ORIGINAL ARTICLE

Force degradation of orthodontic latex

elastics: An in-vivo study
Sadeq M. Adel Qodcieh,a Susan N. Al-Khateeb,a Ziad W. Jaradat,b and Elham S. J. Abu Alhaijaa
Irbid, Jordan

Introduction: Our objectives were to assess the force degradation of orthodontic latex elastics over 48 hours
in vivo and to study the relationship between the amount of mouth opening and the degree of force decay.
Methods: Fifty-two orthodontic patients wearing fixed appliances using Class II elastics were asked to wear
premeasured-force 3/16-in heavy and medium intermaxillary elastics. The force amounts were measured and
compared at different time intervals. Results: Fifty percent of the force was lost after 3.9 hours for the medium
elastics and after 4.9 hours for the heavy elastics. A continuous significant force drop in all elastics was seen at
all time intervals (P \0.05, P \0.001). There was greater force loss in the heavy elastics compared with the me-
dium elastics in vivo at all time intervals (P\0.001); the rates of force loss, however, were similar. Conclusions:
Fifty percent of force degradation occurred in the first 4 to 5 hours. Because of breakage and for oral hygiene
purposes, orthodontic elastics should be changed daily; otherwise, elastics can be used for 48 hours. Force
decay of the elastics was correlated to the lateral distance between the maxillary canine and the mandibular first
molar in occlusion. (Am J Orthod Dentofacial Orthop 2017;151:507-12)

T
he use of elastics in orthodontics was introduced
about a century ago.1,2 Elastics are considered an
essential part of any orthodontic practice.3 Latex
elastics are characterized by high flexibility, relatively
enduring forces, and low cost. Additionally, their use is
easy for patients; they can change the elastics by them-
selves and maintain good oral hygiene while wearing
them.4-6
Force-extension characteristics and force degradation
properties of latex elastics have been reported.7-11 Several
factors may influence force degradation including lumen
size of the elastics, saliva environment, PH, and
thermocycling.4,6,12,13
From Jordan University of Science and Technology, Irbid, Jordan.
a
Department of Preventive Dentistry, Division of Orthodontics, Faculty of
Dentistry.
b
Department of Biotechnology and Genetic Engineering, Faculty of Science and
Art.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Supported by a grant (16/2009) from the Deanship of Scientific Research of Jor-
dan University of Science and Technology.
This research was part of the first author's requirements for his masters thesis.
Address correspondence to: Susan N. Al-Khateeb, Department of Preventive
Dentistry, Division of Orthodontics, Faculty of Dentistry, Jordan University of
Science and Technology, PO Box 3030, Irbid 22110, Jordan; e-mail, susank@
just.edu.jo.
Submitted, April 2016; revised and accepted, August 2016.
0889-5406/$36.00
Ó 2016 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.08.023
Mechanical degradation effects are thought to be the
primary cause for force degradation of orthodontic
elastic bands during clinical use.6,9,14,15 It was reported
that rubber elastics in a watery or oral environment
lose 10% to 40% of their initial force after 30 minutes
to 24 hours after they are applied.11,15 As a
consequence of these observations, Andreasen and
Bishara16 suggested using 40% more force than optimal
at the commencement of elastic application to compen-
sate for the initial loss. Gangurde et al6 suggested that
the elastics did not need to be replaced so frequently
by the patient because, after the initial degradation,
the force may remain relatively constant for a few days.
Most force degradation studies were ex vivo, in which
the experimental conditions could be controlled, and the
results were also reproducible.6,8,9,11 However, the ex-
vivo approach for assessment of mechanical perfor-
mance of biomaterials has been proven to underestimate
the extent and severity of effects induced during intrao-
ral aging of these materials.17 A few studies have been
carried out in vivo to evaluate force decay in elastomeric
chains.18 To our knowledge, no in-vivo studies have
investigated force degradation in orthodontic latex elas-
tics at several time points except for a pilot study con-
ducted with a small sample size and a study
comparing latex-containing and nonlatex-containing
elastics at only few time points.4,19 Accordingly, the
aim of this study was to assess the force degradation
of latex elastics longitudinally over 48 hours in vivo.

