Early Versus Late Intermaxillary Elastics in Patients With Class II Malocclusion
Phase: NA
Conditions: Class II Malocclusion Division 1
Sponsor: Ain Shams University

 
 
 
“Early versus late Intermaxillary Elastics in patients with Class II  
Malocclusion” 
 
A Research Protocol Submitted To Faculty of Dentistry 
Ain-Shams University for Partial Fulfillment of the Master Degree 
In Orthodontics 
 
Submitted by : 
Maha Sabry Sayed Abd El Hameed 
B.D.S,  2016 
Ain-Shams University 
E-mail: mahasabry@asfd.asu.edu.eg 
Mobile no. : 01021231617 
 
Supervisors: 
Dr. Noha Hussein Abbas 
Associate professor of Orthodontics 
Department of Orthodontics and Dentofacial orthopedics 
Faculty of Dentistry, Ain Shams University 
Dr. Mais Medhat Sadek 
Lecturer of Orthodontics  
Department of Orthodontics and Dentofacial Orthopedics 
Faculty of Dentistry, Ain shams University 
01/27/2021 
 

 
 
 
Contents: 
1- Introduction / background 
2- Objective 
3- Study methodology  
4- Study population 
5- Study procedure 
6- Statistical analysis 
7- References 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
8 
 

 
 
 
 
 
Introduction 
 
Class II malocclusion is one of major problems that patients seek 
orthodontic treatment. The dental and skeletal factors ranging from mild to 
severe provide the multiple characters of this malocclusion.1-2 
 
There are a number of orthodontic techniques and appliances for class II 
malocclusion treatment; among these are class II elastics. class II elastics 
correct a class II malocclusion by two actions: 1. maxillary retraction and 
clockwise rotation of the upper arch, and 2. mandibular arch protraction 
and clockwise rotation of the lower arch. This combination of 
antroposterior and vertical effects corrects this malocclusion.3 
 
The force levels of elastics range from being light, medium, heavy and extra 
heavy. The force value of  elastics should be provided by the manufacturers 
for different sizes. It is recommended to stretch the elastic to three times 
the original internal diameter to achieve the force stated on the package.4 
the regular change of elastics is very important because their force level 
decreases rapidly. So effective use of elastics needs excellent patient 
cooperation.  
 
In spite of their popularity, there are no significant data to determine the 
most convenient protocols to correct class II malocclusion with class II 
elastics. there are many variables related to class II elastics such the mode 
of elastics wear, the force value and change of elastics.  
 
Several side effects have been attributed from the use of Class II elastics—
eg, loss of mandibular anchorage, proclination of Lower incisors, extrusion 
of upper incisors, and even worsened smile esthetics due to increased 
gingival exposure.5-6 
 
According to the 20 principles of Alexander discipline, the premature use of 
class II elastics can be very dangerous if used with light arch wires that 

 
 
 
cannot control torque. these elastics can cause proclination of the 
mandibular incisors, lingual tipping of maxillary incisors, mandibular molar 
extrusion and alteration of the occlusal plane. therefore, class II elastics 
should not be used until these factors under control.7  Alexander used 1/4 
inch; 6 Oz elastics extended from maxillary lateral incisor ball hook to 
mandibular first or second molar which. Class II elastics Traditionally run 
from the upper canine hook to the lower first or second molar hook on 
stainless steel rectangular wire. 
 
Sabrina Huang from Taiwan advocated use of the early light short elastics 
and she suggested the ELSE (Elastic, Light, Short and Early) acronym some 
years ago8. Recently, the active early Protocol was introduced by Tom Pitts 
and Duncan Brown. This novel Protocol includes immediate light short 
elastics (ILSE) that allow the orthodontist to apply the elastics early from 
the first appointment. The authors mentioned the guiding principles of ILSE 
which include: shorter elastics is better than longer, full time wear, 
immediate elastics, lighter is better than heavier. They claim the active 
early Protocol is efficient, effective ad predictable producing outstanding 
results with more accurate and tightened slot.9 But these claims are based 
only on their case reports and clinical articles with no evidence based. 
 
 Therefore, the main objective of this study is to evaluate whether the use 
of immediate light short class II elastics can correct canine class II 
malocclusion without significant side effects when compared to the 
conventional longer and heavier elastics used with passive rectangular 
stainless-steel wire.  
 
