Papageorgiou SN, Konstantinidis I, Papadopoulou K, Jäger A, Bourauel C. A systematic review and...

REVIEW ARTICLE

S. N. Papageorgiou

I. Konstantinidis

K. Papadopoulou

A. J€ager

C. Bourauel

A systematic review and

meta-analysis of experimental

clinical evidence on initial aligning

archwires and archwire sequences

Authors' affiliations:S. N. Papageorgiou, C. Bourauel,

Department of Oral Technology, School of

Dentistry, University of Bonn, Bonn,

Germany

S. N. Papageorgiou, K. Papadopoulou,

A. J€ager, Department of Orthodontics,

School of Dentistry, University of Bonn,

Bonn, Germany

I. Konstantinidis, Mount Sinai School of

Medicine, New York, NY, USA

Correspondence to:S. N. Papageorgiou

Department of Orthodontics

School of Dentistry

University of Bonn

Welschnonnenstraße 17

D-53111 Bonn

Germany

E-mail: [email protected]

Papageorgiou S. N., Konstantinidis I., Papadopoulou K., J€ager A.,

Bourauel C. A systematic review and meta-analysis of experimental

clinical evidence on initial aligning archwires and archwire sequences

Orthod Craniofac Res 2014. © 2014 John Wiley & Sons A/S. Published by

John Wiley & Sons Ltd

Abstract

The aim of the study was to assess treatment effects and potential side

effects of different archwires used on patients receiving orthodontic

therapy. Electronic and manual unrestricted searches were conducted in

19 databases including MEDLINE, Cochrane Library, and Google Scholar

until April 2012 to identify randomized controlled trials (RCTs) and quasi-

RCTs. After duplicate study selection, data extraction, risk of bias assess-

ment with the Cochrane risk of bias tool, and narrative analysis, mean

differences (MDs) with confidence intervals (CIs) of similar studies were

pooled using a random-effects model and evaluated with GRADE. A total

of 16 RCTs were included assessing different archwire characteristics on

1108 patients. Regarding initial archwires, meta-analysis of two trials

found slightly greater irregularity correction with an austenitic-active

nickel-titanium (NiTi) compared with an martensitic-stabilized NiTi arch-

wire (corresponding to MD: 1.11 mm, 95% CI: �0.38 to 2.61). Regarding

archwire sequences, meta-analysis of two trials found it took patient trea-

ted with a sequence of martensitic-active copper-nickel-titanium (CuNiTi)

slightly longer to reach the working archwire (MD: 0.54 months, 95% CI:

�0.87 to 1.95) compared with a martensitic-stabilized NiTi sequence.

However, patients treated with a sequence of martensitic-active CuNiTi

archwires reported general greater pain intensity on the Likert scale 4 h

and 1 day after placement of each archwire, compared with a martens-

itic-stabilized NiTi sequence. Although confidence in effect estimates ran-

ged from moderate to high, meta-analyses could be performed only for

limited comparisons, while inconsistency might pose a threat to some of

them. At this point, there is insufficient data to make recommendations

about the majority of initial archwires or for a specific archwire sequence.

Key words: aligning archwire; alignment; archwire sequence; bracket;

fixed orthodontic treatment; initial archwire; orthodontic archwire

Date:Accepted 30 April 2014

DOI: 10.1111/ocr.12048

© 2014 John Wiley & Sons A/S.

Published by John Wiley & Sons Ltd

IntroductionRationale

Developments in the last decades regarding

orthodontic archwires used during fixed appli-

ance treatment include the introduction of vari-

ous archwires from NiTi alloys, multistranded

archwires and esthetic coated or uncoated arch-

wires.

Developments of orthodontic archwires based

on NiTi alloys using a recent classification

(1) and in chronological order include 1) the

martensitic-stabilized (Mstab) – conventional –

NiTi, 2) the austenitic-active (Aact) – known as

superelastic – NiTi, 3) the martensitic-active

(Mact) – heat-activated – NiTi or copper-nickel-

titanium (CuNiTi), and 4) the graded Mact NiTi

archwires. The in vitro beneficial properties of

the last three categories of NiTi archwires have

been previously documented (1–4), but have not

been confirmed clinically (5–7). Retrieval analy-

ses indicated that intra-oral aging (8) may alter

the physical properties of the NiTi archwires (9,

10), the bracket (11) or ligation modules (12).

Multistranded stainless steel (SS) archwires

have been developed to fulfill the requirements

of an ideal archwire (1) and have been proposed

as an economical alternative to NiTi archwires

(13, 14), as they are equally efficient (15) and

produce low force and moment levels (16). Vari-

ous attempts at the development of an esthetic

archwire have been made (17–19). Recently,

shape memory polymeric archwires were devel-

oped (20, 21), in which moieties in the material

act as molecular switches upon irradiation with

UV light of k < 260 nm (22).

Archwire sequences used in clinical practice

vary greatly, with first coming the use of a NiTi

archwire followed by beta titanium or SS arch-

wires and a mean number of four to five arch-

wires per sequence being a popular choice

among orthodontists (23, 24). In general, the

orthodontist strives to use archwires with greater

stiffness and smaller range moving from the

aligning phase to the working and finally the fin-

ishing phase. Investigating a specific archwire

sequence is based on the need to establish a

standard way of reaching the working archwire,

which will be clinically effective and biologically

sound (25, 26).

Previous systematic reviews have attempted to

summarize evidence regarding initial aligning

archwires (27) or specific sequences of archwires

(28). However, inclusion of observational studies,

limited literature search, and exclusion of gray

literature may limit the value and validity of a

systematic review/meta-analysis (29, 30). Also,

most knowledge syntheses focus on a single

archwire characteristic, although it is not agreed

whether it is the bracket, the archwire, or their

interaction that mainly influences the mechani-

cal behavior of the bracket–archwire complex

(31, 32). Therefore, investigation of the bracket–

archwire complex may be more appropriate. As

earlier reviews included trials up to 2008 or

2009, an update was decided.

Objectives

This systematic review aims to critically appraise

existing evidence from randomized controlled

trials (RCTs) and quasi-RCTs regarding the effec-

tiveness, efficiency, and potential side effects of

the various archwires used during fixed appli-

ance orthodontic treatment.

MethodsProtocol

This review’s protocol was made a priori based

on the guidelines of the PRISMA statement (33),

its extension for abstracts (34), and the Cochrane

Handbook for Systematic Reviews of Interven-

tions 5.1.0 (35).

Eligibility criteria

Type of studies

Randomized controlled trials (RCTs) and quasi-

RCTs (36) of parallel or split-mouth design.

Split-mouth trials were eligible, if no carryover

effect was possible and clustering (or pairing) of

teeth was taken statistically into account (37–

39). When trial reports used the word ‘random’

once, but no further information was given, the

2 | Orthod Craniofac Res 2014

Papageorgiou et al. Systematic review on initial archwires and archwire sequences

authors were contacted to clarify whether true

randomization had taken place.

Type of participants

Humans of any age or sex.

Intervention

Placement of initial archwire and/or of the

following archwire sequence in the frame of

orthodontic therapy with fixed orthodontic

appliances to correct existing malocclusion. In

order for a study to be included, all of the

patient’s teeth of one or both jaws (excluding

third and possibly second molars) were required

to have received treatment with fixed orthodon-

tic appliances and archwire(s).

Comparison

Comparable patients for age, sex, and malocclu-

sion receiving therapy with another combination

of archwire and bracket (no untreated control

groups). Trials were excluded, if the comparison

group did not differ from the experimental

group in at least one from the following charac-

teristics: 1) archwire material, 2) archwire cross-

section shape, or 3) archwire cross-section size.

Primary outcome

Tooth alignment as measured by 2-D or 3-D

(intertooth) contact point differences or reduc-

tion in Little’s Irregularity Index (LII) (40). Alter-

natively, the outcome of orthodontic treatment

was included and measured in Peer Assessment

Rating (PAR) scores (41), the Index of Outcome,

Complexity and Need (ICON) (42), or any other

valid measuring method of malocclusion sever-

ity. Both overall correction of the dental arch

and correction of the labial/buccal segments

were included.

Secondary outcomes

1) Time to misalignment correction (where not

defined, a final cutoff value of 2 mm irregularity

was deemed adequate), 2) time to proceed to the

next archwire in the sequence, 3) time to reach

the working archwire, 4) treatment duration, 5)

number of appointments, 6) space closure

of extraction sites, 7) dental/skeletal changes,

8) patient-reported pain intensity measurement

by visual analog scale (VAS) (43), Likert scale (LS)

(44), or other valid scale, 9) clinician-prescribed

or self-prescribed analgesics use, 10) bracket fail-

ure (only for identical groups regarding bonding

systems used), 11) archwire fracture, 12) External

Apical Root Resorption (EARR), and 13) post-

treatment stability and relapse.

