The Principles of the Alexander Discipline

Richard G. Alexander
The Alexander Discipline is based on the premise of a number of principles.
This article lists and briefly describes these principles and the reason each is
considered important in the management of the orthodontic patient in the
Alexander Discipline, (Semin Orthod 2001;7:62-66,) Copyright 2001 by

W.B. Saunders Company

nY e n d u r i n g principle must be built on a

solid foundation, on certain beliefs that
have b e e n tested a n d proven by time a n d experience. In the M e x a n d e r Discipline, a certain
n u m b e r of principles are followed that give this
technique its uniqueness. T h e first three principles focus on the philosophic nature and the
attitudinal a p p r o a c h to the delivery of the Discipline.
O n e of the original goals of the technique is
to m a k e t r e a t m e n t easy and m o r e comfortable
for the patient. For any technique in o r t h o d o n tics to be successful, the patient must be involved
in the procedures. Even though some appliances
are said to be noncompliant, the reality is that
no such thing is possible. Each patient must be
willing to keep their teeth clean, take care of the
appliances, watch what they eat, and be present
for their appointments. Allowing the patient to
b e c o m e a p a r t n e r in the t r e a t m e n t p r o c e d u r e s
not only gives t h e m some ownership in the process, but it ensures that the results will reach a
higher level.
Patient compliance is critical to the success of
this technique. T o o often, other techniques focus on the mechanics of treatment. Mechanics
are important, however, mechanics alone will
not p r o d u c e the optimal result without patient
cooperation. In orthodontic education, p e r h a p s
the forgotten skill is teaching the student motivational techniques for successful results. 1,2

From Arlington, TX.

Address correspondence to IL G. leVi&Alexander, DDS, MSD,
840 West Mitchell, Arlington, TX 76013.
Copyright 2001 by W.B. Saunders Company
1073-8746/01/0702-0001535.00/0
doi:l O.1053/sodo. 2001.23536
62

W h e n the n e e d for this skill is understood, the

clinician will accept the responsibility to learn
techniques that will e n h a n c e their ability to motivate their patients while p r o d u c i n g high-quality
results.
Principle n u m b e r 1 is taken f r o m Allen's 3
b o o k A s a M a n Thinketh, "In all h u m a n affairs
there are efforts and there are results, and the
strength of the effort is the measure of the resuit." F r o m this sentence comes the formula,
Effort = Results.
Principle n u m b e r 2 is based on a n o t h e r
quote, "Sometimes when I consider what trem e n d o u s consequences c o m e f r o m little things,
I am t e m p t e d to think, there are no little
things. ''4
Principle n u m b e r 3 comes f r o m World War II
and is used in m a n y variations today, "keep it
simple stupid. ''3 O f course, the acronym is KISS.
Principle n u m b e r 4 states that you should
plan your work. Accurate diagnosis and treatm e n t planning is critical. No matter what cephalometric analysis (Fig 1) is used, three basic
questions must be answered f r o m the cephalometric tracing before a p r o p e r t r e a t m e n t plan
can be produced:
1. Sagittal skeletal pattern: D e t e r m i n i n g the
Class I, II, or III growth pattern will help
decide what type of orthopedic force is preferred.
2. Vertical skeletal pattern:
Determining
whether the case has a high-, medium-, or
low-angle skeletal pattern will influence
t r e a t m e n t decisions.
3. Incisors position: (a) In most cases, in the
a u t h o r ' s opinion, the best and most stable
position for lower incisors is the position in
which the patient presents. To keep lower

Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 62-66

Alexander Discipline

63

POINTS OF MEASUREMENT
Figure 1. Cephalometric measurements used to determine sagital and vertical skeletal patterns and incisor
positions.
incisors in their original positions is often
our goal. (b) In extraction cases, lower incisors are almost always uprighted. (c) O u r
studies 5-7 have shown that lower incisors can
be advanced up to 3 and remain stable.
Beyond that degree, instability is more
likely. The only time the lower incisors are
advanced beyond this degree is when they
are abnormally retroclined. The latter situation is commonly seen in Class II, Division 2,
and Class II, Division 1 deep-bite cases.
By maintaining good torque control of the
u p p e r incisors, along with the lower incisors, a
balanced interincisal angle is created. This is
critical for long-term stability, s
Principle n u m b e r 5 describes our goals for
stability. Objectives include mandibular incisors
that are balanced on basal bone with a good
interincisal angle, cuspids not expanded, p r o p e r
root artistic positioning, upright mandibular
molars, normal overbite and overjet, and a functional occlusion in centric relation. These goals,
when achieved, have b e e n f o u n d to create
healthy, aesthetically pleasing, and stable results.5.6.s-10

Principle n u m b e r 6 describes specific brackets designed for increased interbracket space;

wings for rotation and correction, then control;
precision p r e t o r q u e d slots; and precision base
variation. Details of the bracket system are discussed by Bagden on page 74 in this issue of
Seminars in Orthodontics.
Principle n u m b e r 7 r e c o m m e n d s "building
treatment" into the bracket placement. In placing brackets, three dimensions are considered:
bracket height, bracket angulation, and mesiodistal bracket position. This is also described
later.
Principle n u m b e r 8 is to obtain predictable
orthopedic correction by using a face bow, face
mask, rapid palatal expansion, lip bumper, or
other auxiliary appliances such as the transpalatal arch, the Nance, lingual arch, magnets, and
distalizing mechanics.
Face bow treatment is discussed in a n o t h e r
article in this issue. In the M e x a n d e r Discipline,
a face bow and face mask are used primarily for
orthopedic forces. This means that these forces
are placed on consolidated, tied-back arch wires
in growing patients. If arch wires are not tied

64

Richard G. Alexander

back, the facebow forces are changed to orthodontic forces, resulting in tooth m o v e m e n t .
Principle n u m b e r 9 discusses the use of a
proven arch form design 12 (Fig 2) and a contemporary arch wire force system. 13 Most patients
are treated by using continuous arch wires beginning with the maxillary arch. T h e initial arch
wire is r o u n d and flexible (.016 NiTi). T h e transitional arch wire has intermediate stiffness (.016
stainless steel or 17 25 titanium alloy). T h e
final wire is stiff, 17 25 stainless steel. T h e only
difference in the m a n d i b u l a r sequence is that
the initial arch wire is a flexible rectangular wire,
for initial torque control. T h e functions of the
arch wires include: elimination of rotations, dev e l o p m e n t of arch form, leveling the arches,
control of torque, a n d final arch form.
Principle n u m b e r 10 is to consolidate
arches early in t r e a t m e n t . T h e p u r p o s e of closing spaces is to c h a n g e 10 to 12 i n d e p e n d e n t
force units (the teeth) into 1 unit. W h e n this
has b e e n a c c o m p l i s h e d , o r t h o p e d i c forces,
such as a face bow or a face mask, can create
skeletal c h a n g e s r a t h e r t h a n dental changes.
Also, iutraoral elastics, w h e n a t t a c h e d to the
ball h o o k s o n the brackets, will n o t m o v e individual teeth or cause spaces to o p e n b e t w e e n
the teeth. C o n s o l i d a t e d arches are a goal o f
this t r e a t m e n t .
Principle n u m b e r 11 is to obtain complete
bracket e n g a g e m e n t w h e n placing arch wires,
ligating with steel ligatures, and maintaining
consolidation with o m e g a loops "tied back."
O n e o f the most i m p o r t a n t concepts of the discipline is using tied-back arch wires.
Principle n u m b e r 12 is to level arches a n d
o p e n the bite with accentuated and reverse
curves of Spee. Clinical experience and research 1:~,14 have substantiated that leveling the
arches and o p e n i n g the bite with the M e x a n d e r
Discipline is not only successful, but also stable
(Fig 3).
Principle n u m b e r 13 advocates p r o g r e s s i n g
into finishing a r c h wires rapidly a n d allowing
sufficient time for the a r c h wire to m o v e the
t e e t h to their desired position. By following
the previous principles a n d s e q u e n c i n g the
t r e a t m e n t plan, the finishing a r c h wire is usually p l a c e d in 6 to 9 m o n t h s in n o n e x t r a c t i o n
patients. In e x t r a c t i o n t r e a t m e n t p r o c e d u r e s ,
p r o g r e s s i n g into finishing arch wires m a y take
9 to 12 m o n t h s All o f the final finishing re-