The review 
 
The correction of class II malocclusion By Intermaxillary elastics is one of 
the popular orthodontic techniques. In 1955 Tovstein used Class II elastics 
In both growing and non-growing patients. He found that non-growing 
Patients with the greatest growth had the least change in the inclination of 
the occlusal plane; conversely, patients with the least growth had the 

 
 
 
greatest change in the occlusal plane. However, changes in inclination of 
the occlusal plane have a tendency to return to the original condition.10  
 
In 1984 Gianelly et al compared between Frankel, headgear and class II 
elastics for class II correction, The results indicate no treatment response 
that is uniquely related to a specific technique. .11  
 
In 1986 Meistrell et al used 1-2 oz class II elastics, he found that the 
maxillary first molar maintained it’s anteroposterior position at the same 
time that SNA was reduced. The mandibular first molar moved forward by 
1.2 mm. Vertical change in both the maxilla and the mandible were within 
normal ranges. No significant change in occlusal or mandibular plane angles 
was observed.12 
 
 In 1999 Nelson et al used 1-2 oz class II elastics. He concluded that the 
changes contributing to Class II correction were mostly dental. Vertically, 
the net effects of treatment were increases in the mandibular plane angle 
and lower anterior facial height.13 
 
In 2006 Combrink et al elastics were successful for the correction of Class II 
discrepancies, promoting mainly dentoalveolar effects.14  
 
In 2007 Uzel et al compared between Class II elastics 3.5 oz 24 h/d and 
RMCC for treatment of Class II dental malocclusion, he found that both 
techniques are Effective for class II correction.15 
 
  In 2008 Serbesis-Tsarudis and Pancherz compared between both class II 
elastics and herbest16 also in the same year Jones et al compared between  
class II elastics and forsus17 both authors found no significant differences 
between the elastics and the appliance. 
  
Recently many authors like Tom Pitts18 and Duncan Brown19 published 
many case reports and clinical articles in which they claimed the 
effectiveness and efficiency of early light short elastics starting. also chris 
chang, Eugene Roberts and Linda Tseng.20 

 
 
 
 
 So, class II elastics have been used for correction of both skeletal and 
dental class II for many years ago with different force levels, different 
amount of extension and different rate of elastics change.  
 
 
 
 
Objective 
 
The aim is to compare the effect of immediate light short elastics versus 
conventional elastics on the Inclination of upper incisors in patients with 
canine class II malocclusion.   
 
  
Methodology 
 
Study population: 
This prospective clinical trial will be conducted on 30  patients  both gender 
, divided into 2 groups: 
 
Group 1: fifteen patients will wear immediate light short Class II elastics.  
 
Group 2: fifteen patients will wear conventional elastics.  
 
Selected from the outpatient clinic of the Orthodontic Department, Faculty 
of Dentistry, Ain Shams University. 
 
The subjects will be selected to fulfill the following 
 inclusion criteria:                                                                                                                                
1- Canine class II malocclusion.  
2- Patients with permenant dentition.  
3- Increased overjet.  
4- Non extraction.  
 

 
 
 
Exclusion criteria: 
1- 
Gummy smile.  
2- 
Gingival recession.  
3- 
Vulnerable patients.  
 
 
 
Study procedure: 
  An informed consent will be signed by the patients’ parents as well as an assent 
will be signed by young patients before their enrollment in the current study in 
which the aim of the study, the methodology and possible complications will be 
clearly described. This research will be reviewed by the Research Ethics 
Committee, Faculty of Dentistry, Ain Shams University. 
 
Full orthodontic records will be taken for patients who meet the inclusion criteria. 
These records are: 
1- 
Extra-oral and intra-oral photographs.  
2- 
Orthodontic study casts. 
3- 
Panoramic radiograph: will be used to detect any dental or bone anomalies. 
4- 
Lateral cephalometric radiograph : for skeletal, dental and soft tissue 
assessment.  
 
 
 
Procedure: 
1- The full orthodontic records will be taken for every patient.  
2- The patients will be randomly allocated by computerized allocation.  
3- The fixed orthodontic appliance including 0.018" Bracket slot Roth 
prescription will be applied.  

