ORIGINAL ARTICLE

Perceived vs measured forces of interarch elastics

Larry J. Oesterle,a Justin M. Owens,b Sheldon M. Newman,c and William Craig Shellhartd Aurora, Colo

Introduction: Orthodontists depend on perceptions derived from education and clinical experience to judge the optimal forces in patient treatment. The purpose of this study was to survey practicing orthodontists to determine the interarch latex elastic forces they prescribe in different malocclusion scenarios. Methods: Thirty orthodontists were presented with 4 clinical scenarios on study models, including Class II and Class III malocclusions in edgewise and light wires. These orthodontists described the size and location of the elastics they would use. The forces produced by the prescribed elastics were measured and compared with actual dry forces measured on a testing machine. Results: The orthodontists force recommendations were a mean of 277 6 89 g and a median of 256 g (range, 132-464 g) for a Class II malocclusion with edgewise wires; a mean of 183 6 59 g and a median of 177 g (range, 59-284 g) for a Class II malocclusion with light wires; a mean of 290 6 83 g and a median of 305 g (range, 151-562 g) for a Class III malocclusion with edgewise wires; and a mean of 216 6 66 g and a median of 209 g (range, 119-344 g) for a Class III malocclusion with light wires. The force levels for light wires were statistically signicantly lower than for edgewise wires. Conclusions: There were considerable variations in the forces selected for all cases. Expert recommendations fell within 1 SD of the mean of the orthodontists recommendations except for the light-wire Class III scenario. Since latex elastic force decays signicantly during a patients use, elastics should be selected with initially higher forces than desired. (Am J Orthod Dentofacial Orthop 2012;141:298-306)

orce levels in orthodontics are critically important, and orthodontists historically are conscientious in applying only the amount of force needed for healthy tooth movement, whether for archwire engagement in brackets, headgear force, or application of interarch elastics. Force levels, however, might be more in the area of art than of the science of orthodontics, with the art having a strong historical background. In 1910, Angle1 wrote of the importance of light forces, stating that when so used it should be very delicate, as described, so that only such gentle forces will be given to the roots of the teeth as to physiologically stimulate the bone-cells. Great force and rapid movement of the apices of the roots of the teeth the writer believes to be
From the School of Dental Medicine, University of Colorado, Aurora. a Professor, chair, and program director, Department of Orthodontics. b Resident, Department of Orthodontics. c Associate professor, Departments of Restorative Dentistry and Orthodontics. d Associate professor and assistant program director, Department of Orthodontics. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Supported by the University of Colorado School of Dental Medicine, Department of Orthodontics. Reprint requests to: Larry J. Oesterle, Department of Orthodontics, University of Colorado School of Dental Medicine, Mail Stop F849, 13065 E 17th Ave, Aurora, CO 80045; e-mail, larry.oesterle@ucdenver.edu. Submitted, June 2010; revised and accepted, August 2011. 0889-5406/$36.00 Copyright 2012 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2011.08.027

unphysiological. Reitan2,3 later found that, with excessive forces, bone and periodontal ligament are compressed and undergo necrosis from ischemia created by blocked blood vessels. The osteoclasts and osteoblasts must then be recruited from healthy adjacent bone before the bone around the tooth can be remodeled. Owman-Moll et al4 later conrmed the efcacy of light forces, nding that the undermining resorption method of tooth movement (heavy force) does not increase the rate at which a tooth will be moved. Although it appears logical that a tooth will move faster if more force is applied, the reality is that the rate of tooth movement is equivalent when comparing undermining resorption tooth movement and physiologic tooth movement. Proft et al5 agreed, stating that heavy continuous orthodontic force can lead to severe root resorption. Other studies6,7 concur that excess forces, including those from interarch elastics,8,9 can damage the periodontal ligament, increasing the risk of root resorption. Excess force can also lead to increased pain. Proft et al suggested that when areas of periodontal ligament necrosis are avoided. . . pain is also lessened. It is clear from these ndings that the use of optimal force levels is important. The question then becomes what is the optimal force to accomplish orthodontic treatment goals, yet not be too heavy to cause pain and root resorption? Specic descriptions of optimal force magnitudes for interarch

