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The effectiveness of laceback ligatures: A randomized controlled clinical trial

Article in Journal of Orthodontics · January 2005

DOI: 10.1179/146531204225020606 · Source: PubMed

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 Journal of Orthodontics, Vol. 31, 2004, 303–311

SCIENTIFIC The effectiveness of laceback ligatures:

SECTION
A randomized controlled clinical trial
R. Irvine and S. Power
Royal Bournemouth Hospital, Bournemouth, UK

F. McDonald
Guy’s, King’s and St Thomas’ Dental Institute, London, UK

Objective: To evaluate the effects of laceback ligatures on the anteroposterior and vertical position of lower incisors and the
mesial position of the lower first molars.
Design: Randomized controlled trial.
Settings: Patients under treatment in the Department of Orthodontics, Royal Bournemouth Hospital, Dorset, during a
6 month period from November 1999 to March 2000.
Subjects: Sixty-two adolescents (mean 13.7 years, range 11.2–16.8 years) with similar malocclusions, requiring extraction of all
first premolars, were randomly assigned to experimental (laceback: 30; 12 male, 18 female) and control (non-laceback: 32; 14
male, 18 female) groups.
Interventions: Treatment using upper and lower fixed appliances following extraction of four premolars. One group had
lacebacks placed, whilst the control group had no lacebacks.
Main outcome measures: The participants were examined clinically and radiographically, and lateral cephalograms with radio-
opaque tooth markers and lower study casts records were taken when lower fixed appliances were placed (T1) and following
sufficient leveling with a 0.018 inch stainless steel round wire (T2). Linear measurements were recorded following digitization
of the lateral cephalograms and using a vernier caliper on the study casts. A Student t-test was used to examine differences
between the two groups following assessment for normality.
Results: In both groups the lower incisors retroclined during T1–T2; (Mean¡SD: Experimental 20.53¡1.9 mm, Control –
0.44¡1.29 mm). There was no statistical significance between the two groups (p50.84). The lower incisors extruded in both
groups; 0.47¡0.98 mm in the experimental group and 0.44¡0.87 mm in the control group. There was no statistical difference
between the groups (p50.9). The lower first molars showed 0.83 mm greater mesial movement in the experimental group,
which was statistically significant (p,0.05). Labial segment crowding decreased in both groups (experimental 23¡1.6 mm,
control 22.67¡2.28 mm), the difference between the groups being non-significant (p50.51). Arch length decreased in
both groups (experimental 22.08¡2.82 mm , control 22.9¡3.06 mm), but the difference between them was not significant
(p50.28).
Conclusions: In first premolar extraction cases, the lower labial segment does not procline during the leveling stage with the
pre-adjusted edgewise appliance and the use of laceback ligatures conveys no difference in the antero-posterior or vertical
position of the lower labial segment. Furthermore, the use of laceback ligatures creates a statistically and clinically significant
increase in the loss of posterior anchorage.
Key words: Randomized controlled trial, lacebacks, pre-adjusted edgewise appliance, straightwire

Received 4th March 2004; accepted 27th May 2004

Introduction provide enough torque and tip to the tooth to allow it

to assume the correct inclination and angulation
Fixed appliances are a common component of con- necessary to achieve an Andrews 6 keys occlusion.1
temporary orthodontic treatment. Engagement of the One of the major disadvantages of incorporating
bracket with a full size rectangular arch wire should, second order values into the pre-adjusted edgewise
providing correct bracket placement has occurred, bracket system, was it created stress on anchorage in

