Escolar Documentos
Profissional Documentos
Cultura Documentos
Orthodontic elastics
By
El-Hassanein Hussein El-Hassanein
(B.D.S.)
Demonstrator in Orthodontic Department
Faculty of Dental Medicine
Al-Azhar University
(Boys-Cairo)
Under supervision of
Dr. Ashraf Atia Ali El-Bedwehi
Assistant Professor of Orthodontics
Faculty of Dental Medicine
Al-Azhar University
(Boys-Cairo)
1428 H –2007 G
1
I. Introduction
II. Composition
III. Advantage
IV. Disadvantage
1. Coloring
2. Fluoride
3. Air
4. Ozone
6. Thermal-cycle
7. pH
8. Mastication
9. Daily diet
10. Staining
12. Water
X. Latex elastics and synthetic elastomers have certain similarities and differences.
2
XII. Uses and Clinical applications
1. Elastic ligatures
2. Elastomeric separators
3. Elastomeric module
4. Elastomeric chains
5. Derotation
6. Rubber bands
7. Dental Crossbite
8. Midline discrepancies
9. Impacted Canines
12. Intrusion
XIV. References
3
Introduction
Materials used in an orthodontic office to apply forces to move teeth include archwire
loops, coil springs, latex elastics and synthetic elastomers. This seminar will give us an
idea about the last two materials.
These two materials which are considered as an essential part of any orthodontic office
are "rubber elastics" and "alastiks" which are plastic (synthetic) elastics. 1
Although there are multiple surveys of natural rubber latex (latex) orthodontic elastics
and other synthetic elastomeric materials (i.e., elastic ligatures, elastomeric chain), there is
limited research on synthetic (nonlatex) orthodontic elastics. The latex and nonlatex elastics
were not similar in their behavior. Furthermore, force delivery over time varied with the
manufacturer.2
The majority of the orthodontic elastics on the market are latex elastics. Since the early
1990s synthetic products have been offered on the market for latex-sensitive patients and
are sold as nonlatex elastics. 2
After placement, the elastic chains are generally changed at 3- to 6-week intervals.
Once the chains are activated, they begin to permanently elongate, thus decreasing the
force that they can exert on the teeth.4
II. Composition
At one time the word "rubber" connotated natural or tree rubber which is a hydrocarbon
polymer of isoprene units. The synthetic rubbers which have been developed possess
different chemical structures, but resemble tree rubber in many physical properties. Both
natural and synthetic rubbers are composed of long, thread-like molecules. The
characteristic property of reversible extensibility results from the randomly coiled structure
of long, folded polymer chains. Upon extension, these randomly coiled chains are elon-
gated into an ordered structure consisting of linear chains except when cross-linked. This
tendency to revert to the original disordered state upon removal of elongation stress
accounts for die elastic behavior.5
1. Natural rubber
Natural rubber, probably used by the ancient Incan and Mayan civilizations, was the
first known elastomer. It had limited use because of its unfavorable temperature behavior
and water absorption properties.3
Calvin S. Case (1893) discussed the use of intermaxillary elastics at the Columbia
Dental Congress.6 However; Henry A. Baker7 is credited with originating the use of inter-
maxillary elastics. Angle (1902) described the technic before the New York Institute of
Stomatology.6
4
Natural rubber may be obtained from hundreds of different types of plants. The major
source, however, is the rubber tree (Hevea brasiliensis). The chemical structure of natural
rubber is cis-1,4 polyisoprene which contains approximately 500 isoprene units in the
average natural rubber polymer chain. This structure varies in molecular weight from plant
to plant, region to region, and from season to season. The gray color found in some rubber
bands denotes an inferior product with inclusions of impurities. Occasionally, the producer
of the raw latex will attempt to bleach die latex resulting in die loss of some of its resilient
properties. Latex elastics should be obtained from orthodontic supply houses that have
adequate quality controls. To obtain optimal properties, the rubber latex which is used in
die preparation of orthodontic elastics is a blend of carefully selected lots of the purest,
high molecular weight latex.5
2. Synthetic rubber
Synthetic rubber polymers, developed from petrochemicals in the 1920s, have a weak
molecular attraction consisting of primary and secondary bonds. At rest, a random
geometric pattern of folded linear molecular chains exists. On extension or distortion, these
molecular chains unfold in an ordered linear fashion at the expense of the secondary bonds.
Cross links of primary bonds are maintained at a few locations along the molecular chains.
