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Effort Equals Results T

"Talent plus knowledge plus EFFORT accountfor success."


he first principie of the Alexander Discipline isEffort Equals

Results (E = R). This basic formula or philosophy is the


foundat ion on which all else is built and is an out growth of a philosophy of life. This equat ion was derived from the book As aMan Thinketh, by James Allen1 (Fig 1-1) More than 100 years ago, Allen stated that. " In all human affairs, there are efforts and there are results, and the strength of the effort is the measure of the result. Chance is not ." Such simple words can have a powerfu l inf luence on those who apply th is philosophy to the ir own lives. No one can expect his or her life to be completely smooth, without bumps in the road. In general, however,

- Gertrude Samuels
the atttude with which the individual approaches these bumps wi ll have a great impact on the outcome. The harder a person works on a problem, the " luckier " he or she becomes. This is so t rue in orthodontics. Whether the challenge is learning to bend omega loops or motivating a patient, the more effort given, the better the results wi ll always be. The concept of E = R has been the theme of our office since its inception . Whe n patients and parents enter, the f irst thing they see is the sign on the wall (Fig 1-2). AII educational material has been prepared with t his thought in mind (see also Fig 20-3).

Keys to Success
After 40 years of c1 inical practice, I have ident if ied several keys to success. Systems come and go, technology changes, but certain truth s remain that are independent of the times and can lead to success . . . whether in orthodontics or in life.

Selfconfidence
One of the most imp ortant elements in each person's life is the concept of self-confidence. Although t his outlook can be misinterpreted as conceit, every orthodontist must have t his attitude if he or she expects to be successf ul. In the children's story The Little Engine That Could, the little t rain kept itself motivated by saying, "1 thi nk I can; I think I can." Like the train in th e fable, orthodontists must give t heir very best with each patient. Alt hough clinicians may fall short occasionally, the y keep tryin g. Baseball immortal Babe Ruth was asked what he thought abo ut when he str uck out. He replied, "Every strike brings me closer to the next home run ." What a posit ive attitude!

Persistence
The informat ion presented in the fo llow ing chapters is a prod uct of my curiosity and persistence. As Calvin Coolidge, the 30th president of the United States, said : Not hing in the world can take the place of persistence.

Talent w ill not . . . noth ing is more common than unsuccessful men with talent. Genius wi ll not . . . unrewarded genius is almost a proverb. Educat ion will not ... the world is full of educated derelicts. Persistence and dete rmination alone are omnipotent. Fig 1-2 The first thing patients see when they enter the autho r's practice is theprincipie upon which it is built. The slogan "Press on" has solved and always w ill solve th e problems of the human race.

Pragmatism
When the E = R formula is applied to orthodo ntic results, every pat ient should be treat ed as if he or she wer e t he ort hodontist's own child or spouse. Nevertheless, although I strive to produce the very best results possible, after treating more than 14,000 patie nts, I have yet to produce the perfect result. Clinicians must be realistic when it comes to working w ith human beings. It has been said, "To strive for excellence is goo d; to st rive for perfect ion is a ter rible waste of tim e." This aphorism is not to be interpreted as an excuse for not delivering the highest quality treatm ent possible. Rath er, it represents an acceptance of the realization that human beings are simply not perfe ct. There comes a t ime at the end of every patient's treatment when practical, realistic decisions must be made to f inalize the results. The orthodontist must weigh the advant ages of continuing treatmen t with the consequences of removing the appliances. If th e results do not come up to the c1inician's standards, the patient and parent s shou ld be informed of th e reasons w hy the treatment goals were not achieved.

Discipline
Every teacher has asked him self or herself wh ether discipline can even be taught. I believe that it can be. The best def initi on of disciplin e I have heard was taught to me by Walter Haley: Discipline: Do what you ough t to do, when you oug ht to do it. whether you wan t to do it or not! No debate:

2 Fig 1-3 Dr Moody Alexander,modeling good patient com munication. When persistence and discipline can be channeled in the right direction , positive results will always be produced. Character has been def ined as "what you do when no one 15 looking." This idea also applies to discipline.

PrincipIe 1 Case Study


Overview
Severe Class 11 skeletal pattern corrected by facebow, compliance, and growth.

Examination and diagnosis


A 13-year-old girl presented with a convex profile, lip st rain, minimal soft tissue pogonion, and asevere Class 11 medium-angle skeletal pattern. Her maxillary incisors were flared, resulting in an 11-mm overjet; her overbite was 4 mm. Slight spacing was found in the mandibular incisor area, and an extremely large gingival display upon smiling was observed.