Address for correspondence: Professor Fraser McDonald,

Department of Orthodontics, Floor 22, Guys Tower, GKT Dental
Institute, St Thomas St, London SE1 9RT, UK.
Email: fraser.mcdonald@kcl.ac.uk
# 2004 British Orthodontic Society DOI 10.1179/146531204225020606
 304 R. Irvine et al. Scientific Section JO December 2004

the initial stages of treatment. These effects were statistically significant. No statistical difference for the
expressed in both the antero-posterior and vertical mean mesial molar migration between the groups was
planes.2 found. If the canine was more distally inclined at the
McLaughlin and Bennett3 argued that the tip incor- start of treatment then incisors were more likely to
porated into the incisor and canine brackets increased procline during treatment regardless of whether lace-
the tendency for the labial segments to tip forward, and backs were used or not. The groups were relatively
that this was more pronounced in the upper arch where small. However, within this study it was reported that
bracket tip was greater. They suggested that the canine the statistical power was such to identify a 3 mm
having the greatest tip value produced the greatest difference (¡2 mm). The final stage study model was
forward movement and if not controlled would lead to taken prior to placement of a 0.01960.025 inch stain-
incisor proclination that would have consequences on less-steel arch wire. This meant that full alignment of the
future stability. upper labial segment had taken place at this stage. Space
First described by McLaughlin and Bennett,3,4 lace- creation would have been required for the full alignment
back ligatures are constructed of either 0.009 or of the labial segment and this could only be achieved in
0.010 inch soft stainless steel tied in a figure of 8 from one of three ways:
the most distally incorporated molar to the canine
1. the canines distalized into the extraction spaces
bracket. They were utilized to control anchorage during
creating space with no influence on incisor
leveling and aligning they are claimed to provide the
proclination;
following benefits:
2. the incisors proclined to create space for their
N prevention of lower labial segment proclination; alignment;
N canine distalization without tipping; 3. space was actively created using traction to the
N protection from masticatory forces for light aligning canine or active push-coil, within the labial segment
archwires across the extraction spaces. to provide space for full incisor alignment.
Their use has become widely accepted in certain Both (2) and (3) would influence incisor proclination or
countries during the leveling and aligning phase with retroclination and therefore the level of crowding within
the pre-adjusted edgewise appliance. Steel ligatures the upper labial segment could have affected the degree
undergo plastic deformation when stretched and as to which it occurred.
lacebacks are tied passively, considerable doubt must The aims of this study were:
exist to their ability to actively distalize canines.
Robinson5 in a prospective study found a 2.47 mm N to evaluate the antero-posterior changes in lower
difference in the lower incisor antero-posterior position labial segment position that occur during leveling and
between cases treated with or without lacebacks. aligning with the pre-adjusted edgewise appliance;
However, this study has never been published and there N to evaluate the changes in antero-posterior position of
are concerns regarding the scope of this trial within the lower labial segment as a consequence of lace-
CONSORT guidelines. backs used during leveling and aligning with the pre-
In the laceback group there was a mean 1.0 mm adjusted edgewise appliance;
distal movement of the incisors and a mean 1.76 mm N to assess any changes in the vertical position of the
mesial movement of the first molars. In contrast the lower labial under the influence of laceback ligatures;
non-laceback group demonstrated a mean 1.47 mm N to assess the influence of lacebacks on the lower first
proclination of the incisors compared with a mean molar.
1.53 mm forward movement of the molars (p,0.01). As a consequence we tested the following hypotheses:
This was a well-constructed study but some problems
with the methodology were present that may have N there are no changes in the lower labial segment
influenced the results (S. N. Robinson, personal during leveling and aligning with the pre-adjusted
communication). edgewise appliance;
Usmani et al.6 published the first randomized clinical N lacebacks do not change the antero-posterior position
controlled trial on the effectiveness of lacebacks. They of the lower labial segment during leveling and
also examined the effect of pretreatment distal angula- aligning with the pre-adjusted edgewise appliance;
tions of the canine on the effectiveness of lacebacks. N lacebacks do not affect the vertical position of the
They found a mean retroclination of the upper incisors lower labial during leveling and aligning;
in the laceback group of 0.5 mm with a mean proclina- N there is no affect on the position of the lower first
tion in the non-laceback group of 0.36 mm, which was molar as a consequence of lacebacks.
 JO December 2004 Scientific Section Effectiveness of lacebacks: An RCT 305