The release of the extension will allow for return to a passive configuration provided the
distraction of the chains is not sufficient to cause rupture of these primary bonds.3
Synthetic polymers are very sensitive to the effects of free radical generating systems,
notably, ozone and ultraviolet light. The exposure to free radicals results in a decrease in
the flexibility and tensile strength of the polymer. Manufacturers have added antioxidants
and antiozonates to retard these effects and extend the shelf life of elastomerics.5,8
Elastomeric chains were introduced to the dental profession in the 1960s and have
become an integral part of many orthodontic practices.3
The composition of plastic elastomers such as Omolast, AlastiKs, Zing String, and
Power Thread are proprietary secrets.5
Polyurethane rubber is a generic term given to the elastic polymers which contain the
uremane linkage. They can be synthesized by extending a polyester or a polyether glycol
or polyhydrocarbon diol with a di-isocyante. In either case the chosen diol that is used is
up in the 500,000 molecular weight range. The basic repeating structure of this polymer
leads to enormous varieties in physical properties for plastic and rubber. Depending upon
the end use, a variety of means of processing and synthesizing may be employed. Polyure-
thane polyesters have been used for elastic ligatures. It has been found that they excel in
strength and resistance to abrasion when compared with natural rubber. They tend to
permanently distort, however, following long periods of time in the mouth and often lose
their elastic properties.5
III. Advantage
They are inexpensive, relatively hygienic and easily applied.3
Placement and removal of chain elastics requires little chair time for the clinician and
minimal patient cooperation during application.9
5
Rubber bands are also easier for a patient to remove and replace.10
Rubber has the particularly valuable quality of a great elastic range, so that the extreme
stretching produced when a patient opens the mouth while wearing rubber bands can be
tolerated without destroying the appliance. 10
The major useful property of natural latex rubber is its resiliency. This property makes
it useful intraorally for the application of tractive forces in the ranges up to 6 or 8 ounces.
Greater forces would result in a large increase in the cross-sectional area of the rubber and
would be difficult to be placed in orthodontic attachments. High quality latex more or less
retains its resilience in water and under optimal conditions displays a minimal force
decay.5
IV. Disadvantage
Elastomeric chains, however, are not without their disadvantages.
Gum rubber, which is used to make the rubber bands commonly used in households and
offices, begins to deteriorate in the mouth within a couple of hours, and much of its
elasticity is lost in 12 to 24 hours. Although orthodontic elastics once were made from this
material, they have been largely superseded by latex elastics, which have a useful
performance life 4 to 6 rimes as long. In contemporary orthodontics, only latex rubber
elastics should be used.10
When extended and exposed to an oral environment, they absorb water and saliva,
permanently stain, and suffer a breakdown of internal bonds that leads to permanent
deformation.11
They also experience a rapid loss of force due to stress relaxation, resulting in a gradual
loss of effectiveness.11, 12
This loss of force makes it difficult for orthodontists to determine the actual force
transmitted to the dentition.3
Baty et al., concluded that one characteristic of elastomeric chains is the inability to
deliver a continuous force level over an extended period of time.3
While Profitt stated that it simply must be kept in mind that when elastomers are used,
the force decay rapidly, and so can be characterized better as interrupted rather than
continuous.10
6
1. Chains
A) Initial force
An initial force loss (Force decay) of 50% to 75% occurred in the first 24 hours.5,11
The greatest amount of force loss took place in the first 3 hours.5
After 24 hours of load, Alastiks suffered a 74% loss of force delivery capability,
whereas latex elastics only lost 42%. After the first day, the force degradation declined in a
relatively stable manner.12
Hershey and Reynolds,13 compared chains from three different companies. Their results
showed no significant differences in the force degradation behavior of the chains, but there
were substantial differences in the initial force delivery of the chains. The authors
concluded that a force gauge should be used in a clinical setting to determine initial loads
of the chains.
Killiany and Duplessis14 reported on the force delivery and force decay characteristics
of the Rocky Mountain “ Energy” chain (RMO) compared with those of a short loop chain
from American Orthodontics. The initial force levels (330 gm) of the new “Energy” chain
at 100% extension were lower than those of the short loop chain (375 gm). After 4 weeks
of storage in a simulated oral environment, the “Energy” chain retained 66% of its initial
force, whereas the short loop chain possessed only 33% of its original force.
De Genova et al.15 showed that the short filament chains generally provided
higher initial force levels and retained a higher percentage of the remaining
force than the long filament chains.
The longer filament chains will deliver a lower initial force at the same
extension and exhibit a greater rate of force decay under load than the closed Three types
7
force values at 100% extension were constant for each individual material. They also noted
that all short filament chains, with the exception of Unitek AlastiKs, produced higher
initial force level at 100% extension, the initial forces being in the range of 403 to 625 gm.
This led Rock et al.16 to recommend extending chains to 50% to 75% of their original
length to provide the desired force of approximately 300 gm.
In general, the most force decay occurs at the first hour, and the greater the initial force,
the greater the force decay of all chains.17
2. Elastics
Most of the relaxation was shown to occur within the first 3–5 hours
after extension, regardless of size, manufacturer, or force level of the elastics.18
Both samples showed initial force drop at the end of the first day. The average drop was
more in the vivo sample group, it was about 31% to 53% compared to the 26% to 47%
force loss of the in vitro sample group. The second force drop was reported by the end of
the 7th day (37% to 61%) for the in vivo sample. This percentage loss was more or less
constant till the end of the 14th day, and then followed by third force drop by the end of
the l5th day (58% to 63%), and fourth force drop at the end of the 21 days of the study
ranging between 65% to 75 %. These findings were different from those obtained from the
in vitro sample group in that; the second force drop at the end of the7th day was equal to
36% to 53%, and the third force drop (40% to 58%) was reported at the end of the 14th
day, and then maintained its level till the end of the 21 days period.19
Force analysis, indicated that, residual remaining force after 14 days of intermaxillary
mechanics, and is not of sufficient magnitude to produce effective tooth movement. 19
So for practical and clinical purposes, and to maintain the initiation of orthodontic tooth
movement in the desired direction by intermaxillary mechanics, elastic bands must be
changed at a maximum of two weeks interval.19
The distal driving force component is about 97.5% and 75% of the elastic force; with
the mouth closed and widely opened respectively this factor must be considered during
force analysis. 19
8
VI. Prestretching effects
1. Chains
Attempts to alleviate the large initial force degradation and improve the constancy of
force delivery have led several investigators to look at the effects of prestretching the
elastomeric chains before placement.