Treatment plan

Usually such patients would be treated by extraction . Because of the spacing in the anterior mandibular arch, however, a decision was made to attempt treatment without removing teeth . Based on the lateral cephalogram, SN/MPwas normal at 33 degrees, and yet it was evident c1inically that the patient had a more vertical skeletal pattern . Sometimes the " numbers" do not tell an accurate story. Therefore, a

Principle 1 Case Study _

ConcIusion
Alth ough every orthodontist loves to treat patients who f ollow the rules, pat ients who do not comply represent a challenge (Fig 1-3). The tendency may be to give up and attempt "noncompliant " treatment. Instead, it is hoped that th e reader will feel and absorb the Alexander Discipline approach and then apply this attitude to all patients and especially to problem cases, where extra effort equals improved results. Principie 20 presents a detailed discussion about patient compliance.

PrincipIe 1 Case Study


Overview
Severe Class 11 skeletal pattern corrected by facebow, compliance, and growth.

Examination and diagnosis


A 13-year-old girl presented with a convex profile, lip st rain, minimal soft tissue pogonion, and asevere Class 11 medium-angle skeletal pattern. Her maxillary incisors were flared, resulting in an 11-mm overjet; her overbite was 4 mm. Slight spacing was found in the mandibular incisor area, and an extremely large gingival display upon smiling was observed.

Treatment plan
Usually such patients would be treated by extraction . Because of the spacing in the anterior mandibular arch, however, a decision was made to attempt treatment without removing teeth . Based on the lateral cephalogram, SN/MPwas normal at 33 degrees, and yet it was evident c1inically that the patient had a more vertical skeletal pattern . Sometimes the " numbers" do not tell an accurate story. Therefore, a

Principle 1 Case Study _

ConcIusion
Alth ough every orthodontist loves to treat patients who f ollow the rules, pat ients who do not comply represent a challenge (Fig 1-3). The tendency may be to give up and attempt "noncompliant " treatment. Instead, it is hoped that th e reader will feel and absorb the Alexander Discipline approach and then apply this attitude to all patients and especially to problem cases, where extra effort equals improved results. Principie 20 presents a detailed discussion about patient compliance.

Reference

1. Allen J. As aMan Thinketh . 1902.

combination facebow was worn 9 to 12 hours daily for 19 months .

Discussion
Note that the maxillary arch was banded while the mandib ular arch was bonded; the patient was treated during the period (1978) when my practice was transitioning from bands to brackets. The patient was extremely compliant as good growth took place, which accounts for the relatively brief (20month) treatment periodo This isa great example of effort = results!

Evaluation
Long-term records (15 years posttreatment) show good stability throughout with the exception of the rotation of the mandibular left lateral incisor. This can be attributed to the poor angulation of the lateral incisor resulting from poor bracket placement. I soon learned to angulate the brackets when bonding . The patient pursued a successful career as an international model, for wh ich her smile proved a valuable asset.

ThereAreNo Little Things


"Trifles make perftction and perftction is not a trifle." - Michelangelo

PoPu,ar motivational book published in the United tle things, I am tempted to think there are no little

States is entitled, Don't Sweat the Small Stuii.' In things. rr the world of orthodontics, however, this is poor In my first book.' chapter 2 was devoted to a discussion advice. On the opposite end of the spectrum, Stephen R. of the "little things" that make all the difference in orthoCovey captured the nation's attention with the principies dontic practice. Although computers have replaced pen he espoused in his book, The 7 Habits of Highly Effective and paper, the basic concepts remain the sarne. People, which was first published in 1989 2 Covey Orthodontists must envision the "biq picture " in their pracfocused on specific habits that anyone could adopt to tice and yet to be successful, they must also tend to all of become more effective. I agree with most of Covey's those little things that, when put together properly, give ideas, but a favorite is the following (based on a quote the final rewarding result. from American author Bruce Barton): "Sometimes when This book focuses on the biomechanics of orthodontic I consider what tremendous consequences come from lit- treatment as well as patient compliance. However, for

2 There Are No Little Thngs


treatment to be successful, office management and

patient treatment mechanics cannot be separated. The more efficient an orthodontist is in treatment mechanics, the more smoothly the whole office can function. The following chapters describe and illustrate each of the little things that should be routinely performed for consistently high-quality results. The outcome of any therapeutic orthodontic procedure depends on proper diagnosis, treatment planning, and management of any skeletal problems. Then it is possible to begin the process of treatment, including selection of the right bracket system, detailed placement of brackets, archwire sequence, use of elastics, finishing, and finally, retention. If the principies involved in each of these steps are understood and performed properly and routinely for each patient, the final results will include consistently beautiful smiles, good functional occlusion, healthy hard and soft periodontal tissues, and long-term stability.

Optimum Treatment Timing


f all the little things that influence the outcome of treatment, timing may be one of the most important. How does a c1inical orthodontist make the very important decision as to when to initiate treatment?

Issues to Consider
While observing cervical maturation can be helpful, one day the profession may have a simple test to accurately pinpoint a patient's stage of growth. For now with growing children, the orthodontist must approach every appointment as if the child is a new patient, because new growth and the treatment mechanics being employed will have altered the prior condition.

