Journal of

Functional Morphology
and Kinesiology

Article
Elastics Selector Gauge as Orthodontics Device
Applied to Inter-Maxillary Traction during
Malocclusion Correction
Sergio Sambataro 1 , Salvatore Bocchieri 1 , Luigi Bafumi 2 , Luca Fiorillo 1,3 ,
Gabriele Cervino 1 and Marco Cicciù 1, *
1 Department of Biomedical and Dental Sciences and Morphological and Functional Imaging,
Messina University, 98100 Messina ME, Italy
2 Private practice, 95100 Catania CT, Italy
3 Multidisciplinary Department of Medical-Surgical and Odontostomatological Specialties,
University of Campania “Luigi Vanvitelli”, 80121 Naples, Italy
* Correspondence: mcicciu@unime.it




Received: 19 June 2019; Accepted: 19 August 2019; Published: 26 August 2019


Abstract: Elastics are the simplest device that can be used during a class correction in orthodontics,
and despite the simplicity of a latex band, they are very effective and powerful. The resultant
inter-maxillary force affects not only the teeth, but even the mandibular position, and consequently
the temporomandibular joints (TMJ). The purpose of our work is to simplify the use of elastics, and to
reduce the amount of inventory for orthodontists, because there is a lot of merceology available on
the market, and different ways of using the elastics. The use of elastics in clinical practice is based
on the force extension values, which are given by the manufacturer for the different sizes of the
elastics, generally when they are stretched to three times their lumen size. Various configurations
allow for the correction of different malocclusions. We propose a new classification and a new device,
the elastic selector gauge, in order to allow clinicians to quickly and easily choose the right elastic in
all conditions.

Keywords: elastics; inter-maxillary traction; class II correction; orthodontics; selector gauge

1. Introduction
In order to understand the application of inter-maxillary elastics, it would be well to understand
things from their beginning. Angle laid the claim to being the first person to use a force from one arch
to the other, by the means of a rubber elastic. However, he used it from the lower arch, to an impacted
canine on the upper, apparently thinking that the availability of movement of a single tooth was all
that was possible.
Since the first cases discussed more than a century ago by Calvin S. Case, and later by Henry A.
Baker, who was the clinician who Angle credited with starting the use of elastics in clinical practice—as
devices for correcting arch relationships—elastics become a valuable auxiliary of any orthodontic
treatment. When combined with good patient cooperation, their use provides the clinician with the
ability to correct both antero-posterior and vertical discrepancies.
Prior to that time, orthodontists had attempted to practice “bite-jumping”, with mandibular
propulsion as the chief method for correcting Class II malocclusion. When that did not work for Class
II correction, they resorted to the extraction of the upper first premolars, for the purpose of gaining
space to retract the upper anterior segment. Anterior retraction was frequently done with extra-oral
traction, without the thought of molar correction with that modality.