Andreasen and Bishara recommend an initial extension of the chain of four times the
desired force level to compensate for inherent force loss.12
Young and Sandrik8 conclude that extending chains three to four times the desired force
would result in permanent deformation of the chain and subsequent reduction in the
desired force level. And they recommended initial extension of the chains by 50% to 75%
of the original length to provide an optimal force level.
Wong,5 recommended prestretching the elastic chains a third of their original length to
prestress the molecular polymeric bonds and improve the strength.
Some products may require an extension of 100% to generate force levels of 300 gm,
whereas others extended by this amount would provide excessive force levels.3
Kuster et al.,20 compared the chains of two companies stored in air and in vivo. Chains
stored in air were extended to 82% and 115% of the original length and, after 4 weeks, had
maintained 70% to 75% of their initial force level. Chains placed in vivo at approximately
100% extension retained 43% to 52% of their initial force level after 4 weeks. At 100%
extension, the force levels of the two chains were 315 gm and 279 gm, respectively.
Kovatch et al.21 reported that rapidly extended chains showed greater initial force levels
than those slowly stretched. At 1 week, however, the chains stretched at the slow rate
exhibited less force decay. Therefore they recommended slowly stretching the modules to
position
2. Elastics
The empirical rule of “3” indicating that the reported force level is achieved on
extending the elastic three times its diameter, does not apply to all cases and shows
remarkable variation, ranging from 2.7 to five.18
Intramaxillary elastics are used between two points in the same dental arch.6 (e.g., class
I elastics from canine to first permanent molar)
Intermaxillary elastics
Intermaxillary elastics are used between the maxillary and the mandibular dental
arches.6
9
Oppenheim advocated the use of intermaxillary rubber dam elastics to be worn at night
only.6
In intermaxillary anchorage, elastics are used to retract the maxillary arch or to bring
the mandibular arch forward when it is in lingual collapse. Elastics also may be used
vertically to bring teeth in opposing arches into occlusion.6
Most of the fixed and some removable appliances rely on elastic force to varying
extents. When intermaxillary elastics are used during the growth period, there is a greater
tendency for the anchor teeth to move labially.6
Bien analyzed elastic force under various conditions. He found intermaxillary elastic
strength of 4 oz. when the mouth is closed shows a distal driving force of 3.9 oz. or a loss
of 2.5 per cent. When the mouth is open the distal force is 3 oz. or a loss of 25 per cent.
When the headgear is used with the elastics parallel with the maxillary arch, the driving
force is 4 oz. and shows no loss.6
FIG. . intermaxillary
FIG.. intermaxillary
elastics; mouth closed.
elastics; mouth open.
Bien found an upward displacement force on the mandibular molars of 2.6 oz. when the
mouth is open and an intermaxillary elastic of 4-oz. tension is used. This force is present
even under optimum anchorage in lingual appliances. When the mouth is closed there is
only 0.9 oz. upward displacement of the mandibular molars. .6
When the headgear is used as indicated there is no upward or rotational force on the
mandibular 1st molars. From a practical standpoint there is little difference between the
force with the mouth closed and when the headgear is used.6
There is a rotational force at the apices of the maxillary and the mandibular molar roots
when intermaxillary elastics are used. Rotational force can be minimized by using light
elastics. When 4-oz. force elastics are used the rotational force in the mandibular molars is
5.4 oz. when the mouth is closed and 4.1 oz. against the mandibular 1st molar when the
mouth is open.6
10
In other words, if an elastic is stretched to apply 100 g of force on a maxillary canine
bracket, the effective distal force will be only 96 g. In situations where four premolar have
been extracted and the space closed, the same Class II elastic, now stretch over a shorter
span, has a horizontal vector of 93% but a significantly increased vertical vector of 37%.
