ALEXANDER DISCIPLINE

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 The Alexanders
La Disciplina Alexander debe su nombre a dos generaciones de
la familia Alexander:
el Dr. C. Moody Alexander y su hijo, Cliff; y
Dr. R.G. "Wick" Alexander y sus hijos J. Moody y Chuck.

Continúan viviendo la tradición de La Disciplina en sus propias prácticas

privadas en Texas y Colorado y avanzando en el estudio de la
ortodoncia a través de las conferencias que realizan regularmente
en todo el mundo.
 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.
 Alexander

Dr. R.G. Wick Alexander

Sus títulos de odontología son de la Rama Dental de la Universidad de Texas; el

D.D.S. en 1962, y el M.S.D. en 1964. El Dr. Alexander comenzó la práctica de la
ortodoncia en Arlington, Texas, en 1964.Es profesor clínico de ortodoncia en la
Universidad de Texas, la Universidad de Nueva York y la Facultad de Odontología
de Baylor. El Dr. Alexander es reconocido internacionalmente por su innovación
en procedimientos de ortodoncia. Es bien conocido por su trabajo en el diseño de
la Disciplina Alexander, un sistema de brackets colocados en los dientes, que es
utilizado por ortodoncistas de todo el mundo.
 The Alexanders

Dr. J. Moody Alexander

Dr. Chuck Alexander

Dr. Cliff Alexander

 INTRODUCCIÓN
Cualquier principio perdurable debe construirse sobre
una base sólida, sobre ciertas creencias que han sido
probadas y comprobadas por el tiempo y la experiencia.
En la Disciplina Alexander se siguen una serie de
principios que confieren a esta técnica su singularidad.
• Los tres primeros principios se centran en la naturaleza
filosófica y el enfoque actitudinal de la impartición de la
Disciplina.
Principio 1: Esfuerzo es igual a resultados
Principio 2: No hay cosas pequeñas
Principio 3 El principio KISS
Principio 4: Establecer metas para la estabilidad
Principio 5 Planifica tu trabajo, luego elabora tu plan
Principio 6 Utilice soportes diseñados para
Prescripciones
Principio 7: Incorporar el tratamiento en el bracket
Colocación
Principio 8: Explotar el crecimiento para obtener información
predecible
Corrección ortopédica
Principio 9: Establecer la forma ideal del arco
Principio 11: Consolidar los arcos al principio del tratamiento
Principio 12: Asegure el acoplamiento completo del soporte y
Mantener la consolidación
Principio 13: ¡Deja que se cocine!
Principio 14: Nivele los arcos y abra la mordida con
Arcos de alambre de curva inversa
Principio 15: Crear simetría
Principio 16 Utilice elásticos intraorales para coordinar la
Arcos
Principio 17: Use un tratamiento sin extracción cuando sea posible
Principio 18: Utilice el tratamiento de extracción cuando sea necesario
Principio 19 Extracción cuidadosa del electrodoméstico y luego retención

Mejorará la estabilidad
Principio 20: Crear cumplimiento
 PRINCIPIO NÚMERO 1

está tomado del libro de Allen Como un hombre piensa:

"En todos los asuntos humanos hay esfuerzos y hay
resultados, y la fuerza del esfuerzo es la medida del
resultado".
De esta frase sale la fórmula,
Esfuerzo = Resultados.
 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.
 PRINCIPIO NÚMERO 4
Establecer metas para la estabilidad
Al mantener un buen control de la torsión de los incisivos superiores,
junto con los incisivos inferiores, se crea un ángulo interincisal
equilibrado. Esto es fundamental para la estabilidad a largo plazo.
Se ha descubierto que los siguientes objetivos, cuando se logran,
ayudan a crear resultados saludables, estéticamente agradables y
estables:
• Prevención de la expansión canina
• Posicionamiento artístico adecuado de la raíz
• Primeros molares mandibulares verticales
• Sobremordida y resalte normales
• Oclusión funcional en relación céntrica
 Las 15 claves para
Éxito de la ortodoncia
Cefalometrías: el análisis del tetrágono plus
Entre ellos se encuentran los
plano incisivo-mandibular mandibular (IMPA), o inclinación del
incisivo mandibular;
plano sella-nasion-mandibular (SN-MP), o el ángulo del plano
mandibular;
Incisivo signal-silla maxilar (U l-SN), o inclinación del incisivo maxilar;
incisivo maxilar incisivo-mandibular (U 1-L 1), o el ángulo interincisal.
• Cuando se combinan estas cuatro medidas, se forma una figura
de cuatro lados, o tetrágono
5. Tetragon plus
La información adicional obtenida del
cefalograma se conoce como tetragón "plus".
Dimensiones del esqueleto sagital
Perfil cefalométrico de los tejidos blandos
6. Anchura intercanina mandibular
El objetivo del tratamiento para esta medición crítica es mantener el ancho
intercanino original.
Los estudios a largo plazo han demostrado que cualquier expansión de más de
1 mm invariablemente recaerá
Clínicamente, la anchura intercanina se finaliza refiriéndose al molde de
estudio mandibular original y superponiendo el arco final sobre el arco
mandibular
7. Anchura de los intermolares maxilares
Cuando se mide desde el surco lingual en la línea cervical de los primeros
molares maxilares, la distancia intermolar maxilar debe estar entre 34 y 38 mm
8. Forma de arco
Un diseño de forma de arco ovoide proporcionará la forma más estética y
estable para la mayoría de los pacientes
9. Arco mandibular nivelado
La nivelación de la curva de Spee en el arco mandibular es fundamental para la
corrección de las mordidas profundas y el mantenimiento de la corrección
de la sobremordida
10. Oclusión
Una buena oclusión es fundamental para la
función, la salud y la estabilidad.
Una oclusión excelente consiste en una buena
relación canina de Clase I, intercuspidación
normal de los dientes posteriores, relaciones
normales de sobremordida y resalte,
protección canina en los movimientos
laterales, guía anterior y una relación céntrica
que coincida con la máxima intercuspación.
11. Posicionamiento de la raíz
12. Salud periodontal
13. Articulación temporomandibular
14. Perfil de los tejidos blandos
15. Sonríe
La Disciplina Alexander está destinada a producir los
siguientes resultados al final del tratamiento de ortodoncia
• Líneas medias dentales coincidentes
• Líneas medias faciales coincidentes
• Dientes colocados estéticamente
• Una línea de sonrisa equilibrada
• Un arco de sonrisa equilibrado
• Ausencia de corredores bucales oscuros
 PRINCIPIO NÚMERO 5
Planifica tu trabajo, luego elabora tu plan
"Comienza con el fin en mente"
Los siguientes ocho factores ayudan a aclarar la
Difícil decisión de tratamiento entre la extracción y la no extracción:
1. Patrones faciales y musculares
2. Patrones funcionales mandibulares
3. Tamaño y forma del diente
4. Discrepancia en la longitud del arco
5. Patrones de erupción inusuales
6. Crecimiento
7. Hábitos
•8. Cumplimiento
Cefalometrías
Independientemente del análisis cefalométrico
que se utilice, se deben obtener tres mediciones
básicas del trazado cefalométrico antes de que
se pueda producir un plan de tratamiento
adecuado:
1. Patrón esquelético sagital
2. Patrón esquelético vertical
3. Posición de los incisivos
Patrón esquelético sagital
La primera determinación cefalométrica que se
realiza es el tipo esquelético del paciente: patrón
esquelético de clase I, II o III.
Las medidas
silla-nasion-point A (SNA)
silla-nasion-point B (SNB)
punto A-nasión-punto B (ANB)
Punto de conexión A porion (NA-Po)
Valoración del ingenio
Patrón esquelético vertical