Stage Of growth
From the orthodontist's perspective, the best time to treat patients is when they are in a period of maximum growth. It is always satisfying to see very difficult cases managed

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with beautiful results that are achieved partly because of good timing between treatment and growth. Excellent results can often be attributed as much to growth as to the skill of the treating practitioner. The converse situation also occurs too often-that is. orthodontists tend to blame "bad growth" for poor results.

Age
Generally, girls begin growth at an earlier age than boys. For example, an 8-, 9-, or 1O-year-old girl usually responds better to headgear treatment than does a boy of the same age. However, girls also complete their growth at an earlier age. Boys, therefore, respond best to orthopedic changes between 12 and 14 years of age. Figures 2-1 and 2-2 demonstrate the gender difference in dental maturity of two patients of the same age. Nevertheless, the window of opportunity for capitalizing on growth in children has great individual variation that must be recognized and taken into consideration. Questions asked during the initial examination can elicit valuable information for determining a patient's stage of growth:

Is the patient growing now? Are the patient's feet growing? Are the patient's pant legs getting short? Has the female patient started her menstrual cycle? Does the patient more closely resemble the father or the mother? How tall is the patient's father? For Class 111 patients: Does anyone on either side of the family have a strong lower jaw like that of the patient?

Orthodontic diagnosis
Another factor that affects the timing of treatment is the patient's specific problem. If the problem involves excessively protruding teeth susceptible to traumatic injury, misaligned teeth that negatively affect a patient's self-image or desire to smile, or impacted or poorly erupting teeth, it is difficult to justify a delay in treatment. Early treatment might therefore be necessary for patients with these problems. The c1inician must weigh the advantages and disadvantages of orthodontic treatment while giving equal consideration to the patient's psychological health and the total treatment time.

PrincipIe 2 Case Study


Overview
A borderline, moderate Class II skeletal pattern with maxillary anterior crowding corrected with combination facebow. Long-term stability was acceptable.

Examination and diagnosis


This ll -year-old girl presented with a medium-angle, Class 1I skeletal pattern. Molars were in Class 11 positions, and she had a 6.5 mm overjet and a 3.5 mm overbite. A 2-mm midline shift and a slight arch length discrepancy were observed . AII four primary second molars were present.

Treatment plan
When first examined, this patient was diagnosed as a first premolar extraction case. After she wore a combination facebow for 10 months while waiting for the second premolars to erupt , the decision was changed to treat her nonextraction.

Discussion
The patient was treated in the early 19705, befo re the days of bonded brackets, which made mandibular incisor cont rol in nonextraction treatment more difficult. This was accomplished with c1ass 3 elastics early in treatment.

Evaluation
Examinatio n of the patient's chart reveals that she had difficulty wearing the facebow. With good growth, persistence fi nally wo n, and acceptable results were achieved with her final occlusion and facial pattern. More than 31 years later, this patient appeared in the office with her 8-year-old daughter in need of orthodontic treatment. In evaluating our former patient's longterm results, it was noted that her overbite and overjet had been very stable. Buccal occlusion is excellent (no

temporomandibular joint issues), and arch forms are stable. After the mandibular fixed retainer had been removed 4 years posttreatment, there was some minor shif ting, especially between the left lateral incisor and canine. In the author's opinion, this was a result of poor root angulation on the left lateral incisor. Remember, this was before the days of pre-angulated brackets. Also, no interproximal enamel reduction was performed on the anterior dentition .

The KISS PrincipIe


In all things, the supreme excellence is simplicity." - Henry Wadsworth Longfellow

n graduate schoo l, at t he University of Texas Denta l

Branch in Houston, I was taug ht the Tweed Technique.' I took the Tweed typodont cou rse twice whi le in schoo l and again while in private practice when my study club : 'aveled to Tucson, Arizona, to hear from the master (Fig 3-1). I was taught structured, systematic sequences that allow orthodont ists to achieve certain goals in treatment. This basic educat ion, although very difficult, was an excellent way to learn t he fundamen tals of orthodontics. Vhen I began private practice, however, I asked myself if :here could be a better way to achieve t he same highuality results using mechanics t hat were gent ler and less :omplicated. Therefore, I began my search by quest ionng the mechanics of the Tweed technique. A pop ular maxim is "Keep it simple, stupid" (KISS). The idea is to avoid unnecessary comp lexity. Wi th a desire to reduce th e comp lexity of biomec hanics, I attempted to create treatment mechanics tha t could be performed in a simple, straightforward, and routine format. This was accomp lished by a process of questioning most of th e concepts I had learned, keeping those concepts that were necessary, and removing those that were not. The goal was to develop a treatment plan that would progress in the most direct course possible. In keeping with the KISS principie, treatment sequencing in the Alexander Discipline is so predictable and simple that fo r most patients the c1ini cal assistants can determ ine the next appointment's procedure.

