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ALEXANDER DISCIPLINE

PRESENTED BY
CHANDRIMA A SREEKUMAR
IIND YEAR PG
The Alexanders
The Alexander Discipline owes its name to two generations of the
Alexander family:

• Dr. C. Moody Alexander and his son, Cliff; and

• Dr. R.G. "Wick" Alexander and his sons J. Moody and Chuck.

They continue to live the tradition of The Discipline in their own


private practices in Texas and Colorado and advancing the study of
orthodontics through the lectures that they regularly conduct
around the world.
The Alexanders

Dr. C. Moody Alexander

Dr. C. Moody Alexander has been practicing orthodontics since 1960.


He graduated from the Orthodontic Department of the University of Texas
Dental Branch in Houston and practiced in Odessa, Texas until 1975 when he
moved to Dallas to start a new practice and teach in the Orthodontic
Department at Baylor College of Dentistry.
He was chairman of the department for ten years.
The Alexanders

Dr. R.G. Wick Alexander

His dental degrees are from the University of Texas Dental Branch; the D.D.S. in
1962, and the M.S.D. in 1964. Dr. Alexander began the practice of orthodontics in
Arlington, Texas, in 1964.He is a Clinical Professor of Orthodontics at The
University of Texas, New York University, and Baylor College of Dentistry. Dr.
Alexander is recognized internationally for his innovation in orthodontic
procedures. He is well known for his work in designing the Alexander Discipline, a
system of Brackets placed on teeth, which is used by orthodontists around the
world.
The Alexanders

Dr. J. Moody Alexander

Dr. Chuck Alexander

Dr. Cliff Alexander


INTRODUCTION
•Any enduring principle must be built on a solid
foundation, on certain beliefs that have been tested and
proven by time and experience.

• In the Alexander Discipline, a certain number of


principles are followed that give this technique its
uniqueness.

• The first three principles focus on the philosophic


nature and the attitudinal approach to the delivery of the
Discipline.
Principle 1 Effort Equals Results
Principle 2 There Are No Little Things
Principle 3 The KISS Principle
Principle 4 Establish Goals for Stability
Principle 5 Plan Your Work, Then Work Your Plan
Principle 6 Use Brackets Designed for Specific
Prescriptions
Principle 7 Build Treatment into Bracket
Placement
Principle 8 Exploit Growth to Obtain Predictable
Orthopedic Correction
Principle 9 Establish Ideal Arch Form
Principle 10 Follow a Logical Archwire Sequence
Principle 11 Consolidate Arches Early in Treatment
Principle 12 Ensure Complete Bracket Engagement and
Maintain Consolidation
Principle 13 Let It Cook!
Principle 14 Level the Arches and Open the Bite with
Reverse-Curve Archwires
Principle 15 Create Symmetry
Principle 16 Use Intraoral Elastics to Coordinate the
Arches
Principle 17 Use Nonextraction Treatment When Possible
Principle 18 Use Extraction Treatment When Necessary
Principle 19 Careful Appliance Removal, Then Retention
Will Improve Stability
Principle 20 Create Compliance
PRINCIPLE NUMBER 1

is taken from Allen's book As a Man Thinketh, "In all


human affairs there are efforts and there are results, and
the strength of the effort is the measure of the result."
From this sentence comes the formula,

Effort = Results.
PRINCIPLE NUMBER 2
•based on another quote, "Sometimes when I consider
what tremendous consequences come from little things, I
am tempted to think, there are no little things.“
•Of all the little things that influence the outcome of
treatment, timing may be one of the most important
•Stage of growth
•Age
•Orthodontic diagnosis
•General rule = once patients have lost all primary teeth, with
the exception of the primary mandibular second molars
•This usually occurs when patients are about 11 to 12 years old
and experience a period of rapid growth.
PRINCIPLE NUMBER 3

•comes from World War II and is used in many variations


today, "keep it simple, Stupid. The acronym is KISS.

•If things are kept simple, all involved-patient,


orthodontist, and staff-can do their jobs more effectively.
PRINCIPLE NUMBER 4
Establish Goals for Stability

By maintaining good torque control of the upper incisors, along


with the lower incisors, a balanced interincisal angle is created.
This is critical for long-term stability.

The following goals, when achieved, have been found to help


create healthy, esthetically pleasing, and stable results:
• Canine expansion prevented
• Proper artistic root positioning
• Upright mandibular first molars
• Normal overbite and overjet
• Functional occlusion in centric relation
The 15 Keys to
Orthodontic Success
• Cephalometries: The tetragon-plus analysis

