The Principles of the Alexander Discipline

Richard G. Alexander
The Alexander Discipline is based on the premise of a number of principles. This article lists and briefly describes these principles and the reason each is considered important in the management of the orthodontic patient in the Alexander Discipline, (Semin Orthod 2001;7:62-66,) Copyright 2001 by

W.B. Saunders Company

nY e n d u r i n g principle must be built on a solid foundation, on certain beliefs that have b e e n tested a n d proven by time a n d experience. In the M e x a n d e r Discipline, a certain n u m b e r of principles are followed that give this technique its uniqueness. T h e first three principles focus on the philosophic nature and the attitudinal a p p r o a c h to the delivery of the Discipline. O n e of the original goals of the technique is to m a k e t r e a t m e n t easy and m o r e comfortable for the patient. For any technique in o r t h o d o n tics to be successful, the patient must be involved in the procedures. Even though some appliances are said to be noncompliant, the reality is that no such thing is possible. Each patient must be willing to keep their teeth clean, take care of the appliances, watch what they eat, and be present for their appointments. Allowing the patient to b e c o m e a p a r t n e r in the t r e a t m e n t p r o c e d u r e s not only gives t h e m some ownership in the process, but it ensures that the results will reach a higher level. Patient compliance is critical to the success of this technique. T o o often, other techniques focus on the mechanics of treatment. Mechanics are important, however, mechanics alone will not p r o d u c e the optimal result without patient cooperation. In orthodontic education, p e r h a p s the forgotten skill is teaching the student motivational techniques for successful results. 1,2

W h e n the n e e d for this skill is understood, the clinician will accept the responsibility to learn techniques that will e n h a n c e their ability to motivate their patients while p r o d u c i n g high-quality results. Principle n u m b e r 1 is taken f r o m Allen's 3 b o o k A s a M a n Thinketh, "In all h u m a n affairs there are efforts and there are results, and the strength of the effort is the measure of the resuit." F r o m this sentence comes the formula, Effort = Results. Principle n u m b e r 2 is based on a n o t h e r quote, "Sometimes when I consider what trem e n d o u s consequences c o m e f r o m little things, I am t e m p t e d to think, there are no little things. ''4 Principle n u m b e r 3 comes f r o m World War II and is used in m a n y variations today, "keep it simple stupid. ''3 O f course, the acronym is KISS. Principle n u m b e r 4 states that you should plan your work. Accurate diagnosis and treatm e n t planning is critical. No matter what cephalometric analysis (Fig 1) is used, three basic questions must be answered f r o m the cephalometric tracing before a p r o p e r t r e a t m e n t plan can be produced: 1. Sagittal skeletal pattern: D e t e r m i n i n g the Class I, II, or III growth pattern will help decide what type of orthopedic force is preferred. 2. Vertical skeletal pattern: Determining whether the case has a high-, medium-, or low-angle skeletal pattern will influence t r e a t m e n t decisions. 3. Incisors position: (a) In most cases, in the a u t h o r ' s opinion, the best and most stable position for lower incisors is the position in which the patient presents. To keep lower

From Arlington, TX. Address correspondence to IL G. leVi&Alexander, DDS, MSD, 840 West Mitchell, Arlington, TX 76013. Copyright 2001 by W.B. Saunders Company 1073-8746/01/0702-0001535.00/0 doi:l O.1053/sodo. 2001.23536 62