Studies were excluded if: 1) different arch

forms or bendings of identical archwires were

compared (i.e., preformed vs. computer-aided

bended archwires, etc.) or 2) patients had previ-

ous active treatment or relevant medical history.

Information sources, search, study selection, and data

collection process

Systematic searches for RCTs and quasi-RCTs

(completed or ongoing) were conducted. A total

of 19 general, open-access, regional, or gray

literature databases were searched from their

inception up to April 2012, including MEDLINE,

Cochrane Library, Google Scholar, and Clinical

Trials (Table S1). There was no language, publi-

cation year, or publication status (i.e., unpub-

lished articles) restriction. Translations of papers

were arranged where necessary.

The reference and citation lists of all included

trials and relevant reviews were scanned for

additional entries. Manual updates of journals

and databases were made weekly up to July

2012. Corresponding authors of registered trials,

conference abstracts, and posters were inquired

on their current status.

One author (SNP) screened all titles and

abstracts obtained from the database searches.

Two authors (SNP and KP) reviewed unblinded

(45) the full text of potentially relevant studies

and completed pre-defined data extraction

forms. Corresponding authors were contacted

for clarifications [with open-ended questions to

avoid overly positive answers (35)], missed trials,

and further data.

Risk of bias in individual or across studies

Two authors (SNP and KP) independently

assessed the risk of bias of the included studies

Orthod Craniofac Res 2014 | 3


using the Cochrane Collaboration’s tool for

assessing risk of bias (46), guided by the Cochra-

ne Handbook for Systematic Reviews of Inter-

ventions (35). Each RCT was assigned an overall

risk of bias in terms of high risk (‘high’ for ≥2key domains), unclear risk (‘unclear’ for ≥2 key

domains), and low risk for the remaining. The

exact definitions used for each of the domains

were pre-specified in the protocol (available on

request).

The quality of evidence and strength of recom-

mendations for each meta-analysis outcome

were ultimately assessed according to the

GRADE approach (Grades of Recommendation,

Assessment, Development, and Evaluation) (47).

Disagreements concerning study selection,

data extraction, or risk of bias were settled by a

third author (IK), and agreement was assessed

using the unweighted j coefficient (48). The two

authors were calibrated before the actual proce-

dures by pilot running the search results of a

previous systematic review (49) regarding all

duplicate procedures, until almost perfect agree-

ment (j > 0.8) was reached both between

authors and with the results of that review.

Summary measures, synthesis of results, and additional

analyses

Data were considered suitable for pooling if sim-

ilar interventions were used in the same way

and similar outcomes were reported. A random-

effects model as proposed by DerSimonian and

Laird (50) was chosen, because the observed

effect was expected to differ across studies due

to differences in the sample (i.e., patient’s den-

tal/skeletal age) and implementation (i.e., treat-

ment with/without extractions or different

mechanics used). In case of meta-analyses with

three or more trials, 95% prediction intervals

(PIs) (51, 52) were calculated to predict treat-

ment effects in a new trial. Although all 95% PIs

were calculated, only PIs for significant meta-

analyses are provided here (the remainder being

available on request).

The extent and impact of between-study heter-

ogeneity were assessed by inspecting the forest

plots and by calculating the tau-squared and the

I2 statistic, respectively. When heterogeneity was

present (I2 between 25% and 75%), possible

sources of heterogeneity were sought with strati-

fication by bracket/archwire or treatment char-

acteristics. When heterogeneity was >75%, data

were not pooled. If a sufficient number of trials

were identified (n > 7), analyses were planned

for ‘small-study effects’ and publication bias.

All analyses were carried on the basis of inten-

tion-to-treat (worst-case analysis) when possible.

Experimental groups were defined by character-

istics of the bracket–archwire complex, as listed

in the inclusion criteria section. For example, a

possible comparison could be a trial arm of con-

ventionally ligated (CL) metallic 0.022″ brackets

with a 0.016″ Mact CuNiTi initial archwire versus

a trial arm of self-ligating (SL) ceramic 0.022″

brackets with a 0.014″ Mstab NiTi archwire. When

two or more arms were classified, the same (for

example two different brands of brackets

identical to all characteristics), fixed-effect meta-

analysis was used to merge them, prior to com-

parison with the group that differed. For trials

providing before-and-after data for two groups

but no increments, a modest pre-/post-correla-

tion of 0.25 was used (after sensitivity analyses

with 0.25, 0.50, and 0.75). Split-mouth trials were

meta-analyzed separately from parallel trials,

identifying differences in effect size due to

design and pooled only if similar (39), as data

for the ‘inverse variance method’ were often

unavailable.

Mean differences (MD) or standardized mean

differences (SMD) for continuous outcomes and

their corresponding 95% confidence intervals

(CIs) were calculated. When possible, explor-

atory stratified analyses according to the

bracket/archwire characteristics used to define

the groups were performed with pre-specified

subgroup analyses (SG): (i.e., SL vs. CL brackets;

metallic vs. ceramic brackets). Robustness of

the results was a priori to be checked according

to 1) severity of the initial malocclusion and

2) the inclusion of extractions in the treatment

plan. A priori sensitivity analyses for each

outcome were planned based on the improve-

ment of the GRADE classification. RevMan ver-

sion 5.1 (Nordic Cochrane Centre, Cochrane



Collaboration, Copenhagen, Denmark) was used

to carry out the meta-analyses for comparable

trials and outcomes, and Stata version 10 (Stata-

Corp LP, College Station, TX, USA) was used for

calculating Cohen’s j and 95% PIs. Significance

(a) was set at 0.05, except for a 0.10 used for the

heterogeneity tests (53).

ResultsStudy selection

A total of 1528 citations were identified electroni-

cally and nine more manually (Fig. 1). After

duplicate exclusion, 762 articles were screened

and another 632 articles were excluded on the

basis of title and abstract. From the 130 articles

that remained, 106 articles were excluded on the

basis of their full text. Eleven articles more were

finally not included, as no full text was obtained.

A total of 18 trial authors were contacted for full-

text provision, clarifications, or additional unpub-

lished data. Two author e-mails could not be

found, while six trialists responded. Another 24

articles were excluded from the present review, as

they assessed bracket characteristics. Finally, a

number of possibly eligible trials (n = 8) were

excluded: No response and trial were deemed

ineligible (54), abstract/posters with no available

text (55–58), and ongoing trials (ISRCTN identifi-

ers: ISRCTN38412478, ISRCTN75477546).

Study characteristics and risk of bias

A total of 16 full-text reports were finally

included, describing 1108 patients included in

Fig. 1. PRISMA flow diagram of the study selection procedure.



16 RCTs published between 1990 and 2012. All

trial reports were in English, except for one in

Chinese (59). The bracket and archwire products

used in the included trials are provided sepa-

rately in Table S2. The kappa score for the selec-

tion of studies, the data extraction, and the risk

of bias assessment were 0.870, 0.916, and 0.921,

respectively, indicating an almost perfect level of

inter-reviewer agreement (48).

Trial characteristics and risk of bias assess-

ment for each of the 16 trials, based on pub-

lished data and author communication, are

given in Table 1, Table S3, Table 2, Table S4,

and Table 3, respectively. One split-mouth trial

(60) was included, which used appropriate statis-

tical methods (Wilcoxon signed-rank test). Only

three trials (61–63) provided a CONSORT flow-

chart with complete patient data.

Trials on initial archwires

A total of 13 trials with 863 patients were

included, assessing various factors: cross-section

of archwires (64), N+ implantation of archwires

(60, 65), and archwire materials (61–63, 66–71).

The association of archwire cross-section size

with reported pain intensity during the first

7 days after initial archwire placement was

investigated by Erdinc� and Dinc�er (64), who

reported significantly less pain and lower analge-

sic use in the 0.016″ group compared with the

0.014″ group. The method of N+ ion implanta-

tion of b-Ti or NiTi archwires, to alter surface

roughness and presumably facilitate easier slid-

ing, was investigated in two trials (60, 65) that

did not find a significant improvement.

Mact NiTi archwires

The use of an initial Mact NiTi compared with a

Mstab NiTi archwire was assessed in two trials

that reported no significant difference on allevia-

tion of tooth irregularity (69) or time to align the

anterior teeth (62).

The use of an initial Mact NiTi compared with

an Aact NiTi archwire was assessed in three tri-

als, two of which found no difference in tooth

alignment (69, 70). In the third trial (72),

patients treated with a Mact NiTi initial archwire

were reported to have lower pain intensity (VAS)

at the second, third, and fourth day after arch-

wire insertion. Treatment efficacy between

patients treated with Mact NiTi compared with a

multistranded SS initial archwires was assessed

on the basis of 3-D contact point movement by

two trials (66, 70) that found no significant dif-

ference, while issues of sample adequacy and

existing bias may reduce validity of the results.

Aact NiTi archwires

As stated above, significant differences in pain

intensity or analgesic use were found after an

initial Aact NiTi or a Mact NiTi archwire (72).

