Finishing and Retention Procedures in the Alexander Discipline

Finishing and Retention Procedures in the
Alexander Discipline
Tucker Haltom
Carefully transitioning from orthodontic treatment into the retention phase
of orthodontics requires planning and preparation throughout treatment.
Precision finishing is critical for excellent results. By achieving established
goals and following specific steps in retention, the patient can have excel-
lent long-term stability. This article highlights some of the factors consid-
ered important in planning and performing retention according to the Alex-
ander Discipline. (Semin Orthod 2001;7:132-137.) Copyright © 2001 by W.B.
Saunders Company
The problem of retention must be solved during treatment or
it will not be solved at all.
Dr. Fred Schudy
T
reatment goals are the same today as they
were when Tweed a wrote them in 1955.
1. Pleasing balance and harmony of facial
lines: no lip strain should be present after
treatment. Often lip strain is the determin-
ing factor in an extraction decision. Facial
maturation, facial growth, and treatment
changes in nonextraction treatment can cor-
rect lip strain, and, of course, are consid-
ered.
2. Correct occlusion.
3. Healthy tissues.
4. Long-term stability.
In the Alexander Discipline the ultimate ob-
jective is to produce quality results and treat-
ment stability, nonextraction treatment when-
ever possible within the treatment goals, and
teeth placed in positions so that life-time reten-
tion is not necessary.
It is very difficult to align teeth with an im-
properly fitted appliance. Great care is taken
with bracket and band placement because the
precision of this early procedure contributes
From Albuquerque, NM.
Address correspondence to Tucker Haltom, DDS, MS, 10433
Lawima de O~v NE, Albuquerque, NM 87111.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0010~35. 00/0
doi: 10.1053/sodo. 2001.23559
greatly to ideal finishing. Brackets are placed
exactly flat on the teeth, centered and angulated
correctly, and carefully measured with a height
gauge (Fig 1). Because root positioning is
considered to be of significant importance,
midtreatment panoramic radiographs are taken
to evaluate root positioning. Full thickness
0.017 × 0.025-inch arch wires are then adjusted
or brackets repositioned as indicated for ideal
root positioning. A primary goal of the Alex-
ander Discipline is to spread out the roots of the
lower incisors because it is thought that this adds
to long-term stability (Fig 2).2
In addition, during treatment any undesir-
able interdental papilla spaces may be closed by
using air rotor slenderizing. Ideal gingival line
disharmonies are corrected with vertical posi-
tioning of incisors, and less often by using sur-
gical recontouring of the gingiva.
Certain criteria must be met before the patient
is ready for retention. 3 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 pro-
clined excessively, the lower incisors tend to
upright over time.
132 Seminars in Orthodontics, Vol 7, No 2 (]une), 2001: pp 132-137

Figure 1. Measuring bracket height with gauge
aligned evenly with slot torque on all teeth except the
lower incisors. Measurement is made to slot opening
on these teeth.
• Original lower intercuspid width must be
maintained. Expanded lower cuspids typically
constrict after removal of retention appli-
ances.
• Lower first molars should be upright to main-
tain 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
should be optimal.
In addition, a circumferential supracrestal fi-
berotomy is performed on all adults with se-
verely rotated teeth 2 months before fixed appli-
ance removal. Removal of hyperplastic tissue in
the maxillary central incisor area is also per-
formed where heavy diastemas are present, es-
pecially if they are considered to be familial
traits.
The Countdown to Retention
When all the goals of the optimally treated pa-
tient 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 finish-
ing elastics.
Appointment 2 (3 weeks later): Occlusal check
and final adjustments, and possible sectioning
Alexander Discipline-Finishing and Retention 133
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 ante-
rior overbite. This is accomplished by arch wire
sectioning and the wearing of specifically at-
tached elastics: (3/4-in 2-oz Ostrich; Ormco,
Glendora, CA) in the posterior section of the
arches, and, if necessary, placement of an ante-
rior box elastic, (3/16-in 6-oz Impala; Ormco).
First Appointment
Before the procedures of this appointment be-
gin the patient is given specific instructions and
motivated to follow the instructions. The patient
is told that they can chew sugarless gum and the
braces will be removed in 6 weeks. They are also
informed that elastics are difficult to wear but
must be worn 18 to 20 hours a day
Arch wire sectioning and elastic configura-
tion is determined by the patient's original mal-
occlusion. If the beginning overbite was deep,
the lower arch wire is sectioned distal to the
cuspids and the posterior arch wires are re-
moved. With open-bite problems, the upper
arch wire is sectioned in a similar manner. If the
original overbite was close to normal, either or
both arch wires may be sectioned. A distal end
cutting instrument with no distal end holder can
be used to section the wires in the mouth or the
wires can be removed, sectioned, and the ends
rolled in for smoothness. For easy placement
and good retention of elastics, the wires must be
Figure 2. Panoramic radiograph showing ideal root
positioning after appliances removed.