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3 The KISS Prin ciple


Fig 3-1 Dr Charles Iweed.

Benefits
The KISS principie perm eates every prin cipi e espou sed in

thi s book. Occasionally, orthodo nt ists ask, "Why bend omega loops?" or "Why ligat e w it h steel ligature vvire?" These procedures take additional time when initi ally perform ed; in the end, however, it is much more effect ive to have omega loops available so that th e archwire can be tied back and kept consolidated th rou ghout treatrnent . The use of steel ligature wi re allows better engagement of the archwire in the brac ket slot and eliminates the need to change the ort hodont ic elastomers at each appointment. The idea is to expend a small, extra effort earlier t hat wi ll pay big divid end s throughout the rest of the t reatment. Good patient compliance is vital for successful treatment. Simp lifie d techniques reduce the complexity and number of instructions necessary for the patient to follow. The patient can more easily perform the duties necessary for successful results, makin g the success rate significantly greater. If thin gs are kept simple, all involved-patient, orthodontist, and staff- can do their jobs more effectively.

Conclu sion
Simple does not necessarily equal easy. Keeping thi ngs
simple can be hard work . A good deal of time and eff ort must be devoted to allow t reatment to flow smoothly and successfully to th e desired goal. Too often in orthodont ic management, t here is confusion between efficiency and effectiveness. Stephen Coveyl did not choose to refer to peopl e who were " highly eff icient " in th e ti t le of his book; he chose the words " highly effective." Efficiency is doing thin gs right. Effectiveness is doing the righ t th ings. The Alexander Discipline is designed for effectiveness, to do the right th ings. Emergin g technology wi ll surely allow our methods and app liance design to be more eff icient and effective; how ever, the fundamental truths of final tooth positioning for functional , healthy,

Prin ciple 3 Case Study


Overview
This case demonst rates how a rather difficult malocclusion and Class 11 skeletal pattern can be treated using the KISS principie .

Examination and diagnosis


A 1O\<-year-old girl presented with a medium Angle Class 11 division 1 skeletal pattern . Her molars were Class 11, and she had an overjet of 10 mm and an overbite of 5 mm . Her maxillary intermolar width measured 32 mm, indicating the need for expansiono The mandibular arch showed moderate crowding of more than 4 mm. The lower midline was shifted 2 mm to the left. Her soft tissue profile showed a prominent nose and a deficient mandible.

Treatment plan
Because of the patient's thin lips and pointed nose, it seemed unadvisable to consider extracting teeth, so the decision was made to treat this patient with nonextraction . Initially, a rapid palatal expander was placed, and the palate was expanded appro ximately 7 mm . During

th is time, a lip bumper was placed in the mandibular arch to gain moderate space. To address the skeletal problem , a combination facebow was worn at night. After full bracket placement and routine archwire sequencing, elastics were worn to achieve final occlusion.

Discussion
Although the patient had only one loose band, she did break 11 appointments. This. along with delayed bonding of the mandibular second molars, unnecessarily extended her treatment time. At the end of active treatment, she was having problems wearing her midline elastics. After 1 told her the "wedding story" (see principie 20), however, she corrected the midlines perfectly.

Follow-up
This young lady is an example of a typical patient treated in our office. Acceptable growth and eventual compliance combined to produce the finished result. She recently won a beauty contest. 17

Estab ish Goals for Stability


'We should look to the end in all things." - Jean La Fontaine

ew things in orthodontics are trul y new. The basic

method of tooth movement has changed little since the early 19005. Of course, the Alexander Discipline has enefited greatly from improvements in materials and pro:: edures, such as newer metallurgy and bracket bonding. Specific approaches, techniques, and materials will continuelly change, but the fundamental truths will always remain :he same. Early in the history of orthodontics, just getting the :eet h to move must have been very excitin g. The idea was :0 get the teet h " st raiqht ." History has shown, however, :hat thi s goal is not enough. That word relapse has contin. rally raised its ugly head. Getting the teeth st raight was :ery important, but time has show n that keeping the m straight is anothe r challenge. Therefore, the next level of orthodont ics is to keep the teeth straight. During this past century, orthodontists have learned some :acts regarding the placement of teeth at the end of treatnent that wil l affect the total outcome of the treatment.

One trut h that cannot be debated is the precept " Primum non nocere" (" First, do no harrn" ). It is possible for orthodontic treatment to cause plenty of harm: overexpansion, flaring, extrusion, poorly tipped roots, and the list goes on. It is the responsibility of the orthodontist to position the teeth so that the chances fo r healthy, stable results are more favorable. For example, orthopedic forces should control and/or encourage good growth . Orthodontic forces should not move the teeth into positions that vvrll be unstable. There are many unresolved issues in orthodontics: Are there limits or boundaries in orthodontics? What is the "stan dard of care" ? How much of orthodont ics has become a science, rather than remaining an art ? Hasthe specialty of orthodontics matured to the point at which the majority of orthodontists would examine the same patient and agree on the goals and specific treatme nt plan?