J. Funct. Morphol. Kinesiol. 2019, 4, 63; doi:10.3390/jfmk4030063 www.mdpi.com/journal/jfmk

J.
J. Funct.
Funct. Morphol.
Morphol. Kinesiol.
Kinesiol. 2019,
2019, 4,
4, x63FOR PEER REVIEW 22 of
of 13
12

With the demonstration of anchorage from the lower arch to the upper, and with the use of
With
elastics, the demonstration
Angle changed his opinion of anchorage from the
from extraction to lower arch to the
non-extraction, upper,
which wasand with
to be the use of
manifested in
elastics,
his Angleinchanged
teachings his career histhereafter.
opinion from extraction
He showed thatto elastics
non-extraction,
were tied which
in, and wasdemonstrated
to be manifestedthat
in his teachings
molar correctioninwithhis career thereafter.
inter-maxillary He showed
elastics could that elastics were
be achieved tiedmonths
in three in, and[1,2].
demonstrated that
molarThecorrection
most commonwith inter-maxillary
type of elasticelastics
currentlycould
used beisachieved
the latexintype,
threewhich
months [1,2].
is manufactured in the
same manner as the India rubber band. A rubber tubing is prepared by a dipping process on ainsteel
The most common type of elastic currently used is the latex type, which is manufactured the
same manner
mandrel as thethickness:
of varying India rubber the band. A rubber
more dips, tubingthe
the thicker is prepared
tube. Theby a dipping
elastic is thenprocess on a steel
sliced from that
mandrel
tubing inof varying
varying thickness:
widths. the more dips,
Manufacturers referthe
to thicker
“light” the tube. Theelastics,
or “heavy” elastic is then sliced
depending onfrom that
the wall
tubing in varying
thickness widths.
of the tubing. FourManufacturers
factors play arefer parttoin“light”
the tubingor “heavy”
quality elastics, depending on
and characteristics: Thethe wall
size of
thickness
the lumen of of the tubing,
tubing. the Four factors of
thickness play
theawall,
partthein the
widthtubing
of thequality
cut, andandthecharacteristics:
properties of the The size
elastic
of the lumen of the tubing, the thickness of the wall, the width of the cut, and the properties of the
material.
elastic material.
Different factors influence the effects of an elastic on a tooth: such as, the site of application, the
Differentthrough
distribution factors influence
the periodontal the effects of an elastic
ligament, on a tooth:
the direction, suchdiameter,
length, as, the siteandof application,
contour of the
root, the alveolar process, the tooth rotation and health, age, and above all the co-operation
distribution through the periodontal ligament, the direction, length, diameter, and contour of theofroot,
the
the alveolar
patient. process,
The force the tooth
produced by rotation andon
the elastics health,
a tooth age, and above
or teeth all the
does not co-operation
depend only on itsofmagnitude.
the patient.
Different
The force sizes and
produced by the force levelson
elastics are available
a tooth on the
or teeth doesmarket, but thisonly
not depend obliges
on itsorthodontists
magnitude. to buy
a lot Different sizesfor
of material; andexample,
force levels are available
Ormco (Sybronon the market,
Dental but this
Specialties, obliges orthodontists
Glendora, CA, USA) offers to buy36a
different types for
lot of material; of elastic
example, packs,
Ormco American
(SybronOrthodontics
Dental Specialties, (Sheboyagan,
Glendora,WI, CA,USA)
USA)offers
offers3136 different
different
types of
types, 3Melastic
Unitek packs, American
(Monrovia, CA, Orthodontics
USA) offers 30(Sheboyagan,
different types, WI, USA)
while offersMountain
Rocky 31 different types, 3M
Orthodontics
(Denver, CO, USA)CA,
Unitek (Monrovia, offersUSA)27 different
offers 30types.
different types, while Rocky Mountain Orthodontics (Denver,
The aim
CO, USA) of this
offers study istypes.
27 different to give to the profession a simple scientific approach toward selecting
the proper
The aim elastics
of thisfor
studytheiscorrection
to give to of themalocclusions,
profession a simple and to reduce approach
scientific the inventorytoward of selecting
orthodonticthe
offices. elastics for the correction of malocclusions, and to reduce the inventory of orthodontic offices.
proper

2. Materials
2. Materials and
and Methods
Methods
The large
The largevariety
varietyofofmerceology
merceology creates confusion,
creates as itasis itdifficult
confusion, to select
is difficult the most
to select the efficient elastic
most efficient
in different clinical situations.
elastic in different clinical situations.
We first
We recommend the
first recommend the adoption
adoption ofof one
one size
size of
of wall
wall thickness,
thickness, whichwhich isis small
small enough
enough to to fit
fit under
under
the wing
the wing ofof aa bracket, and so
bracket, and so for
for this
this study
study wewe chose
chose the
the 55 ozoz elastics,
elastics, and
and decided
decided toto vary
vary only
only the
the
length of the elastics in the selection (Figure
length of the elastics in the selection (Figure 1). 1).

Figure 1.
Figure 3/16”, 1/4”,
1. 3/16”, 1/4”, and
and 5/16”
5/16” 5-oz elastics Energy Pak™ from Rocky Mountain Orthodontics.