On the other hand, Class II elastics that are stretched over a long distance from the distal of
the mandibular second molar to the mesial of the maxillary canine have a horizontal effect
of 98% and a smaller vertical vector of 20%. There fore, to get the greatest distal effect of
Class II elastics with the smaller collateral vertical vector, elastics should be applied from
the farthest distal point, i.e., the distal of the mandibular second molar. The same concepts
apply to Class III elastics, only in the opposite direction.22
1. Color
The remaining force and the percentage of remaining force at each interval, except
initial, of the Rocky Mountain energy chain were greater than that of the American
Orthodontic chain including transparent and grey.17
When comparing the American Orthodontic elastomeric chains, the remaining forces
and the percentage of remaining force of the transparent chains were greater than that of
the grey chains.17
11
While Baty et al., stated that In general, the colored chains of a particular manufacturer
behaved similarly to the gray chain of that manufacturer, the exception to this being the
Ormco purple and green chains.24
2. Fluoride
The initial force levels of Fluor-I-Chain and gray chain when stretched by 100% their
original length were 316g and 280g respectively. After 1 week, Fluor-I-Chain’s force level
had degraded to 43 g or 14% of its original force. This force level would not be adequate to
retract a canine. Gray chain at one week had a force level of 107 g which remained fairly
constant through the remaining 2 weeks. 25
Water and artificial saliva (Oralube) significantly affected Fluor-I-Chain’s initial force
displacement beginning at 4 hours of immersion. 25
Fluor-I-Chain does release fluoride over a 3 week period at a level that could have the
potential to inhibit demineralization and promote remineralization.25
Elastomeric chains exhibit good elastic behavior when distracted to an initial force of
less than 300g. When forces exceeded 300g, permanent deformation occurred and the force
delivery was less predictable. Exposure to artificial saliva and topical fluoride affected the
elastic properties of the elastomeric chains and increased the distraction required to deliver
both the 150g and 300g force. The increase in distraction for a force of 150g, however, was
relatively small and probably insignificant in the clinical setting. The distraction required
to produce 300g was significantly larger and appeared to be clinically significant. Pre-
stretching the elastomeric chains by 100% of their initial length was not found to be
advantageous in terms of the load relaxation behavior. There was less load relaxation
found in chains that were immersed in distilled water and Acidulated Phosphate Fluoride
than in chains exposed only to air. The observed relaxation may be a problem in the
clinical situation only when the module is required to deliver high forces, >300g, or if there
is prolonged exposure to fluoride media. Pre-stretching appeared to have an overall
beneficial effect only for Ormco Generation II power chain.26
12
3. Air
4. Ozone
The most significant limitation of natural latex is its enormous sensitivity to the effects
of ozone or other free radical generating systems such as sunlight or ultraviolet light that
produces cracks. The ozone breaks down the unsaturated double bonds at the molecular
level as the water molecule is absorbed. This weakens the latex polymer chain. The
swelling and staining is due to the filling of the voids in the rubber matrix by fluids and
bacteria debris. In clinical use the latex elastics are replaced before this stage is reached.
Antiozone and antioxidant agents are added at the time of manufacture of the latex tubing.
However, when it is chopped into individual latex bands, the surface area is increased and
ozone can diffuse more rapidly into the bands. This sharply limits the shelf life of the latex
elastics. Out-of-date elastics may break after a few elongation-relaxation cycles. Usually,
this type of break is due to crack-propagation which occurs somewhere in the elastics due
to ozone effects. An additional manifestation of ozone attacks on latex bands is the reduced
force values which may be seen after a short period of two or three months after
manufacture. Commonly, one may see elastics, which are rated at four ounces when
manufactured, show force value of 2.5 to 3 ounces after a few months of storage. The ten-
sile strength, therefore, is unpredictable and is more critical in higher force range
applications.5
Exposure to gluteraldehyde solution affected the strength and the distention required to
deliver a force of 500g of certain elastomeric chains. However, the resultant changes were
relatively small and are probably insignificant in the clinical setting. 27
The use of alkaline gluteraldehyde solutions for this purpose may have no deleterious
effects when the clinical use of the elastomeric chains is considered. In particular, the
displacement required to produce a 500g force increased by 5mm, at most, following long-
term exposure to gluteraldehyde solution; the force to break the chains only decreased by
approximately 20 to 100g under the same conditions. Discoloration of some chains
occurred in the sterilizing solutions but this change appeared to have no effect on the chain
properties. The findings suggest that cold disinfection and/or sterilization via
gluteraldehyde solutions (Sporicidin and Cidex-7) may be an effective and convenient
approach for elastomeric chains.27
6. Thermal-cycle
De Genova et al.,15 investigated force degradation of chains from three companies that
were maintained at a constant length and stored in artificial saliva. In the first study, one
set of specimens was maintained at 37° C and another was thermal cycled between 15° C
13
and 45° C. They reported that the thermal-cycled chains displayed significantly less force
loss after 3 weeks. Starting with an initial force level of 300 to 400 gm, this difference,
however, was only 7 to 10 gm. and reported some minor improvement in the retention of
force after 3 weeks.
7. pH
Oral pH almost certainly has a significant influence on the decay rate of orthodontic
polyurethane chain elastics.9
All the test products yielded a significantly greater force-decay rate in the basic (pH
7.26) solution than in the acidic (pH 4.95) solution over 4 weeks.9
A hypothesis is presented that the decay rate of orthodontic polyurethane chain elastics
is inversely proportional to the oral pH, with a corollary that basic pH levels (above
neutral) are most hostile to polyurethane chain elastics, thus increasing their force-decay
rates.9
Clinically, it would seem that an oral pH lower than 7.26 would retard the force-decay
rate of the chain elastics. Before this study, we did not expect to find that decreased pH
associated with dental plaque in the presence of carbohydrates may actually decrease the
force-decay rate of the chain elastics and thus potentially enhance their effectiveness. The
clinician does not have an ability to control the patient's oral environment, but he or she
must have knowledge of the individual elements within it that can affect the mechanics
plan selected.9
8. Mastication
The forces of mastication and the intraoral environment cause natural rubber to break
down by formation of knotty tearing mechanisms.5
9. Daily diet
At the various levels of simulated daily dietary challenge/patient compliance, the latex
elastics maintain their applied force over a day of wear.28
No differences were found between daily diet/patient compliance levels. Except for
band breakage or recommended reasons of oral hygiene, beyond the once-per-day
experience, there may be no need to change elastics during the day.28
10. Staining
B. Gradual staining (chocolate drink, Lea & Perrins sauce, red wine, tomato ketchup)
C. Rapid staining (coffee produced severe staining after only six hours, tea)
14
11. Oral cavity
Ash and Nikolai,30 compared force decay of chains extended and stored in air, water,
and in vivo. They reported that chains exposed to an in vivo environment exhibited
significantly more force decay after 30 minutes than those kept in air. No difference was
noted between the chains maintained in water and those in vivo until 1 week. However,
after 3 weeks, the chains stored in vivo had a greater force loss than those stored in water,
but both still maintained force levels of more than 160 gm. They postulated that the effects
of mastication, oral hygiene, salivary enzymes, and temperature variations within the
mouth influenced the degradation rates of in vivo chains. Although they stated that their
initial extension was too much.