507
508
MATERIAL AND METHODS
Fifty-two orthodontic patients (40 female, 12 male)
between 14 and 27 years of age (mean, 20.7 years; SD,
63.5 years) treated at the orthodontic clinics of the
Dental Teaching Clinics, Faculty of Dentistry, at Jordan
University of Science and Technology in Irbid, Jordan,
participated in this study.
The patients wore straight-wire fixed appliances
(Omni Arch; GAC, Bohemia, NY) with Roth prescription
(0.022-in slot). The patients used Class II elastics on
0.019 3 0.025 stainless steel wires as part of their treat-
ment. This study was approved by the institutional
research board of Jordan University of Science and Tech-
nology (approval number IRB/12/300).
For each participant, the following measurements
were made.
1. Distance from the maxillary canine to the mandib-
ular molar on the same side in centric occlusion
(DCO). The measurement was performed from the
cusp tip of the maxillary canine to the tip of the me-
siobuccal cusp of the mandibular first molar.
2. Maximum mouth opening measured from the
incisal edge of the maxillary central incisors to the
incisal edge of the mandibular central incisors
(MMO).
3. The distance from the cusp tip of the maxillary
canine to the mesiobuccal cusp of the mandibular
first molar on the same side in maximum mouth
opening (MMOLat).
4. The rubber bands' breakage rates over time and
their color changes.
A millimetric stainless steel ruler (Moyoko/Union
Broach; Endo Ruler, Montgomeryville, Pa) was used to
measure these distances to the nearest 0.5 mm.
Samples of medium (4 oz) and heavy (6 oz) force elas-
tics with 3/1600 diameter (3M Unitek, Monrovia, Calif)
were used in this study by each participant. All elastics
had recent manufacturing dates and were stored in
sealed plastic packages in a cool and dark environment
according to the manufacturer's instructions.
A set of 7 tubes contained the premeasured
medium elastics. Each tube was marked with the pa-
tient's name, type of elastic, and one of the following
time intervals: 1, 3, 6, 12, 18, 24, or 48 hours. A similar
set of 7 tubes with heavy elastics was also distributed to
all participants.
The participants were instructed to wear the elastics
according to the assigned intervals marked on the tubes.
After the end of each interval, they were instructed to put
the elastic back in its tube. The tubes were collected
within 2 to 3 hours at most. The force delivered by the
March 2017  Vol 151  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Qodcieh et al
elastics was then remeasured 3 times, and the mean of
the 3 readings was recorded.
Before each elastic was worn by the patients, the
force delivered by the elastic was measured 3 times using
a force gauge (Federwaage, bis 1000-g dial-type, stress
and tension gauge; Dentaurum, Pforzheim, Germany).
Mean force of the 3 readings was recorded. To measure
the force, each elastic was stretched with the force gauge
from a 1.5-mm thick pin fixed on a custom-made acrylic
base with a ruler on the side to determine the stretching
distance. A groove was made along the ruler to facilitate
stretching the elastics with accuracy. The elastics for
each patient were stretched the same distance as
measured intraorally from the tip of the canine to the
tip of the first molar in centric occlusion of each partic-
ipant.
A pilot study was conducted on 10 participants
before this study. The participants were given elastics
to wear for 24 hours, 1 on the right side and 1 on the
left. The force losses were measured on both sides and
compared (using the Student t test for independent sam-
ples). No difference (P 5 0.33) was recorded between the
right and left sides. Accordingly, the participants were
instructed to wear the experimental elastics on the right
side only. All participants received extra similar elastics
to wear on the left side according to their orthodontists'
recommendation.
Sixty elastics (30 medium, 30 heavy) were randomly
selected from the elastic bags and measured 3 times,
and the mean reading was recorded. The same elastics
were remeasured according to the same procedure after
3 weeks. The elastics were stored in a sealed package in a
dark and cool environment as recommended by the
manufacturer during these 3 weeks.
Dahlberg's formula20 for the double measurement
error was used to calculate the standard error of the
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
P
method ðS 5 ðd1  d2Þ2 =2n Þ and Houston's co-
efficient of reliability21 was calculated. The Dahlberg
errors were 5.02 cN for the heavy elastics and 3.63 cN
for the medium elastics, with reliability above 95%.
Statistical analysis
Data analysis was carried out using the Statistical
Package for Social Science computer software (version
17.0; SPSS, Chicago, Ill).
Descriptive statistics were used (means, standard de-
viations, and percentages of force loss). A general linear
model with repeated-measures analysis was used to
investigate the effects of time, extension distance, and
type of elastics. One-way analysis of variance was used
to compare the amounts of force degradation between
Qodcieh et al 509