ORMCO

Part No 20%0060

Figure 2. Most maxillary arch forms will fall

within 1 SD of this template. Two mandibular arch
forms are needed to accomplish this. (Courtesy of
Ormco Corp, Gleudora, CA.)

q u i r e m e n t s are p l a c e d into the stainless steel

finishing a r c h wire: a r c h f o r m , torque, curve,
a n d o m e g a loops. After this wire has b e e n
p r o p e r l y tied in (full-bracket e n g a g e m e n t a n d
tied b a c k with steel ligature wires), time is
n e e d e d for the g e n e r a t e d forces to have their
effects a n d to m o v e the teeth into their final
positions. O f t e n this wire will r e m a i n in place
until fixed appliances are r e m o v e d .
Principle n u m b e r 14 focuses on creating symmetry. Coordination of the arches is essential to
establish occlusal symmetry. T h e maxillary and
m a n d i b u l a r arch forms have now b e e n individually finalized and the goal then is to get the
maxillary and m a n d i b u l a r arches coordinated.
Coordination is accomplished by using pref o r m e d arch wires in b o t h arches as well as symmetrically adjusting the inner bow of the face
bow and the lip b u m p e r . Final symmetry is es-

Alexander Discipline

65

Figure 3. Mandibular heat-treated 17 x 25 ss arch wire with reverse curve of Spee tied in and tied back (A).
Six months later with both arches level (B).
tablished by specific elastics in finishing arch
wires.
Principle n u m b e r 15 r e c o m m e n d s that finishing arch wires be in place before initiating elastic
wear. By establishing arch form and p r o p e r
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 b o n d e d to prevent flaring of the
lower incisors, a n d / o r while closing lower extraction spaces with a closing loop arch wire in
m a x i m u m anchorage situations; and Class I1
elastics may be used when closing lower extraction spaces with a closing-loop arch wire to move
lower molars forward in m i n i m u m anchorage
situations.
Principle number 16, in nonextraction cases, u~
r e c o m m e n d s initiating treatment in the u p p e r
arch and progressing into finishing arch wires as
soon as possible. Because the major goal in nonextraction treatment is to control the position of
the lower anterior teeth, total focus can then be
placed on these teeth when the lower arch is
b a n d e d / b o n d e d . The lower anterior teeth are
controlled by - 5 torque in lower incisor brackets, - 6 tip on lower first molars, the use of
initial flexible rectangular arch wire, slenderizing teeth if necessary, and Class II1 elastics if
necessary.
Principle n u m b e r 17 r e c o m m e n d s that, in
extraction cases, treatment be initiated in the
u p p e r arch. The objective is to remove potential
bracket interferences by improving the overbite
with an accentuated cmwe of Spee and retract-