 
 
 
4- For both groups the disocclusion (disarticulation) will be done by adding 
glass ionomer luting cement at posterior Region that unlock the 
occlusion for greater freedom of teeth movements helping for easier 
and faster teeth movements. 
The glass ionomer cement will be added at the central fossa of lower 
first molar to be more comfortable for patients. 
Medicim glass ionomer luting cement will be used.  
The disarticulation for group 1 will be done in the beginning of the 
treatment but in group 2 once Patients start to wear elastics at passive 
0.016x0.022" stainless steel wire. 
5- For group 1: the patients will be instructed immediately after bonding 
and initial wire placement to wear light short elastics from the upper 
first premolar to the lower first molar. The force level of elastics is 
within light range from 2oz - 3.5oz.  
6- For group 2: the patients will be instructed to wear long elastics from 
the upper canine to the lower first molar, once the patients reach to 
0.016x0.022" stainless steel passive wire. The force level of elastics is 
within medium range from 4oz -5oz.   
7- The elastics force level will be measured every visit by gauge to ensure 
that it is within the range.  
8- For both groups patients instructed and motivated to wear the elastics 
full time and change it every 12 hours . It is essential for the patient to 
demonstrate their ability to properly wear and remove the elastics 
before leaving the clinic.  
9-   Follow up charts will be given to the patients.  
10- 
For both groups the following records will be taken before elastics 
wear and after, once patients reach to canine class I: 
1- The lateral cephalometric radiographs.   
2-  Impressions For cast analysis.  
3- Standardized smile photographs.  
  
 
 

 
 
 
Methods of assessment: 
1- Pre-operative T1 and postoperative T2 lateral cephalometric 
radiographs measures are compared and assessed. 
2- Pre-operative and postoperative casts are compared and assessed.  
3- Pre-operative and postoperative smile photographs are compared 
and assessed.  
4- Calculation of The total period of elastics wear till the class I canine 
relationship achieved for both groups is compared and assessed.  
 
 
Measuring unit
 
Measuring tool
 
Outcome
 
• Degre 
 
 
 
 
• Degree/
mm 
 
 
 
 
• Lateral 
cephalometry. 
• Lateral 
cephalometry. 
 
 
• Upper incisor 
inclination  
(UI/PP) and 
(U1/SN). 
 
• Upper incisors 
inclination and 
position (U1/NA) 
 
 
Primary 
outcome
 
 
• Degree 
 
 
 
• Degree/
mm 
 
 
 
 
• Degree 
 
 
 
• Lateral 
            Cephalometry 
 
 
• Lateral 
cephalometry. 
 
 
 
 
• Lateral 
cephalometry  
 
 
• Lower incisor 
inclination 
(LI/MP). 
 
• Lower incisors 
inclination and 
position (L1/NB) 
 
 
 
• Occlusal plane 
inclination 
(anatomical 
occlusal plane). 
Secondary 
outcomes

 
 
 
 
 
 
 
 
 
• Degree 
 
 
 
• mm 
 
 
 
 
 
• Degree 
 
 
• Mm 
 
 
 
 
 
• Degree 
 
 
• Degree 
 
 
 
 
 
• Degree 
 
 
 
• Mm 
 
 
 
• mm 
 
 
 
 
 
 
 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry. 
 
 
 
 
• Lateral 
cephalometry 
 
• Lateral 
cephalometry. 
 
 
 
 
• Lateral 
cephalometry. 
 
• Lateral 
cephalometry. 
 
 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry 
 
 
• Lateral 
cephalometry 
 
Op/(Me-Go) 
Op/FH 
Op/AB 
 
 
• Mandible to cranial 
base (SNB)  
 
• Mandible to cranial 
base (Pg to N 
perpendicular to 
FH). 
 
 
 
• Maxilla to cranial 
base (SNA). 
 
• Maxilla to cranial 
base (point A to N 
perpendicular to 
FH). 
 
 
• ANB angle. 
 
 
• FH, palatal and SN 
planes to 
mandibular plane 
angles. 
 
 
• Ar Go Me 
 
 
 
• ANS Me 
 
 
 
• S Go 
 
 

 
 
 
 
Page 
 
• Nasolabial angle. 
 
 
• Angle of facial 
convexity (G-Sn/ 
Sn-Pg'). 
 
• Facial angle 
(FH/N'Pg'). 
 
 
• Upper lip 
thickness. 
 
 
• Lower lip 
thickness. 
 
 
 
• Mentolabial 
angle. 
 
 
• Upper lip/ E-line. 
 
 
 
• Lower lip/ E-line 
 
 
 
• Arch form  
• Curve of spee 
• Arch length  
• Arch width  
 
 
 
 
 
• Smile analysis 
• Lateral 
cephalometry. 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry. 
 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral 
cephalometry. 
 