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 62-66

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POINTS OF MEASUREMENT
Figure 1. Cephalometric measurements used to determine sagital and vertical skeletal patterns and incisor positions. incisors in their original positions is often our goal. (b) In extraction cases, lower incisors are almost always uprighted. (c) O u r studies 5-7 have shown that lower incisors can be advanced up to 3 and remain stable. Beyond that degree, instability is more likely. The only time the lower incisors are advanced beyond this degree is when they are abnormally retroclined. The latter situation is commonly seen in Class II, Division 2, and Class II, Division 1 deep-bite cases. By maintaining good torque control of the u p p e r incisors, along with the lower incisors, a balanced interincisal angle is created. This is critical for long-term stability, s Principle n u m b e r 5 describes our goals for stability. Objectives include mandibular incisors that are balanced on basal bone with a good interincisal angle, cuspids not expanded, p r o p e r root artistic positioning, upright mandibular molars, normal overbite and overjet, and a functional occlusion in centric relation. These goals, when achieved, have b e e n f o u n d to create healthy, aesthetically pleasing, and stable results.5.6.s-10 Principle n u m b e r 6 describes specific brackets designed for increased interbracket space; wings for rotation and correction, then control; precision p r e t o r q u e d slots; and precision base variation. Details of the bracket system are discussed by Bagden on page 74 in this issue of Seminars in Orthodontics. Principle n u m b e r 7 r e c o m m e n d s "building treatment" into the bracket placement. In placing brackets, three dimensions are considered: bracket height, bracket angulation, and mesiodistal bracket position. This is also described later. Principle n u m b e r 8 is to obtain predictable orthopedic correction by using a face bow, face mask, rapid palatal expansion, lip bumper, or other auxiliary appliances such as the transpalatal arch, the Nance, lingual arch, magnets, and distalizing mechanics. Face bow treatment is discussed in a n o t h e r article in this issue. In the M e x a n d e r Discipline, a face bow and face mask are used primarily for orthopedic forces. This means that these forces are placed on consolidated, tied-back arch wires in growing patients. If arch wires are not tied

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back, the facebow forces are changed to orthodontic forces, resulting in tooth m o v e m e n t . Principle n u m b e r 9 discusses the use of a proven arch form design 12 (Fig 2) and a contemporary arch wire force system. 13 Most patients are treated by using continuous arch wires beginning with the maxillary arch. T h e initial arch wire is r o u n d and flexible (.016 NiTi). T h e transitional arch wire has intermediate stiffness (.016 stainless steel or 17 25 titanium alloy). T h e final wire is stiff, 17 25 stainless steel. T h e only difference in the m a n d i b u l a r sequence is that the initial arch wire is a flexible rectangular wire, for initial torque control. T h e functions of the arch wires include: elimination of rotations, dev e l o p m e n t of arch form, leveling the arches, control of torque, a n d final arch form. Principle n u m b e r 10 is to consolidate arches early in t r e a t m e n t . T h e p u r p o s e of closing spaces is to c h a n g e 10 to 12 i n d e p e n d e n t force units (the teeth) into 1 unit. W h e n this has b e e n a c c o m p l i s h e d , o r t h o p e d i c forces, such as a face bow or a face mask, can create skeletal c h a n g e s r a t h e r t h a n dental changes. Also, iutraoral elastics, w h e n a t t a c h e d to the ball h o o k s o n the brackets, will n o t m o v e individual teeth or cause spaces to o p e n b e t w e e n the teeth. C o n s o l i d a t e d arches are a goal o f this t r e a t m e n t . Principle n u m b e r 11 is to obtain complete bracket e n g a g e m e n t w h e n placing arch wires, ligating with steel ligatures, and maintaining consolidation with o m e g a loops "tied back." O n e o f the most i m p o r t a n t concepts of the discipline is using tied-back arch wires. Principle n u m b e r 12 is to level arches a n d o p e n the bite with accentuated and reverse curves of Spee. Clinical experience and research 1:~,14 have substantiated that leveling the arches and o p e n i n g the bite with the M e x a n d e r Discipline is not only successful, but also stable (Fig 3). Principle n u m b e r 13 advocates p r o g r e s s i n g into finishing a r c h wires rapidly a n d allowing sufficient time for the a r c h wire to m o v e the t e e t h to their desired position. By following the previous principles a n d s e q u e n c i n g the t r e a t m e n t plan, the finishing a r c h wire is usually p l a c e d in 6 to 9 m o n t h s in n o n e x t r a c t i o n patients. In e x t r a c t i o n t r e a t m e n t p r o c e d u r e s , p r o g r e s s i n g into finishing arch wires m a y take 9 to 12 m o n t h s All o f the final finishing re-