Materials and method

Sixty-two participants were enrolled on the study, 30 (12
male, 18 female) in the laceback group and 32 (14 male,
18 female) non-laceback controls. These study group
sizes were determined as those necessary to detect a
similar level of difference to previous studies.6 This gave
the study a statistical power of 0.988 to detect a 2 mm
difference in lower incisor positions at the significance
level of p50.05. Each patient was randomly assigned to
one of the groups by the toss of a coin. The majority of
participants had either a Class I or a mild Class II
division 1 incisor relationships with crowding (Class I,
29; Class II division 1, 29; Class II division 2, 2; Class
III, 2 with a uniform distribution between experimental
and control groups).
Ethical approval for the study was sought from the
East Dorset Local Research Ethics Committee and was
granted on the 25th May 2001(LREC NO 29/01/E). The
participants and parents (as appropriate) were invited to
take part in the study after their recall from the
treatment waiting list in preparation for active ortho-
dontic therapy. After discussion only those willing to
provide fully informed consent were accepted for the
study.
The recruitment of the participants and subsequent
numbers reflected a reasonable degree of loss to follow
up (Figure 1).

Patient selection
Figure 1 Profile of a randomized clinical trial to evaluate the
The inclusion criteria for patient entry into the study effect of lacebacks on the position of the lower incisors during
initial aligning
were as follows:

N a malocclusion requiring the extraction of all first 4. The plan of treatment for the study was to follow
premolars; each patient to the point at which leveling and
N no previous orthodontic treatment; aligning of the buccal segments had been achieved
N lateral cephalometric radiographs to have been taken with a 0.018 inch stainless steel arch wire; it was
of the patient within the previous 12 months at the agreed that this should be following six weeks with
start of treatment. the 0.018 inch stainless steel arch wire in situ.
All teeth from first molar to first molar had attachments
Treatment protocol placed. Severe vertical or rotational discrepancies
between adjacent teeth were partially ligated at the first
The treatment procedure was as follows: visit. Extremely crowded and displaced teeth in the
labial segment were passively tied to the arch wire and
1. All participants were treated by the same operator
were not engaged until sufficient space was available.
(SP).
Each patient went through the same arch wire sequence
2. All first premolars were extracted approximately 1–
of 0.014 inch NiTi, 0.018 inch NiTi and 0.018 inch
2 weeks prior to the fitting of appliances.
stainless steel. Participants were seen routinely at 6-week
3. Upper and lower fixed appliances using 3 M Unitek
intervals.
Dyna Lock pre-adjusted edgewise brackets from
the non-extraction series (Andrews values for tip 5. The arch wire was cut distal to the first molar tube
and torque using a 0.022 inch slot). and no cinching of the arch wire took place.
 306 R. Irvine et al. Scientific Section JO December 2004

6. No bite planes, lingual arches, inter maxillary Most of lateral cephalometric radiographs were taken
elastics or headgear direct to the lower arch was by one operator (RI), but if he was not available the
used during the study period. radiographer would take the exposures under the
7. Laceback ligatures were passively tied from the supervision of one of the consultants (SP). The patient
first molar tube to the canine bracket on both sides was positioned standing in the machine in the natural
in the experimental group and tightened to take up head position.
any apparent reduction in tension in the laceback
at routine visits. Digitization of lateral cephalometric radiographs
8. Records of each case included standardized lateral
cephalometric radiographs. Study models were Lateral cephalometric radiographs were scanned using a
taken immediately after the placement of fixed flat bed transparent scanner and the images stored on an
appliances (T1) and again following leveling of the Apple Macintosh computer. The images were then
canine with a 0.018 inch stainless-steel arch wire digitized on screen using the Quickceph digitization
(T2). The Ethics committee accepted the second program incorporating additional software to analyse
radiograph as part of both validation of clinical the specific points relevant to the study. Panesar7
techniques and to support information to deter- identified on-screen digitization as the most accurate
mine how to close the extraction space; either by method of cephalometric tracing. Four specific points
maintaining the position of the labial segments and were identified for measuring antero-posterior changes
allowing the buccal segments to move mesially or in the incisor and first molar positions (Figure 2):
by retraction of the labial segment. Due to the time
the participants were on the waiting list, T2 N I—the incisor tip of the lower right central incisor.
radiographs were all taken a minimum of 14 N IM—the point where the radio-opaque marker left
the occlusal aspect of the lower right central incisor
months from T1 radiographs.
bracket.
Group characteristics N M6—the mesio-buccal cusp of the lower right first
molar.
Patients in the two groups were matched for age at N MM—the most inferior point of the radio-opaque
T1 (Experimental mean age 13.6¡1.5 years; control marker placed in the bonded tube on the lower right
mean age 13.8¡1.5 years), had similar lengths of first molar.
treatment T2–T1 (Experimental group 7.1¡2.5 months; Two methods of measuring anteroposterior linear
control group 7.1¡2.3 months) and had similar sex changes in lower incisor and lower first molar positions
distributions. were evaluated for accuracy.