Four aspects
Four aspects must
must be
be evaluated
evaluated in
in order
order to
to choose
choose the right elastics
the right elastics for
for the
the orthodontic
orthodontic needs
needs of
of
the patients, and they are:
the patients, and they are:
(1)
1) Distances
Distances
2) Root mass
In order to calculations
have an average of distances in common malocclusions, we studied a sample of N50
3) Vector analysis
class II models (40 cases T1–T2, of which 20 were in full class II, 20 were in neutro-occlusion, and 10
4) Decay
were rate cases, all in neutro-occlusion). The distances were taken from the distal third of the
extraction
lowerInfirst
1) andtosecond
order have anmolars,
averageto of
thedistances
mesial third of the upper
in common canines, aswe
malocclusions, thestudied
points of application
a sample of
of N50
elastics in a Class II correction. This part is an in vitro study on cast models.
class II models (40 cases T1–T2, of which 20 were in full class II, 20 were in neutro-occlusion, and
10 were
(2) Root massextraction
calculationscases, all in neutro-occlusion). The distances were taken from the distal third
of the lower first and second molars, to the mesial third of the upper canines, as the points of
The amountof
application ofelastics
force needed for teeth
in a Class movements
II correction. Thiscan
partbeisobtained bystudy
an in vitro calculating
on castfrom the rating
models.
scale for roots (Figure 2). It considers in square millimeters the root surface exposed
2) The amount of force needed for teeth movements can be obtained by calculating from the rating to the bone, in a
directscale
linefor
of roots
movements. The
(Figure 2). It experiments [3–11] millimeters
considers in square led to the conclusion that one
the root surface gramto
exposed perthesquare
bone,
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J. Funct. Morphol. Kinesiol. 2019, 4, 63 3 of 12

in a direct line of movements. The experiments [3–11] led to the conclusion that one gram per
square millimeter of root surface is a basic reference for tooth movement. According to these
studies,
millimeter the surface
of root force toiscorrect
a basicthe class IIfor
reference malocclusion moving
tooth movement. distally for
According the upper
to these firstthe
studies, molar
forceis
120 g.
to correct the class II malocclusion moving distally for the upper first molar is 120 g.

Figure2.2.Mean
Figure Meanvalues
valuesofofroot
rootsurface
surfacepresentation
presentationon
onthree
threedimensions
dimensionsofofspace
spacefor
forpermanent
permanentteeth:
teeth:
Sagittal, transverse, and vertical. Rotation values are equals to sagittal data.
Sagittal, transverse, and vertical. Rotation values are equals to sagittal data.

(3) Vector analysis

3) An elastic in the right position determines an angle that can be considered with a vector analysis
Anof elastic
the force.
in theWhen
rightvector
positiondiagrams are an
determines used,
anglethethat
horizontal and vertical
can be considered components
with can be
a vector analysis
of the calculated.
force. WhenThe calculation
vector diagramsisare made bythe
used, taking the forces
horizontal used and
and vertical estimatingcan
components thebeangle of the
calculated.
elastic as itis crosses
The calculation made by thetaking
occlusal
the plane
forcesand
usedthen
andmultiplying
estimating the it by the cosine
angle of the as
of the elastic angle for the
it crosses
horizontal,
the occlusal planeand andthen
thenthe sine of theitangle
multiplying by theforcosine
the vertical pull. As
of the angle foryou
the can see in Figure
horizontal, 2, inthe
and then the
sine ofinitial condition,
the angle for the the distance
vertical pull. of
Astheyoupoint of in
can see theFigure
application
2, in theofinitial
the elastic is longer,
condition, whilst the
the distance of
vertical
the point component
of the application is shorter, and the
of the elastic horizontal
is longer, whilstcomponent
the verticalis greater.
component is shorter, and the
It is for this
horizontal reason that
component the elastic is hooked as far distally as possible on the molar, and as far as
is greater.
Itpossible
is for thismesially on the
reason that the canine.
elastic isDuring
hookedthe correction,
as far distally asorpossible
in an extraction case,and
on the molar, theasvertical
far as
possiblecomponent
mesially on will increase
the canine.and the horizontal
During component
the correction, or in an will decrease.
extraction case, the vertical component
will increase and the horizontal component will decrease.
J. Funct. Morphol. Kinesiol.
Kinesiol. 2019,
2019, 4,
4, x63FOR PEER REVIEW 4 of 13
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Different patterns of rest position were studied by Ricketts [12], and the average was 3°, which is
Different patterns
important in orderof to
rest positionthe
evaluate were studied by
reciprocal Ricketts
position of [12],
bothand
thethe averageand
maxillary 3◦ , which is
was mandibular
important
arches.inIn
order to evaluate
addition, the reciprocal
we considered position
the angle of both
between theelastics
the maxillary
and and
the mandibular
lower arch wirearches.
at
In addition, we considered the angle
different distances (Figure 3). between the elastics and the lower arch wire at different distances
(Figure 3).