• Among these are the


1. mandibular incisor-mandibular plane (IMPA), or the mandibular
incisor inclination;
2. sella-nasion-mandibular plane (SN-MP), or the mandibular plane
angle;
3. Maxillary incisor-sella-nasion (U l-SN), or the maxillary incisor
inclination;
4. maxillary incisor-mandibular incisor (U 1-L 1), or the interincisal
angle.
• When these four measurements are combined, a four-sided figure,
or tetragon, is formed
5. Tetragon plus
• Additional information garnered from the
cephalogram is referred to as tetragon “plus.“
• Sagittal skeletal dimensions
• Cephalometric soft tissue profile
6. Mandibular intercanine width
• The treatment goal for this critical measurement is to maintain the
original intercanine width.
• Longterm studies have shown that any expansion of more than 1
mm will invariably relapse
• Clinically, the intercanine width is finalized by referring back to the
original mandibular study cast and superimposing the final archwire
over the mandibular arch
7. Maxillary intermolar width
• When measured from the lingual groove at the cervical line of the
maxillary first molars, the maxillary intermolar distance should be
between 34 and 38 mm
8. Arch form
• An ovoid arch form design will provide the most esthetic and stable
form for most patients
9. Leveled mandibular arch
• Leveling the curve of Spee in the mandibular arch is critical to the
correction of deep bites and the maintenance of overbite
correction
10. Occlusion
• Good occlusion is critical for function, health,
and stability.
• Excellent occlusion consists of a good Class I
canine relationship, normal intercuspation of
posterior teeth, normal overbite and overjet
relationships, canine protection in lateral
movements, anterior guidance, and a centric
relation that coincides with maximum
intercuspation.
11. Root positioning
12. Periodontal health
13. Temporomandibular joint
14. Soft tissue profile
15. Smile
The Alexander Discipline is intended to produce the
following results at the end of orthodontic
treatment
• Coincident dental midlines
• Coincident facial midlines
• Esthetically positioned teeth
• A balanced smile line
• A balanced smile arc
• Absence of dark buccal corridors
PRINCIPLE NUMBER 5
Plan Your Work, Then Work Your Plan
•"Begin with the end in mind,“
•The following eight factors help to clarify the sometimes
difficult treatment decision between extraction and nonextraction:
1. Facial and muscle patterns
2. Mandibular functional patterns
3. Tooth size and form
4. Arch length discrepancy
5. Unusual eruption patterns
6. Growth
7. Habits
8. Compliance
Cephalometries
• No matter what cephalometric analysis is used,
three basic measurements must be obtained
from the cephalometric tracing before a proper
treatment plan can be produced:
• 1. Sagittal skeletal pattern
• 2. Vertical skeletal pattern
• 3. Incisor position
Sagittal skeletal pattern
• The first cephalometric determination to be
made is the patient's skeletal type: Class I, II, or
III skeletal pattern.
The measurements
• sella-nasion-point A (SNA)
• sella-nasion-point B (SNB)
• point A-nasion-point B (ANB)
• nasion-point Aporion (NA-Po)
• Wits appraisal
Vertical skeletal pattern

• Whether the patient has a high-, medium-, or


low-angle skeletal pattern will also influence
treatment decisions.
• The sella-nasion-mandibular plane (SN-MP)
• Frankfort mandibular plane angle
• occlusal plane-mandibular plane
• y-axis
1.SN-MP angle ---35 degrees or less , Class II skeletal
patterns can best be treated with a cervical facebow.
During the treatment of a skeletal Class III patient using a
face mask, the force vector is often directed at 45 degrees
in relation to the occlusal plane, depending on the smile
line.
2. SN-MP angle -- 36- 41 degrees , the vertical dimension is
best managed with the use of a combination-pull facebow
(occipital and cervical straps) in patients with a skeletal
Class II relationship.
• The elastic force vector of a face mask used to treat high-
angle Class III patients should be directed parallel to the
occlusal plane to prevent the extrusion of the maxillary
teeth .
3. SN-MP angle -- 42 degrees or greater, every effort
is made to inhibit further vertical growth of the
maxilla.
• A high-pull facebow combination is prescribed for
patients with a high-angle skeletal Class II pattern.
• If the diagnosis is a high-angle skeletal Class III
pattern, the elastic force vector of the face mask is
directed almost parallel to the occlusal plane.
• For high-angle patients with arch length
discrepancies, extraction therapy may be
indicated.
Incisor position

1. In most cases, the best and most stable


position for mandibular incisors is the position
in which the patient presents. Maintaining
these teeth in their original positions is the
goal.
• In high-angle cases--incisors may be more
upright.
• Low angle deep bite cases –incisors be
proclined from their original position.
2. In extraction cases, mandibular incisors are
usually uprighted. If an adequate interincisal
angle is also achieved, this treatment is stable.
3. Studies have indicated that mandibular incisors
can be advanced up to 3 degrees and remain
stable-the 3-degree rule.
• Beyond that critical 3 degrees, instabil ity is more
likely.
Maxillary incisors
• Maintenance of good torque control of the
maxillary incisors, along with the mandibular
incisors, will result in a balanced interincisal angle.
Soft tissue profile
• Convex profile or bimaxillary protrusion: extraction
• Normal or Class II profile: nonextraction or
borderline
• Concave profile: nonextraction
Mandibular incisor position
• Proclined incisors: extraction
• Normally inclined incisors: nonextraction or
borderline
• Retroclined incisors: nonextraction
Attached gingiva
• Thin, narrow attached gingiva or gingival recession :
extraction
• Compromised gingiva: borderline
• Healthy gingiva: nonextraction
Growth potential
• Past growth potential : extraction
• End of peak growth period: borderline
• Within or before pubertal growth period : nonextraction ·
Vertical skeletal pattern
• High-angle (dolichocephalic): extraction
• Medium-angle (mesocephalic): nonextraction or
borderline
• Low-angle (brachycephalic): nonextraction
Mandibular arch length discrepancy
• Severe (more than 6 mm): extraction
• Moderate (4 to 6 mm): borderline
• Slight (less than 4 mm): nonextraction
Maxillary intermolar width (cast analysis)
• Narrow; less than 33 mm can be expanded: change
borderline into nonextraction
• Normal; expansion not a factor
Patient compliance
In a borderline case:
• Poor cooperation: extraction
• Moderate cooperation : borderline
• Excellent cooperation: nonextraction
PRINCIPLE NUMBER 6
Use Brackets Designed
for Specific Prescriptions