El hecho de que el paciente tenga un patrón

esquelético de ángulo alto, medio o bajo
también influirá en las decisiones de
tratamiento.
El plano sella-nasion-mandibular (SN-MP)
Ángulo del plano mandibular de Frankfort
plano oclusal-plano mandibular
• eje Y
1. Ángulo SN-MP ---35 grados o menos, los patrones
esqueléticos de Clase II se pueden tratar mejor con un arco
facial cervical. Durante el tratamiento de un paciente
esquelético de clase III con una mascarilla, el vector de
fuerza a menudo se dirige a 45 grados en relación con el
plano oclusal, dependiendo de la línea de la sonrisa.
2. Ángulo SN-MP: 36-41 grados, la dimensión vertical se
maneja mejor con el uso de un arco facial de tracción
combinada (correas occipitales y cervicales) en pacientes
con una relación esquelética de Clase II.
El vector de fuerza elástica de una mascarilla utilizada para
tratar a pacientes con clase III de ángulo alto debe
dirigirse paralelamente al plano oclusal para evitar la
extrusión de los dientes maxilares.
3. Ángulo SN-MP: 42 grados o más, se hace todo lo posible
para inhibir un mayor crecimiento vertical del maxilar.
Se prescribe una combinación de arco facial de alto tiro
para pacientes con un patrón esquelético de clase II de
ángulo alto.
Si el diagnóstico es un patrón esquelético de clase III de
ángulo alto, el vector de fuerza elástica de la mascarilla se
dirige casi paralelo al plano oclusal.
Para los pacientes de ángulo alto con discrepancias en la
longitud del arco, puede estar indicada la terapia de
extracción.
Posición de los incisivos

1. En la mayoría de los casos, la mejor y más estable

posición para los incisivos mandibulares es la posición
en la que se presenta el paciente. El objetivo es
mantener estos dientes en sus posiciones originales.
En los casos de ángulo alto, los incisivos pueden estar
más erguidos.
Casos de mordida profunda de ángulo bajo: los
incisivos deben desplazarse de su posición original.
2. En los casos de extracción, los incisivos mandibulares
suelen estar enderezados. Si además se consigue un
ángulo interincisal adecuado, este tratamiento es estable.
3. Los estudios han indicado que los incisivos
mandibulares pueden avanzar hasta 3 grados y
permanecer estables: la regla de los 3 grados.
Más allá de esos 3 grados críticos, la inestabilidad es más
probable.
Incisivos maxilares
El mantenimiento de un buen control de la torsión de los
incisivos maxilares, junto con los incisivos
mandibulares, dará como resultado un ángulo
interincisal equilibrado.
Perfil de los tejidos blandos
• Perfil convexo o protrusión bimaxilar: extracción
• Perfil normal o de clase II: sin extracción o
limítrofe
• Perfil cóncavo: sin extracción
Posición de los incisivos mandibulares
• Incisivos proclinados: extracción
• Incisivos normalmente inclinados: sin extracción o
limítrofes
• Incisivos retrocrinados: no extracción
Encía adjunta
• Encía delgada y estrecha o recesión gingival: extracción
• Encía comprometida: limítrofe
• Encía sana: no extracción
Potencial de crecimiento
• Potencial de crecimiento pasado: extracción
• Fin del período de crecimiento máximo: límite
• Dentro o antes del período de crecimiento puberal: no extracción ·
Patrón esquelético vertical
• Ángulo alto (dolicocéfalo): extracción
• Ángulo medio (mesocéfalo): sin extracción o limítrofe
• Ángulo bajo (braquicéfalo): sin extracción
Discrepancia en la longitud del arco mandibular
• Severas (más de 6 mm): extracción
• Moderado (4 a 6 mm): límite
• Leva (menos de 4 mm): sin extracción
Anchura de los intermolares maxilares (análisis de moldes)
•Estrecho; Menos de 33 mm se pueden expandir: cambiar el límite a no
extracción
•Normal; La expansión no es un factor
Cumplimiento por parte del paciente
En un caso límite:
• Mala cooperación: extracción
• Cooperación moderada: límite
• Excelente cooperación: no extracción
 PRINCIPIO NÚMERO 6
Usar soportes diseñados
para Prescripciones Específicas
Describe los soportes específicos diseñados para
aumentar el espacio entre soportes
alas para rotación y corrección, luego control;
Ranuras pretorqueadas de precisión
•Variación de base de precisión.
 PRINCIPIO NÚMERO 7
Incorpore el tratamiento en
Colocación de brackets

recomienda "incorporar un tratamiento" en la colocación

del bracket. A la hora de colocar los brackets, se tienen en cuenta
tres dimensiones:
altura del soporte,
angulación de los brackets, y
posición mesiodistal.
 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°
Mandibular Arch
that 5° of torque is lost for each 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