Figure 3. Degrees of mouth opening at rest position.

Figure 3. Degrees of mouth opening at rest position.
(4) Decay rate
4) The decay rate of orthodontic elastics was measured by us in vivo, in three different patients:
The decay rate of orthodontic elastics was measured by us in vivo, in three different patients: each
each wearing two 3/16”, 1/4”, and 5/16” 5-oz elastics (Energy Pak™ from Rocky Mountain
wearing two 3/16”, 1/4”, and 5/16” 5-oz elastics (Energy Pak™ from Rocky Mountain Orthodontics,
Orthodontics, Denver, USA) for a week. Every 24 h, we measured with a dynamometer the force
Denver, USA) for a week. Every 24 h, we measured with a dynamometer the force developed from the
developed from the elastics at different lengths (for the distances that we have studied on casts,
elastics at different lengths (for the distances that we have studied on casts, see Section 3).
see Section 3.1).
One factor which does seem to be common is the sizing, which has been graduated in 1/16 inch
One factor
increments. Thus,which does seem
a graduation to besuch
exists, common
as: 1/8isorthe sizing,
2/16, 3/16,which
1/4 or has
4/16,been
5/16,graduated
3/8 or 6/16,in1/21/16
or inch
8/16;
increments.
which are theThus,
usuala sizes.
graduation exists, such the
For simplification as: elastics
1/8 or 2/16,
were3/16, 1/4 #2,
labeled or 4/16,
#3, #4,5/16,
#5, #63/8etc.,
or 6/16, 1/2 or
referring to
8/16; which are the usual
each sixteenth of an inch. sizes. For simplification the elastics were labeled #2, #3, #4, #5, #6 etc.,
referring to each sixteenth
We considered of an
the outer inch. of each of the elastics: The #3 elastic is 6 mm, the #4 elastic is
diameter
8 mm, We considered
and the outer
the 5# elastic diameter of each of the elastics: The #3 elastic is 6 mm, the #4 elastic is
is 10 mm.
8 mm, and
For thereasons,
these 5# elastic
weissuggest
10 mm.pulling the 5-oz elastics to four times the size of their outer diameter,
For to
in order these
havereasons,
a greaterwerange
suggest pullingwith
of lengths, the a5-oz elastics
constant to at
force four
thetimes
same the size of
distance fortheir outer
one week,
diameter, in order to have a greater range of lengths, with a constant
and with the proper distalization force, considering the following formula: force at the same distance for
one week, and with the proper distalization force, considering the following formula:
Fd = Fel − d − Fes
Fd = Fel − d − Fes
Fd== distalization force
Fd

Fel== force
Fel force of a new elastic
dd==25%
25% decay
decay (Fel
(Fel ×
× 0.25)
0.25)
Fdec== decayed
Fdec decayed force
force (Fel −
− d)
d)
Fes==extrusive
Fes extrusiveforce
force (Fdec
(Fdec ×
× sin of angle
angle between
between arch
archwires)
wires)
In
In the
the correction
correction of Class II
of Class malocclusion, from
II malocclusion, from aa clinical
clinical point
point of
of view,
view, the only variable
the only variable that
that
changes in the selection of the elastic is the distance from the molar to the canine. For this reason,
changes in the selection of the elastic is the distance from the molar to the canine. For this reason, it is it
is useful and desirable to have a tool that quickly suggests the correct elastic to use, based on
useful and desirable to have a tool that quickly suggests the correct elastic to use, based on the distance the
distance
from the from
molarthe
to molar to the canine.
the canine.