•describes specific brackets designed for increased


interbracket space
•wings for rotation and correction, then control;
•precision pretorqued slots
•precision base variation.
PRINCIPLE NUMBER 7
Build Treatment into
Bracket Placement
recommends "building treatment" into the bracket placement.
In placing brackets, three dimensions are considered:

1. bracket height,
2. bracket angulation, and
3. mesiodistalbracket position.
PRINCIPLE NUMBER 8
Exploit Growth to Obtain Predictable Orthopedic
Correction
Is to obtain predictable orthopedic correction by using

•a face bow,
•facemask,
•rapid palatal expansion,
•lip bumper,
•auxiliary appliances such as the transpalatal arch, the
Nance lingual arch, magnets, and distalizing mechanics.
PRINCIPLE NUMBER 9
Establish Ideal ArchForm
This principle discusses the use of a proven arch form
design and a contemporary arch wire force system.
Most patients are treated by using continuous arch wires
beginning with the maxillary arch.

•The initial arch wire is round and flexible (.016 NiTi).


•The transitional arch wire has intermediate stiffness
(.016 stainless steel or 17 X 25 titanium alloy).
•The final wire is stiff, 17 X 25 stainless steel.
PRINCIPLE NUMBER 9

The only difference in the mandibular


sequence is that the initial arch wire is
a flexible rectangular wire, for initial
torque control.
The functions of the arch wires include:
elimination of rotations, development
of arch form, leveling the arches,
control of torque, and final arch form.
PRINCIPLE NUMBER 10
Follow a Logical Archwire Sequence

Three goals for archwires are


(1) to ensure patient comfort

(2) to maximize the potential of each wire

(3) To attain the final archwire as soon as possible.


Archwire Types flexible, transitional, closing, and stiff.
Flexible (initial) archwire
• Maxillary arch: 0.016-inch nickel-titanium (NiTi), 0.0175-
• inch Triple Flex SS; 0.017 x 0.025-inch NiTi
• Mandibular arch: 0.016 x O.022-inch or 0.017 x 0.025-inch
• D-RectlTurbo/copper nickel-titanium (CuNiTi)
Transitional (intermediate) archwire
• Maxillary arch: 0.016-inch SS; 0.017 x 0.025-inch titaniummolybdenum alloy
(TMA)
• Mandibular arch: 0.016 x 0.022-inch TMA; 0.016 x 0.022- inch SS
Closing archwire
• Maxillary arch: 0.017 x 0.025-inch SS with closing loops; 0.017 x 0.025-inch
T-Ioops
• Mandibular arch: 0.016 x O.022-inch SS with closing loops
Stiff (finishing) arch wire
• Maxillary arch: 0.017 x 0.025-inch SS
• Mandibular arch: 0.017 x 0.025-inch SS
PRINCIPLE NUMBER 11
Consolidate Arches Early in
Treatment
•The purpose of closing spaces is to change 10 to 12 independent
force units (the teeth) into 1 unit.
•When this has been accomplished, orthopedic forces, such as a
face bow or a face mask, can create skeletal changes rather than
dental changes.
•Also, intraoral elastics, when attached to the ball hooks on the
brackets, will not move individual teeth or cause spaces to open
between the teeth.
•Consolidated arches are a goal of this treatment.
PRINCIPLE NUMBER 12
Ensure Complete Bracket Engagement and
Maintain Consolidation

•to obtain complete bracket engagement when


placing arch wires, ligating with steel ligatures,
and maintaining consolidation with omega loops
"tied back.“

•One of the most important concepts of the


discipline is using tied-back arch wires.
PRINCIPLE NUMBER 13
Let It Cook!
•Principle number 13 advocates progressing into finishing arch
wires rapidly and allowing sufficient time for the arch wire to
move the teeth to their desired position.
•By following the previous principles and sequencing the
treatment plan, the finishing arch wire is usually placed in 6 to
9 months in nonextraction patients.
• In extraction treatment procedures, progressing into finishing
arch wires may take 9 to 12 months.
• All of the final finishing requirements are placed into
the stainless steel finishing arch wire: arch form,
torque, curve, and omega loops. After this wire has
been properly tied in (full-bracket engagement and
tied back with steel ligature wires), time is needed for
the generated forces to have their effects and to move
the teeth into their final positions.
• Often this wire will remain in place until fixed
appliances are removed.
PRINCIPLE NUMBER 14
Level the Arches and Open the Bite with
Reverse-Curve Archwires
•One of the most common malocclusions found throughout the world is the
deep bite malocclusion.

• In a true deep bite case, the patient exhibits an excessive anterior overbite
and an excessive curve of Spee in the mandibular arch.

•The Alexander Discipline is an effective continuous archwire technique for


leveling the curve of Spee in Class II, division 1 deep bite cases treated
nonextraction.

•The method of leveling the curve of Spee with the Alexander Discipline is by a
combination of mainly bicuspid extrusion, and minor incisor intrusion.

• The Alexander Discipline effectively controls the mandibular incisor position


during the leveling process and does not cause excessive flaring of the
mandibular incisors as a side effect of leveling.
PRINCIPLE NUMBER 15
Create Symmetry
•focuses on creating symmetry.

•Coordination of the arches is essential to establish occlusal symmetry.

•The maxillary and mandibular arch forms have now been individually
finalized and the goal then is to get the maxillary and mandibular arches
coordinated.