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latex elastics are difcult to nd in the literature and are found primarily in textbooks. Nanda10 stated that an accurate measure of the optimal force eludes determination. Mulligan11 acknowledged the difculty in dening optimal force values when he stated that an acceptable range of response . . . can vary greatly with each individual. Graber and Vanarsdall12 made a similar statement regarding optimal force magnitudes but provided no specic, measurable forces. Although the literature gives little evidence for optimal force magnitudes, several orthodontists regarded as experts have made recommendations for optimal forces when using latex interarch elastics. Proft et al5 listed 2 forces for ideal elastics forces, depending on the size of wire. When using large rectangular wires, he recommended approximately 250 g per side for interarch corrections in his latest textbook edition; this is a reduction from the 300 g in the earlier edition. When using a lighter round wire, Proft et al recommended only half of the force used for the rectangular wires, or 125 g. Langlade14 used estimates of root surfaces in conjunction with the suggestion of Ricketts et al15 of 150 g per square centimeter of resorptive root surface for tooth movement to calculate the force needed to move the maxillary and mandibular dentitions en masse. Based on Langlades calculations, an estimated force of 318 g per side would be required. The Alexander16 discipline provides no force value but advocates the use of .25- in, 6-oz (0.64 cm, 170 g) elastics attached from the maxillary lateral incisor to the mandibular second molar in Class II corrections, and .25-in, 3.5-oz (0.64 cm, 99 g) elastics attached from the maxillary rst molar to the mandibular canine. The recommendations for interarch latex elastics forces are based solely on expert opinions. No studies have compared the experts opinions to the actual forces used by practicing orthodontists. The purpose of this study was to survey practicing orthodontists to determine the interarch latex elastic forces they prescribe in various malocclusion scenarios.
MATERIAL AND METHODS

Thirty experienced practicing orthodontists participated in this study, which included all full-time and part-time faculty (n 5 15) at the University of Colorado School of Dental Medicine, Department of Orthodontics, and 15 additional orthodontists practicing in the Denver metropolitan area. The University of Colorado did not have an orthodontic training program until 2004, so the participating orthodontists reect great diversity of training programs and geographic origins, including East Coast, West Coast, and Midwest. Of the 30

orthodontists, 3 did not follow the study protocol and were excluded. The remaining 27 orthodontists were considered representative of the orthodontic community. A questionnaire and 2 sets of study models were presented to each orthodontist or clinician along with samples of all latex elastics in the study to allow them to feel the amount of force exerted. The orthodontists were allowed to apply the elastics to the models to determine the force. They were given instructions and asked to complete a questionnaire that allowed them to mark the size and location of the latex elastics that they would use to correct the malocclusion in each of the 4 cases. To prevent the confounding variable of intraoral force decay, the participants were told that the patient would wear the elastics for 20 hours per day and change them 3 times per day with the goal of obtaining a Class I molar and canine relationship. The 4 cases differed by the type of malocclusion and the archwire size. Case 1 described a patient in the nishing stages with an edgewise stainless steel archwire (0.018 3 0.025 in [0.45 3 0.63 mm]) and a half-step Class II malocclusion of both the molars and the canines. Case 2 was also a half-step Class II malocclusion but in an earlier stage of treatment with a lighter wire: a round stainless steel archwire (0.018 in [0.45 mm]). Both cases 3 and 4 were described as half-step Class III malocclusions, with an edgewise stainless steel archwire (0.018 3 0.025 in or 0.45 3 0.63 mm) in case 3 and a smaller round stainless steel archwire (0.018 in or 0.45 mm) in case 4. The models had brackets attached to all teeth with cyanoacrylate (Super Glue; Pacer Technology; Rancho Cucamonga, Calif), and an archwire was in place. All brackets had hooks on the distal aspect of the bracket except for the molar tubes, which had distally curved hooks on the mesial aspect of the tube. Each selected bracket had a hook to allow the orthodontists to place the elastic in the desired position; the brackets were presented to the orthodontists as a generic appliance with only the above denitions and no technique or philosophy connection. The hooks allowed the orthodontists to attach latex elastics to any tooth on the model except for the central incisors. The models were trimmed to American Board of Orthodontics specications and stabilized in the described occlusion for each case by using hot glue on the lingual or palatal surface. A reference box of latex elastics was included that contained a range of elastics (Rocky Mountain Orthodontics, Denver, Colo). The sizes were (1) 3/8 in (9.5 mm): 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g); (2) 5/16 in (7.9 mm): 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g); (3) 1/4 in (6.4 mm): 2 oz (57 g), 3 oz