The use of an initial Aact NiTi archwire was

compared with a Mstab NiTi archwire in terms of

3-D contact point movement (61, 70), LII reduc-

tion (69), and pain intensity (67). The SMD was

used to pool contact point movement, and LII

reductions from two trials were pooled, while

data from the third one were unavailable.

Meta-analysis showed that use of Aact NiTi initial

archwires was associated with a small and statis-

tically nonsignificant benefit in irregularity alle-

viation compared with Mstab NiTi initial

archwires (Table 4; Fig. 2), with evidence being

classified according to GRADE as ‘moderate’.

Finally, pain intensity and analgesic use differed

significantly between groups only at the fourth

day, with the Aact NiTi group reporting less pain.

Pain after engagement of an initial Aact NiTi

archwire was compared in a trial to a multi-

stranded SS archwire (68), without finding signif-

icant differences. Regarding the comparison of

alignment efficiency, the results were contradic-

tory, with one trial finding no difference in LII

reduction (69) and one trial finding significantly

higher 3-D contact point movement of the ante-

rior segment for the Aact NiTi compared with the

multistranded SS archwires (71).

Multistranded archwires

As stated above for each type of NiTi archwire,

no differences were found between multistran-

ded SS archwires compared with Aact NiTi arch-

wires in terms of intertooth contact point

movement (70, 71) or patient pain intensity (68).

Moreover, no difference was found between



Table 1. Main characteristics of included trials regarding initial archwires

Trial

First author Design

Setting (country; clinic;

recruitment dates; mean

follow-up; % dropouts) Bracket/ligature Initial archwire (A1)

Cioffi (72) Single-center double-blind

two-arm parallel RCT

Italy; university; January 2009-

NR; 7 days; 0% dropouts

SS CL 0.022″

brackets/

elastomeric

Gp1: 0.016″ Aact NiTi

Gp2: 0.016″ Mact NiTi

Cobb III (65) Single-center three-arm

parallel RCT

USA; university; recruitment

dates NR; 12 months; 2%

dropouts


GpA: SS CL 0.018″

brackets/

elastomeric

Gp2: 0.016″ N+ implanted

Aact NiTi

GpB: SS CL 0.022″

brackets/

elastomeric

Gp3: 0.0175″

multistranded SS

Erdinc� (64) Single-center two-arm

parallel RCT

Turkey; university; recruitment

dates NR; 7 days; 0% dropouts

SS CL 0.018″

brackets/NR

Gp1: 0.014″ Mstab NiTi


Evans (66) Multicenter three-arm

parallel RCT

Country NR; setting NR;

recruitment dates NR; 8 weeks;

9% dropouts

SS slot size NR CL

brackets/

elastomeric

(usually)

Gp1: 0.016 9 0.022″

medium force Mact NiTi

28°C

Gp2: 0.016 9 0.022″

graded Mact NiTi 32.5°C

Gp3: 0.0155″

multistranded SS

Fernandes (67) Multicenter two-arm

parallel RCT

Norway; university/private;

recruitment dates NR; 7 days;

7.4% dropouts (regarding the

pain recordings)

(brackets were

standardized) SS

CL slot size NR

brackets/NR

Gp1: 0.014″ light force

Aact NiTi


Jones (68) Single-center two-arm

parallel RCT

Wales; university; recruitment

dates NR; 15 days; 6.7%

dropouts

SS CL 0.018″

brackets/NR

Gp1: 0.014″ heavy Aact

NiTi

Gp2: 0.015″ multistranded

SS

Kula (60) Single-center triple-blind

two-arm split-mouth RCT

USA; setting NR; recruitment

dates NR; 6 months

(maximum); 23.1% dropouts

SS CL 0.022″

brackets/

elastomeric

Gp1: 0.019 9 0.025″ b-Ti

Gp2: 0.019 9 0.025″

N+ implanted b-Ti

O’Brien (61)# Single-center two-arm

parallel RCT

England; university; recruitment

dates NR; 5 weeks; dropouts

NR

SS CL 0.018″

brackets/

elastomeric or SS



Ong (69) Single-center double-blind

three-arm parallel RCT

Australia; private; recruitment

dates NR; 4.1 months; 3.8%

dropouts

SS CL 0.018″

brackets/

elastomeric



Gp3: 0.014″ Mact CuNiTi

35°C

Pandis (62)# Single-center double-blind


Greece; private; December 2006

–December 2007; 6 months;

0% dropouts

SS active SL 0.022″

brackets/None

Gp1: 0.016″ Mact CuNiTi

35°C




multistranded SS archwires compared with Mact

NiTi archwires in terms of intertooth contact

point movement (66, 70). In contrast, multistran-

ded Aact NiTi archwires were reported to be sig-

nificantly more efficient in terms of 3-D contact

point movement than its single-stranded ana-

logs.

Trials on archwire sequences

Four trials (59, 69, 73, 74) investigated archwire

sequences used on 364 patients with SS CL

brackets. AlQabandi et al. (73) compared a

sequence of round SS archwires with progres-

sively greater cross-section with a sequence of a

rectangular Mact CuNiTi archwire, followed by a

rectangular SS archwire and found no significant

difference in treatment effects.

Ji et al. (59) similarly compared a sequence of

four progressively larger round Mstab NiTi arch-

wires, followed by two rectangular SS archwires

and a sequence of 0.016″ Mact round NiTi, fol-

lowed by a rectangular Mact NiTi and a rectangu-

lar SS archwire. No significant difference was

found in treatment duration or bracket failure

between the groups, while significantly more

archwire fractures were observed in the first

(Mstab NiTi) group. Nevertheless, caution is

advised due to the lack of sample size calculation,

the unclear risk of bias, and the lack of complete

reporting that precluded direct assessment.

Mandall et al. (74) randomized patients in

three sequences including various NiTi, CuNiTi,

and SS archwires, which are all manufactured by

the same company (Table S2). Assessed out-

comes included time/appointments to reach the

working archwire, pain intensity (LS) after arch-

wire insertion, and EARR of the maxillary central

incisor. No significant difference was found

among groups for any outcome in the maxillary

arch. In the mandibular arch, however, signifi-

cantly less time to reach the working archwire

and significantly lower pain intensity (LS) at 4 h,

the first and the seventh day after insertion were

reported for the archwire sequence ‘round and

then rectangular Mstab NiTi’ (Gp1) compared

with the sequence ‘round Mstab NiTi and then

round SS’ (Gp2). Also, significantly lower pain

intensity (LS) at the first, third, and seventh day

after insertion was reported for the ‘round then

rectangular Mstab NiTi’ sequence compared with

the sequence ‘rectangular Mact CuNiTi.’

Table 1. (continued)

Trial

First author Design



follow-up; % dropouts) Bracket/ligature Initial archwire (A1)

Quintao (70) Single-center four-arm

parallel RCT

Brazil; university; recruitment


NR

SS CL 0.022″

brackets/NR

Gp1: 0.016″ light force

Aact NiTi

Gp2: 0.016″ Mact NiTi

Gp3: 0.0155″

multistranded SS

Gp4: 0.014″ SS

Sebastian (63) Single-center double-blind


India; university; recruitment

dates NR; 12 weeks; 0%

dropouts

SS CL 0.022″

brackets/

elastomeric

(usually) and SS

Gp1: 0.016″ multistranded

Aact NiTi


West (71) Single-center two-arm

parallel RCT

Ireland; setting NR; recruitment


NR

SS CL slot NR

brackets/NR


Gp2: 0.0155″

multistranded SS

A1, first archwire; RCT, randomized controlled trial; NR, not reported; SS, stainless steel; CL, conventionally ligated; Gp, group;Aact, austenitic-active; NiTi, nickel-titanium; Mact, martensitic-active; Mstab, martensitic-stabilized; b-Ti, beta titanium; SL, self-ligating;#including data from author communication.