•Coordination is accomplished by using preformed arch wires in both


arches as well as symmetrically adjusting the inner bow of the face bow
and the lip bumper.

• Final symmetry is established by specific elastics in finishing arch wires


Treatment proceeds
in the following sequence:
1. Creation of an ideal maxillary arch
with facebow (if necessary) and
archwires.
2. Creation of an ideal mandibular
arch with a lip bumper (if necessary)
and archwires.
3. Coordination of the arches with
elastics.
PRINCIPLE NUMBER 16
Use Intraoral Elastics to Coordinate the Arches

•Principle number 15 recommends that finishing arch wires be in


place before initiating elastic wear.

•By establishing arch form and proper torque controls before using
intraoral elastics, the elastic forces act more orthopedically,
moving the entire arches without adversely affecting the teeth.
The exceptions to this rule include:
• the use of cross-bite elastics when necessary;
• Class III elastics may be used when the lower arch is
initially bonded to prevent flaring of the lower
incisors, and/or while closing lower extraction spaces
with a closing loop arch wire in maximum anchorage
situations
• Class II elastics may be used when closing lower
extraction spaces with a closing-loop arch wire to
move lower molars forward in minimum anchorage
situations.
In general, the use of elastics in the Alexander
Discipline system of biomechanics is divided into
three sequences:
1. Early in treatment
• C rossbite elastics
• Class 3 elastics after bonding of the mandibular arch
to prevent incisor flaring
2. Midtreatment
• Box elastics to help close open bites and/or level the
mandibular arches
• Class 2 elastics for minimum mandibular anchorage
in extraction cases
• Class 3 elastics to maximize mandibular anchorage in
extraction cases
3. Finishing archwires
• Class 2 elastics to achieve occlusion in centric relation
• Midline elastics with class 2 or class 3 elastics (never
combine midline and maxillomandibular elastics
because they can cant the occlusal plane)
• Box elastics to improve occlusion
• Finishing elastics
PRINCIPLE NUMBER 17
Use Nonextraction Treatment When Possible
•Principle number 17, in non extraction cases, recommends initiating
treatment in the upper arch and progressing into finishing arch wires as
soon as possible.

• Because the major goal in non extraction treatment is to control the


position of the lower anterior teeth, total focus can then be placed on
these teeth when the lower arch is banded/bonded.

•The mandibular anterior teeth are controlled by:


1. A -5-degree torque in mandibular incisor brackets
2. A -6-degree tip on mandibular first molars
3. An initial, flexible rectangular archwire
4. Slenderizing, if necessary
5. Class 3 elastics, if necessary
PRINCIPLE NUMBER 18
Use Extraction Treatment When Necessary
•Principle number 18 recommends that, in extraction cases,
treatment is delayed in the mandibular arch to allow time for
driftodontics.

•This is the term the author coined to describe the spontaneous


unraveling of the lower anterior teeth, making it much easier to
place brackets after 4 to 6 months.

• When the upper cuspids have been retracted to a Class I


relationship, the lower arch should be bonded/banded.
Two types of malocclusion almost always
require premolar extractions.
1. patients with extreme mandibular arch
length discrepancy have more tooth mass
than the dental arch can accommodate
2. severe bimaxillary prognathism.
PRINCIPLE NUMBER 19
Careful Appliance Removal, Then Retention Will
Improve Stability
•Principle number 19 advises the use of a specific retention
plan incorporating retainer design, time sequence, and
resolution of third molar teeth in an effort to ensure long-term
stability.

•The upper "wrap-around" retainer wire is fabricated to a


specific design and has proven to be extremely effective
according to the author.

•Also recommended is the fixed lower cuspid- to-cuspid


retainer design using an .0215 Triple- Flex wire (Ormco,
Glendora, CA) bonded to each tooth.
• After bracket removal, the upper retainer is
worn only 8 to 10 hours per 24-hour period,
being placed after dinner and removed the
next morning.
• The patient is instructed not to wear it out of
their home.
• The resulting reduction of lost and broken
retainers has been remarkable.
PRINCIPLE NUMBER 20
Create Compliance
•Although every case is unique in some ways, in many ways every
case is also the same.

•Creating a compliant patient begin s with the attitude of the


orthodontist. Orthodontists are in the "people" business.

•Treatment goals will be achieved if orthodontists believe in the


delivery system, properly educate patients, and effectively
motivate them to follow instructions.

•This kind of communication takes time but produces worthwhile


results.
Appliance Design

•The Alexander design maximizes the concept of straight wire


appliances.

•This is a Discipline that not only uses a force delivery system


that has been well conceived and tested, it also has a system of
Principles that guides the practitioners through each case with
a level of conformity, ensuring predictable final results.

•Once a case is well constructed with the Alexander system,


the Principles serve as a guide throughout the treatment of the
case.
Evolution of the appliance
1978
The original appliance was developed and called as
Vari-Simplex Discipline.

1985

Generation 2: Mini Wick appliance: In this design, a


stronger metal alloy was used, brackets were reduced in
size, and the wings were redesigned to be more
efficient.

1997
Generation 3: Alexander Signature appliance
Appliance Design

•This was the intent of Dr. Alexander when he first introduced


his "Vari-Simplex" bracket system in 1978.

•"Vari" referred to the variety of bracket types used and

•"Simplex" related to the concept of keeping all aspects of the


Discipline as simple as possible.
Appliance Design

Arch wire fabrication and the incorporation of many aspects of


treatment options into the brackets (ie, elastics hooks and
rotational wings on the brackets) added up to the "simplex"
concept.