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(85 g), 3.5 oz (99 g), 4.5 oz (128 g), 5 oz (142 g), and 6 oz (170 g); and (4) 3/16 in (4.8 mm): 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g). Each group of latex elastics was clearly labeled by size and force for easy identication. The orthodontists placed the elastics on the models and marked on the questionnaire to which 2 teeth (1 anterior and 1 posterior) the elastics were attached. They were instructed to use the elastic placement and size that they routinely used in their ofce and asked not to write any additional comments or add additional sizes of elastics not listed on the questionnaire. To determine the actual elastic force produced, all 21 latex elastic sizes were tested dry, in vitro, by using a mechanical testing machine (Bionix II; MTS, Eden Prairie, Minn). Five elastics per size were stretched to 60 mm. The elastics were stretched to 60 mm starting from the initial point at which 0.005 N (0.5 g) of force registered on the testing machine. The grams of force exerted by the elastics were measured as they were stretched, producing a forceextension curve for each size of elastic tested. The sample size was determined by referencing a similar study.17 By using the equation n 5 (sdv12 1 sdv22) 3 7.84/(effect size)2 (sdv 5 standard deviation), the required sample size for each elastic tested was found to be 2. However, 5 elastics for each size were tested to increase the power of the study. The force extension curves were created from 911 recorded data points, and the data points for each of the 5 tested elastics of the same size and force were averaged at each data point. To relate the amount of elastic stretch to the actual force produced, the study models were mounted on an articulator in centric occlusion. The articulator was then opened 3 mm at the central incisors from centric occlusion to simulate the clinical rest position. The 3-mm clinical rest position was within the range of 2 to 4 mm found in previous studies.18-20 The distance from the anterior attachment to the posterior attachment point listed by the orthodontist was then measured directly from the mounted models. This distance was then used with the appropriate force-extension curve data to determine the amount of force delivered. The amount of force specied by each orthodontist in each clinical situation was determined, and the means and standard deviations for all orthodontists were calculated. For the expert forces, the values of Proft et al5 were taken directly from his textbook of 250 g per side when in large rectangular wire and 125 g per side when in light round wire. Alexander16 did not give force levels, but recommended a .25-in (6.4 mm), 6-oz (170 g) elastic stretched between the maxillary lateral incisor and the mandibular second molar for Class II corrections and a .25-in (6.4 mm), 3.5-oz (99.2 g) elastic between the mandibular

canine and the maxillary rst molar for Class III corrections. By using the distance stretched and the force extension curves, the force values on our test models were approximately 380 g (a 40-mm stretch) for a Class II correction and 300 g (a 30-mm stretch) for a Class III correction. Alexander did not have a lighter wire recommendation. Langlade14 used 318 g per side. Langlade did not differentiate between light and heavy wires but determined the force based on the resorptive root surface, which would be the same for light and heavy wires.
Statistical analysis

The medians, means, and standard deviations were calculated for all outcomes by using SigmaStats Software (Jandel Corp, Corte Madera, Calif). Analysis of variance (ANOVA) was used to determine whether there were differences between the orthodontists average force levels in the different case scenarios. The 1-way analyses were followed by a Student-Newman-Keuls a posteriori test. The alpha level was set at P #0.05. Comparisons within each treatment group were determined to be more representative if the standard deviations were used to determine the central tendency of all orthodontists. Since the literature recommendations are based on experts opinions, rather than actual data, the use of a statistical analysis was deemed inappropriate; hence, comparisons were made with the standard deviations.
RESULTS

