Alexander discipline

ppt on alexander discipline

1. ALEXANDER DISCIPLINE - PRESENTED BY CHANDRIMA A SREEKUMAR IIND YEAR PG

2. 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. The Alexanders

3. The Alexanders 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. C. Moody Alexander

4. Dr. R.G. Wick Alexander The Alexanders 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.

5. Dr. J. Moody Alexander The Alexanders Dr. Cliff Alexander Dr. Chuck Alexander

6. INTRODUCTION Any enduring principle must be built on a solid foundation, on certain beliefs that have been tested and proven by time and experience . In the Alexander 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.

7. Principle 1 Effort Equals Results Principle 2 There Are No Little Things Principle 3 The KISS Principle Principle 4 Establish Goals for Stability Principle 5 Plan Your Work, Then Work Your Plan Principle 6 Use Brackets Designed for Specific Prescriptions Principle 7 Build Treatment into Bracket Placement Principle 8 Exploit Growth to Obtain Predictable Orthopedic Correction Principle 9 Establish Ideal Arch Form Principle 10 Follow a Logical Archwire Sequence

8. Principle 11 Consolidate Arches Early in Treatment Principle 12 Ensure Complete Bracket Engagement and Maintain Consolidation Principle 13 Let It Cook! Principle 14 Level the Arches and Open the Bite with Reverse-Curve Archwires Principle 15 Create Symmetry Principle 16 Use Intraoral Elastics to Coordinate the Arches Principle 17 Use Nonextraction Treatment When Possible Principle 18 Use Extraction Treatment When Necessary Principle 19 Careful Appliance Removal, Then Retention Will Improve Stability Principle 20 Create Compliance

9. 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.

10. 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.

11. 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.

12. 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 . The following goals, when achieved, have been found to help create healthy, esthetically pleasing, and stable results: • Canine expansion prevented • Proper artistic root positioning • Upright mandibular first molars • Normal overbite and overjet • Functional occlusion in centric relation PRINCIPLE NUMBER 4 Establish Goals for Stability

13. The 15 Keys to Orthodontic Success Cephalometries : The tetragon-plus analysis Among these are the mandibular incisor- mandibular plane (IMPA ), or the mandibular incisor inclination; sella-nasion-mandibular plane (SN-MP), or the mandibular plane angle; Maxillary incisor- sella - nasion (U l-SN), or the maxillary incisor inclination; maxillary incisor- mandibular incisor (U 1-L 1), or the interincisal angle . When these four measurements are combined , a four-sided figure, or tetragon, is formed

14. 5. Tetragon plus Additional information garnered from the cephalogram is referred to as tetragon “plus.“ Sagittal skeletal dimensions Cephalometric soft tissue profile

15. 6. Mandibular intercanine width The treatment goal for this critical measurement is to maintain the original intercanine width. Longterm studies have shown that any expansion of more than 1 mm will invariably relapse Clinically, the intercanine width is finalized by referring back to the original mandibular study cast and superimposing the final archwire over the mandibular arch 7. Maxillary intermolar width When measured from the lingual groove at the cervical line of the maxillary first molars, the maxillary intermolar distance should be between 34 and 38 mm 8. Arch form An ovoid arch form design will provide the most esthetic and stable form for most patients 9. Leveled mandibular arch Leveling the curve of Spee in the mandibular arch is critical to the correction of deep bites and the maintenance of overbite correction

16. 10. Occlusion Good occlusion is critical for function , health , and stability. Excellent occlusion consists of a good Class I canine relationship, normal intercuspation of posterior teeth , normal overbite and overjet relationships, canine protection in lateral movements, anterior guidance, and a centric relation that coincides with maximum intercuspation .

17. 11. Root positioning 12. Periodontal health 13. Temporomandibular joint 14. Soft tissue profile 15. Smile The Alexander Discipline is intended to produce the following results at the end of orthodontic treatment • Coincident dental midlines • Coincident facial midlines • Esthetically positioned teeth • A balanced smile line • A balanced smile arc • Absence of dark buccal corridors

18. PRINCIPLE NUMBER 5 Plan Your Work , Then Work Your Plan " Begin with the end in mind ,“ The following eight factors help to clarify the sometimes difficult treatment decision between extraction and nonextraction : 1. Facial and muscle patterns 2. Mandibular functional patterns 3. Tooth size and form 4. Arch length discrepancy 5. Unusual eruption patterns 6. Growth 7. Habits 8. Compliance

19. Cephalometries No matter what cephalometric analysis is used, three basic measurements must be obtained from the cephalometric tracing before a proper treatment plan can be produced: 1. Sagittal skeletal pattern 2. Vertical skeletal pattern 3. Incisor position

20. Sagittal skeletal pattern The first cephalometric determination to be made is the patient's skeletal type: Class I, II, or III skeletal pattern. The measurements sella - nasion -point A (SNA ) sella - nasion -point B ( SNB ) point A- nasion -point B ( ANB) nasion -point Aporion ( NA-Po) Wits appraisal

21. Vertical skeletal pattern Whether the patient has a high-, medium-, or low-angle skeletal pattern will also influence treatment decisions. The sella-nasion-mandibular plane (SN-MP ) Frankfort mandibular plane angle occlusal plane- mandibular plane y-axis

22. 1.SN-MP angle ---35 degrees or less , Class II skeletal patterns can best be treated with a cervical facebow . During the treatment of a skeletal Class III patient using a face mask, the force vector is often directed at 45 degrees in relation to the occlusal plane, depending on the smile line. 2. SN-MP angle -- 36- 41 degrees , the vertical dimension is best managed with the use of a combination-pull facebow (occipital and cervical straps ) in patients with a skeletal Class II relationship. The elastic force vector of a face mask used to treat high-angle Class III patients should be directed parallel to the occlusal plane to prevent the extrusion of the maxillary teeth .