"Discipline" rather than "appliance" was chosen to reflect that


the orthodontist must be knowledgeable in all aspects of
edgewise mechanics and must play an active role in the
application and follow-up treatment of each patient.
Appliance Design

•As previously mentioned, the Vari-Simplex Discipline was


developed as a conglomeration of other brackets designs.

•The initial goal of developing a simple, philosophically


nonextraction technique, which would produce reproducible
superior results in a consistent fashion, while being convenient to
the patient, was the driving force behind the evolution of Dr.
Alexander's Discipline.
Appliance Design

•The most important factor in determining the original Vari-Simplex


(Ormco Corp, Glendora, CA) Discipline was the tooth location and the size
and shape of the teeth, especially the mesiodistal width and curvature.

•These factors influenced the interbracket width, which affected the


ability to rotate teeth and level the arches.
Tweed to Vari-Simplex
• The Discipline maintains many of Tweed technique, and
was developed from its principles.

• It has benefited from growth dynamics while remaining


true to its three goals: high quality result, ease and
convenience for the patient, and minimized chair-side time.

• In Alexander Discipline, the patient ends up with balanced


facial proportion consistent with skeletal pattern, which is
the key objective to treat the case.

• Non-extraction therapy is preferable whenever possible.


• Vari-Simplex philosophy retains following
three fundamentals of Tweed technique:
1. Anchorage preparation (uprighting
mandibular molars)
2. Positioning of mandibular incisors over basal
bone
3. Orthopedic alteration with headgear
Advantages

• Bracket selection.
•The first, and most important, advantage of the Alexander
Discipline is that the system is composed of a number of
bracket designs.
•The security of the system, and its mechanics, allows for
twin brackets on anterior maxillary teeth, single-wing Lang
brackets on all four cuspids, and single-wing Lewis brackets
on premolars and lower incisors.
BRACKET SELECTION
Advantages

By creating a variation (hence Vari-) in types of brackets selected,


the advantages of each design are used in a single-slot (0.018" X
0.025") design.

Although other systems use brackets of varying slot size, the


Alexander Discipline uses varying brackets of identical slot size. In
situations in which mesial and distal wings are necessary for
rotational control, they are incorporated. This Variation leads to a
SIMPLEX Discipline.
Interbracket space

•Using single brackets with wings in the


lower anterior and buccal segments allows
maximal interbracket distance.

• The new metals available allow the


practitioner to engage stiffer (larger) wires
faster with such a bracket design.

•This allows for faster leveling, less


discomfort, and improved torque control.
This also allows the orthodontist to get into
their final arch wires faster.
Single brackets create increased inter-bracket space
ROTATIONAL CONTROL
•Rotation wings on cuspids,
bicuspids, and lower anteriors
provide for improved rotational
control and individual activation of
particularly involved teeth.

•In those situations in which a single


tooth does not respond to
conventional mechanics,
Rotational wings
individual forces can be applied by
activating, deactivating, or removing
individual wings.
TORQUE
•Each bracket has a 0.018 X 0.025 inch
BRACKET TORQUES
wire slot. Maxillary Arch
Centrals 14°
Laterals 7°
•Slot sizes do not vary from anterior Cuspids – 3°
Bicuspids – 7°
to posterior brackets and, realizing Molars – 10°
that 5° of torque is lost for each Mandibular Arch
Incisors – 5°
0.001-inch "play" in the slot, final Cuspids – 7°
1st Bicuspids – 11°
ideal wires (0.017" X 0.025") are 2nd Bicuspids – 17°
constructed to fill the slot as much as 1st Molars – 22°
2nd Molars 0° or – 27°
possible.
Lower incisor torque
•Contrary to many bracket prescriptions, —5° torque is
incorporated into lower incisor brackets.

• This allows for more efficient control of these teeth during the
leveling process and actually sets up anterior anchorage in those
situations where the mandibular posterior teeth are to be
protracted in the correction of Class II malocclusions.

•The -5° torque also aids in ideally maintaining the position of


these teeth over the mandibular basal bone.

•The use of a flexible rectangular arch wire in the lower arch is


recommended as soon as possible to optimally control torque in
this critical area.
Anchorage Considerations

•The mandibular first molar is also constructed to have a —6°


tip incorporated into its design. This, being a throwback to the
Tweed technique, is essential in establishing posterior
anchorage in Alexander cases.

•By creating this situation, the basic construction of a case


allows the mesial aspect of mandibular molars to be
uprighted, which, in turn, incorporates leveling mechanics
with attention to anchorage demands.
Lower first molar tip

The —6° tip of the molar bands also positively


contributes to a nonextraction philosophy in that it
allows distal movement of the molar crowns, which can
create additional arch length where needed.
Band placement is critical on the first molar.
Lower first molar tip

•For a typical case the band must be placed, as always, with the
occlusal margin of the band parallel with the occlusal surface of
the molar at the marginal ridges.
•In open bite situations, care must be given to tip the distal
aspect of the band gingivally so that the mesial cusp is not
supererupted and the distal aspect is supported, which
minimizes the bite opening effect of the —6° tip of the bracket
placement.
TWIN BRACKETS
•Twin (Diamond) brackets (Ormco Corp) are used
on large, flat-surfaced teeth (namely, maxillary
central and lateral incisors).
•The flat surfaces of these teeth permit full arch
wire engagement in the twin brackets.
•Ball hooks for elastic placement are usually
placed on lateral incisor brackets.
•There is little trouble tying the wire into these
brackets because of their ease of accessibility, and
the brackets allow for 5 to 6 mm of interbracket
width, which is sufficient for flexibility, rotational
control, and torquing.
• These brackets are smooth and minimize
irritation on labial tissues
LANG BRACKETS

•These brackets, originally developed by Dr.