Landmark identification 1. 7u to SN (Figure 2) was used as a horizontal

reference line and a y-axis dropped perpendicular to
To improve the accuracy and validity of the study it was this through Sella.8,9 Linear measurements to the 4
decided that the lower right first molar (46) would be cephalometric points were recorded perpendicular to
used to study the mesial molar movement and the lower this y-axis to assess antero-posterior changes.
right central incisor (41) would be used to study the 2. Fiducial points (F1, F2, Figure 2) were marked on
anteroposterior movement of the lower labial segment. the T1 radiograph below the lower border of the
To evaluate a method to identify the teeth, the mandible. These points were transferred to the T2
mandibular arch of a dried skull was bonded with a radiograph following superimposition on Björk
pre-adjusted edgewise appliance. A method utilizing structures.10 Connecting these two fiducial points
identification markers constructed of 0.02160.025 inch created an x-axis and a y-axis was raised perpendi-
stainless-steel wire was the most successful when cular to this through the most posterior fiducial
analysing the lateral skull radiographs. The markers point. Linear measurements to the 4 cephalometric
were placed into the tube of 46 and the bracket of 41, points were recorded perpendicular to this y-axis to
and were tied with elastic ligatures. assess antero-posterior changes. Linear measure-
ments perpendicular to the x-axis to points I and IM
Patient positioning were recorded to assess vertical changes in the
incisor positions.
The mid-sagittal plane to cephalometric film distance
was standardized for all the lateral cephalometric The two methods were analysed to find the method and
radiographs, producing a magnification factor of 11%. cephalometric landmarks that carried the lowest method
 JO December 2004 Scientific Section Effectiveness of lacebacks: An RCT 307

An estimate of crowding or spacing within the lower

labial segment was produced by comparison between the
estimation of the amount of space available for the
alignment of teeth and the combined mesio-distal widths
of the teeth.8 The measurements were made using
Vernier calipers with gradations allowing for readings
to an accuracy of 0.1 mm.
In addition to the above measurements, the change in
arch length between the two groups was also studied.
Using the same procedure as above the arch length was
measured as the sum of a straight line between the
marginal ridge of the lower first molar and the mesio-
incisal edge of the most prominent central incisor on
both sides of the arch.
Twenty sets of study models were randomly selected
and measured twice after a 4-week interval to determine
the method error of measurements. This was analysed
using a paired t-test, again following confirmation of
normality and there was no statistically significant
difference.