A comparison of the orthodontists force values and recommended force levels is presented in the Table and Figures 1-4. The force-extension graphs for the 21 sizes of latex elastics are shown in Figures 5-8. For the testing machine results, as the extension increased, the force increased nonlinearly for all elastics; the force started out low with 5-mm extensions and then increased to an extension of 40 to 50 mm, when the slope (the force) began to increase dramatically for most elastics. There were great variations between the orthodontists selected forces. Whereas the mean and median forces for a Class II correction were 277 6 89 g and 256 g, the total range was large (132-464 g). The same large ranges were found for the Class II light-wire scenario (59-284 g), the Class III edgewise scenario (151562 g), and the light-wire Class III scenario (119-344 g). The orthodontists selected a statistically greater force for correction on heavier edgewise archwires than the lighter round archwire for both the Class II and Class III cases. Compared with the recommended force levels, the recommendation of Proft et al5 fell within the 1-SD range for all cases, except for the Class III correction on light archwires in which the orthodontists used

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Table. Forces selected by the orthodontists for the 4 cases with medians, means, standard deviations, ranges, 1-SD ranges, and experts recommended forces
Orthodontists selections Molar class II II III III Median (g) 256 177 305 209 Mean 6 SD (g) 277 6 89 183 6 59 290 6 83 216 6 66 1-SD Minimum/ range maximum (g) (g) 188-366 132/464 124-242 59/284 207-373 151/562 150-282 119/344 Statistical difference P #0.05 a b a b Proft5 (g) 250 125 250 125 Literature Alexander16 (g) 380 NA 300 NA Langlade14 (g) 318 318 318 318

Case 1 2 3 4

Wire size (in) 0.018 3 0.025 0.018 0.018 3 0.025 0.018

n 27 27 27 27

Statistical differences comparing mean force levels selected by orthodontists between the 4 cases with the same letter represent no statistical difference at the P #0.05 level. N/A, Not applicable.

Case #1
500 475 450 425 400 375 350 325 300 275 250 225 200 175 150 125 100 75 50 25 0

Force (grams)

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Clinician ID

Fig 1. Forces selected by the orthodontists for case 1Class II, 0.018 3 0.025-in stainless steel archwire. The solid line represents the mean of the orthodontists forces and the dashed lines the 1-SD limits.

a much heavier force (mean, 216 6 66 g; median, 177 g) than Proft et als recommendation (125 g). The recommended values of Langlade14 fell within the 1-SD range for edgewise wires but were high for the lighter wires; however, Langlade did not distinguish between edgewise and light wires. Alexander16 applied his forces to edgewise wires with no light-wire recommendation. His Class II correction forces is above the 1-SD range but by only 14 g, and his Class III correction forces fall within the 1-SD range of this studys orthodontists.
DISCUSSION

Orthodontists have successfully used elastics since the late 1800s; however, there are no evidence-based

studies that denitively provide optimum forces for Class II and Class III corrections.21 In a systematic review, Ren et al22 concluded that no evidence-based force level could be recommended for the optimal efciency in clinical orthodontics. One reason for the lack of optimal values are the great variations in patients. Variations exist in patient cooperation (amount of time worn), patient response to the forces, and the amount of mouth opening during elastic wear. We have witnessed these extraordinary variations in clinical care, with some patients responding well, and others going for months with no response while proclaiming great cooperation. Variations also exist in the recommendations of the orthodontists in this study. Although the mean and

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Case #2
300 275 250 225 200

Force (grams)

175 150 125 100 75 50 25 0

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Clinician ID

Fig 2. Forces selected by the orthodontists for case 2Class II, 0.018-in stainless steel archwire. The solid line represents the mean of orthodontists forces and the dashed lines the 1-SD limits.
Case #3
600 575 550 525 500 475 450 425 400 375 350 325 300 275 250 225 200 175 150 125 100 75 50 25 0

Force (grams)