3. Results
Results
We focused our work on analyzing three aspects: The distance, the vector analysis, and the decay
We focused decay
of the elastic. We obtained the following
following results
results in
in the
the aspects
aspects investigated
investigatedin
inMaterials
Materialsand
andMethods:
Methods:
1) Distance
J. Funct. Morphol. Kinesiol. 2019, 4, 63 5 of 12

(1)J.Distance:
Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 5 of 13

J. Funct. Morphol. Kinesiol.

We calculated the2019, 4, x FORpresent
distances PEER REVIEW
from the lower molars to the canines in our sample, 5and
of 13we
We calculated the distances present from the lower molars to the canines in our sample, and we
simulated all of the conditions in class II at the beginning of the correction, during the correction,
simulated all of the the
We calculated conditions
distances in class II at the the
beginning of the correction, during thesample,
correction, and
and after the correction, even in thepresent from
cases where lower molars
(for orthodonticto the canines
needs) in our
four premolars wereand we
extracted
after the correction, even in the cases where (for orthodontic needs) four premolars were
simulated all of the conditions in class II at the beginning of the correction, during the correction, and extracted
(extraction cases).
(extraction cases).Identifying
Identifying the correct
thecases
correct distance
distance is the starting
is the startingpoint
pointfor
foraacorrect
correctchoice
choice of elastics.
after the correction, even in the where (for orthodontic needs) four premolars wereofextracted
elastics.
For better
For betterunderstanding,
understanding, we represent
wecorrect
represent the different
the different kinds of
kinds pointthe
of theforpossible
possible clinical
clinical conditions
conditions in in
(extraction cases). Identifying the distance is the starting a correct choice of elastics.
Figures
Figures4–8. These
4–8. Thesearearethe
theaverages
averages we we found
found in in our
ourin invitro
vitrostudy:
study:
For better understanding, we represent the different kinds of the possible clinical conditions in
Figures
45 45
mm mmfrom4–8.the
from These
lower
the aresecond
lower the averages
second molarwe
molar in found
infull in our
fullClass
Class II in vitro 4)
II (Figure study:
4)
40
40 45
mm mm
mm from
from
from thethe lower
thelower second
lowersecond molar
secondmolar
molarin in mild
inmild Class II (Figure4)4)
(Figure
ClassIIII(Figure
full Class 4)
35
35 40
mm mm
mm from
from
from thethe
the lowersecond
lower
lower secondmolar
second molarafter
molar after
in correction
mild (Figure 4)
Class II (Figure
correction (Figure 5)
5)
35 mm
mm from
from the
the lower
lower second
first molar in full Class II (Figure 6) 5)
35 35
mm from the lower first molarmolar after
in full correction
Class II (Figure (Figure
6)
30
35 mm
mm from
from the
the lower
lower first
first molar
molar in
in mild
full Class
Class II II (Figure
(Figure 6)6)
30 mm from the lower first molar in mild Class II (Figure 6)
25 mm from the lower first molar after correction
30 mm from the lower first molar in mild Class II (Figure 6) (Figure 7)
25 20
mm mmfrom
fromthe lower
the lowerfirst
firstmolar
molarafter correction
in extractive (Figure
cases 7)
(Figure
25 mm from the lower first molar after correction (Figure 7) 8)
20 mm from the lower first molar in extractive cases (Figure 8)
20 mm from the lower first molar in extractive cases (Figure 8)

Figure 4. Distance from the lower second molar in Class II.

Figure 4. Distance from the lower second molar in Class II.
Figure 4. Distance from the lower second molar in Class II.

Figure 5. Distance from the lower second molar after correction.

 J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 6 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 6 of 13
Figure 5. Distance from the lower second molar after correction.
Figure
J. Funct. Morphol. Kinesiol. 2019, 4, 635. Distance from the lower second molar after correction. 6 of 12

Figure 6. Distance from the lower first molar in Class II.

Figure 6. Distance from the lower first molar in Class II.
Figure 6. Distance from the lower first molar in Class II.

J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 7 of 13

Figure 7. Distance from the lower first molar after correction.
Figure 7. Distance from the lower first molar after correction.
Figure 7. Distance from the lower first molar after correction.

Figure 8. Distance from the lower first molar in the extractive case.

Figure 8. Distance from the lower first molar in the extractive case.