Statistical methods
The following tests (Sigma Stat Version 2.01, California)
were used to analyse the experimental data:
N Student t-test;
N Mann–Whitney U-test: this was used when one or
Figure 2 Linear cephalometric measurements using y-axis both variables were significantly skewed.
constructed fiducial points. Linear measurements: i. M6-y-axis; ii.
MM-y-axis; iii. I-y-axis; iv. IM-y-axis; v. I-x-axis; vi. IM-x-axis Before analysis with either test the data were analysed
for normality using the Kolmogorov-Smirnov test (with
Lilliefors correction; p was set as 0.05). Data that
error. Twenty participants records were chosen at demonstrated a Gaussian distribution was analysed
random and digitization of the cephalometric points using parametric statistics (Student t-test), whilst non-
were performed for each method. These measurements parametric statistics (Mann–Whitney U) were used for
were repeated exactly 4 weeks later and the difference skewed data.
between the two sets of measurements was analysed
using a paired t-test following an analysis of normality
to validate the use of the Student t-test (Sigma Stat Results
Version 2.01, California). This demonstrated that the
A summary of the results is presented as tables
fiducial point method using landmarks I and MM
provided the greatest accuracy, and this was used in the The cephalometric and study model data before and
study. after treatment (T1 andT2) are reported in Tables 1–4.
The means and standard deviations for each variable are
Study model analysis listed together with the differences between the two
groups.
Lower arch alginate impressions were taken when Table 5 shows the serial changes (T1–T2) for both
lower fixed appliances were placed (T1) and following groups.
6–8 weeks leveling with a 0.018 inch stainless-steel Both groups were evenly matched at T1 and T2 and
round wire (T2). Impressions were immediately taken no statistically significant differences existed between
to the laboratory and, following a 20-minute immersion them for any of the measurements undertaken.
in a cold sterilizing fluid, the impressions were poured The lower incisor in both groups retroclined (experi-
using a plaster/stone mix. mental 20.53¡1.9 mm, control 20.44¡1.29 mm)
 308 R. Irvine et al. Scientific Section JO December 2004

Table 1 Experimental and control groups: a comparison at T1 cephalometric and study model measurements

Experimental 95% CI Control SD Difference

Mean Mean

y—I 60.57 51.47–69.67 61.05 50.79–71.31 20.48 NS (p50.69)

y—MM 43.07 31.91–54.23 43.51 33.85–53.17 20.44 NS (p50.74)
x—I 39.88 34.12–45.64 40.14 33.96–46.27 20.26 NS (p50.74)
Crowding 3.12 20.1–6.34 3.04 21.44–7.52 0.09 NS (p50.86)
Arch length 58.25 46.69–66.81 58.45 51.77–65.13 20.20 NS (p50.84)

All measurements in mm. No statistically significant differences existed between the groups at T1.
Both groups were equally matched for crowding and arch length at T1.
NS, not statistically significant; *statistically significant p,0.05; **statistically significant p,0.01; ***statistically significant p,0.001.

Table 2 Experimental and control groups: a comparison at T2 cephalometric and study model measurements

Experimental 95% CI Control 95% CI Difference

Mean Mean

y–I 60.04 50.36–69.72 60.61 50.07–71.15 20.57 NS (p50.66)

y—MM 43.82 32.72–54.92 43.43 34.85–52.01 0.39 NS (p50.76)
x—I 40.35 34.01–46.69 40.58 34.52–46.64 20.23 NS (p50.77)
Crowding 0.12 –2.66–2.9 0.37 24.87–5.61 20.25 NS (p50.85)
Arch length 56.17 46.35–65.99 55.54 47.2–63.88 0.63 NS (p50.59)

All measurements in mm.

No statistically significant differences existed between the groups at T2.
Both groups were equally matched in crowding and arch length at T2.

Table 3 Experimental group: a comparison at T1 and T2 cephalometric and study model measurements

T1 95% CI T2 95% CI Difference

Mean Mean

y–I 60.57 51.47–69.67 60.04 50.36–69.72 –0.53 NS (p50.67)

y—MM 43.07 31.91–54.23 43.82 32.72–54.92 0.75 NS (p50.60)
x—I 39.88 34.12–45.64 40.35 34.01–46.69 0.47 NS (p50.55)
Crowding 3.12 20.1–6.34 0.12 22.66–2.9 –3.00***
Arch length 58.25 46.69–66.81 56.17 46.35–65.99 –2.08 NS (p50.08)

All measurements in mm.

The mean changes that occurred in lower incisor and lower first molar positions during leveling in the experimental group were not statistically significant.
The reduction of crowding in the experimental group during leveling was highly statistically significant. The reduction in arch length was not statistically
significant.