Howard Lang, are used on cuspids, which
are large, round-surfaced teeth at the
corners of the arches.
•The contoured pad fits beautifully on the
surface of the tooth and the straight wing
eliminates interference with complete arch
wire engagement.
LANG BRACKETS

Thus, the bracket is easily ligated and


interbracket width is maximized. Twin brackets
on cuspids are not the brackets of choice
because they can interfere with opposing cusps
on occlusion (actually often causing cusp
attrition) and it is often impossible to get full
bracket engagement on these teeth early in
treatment.
LEWIS BRACKETS

•Lewis brackets are used on round


surfaced teeth not located at the corners
of the arches (maxillary and mandibular
bicuspids) as well as small, flat-surfaced
teeth (mandibular incisors).
•The Lewis bracket is a fixedwing single
bracket that again contributes positively
to the concept of increased interbracket
width.
LEWIS BRACKETS
•The wings provide a distinct advantage in
having a built-in auxiliary for rotational
control, much in the same fashion as those on
the Lang brackets.
• By activating these wings, additional
rotational force can be exerted if necessary.
No additional wedges or particular ties are
necessary.
•These wings allow for fast, efficient, safe (ie,
little chance for bracket debonding during
activation) and predictable action.
LEWIS BRACKETS
•It is also common to remove the wing on either side of the
main bracket in situations in which rotations are so severe that
the bracket cannot otherwise be placed in its ideal position.
•The offending wing can be clipped or ground off, leaving the
opposite wing to create the desired rotational movement.
LEWIS BRACKETS

•Where twin brackets are used in situations where teeth are


severely rotated, ideal bracket position is not possible.

•The latter situation would require rebonding at a later time in


treatment when space becomes available.

•This rebonding often requires an additional appointment that


can be avoided with the use of Lewis and/or Lang brackets.
MOLAR BANDS
•Twin brackets with convertible sheaths are used on the
first molars.
•Headgear tubes are used on the maxillary molars and are
manufactured to be on the occlusal aspect of the band.
•The mandibular first molar bands can be constructed
with convertible arch wire tubes and lip bumper tubes
placed on the gingival aspect of the bracket.
•This allows the convertibility of the tubes as well as
allowing for the placement of lip bumpers in indicated
situations.
MOLAR BANDS

Single buccal tubes are used on


both mandibular and maxillary
second molar teeth.
Elastic hooks are located on all
first and second molar brackets,
and also as distal offsets used for
tying back arch wires. Lingual
elastilugs are placed on all molar
bands.
SPECIFICATIONS OF THIS APPLIANCE

•The Discipline has strict guidelines concerning bracket heights


and positions and are shown in.
•It must be kept in mind that each bracket must be parallel to
the long axis of each tooth, regardless of the bracket and tooth.
•Guide markings are milled into each bracket to assist in correct
long-axis placement.
SPECIFICATIONS OF THIS APPLIANCE
Bracket Height
Bracket Height
Bracket placement in first bicuspid extraction
cases

bicuspids are positioned with the mesial


bracket angled toward the extraction site.
By doing so, the roots of the
teeth are uprighted toward the extraction
area allowing for improved parallelism with
resulting easier retraction of the cuspids.
Bracket placement in second bicuspid extraction
cases
Bracket Angulation
Bracket Angulation
Bracket Torque
Bracket Torque
Bracket base thickness
BRACKET IN-OUT
Maxillary Arch Base
Centrals Standard
Laterals Thick
Cuspids and Bicuspids Thin
Molars Thinnest

Mandibular Arch Base


Anteriors Thick
Cuspids and Bicuspids Thin
Molars Thinnest
ARCH WIRE SELECTION AND SEQUENCE

•Proper arch wire selection and sequence allows the vari-simplex discipline to
deliver results.

•The combination of greater interbracket width achieved with lewis and lang
brackets, improved resiliency of arch wires such as multi stranded and bet
titanium or nickel titanium wires and the vari simplex discipline itself have all
contributed to the reduction of time consuming arch wire changes.
ARCH WIRE SELECTION AND SEQUENCE

•Before selection of each arch wire, the doctor must identify the
intended purpose.

•The initial goal in most cases is the elimination of rotations. This is


best accomplished by multi stranded round and rectangular wires,
beta titanium or nickel titanium wires.

•Levelling and space closure are often primary goals of the next
wire. This is usually a rectangualr wire, either beta titanium or
stainless steel, depending on the specific need.