2) Vector analysis:
Consequently, we calculated in our models the angles formed by the lower arch wire, and the
J. Funct. Morphol. Kinesiol. 2019, 4, 63 7 of 12

Figure 8. Distance from the lower first molar in the extractive case.
(2) Vector analysis:
2) Vector analysis:
Consequently, we calculated in our models the angles formed by the lower arch wire, and the
Consequently, we calculated in our models the angles formed by the lower arch wire, and the
elastic applied from the molar to the canine, in order to obtain the vertical component (extrusive),
elastic applied from the molar to the canine, in order to obtain the vertical component (extrusive),
and the horizontal one (distalizing). We found the following results:
and the horizontal one (distalizing). We found the following results:
for a distance between 40–45 mm, the angle is 14◦ (second molar) (Figure 4)
for a distance between 40–45 mm, the angle is 14° (second molar) (Figure 4)
for a distance between
for a distance 30–35 30–35
between mm, the
mm,angle is 20◦is(first
the angle molar)
20° (first (Figure
molar) 6) 6)
(Figure
for a distance between 20–25 mm, the angle is 25◦ (extractive cases) (Figure 8)
for a distance between 20–25 mm, the angle is 25° (extractive cases) (Figure 8)
(3)3)
Decay:
Decay:
WeWefound
foundthat the
that thedecay
decayrate
ratein
inone
oneweek
week is about 25%,so
about 25%, sothe
thelatex
latexelastics
elasticscancan
bebe employed
employed forfor
one whole week maintaining 75% of their pull, which will produce a constant force for
one whole week maintaining 75% of their pull, which will produce a constant force for a long period, a long period,
as as
advocated
advocated bybymany
manyauthors
authors[4,7,10].
[4,7,10]. For
For this
this reason,
reason, itit is
isadvisable
advisabletotoask
asktotothe
thepatients
patientsto to change
change
their
their elastics
elastics everyweek
every week(Figures
(Figures99and
and10).
10).

J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 8 of 13

Figure9.9.Force
Figure Force delivered
delivered by an
an elastic
elastic#4
#4during
duringaaweek.
week.

Figure 10. Force delivered by an elastic #4 during a week.

Figure 10. Force delivered by an elastic #4 during a week.

The following formulas contain our results for every elastic that we considered:
#3 Fd = Fel − d − Fes
Fd = 235 − (235 × 0.25) − (176.25 × 0.42)
J. Funct. Morphol. Kinesiol. 2019, 4, 63 8 of 12

The following formulas contain our results for every elastic that we considered:

#3 Fd = Fel − d − Fes

Fd = 235 − (235 × 0.25) − (176.25 × 0.42)

Fd = 235 - 58.75 - 74.025 = 102.225 gr

Fd = distalization force

Fel = force of a new elastic

d = 25% decay (Fel × 0.25)

Fdec = decayed force (Fel − d)

Fes = extrusive force (Fdec × sin of angle between arch wires 25◦ ) = 24 gr

#4 Fd = Fel − d − Fes

Fd = 235 − (235 × 0.25) − (176.25 × 0.34)

Fd = 235 − 58.75 − 59.92 = 116.33 gr

Fd = distalization force

Fel = force of a new elastic

d = 25% decay (Fel × 0.25)

Fdec = decayed force (Fel − d)

Fes = extrusive force (Fdec × sin of angle between arch wires 20◦ ) = 32 gr

#5 Fd = Fel − d − Fes

Fd = 235 − (235 × 0.25) − (176.25 × 0.29)

Fd = 235 − 58.75 − 51.125 = 125.125

Fd = distalization force

Fel = force of a new elastic

d = 25% decay (Fel × 0.25)

Fdec = decayed force (Fel − d)

Fes = extrusive force (Fdec × sin of angle between arch wires 17◦ ) = 40 gr

Studying the parallelogram of force, you can see that the vertical pull over the treatment period
will average to about one-third of the oblique pull, while two-thirds of it is horizontal; so, the longer
the distance between the ends, where the elastic is attached, the more horizontal the pull becomes.
For this reason, it is desirable to apply the elastic from the lower second molar, when it is present,
to the upper canine. Thus, you may reduce the vertical component, which results in the extrusion of
the upper arch (as an undesirable side effect).
Furthermore, it is also advisable to use the hook extensions incisally on the upper arch, in order to
make the pull more horizontal. It is also important to underline that when you stretch the elastics
to four times their lumen, the force is the same for the three different types of the elastics that we
have used.
J. Funct. Morphol. Kinesiol. 2019, 4, 63 9 of 12