Table 2. Main characteristics of included trials regarding sequences of archwires

Trial

First author Design



follow-up; % dropouts) Bracket/ligature Archwire sequence

AlQabandi (73) Single-center two-

arm parallel RCT

USA; university;

recruitment dates NR;

6.2 months; dropouts NR

SS CL 0.018″ brackets/NR Gp1:

A1-??: SS (progressively larger

cross-section archwires)

A(last): 0.016″ SS

Gp2:

A1: (15 patients)

0.016 9 0.022″ Mact CuNiTi

35–37°C

A2: 0.016 9 0.022″ SS

Ji (59) Single-center two-

arm parallel RCT

China; university; July

2006–November 2008;

5.0 months; 0% dropouts

SS CL 0.022″ brackets/NR Gp1:

A1: 0.012″ Mstab NiTi




A5: 0.018 9 0.025″ SS

A6: 0.019 9 0.025″ SS

Gp2:

A1: 0.016″ Mact NiTi (0.012″ in

severe crowding)

A2: 0.019 9 0.025″ Mact NiTi

A3: 0.019 9 0.025″ SS

Mandall (74)# Multicenter single-

blind three-arm

parallel RCT

England; university/

hospital/private;


9.3 months (until

placement of the last

working archwire); 9.7%

dropouts

SS CL 0.022″ brackets/

ligation methods left to

clinical judgment;

ultimately found to be

equally divided among

groups

Gp1:


A2: 0.018 9 0.025″ Mstab NiTi

A3: 0.019 9 0.025″ SS

Gp2:


A2: 0.016″ SS

A3: 0.020″ SS

Gp3:

A1: 0.016 9 0.022″ Mact CuNiTi

35°C

A2: 0.019 9 0.025″ Mact CuNiTi

35°C

A3: 0.019 9 0.025″ SS



Table 2. (continued)

Trial

First author Design



follow-up; % dropouts) Bracket/ligature Archwire sequence

Ong (69) Single-center

double-blind

three-arm parallel

RCT

Australia; private;


4.1 months; 3.8%

dropouts

SS CL 0.018″ brackets/

elastomeric

Gp1:


A2: 0.017 9 0.017″ Mact NiTi

27°C

A3: 0.016 9 0.022″ SS

Gp2:

A1: 0.014″ Aact NiTi

A2: 0.016 9 0.022″ graded

Mact NiTi 32.5°C

A3: 0.016 9 0.022″ SS

Gp3:

A1: 0.014″ Mact CuNiTi 35°C

A2: 0.014 9 0.025″ Mact CuNiTi

35°C

A3: 0.016 9 0.022″ SS

RCT, randomized controlled trial; NR, not reported; SS, stainless steel; CL, conventionally ligated; Gp, group; Mact, martensitic-active;CuNiTi, copper-nickel-titanium; Mstab, martensitic-stabilized; NiTi, nickel-titanium; Aact, austenitic-active; #including data from authorcommunication.

Table 3. Assessment of risk of bias* in randomized controlled trials included in the systematic review

Trial

First author

Sequence

generation

Allocation

concealment

Blinding

(clinician/patients)

Blinding

(assessor)

Incomplete

outcome data

Selective outcome

reporting

Other

biases Overall

AlQabandi (73) ?? ?? ?? � ?? + + ??

Cobb (65) + ?? ?? ?? ?? ?? ?? ??

Cioffi (72) + + + + + � + +

Erdinc� (64) ?? ?? ?? ?? � + ?? ??

Evans (66) ?? ?? ?? � ?? � ?? �Fernandes (67) ?? ?? ?? ?? � + ?? ??

Ji (59) ?? ?? ?? + + � ?? ??

Jones (68) ?? ?? ?? + ?? + ?? ??

Kula (60) ?? ?? + + � + ?? ??

Mandall (74)† + + + + + + + +

O’Brien (61)† + ?? ?? + � + + ??

Ong (69) + + + + + + + +

Pandis (62)† + + + + + + + +

Quintao (70) ?? ?? ?? � ?? + ?? ??

Sebastian (63) + + + + + + ?? +

West (71) + ?? ?? � ?? + ?? ??

+: adequately assessed (low risk of bias); �: inadequately assessed (high risk of bias); ??: unclear.*Based on Cochrane risk-of-bias tool (35). The excerpts of the included studies that were used to make the judgement are availableupon request from the review authors.†Including data from author communication.



Ong et al. (69) randomized patients in three

sequences with NiTi and CuNiTi archwires from

three different companies (Table S2). No signifi-

cant difference was found in time to reach the

working archwire and pain intensity (LS) at 4 h

and on the first, third, or seventh day after inser-

tion between any two archwire sequence groups.

Significantly higher alleviation of the mandibular

anterior irregularity (LII) was reported for the

second trial arm (GAC sequence) compared with

the third trial arm (Ormco sequence), when the

third archwire was reached (difference in LII

reduction = 1.9 mm, 95% CI: 0.16–3.64 mm,

p = 0.030).

The last two trials (69, 74) were pooled to

compare the Mact CuNiTi sequence with the

Mstab NiTi sequence of each trial. The forest

plots are presented in Figs 3 and 4, while the

Table 4. GRADE summary of findings table for meta-analyses on initial archwires’ data

Patients: receiving fixed appliances for tooth alignment

Settings: private practice (not reported for one trial)

Intervention: Aact NiTi initial archwire

Comparison: Mstab NiTi initial archwire

Outcome

(follow-up)

Brackets used

Illustrative comparative risks* (95% CI)No. of

participants

[trials]

Quality of

evidence

(GRADE) Comments

Assumed risk Corresponding risk

Mstab NiTi Gp Aact NiTi Gp

Tooth alignment

(reduction of LII scores

and 3-D contact point

movement)*

mm of LII (follow-up:

5 weeks)

CL brackets

Mean LII reduction

in Mstab NiTi

groups 3.7 mm

Mean LII reduction in Aact

NiTi groups 1.11 mm

higher (0.38 lower to

2.61 higher)

126 [2 (61, 69)] ⊕⊕⊕○Moderate†

Scores estimated

using a SMD of

0.26 (�0.09 to

0.61) for LII and

contact point

movement;

p = 0.140;

I2 = 0%

Aact, austenitic-active; NiTi, nickel-titanium; Mstab, martensitic-stabilized; CI, confidence interval; Gp, group; LII, Little’s irregularity index;3-D, three-dimensional; CL, conventionally ligated; SMD, standardized mean difference.*No significant difference between data from the two outcome measures (between-subgroups analysis).†Downgraded by 1 for risk of bias in one trial: risk of attrition bias and possibly incomplete blinding.

Fig. 2. Forest plot for meta-analysis of tooth alignment between an Aact nickel-titanium (NiTi) and a Mstab NiTi initial archwire.



results of meta-analyses together with the qual-

ity of evidence according to GRADE are provided

in Table 5. No significant difference between the

two sequences was found regarding the time to

reach the working archwire (Fig. 3). Patients

treated with the Mact CuNiTi sequence reported

generally greater pain intensity compared to

those treated with the Mstab NiTi sequence

(Fig. 4), which was significant at 4 h and on the

first day after insertion. The small number of tri-

als precluded any heterogeneity explanations,

while meta-analysis for reported pain on the

seventh day was not undertaken due to extreme

heterogeneity (I2 > 75%). The quality of recom-

mendations according to GRADE was moderate

to high.

Due to the small number of studies included

for each outcome, no formal assessment of

‘small-study effects’ (including publication bias),

subgroup analysis according to bracket or treat-

ment characteristics or sensitivity analysis could

be undertaken.

DiscussionSummary of evidence

This systematic review included 16 trials with

considerable variations in trial conduct and out-

come reporting and a total of 1108 patients. A

considerable lack of evidence exists regarding

both the various initial archwires and complete

Fig. 3. Forest plot for the meta-analysis of time to reach the working archwire between a Mact CuNiTi and a Mstab nickel-titanium

(NiTi) archwire sequence.

Fig. 4. Forest plot for meta-analysis of pain intensity (Likert Scale) after placement of archwire between a Mact CuNiTi and a

Mstab nickel-titanium (NiTi) archwire sequence (reported means of values after first, second, and third archwire).



archwire sequences that are commercially avail-

able.

Orthodontic mechanotherapy has been based

on the incremental variation of archwire

dimension or archwire material (and modulus

of elasticity) (75). The effect of the size and

shape of the archwire’s cross-section could not

be assessed in this review. Various authors

have reported a correlation between frictional

behavior and vertical wire dimension (76–78),

with friction increasing as vertical wire dimen-

sion becomes greater. Conversely, an increased

clearance between wire and bracket results in

reduced friction, as well as in diminished con-

trol during tooth movement (79). Regarding the

cross-section shape, even an artificially induced

Table 5. GRADE summary of findings table for meta-analyses on archwire sequences’ data

Patients: receiving fixed appliances for tooth alignment

Settings: university, hospital and private practice

Intervention: sequence of Mact CuNiTi archwires

Comparison: sequence of Mstab NiTi archwires

Outcome

(follow-up)

Brackets used

Illustrative comparative risks* (95% CI)

No of participants

[trials]

Quality of

evidence (GRADE) Comments

Assumed risk Corresponding risk

NiTi sequence CuNiTi sequence

Time to working

archwire (CL

brackets)

Mean time to reach

working archwire

ranged across

NiTi groups from

4.0 to 6.8 months

Mean time to reach

working archwire

in the CuNiTi

groups

0.54 month

greater (0.87

lower to 1.95

higher)

155 [2 (69, 74)] ⊕⊕⊕○Moderate*

p = 0.450; I2 = 66%

Pain intensity at 4 h

on LS scale: 0–7

(CL brackets)

Mean pain intensity

ranged across

NiTi groups from

2.4 to 2.9 points

Mean pain intensity

in CuNiTi groups

0.59 points

greater (0.10–1.08

higher)