In the oral cavity, elastics absorb water and saliva, which cause a breakdown of the
internal bonds and permanent deformation of the material. In addition, the elastics swell
and stain due to the filling of the voids in the rubber matrix by fluids and bacterial debris.
These lead to a loss in force delivered to the tooth. To minimize such side effects,
orthodontists recommend that patients change their elastics twice daily, but this requires
faithful patient adherence. Elastomeric chains gained in popularity because they were more
in the control of the clinician. They too experience a rapid loss of force as a result of stress
relaxation.22
12. Water
Huget et al.,31 concluded that the load decay associated with elastomeric chains for 1
and 7 days of water storage may be the result of water sorption and the concurrent
formation of hydrogen bonds between the water molecules and macromolecules of the
elastomers. A gas chromatography test was performed on the water in the storage vials to
establish the presence of any organic materials leached from the chains, organic material
did not appear in the storage media until the fourteenth day of immersion.
There is a great variability, as much as 50%, in the tensile strength of the plastic
materials taken from the same batch and stretched under the same conditions. 5
The force decay of synthetic elastomers, stretched over a specific length and time,
exhibited a great loss in force. This loss could be as great as 73% during the first day. The
decay of force continued at a slower rate during the rest of the 21 day period. 5
The Ormco Power Chain was more resilient than the Unitek AlastiK chain. The Unitek
AlastiKs had more force and stretched less. 5
Unitek AlastiK C2 double links, when stretched 17 millimeters, had a higher initial
force averaging 641 grams (22.5 ounces) than the Ormco Power Chain which averages 342
grams (12.0 ounces). In one day the force was reduced to 171 grams (6.0 ounces) for both
materials. 5
15
The approximate force generated when stretched dry, within the elastic limit, was 22
grams per millimeter for 3/16" heavy latex elastics. The Unitek AlastiK C2 gave a force of
89 grams per millimeter, while the Ormco Power Chain had a value of 46 grams per
millimeter. The modulus of elasticity of all of the materials was much lower after immer-
sion in the water bath. 5
The force decay under constant force application to latex, elastic, polymer chains, and
tied loops showed that the greatest amount of force decay occurred during the first three
hours in the water bath. The forces remained relatively the same throughout the rest of the
test period. 5
The synthetic elastomers should be prestretched before being placed in the mouth. The
elastomers should be used within their resilient ranges. 5
Clinical treatment procedures should take into consideration the rapid initial force decay
of elastic materials that occurs during the first day and the residual forces remaining. 5
American Orthodontics latex elastics (0.25 inch, 4.5 ox, 6.25 mm, 127.5 g) retained
significantly more force over time than their nonlatex equivalents. 2
Cyclic testing (repeated stretching )of orthodontic elastics caused significantly more
force loss than static testing but this effect was seen early in testing and did not change the
rate of force decay after this. 2
Because of higher rates of force loss that continued throughout testing, it is more
important that nonlatex elastics be changed at regular intervals not exceeding 6-8 hours. 2
Cyclic testing caused significantly more force loss and this difference occurred
primarily within the first 30 minutes. For statically tested elastics the percentage of initial
force remaining at 4, 8, and 24 hours was 87%, 85%, 83%, and 83%, 78%, 69% for latex
and nonlatex elastics, respectively. For cyclically tested elastics the percentage of initial
force remaining at 4, 8, and 24 hours was 77%, 76%, 75%, and 65%, 63%, 53% for latex
and nonlatex elastics, respectively.2
16
On the other hand, stainless steel ligatures can be tied either too tight or too loose,
depending on the technique and needs of the clinician.22
1. Elastic ligatures
Elastic ligatures of light, medium and heavy thickness may be used for
separating teeth before fitting bands, rotating teeth, space closure, tooth
alignment, canine retraction and for bringing teeth into the line of
occlusion. The elastic ligature is drawn through the interproximal space of the teeth
with a fine ligature wire and tied under tension.6
Cotton thread
2. Elastomeric separators
a) Elastomeric ring
17
b) Safe-T-Separators
c) Dumbbel Separators
d) Stick Separators
e) Durasep Separators
3. Elastomeric module
Ligature-forceps
Mini modules
18
4. Elastomeric chains
Polyurethane chain elastics are commonly used in orthodontics for intra-arch tooth
movement.9
They are used to generate light continuous forces for canine retraction, diastema
closure, rotational correction, and arch constriction.15
5. Derotation
The patient in the early or late mixed dentition who presents with a severely rotated
tooth may not require immediate full treatment, but esthetic considerations usually dictate
correction of the problem. Will describes a simple method of derotating a single tooth,
utilizing a fixed lingual or palatal arch in conjunction with the "rotation tie" commonly
used in lingual orthodontics.32
Solder a lingual or palatal arch to molar bands and cement it to the first permanent
molars. Take care to position the arch in close proximity to the lingual aspect of the tooth
to be derotated. The arch will thus act as a stop, preventing the tooth from moving
lingually.32
Bond a button to the lingual surface of the rotated tooth in a location with respect to the
height of the gingival margin, so that the gingiva will not be damaged when the rotation tie
is placed.32
Slip one end of a length of elastic chain under the archwire (Fig. 1). Thread the end of
the chain through the last link in the direction toward which the tooth is to be rotated. Pull
tight, tying the chain to the archwire (Fig. 2).32
Bring the chain around the labial side of the tooth, passing through both interproximal
contacts, and attach it to the button (Fig. 3). An additional bonded button or composite
resin can be placed on the labial surface (Fig. 4) to prevent any incisal slippage of the
chain, which would render the technique useless.32
19
Fig. 3 Chain passed through both
Fig. 4 Labial button can be added to
interproximal contacts before being
prevent incisal slippage of chain.