4. Discussion
Different kinds of malocclusions can be corrected with different approaches and appliances, but in
some cases, it is necessary to extract healthy teeth in order to reduce the convexity, and this is extractive
therapy [7,8]. In young patients with a dolichofacial pattern, cervical headgear is the best approach
to correct the class II malocclusion by orthopedic maxillary alteration, with a superb control of the
vertical dimension [13]. In very difficult cases, in which the skeletal discrepancy is too much, or in
protocol surgery first [14], the condition could be solved with orthognatic surgery which allows us to
treat severe conditions [15–17]; but surgery exposes the patients to risks [18–20]. Sometimes surgical
correction is the only option, but certain orthodontic approaches can reduce the need of maxillo-facial
surgery [21,22], and the use of drugs [18,23–25] and their side effects [26,27]—considering that the final
objective of an orthodontic therapy is the stability of occlusion, and consequently the equilibrium of
the kinetic chain of the body [28,29].
Class II correction is one of the most common conditions, especially in the Caucasian race [30,31].
Different strategies of therapy were carried out, but inter-maxillary traction made by elastics is
nowadays the simplest strategy, and one of the most efficient, if correctly used [32]. Elastics can be also
used for different reasons: To reinforce anchorage in a case where an extraction has been done, to allow
the maxillary incisors to move backwards, to correct midline deviation, and to move the lower denture
forward. The side effects of Class II elastics should be considered before using them [32].
The common side effects, from the improper use of elastics are: The steepening of the occlusal
plane, the extrusion of the lower first molar, the flaring of the lower incisors, and the extrusion of the
upper incisors. The first three effects could be avoided by the use of skeletal anchorage, or cortical
anchorage. Skeletal anchorage is achieved by using temporary anchorage devices (TADs), which are
small screw-like dental implants made of a titanium alloy. As the name implies, they are temporary,
as they usually only remain in place during some months of the treatment, and then they are removed.
They are placed through the cortical bone in order to become an application point for the elastic
traction [33]. Cortical anchorage is a biological method to obtain a valid application site of elastics
during Class II correction. When the roots engage the cortical plates, the action will become static and
a tooth root becomes a point of resistance, and hence it becomes an anchor for an undetermined period
of time. The most efficient tool in order to obtain cortical anchorage is the utility arch. Compact bone
not only offers resistance to the tooth movement, but, conversely, it can be used for anchorage, and is
recognized and employed to this advantage. This is accomplished by the teeth situated behind the
compact elements of bone, so that the pressure of the root is almost in direct contact with the bone,
and incapable of easy backward resorption [30].
The extrusion of the upper incisors, with the consequent decreasing of their torque, and the
deepening of the bite, produces a gummy smile. This could be avoided by using sectional mechanics,
that consist in the cutting of the upper archwire at the level of the canine; thereby excluding the upper
incisors from the traction made by the elastics. The two sections obtained could be used to transfer the
force applied on the canine directly to the upper molars. Furthermore, the sections could be activated
with an intrusion bend that produces 50 g of force, that will prevent the extrusion of the canine as
given by the vertical component of the elastic pull.
As we have seen, in order to correct the class II malocclusion, we need 120 g of force to move the
upper molar distally. Hence, we chose 5 oz elastics and we stretched the #3, #4, #5, #6 elastics to four
times the outer diameter (about five times if we consider the inner diameter), and this produced the
same force, which was about 235 g, with the different lengths of elastics. This amount of force must not
scare, as by subtracting the correction factors (vector and decay) that we consider in our formula, we
have obtained the effective distalization force that we wanted.
Studies of orthodontic elastics have typically used the manufacturer’s recommendations for
extending the elastics to three times their lumen, when examining force extension characteristics [34–38].
Some studies used extensions of 20–50 mm, proposing that it was the normal range for clinical
J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 10 of 13