21 4 Establish Goals for Stability

Role ofthe Patient


The most imp ort ant factor in the formula for success is the patient. Three factors wi ll always prevent orthodontics from being an exact science: the patient's growth, habits, and compliance. Predicting the cephalometric skeletal changes that wi ll result from orthodontic or orthopedic for ces is at best an erratic science. Treating growing children is like attempt ing to hit a moving target. The amount and direction of growth wi ll have a significant role in determining the result. When a specific orthopedic force is applied, each human being can respond differently. In genera l, orthopedic improvement can be accomplished in most growing patients. The sagittal skeletal dimension can be altered favorably in growin g patients. Vertica lly growing patients with a high mandibular plane angle can be improved, although their direction of growth is not as favorable as that of patients with a lower mand ibular plane ang le. The most predictable orthopedic improvement can be observed when the transverse dimension is expanded . Habits such as thumbsucking, mouth breathing , bruxism, and tongue thrusting can have detr imental effects on the treatment outcome, regardless of the skeletal pattern. In most patients. however, the key to success is patient comp liance. As discussed in princ ipie 20, orthodontists are on ly as good as their patien ts.

Evidence-Based Orthodontics
In one of his lectures many years ago, Dr Fred Schudy from Houston, Texas, joking ly stated, "Figures don't lie . .. but liars f igure." When discussing the goals in orthodonti c treatment, I rely on very specif ic research performed by various people . Residents from the Baylor College of Dentistry orthodontic department have performed much of my research, many times using patient records from my office. This could create a conflict of interest if 1 had personally selected these records. To prevent this from occurring, I

have adopted some rules for use of my case records. The resident is given complet e access to all records. There is no " cherry picking"; I have never selected the patient records to be used in any study. The residents select the cases that they wi ll study based on th eir study protocol. They are not permitted to remove any records from the office. Orthodontic residents from oth er universities in the United States and from around the world have studied these records. This is import ant so that the doctors around the world who hear the results of these studies can be confident of the ir object ivity. It is incumbent on all orthodontists to practice evidencebased orthodontics, w henever that evidence exists. AII results discussed in research must be accompa nied by stati stical data . lt is the goal to arrive at a stat ist ically valid mean. That mean will always have a range, however (the standard deviation). The numbers and measurements presented in research are often just guidelines, not absolut e values. As Dr Peter Buschang says, "There is no such thing as a 'me an' patient." As alway s, th ere will be exceptions to every rule; however, the principies advocated in this book are an attempt to make orthodonti cs more of a science and less of an art. The following goals, when achieved, have been found to help create healthy, esthetically pleasing, and stable results: Mandibular incisors balanced on basal bone Maxillary incisors positioned to create a good interincisal ang le Canine expansion prevented Proper artistic root positioning Upright mandibular fir st molars Norma l overbite and overjet Functional occlusion in centric relat ion

The 15 Keys to Orthodontic Success


Throughout the history of modern orthodontics, the diagnostic records of the patient have been used to evaluate the patient's problems and determine the resultant t reatment plan. These records consist of a lateral cephalogram, panoramic radiograph, study casts, intr aoral photographs, and facial photographs. From each of these records, crit ical informat ion is obtained and then evaluated . After much research and evaluat ion of part icular measurements from many patie nt s' long-term records, certa in norms appear evident; these norms have helped to establish set goals for th e treatment of patients. Among all of the possibilities, 15 measurements taken from the diagnostic records can provide a br ief yet accurate determination of goa ls necessary to achieve successfu i treatment and long-term stabi lity for the individua l pat ient.

Cephalometres: The tetragon-plus analyss


:::ertain established cephalometric measurements can be -ifluenced and/or controlled during treatment. Among .nese are the mandibular incisor-mandibular plane (IMPA), J f the mandibular incisor inclination ; sella-nasion-mandibular olane (SN-MP), or the mandibular plane angle; maxillary

-icisor- sefa-nasion (Ul-SN), or the maxillary incisor inclination; and maxi llary inciso r- mandibular incisor (U 1-L1), or the ''l terincisal angle. When these four measurements are comoined. a four-sided figure, or tetragon, is formed (Fig 4-1). A <ey to successful treatment can be the control of these angles or change to more ideal positions.

1. Mandibular incisor inclinat ion


Three possibilities exist for an ideal posttreatment value for I PA (Fig 4-2): In most nonextraction treatments, the mandibular incisors should be maintained within 3 degrees of their original position (the 3-degree rule). 2. In patientswith a deep bite, especially a division 2 deep bite, the mandibular incisors are often inclined lingually and should be advanced, sometimes significantly. 3. In patients with bimaxillary protrusion, the incisors are often significantly flared. In these patients, the incisors should be retracted more than 3 degrees. Because the majority of patients are treated without extraction, it is critical to control the position of the -nandibular incisors and prevent labial flaring. This is perhaps one of the most common mistakes made in orthodontics beca use many c1 inicians fail to address this issue. Almost all studies indicatethat violating the 3-degree rule (inclining the incisorsmore than 3 degreesfrom their original position)will result in a higher incidence of relapse in the long term."? Clinically, -5-d egree torque in the mandibular incisor bracket will help to control this critical position. This is discussed in greater detail in principie 17.