Table 4 Control group: a comparison at T1 and T2 cephalometric and study model measurements

T1 95% CI T2 95% CI Difference

Mean Mean

y–I 61.05 50.79–71.31 60.61 50.07–71.15 20.44 NS (p50.74)

y—MM 43.51 33.85–53.17 43.43 34.85–52.01 20.08 NS (p50.95)
x—I 40.14 33.96–46.27 40.58 34.52–46.64 0.44 NS (p50.56)
Crowding 3.04 21.44–7.52 0.37 24.87–5.61 22.67 ***
Arch length 58.45 51.77–65.13 55.54 47.2–63.88 22.9**

All measurements in mm.

The mean changes that occurred in lower incisor and lower first molar positions during leveling in the control group were not statistically significant.
The reduction of labial segment crowding and arch length in the control group during leveling was highly statistically significant.
 JO December 2004 Scientific Section Effectiveness of lacebacks: An RCT 309

Table 5 Experimental and control groups: serial changes T1–T2 cephalometric measurements

Experimental 95% CI Control 95% CI Difference

Mean Mean

y–I 20.53 24.33–3.27 –0.44 23.02–2.14 20.09 NS (p50.84)

y—MM 0.75 21.41–2.91 –0.08 23.18–3.02 0.83*
x—I 0.47 21.49–2.43 0.44 21.3–2.18 0.03 NS (p50.90)
Crowding 23.00 26.2–0.2 22.67 27.23–1.89 20.33 NS (p50.51)
Arch length 22.08 25.65–2.07 22.90 29.02–3.22 0.82 NS (p50.28)

All measurements in mm.

The differential mesial molar movement between the two groups was statistically significant. No statistical significant difference existed between the two
groups with respect to changes in incisor positions.
No statistical significance existed between the two groups with respect to decrease in crowding and arch length.

and extruded (experimental 0.47¡0.98 mm, control and McLaughlin and Bennett,3 who suggested that the
0.44¡0.8 mm) during the observation period; no pre-adjusted edgewise appliance proclined the labial
statistically significant difference was observed between segments and compromised anchorage during the initial
the two groups. Crowding (experimental 23¡1.6 mm, stages of treatment. What factors could possibly
control 22.67¡2.28 mm) and arch length (experi- account for the discrepancy between these results and
mental 22.08¡2.82 mm, control 22.9¡3.06 mm) both their clinical observations? The standard edgewise
decreased over the observation period and differences appliance uprights teeth 90u to the occlusal plane
between the groups were again non-significant. There provided full engagement of the slot by the arch wire.
was a statistically significant difference with respect to According to Hussels and Nanda11 these teeth would
the mesial movement of the lower first molar (experi- occupy less space than they would at Second Order
mental 0.75¡1.08 mm, control 20.08¡1.55 mm; p5 angulations and, therefore, more space within the arch
0.05). This 0.83 mm molar movement variation was felt would be present when compared to pre-adjusted
to be of clinical significance in terms of anchorage control. edgewise cases at the end of leveling and aligning. The
use of flexible archwires would also encourage these
Discussion dental changes.12 This space deficiency was interpreted
as loss of anchorage and attributed to the lower incisors
Summary of results becoming proclined and dragging the first molar
anteriorly. This study suggests that, rather than ‘burn-
In both groups the lower incisors retroclined during the ing’ anchorage this loss of space within the arch was a
time between T1 and T2 (experimental 20.53¡1.9 mm, reflection of teeth aligning around the arch wire as they
control 20.44¡1.29 mm) and there was no statistical achieved Andrews second key in the first stage of
significance between the two groups (p50.84). The treatment.
lower incisors extruded in both groups; 0.47¡0.98 mm
Rather than proclining, the lower labial segment in the
in the experimental group and 0.44¡0.87 mm in
control group in this study showed a mean non-
the control group. This difference showed no statistical
significant retroclination of 0.44 mm. The experimental
difference between the groups (p50.9). The lower first
group also showed a mean retroclination of the lower
molars showed 0.83 mm greater mesial movement in the
labial segment of 0.53 mm, this was also not statistically
experimental group (p,0.05). Labial segment crowding
significant. The difference of 0.09 mm greater retro-
decreased in both groups (Experimental 23¡1.6 mm,
clination in the experimental group was not statistically
control 22.67¡2.28 mm; p50.51). Arch length decreased
significant (p50.84). It can be concluded from this
in both groups (experimental 22.08¡2.82 mm, control
evidence that passive laceback ligatures have no
22.9¡3.06 mm; p50.28).
influence on the antero-posterior position of the lower
labial segment.
Comparison with other studies
These results differ from the finding of Robinson5 and
This demonstrates that in this study, rather than Usmani et al.,6 who found a 2.47 and 0.86 mm
proclining during the leveling stage of treatment the difference, respectively, between the two groups.
lower incisors retroclined slightly. This result is in There was a major bias in the Robinson study5 in the
contrast with the observations of Meyer and Nelson2 non-randomization of participants, who were allocated
 310 R. Irvine et al. Scientific Section JO December 2004