ORMCO

Part No 20%0060

Figure 2. Most maxillary arch forms will fall within 1 SD of this template. Two mandibular arch forms are needed to accomplish this. (Courtesy of Ormco Corp, Gleudora, CA.)

q u i r e m e n t s are p l a c e d into the stainless steel finishing a r c h wire: a r c h f o r m , torque, curve, a n d o m e g a loops. After this wire has b e e n p r o p e r l y tied in (full-bracket e n g a g e m e n t a n d tied b a c k with steel ligature wires), time is n e e d e d for the g e n e r a t e d forces to have their effects a n d to m o v e the teeth into their final positions. O f t e n this wire will r e m a i n in place until fixed appliances are r e m o v e d . Principle n u m b e r 14 focuses on creating symmetry. Coordination of the arches is essential to establish occlusal symmetry. T h e maxillary and m a n d i b u l a r arch forms have now b e e n individually finalized and the goal then is to get the maxillary and m a n d i b u l a r arches coordinated. Coordination is accomplished by using pref o r m e d arch wires in b o t h arches as well as symmetrically adjusting the inner bow of the face bow and the lip b u m p e r . Final symmetry is es-

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Figure 3. Mandibular heat-treated 17 x 25 ss arch wire with reverse curve of Spee tied in and tied back (A). Six months later with both arches level (B). tablished by specific elastics in finishing arch wires. Principle n u m b e r 15 r e c o m m e n d s that finishing arch wires be in place before initiating elastic wear. By establishing arch form and p r o p e r 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 b o n d e d to prevent flaring of the lower incisors, a n d / o r while closing lower extraction spaces with a closing loop arch wire in m a x i m u m anchorage situations; and Class I1 elastics may be used when closing lower extraction spaces with a closing-loop arch wire to move lower molars forward in m i n i m u m anchorage situations. Principle number 16, in nonextraction cases, u~ r e c o m m e n d s initiating treatment in the u p p e r arch and progressing into finishing arch wires as soon as possible. Because the major goal in nonextraction 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 b a n d e d / b o n d e d . The lower anterior teeth are controlled by - 5 torque in lower incisor brackets, - 6 tip on lower first molars, the use of initial flexible rectangular arch wire, slenderizing teeth if necessary, and Class II1 elastics if necessary. Principle n u m b e r 17 r e c o m m e n d s that, in extraction cases, treatment be initiated in the u p p e r arch. The objective is to remove potential bracket interferences by improving the overbite with an accentuated cmwe of Spee and retracting the cuspids before b o n d i n g / b a n d i n g the lower arch. U p p e r cuspid teeth are retracted with power chains on .016 stainless steel arch wire. This procedure usually takes 6 to 8 months. Principle n u m b e r 18 r e c o m m e n d s that, in extraction cases, 17 treatment is delayed in the mandibular arch to allow time for driftodontics (Fig 4). This is the term the author coined to describe the spontaneous unraveling of the lower anterior teeth, making it m u c h easier to place brackets after 4 to 6 months. W h e n the u p p e r cuspids have been retracted to a Class I relationship, the lower arch should be bonded/banded. Principle n u m b e r 19 advises the use of a specific retention plan ls,-~ incorporating retainer design, time sequence, and resolution of third molar teeth in an effort to ensure long-term stability. The u p p e r "wrap-around" retainer wire is fabricated to a specific design and has proven to be extremely effective according to the author. Also r e c o m m e n d e d is the fixed lower cuspid-to-cuspid retainer design using an .0215 Triple-Flex wire (Ormco, Glendora, CA) b o n d e d to each tooth. After bracket removal, the u p p e r 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 n u m b e r 20 is "to work your plan." A l t h o u g h every case is u n i q u e in some ways, in m a n y ways every case is also the same. The general t r e a t m e n t plan in most cases as outlined in these principles is to treat the u p p e r

