Alexander discipline

ALEXANDER DISCIPLINEALEXANDER DISCIPLINE
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www.indiandentalacademy.com

Contents
 Introduction
 The Alexanders
 Principles
 Appliance design
 Specifications of Alexander
discipline
 Advantages
 Various bracket designs
 Bracket positioning
 Arch wire sequencing
 Anchorage considerations
 Retention and finishing
 Conclusion
•Patient management
•Practice management
•Other aspects

The AlexandersThe 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.

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.

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. www.indiandentalacademy.com

Dr. J. Moody Alexander
Dr. Cliff Alexander
Dr. Chuck Alexander

INTRODUCTION
The Alexander Discipline is based on the premise of a
number of principles.
Any enduring principle must be built on a solid foundation,
on certain beliefs that have been tested and proven by time
and experience.

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.Effort = Results.

PRINCIPLE NUMBER 2
is based on another quote, "Sometimes when I
consider what tremendous consequences come from
little things,
I am tempted to think, there are no littleno little
things."things."

PRINCIPLE NUMBER 3
comes from World War II and is used in many
variations today, "keep it simple, Sir."keep it simple, Sir. The acronym
is KISS.KISS.

PRINCIPLE NUMBER 4
states that you should plan your work. Accurate
diagnosis and treatment planning is critical. No
matter what cephalometric analysis is used, three
basic questions must be answered from the
cephalometric tracing before a proper treatment
plan can be produced.

PRINCIPLE NUMBER 4

PRINCIPLE NUMBER 4
1. Sagittal skeletal pattern: Determining 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 treatment decisions.
3. Incisors position: (a) In most cases, in the author's
opinion, the best and most stable position for lower
incisors is the position in which the patient presents. To
keep lower incisors in their original positions is often our
goal.

PRINCIPLE NUMBER 4
(b) In extraction cases, lower incisors are almost always
uprighted.
(c) studies 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
upper incisors, along with the lower incisors, a
balanced interincisal angle is created. This is
critical for long-term stability.
PRINCIPLE NUMBER 4

PRINCIPLE NUMBER 5
Goals for stability. Objectives include-
1. mandibular incisors that are balanced on basal bone with a
good interincisal angle,
2. cuspids not expanded,
3. proper root artistic positioning, upright mandibular molars,
4. normal overbite and overjet, and
5. a functional occlusion in centric relation.
These goals, when achieved, have been found to create healthy,
aesthetically pleasing, and stable results.

PRINCIPLE NUMBER 6
describes specific brackets designed for increased
interbracket space;
wings for rotation and correction, then control;
precision pretorqued slots; and
precision base variation.

PRINCIPLE NUMBER 7
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
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
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
is to 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 11
Principle number 11 is 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 12
Principle number 12 is to level arches and
open the bite with accentuated and reverse
curves of Spee. Clinical experience and research
have substantiated that leveling the
arches and opening the bite with the Alexander
Discipline is not only successful, but also stable.

PRINCIPLE NUMBER 13
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

PRINCIPLE NUMBER 14
Principle number 14 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.

PRINCIPLE NUMBER 15
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.

PRINCIPLE NUMBER 15
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; and 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

PRINCIPLE NUMBER 16
Principle number 16, in nonextraction cases,
recommends initiating treatment in the upper
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
banded/bonded. 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 III elastics if necessary.

PRINCIPLE NUMBER 17
Principle number 17 recommends that, in
extraction cases, treatment be initiated in the
upper arch. The objective is to remove potential
bracket interferences by improving the overbite
with an accentuated curve of Spee and retracting the
cuspids before bonding/banding the
lower arch.

PRINCIPLE NUMBER 18
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.

PRINCIPLE NUMBER 19
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.

PRINCIPLE NUMBER 20
Principle number 20 is "to work your plan.""to work your plan."
Although every case is unique in some ways,
in many ways every case is also the same.

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.

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.

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.
Appliance Design

In some instances, the optimal bracket design was a
single bracket with wings and, in other situations, a twin
bracket design was most advantageous. Likewise, in the
case of the single brackets, some were of Lewis (Ormco
Corp) design and others were of Lang design (Ormco
Corp). The intentional different designs of particular
brackets provide distinct advantages over other systems
that use identical bracket architecture for each tooth.
Appliance Design

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 suffer (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.

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,
individual forces can be applied by activating,
deactivating, or removing individual
wings.

TORQUE
Each bracket has a 0.018 X 0.025
inch wire slot. Slot sizes do not vary from anterior to
posterior brackets and, realizing that 5° of torque is
lost for each 0.001-inch "play" in the slot, final ideal
wires (0.017" X 0.025") are constructed to fill the slot
as much as 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

TWIN BRACKETS

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 latter
allows for superior hygiene and accessibly for
headgear where indicated. 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 placement in first bicuspid
extraction cases

Bracket placement in second bicuspid
extraction cases

Bracket Angulation

Bracket Torque

Bracket base thickness

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.

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.

Non extraction cases
Maxillary arch
•o.o175 multistranded
•0.016 stainless steel
•00.017X0.025” stainless steel finishing

Non extraction cases
Mandibular arch
•o.o17X0.025 multistranded
•0.016X0.022 stainless steel or 0.017X0.025” beta titanium

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

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

Retention and finishing
The problem of retention must be solved during treatment
or
it will not be solved at all.
Dr. Fred Schudy

In the Alexander Discipline the ultimate objective
is to produce quality results and treatment
stability, nonextraction treatment whenever
possible within the treatment goals, and
teeth placed in positions so that life-time retention
is not necessary. A primary goal of the Alexander
Discipline is to spread out the roots of the
lower incisors because it is thought that this adds
to long-term stability

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.

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.

•Original lower intercuspid width must be
maintained. Expanded lower cuspids typically
constrict after removal of retention appliances.
• Lower first molars should be upright to maintain
a leveled mandibular arch and overbite
correction.
• Habits should have been eliminated.
• Midlines should be coincident and correct.
• Correct arch form.
• Correct curve of Spee and curve of Wilson

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.

Appointment 3 :(3 weeks later): Fixed appliances
removal.
Appointment 4: (2 days later): Seating of the
retainers.

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).

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
The Alexander discipline is based on the premise of a number
of principles. In the Alexander discipline, a certain number of
principles are followed that give this technique its
uniqueness.
The ultimate objective is a well treated patient, completed in
a timely fashion with a satisfied patient, parents and doctor.

REFERENCES
•The Alexander Discipline- Contemporary concepts and philosophies by
R.G. Wick Alexander published by Ormco corporation
•Textbook of Orthodontics by Lee Graber
•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

Alexander discipline

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