of the quality of the articles) and this paper looked at the Insignia system of digitally positioned brackets compared with conventional placement. The results were interesting!

There were 180 patients in this RCT and when completed, they analysed 85 patients in the customized group and 89 in the non-customized group. The authors found no difference in treatment duration (digital = 1.3 years vs. conventional = 1.2 years) or quality of outcome as measured by the PAR (Peer Assessment Rating) index. Most importantly, the Orthodontist did have a significant effect on treatment duration, quality of treatment outcome, and number of visits (P < 0.05) - not the appliance used. Interestingly, the customized orthodontic group also had more loose brackets, a longer planning time, and more complaints (P < 0.05).

In the rush (pardon the pun) for faster treatment and to seem to be on the cutting edge, we can leap into new technologies. Sometimes they deliver what they claim while at other times they do not. Such systems usually involve additional cost with an expectation by the patient of faster treatment but in this case, it wasn’t delivering what it claimed. Some practitioners may prefer these systems and that is a personal choice just as some prefer one bracket type over another, but when claims are made of a faster or better outcome (and often at added cost)… proof rather than opinion is required. As Carl Sagan (Astrophysicist) famously stated; ‘Extraordinary claims require extraordinary evidence’.