128 [2 (69, 74)] ⊕⊕⊕⊕

High

p = 0.020; I2 = 0%

Pain intensity on

first day

Points on LS

scale: 0–7 (CL

brackets)

Mean pain intensity

ranged across

NiTi groups from

2.8 to 2.9 points

Mean pain intensity

in CuNiTi groups

0.72 points

greater (0.04–1.41

higher)

128 [2 (69, 74)] ⊕⊕⊕○Moderate†

p = 0.040; I2 = 58%

Pain intensity on

third day

Points on LS

scale: 0–7 (CL

brackets)

Mean pain intensity

ranged across

NiTi groups from

1.7 to 1.9 points

Mean pain intensity

in CuNiTi groups

0.46 points

greater (0.23

lower to 1.14

higher)

127 [2 (69, 74)] ⊕⊕⊕○Moderate†

p = 0.190; I2 = 74%

Mact, martensitic-active; CuNiTi, copper-nickel-titanium; Mstab, martensitic-stabilized; NiTi, nickel-titanium; CI, confidence interval; CL,conventionally ligated; LS, Likert scale.*Downgraded by 1 for inconsistency: moderate heterogeneity and confidence regarding decision could be possibly affected by hetero-geneity.†Did not downgrade for inconsistency: moderate to high heterogeneity, but decision regarding clinical decision unaffected.



beveling of rectangular archwires can reduce

friction (80).

Ion implantation of b-Ti or NiTi archwires was

assessed independently by two trials with no sig-

nificant effect found. These investigations are

based on in vitro data showing that altering of

the surface roughness of the archwire may

reduce corrosion, friction and possibly enable

faster sliding of the archwire (81–83). However,

this may hold true only when both opposing

surfaces have been ion implanted (60). Also, NiTi

archwires are subject to surface alterations by

intra-oral conditions and/or bracket engagement

(10), which could modify their performance. The

idea that surface roughness and friction reduc-

tion is crucial to efficient mechanics also forms

the basis of using metal or silica inserts or

glazed slot bases in ceramic brackets (84).

Although current evidence suggests that the clin-

ical role of friction may have been overestimated

(85), further research under non-simplified con-

ditions and in collaboration with biomedical

engineers is recommended (86).

A wide variety of NiTi-based archwires is

available, which have been studied extensively

in vitro (5, 7, 15, 83, 87–89). Factors of archwires

that must be taken into account are their bio-

compatibility (90) and intra-oral aging (8, 91),

followed by an increased risk of fracture (9),

especially when planning longer appointment

intervals, although the actual causes remain

unclear (92).

Limited data preclude firm conclusions on the

use of Mact NiTi archwires. Pandis et al. (62)

reported no significant advantage in alleviation

of mandibular anterior tooth irregularity com-

pared with Mstab NiTi, while Cioffi et al. (72)

reported lower pain intensity at the second,

third, and fourth day after placement compared

with Aact NiTi. Both studies provide evidence

that would be rated as ‘high quality’ by the

GRADE approach; nevertheless, additional stud-

ies are needed.

Meta-analysis of two trials found that Aact

NiTi was slightly more effective in tooth align-

ment than Mstab NiTi, although not to a signifi-

cant extent. However, this difference must be

verified by subsequent large studies, as the

small number of trials or differences in trial

conduct and outcomes reported could have

affected this estimate. Nevertheless, many of the

included trials reported that considerable wire

deflections are needed for the superelastic

plateau of Aact archwires to be clinically useful

(93). Also, recent observational evidence indi-

cates that the bracket prescription may possibly

affect the clinical performance of Aact NiTi arch-

wires (94).

No clear conclusions can be made for the use

of multistranded archwires due to the diverse

comparisons between single- and multistranded

archwires and serious methodological issues. In

the trial of Sebastian et al. (63), a significant

advantage of the multistranded Aact NiTi arch-

wire was reported compared with its single-

stranded analog with the provided evidence

rated as ‘high quality’.

Many different esthetic archwire coatings

have been used to improve the frictional and

esthetic characteristics of orthodontic archwires

(95), with a number of issues identified. For

example, epoxy resin-coated Aact NiTi archwires

have been reported to produce lower loading

and unloading force values than uncoated arch-

wires of the same nominal dimensions for CL

brackets and even more with SL brackets (96).

Also, retrieved specimens presented increased

surface roughness, deterioration of esthetics,

and reduction of unloading force values, the

latter being observed for CL and not SL brack-

ets (18). On the other hand, certain coatings of

archwires may prevent or minimize archwire

corrosion of orthodontic archwires intra-orally

(97).

The use of an archwire sequence of Mact CuNiTi

was found to be associated with greater pain

intensity compared with a sequence of Mstab NiTi

at 4 h and 1 day after archwire insertion. This

issue should not be taken lightly, as post-

insertion pain is more intense and lasts longer

than post-extraction pain (98). Orthodontic pain

may be influenced by numerous factors (99),

which may lead to poor patient compliance or

treatment discontinuation (100, 101) and are

believed to be associated with the amount of

force applied to the tooth (102). Also, the two



identified and pooled trials of archwire sequences

differed in some aspects. Mandall et al. (74) used

sequences from a single company, while Ong

et al. (69) from three different companies. Arch-

wire change in Mandall et al. was made when the

archwire was passive, while in Ong et al. when

the archwire could be completely engaged.

Finally, Ong et al. used brackets of smaller slot

size than Mandall et al. (0.018″ vs. 0.022″), result-

ing in reduced slot-wire play and potentially

more efficient treatment, although this has not

yet been empirically proven (103).

Strengths and limitations

The conduct and reporting of this review was

based on standard guidelines (33–35). Apart

from published articles, unpublished/ongoing

trials were inquired upon and additional data

were provided after communication with trial-

ists. Blinding is not always possible, and when

not, it is inappropriate to describe all such stud-

ies as of ‘low quality’ (35). Unclear classifica-

tions were not resolved by exclusion of the trial,

but included, reported, and will be improved in

a following update (planned in 5–6 years). Sensi-

tivity analyses took into account sources of

unclear or high risk of bias. Methodological ade-

quacy of included trials was assessed in terms of

within-study risk of bias, sample size calcula-

tions, assessment of the method error, and

appropriateness of statistics used [as for exam-

ple in split-mouth trials (39)]. Between-study

heterogeneity was both tested and included in

the random-effects model, while the 95% PIs

were calculated, because robust conclusions

from random-effects meta-analyses mandate

their use (52). Finally, the GRADE approach was

used to evaluate the across studies evidence

provided by the meta-analyses (47). However,

the major limitation of this review is the lack of

substantial high-level evidence for many of the

interventions and outcomes assessed. Secondly,

the lack of consistent reporting across studies,

missing data due to non-response of trialists,

and inability to examine publication bias and

other reporting biases may have increased the

risk of bias.

Conclusions

There is insufficient data at present to make rec-

ommendations for the use of any available arch-

wire type regarding effectiveness, efficacy,

treatment outcome, or potential side effects. The

meta-analyses conducted are limited by the

small number of trials and methodological issues

and must therefore be subsequently confirmed.

Regarding initial archwires, meta-analysis of

two trials indicates that in CL brackets, use of an

austenitic-active NiTi initial archwire was not

significantly more effective in tooth alignment

than a martensitic-stabilized NiTi archwire

(moderate evidence quality).

Regarding archwire sequences, meta-analysis

of two trials indicates that in CL brackets, a

sequence of martensitic-active CuNiTi archwires

compared with a sequence of martensitic-stabi-

lized NiTi archwires:

• Has no effect on time needed to reach the

working archwire (moderate evidence), and

• Results in greater patient-reported pain inten-

sity, which was statistically significant 4 h and

1 day after placement of each archwire (mod-

erate to high evidence).

The clinical effects of orthodontic archwires

should be evaluated in parallel RCTs, reported

according to the CONSORT statement and with

detailed intervention and outcome data to justify

their use.

Clinical relevance

Regarding initial archwires, superelastic NiTi arch-

wire was not more effective in tooth alignment

compared with conventional NiTi. Regarding

sequences of archwires, use of a heat-activated

NiTi archwire sequence was associated with

greater pain intensity 4 h and 1 day after inser-

tion of each archwire, but did not differ in terms

of effectiveness from a conventional NiTi archwire

sequence. Further studies are needed to justify

the clinical superiority of any type of archwire

used during orthodontic treatment over another.



Acknowledgements: We thank the following authors for

providing missing articles, clarifications, and/or addi-

tional data: Bondemark L. (Malm€o University, Malm€o,

Sweden), Cioffi I. (University of Naples Federico II,

Naples, Italy), Kula K. (Indiana University, Indianapolis,

Ind), Mandall N.A. (Tameside General Hospital, Ashton

under Lyne, UK, O’Brien K. (University of Manchester,

Manchester, UK). and Pandis N. (Private Practice, Corfu,

Greece) for providing individual patient data.