23. 3. SN-MP angle -- 42 degrees or greater, every effort is made to inhibit further vertical growth of the maxilla. A high-pull facebow combination is prescribed for patients with a high-angle skeletal Class II pattern. If the diagnosis is a high-angle skeletal Class III pattern, the elastic force vector of the face mask is directed almost parallel to the occlusal plane. For high-angle patients with arch length discrepancies, extraction therapy may be indicated.

24. Incisor position 1. In most cases, the best and most stable position for mandibular incisors is the position in which the patient presents. Maintaining these teeth in their original positions is the goal. In high-angle cases--incisors may be more upright. Low angle deep bite cases –incisors be proclined from their original position.

25. 2. In extraction cases, mandibular incisors are usually uprighted . If an adequate interincisal angle is also achieved , this treatment is stable . 3. Studies have indicated that mandibular incisors can be advanced up to 3 degrees and remain stable-the 3-degree rule . Beyond that critical 3 degrees, instabil ity is more likely . Maxillary incisors Maintenance of good torque control of the maxillary incisors, along with the mandibular incisors, will result in a balanced interincisal angle .

26. Soft tissue profile • Convex profile or bimaxillary protrusion: extraction • Normal or Class II profile: nonextraction or borderline • Concave profile: nonextraction Mandibular incisor position • Proclined incisors: extraction • Normally inclined incisors: nonextraction or borderline • Retroclined incisors: nonextraction

27. Attached gingiva • Thin, narrow attached gingiva or gingival recession : extraction • Compromised gingiva : borderline • Healthy gingiva : nonextraction Growth potential • Past growth potential : extraction • End of peak growth period: borderline • Within or before pubertal growth period : nonextraction · Vertical skeletal pattern • High-angle ( dolichocephalic ): extraction • Medium-angle ( mesocephalic ): nonextraction or borderline • Low-angle ( brachycephalic ): nonextraction

28. Mandibular arch length discrepancy • Severe (more than 6 mm): extraction • Moderate (4 to 6 mm): borderline • Slight (less than 4 mm): nonextraction Maxillary intermolar width (cast analysis) • Narrow; less than 33 mm can be expanded: change borderline into nonextraction • Normal; expansion not a factor Patient compliance In a borderline case: • Poor cooperation: extraction • Moderate cooperation : borderline • Excellent cooperation: nonextraction

29. PRINCIPLE NUMBER 6 Use Brackets Designed for Specific Prescriptions describes specific brackets designed for increased interbracket space wings for rotation and correction, then control; precision pretorqued slots precision base variation.

30. PRINCIPLE NUMBER 7 Build Treatment into Bracket Placement recommends "building treatment" into the bracket placement. In placing brackets, three dimensions are considered: bracket height, bracket angulation , and mesiodistalbracket position.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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) archwi re 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

36. 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.

37. 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 .

38. 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.

39. 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.

40. 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 .

41. 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

42. 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 .

43. 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.

44. 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.

45. 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

46. 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

47. 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

48. 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 .

49. Two types of malocclusion almost always require premolar extractions . patients with extreme mandibular arch length discrepancy have more tooth mass than the dental arch can accommodate severe bimaxillary prognathism .

50. 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.

51. 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 .

52. 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 .

53. 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.

54. 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

55. 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.

56. 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.

57. 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 .

58. 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

59. 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.

60. 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

61. 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.

62. BRACKET SELECTION

63. 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.

64. 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.

65. Single brackets create increased inter-bracket space

66. 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 . Rotational wings

67. 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. BRACKET TORQUES Maxillary Arch Centrals 14° Laterals 7° Cuspids – 3° Bicuspids – 7° Molars – 10° Mandibular Arch Incisors – 5° Cuspids – 7° 1st Bicuspids – 11° 2nd Bicuspids – 17° 1st Molars – 22° 2nd Molars 0° or – 27°

68. 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.

69. 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.

70. 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.

71. 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.

72. 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

73. 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 .

74. 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.

75. 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.

76. 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.

77. 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 .

78. 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.

79. 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.

80. 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.

81. 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.

82. SPECIFICATIONS OF THIS APPLIANCE

83. Bracket Height

84. Bracket Height

85. 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 .

86. Bracket placement in second bicuspid extraction cases

87. Bracket Angulation

88. Bracket Angulation

89. Bracket Torque

90. Bracket Torque

91. 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

92. 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.

93. 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.

94. ARCH WIRE SELECTION AND SEQUENCE Non extraction cases Maxillary arch o.o175 multistranded 0.016 stainless steel 00.017X0.025” stainless steel finishing

95. 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

96. 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

97. 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

98. 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.

99. 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.

100. 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.

101. 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.

102. 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

103. 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.

104. 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.

105. 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

106. 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 .

107. 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.

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

109. 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.

110. 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 .

111. 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 .

112. 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.

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

114. 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 ).

115. Countdown to retention

116. Countdown to retention

117. Retention The four treatment goals of the Alexander Discipline in the lower cuspid to cuspid area that lead to long-term stability are - 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.

118. 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 .

119. Retainer

120. 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.

121. 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.

122. 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

123. 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