Studies of orthodontic elastics have typically used the manufacturer’s recommendations for
extending the elastics
J. Funct. Morphol. to three
Kinesiol. 2019, 4, 63 times their lumen, when examining force extension characteristics 10 [34–
of 12
49]. Some studies used extensions of 20–50 mm, proposing that it was the normal range for clinical
use [50–56]. In our study, extension distances were obtained from casts of our clinical cases, and we
use
showed[39–41].
that In
theour study,
range extension
is 20–45 mm. distances were obtained from casts of our clinical cases, and we
showed that the range is 20–45 mm.
In theory, by evaluating the parallelogram of forces, we find an elastic yield of 75% of force
In theory,
horizontally, andbyabout
evaluating
25% ofthe theparallelogram of forces,
force to be effective in thewe find an
vertical elastic
(with a 20°yield of of
angle 75%pullofacross
force
horizontally, and about 25% of the force to be effective in the vertical (with a 20 ◦ angle of pull across
the occlusal plane).
the occlusal
In termsplane).
of the decay rate, in our measurement (Figure 9) there is a decay of 25% after one day,
In terms
and then of the
the force decay rate,
remains almost in constant
our measurement
for one week,(Figure
and 9)so there is a decay
the patient couldofuse25% theafter
sameone day,
elastic
and then the force remains almost constant for one week, and so the patient could
during this period. In this way, a constant force, as advocated by Burstone, is more effective on tooth use the same elastic
during
movements this period.
[4]. In this way, a constant force, as advocated by Burstone, is more effective on tooth
movements [4].
By integrating all of the data at our disposal, and by applying the formula used to calculate the
forceBy integrating
really availableallfor of distalization,
the data at our wedisposal,
created theandelastic
by applying
selectorthe formula
gauge used
(Figure to acalculate
11); the
device that
force
allowsreally availabletofor
practitioners distalization,
easily detect thewe created
elastic to bethe elastic
used selector
to treat eachgauge
kind of(Figure 11); a device
malocclusion. that
It is used
allows practitioners to easily detect the elastic to be used to treat each kind of malocclusion.
by positioning the left end of the instrument at the distal point of the application of the elastic, and It is used
by
thenpositioning
by detectingthe left
the end of theofinstrument
number the elasticatrequired
the distalwhen
pointthe
of the application
mesial point ofofthethe application
elastic, and then
falls
by detecting
between thethe number
notches ofofthe
the instrument.
elastic requiredJustwhen
threetheelastics
mesial point of the
(#3, #4, #5)application
can correct falls between
almost all
the notches
malocclusions. of the instrument. Just three elastics (#3, #4, #5) can correct almost all malocclusions.

Figure 11. Our “elastic selector gauge”.

5. Conclusions
5. Conclusions
Our classification,
Our classification, in
in association
association with
with the elastic selector
the elastic selector gauge,
gauge, will
will allow
allow clinicians to make
clinicians to make the
the
most
most effective
effectivechoice
choiceof of
elastics for class
elastics corrections
for class in every
corrections in condition; without without
every condition; having a having
big inventory,
a big
effort, and waste of time.
inventory, effort, and waste of time.

6. Patents
6. Patents
The results of this work encouraged us to apply for the patent for industrial invention for
The results of this work encouraged us to apply for the patent for industrial invention for our
our device, regularly registered at Italian patent and trademark office on 17/06/2019 with number
device, regularly registered at Italian patent and trademark office on 17/06/2019 with number
102019000009261 entitled: “Elastic selector gauge as orthodontic device: ESGO”.
102019000009261 entitled: “Elastic selector gauge as orthodontic device: ESGO”.
Author Contributions: Conceptualization, S.S. and L.B.; methodology, G.C. and L.F.; validation, G.C., M.C.;
Authoranalysis,
formal Contributions: Conceptualization,
S.S.; investigation, S.S.
S.S.; data and L.B.;
curation, methodology,
L.B.; G.C. and
writing—original L.F.;
draft validation,S.B.
preparation, G.C.,
andM.C.;
L.F.;
formal analysis, S.S.;
writing—review investigation,
and editing, S.S.;visualization,
G.C., S.B.; data curation,M.C.;
L.B.;supervision,
writing—original
M.C. draft preparation, S.B. and L.F.;
writing—review
Funding: and editing,
This research G.C.,
received noS.B.; visualization,
external funding. M.C.; supervision, M.C.
Funding: of
Conflicts This research
Interest: received
The authorsno external
declare no funding.
conflict of interest.
Conflicts of Interest: The authors declare no conflict of interest.
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