attached to lingual button.
Compared to fixed appliances, the rotation tie is a fast and easy way to correct rotations
in the early or late mixed dentition. Chair time is minimal, both at initial and follow-up
visits. Patient cooperation is not as critical as with removable appliances or elastics. From
an esthetic standpoint, the appliance is virtually invisible.32
20
To rotate a tooth distolingually, tie an elastomeric ligature in a figure-8 to the distal
wing of the bracket (Figs. A). After placing the archwire, tie the mesial wing of the bracket
to the archwire with a ligature wire or an elastic tie (Figs. B).33
6. Rubber bands
Rubber bands were used from the beginning, in orthodontics to transmit force from the
upper arch to the lower.10
7. Dental Crossbite
Rarely is one tooth alone tipped. In most cases, its antagonist in the opposite arch is out
of position also. Thus, the maxillary first molar may be tipped lingually and the
mandibular first molar is tipped slightly buccally, so both teeth must be moved.34
21
8. Midline discrepancies
In this circumstance, the midline often can be corrected by using asymmetric Class II
(or Class III) elastic force. As a general rule, it is more effective to use Class II or Class III
elastics bilaterally with heavier force on one side than to place a unilateral elastic.
However, if one side is totally corrected while the other is not, the patient usually tolerates
a unilateral elastic reasonably well. It is also possible to combine a Class II or Class III
elastic on one side with a diagonal elastic anteriorly, to bring the midlines together
(Figure). Coordinated steps in the arch-wires also can be used to shift the teeth of one arch
more than the other.10
9. Impacted Canines
22
canine. These techniques introduce significant side effects, such as tipping of the adjacent
teeth if the main archwire is deflected, and provide only poor control of the movement of
the canine. This appliance design also has a high load deflection rate due to the rapid decay
of the force delivered by the elastic and the necessity of using a very rigid arch-wire to
avoid deflection.22
Palatally impacted canines have traditionally been moved into the arch
with elastic chains or elastic threads extending from the canine to the main
buccal archwire. A palatally impacted canine needs movement in two
directions. An eruptive force is necessary to bring the tooth to the level of the occlusal
plane, and a buccal force to bring the tooth into alignment in the arch. The conventional
use of elastics to arch wires is often accompanied by undesirable side effects on the
adjacent teeth. In the horizontal plane, the buccal movement of the canine is accompanied
by a lingual displacement of the adjacent teeth, mesial-in rotation of the premolar, and
distal-in rotation of the lateral incisor. In the vertical plane, the eruption of a palatally
impacted canine is associated with similar side effects as discussed for erupting high
buccal canines. Canine bypasses associated with overlaid superelastic wires can be used
successfully to erupt palatally placed canines.22
In Rocky Mountain clear chain, 40 mm stretch length was optimal for clinic use. The
effective canine retraction may be no more than 3 weeks, meaning that it may be changed
about 3 weeks during clinical usage.17
Sonis et al.,35 compared in vivo canine retraction by using two elastomeric chains and a
nylon covered latex thread. All the materials were extended sufficiently to produce 350 to
400 gm of initial force. Patients were seen at 3-week intervals to measure the amount of
space closure and to change the elastic modules. No significant difference in tooth
movement was noted for any of the products. The elastomeric auxiliaries were found to be
more hygienic and required less chair time to apply than did the elastic thread.
