The Principles of the Alexander Discipline - New York University

The Principles of the Alexander Discipline
Richard G. Alexander
A
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 enduring principle must be built on a
solid foundation, on certain beliefs that
have been tested and proven by time and experience.
In the Mexander 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.
One of the original goals of the technique is
to make treatment easy and more comfortable
for the patient. For any technique in orthodontics
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
become a partner in the treatment procedures
not only gives them 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. Too often, other techniques focus
on the mechanics of treatment. Mechanics
are important, however, mechanics alone will
not produce the optimal result without patient
cooperation. In orthodontic education, perhaps
the forgotten skill is teaching the student motivational
techniques for successful results. 1,2
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
When the need for this skill is understood, the
clinician will accept the responsibility to learn
techniques that will enhance their ability to mo-
tivate their patients while producing high-quality
results.
Principle number 1 is taken from Allen's 3
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 re-
suit." From this sentence comes the formula,
Effort = Results.
Principle number 2 is based on another
quote, "Sometimes when I consider what tre-
mendous consequences come from little things,
I am tempted to think, there are no little
things. ''4
Principle number 3 comes from World War II
and is used in many variations today, "keep it
simple stupid. ''3 Of course, the acronym is KISS.
Principle number 4 states that you should
plan your work. Accurate diagnosis and treat-
ment planning is critical. No matter what ceph-
alometric analysis (Fig 1) is used, three basic
questions must be answered from the cephalo-
metric tracing before a proper treatment plan
can be produced:
62 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 62-66
1. Sagittal skeletal pattern: Determining the
Class I, II, or III growth pattern will help
decide what type of orthopedic force is pre-
ferred.
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

Alexander Discipline 63
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 inci-
sors are almost always uprighted. (c) Our
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 situa-
tion 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, s
Principle number 5 describes our goals for
stability. Objectives include mandibular incisors
that are balanced on basal bone with a good
interincisal angle, cuspids not expanded, proper
root artistic positioning, upright mandibular
molars, normal overbite and overjet, and a func-
tional occlusion in centric relation. These goals,
when achieved, have been found to create
healthy, aesthetically pleasing, and stable re-
sults.5.6.s-10
Principle number 6 describes specific brack-
ets designed for increased interbracket space;
wings for rotation and correction, then control;
precision pretorqued slots; and precision base
variation. Details of the bracket system are dis-
cussed by Bagden on page 74 in this issue of
Seminars in Orthodontics.
Principle number 7 recommends "building
treatment" into the bracket placement. In plac-
ing brackets, three dimensions are considered:
bracket height, bracket angulation, and mesio-
distal bracket position. This is also described
later.
Principle number 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 transpala-
tal arch, the Nance, lingual arch, magnets, and
distalizing mechanics.
Face bow treatment is discussed in another
article in this issue. In the Mexander 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

64 Richard G. Alexander
back, the facebow forces are changed to orth-
odontic forces, resulting in tooth movement.
Principle number 9 discusses the use of a
proven arch form design 12 (Fig 2) and a contem-
porary arch wire force system. 13 Most patients
are treated by using continuous arch wires be-
ginning with the maxillary arch. The initial arch
wire is round and flexible (.016 NiTi). The tran-
sitional arch wire has intermediate stiffness (.016
stainless steel or 17 × 25 titanium alloy). The
final wire is stiff, 17 × 25 stainless steel. 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, de-
velopment 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 clos-
ing 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, iutraoral elastics, when attached to the
ball hooks on the brackets, will not move in-
dividual teeth or cause spaces to open between
the teeth. Consolidated arches are a goal of
this treatment.
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 dis-
cipline is using tied-back arch wires.
Principle number 12 is to level arches and
open the bite with accentuated and reverse
curves of Spee. Clinical experience and re-
search 1:~,14 have substantiated that leveling the
arches and opening the bite with the Mexander
Discipline is not only successful, but also stable
(Fig 3).
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 usu-
ally 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 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.)
quirements 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 focuses on creating sym-
metry. Coordination of the arches is essential to
establish occlusal symmetry. The maxillary and
mandibular arch forms have now been individ-
ually finalized and the goal then is to get the
maxillary and mandibular arches coordinated.
Coordination is accomplished by using pre-
formed arch wires in both arches as well as sym-
metrically adjusting the inner bow of the face
bow and the lip bumper. Final symmetry is es-

Alexander Discipline 65
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 number 15 recommends that finish-
ing 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, mov-
ing 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 ex-
traction spaces with a closing loop arch wire in
maximum anchorage situations; and Class I1
elastics may be used when closing lower extrac-
tion spaces with a closing-loop arch wire to move
lower molars forward in minimum anchorage
situations.
Principle number 16, in nonextraction cases, u~
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 lower anterior teeth are
controlled by -5 ° torque in lower incisor brack-
ets, -6 ° tip on lower first molars, the use of
initial flexible rectangular arch wire, slenderiz-
ing teeth if necessary, and Class II1 elastics if
necessary.
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 cmwe of Spee and retract-
ing the cuspids before bonding/banding the
lower arch.
Upper cuspid teeth are retracted with power
chains on .016 stainless steel arch wire. This
procedure usually takes 6 to 8 months.
Principle number 18 recommends 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 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 advises the use of a spe-
cific retention plan ls,-~ 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 au-
thor. Also recommended is the fixed lower cus-
pid-to-cuspid retainer design using an .0215 Tri-
ple-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 re-
duction of lost and broken retainers has been
remarkable.
Principle number 20 is "to work your plan."
Although every case is unique in some ways,
in many ways every case is also the same. The
general treatment plan in most cases as out-
lined in these principles is to treat the upper

66 Richard G. Alexander
Figure 4. Pretreatment mandibular occlusal view (A). Four months later, showing driftodontics (B).
arch first by using a specific series of arch
wires. If the case requires orthopedic correc-
tion, it is initiated on the maxillary arch with
an rapid palatal expander (RPE) and/or face
bow or facemask. Approximately 6 months af-
ter commencing maxillary arch treatment,
treatment is initiated in the lower arch. A
specific series of arch wires are used to posi-
tion the mandibular teeth. After the finishing
arch wires are in place, appropriate elastics are
used to coordinate the arches and finalize the
occlusion. 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 of the next appointment, future
scheduling is simplified and treatment progress
can be easily monitored so that the treatment
can be completed on schedule.
The ultimate objective is a well-treated pa-
tient, completed in a timely fashion, with a sat-
isfied patient, parents, and doctor.
References
1. Alexander RG, Alexander CM, Alexander C, et al. Cre-
ating the compliant patient. J Clin Orthod 1996;30:493-
497.
2. Stroud J. The psychosocial effect of orthodontic treat-
ment [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 Schus-
ter, 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, cepha-
lometric 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 sta-
bility 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. Phil-
adelphia, 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. Clin-
ical 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 continu-
ous archwire technique-a long-term cephalometric anal-
ysis. 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 count-
down to retention. J Clin Orthod 1983;18:214-218.