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Clinician ID

Fig 3. Forces selected by the orthodontists for case 3Class III, 0.018 3 0.025-in stainless steel archwire. The solid line represents the mean of orthodontists forces and the dashed lines the 1-SD limits.

median forces for Class II correction on an edgewise wire were 277 and 256 g, the variation was great, with a 1-SD range from 188 to 366 g; however, the total range was 132 to 464 g. The same was true of the elastic forces for the other 3 cases. The orthodontists did agree that lighter wires were an indication for lighter forces, with the mean recommended values statistically lower for lighter wires. Even if there was an optimal force for interarch elastics, most orthodontists do not clinically measure the forces

they are delivering. In the study of Kurol et al,23 only 3 of the 19 clinicians they surveyed measured forces during the previous month, and 14 of the 19 had not checked forces within the last few years. Whereas that study involved archwire forces in an arch rather than elastic force, it does demonstrate that orthodontists use their clinical judgment in selecting forces that are based on their tactile senses, previous clinical successes, recommendations from their training, and recommendations from experts. The experts themselves vary in their recommendations, as

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Case #4
375 350 325 300 275 250

Force (grams)

225 200 175 150 125 100 75 50 25 0

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27

Clinician ID

Fig 4. Forces selected by the orthodontists for case 4Class III, 0.018-in stainless steel archwire. The solid line represents the mean of orthodontists forces and the dashed lines the 1-SD limits.

3500 3000 2500 Force (grams-force) 2000 1500 1000 500 0 0

2 oz 3 oz 3.5 oz 4.5 oz 5 oz

10

20

30 Extension

40

50

60

Fig 5. Force-extension curves for 3/16-in (4.8 mm) elastics: 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g). Vertical dotted lines indicate 2 and 3 times lumen diameter stretch.

demonstrated by the comparative values quoted in this study. The recommendations of Proft et al5,13 are the most precise, providing elastic forces for both edgewise and lighter round wires, but even his recommendation changed from 300 to 250 g of force between textbook editions. The recommendation of Alexander16 was somewhat higher than that of Prott et al, but was used only for edgewise archwires, whereas that of Langlade14 is between them. For Class II corrections on edgewise wire, both Profts and Langlades recommended forces fall within 1 SD

of what our study orthodontists selected, whereas Alexanders recommendation was 14 g above the 1-SD upper limit. For Class III corrections on edgewise archwires, all experts recommendations fell within 1 SD of the study orthodontists. In general, most of the orthodontists surveyed varied signicantly, but the mean and median forces were relatively close to the experts recommended force levels. A number of other factors also inuence the latex elastic force delivered to the patient. These factors include the amount of stretch of the elastic and the force

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1,200

2 oz 3 oz

1,000

3.5 oz 4.5 oz

Force (grams-force)

800

5 oz 6 oz

600

400

200

0 0 10 20 30 Extension (mm) 40 50 60

Fig 6. Force-extension curves for 1/4-in (6.4 mm) elastics: 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), 5 oz (142 g), and 6 oz (170 g). Vertical dotted lines indicate 2 and 3 times lumen diameter stretch.

1200

2 oz 3 oz 3.5 oz 4.5 oz 5 oz

1000 Force (grams-force)

800

600

400

200

0 0 10 20 30 Extension (mm) 40 50 60

Fig 7. Force-extension curves for 5/16-in (7.9 mm) elastics: 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g). Vertical dotted lines indicate 2 and 3 times lumen diameter stretch.

degradation with an extended time in a wet environment, the continuous stretching and relaxing in oral movements, and even different suppliers. Most manufacturers recommend stretching an elastic 2 or 3 times the relaxed diameter to obtain the listed amount of force. To obtain the rated force, Rocky Mountain Orthodontics recommends stretching its latex elastics three times the slack diameter.24 In this study, the manufacturers suggested force levels were closest to the 2-times stretch of the lumen diameter for all elastics, and stretching the elastic to 3 times its lumen size

increased the force signicantly, as shown in the force-extension graphs. For example, for a .25-in, 4.5-oz (6.4 mm, 142 g) elastic, the force exerted at a 2-times stretch was 147 g, slightly above the rated force; at a 3-times the stretch, the elastic produced 206 g, or 60 g above the rated force of 142 g. In this study, we measured only the initial force produced by the elastics; however, the forces delivered by latex elastics decrease with wear by a number of other factors. Kanchana and Godfrey25 tested latex elastics from 4 manufacturers and also found that, at the