2. Ma ndibular plane angle


The goal is to maintain the mandibular plane angle (SNMP) as close as possible to the pretreatment value (Fig 43). In very low-angle cases, the mandibular plane may have to be increased during treatment. In patients with average vertical dimensions and good growth potential, orthopedic forces, if managed properly, can be very successful without signif icant ly increasing the vertical plane. The problem arises when the patient presents with a high-angle vertical pattern . In sueh cases, maxillary molar control is critical to prevent molar extrusion.' For example, if headgear is misused and only a cervical neck st rap is prescribed for high-angle patients, the maxillary molars may be extruded, causi ng vertical openings. Specif ic controls are discussed in later principies.

3. Maxillary incisor inclination


In normal skeletal patterns, the maxillary incisor should be inclined 101 to 105 degrees relative to SN (Fig 4-4). An exception to this rule applies to patients with a high mandibular plane angle. Often in these types of cases, the incisor can be positioned more vertically, decreasing the UlSN angle. In contrast, when a patient has a low-angle pattern, the maxillary incisor inclination can often be greater.
Controll ing t he inciination (torque) of the maxillary incisor is critical to the creat ion of adequate incisal guidance, which leads to the fourth angle in th e tetragon . With the Alexander bracket prescriptions, incisor inclination (to rque control) can be accom plished with a 0.017 x 0.025-inch

stainless steel archw ire in th e pretorqued 0.018-inch slot anter ior bracke ts.

4. Interincisal angle
The accepted angle between the maxi llary and mandibular incisors (U1-L1) is from 130 to 134 degrees (Fig 4-5). As with the other measurements, U1-L1 may vary, depending on an individual's skeletal vertical pattern . Alt hough orthodontists have limited options for positioning of the man dibular incisors, th e maxilla allows more freedom in t he positioning of the maxillary incisors. However, t he final position of the maxillary incisors is direct ly relate d to the position of th e mandi bular incisors.

S. Tetragon plus
Add it ional information garnered from the cephalogram is referred to as tetragon "plus." These data include the measurements to det ermine sagitta l skeleta l dime nsions and the cephalometric soft tissue profile.

Sa. Sagittal skeletal dimensions


Ideally, treatment of a skeletal Class 1, 11, or 111 malocclusion w ill result in a sagi ttal jaw relat ionsh ip (sellanasionpoint B) of 1 to 3 degrees (Fig 4-6). In Class 11 children who are in a growth period and exhibit good compliance , such results can be achieved w it h th e use of facebow. Class 11 1 skeleta l patterns, how ever, do not always show a successful respon se to t reatment mechanics. Use of the Wits appraisa l can also be helpfu l in forming a diagn osis for patients with t his type of malocc lusion. Class 1I I treatment mech anics is discussed in detail in subsequent volumes in thi s series.

Sb. Cephalometric soft tissue profile


Ideally, Holdaway's harmony line, connect ing the soft tissue pogonion with the uppe r lip, should touch the lower lip and bisect the nose (Fig 4-7). However, many variations of this esthetic measurement can exist, depend ing on t he size of the chin and nose. For example, in Asian patients, an ideal line might toueh soft tissue pogonion, the

lips, 6. Mandibular intercanine width and the tip of the nose. The treatment goal for this crit ieal measurement is to The tetragon "plu s" combines all of these eephalometmaintain the original intereanine wi dth (Fig 4-10). Long' e measurements (Fig 4-8). term studies have shown that any expansion of more than 1 mm will invariably relapse.? No matter how of ten the researeh reeon firms this fact ,

Study casts orthodontists eontinually look for excuses to break this


rule. A eommon belief is that, with extraetion treatment, Jlaster study easts are used throughout the world asa primary the mandibular eanines can be retraeted to a wider part of iagnost ie aid (Fig 4-9) In rea lity, it is impossible to reaeh a the areh; therefore, eanine expansion is aeeeptable . If this diagnosis only through the use of study easts. However, there were true. the long-term studies of extraet ion t reatment are four very important factors that can be measured on the wo uld show the stabr lity of eanine expansionoThe literastudy easts; these faetors must be controlled if sueeessful ture does not support this.6.7 orthodontie treatment is to be aecomplished. The only exeept ion to this rule might be when the eanines have erupted lingually, inside the normal areh. Inthese cases, the canines can be expanded into that normal sufficient to allow space for crowded teeth and improve the arch form (Fig 4-11). appearance in the buccal corridors. In most cases, if this Clinically, the intercanine width is finalized by referring width is 33 mm or less. the treatment plan will include