•The last step, final leveling and arch form finishing, is always
performed with stainless steel wire.
ARCH WIRE SELECTION AND SEQUENCE

Non extraction cases

Maxillary arch

•o.o175 multistranded

•0.016 stainless steel

•00.017X0.025” stainless steel finishing


ARCH WIRE SELECTION AND SEQUENCE

Non extraction cases

Mandibular arch

•o.o17X0.025 multistranded

•0.016X0.022 stainless steel or 0.017X0.025” beta


titanium

•00.017X0.025” stainless steel finishing


ARCH WIRE SELECTION AND SEQUENCE

Extraction cases

Maxillary arch

•o.o17X0.025 or 0.0175” multistranded

•0.016” stainless steel for retracting cuspids

•0.018X0.025” stainless steel with closing loops

•0.017X0.025” stainless steel finishing


ARCH WIRE SELECTION AND SEQUENCE

Extraction cases

Mandibular arch

•o.o17X0.025 or 0.0175” multistranded

•0.016” stainless steel or o.o17X0.025 multistranded

•0.016X0.022” stainless steel with closing loops

•0.017X0.025” stainless steel finishing


The Orthodontic Management of Vertical Deficiencies
in the Alexander Discipline

• Vertical deficiencies are most often corrected by intruding the anterior


teeth, extruding the posterior teeth, or a combination of the two.
• Maxillary Bracket Height- maxillary six anterior brackets are placed 0.5-
mm more incisally and the posterior brackets are placed 0.5-mm more
gingivally.
• Curve of Spee - After the initial arch wire, an accentuated curve of Spee is
placed to open the bite
• When determining the amount of curve to place in the arch wire, it is
important to look at the patient's "smile line.“
• If the incision-stomion measurement does not show a full clinical crown,
then great care must be taken with the amount of curve placed in the arch
wire.
• When gingival tissue is exposed when smiling, more curve can be placed in
the arch wire.
• If the bite has not opened adequately after a few
months of treatment in the finishing arch wires, a bite
plate is placed.
• The face bow "stabilizes" the molars while the arch wire
intrudes "holds" the anterior teeth as the face grows.
• Treatment of the mandibular arch is initiated
approximately 6 months after the maxillary brackets are
placed.
• No elastics should be used until finishing arch wires are
in place.
• Retention – similar to that of other patients except that
a bite plate is placed on the maxillary retainer.
• The patient sleeps in the retainer for 2 to 3 years.
• Precision control of intraoral and extraoral forces makes
this system work efficiently.
The Relationship Between the Curve of Spee,
Relapse, and The Alexander Discipline
Sal Carcara, C. Brian Preston, and Ossama Jureyda
(Semin Orthod 2001;7:90-99.)
• The records of 31 randomly selected patients treated by
nonextraction with the Alexander Discipline were studied.
• The results show that the Alexander Discipline levels the curve of
Spee in Class II, Division I deep-bite cases and that when relapse
occurs, the curve of Spee returns to a lesser extent than was
present before orthodontic treatment.
• With the Alexander Discipline, a pretreatment curve of Spee that is
not completely level posttreatment has a slightly higher incidence
and magnitude of relapse than a pretreatment curve of Spee that is
completely level posttreatment.
• This study indicated that, based on the pretreatment curve of Spee,
there is no ability to predict relapse in mandibular intercanine
width, overbite, overjet, mandibular incisor irregularity, and arch
length in Class II, Division I deep-bite cases treated with the
Alexander Discipline.
Face Bow Correction of Skeletal Class II
Discrepancies in the Alexander Discipline
• Alexander advocated a continuous upper arch wire
to prevent molar tipping while adding tied-back
omega loops to reduce their extrusion and keep the
arch consolidated
• Although this approach prevented the distal
movement of the maxillary first molars, another
effect was observed.
• the Class II skeletal problem was being corrected by
the forward movement or growth of the mandible.
• facebow is can affect or control all three planes of
space, it is a unique appliance for skeletal correction.
Keys to Optimal Face Bow Results
• Face bow therapy has been shown to be effective, however, a
successful outcome requires
• Cooperation.
The face bow should be worn consistently. Eight to 10 hours
every night is usually adequate. In extreme anteroposterior and
vertical discrepancies, more wear can be beneficial.
• Growth.
If the patient is not growing, no skeletal changes will occur.
• Tie back on continuous arch wire.
If the upper arch wire is not consolidated into one unit, the
face bow will individually tip molars distally, resulting in the loss
of effective anterior growth expression of the mandible and
possible extrusion of upper molars. In addition to maintaining
the space closure by tying back the arch wire, the wire in the
molar tube keeps the molars upright, helping prevent their
extrusion
Treatment of Class III Malocclusions
in the Alexander Discipline
• In the diagnosis and treatment planning of Class III
malocclusions, a distinction must be made between
pseudo- and true Class III skeletal patterns.
• The optimal time to initiate treatment is an important
consideration.
• The Alexander Discipline treatment mechanics includes
the face mask, chin cap.
• Class III elastics, and/or lip bumper and rapid palatal
expansion.
• In the nongrowing patient, surgical options are used.
• Pseudo-Class III malocclusions respond well to face
mask therapy.
• The elastic attachment from the face mask is usually
to the ball hooks on the maxillary lateral incisors.
• elastic forces from the face mask should be attached
to a consolidated, tied-back arch wire
• VME- elastic vector as parallel to the occlusal plane
• VMD - a vector of 45° in relation to the occlusal plane
• elastic force begins with 150 g/elastic per side, this
increases for the next two appointments until it
reaches approximately 500 g, 14 hours per day, 6 to
12 months.
• Use of a rapid palatal expansion (RPE) with a face
mask will enhance the effectiveness of the
protraction.
• authors recommend using the RPE if needed to
improve the transverse dimension, otherwise the
face mask alone can resolve the problem.
• Anterior crossbites (pseudo-Class III) and skeletal
Class III malocclusions can sometimes be treated
by the extraction of teeth.
• extracting one lower incisor works best when the
upper lateral incisors are smaller than normal and
the molar relationship is closer to a "super" Class I
occlusion
• chin cap is less effective than the face mask.
• Today it is used during the maintenance phase of a
two-phase treatment or to help "hold" the mandible
during retention after full treatment has been
completed.
• The use of Class III elastics can be effective in
dentoalveolar compensation by tipping the anterior
teeth
• Lower molars can be uprighted and distalized slightly
by attaching Class III elastics to a lip bumper.
• True Class III (Skeletal) Malocclusions , If both
arches have significant significant
discrepancies, a possible solution is the
extraction of upper second bicuspid and lower
first bicuspid teeth with use of class III elastics
• If the maxillary arch has less crowding, an
appropriate decision may be to extract teeth
only in the mandibular arch.
Retention and finishing