23
11. Deep bite
12. Intrusion
Many Class II patients have deep overbite, so one may take advantage of
simultaneously intruding incisors while posterior teeth are tipped back. Figure shows a
three-piece tip-back mechanism. A rigid anterior segment fits the four incisors that are to
be intruded. A posterior tip-back spring produces a tip-back moment, tipping the first
molar distally. Note that the spring is free to slide distally on the posterior extension of the
anterior segment. Transseptal fibers or figure eight ties keep the bicuspids moving distally
along with the molar. Since individual tipping of teeth is required, no archwire is placed in
the buccal segment. By placing the intrusive hooks on the anterior segment either
anteriorly or posteriorly, one can either flare the incisors or retract them simultaneously
during the tip back of the posterior teeth. The same type of spring can be used to move the
anterior teeth distally and simultaneously intrude them. The three-piece intrusion arch has
intruded and retracted the upper incisors. During treatment, the intrusive force was placed
along the long axis and through the center of resistance and later moved lingually to
produce the lingual movement of the upper incisors.22
24
Distal elastic has been added to change the direction
of force so that intrusion occurs parallel to the long axis
of the incisors. Placing the hook distal to the center of
resistance of the anterior segment produces incisor
retraction. A, Appliance; B, tracing showing incisor
intrusion and retraction.22
As with deep bite, it is important to analyze the source of the difficulty if an anterior open bite
persists at the finishing stage of treatment. Only rarely is a persistent open bite caused by lack
of eruption of the upper incisors, so elongating these teeth usually is undesirable. If the open
bite results from excessive eruption of posterior teeth, whether from a poor growth pattern or
improper use of interarch elastics, correcting it at the finishing stage can be extremely
difficult.10
If no severe problems with the pattern of facial growth exist, however, a mild open bite
at the finishing stage of treatment usually is due to an excessively level lower arch. This
condition is managed best by elongating the lower but not the upper incisors, thereby
creating a slight curve of Spee in the lower arch. Because of the stiffness of the rectangular
archwires used for finishing, even with 18-slot edgewise it is futile to use vertical elastics
without altering the form of the archwires to provide a curve of Spee in the lower arch.
Moreover, it is preferable to replace a heavy rectangular lower archwire with a lighter
round wire before using anterior vertical elastics.10
The preferred approach is to place a light round wire (16 or 18 mil steel) in the lower
arch, with a slight curve of Spee and any vertical steps necessary to correct marginal ridge
discrepancies, while retaining a full-dimension rectangular archwire in the upper arch.
Posterior marginal ridge discrepancies may also contribute to the open bite and should be
eliminated with small vertical steps in the archwires. Light elastic force is then used to
augment the action of the archwires, elongating the lower incisors to close the open bite.
Elongating lower anterior teeth in this way, of course, is no substitute for controlling
posterior vertical development. If carried to an extreme, this will produce an esthetically
unacceptable relationship even if proper occlusion is achieved.10
As a general guideline, mildly excessive overbite at the finishing stage usually is treated
best by slightly intruding the maxillary incisors, using an auxiliary depressing arch and
segmenting the main archwire; but mild open bite at the end of treatment usually is treated
best by elongating the lower but not the upper incisors. This is both more esthetic and more
stable than elongating the upper incisors.10
25
14. Molar Correction with Inter-arch Elastics
Class II elastics, in short, may produce occlusal relationships that look good on dental
casts but are less satisfactory when viewed from the perspective of skeletal relationships
and facial esthetics.10
Because of their vertical effects, prolonged use of Class II elastics, particularly with
heavy forces, is rarely indicated. Using Class II elastics for 3 or 4 months at the completion
of treatment of a Class II patient to obtain good posterior interdigitation is often
acceptable. Applying heavy Class II force for 9 to 12 months as the major method for
correcting a Class II malocclusion is rarely good treatment.10
Class III elastics also have a significant extrusive component, tending to elongate
the upper molars and the lower incisors. Elongating the molars enough to rotate the
mandible downward and backward is disastrous in Class II treatment but, within
limits, can help treatment of a Class III problem. If Class III elastics are used to
assist in retracting mandibular incisors, high-pull headgear to the upper molars worn
simultaneously with the elastics can control the amount of elongation of the upper
molars. Elongation of the lower incisors, however, still can be anticipated.10
26
XIII. Infection (Contamination) control
a) Gloves
Despite the most careful precautions, a certain percentage of gloves will always fail. It
also appears that, to date, latex is a more reliable material than vinyl for gloves that are
worn to avoid the spread of infection. Furthermore, since it appears that a number of
gloves will be punctured in use, it is important that other aspects of cross-infection control,
such as hepatitis B vaccination for those placed at risk and effective sterilization and
disinfection procedures, must be emphasized. Most punctures occurred in the left thumb
and forefinger, despite the fact that all the clinicians were right-handed. A number of the
gloves investigated had more than one puncture.37
Although ceramic brackets have made orthodontic treatment acceptable to many adults,
staining of clear elastomeric ligature modules by certain foods can still create an unesthetic
appearance. a simple tool that allows the patient to change stained modules at home.