back to the original mandibular study cast (Fig 4-12) and palatal expansion with a rapid palata l expander or archwires. superimposing the f inal archwire over the mandibular arch While expansion of the mandibular intercanine dimension (Fig 4-13) should be avoided, the maxillary molars can be expanded, which in turn will allow the uprighting or the expansion of 7. Maxillary intermolar width mandibular molars. This implies that it is also possible to When measured from the lingual groove at the cervical line slightly expand the premolars (a line between the mandibuof the maxillary first molars, the maxillary intermolar dislar can ines and first molars). This is supported by a long-term tance should be between 34 and 38 mm (Fig 4-14). If the study of stability.? The difference between these regions sizes of the individual teeth are dose to normal, thiswidth is might be explained by the balance between the facia l mus.ulature and the tongue. The orbicularis oris places suff icient oressure on the anterior teeth to resist excessive flaring or expansionoThe buccinator muscles, however, offer less pressure. allowing more stable expansion in the buccal segments.

8. Arch form
.-\n ovoid arch form design will provide the most estheticand stable form for most patients (Fig 4- 15). This conclusion is oased on the following rationale: If the mandibular canine area is not expanded and the positions of the mandibular ncisors are controlled, the maxillary and mandibular anterior arch forms will be mostly predetermined. If the maxillary .nterrnolar width is made to be approximately 36 mm, the maxillary and mandibular posterior widths and arch forms are then determined. Thus, a line formed between the canines and the molars results in an ovoid arch formo This ovoid arch form will also be very esthetic because the posterior teeth (buccal segments) are sequentially expanded, filling the patient's buccal corridors (Fig 4-16). A detailed analysis of arch form is presented in principie 9.

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. Leveling is often overlooked in case evaluation, but my studies show that the better the leveling, the better is the stability (Fig 4-17 )8.9 Clinically, this arch leveling is accomplished by placing a reverse curve in the archwire. The exceptio n to th is rule is in the treatment of open bite-type malocclusions. In these pat ients, a slight curve of Spee in the mandibular arch is desired. Prin cipie 14 elaborates on the mechanics of leveling the arches.

10. Occlusion
Everyone agrees that good occlusion is critical for function, health, and stability. Excel lent 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 cent ric relation that coincideswith maximum intercuspation

Panoramic radiograph

11. Root positioning


As displayed in the panoramic radiograph, the roots of the anterior teeth, canine to canine, should be divergent in both the maxrlla and the mandible (Fig 4-19). The angulations to accomplish this root positioning are integrated into the bracket prescriptions.

After treatment of patients with deep bite, the mandibular first molars should be upright. A - 6 degree angulat ion on the mandibular first molar tube is designed to help accomplish this result (Fig 4-19). In extract ion cases, the roots of the teeth adjacent to the extraction sites should be parallel to each other at the end of active treatment (Fig 4-20). Proper bracket placement will accomplish t his goal; this subject is addressed in principie 7.

12. Periodont al health


Although periapical radiographs are necessary to show specific bone 1055, carefu l observation of the interproximal Fig 4-20 In this case, four first premolars were extracted. The roots in the extraction space are parallel to each other. Fig 4-22 Observation of thecondyles in the panoramicradiograph isa preliminary method of diagnosing temporomandibular joint problems. bone; root apices; and unusual conditio ns such as impactions, abscesses, and root reso rption can be accomplished in detailed examination of a high-quality panoramic radiograph (Fig 4-21).

13. Temporomandibular joint


Depending on other factors, initial diagnosis of th e temporomandibular joint conditions can be made by observing the size and shape of the condyles on a panoramic radiograph of good quality (Fig 4-22). If joint symptoms are present, a more thorough investigation is required.

Facial photographs
14. Soft tissue profi le
The final position of the lips is dependent on th e position of the maxillary and mandibular anterior teeth that create the interincisal angle (Fig 4-23). If these teeth are positioned too far labial or lingual, an unfavorable facial profi le can resul t.
As mentioned earlier, the ideal profile in a white individ_ a l is represented by a line touching the lower soft tissue =1in and the upper lips and bisecting the nose. Because , ost profiles tend to flatten with age, when a compromise -egarding the patient's profile is necessary, it is always : referable to finish treatment so that the patient has a - ore protrusive profile.

15.Smile
- ne Alexander Discipline is intended to produce the follow19 results at the end of orthodontic treatment (Fig 4-24): Coincident dental midlines Coincident facial midlines Esthetically positioned teeth A balanced smile line A balanced smile arc Absence of dark buccal corridors Unless the patient has skeletal problems, such as verti: al maxillary excess or asymmetric growth patterns, these qoals should be attainable in most patients.