effect (P \0.05) as shown by the general linear model.

Table I. Means, standard deviations, and percentage
MMOLat had no effect on force changes.
of force loss in medium and heavy elastics over time
DCO was strongly correlated with the amounts of
Medium elastics Heavy elastics force loss at the different time intervals (with an r value
Time
interval Mean 6 SD Force loss Mean 6 SD Force
between 0.71 and 0.89). Table III shows the Pearson cor-
(h) (cN) (%) (cN) loss (%) relation coefficient values and their significance at all
1 26.3 6 8.6 13.4 38.2 6 14.0 12.0 time intervals for medium and heavy elastics. No corre-
3 31.7 6 9.5 15.7 42.0 6 12.6 13.8 lation was found between force degradation and mouth
6 37.8 6 10.9 18.5 52.3 6 12.6 16.9 opening either anteriorly or laterally.
12 39.8 6 11.0 19.9 59.5 6 13.9 19.2
18 46.4 6 10.8 22.2 65.8 6 16.6 21.1
Rubber bands have changed in color after usage from
24 59.4 6 17.3 28.2 85.7 6 21.1 26.8 yellowish straw color to off-white, with a swollen
48 66.0 6 17.9 30.9 98.7 6 25.6 30.2 appearance.
A few elastics were broken during the study. The
breakages occurred during the last scheduled time inter-
the different time intervals. Pearson correlation coeffi- vals. Numbers and percentages of broken medium and
cients (r) were calculated for the force losses at the heavy elastics at the corresponding time intervals are
different time intervals for the medium and heavy elas- shown in Table IV.
tics and all the measured distances intraorally. Addition-
ally, linear regression analysis was carried out to check DISCUSSION
the effect of the measured distances on force degrada- In this study, we evaluated the force degradation of
tion. orthodontic elastics longitudinally in vivo. Most previous
studies were conducted ex vivo, where the experimental
RESULTS conditions could be controlled and give reproducible re-
Means and standard deviations of force loss from the sults.6,9,11,15 However, the ex-vivo approach for investi-
medium and heavy elastics at the measured time inter- gation of the mechanical performance of biomaterials
vals are shown in Table I. The Figure shows the gradual has been associated with underestimations of the extent
loss of force over time from both medium and heavy and severity of the effects induced by such materials dur-
elastics. ing intraoral aging.17
There was a rapid loss of force during the first few The participants in this study were cooperative and
hours followed by a more gradual degradation. Fifty precise and managed their elastics properly. Although
percent of the forces were lost after 3.9 hours for the me- the sample size was large, female subjects outnumbered
dium elastics and after 4.9 hours for the heavy elastics. male subjects by almost 3 times. Such differences in
Continuous significant drops in elastic force for the me- numbers might have partly affected the results, consid-
dium and heavy elastics were seen at all time intervals ering the difference in masseter muscle activity between
(P \0.05, P \0.001) except between the 6 and the sexes.22
12 hour interval for medium elastics and between the All elastic samples were tested at the following inter-
1 and 3 hour interval for heavy elastics. Table II shows vals: 1, 3, 6, 12, 18, 24, and 48 hours. The first 3 intervals
the differences between the time intervals and their sig- represented the period of large initial fall of force in
nificance for medium and heavy elastics. several studies. Some studies reported high slopes in
There was greater force loss in the heavy elastics force degradation in the first 3 to 5 hours, whereas other
when compared with the medium elastics at all time in- studies found force degradation in the first hour.4,7,9,15
tervals (P \0.001) as shown in the Figure. The percent- The next 3 time intervals showed slower and
ages of force loss from the original values at each time continuous force degradation for the rest of the day.
interval, however, were similar in the medium and heavy Several studies used the 24-hour interval as the last
elastics. time point for their measurements.4,11 The 48-hour
The means and standard deviations were interval represented the longest period that the rubber
24.1 6 4.2 mm for DCO, 47.4 6 6.1 mm for MMO, bands can survive intraorally, and it was used by other
and 46.5 6 6.7 mm for MMOLat. studies.4,6
DCO, representing the stretching distance of elastics, The measured distances in the patient's mouth—DCO,
had a tendency to affect the force decay but did not MMO, and MMOLat—represented the amounts of stretch
reach a significant level (P 5 0.06), whereas the of the elastics. DCO is considered as the most reproduc-
maximum mouth opening anteriorly had a significant ible distance to measure.23,24