(Always tie in rotated teeth with stainless steel ligatures.)38
The changer is made of .028" stainless steel wire with one end bent into a handle and
the other bent into a hook. The patient is shown how to engage the hook under the
elastomeric module and remove it. Each patient is given a length of closed elastomeric
chain and shown how to place an individual link under the bracket wings and cut it from
the chain with a scissor.38
One of the weakest links in the barrier control chain has been individual
and chain elastomeric ligatures. If they are removed from trees, canes, or
spools at chairside, the unused ligatures become contaminated. Ten minutes of “cold
sterilization” serves only to disinfect, not to sterilize. Even the disinfection requires
considerable rinsing and drying and may result in degradation of the material.39
Uses an 18-section tackle box with the top removed, cover the box at night and leave it
uncovered during office hours.39
One section is filled with individual elastomeric ligatures. Other sections hold
cut-up trees of two, four, six, eight, and 10 ligatures, and another contains
presectioned chain sections of two, four, six, eight, 10, and 12. Various
separators and rotation wedges are also in the box. Elastomerics are removed
as needed with a sterilized tweezer, reducing the risk of contamination.39
Keep clear and gray ligatures in separate sections; the clear chains seem to discolor
faster once they are removed from the spool. Try to use all the ligatures in a section before
adding new ones.39
27
d)Avoiding Cross-Contamination of Elastomeric Ligatures
Purchase clear tubing with a lumen of about 5/16" at a hardware store, cut it into 3-4"
sections, and cold-sterilize the sections. Cut strips of elastomeric ligatures into sections
about ½'' longer than the tubes. Insert the ligature sections into the tubes, leaving the ends
of the ligature sticks protruding.40
During archwire placement, the operator contacts only the outside tubing while
removing ligatures.40
The used section of ligatures is cut off and discarded after ligation.40
And the remaining section is inserted into a clean and sterilized tube. The used tube is
placed in a cold-sterilizing solution.40
XIV. References
1. Bishara SE, Andreasen GF. A comparison of time related forces between plastic
Alastiks and latex elastics. Angle Orthod.1970; 40:319–328.
2. Kersey ML, Glover KE, Heo G, Raboud D, Major PW. A comparison of dynamic
and static testing of latex and nonlatex orthodontic elastics. Angle Orthod.2003; 73:181–
186.
3. Baty DL, Storie DJ, von Fraunhofer JA: Synthetic elastomeric chains: A literature
review. Am J Orthod Dentofac Orthop.1994; 536-542.
4. Stevenson JS, Kusy RP. Force application and decay characteristics of untreated and
treated polyurethane elastomeric chains. Angle Orthod.1994; 6: 455-467.
28
9. Ferriter J, Meyers C, Lorton L. The effect of hydrogen ion concentration on the force
degradation rate of orthodontic polyurethane chain elastics. Am J Orthod Dentofac
Orthop.1990;98:404-10.
10. Profitt WR, Fields HW Jr, eds. Contemporary Orthodontics. 3rd ed. St Louis, Mo:
Mosby Inc; 2000.
11. Andreasen GF, Bishara SE. Comparison of alastik chains and elastics involved with
intra-arch molar to molar forces. Angle Orthod.1970;40:151-8.
12. Andreasen GF, Bishara SE. Relaxation of orthodontic elastomeric chains and
modules in vitro and in vivo. Angle Orthod.1970; 40:319-28.
18. Christiana Gioka; Spiros Zinelis; Theodore Eliades; George Eliades Gioka C,
Zinelis S, Eliades T, Eliades G. Orthodontic Latex Elastics:A Force Relaxation Study.
Angle Orthod. 2006; 76: 475–9.
19. Abdel-Kader HM. Elastic band fatigability during intermaxillary mechanics. Egypt
Orthod J.1987; 1, 59-71.
20. Kuster R, Ingervall B, Burgin W. Laboratory and intraoral test of the degradation of
elastic chains. Eur J Orthod. 1986; 8:202-8.
24. Baty DJ, Volz JE, and von Fraunhofer JA: Force delivery properties of colored
elastomeric modules. Am J Orthod Dentofac Orthop.1994; 106:40-6.
29
25. Storie DV, Regennitter F, von Fraunhofer JA. Characteristics of a fluoride-releasing
elastomeric chain. Angle Orthod.1994; 3:199-210.
26. von Fraunhofer J. A.,Coffelt M-T. P., Orbell G.M.The effects of artificial saliva and
topical fluoride treatments on the degradation of the elastic properties of orthodontic
chains. Angle Orthod.1992; 4: 265-74.
28. Beattie S: An In Vitro Study Simulating Effects of Daily Diet and Patient Elastic
Band Change Compliance on Orthodontic Latex Elastics. Angle Orthod.2004; 74:234-9.
29. Lew K. Staining of Clear Elastomeric Modules from Certain Foods. J Clin Orthod.
1990; 1990: 472 –4.
30. Ash J, Nikolai R. Relaxation of orthodontic elastic chains and modules in vitro and
in vivo. J Dent Res 1978; 57:685-90.
32. Van Heerden PW, Roux JP. Derotating a Tooth with a Lingual Rotation Tie. J Clin
Orthod. 1991:160 - 162
34. Moyers RE. Handbook of Orthodontics. 4th ed., Chicago. Year Book Medical
Publishers; 1988.
35. Sonis A, Van der Plas E, Gianelly A. A comparison of elastomeric auxiliaries versus
elastic thread on premolar extraction site closure: an in vivo study. Am J Orthod Dentofac
Orthop.1986; 89:73-7.
36. Hocevar RA. Orthodontic force systems: Technical refinements for increased
efficiency. Am J Orthod Dentofac Orthop.1982 ;1-11.
37. Burke FJT, Lewis HG, Wilson NHF. The incidence of puncture in gloves worn
during orthodontic clinical practice. Am J Orthod Dentofac Orthop.1991 ; 477-81.
38. Counihan DR. Elastomeric Module Changer for Patient Use. J Clin Orthod.
1996;575 - 575
30