The problem of retention must be solved during


treatment or
it will not be solved at all.

Dr. Fred Schudy


Retention and finishing
Certain criteria must be met before the patient is ready for retention. These
criteria include
• Ideal occlusion.
• Cuspid protected, with centric occlusion and centric relation coincident.
• Normal overbite and overjet.
• Proper artistic positioning.
• Spread out incisor roots, especially the lower incisor roots.
• Correct torque of the upper incisors to allow for a good interincisal angle.
• Lower incisors balanced over basal bone within 3° of their original position.
When proclined excessively, the lower incisors tend to upright over time.
Retention and finishing

•In addition, during treatment any undesirable interdental


papilla spaces may be closed by using air rotor slenderizing.

•Ideal gingival line disharmonies are corrected with vertical


positioning of incisors, and less often by using surgical
recontouring of the gingiva.
Retention and finishing

•In addition, a circumferential supracrestal fiberotomy is


performed on all adults with severely rotated teeth 2 months
before fixed appliance removal.
•Removal of hyperplastic tissue in the maxillary central incisor
area is also performed where heavy diastemas are present,
especially if they are considered to be familial traits.
Countdown to retention

When all the goals of the optimally treated patient are met and
fixed appliance removal time is approaching, four appointments
are made with specific objectives for each appointment.

Appointment 1: Sectioning of wires and finishing elastics.

Appointment 2: (3 weeks later): Occlusal check and final


adjustments, and possible sectioning of the opposing arch wire
and removal of molar bands.
Countdown to retention

Appointment 3 :(3 weeks later): Fixed appliances removal.

Appointment 4: (2 days later): Seating of the retainers.


Countdown to retention

•These last 6 weeks of treatment are devoted to finalizing the


posterior occlusion and the anterior overbite.

•This is accomplished by arch wire sectioning and the wearing of


specifically attached elastics: (3/4-in 2-oz Ostrich; Ormco,
Glendora, CA) in the posterior section of the arches, and, if
necessary, placement of an anterior box elastic, (3/16-in 6-oz
Impala; Ormco).
Countdown to retention
Countdown to retention
Retention

The four treatment goals of the Alexander Discipline in the


lower cuspid to cuspid area that lead to long-term stability
are -

1. Maintain the cuspid-to-cuspid width close to the original


dimension.

2. Lower incisors upright within 3° of original angulation.

3. Roots of lower incisors spread out properly.

4. Interproximal enamel reduction done.


Retainer

•A wraparound retainer design is


constructed with the facial bow
soldered to C-clasps around the
terminal molar (usually second
molars).
• A preformed retainer wire has been
designed to eliminate the tendency in
previous designs for the anterior
portion of the wire to slip gingivally.
Retainer
Retainer
•In recent years, the bonded multistranded
mandibular cuspid to cuspid has become very
popular, mainly because of its ease of placement
and its effectiveness in preventing relapse.
•A 0.0215 multistranded wire (Triple-Flex; Ormco,
Glendora, CA) is contoured directly or indirectly
on the lingual surface of the anteriors from the
cuspid to the opposite cuspid.
•In extraction cases, the wire can be extended to
the mesial groove of the bicuspids.
Conclusion
•Alexander orthodontic philosophy is a unique
orthodontic treatment approach designed to provide
excellent outcome results in easy systematized
manner.

•Its uniqueness accomplished through the application


of a certain number of principles.
REFERENCES
•THE 20 PRINCIPLES OF THE ALEXANDER DISCIPLINE -R. G. "Wick"
Alexander. Quintessence Publishing Co, Inc
•Alexander RG. The Vari-Simplex Discipline. J Clin Orthod 1983;
17(6):380–392.
•Alexander CD, Alexander JM. Facebow correction of skeletal Class II
discrepancies in the Alexander Discipline. Semin Orthod 2001;
7(2):80–84.
•The principles of Alexander discipline by Richard G. Alexander,
Seminars in Orthodontics, vol &, no.2 June 2001:pg 62-66
•The Alexander discipline: Appliance design and Construction, M.
Alan Bagden, Seminars in Orthodontics, vol &, no.2 June 2001:pg
74-79
• The relationship between the curve of spee, relapse, and the
Alexander Discipline, Sal Carcara, C. Brian Preston and Ossama
Jureyda, Seminars in Orthodontics, vol &, no.2 June 2001:pg
90-99
• Finishing and retention procedures in the Alexander
discipline, Tucker Haltom, Seminars in Orthodontics, vol &,
no.2 June 2001:pg 132-137

• Al-Zubair NM: Alexander Discipline: Concept & Philosophy ,


Orthodontic Journal of Nepal, Vol. 5, No. 1, June 2015