134 Tucker Haltom
Figure 3. Finishing elastics with Class II vector.
tied with steel ligatures or Kobayashi hooks
(American Orthodontics, Sheboygan, WI). The
upper incisors may be ligated together by using
a 0.007 ligature wire when indicated. Other ar-
eas susceptible to spacing can also be ligated
together.
The intermaxillary elastics are attached to
three upper teeth and three lower teeth in an up
and down fashion with specific angulations. 4 If
the original malocclusion was Class I or Class II
then the elastics are worn with a Class II vector
(Fig 3). The same process is followed in Class
III occlusions placing the elastics as shown
(Fig 4).
Second Appointment (3 Weeks Later)
At this time the patient is very close to comple-
tion. Maxillary molar bands are now removed.
After checking the occlusion, minor final repo-
sifioning bends may be performed. Patients are
asked to chew and squeeze sugarless gum. At this
appointment, instructions for elastic wear at
nighttime only is often given. Tooth shaping
A B C
Figure 4. Finishing elastics with Class III vector.
may also be performed. The appointment for
band removal is made.
Third Appointment (3 Weeks Later)
All remaining bands and brackets are removed.
The teeth are polished and cleaned. Campbell's
polishing sequences are used to produce a beau-
tiful enamel finish (Fig 5). 5 Interproximal con-
tact points are now polished by using the Dome
Interproximal Tooth Stripper (Dome, Inc, Tar-
zana, CA) (Fig 6). This creates a small amount of
space for these teeth to settle in the arch. It also
smooths and lightly flattens the contact areas for
added precision in interproximal contacts and
creates a broader contact area to reduce contact
slippage. The Dome wide abrasive strip is used
so it may reach through the circumferential su-
pracrestal fibers performing a slight fiberotomy
as indicated by rotations and where age or peri-
odontal condition do not contraindicate the
procedure. Only the contact areas are stripped if
there are contraindications to a fiberotomy.
Figure 5. Results after polishing enamel. Lateral (A), frontal (B), and lateral (C).

Figure 6. Interproximal enamel reduction with Dome
stripper.
The four treatment goals of the Mexander
Discipline in the lower cuspid to cuspid area that
lead to long-term stability are (Fig 7)
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.
Impressions for working models and final
models are taken and the posttreatment review
is conducted. One of the joys in orthodontics is
to celebrate with the patient and parents after
appliances are removed. Showing the changes
achieved during treatment reinforces the need
to follow instructions during retention. The
third molar teeth are also discussed.
Fourth Appointment
Two days after the appliances are removed, the
retainers are seated. 6
The Maxillary 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 (Fig 8) has been de-
signed to eliminate the tendency in previous
designs for the anterior portion of the wire to
slip gingivally. The advantages of this preformed
wire include
Alexander Discipline-Finishing and Retention 135
Figure 7. Finishing goals for lower anteriors.
2. Round surface against the lips for comfort.
3. Increased wire stiffness that resists slipping
gingivally.
4. Lateral incisor offset bends.
5. Smaller adjustment loops positioned more
posteriorly.
6. Arch form conforms to Alexander/Orthos
design.
This preformed retainer wire allows much
faster adaptation in the laboratory so that re-
tainer construction is more efficient. Also, the
appliance is much more "patient friendly" be-
cause of the wire's stiffness and the unique an-
terior wire-and-loop design.
Special attention should be given to the up-
per second molars. In many cases, these teeth
have not fully erupted when the retainer is con-
structed and therefore the acrylic on the lingual
and the retainer wire on the distal should be
contoured to allow the teeth to continue to
erupt. This is accomplished by placing a C-clasp
around the maxillary second molar. The clasp is
1. Flat surface against the anterior teeth for
stability. Figure 8. Preformed wraparound retainer wire.