Conflict of interest

The authors report no commercial, proprietary,

or financial interest in the products or compa-

nies described in this article.

Literature search update

An update of the systematic literature search

was undertaken after acceptance of the paper on

April first, 2014 in four databases (Cochrane

Library, MEDLINE, Scopus, and ISI Web of

Knowledge) using the same search strategies as

listed in Table S1. After study selection, two

additional eligible studies were identified (Gravi-

na MA, Brunharo IH, Fraga MR, Artese F, Cam-

pos MJ, Vitral RW et al. Clinical evaluation of

dental alignment and leveling with three

different types of orthodontic wires. Dental Press

J Orthod 2013;18:31–7 & Sandhu SS, Sandhu J. A

randomized clinical trial investigating pain asso-

ciated with superelastic nickel-titanium and

multistranded stainless steel archwires during

the initial leveling and aligning phase of ortho-

dontic treatment. J Orthod 2013;40:276–85) and

it was judged that they would not overly influ-

ence the review’s conclusions. They are planned

to be incorporated in a future update of the sys-

tematic review.

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Supporting Information

Additional Supporting Information may be

found in the online version of this article:

Table S1. Search strategies used for each data-

base with the corresponding results.

Table S2. Product names of brackets and arch-

wires used in the included trials.

Table S3. Supplementary trial characteristics

from Table 1.

Table S4. Supplementary trial characteristics

from Table 2.



1

APPENDICES

Table S1. Search strategies used for each database with the corresponding results

Electronic database Search strategy used Limits Hits Included

General sources

CDSR searched via Cochrane Library on 17.04.2012

www.thecochranelibrary.com orthodon* AND (wire* OR "arch-wire" OR archwire*) - 2 0

CENTRAL searched via Cochrane Library on

17.04.2012 www.thecochranelibrary.com orthodon* AND (wire* OR "arch-wire" OR archwire*) - 194 32

DARE searched via Cochrane Library on 17.04.2012

www.thecochranelibrary.com orthodon* AND (wire* OR "arch-wire" OR archwire*) - 1 0

MEDLINE searched via PubMed (1950 – 17.04.2012) www.ncbi.nlm.nih.gov/sites/entrez/

#1 randomized controlled trial [pt] - 321771 0

#2 controlled clinical trial [pt] - 83625

#3 randomized [tiab] - 260825

#4 placebo [tiab] - 139787

#5 drug therapy [sh] - 1509765

#6 randomly [tiab] - 179501

#7 trial [tiab] - 301368

#8 groups [tiab] - 1189409

#9 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 - 2960884

#10 animals [mh] NOT humans [mh] - 3662101

#11 #9 NOT #10 - 2535199

#12

(orthodon* AND (wire* OR "arch-wire" OR archwire*)

AND (initial* OR first OR aligning OR sequence* OR order OR crowd* OR decrowd* OR "de-crowd*" OR

levelling* OR alleviat*))

- 900

#13 #12 AND #13 - 215 20

((orthodontic wire[MeSH Terms]) OR (orthodontic

wires[MeSH Terms])) AND random* MeSH terms 147 30

Scopus (1966 - 17.04.2012) www.scopus.com orthodont* AND random* AND (wire* OR "arch-wire*"

OR archwire*)

Title/abstract/keywor

ds 224 24

Open access sources

Biomed Central (1997 - 17.04.2012)

http://www.biomedcentral.com/search

orthodont* AND random* AND (wire* OR "arch-wire*"

OR archwire*) - 4 0

DOAJ searched on 17.04.2012 http://www.doaj.org/ orthodontic and wire - 25 0

orthodontic and wires - 17

orthodontic and archwire - 4

orthodontic and archwires - 4

Regional sources

BBO (including LILACS) searched on 17.04.2012

http://regional.bvsalud.org/php/index.php?lang=en

(orthodon* AND random* AND (wire* OR "arch-wire"

OR archwire*) AND (initial* OR first OR aligning OR

sequence* OR order OR crowd* OR decrowd* OR "de-crowd*"))

Controlled clinical

trials 104 20

IndMed (1985 - 17.04.2012) http://indmed.nic.in/ orthodontic AND (wire OR wires OR archwire OR

archwires OR (arch wire)) 4 0

Scielo searched on 17.04.2012

http://www.scielo.org/php/index.php?lang=en

orthodont* AND (wire* OR archwire*) AND (random*

OR blind* OR control*) - 10 0

Grey literature sources

ClinicalTrials.gov searched on 17.04.2012

http://clinicaltrials.gov/ orthodontic AND (wire OR archwire OR "arch-wire") Basic search 6 1

Conference Paper Index searched via Cambridge Scientific Abstracts (1982 – 17.04.2012)

http://journals.cambridge.org/action/search

orthodontic AND (randomized OR randomised)

Journals; Abstracts/dissertation

/miscellaneous/resear

ch articles; Exclude book reviews/front

matter/back matter

24 0

Digital Dissertations searched via UMI/ProQuest on

17.04.2012 http://proquest.umi.com/login


OR archwire*) 35 2

German National Library of Medicine (ZB MED) searched on 17.04.2012 http://www.medpilot.de

orthodont$ AND (wire$ OR archwire$ OR "arch-wire")

AND random$

Exclude books

0 0

Google Scholar searched on 17.04.2012 www.scholar.google.com

"initial archwire","randomized controlled",orthodontic

Medicine, Pharmacology, and

Veterinary Science

37

"initial archwire","randomised controlled",orthodontic 8

"initial arch-wire","randomized controlled",orthodontic 9

"initial arch-wire","randomised controlled",orthodontic 4

"first archwire","randomized controlled",orthodontic 15

"first archwire","randomised controlled",orthodontic 1

"first arch-wire","randomized controlled",orthodontic 2

"first arch-wire","randomised controlled",orthodontic 2

"aligning archwire,"randomized controlled",orthodontic 22

"aligning archwire","randomised controlled",orthodontic 6

"aligning arch-wire,"randomized controlled",orthodontic 2

"aligning arch-wire","randomised controlled",orthodontic 0

"archwire sequence","randomized controlled",orthodontic 24

"archwire sequence","randomised controlled",orthodontic 4

2

"arch-wire sequence","randomized controlled",orthodontic

4

"arch-wire sequence","randomised controlled",orthodontic 0

"archwire group","randomized controlled",orthodontic 4

"archwire group","randomised controlled",orthodontic 1

"arch-wire group","randomized controlled",orthodontic 1

"arch-wire group","randomised controlled",orthodontic 1

"archwire group","randomized controlled",orthodontic 1

"archwire group","randomised controlled",orthodontic 1

"arch-wire group","randomized controlled",orthodontic 1

"arch-wire group","randomised controlled",orthodontic 1

"archwire order","randomized controlled",orthodontic 0

"archwire order","randomised controlled",orthodontic 0

"arch-wire order","randomized controlled",orthodontic 0

"arch-wire order","randomised controlled",orthodontic 0

"initial wire","randomized controlled",orthodontic 7

"initial wire","randomised controlled",orthodontic 1

"first wire,"randomized controlled",orthodontic 4

"first wire,"randomised controlled",orthodontic 6

"wire sequence,"randomized controlled",orthodontic 5

"wire sequence,"randomised controlled",orthodontic 8

"wire group,"randomized controlled",orthodontic 5

"wire group,"randomised controlled",orthodontic 10

"wire group","randomized controlled",orthodontic 1

"wire group","randomised controlled",orthodontic 2

Sum (overlap) 200 22

ISI Web of Knowledge (1945 - 17.04.2012)

http://wok.mimas.ac.uk/


OR archwire*) Topic 81 15

metaRegister of Controlled Trials (all registers active

and archived) searched on 17.04.2012 http://www.controlled-trials.com/mrct/

orthodont% AND (archwire% OR wire%) - 22 3

OpenSIGLE (1980 - 17.04.2012)

http://www.opengrey.eu/ orthodont* AND (wire* OR "arch-wire" OR archwire*) - 1 0

Scirus searched on 17.04.2012 http://www.scirus.com/ orthodont* AND random* AND (wire* OR "arch-wire*"

OR archwire*)

Medicine;

Abstracts/articles/articles in

press/conferences/pre

prints/theses and dissertations.

204 10

Overall articles from electronic search 32

$ Highly-sensitive search strategy tested, in all databases, but included too few results and was omitted in many databases.

BBO, Bibliografia Brasileira de Odontologia; CDSR, Cochrane Database of Systematic Reviews; CENTRAL, Cochrane Central Register of Controlled Trials; DARE,

Database of Abstracts of Reviews of Effects; DOAJ, Database of Open Access Journals; ISI, Institute for Scientific Information; LILACS, Literatura Latino-Americana e do

Caribe em Ciências da Saúde; MeSH, Medical Subject Headings; Scielo, Scientific Eletronic Library on line; UMI, University Microfilms International.