 
• Lateral cephalometry 
•  
 
 
• scanned cast  
• scanned cast  
• scanned cast  
• scanned cast  
 
 
 
 
• Degree 
 
 
• Degree 
 
 
 
• Degree 
 
 
 
• mm 
 
 
 
• mm 
 
 
 
 
• Degree 
 
 
 
• mm 
 
 
 
• mm 
 
 
 
• mm 
• mm 
• mm 
• mm 
 
 
 
• mm 

 
 
 
 
 
 
 
• Time of elastic 
wear 
 
  
 
 
Standardized 
extraoral 
photos 
 
 
 
 
 
 
 
 
• Months 
/days 
▪ All data will be tabulated and statistically analyzed. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
 
1- Baccetti T, Franchi L, Kim LH. Effect of timing on the outcomes of 1-phase nonextraction therapy of Class II 
malocclusion. Am J Orthod Dentofacial Orthop 2009;136:501-9. 
 
2- Baccetti T, Franchi L, Stahl F. Comparison of 2 comprehensive Class II treatment protocols including the bonded 
Herbst and headgear appliances: a double-blind study of consecutively treated patients at puberty. Am J Orthod 
Dentofacial Orthop 2009;135:698.e1-10; discussion 698-9 
 
3 - Kozlowski J. Honing Damon system mechanics for the ultimate in efficiency and excellence. Clin Impressions 
2008;16:23-28.  
4 - Proffit WR , Fields Jr HW, Sarver DM. Contemporary orthodontics, 4th ed. St. Louis: Mosby Elsevier; 2007. 
5 - Janson G, Sathler R, Fernandes T, Branco N, de Freitas M. Correction of Class II malocclusion with Class II 
elastics: a systemic review. Am J Orthod Dentofacial Orthop 2013;143:383-92. 
 
6 - Ellen EK, Schneider BJ, Sellke T. A comparative study of anchorage in bioprogressive versus standard edgewise 
treatment in Class II correction with intermaxillary elastic force. Am J Orthod Dentofacial Orthop 1998;114:430-6. 
7 - R. G. “Wick” Alexander, The 2o principles of the alexander discipline book. 2008 
 
8 - Pitts, T and Brown, D – Overcoming Challenges in PSL with “Active Early” and H4. The Protocol Issue 4, 2016; 8-
19 
9 - Pitts, T and Brown, D – immediate, Light, Short Elastics with Disarticulation. The Protocol Issue 6, 2017; 8-16 
 
10 -Tovstein BC. Behavior of the occlusal plane and related structure in the treatment of Class II maloclusion. Angle 
Orthod 1955;25:189-98. 
 
11 -Gianelly AA, Arena SA, Bernstein L. A comparison of Class II treatment changes noted with the light wire, 
edgewise, and Frankel appliances. Am J Orthod 1984;86:269-76.  
 
12 -Meistrell ME Jr, Cangialosi TJ, Lopez JE, Cabral-Angeles A. Acephalometric appraisal of nonextraction Begg 
treatment of Class II malocclusions. Am J Orthod Dentofacial Orthop 1986;90:286-95. 
 
13 -Nelson B, Hansen K, H€agg U. Overjet reduction and molar correction in fixed appliance treatment of Class II, 
Division 1, malocclusions: sagittal and vertical components. Am J Orthod Dentofacial Orthop 1999;115:13-23. 
 
14 -Combrink FJ, Harris AM, Steyn CL, Hudson AP. Dentoskeletal and soft-tissue changes in growing Class II 
malocclusion patients during nonextraction orthodontic treatment. SADJ 2006;61:344-50.  
 
15 -Uzel A, Uzel I, Toroglu MS. Two different applications of Class II elastics with nonextraction segmental 
techniques. Angle Orthod 2007;77:694-700. 
 
16 -Serbesis-Tsarudis C, Pancherz H. “Effective” TMJ and chin position changes in Class II treatment. Angle Orthod 
2008;78:813-8. 
 
17 -Jones G, Buschang PH, Kim KB, Oliver DR. Class II Non-extraction patients treated with the Forsus fatigue 
resistant device versus intermaxillary elastics. Angle Orthod 2008;78:332-8. 
 
18 - Pitts T. Begin with the end in mind: bracket placement and early elastics protocols for smile arc protection. 
Clin Impressions 2009;17:4-13. 

 
 
 
 
 
19 - Pitts, T and Brown, D – immediate, Light, Short Elastics with Disarticulation. The Protocol Issue 6, 2017; 8-16.  
20 - Tseng, L and Chang, C and  Roberts, E – Correction of a Full Cusp Class II Malocclusion and Palatal 
Impingement with Intermaxillary Elastic. Int J Othod Implantol 2015;38:54-72.