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1200

2 oz 3 oz

1000

3.5 oz 4.5 oz

Force (grams-force)

800

5 oz

600

400

200

0 0 10 20 30 Extension (mm) 40 50 60

Fig 8. Force-extension curves for 3/8-in (9.5 mm) elastics: 2 oz (57 g), 3 oz (85 g), 3.5 oz (99 g), 4.5 oz (128 g), and 5 oz (142 g). Vertical dotted lines indicate 2 and 3 times lumen diameter stretch.

3-times stretch, the delivered force was 9.5% to 41.9% above the rated value when tested dry. They also found signicant variations between manufacturers, with some elastics producing consistently higher forces than others. Other factors are the force decay over time and the force decay from repeated stretching. Kersey et al17 found that, during the rst half hour, .25-in, 4.5-oz (6.4 mm, 142 g) latex elastics lost nearly 10% of their force in static testing and, by 2 hours, had lost 14% of their force. An even greater force loss occurred when the elastics were cycled (stretched and relaxed), with a nearly 20% force loss at half an hour and a 22% force loss after 2 hours of cycling, but, after that, the force loss was relatively small. Liu et al26 also found a loss of elastic force from repeated stretching. In their study, the .25-in, 4.5-oz (6.4 mm, 142 g) elastic at a 3-times stretch delivered 186 g of initial force, which, if reduced by 22% after 2 hours of stretching to approximately 145 g, is close to the 142-g rated force. In addition to the effects of physical stretching, placing latex elastics in a wet environment creates additional force decay. Water is absorbed by the latex, and both inorganic and organic constituents leach out, reducing the surface hardness of the latex elastic and producing surface cracking and crazing.27-29 The force loss from a wet environment can be as much as 30% in the rst hour25 and increasing to 40% over 24 hours.30 Storage conditions and the amount of elongation are other factors that additionally decrease the elastic force.30 The loss of force has led authors to recommend selecting an elastic rating 1.3 to 1.6 times25 or 40%31

above the desired treatment force. This might explain why the forces specied by some orthodontists in this study had high levels of elastic force, but it still leaves open the question of why some orthodontists used low force levels. The experts opinions are also variable; although not stated, the higher values of Alexander16 might incorporate the force-loss factor, whereas those of Proft et al5,13 and Langlade14 might not. When all of these factors in physical changes are combined with the patient factors of length of time the elastics are worn, missed days of wear, variability of the stretched distance, patient growth, individual response, and many other factors, it is little wonder that orthodontists choices in prescribed elastics are so variable. Orthodontists must therefore rely on judgment and the art of orthodontics in patient.
CONCLUSIONS

1. 2.

3.

Great variations were found between orthodontists in elastic forces prescribed. With the exception of Class III treatment on light wires, the experts recommendations fell within 1 SD of the mean of the study orthodontists recommendations. Many factors decrease the force of latex elastic during wear; therefore, an elastic with a greater initial force than desired should be prescribed.

We thank Rocky Mountain Orthodontics, Denver, Colo, for the donation of elastics and brackets.