according to operator preference S. N. Robinson, Conclusions

personal communication). This would give the extrac-
tion choice, as a reflection of crowding, and the choice of In first premolar extraction cases, the lower labial
T2 intervention time (following full labial segment segment does not procline during the leveling stage with
alignment) greater influence on the results of the two the pre-adjusted edgewise appliance.
groups. The use of laceback ligatures conveys no statistical or
The Usmani et al.6 study was randomized and clinical difference in the anteroposterior or vertical
reported a smaller difference of 0.86 mm in the upper position of the lower labial segment or in the relief of
arch where canine tip is greater. This study also took T2 labial segment crowding.
measurements following full labial segment alignment. The use of laceback ligatures creates a statistically and
This may have influenced the findings, as twice the clinically significant increase in the loss of posterior
crowding was present in the control group. This study anchorage, through mesial movement of the lower first
also lacked insufficient power to record negative findings molars.
(p50.625), with an increased size of study group the
results may have differed.
Authors and contributors
Implications for clinical practice Fraser McDonald was responsible for study design,
logistic, administrative, and technical support and data
With the results of this report and also supported by interpretation; drafting, critical revision and final
Usmani et al.6 the validity of lacebacks as an adjunct for approval of the article. Robert Irvine was responsible
the straight wire technique has to be questioned. Further for recruitment of participants and data collection,
work is required to examine the levels of plaque analysis, and drafting, critical revision and final
accumulation with and without lacebacks as the approval of the article. Susan Power was also respon-
possibility that the appliance is a plaque retention factor sible for recruitment of participants and treatment,
is clear. analysis, and drafting, critical revision and final
approval of the article. Fraser McDonald is the
Implications for research guarantor.

There are several implications for further work, but the

most logical concept is now to examine cases that are References
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Orthod 1972; 62: 296–309.
2. Meyer M, Nelson G. Preadjusted edgewise appliances:
Validity of the study groups theory and practice. Am J Orthod 1978; 73: 485–98.
3. McLaughlin RP, Bennett JC The transition from standard
In order to draw conclusions the validity of both the
edgewise to preadjusted appliance systems. J Clin Orthod
control and experimental groups must be considered.
1989; 23: 142-53.
Comparisons of the initial measurements (T1) demon-
4. McLaughlin RP, Bennett JC, Trevisi HJ. Systemised
strated no statistically significant difference between the
Orthodontic Treatment Mechanics. Mosby, Edinburgh,
groups. Both groups were evenly matched for age and
2001: 101–2.
sex at the start of treatment. Malocclusions within the
5. Robinson SN. An evaluation of the changes in lower incisor
groups were evenly distributed. position during the initial stages of clinical treatment using
Randomization of this prospective study ensured that a pre-adjusted edgewise appliance. MSc Thesis, University
all other variables were equally distributed between the of London, 1989.
two groups. 6. Usmani T, O’Brien KD, Worthington HV, Derwent, S,
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