American Journal of Orthodontics and Dentofacial Orthopedics March 2017  Vol 151  Issue 3
510 Qodcieh et al

Fig. Force decay of medium and heavy elastics over time.

Table II. Change in force between the time intervals Table III. Pearson correlation coefficient (r) values be-
and their significance for medium and heavy elastics tween the force loss at the different time intervals and
the distance between maxillary canine and mandibular
Force change (cN), Force change (cN),
Time interval (h) medium elastics heavy elastics first molar at centric occlusion
0 0.0 0.0 Time interval (h) Medium elastics Heavy elastics
1 26.3z 38.2z
1 0.85* 0.86*
3 5.4* 3.8 (NS)
3 0.89* 0.80*
6 6.1y 10.3z
6 0.89* 0.73*
12 2.0 (NS) 7.2z
12 0.88* 0.71*
18 6.5* 6.3*
18 0.89* 0.83*
24 13.0z 19.9z
24 0.89* 0.84*
48 6.7* 13.0y
48 0.89* 0.84*
NS, Not significant.
*P \0.05; yP \0.01; zP \0.001. *P \0.001.

The force degradation pattern exhibited a rapid
initial fall of force in the first few hours followed by a
slower decay for the remaining 48 hours. A similar
pattern was reported in other studies but in an ex-vivo
setup.9,15,16 Fifty percent of the force was lost after 4
to 5 hours by both medium and heavy elastics. This
result was similar to that reported by Gioka et al9;
most of the elastic relaxation occurred within the first
3 to 5 hours after extension.
The elastics used in this study were stretched accord-
ing to the recommendations of the treating orthodon-
tists; in some patients, this was more than
recommended by the manufacturer. After a few hours,
however, the force dropped by 50% of its value to reach
to an amount between 100 and 150 cN for the medium
and heavy elastics, respectively.
Significant force losses were recorded at all time in-
tervals except between 6 and 12 hours in medium elas-
tics and between 3 and 6 hours in heavy elastics. This
might be because during these time periods the partici-
pants had less dynamic oral activities after their lunch.25
Fernandes et al10 reported similar findings.
Fifty percent of the force was lost in the medium elas-
tics earlier than the heavy elastics by almost an hour
in vivo. Russell et al8 reported faster rates of force loss
for heavy elastics in the first few hours compared with
medium elastics in some brands, although equal rates
of force loss were reported for other brands. They also