136 Tuck~ Haltom
Figure 9. "C" clasp not touching distolingual cusp of
second molar.
designed so that it does not touch the distolin-
gual cusps (Fig 9). The labial bow retainer wire
is soldered to the C-clasp in the distobuccal cusp
area, leaving enough space to adjust the C-clasp
for greater retention. When preparing the max-
illary retainer for delivery, care is taken to recon-
tour the acrylic to prevent it touching the lingual
surfaces of the teeth (Fig 10). This enables the
posterior teeth to continue settling after appli-
ance removal. If desired, the bite plate is ad-
justed anteriorly to allow the teeth to occlude
without touching any acrylic, so that when the
patient closes, only teeth are occluding with
teeth.
Figure 10. Maxillary retainer ready for deliver},.
The Mandibular Retainer
In recent years, the bonded multistranded man-
dibular cuspid to cuspid has become very popu-
lar, mainly because of its ease of placement and
its effectiveness in preventing relapse. A 0.0915
multistranded wire (Triple-Flex; Ormco, Glen-
dora, 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. To place the retainers
the preformed wire is held in place with dental
floss or elastics (Fig 11). The wire is bonded to
each of the anterior teeth with a low-viscosity
light-cured bonding agent. If slight lower incisor
malalignments are present, a 90 ° utility plier
(Fig 19) can be used to position the contacts
Figure 11. Dental floss holding 0.0215 multistranded Figure 12. Utility plier adjusting contact points be-
wire. fore light curing.

properly by gently squeezing the teeth as shown.
Instruction for Retention
The patient is instructed to wear the maxillary
retainer for only 10 to 12 hours from the begin-
ning, putting it on after the evening meal and
wearing it all night long. This procedure greatly
reduces the loss or breakage of retainers.
Retention Appointments
The patient is seen in 8 weeks for final records
and retainer adjustment. Another appointment
is made in another 8 weeks to adjust the re-
tainer. At this time the patient may wear the
retainer only when they sleep.
The patient is then scheduled to return in 12
months. The second year the maxillary retainer
is worn three times a week, and during the third
year, retainer wear is reduced to once a week.
After a decision has been made relative to the
third molars, the lower cuspid-to-cuspid fixed
retainer may be removed, unless the patient pre-
fers that it remain in place. The patient is ad-
vised to "Be your own orthodontist" and period-
Alexander Discipline-Finishing and Retention 137
ically place the upper retainer to see that it still
fits. At this time the patient is released from
active treatment, with the knowledge that their
records are kept on file if needed.
Conclusion
Careful attention to retention problems during
treatment, precision and artistic finishing, im-
proved retainer design, and a more reasonable
schedule of retainer wear all contribute to
achieving a beautiful occlusion and long-term
stability.
References
1. Tweed CH. Clinical orthodontics. St. Louis: CV Mosby,
1966.
2. Williams R. Elimination lower retention. J Clin Orthod
1985;22:342-349.
3. Alexander RG. The Alexander Discipline. Glendora, CA:
Ormco, 1986.
4. Steffen MJ. Five cent tooth positioners. J Clin Orthod
August, 1987:524-529.
5. Campbell P. Enamel polishing. Angle Orthod 1995;65:
103-110.
6. Alexander RG. Retention-a practical approach to that
critical last step to stability. In: Clinical Impressions. Glen-
dale, CA: Ormco, 1997, 14-17.