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REFERENCES 1. Angle E. Bone-growing. Dent Cosmos 1910;52:261-7. 2. Reitan K. Tissue behavior during orthodontic tooth movement. Am J Orthod 1960;46:881-900. 3. Reitan K. Effects of force magnitude and direction of tooth movement on different alveolar bone types. Angle Orthod 1964;34: 244-55. 4. Owman-Moll P, Kurol J, Lundgren D. Effects of a doubled orthodontic force magnitude on tooth movement and root resorption. An inter-individual study in adolescents. Eur J Orthod 1996;18:141-50. 5. Proft WR, Fields HW, Sarver DW. Contemporary orthodontics. 4th ed. Philadelphia: Mosby; 2007. p. 340, 349, 591. 6. Brudvik P, Rygh D. Non-clast cells start orthodontic root resorption in the periphery of hyalinized zones. Eur J Orthod 1993;15:467-80. 7. Brudvik P, Rygh D. Root resorption beneath the main hyalinized zone. Eur J Orthod 1994;16:249-63. 8. Mirabella AD,  Artun J. Risk factors for apical root resorption of maxillary anterior teeth in adult orthodontic patients. Am J Orthod Dentofacial Orthop 1995;108:48-55. 9. Levander E, Malmgren D, Stenback K. Apical root resorption during orthodontic treatment of patients with multiple aplasia: a study of maxillary incisors. Eur J Orthod 1998;20:427-34. 10. Nanda R. Biomechanics and esthetic strategies in clinical orthodontics. St Louis: Elsevier Saunders; 2005. p. 13. 11. Mulligan TF. Common sense mechanics in everyday orthodontics. Phoenix, Ariz: CSM Publishing; 1998. p. 21. 12. Graber TM, Vanarsdall RL. Orthodontics: current principles and techniques. 3rd ed. St Louis: Mosby; 2000. p. 269. 13. Proft WR. Contemporary orthodontics. 3rd ed. Philadelphia: Mosby; 2000. p. 565. 14. Langlade M. Optimization of orthodontic elastics. Bohemia, NY: GAC International; 2000. p. 7. 15. Ricketts RM, Bench RW, Gugino CF, Hilgers JJ, Schulhof RJ. Bioprogressive therapy. Denver, Colo: Rocky Mountain Orthodontics; 1979. 16. Alexander RG. The Alexander discipline. Glendora, Calif: Ormco; 1986. p. 151.

17. 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;73:181-6. 18. Garnick J, Ramfjord SP. An electromyographic and clinical investigation. J Prosthet Dent 1962;12:895-911. 19. Schweitzer JM. Oral rehabilitation. Philadelphia: Mosby; 1951. p. 514-8. 20. Okeson JP. Management of temporomandibular disorders and occlusion. 4th ed. St Louis: Mosby; 1998. p. 160. 21. Angle EH. Treatment of malocclusion of the teeth. 7th ed. Philadelphia: SS White Manfacturing; 1907. p. 257. 22. Ren Y, Maltha J, Kuijpers-Jagtman A. Optimum force magnitude for orthodontic tooth movement: a systematic literature review. Angle Orthod 2003;73:86-92. 23. Kurol J, Franke P, Lundgren D, Owman-Moll P. Force magnitude applied by orthodontists: an inter- and intra-individual study. Eur J Orthod 1996;18:69-75. 24. Rocky Mountain Orthodontics Product Catalog. Denver, Colo: Rocky Mountain Orthodontics; 2008. p. 39. 25. Kanchana P, Godfrey K. Calibration of force extension and force degradation characteristics of orthodontic latex elastics. Am J Orthod Dentofacial Orthop 2000;118:280-7. 26. Liu CC, Wataha JC, Craig RG. The effect of repeated stretching on the force decay and compliance of vulcanized cis-polyisoprene orthodontic elastics. Dent Mater 1993;9:37-40. 27. Billmeyer FW. Textbook of polymer science. 3rd ed. New York: John Wiley & Sons; 1984. p. 361-82. 28. Kapila S. Commentary: characteristics of elastomeric chains. Angle Orthod 1994;64:465-6. 29. Ruyter IE. Physical and chemical aspects related to substances released from polymer materials in an aqueous environment. Adv Dent Res 1995;9:344-7. 30. Yogosawa F, Nisimaki H, Ono E. Degradation of orthodontic elastics. J Jpn Orthod Soc 1967;26:49-55. 31. Andreason GF, Bishara SE. Comparison of alastik chains with elastics involved with intra-arch molar to molar forces. Angle Orthod 1970;40:151-8.

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