March 2017  Vol 151  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Qodcieh et al
Table IV. Numbers and percentages of broken elastics
during the study
Time interval Broken elastics (n) Percentage (%)
24-h M 2 3.8
24-h H 2 3.8
48-h M 10 19.2
48-h H 9 17.3
M, Medium elastics; H, heavy elastics.
reported that medium elastics were more homogenous
and showed less variation within the sample compared
with their light and heavy counterparts. Therefore, me-
dium elastics were recommended as the clinician's first
choice.15
Greater force loss was noticed in heavy elastics
compared with medium elastics in this study. On the
contrary, previous studies on latex elastics have sug-
gested that thicker elastics maintain higher forces over
time, while smaller elastics are more consistent in their
force delivery but might be more susceptible to creep
and show more force loss over time.19,26 The
percentage of force loss, however, seemed more
comparable in both medium and heavy force elastics.
Wong27 and Taloumis et al28 reported that the greater
the initial force of the rubber band, the greater the
amount of force decay, whereas other authors reported
that the initial force had no relationship to the amount
of force decay.29,30 Hwang and Cha31 reported a rela-
tionship between the initial force and the amount of
force decay but in silicone rubber bands.
Less than 30% of the original elastic force was lost af-
ter 24 hours. After that, the further force reduction was
relatively small. Liu et al32 confirmed that the force value
was remarkably stable after 1 day because the structural
changes caused by repeated stretching were not cumu-
lative. Some studies have suggested that elastics do
not need to be replaced so frequently because, after
most of the force decay in the first day, the force could
remain relatively constant for a few days.4,6,33
However, a daily change of the elastics is advisable
because of more elastic breakage after 24 hours and
for oral hygiene considerations.
Clinically, a decision must be made whether to start
with a higher force than deemed necessary or end up
with lower forces than desired after a short time in the
mouth.25 One study suggested changing the rubber
bands twice daily to keep a relatively high level of force.9
Other authors suggested that elastic bands with higher
force than needed should be used, and they should be
prestretched before use to prevent the higher forces in
the first few hours.4
American Journal of Orthodontics and Dentofacial Orthopedics
511
Rubber bands underwent some changes in their
appearance; they changed color from yellowish straw
color to off-white. They also had a swollen appearance.
Similar changes have been observed in other studies.15
Maximum mouth opening anteriorly had a signifi-
cant effect on force decay but not on the lateral distance.
There are no reports in the literature on the effect of
maximum mouth opening on the force degradation of
elastics either anteriorly or laterally. There was a signif-
icantly strong correlation between DCO and force decay.
Other studies reported that more elongation of the elas-
tics potentiated an increased force degradation.8,9,34
Some factors may interact with the effect of maximum
mouth opening or the lateral distance at centric
occlusion such as food consumption, temperature
changes, and activity of the perioral muscles. It is
impossible to study the effect of each variable alone in
the oral environment.9
It is not only important for practitioners to know the
properties of elastics well, but it is also necessary for
manufacturers to well document and report the proper-
ties of force degradation of their products because of the
differences in properties of the various brands of
elastics.33
CONCLUSIONS
1. Fifty percent of force degradation occurred in the
first 4 to 5 hours, followed by continuous and
gradual force degradation for the remaining time
intervals.
2. Because of breakage and for oral hygiene purposes,
orthodontic elastics should be changed every
24 hours. Otherwise, elastics can be used for 48 hours.
3. Force decay of the elastics was correlated with
lateral distance between the maxillary canine and
the mandibular first molar at centric occlusion.
4. The amount of anterior mouth opening had a sig-
nificant effect on force degradation of the elastics.
ACKNOWLEDGMENT
We thank Yousef Alkhader for his help in statistical
analysis and all patients who participated in the study
for their cooperation and enthusiasm in using the elas-
tics for the assigned time periods.
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