3

Table S2. Product names of brackets and archwires used in the included trials

Trial Bracket product name Archwire(s)* product name

AlQabandi 1999

(59) NR

Gp1: A1-Alast: NR

Gp2:

A1: Damon Copper Ni-Ti; Ormco, Glendover, CA/Neo Sentalloy; GAC, Central Islip, NY

A2: NR

Cioffi 2012 (60) NR Gp1: A1: Nitinol Super-Elastic; 3M Unitek, Monrovia, CA Gp2: A1: Nitinol Heat-Activated; 3M Unitek, Monrovia, CA

Cobb 1998 (61) Gp1: A1: Sentalloy; GAC, Central Islip, NY

GpA: NR Gp2: A1: Sentalloy; GAC, Central Islip, NY & Spire Corporation GpB: NR Gp3: A1: Wildcat Wire, GAC, Central Islip, NY

Erdinç 2004 (62) Roth System; Forestadent, Pforzeim, Germany Gp1: A1: NR, Ormco, Glendora, CA

Gp2: A1: NR, Ormco, Glendora, CA

Evans 1998 (63) NR

Gp1: A1: Titanium Heat Memory Alloy; American Orthodontics, Sheboygan, Wis

Gp2: A1: Bioforce; GAC, Central Islip, NY Gp3: A1: Dentaflex; Dentaurum, Ispringen, Germany

Fernandes 1998

(64) NR

Gp1: A1: Sentalloy; GAC, Central Islip, NY

Gp2: A1: Nitinol; 3M Unitek, Monrovia, CA

Ji 2010 (65) MBT; 3M Unitek, Monrovia, CA Gp1: A1-6: NR

Gp2: A1-3: NR

Jones 1992 (66) NR; Rocky Mountains Orthodontics, Denver, Colo. Gp1: A1: Japanese NiTi; GAC, Central Islip, NY

Gp2: A1: Twist Flex; 3M Unitek, Monrovia, CA

Kula 1998 (67) Ormco/"A" Company, Orange, CA) Gp1: A1: TMA; Ormco, Glendover, CA Gp2: A1: TMA; Ormco, Glendover, CA & Spire Corporation

Mandall 2006 (68) NR

Gp1:

A1: Nitinol; 3M Unitek, Monrovia, CA A2: Nitinol Heat-Activated; 3M Unitek, Monrovia, CA

A3: Ortoform II; 3M Unitek, Monrovia, CA


A2: Bioforce; GAC, Central Islip, NY

A3: Ortoform II; 3M Unitek, Monrovia, CA Gp3:

A1-2: Damon Copper Ni-Ti; Ormco, Glendover, CA

A3: Ortoform II; 3M Unitek, Monrovia, CA

O'Brien 1990 (69) NR Gp1: A1: Titanol; Forestadent, Milton Keynes, UK

Gp2: A1: Nitinol; Unitek, Monrovia, CA

Ong 2011 (70) Victory; 3M/Unitek, Monrovia, CA

Gp1: A1: Nitinol; 3M Unitek, Monrovia, CA

A2: Nitinol Heat-Activated; 3M Unitek, Monrovia, CA

A3: Ortoform II; 3M Unitek, Monrovia, CA Gp2:

A1: Sentalloy; GAC, Central Islip, NY

A2: Bioforce; GAC, Central Islip, NY A3: Ortoform II; 3M Unitek, Monrovia, CA

Gp3:

A1-2: Damon Copper Ni-Ti; Ormco, Glendover, CA A3: Ortoform II; 3M Unitek, Monrovia, CA

Pandis 2009 (71)# In-Ovation R; GAC, Bohemia, NY Gp1: A1: Damon Copper Ni-Ti; Ormco, Glendover, CA

Gp2: A1: NR, Modern Arch, Wyomissing, PA

Quintao 2005 (72) NR, GAC, Central Islip, NY


Gp2: A1: G&H Thermal Activated NiTi; G&H Wire Company, Greenwood, Ind

Gp3: A1: Pentacat; GAC, Central Islip, NY Gp4: A1: AccuForm;GAC, Central Islip, NY

Sebastian 2011 (73) Victory; 3M/Unitek, Monrovia, CA A1: Speed Supercable; Strite Industries, Cambridge, ON

A2: Rematitan Lite; Dentaurum, Pforzheim, Germany

West 1995 (74) NR Gp1: A1: NiTi; Ormco, Monrovia, CA

Gp2: A1: Dentaflex; Dentaurum, Ispringen, Germany

A1/A2/A3,…, 1rst

archwire/2nd

archwire/3rd

archwire/….; Gp, group; NR, not reported.

4

Table S3. Supplementary trial characteristics from Table 1a

Trial Sample characteristics (allocated (completed); sex M/F; mean age; Inclusion criteria; Exclusion

criteria; baseline outcome values per Gp) Treatment details Outcomes

Other issues (sample size calculation; method error assessment; conflict of

interest)

Cioffi 2012 (60)

30 patients (30); M/F 11/19; 14.7 years; Included: patients with full and vital dentition;

Excluded: patients with active periodontal disease, planned tooth extraction, previous orthodontic treatment, skeletal asymmetries, diseases affecting pain perception or in therapy of

pain conditions; arch-length deficiency Gp1: 0.5 (4.0) mm, Gp2: -2.2 (3.0) mm

Full-arch mechanics (max or

man) for alignment; no extractions; patients free to take

any self-prescribed analgesic

Patient-reported (pain diary): 1. Pain intensity

(VAS). 2. Analgesic use. 3. Sports practicing. 4. Overlapping pain. 5. Stressful events. 6.

Headache

Sample size adequate; method error NA; no commercial conflict

Cobb III

1998 (61)

126 patients (123); M/F NR; mean ages 15.2-17.3 years; Included: patients with complete permanent dentition, with irregularity > 5 mm, planned to receive treatment in one or both

arches; Excluded: patients with extractions/approximations, > 3 mm vertically malpositioned tooth, periodontal pocketing > 4 mm or craniofacial syndrome; irregularity severity NR

Full-arch mechanics (one or both arches) for alignment; no

extractions

Clinical: 1. Time to alignment (< 2 mm LII).

Study models (digital caliper): 1. Alignment rate

Sample size not calculated; method error partly assessed (duplicate and

SD < 0.1 mm); small business initiative contract with national grant

Erdinç 2004 (62)

109 patients (109); M/F 52/57; 14.2 years; Included: patients planned to receive treatment in

maxillary or both arches; Excluded: patients planned to receive extra-oral appliances, palatal

arches or quad-helix appliances; irregularity severity NR

Full-arch mechanics (max or both

arches) for alignment; patients free to take any self-prescribed

analgesic

Patient-reported (questionnaire): 1. Pain intensity

(VAS). 2. Regions of pain. 3. Analgesic use. 4.

Effect of pain on daily life

Sample size not calculated; method error NA; no conflict

Evans 1998 (63)

56 patients (51); M/F NR; Included: patients under 18 years; Excluded: patients with

periodontal disease, loss of attachment or with previous orthodontic treatment. Any initial phase of either expansion with quadhelix or distal molar movement had been stabilized for 2 months;

irregularity severity NR

Full-arch mechanics (max or both arches) for alignment

Study models (coordinate measuring machine):

1. Tooth movement assessed with 2D and 3D intertooth (contact) point movement (max/man -

whole arch, anterior and posterior segment)

Sample size falsely calculated for two arms, although three arms are

included; method error assessed

(Dahlberg’s formula); no commercial conflict

Fernande

s 1998

(64)

128 patients (NR); M/F 56/72; 12.6 years; Included: Caucasian patients; Excluded: patients

having received previous orthodontic treatment, including extra-oral appliances, palatal expansion appliances or having taken analgesics prior to archwire placement; irregularity

severity NR

Full-arch mechanics (one or both

arches) for alignment; patients free to take any prescription-free

analgesic

Patient-reported: 1. Pain intensity (VAS). 2. Analgesic use

Sample size not calculated; method error NA; conflicts NR

Jones

1992 (66)

45 patients (42); M/F NR; 13.2 years; Included: patients requiring at least one premolar extraction; Excluded: patients with banded molars, palatal arch, Nance button, quadhelix or

extra-oral traction; irregularity severity NR

Full-arch mechanics (max or mand) for alignment; at least one

extraction; analgesic

(Paracetamol; Arthur H. Cox & Co., London, England) prescribed

to all patients

Patient-reported (questionnaire): 1. Pain intensity (VAS). 2. Location and frequency of

pain/discomfort. 3. Analgesic use

Sample size calculation reported, but no data given; method error NA;

conflicts NR

Kula

1998 (67)

39 patients (30); M/F 13/17; range 10 to 42 years; Included: patients with planned extraction of both maxillary first premolars; Excluded: patients with appliance breakage, lack of cooperation

regarding appointments’ attendance, extended time to reach the space closure stage of

treatment; space to be closed NR, but no significant difference

Full-arch mechanics (max) and NiTi coil springs (Sentalloy;

GAC, Central Islip, NY) for

space closure after extraction of both maxillary first premolars;

teeth in the posterior and anterior

segments tied to each other with

SS ligatures under the archwire;

incisors’ retraction done either at

the same time or after canine retraction; NiTi coil springs and

any supplemental anchorage

consistent between sides

Clinical: 1. Time to space closure (censored at

space closure of one side; maximum 6 months).