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Figure 4. Pretreatment mandibular occlusal view (A). Four months later, showing driftodontics (B).

arch first by using a specific series o f arch wires. If the case requires o r t h o p e d i c correction, it is initiated o n the maxillary arch with an rapid palatal e x p a n d e r (RPE) a n d / o r face b o w or facemask. A p p r o x i m a t e l y 6 m o n t h s after c o m m e n c i n g maxillary arch treatment, t r e a t m e n t is initiated in the lower arch. A specific series o f arch wires are used to position the m a n d i b u l a r teeth. After the finishing arch wires are in place, appropriate elastics are used to c o o r d i n a t e the arches and finalize the o c c l u s i o n . Retainers are then placed. Following these basic step-by-step procedures allows the clinician to control treatment progress. By being able to anticipate treatment objectives o f the next appointment, future scheduling is simplified and treatment progress can be easily m o n i t o r e d so that the treatment can be c o m p l e t e d on schedule. The ultimate objective is a well-treated patient, c o m p l e t e d in a timely fashion, with a satisfied patient, parents, and doctor. References
1. Alexander RG, Alexander CM, Alexander C, et al. Creating the compliant patient. J Clin Orthod 1996;30:493497. 2. Stroud J. The psychosocial effect of orthodontic treatment [master's thesis]. Dallas, TX: Baylor College of Dentistry, 1996. 3. AllenJ. As a man thinketh. Classics of inspiration. Kansas City, MO, Halhnark Cards, Inc, 1971, 57. 4. Covey S. First things first. New York, Simon and Schuster, 1994, 287.

5. Glenn G, Sinclair PM, Alexander RG. Non-extraction orthodontic therapy: Post-treatment dental and skeletal stability. AmJ Orthod 1987;92:321-328. 6. Ehns T. The long-term stability of class II, division 1, nonextraction cervical face-bow therapy: Part 1, model analysis. AmJ Clin Orthod 1996;109:271-276. 7. Elms T. The long-term stability of class II, division 1, nonextraction cervical face-bow therapy: Part 2, cephalometric analysis. Am J Clin Orthod 1996;109:386-392. 8. Nevant CT, Bnschang PH, Alexander RG, et al. Lip bumper therapy for gaining arch length. Am J Orthod 1991;100:330-336. 9. Alexander JM. A comparative study of orthodontic stability in class I extraction cases [master's thesis]. Dallas, TX: Baylor College of Dentistry, 1995. 10. Alexander RG. Treatment and retention for long-term stability. In: Retention and stability in orthodontics. Philadelphia, W.B. Saunders, 1993. 11. Alexander RG. The quest for long-term stability. In: Sachdeva R (ed). Orthodontics for the next millennium. Glendora, CA: Ormco, 1997. 12. Alexander RG. A practical approach to arch form. Clinical Impressions 1992;1:3-5. 13. Alexander RG. The Alexander Discipline. In: Engel GA (ed). Glendora, CA: Ormco, 1986. 14. Bernstein R. Leveling the curve of Spee with a continuous archwire technique-a long-term cephalometric analysis. Master's Thesis, State University of New York at Buffalo, Buffalo, NY, January, 1999. 15. Alexander RG. The Alexander Discipline. In: Engel GA (ed). Glendora, CA: Ormco, 1986, chap 7. 16. Alexander RG. The Alexander Discipline. In: Engel GA (ed). Glendora, CA: Ormco, 1986, chap 9. 17. Alexander RG. The Alexander Discipline. In: Engel GA (ed). Glendora, CA: Ormco, 1986, chap 10. 18. Alexander RG. The Alexander Discipline. In: Engel GA (ed). Glendora, CA: Ormco, 1986, chap 14. 19. Alexander RG. The vari-simplex discipline-part 4 countdown to retention. J Clin Orthod 1983;18:214-218.