ing the cuspids before b o n d i n g / b a n d i n g the

lower arch.
U p p e r cuspid teeth are retracted with power
chains on .016 stainless steel arch wire. This
procedure usually takes 6 to 8 months.
Principle n u m b e r 18 r e c o m m e n d s that, in
extraction cases, 17 treatment is delayed in the
mandibular arch to allow time for driftodontics
(Fig 4). This is the term the author coined to
describe the spontaneous unraveling of the
lower anterior teeth, making it m u c h easier
to place brackets after 4 to 6 months. W h e n
the u p p e r cuspids have been retracted to a
Class I relationship, the lower arch should be
bonded/banded.
Principle n u m b e r 19 advises the use of a specific retention plan ls,-~ incorporating retainer
design, time sequence, and resolution of third
molar teeth in an effort to ensure long-term
stability. The u p p e r "wrap-around" retainer wire
is fabricated to a specific design and has proven
to be extremely effective according to the author. Also r e c o m m e n d e d is the fixed lower cuspid-to-cuspid retainer design using an .0215 Triple-Flex wire (Ormco, Glendora, CA) b o n d e d to
each tooth. After bracket removal, the u p p e r
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 n u m b e r 20 is "to work your plan."
A l t h o u g h every case is u n i q u e in some ways,
in m a n y ways every case is also the same. The
general t r e a t m e n t plan in most cases as outlined in these principles is to treat the u p p e r

66

Richard G. Alexander

Figure 4. Pretreatment mandibular occlusal view (A). Four months later, showing driftodontics (B).

arch first by using a specific series o f arch

wires. If the case requires o r t h o p e d i c correction, it is initiated o n the maxillary arch with
an rapid palatal e x p a n d e r (RPE) a n d / o r face
b o w or facemask. A p p r o x i m a t e l y 6 m o n t h s after c o m m e n c i n g maxillary arch treatment,
t r e a t m e n t is initiated in the lower arch. A
specific series o f arch wires are used to position the m a n d i b u l a r teeth. After the finishing
arch wires are in place, appropriate elastics are
used to c o o r d i n a t e the arches and finalize the
o c c l u s i o n . Retainers are then placed.
Following these basic step-by-step procedures
allows the clinician to control treatment
progress. By being able to anticipate treatment
objectives o f the next appointment, future
scheduling is simplified and treatment progress
can be easily m o n i t o r e d so that the treatment
can be c o m p l e t e d on schedule.
The ultimate objective is a well-treated patient, c o m p l e t e d in a timely fashion, with a satisfied patient, parents, and doctor.
References
1. Alexander RG, Alexander CM, Alexander C, et al. Creating the compliant patient. J Clin Orthod 1996;30:493497.
2. Stroud J. The psychosocial effect of orthodontic treatment [master's thesis]. Dallas, TX: Baylor College of
Dentistry, 1996.
3. AllenJ. As a man thinketh. Classics of inspiration. Kansas
City, MO, Halhnark Cards, Inc, 1971, 57.
4. Covey S. First things first. New York, Simon and Schuster, 1994, 287.

5. Glenn G, Sinclair PM, Alexander RG. Non-extraction

orthodontic therapy: Post-treatment dental and skeletal
stability. AmJ Orthod 1987;92:321-328.
6. Ehns T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 1, model
analysis. AmJ Clin Orthod 1996;109:271-276.
7. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 2, cephalometric analysis. Am J Clin Orthod 1996;109:386-392.
8. Nevant CT, Bnschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
9. Alexander JM. A comparative study of orthodontic stability in class I extraction cases [master's thesis]. Dallas,
TX: Baylor College of Dentistry, 1995.
10. Alexander RG. Treatment and retention for long-term
stability. In: Retention and stability in orthodontics. Philadelphia, W.B. Saunders, 1993.
11. Alexander RG. The quest for long-term stability. In:
Sachdeva R (ed). Orthodontics for the next millennium.
Glendora, CA: Ormco, 1997.
12. Alexander RG. A practical approach to arch form. Clinical Impressions 1992;1:3-5.
13. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986.
14. Bernstein R. Leveling the curve of Spee with a continuous archwire technique-a long-term cephalometric analysis. Master's Thesis, State University of New York at
Buffalo, Buffalo, NY, January, 1999.
15. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 7.
16. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 9.
17. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 10.
18. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 14.
19. Alexander RG. The vari-simplex discipline-part 4 countdown to retention. J Clin Orthod 1983;18:214-218.