Study models (digital caliper): 1. Rate of space

closure per month (max)

Sample size not calculated; method

error assessed (ICC); no commercial

conflict

O'Brien 1990

(69)#

40 patients (40); M/F 9/11 (reported only for one group); 13.2 years; Included: patients planned to receive fixed-appliance therapy; Excluded: NR; contact point distance Gp1: 15.6 (6.1), Gp2:

18.9 (6.9)

Full-arch mechanics (max) for

alignment


1. Tooth movement assessed with 3D intertooth

(contact) point movement (max; anterior segment)

Sample size not calculated; method error assessed (Cronbach’s α and t-

test); material donation

5

Ong 2011

(70)

132 patients (127); M/F 52/80; 15.4 years; Included: patients of any age/sex planned to receive

treatment in both arches and brackets placed on all teeth during same appointment. Patients with

planned extractions or previous orthodontic treatment were not excluded; Excluded: patients

with craniofacial abnormalities, asymmetrical arches or missing incisors or canines; LII Gp1:

6.6 (5.0) mm, Gp2: 7.8 (4.9) mm, Gp3: 5.8 (3.5) mm

Full arch mechanics (both arches)

for alignment

Study models (digital caliper): 1. Tooth

irregularity (man; anterior segment; LII)

Sample size adequate; method error

assessed (Bland-Altman method and

t-test); no commercial conflict.

Pandis

2009

(71)#

60 patients (60); M/F 14/46; 13.1 years; Included: patients planned to receive non-extraction treatment in mandibular arch, with all permanent teeth; Excluded: patients with spaces in

mandibular arch, crowding of posterior segments, intermaxillary or other intraoral or extraoral

appliances including elastics, lip bumpers, maxillary expansion appliances or headgear; maxillary anterior LII Gp1: 5.3 (2.3) mm, Gp2: 5.6 (2.0) mm

Full-arch mechanics (man) for

alignment; no extractions; molars

bonded with tubes

Clinical: 1. Time to alignment of anterior teeth (man)

Sample size adequate; method error NA; no conflict

Quintao

2005 (72)

45 patients (45); M/F 17/28; 13.0 years; Included: patients planned to receive treatment in both

arches, with full permanent dentition, tooth irregularity allowing full archwire engagement, overjet/overbite allowing bracket placement on lower anterior teeth and good oral

hygiene/periodontal health; Excluded: patients with relevant medical history, previous

orthodontic treatment, maxillary expansion device; irregularity severity NR

Full-arch mechanics (both arches) for alignment; bands were fitted

to the molars


1. Tooth movement assessed with 3D intertooth

(contact) point movement (max; whole arch and anterior segment)


error not assessed; conflicts NR

Sebastian 2011 (73)

24 patients (24); M/F 0/24; 13.7 years; Included: patients with severe mandibular anterior

crowding (> 6 mm), Class I skeletal pattern, planned to receive nonextraction treatment in

mandibular arch, with all mandibular teeth and no spacing; Excluded: patients with relevant medical history, intake of drugs, experience of periodontal disease/loss of attachment, previous

orthodontic treatment, involving intermaxillary or other intraoral or extraoral appliances during

the study period; LII Gp1: 8.8 (1.5) mm, Gp2: 8.7 (1.6) mm

Full-arch mechanics (man) for

alignment; no extractions; patients free to take any

prescription-free analgesic


1. Tooth movement assessed with 3D intertooth (contact) point movement (man; anterior

segment)

Sample size adequate; method error

assessed (reliability and limits of

agreement); conflicts NR

West

1995 (74)

62 patients (62); M/F 21/41; 15.1 years; Included: patients planned to receive treatment in at least one arch; Excluded: patients with relevant medical history, previous orthodontic treatment,

including quadhelix or other maxillary expansion device; irregularity severity NR

Full-arch mechanics (one or both

arches) for alignment


1. Tooth movement assessed with 2D and 3D

intertooth (contact) point movement (max/man; whole arch and anterior segment)

Sample size adequate; method error not adequately assessed (average

taken); conflicts NR

M/F, male/female; Gp, group; NR, not reported; max, maxilla; man, mandible; VAS, visual analog scale; NA, not applicable; LII, Little’s irregularity index; SD, standard deviation; 3D, three dimensional; SS, stainless steel; NiTi, Nickel-

Titanium; ICC, intraclass correlation coefficient; 2D, two dimensional.

6

Table S4. Supplementary trial characteristics from Table 1b

Trial Sample characteristics (allocated (completed); sex M/F; mean age;

Inclusion criteria; Exclusion criteria; baseline outcome values per Gp) Treatment details Outcomes

Other issues (sample size calculation; method error

assessment; conflict of interest)

AlQaban

di 1999

(59)

28 patients (28); M/F 14/14; 14.6 years; Included: patients with crowding

≤ 3 mm, moderate to deep curve of Spee, planned to receive non-extraction therapy on the mandibular arch; Excluded: NR; malocclusions

by group Class I/Class II Gp1: 17%/83%, Gp2: 19%/81%

Full-arch mechanics (man) for leveling the

curve of Spee; no

extractions; archwire not chinched

Study models: 1. Arch depth from the canines (man). 2. Intercanine width

(man). 3. Arch depth from the molars (man). 4. Depth of the curve of Spee. 5. Amount of crowding (man anterior segment)

Radiographic (cephalometric analysis with Björk’s superimposition): 1. Incisor angulation (man). 2. Change in axial inclination of the incisor

(man). 3. Distance of the center of rotation of the incisor (man)

Post-hoc sample calculation

showed that power probably inadequate; method error assessed

(t-test); material donation

Ji 2010

(65)

80 patients (80); M/F 40/40; 12-14 years; Included: patients with

complete permanent dentition and Class I malocclusion planned to

receive treatment with tooth extractions; Excluded: patients with

previous orthodontic or orthognathic treatment, TMJDs, history of

periodontal disease, CLP or any other defect of the tooth or bone tissues,

bad oral habits; irregularity severity NR

Full-arch mechanics

(arch NR) for alignment

Clinical: 1. Alignment duration. 2. Treatment duration. 3. Number of

appointments. 4. Bracket failures. 5. Archwire breakage


error NA; no commercial conflict

Mandall 2006

(68)#

154 patients (129); M/F 62/92; 14.2 years; Included: patients under 18

years planned to receive therapy on both arches, with no extractions or

up to four premolar extractions; Excluded: patients wit pain from other dental or medical condition that could affect the reported discomfort,

planned to be treated with palatal arch, headgear or quadhelix at the same

visit that the initial archwire was placed; LII (man) Gp1: 6.5 (5.1) mm, Gp2: 5.7 (4.3) mm, Gp3: 6.1 (4.8)

Full-arch mechanics

(both arches); possible

premolar extractions; history of trauma,

central incisor filling or

history of EARR were recorded

Clinical: 1. Time to reach the working archwire. 2. Number of

appointments

Radiographic (periapical radiograph): 1. EARR of the central incisor

(max)

Patient-reported (questionnaire): 1. Pain intensity (LS).

Sample size adequate; method error assessed (ICC); no

commercial conflict

Ong 2011 (70)

132 patients (127); M/F 52/80; 15.4 years; Included: patients of any

age/sex planned to receive treatment on both arches and had brackets

placed on all the teeth at the same appointment. Patients with planned

extractions or previous orthodontic treatment not excluded; Excluded:

patients with craniofacial abnormalities, asymmetrical arches or missing incisors or canines; LII Gp1: 6.6 (5.0) mm, Gp2: 7.8 (4.9) mm, Gp3: 5.8

(3.5) mm

Full arch mechanics

(both arches) for

alignment

Clinical: 1. Time to reach the working archwire (man)

Study models (digital caliper): 1. Tooth irregularity (man; anterior

segment; LII). 2. Intercanine width (man)

Patient-reported (questionnaire): 1. Pain intensity (total and at archwire

change; LS)

Sample size adequate; method

error assessed (Bland-Altman method and t-test); no commercial

conflict

M/F, male/female; Gp, group; NR, not reported; man, mandible; TMJD, temporomandibular joint disorder; CLP, cleft lip palate; NA, not applicable; LII, Little’s irregularity index; EARR, external apical root resorption; max,

maxilla; LS, Likert scale; ICC, intraclass correlation coefficient.

Papageorgiou SN, Konstantinidis I, Papadopoulou K, Jäger A, Bourauel C. A systematic review and...

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