Con clusion
There is an old saying: "AII roads lead to Rome." How ever, in orthodontics Rome may be difficult to find, oecause there are many different roads to take. It is important to identify the goals and objectives for achieving

an ideal orthodontic result. If the 15 goals discussed here can be obtained through treatment, then treatment vill routinely produce healthy, functional, esthetic, and stable results. The systematic procedures needed to correct specific malocclusions are addressed in other principies in this book. Consistency in treatment mechanics willlead to consistent results.

PrincipIe 4 Case Study


Overview
The challenge is to align the crowded teeth properly without changing thi s beautiful profile .

Examination and diagnosis


This young adult (18 years, 7 months) presented with a borderline nonextraction skeletal elass I occlusion and a beaut iful soft tissue profile, but a moderate curve of Spee and an arch length discrepancy of 5+ mm.

Treatment plan
Our goal was to control the mandibular incisors and canine width wh ile treating the patient nonextraction . This was accomplished by means of judicious use of to rque control, interprox imal enamel reduction , and class

Discussion
The challenge was to treat the patient nonextraction while properly aligning the teeth and maintaining the prof ile. The sequence of mandibular occlusal photos demonstrates how the anterior crowding was resolved and how the position of the incisors and the intercanine width were controlled. The patient was extremely compliant, which accounts for the relatively brief (20-mont h) treatment period o

Evaluation
The patient's prof ile was maintained while the malocclusion was successfully t reated in a simple manner.

Plan Your Work, Then Work Your Plan T


"Conc ntrate on finding your goal . . . then concentrate on reaching it."
he history of diagnosis and treatment planning has f ollowed an interesting trail over the past 100 years. From Angle's early commitment to nonextracti on

treatment and his battles with Calvin Case1,2 to Tweed's extract ion philosophy in the midtwenti et h century, the discussions have cont inued. More recent app liances (fixed and removable) and treatme nt philosop hies are promoting nonextraction treatment. Today, the debate concerning nonext ract ion treatment versus extraction t reatment continues. In our practice in Ar lington, Texas, approximately 85% of patie nts are t reated w ithout extraction . The average num ber of extract ion cases in the United States is about 20% of all pat ients t reated, w it h some individual orthodontists extracting up to 50%. A percentage of th ese cases might be considered borderline. Of course, worldwide differences in patient characteristics, such as skeletal patterns, toot h sizes and shapes, and soft tissue profiles, etc, could change these percentages significantly. The following eight factors help to c1 arify the sometimes diffic ult t reatment decision between extraction and nonext ract ion: 1. Facial and muscle patterns 2. Mandibular functional patterns 3. Tooth size and form 4. Arch length discrepancy 5. Unusual erupt ion patterns 6. Growt h

- Col Michael Friedson


7. Habits 8. Compl iance "Begin with the end in mind," is another Stephen Covey3 truism . However, it is necessary to fir st establish goals and understand how they can be achieved. The ends, or goals, of treatment were discussed in detail in principie 4. To ensure that these goa ls can be achieved, orthodontists must discipline themselves to compi le high-quality diagn ostic records. The quality of patients' records can be a direct reflection of the quality of the treatment provided (Fig 5-1). Chapte r 4 in my original book" detai ls the fu ndamentals of diagnosis and t reatment planning . The remainder of the present principie discusses additional factors that help to comp lete th e process.

Cephalometrics
No matter wh at cephalometric analysis is used, three basic measurement s 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

Sagittal skeletal pattern


The first cephalometric determination to be made is the patient's skeletal type: Class 1, 11, or I1I skeletal pattern. Addressing the skeletal discrepancy at the beginning of treatment will enable the clinician to determine the necessary type and direction of orthopedic force. The measurements sella-nasion-poi nt A (SNA), sel la-nasion-po int B (SNB), point A-nasion-point B (ANB), and nasion-po int Aporion (NA-Po) and the Wits appraisal can help to provide the answer. In most cases, the ANB angle will provide the needed

information. For a patient with a Class 11skeletal pattern, it is necessary to determine if the patient exhibits maxil lary prot rusion or mandibular deficiency. The angles SNA, SNB, and ANB are very helpful in this diagnosis. For Class 111 patients, the Wits appraisal may be more meaningful, especially in those with high-angle Class1I1 malocclusions (Fig 5- 2).

Vertical skeletal pattern


Whether the patient has a high-, medium-, or low-angle skeletal pattern will also influencetreatment decisions. The sella-nasion-mandi bular plane (SN-M P), Frankfort mandibular plane angle, occlusal plane- mandibular plane, and y-axis are measured and compared to provide an accurate assessment of the pat ient's skeletal vertical pattern. In keeping with the "keep it simple, stupid" (KISS) principie, SN-MP is routinely used as the reference measurement. A simple analysis follows: 1. When the SN-MP angle is 35 degrees or less (Fig 5-3), Class 11 skeleta l patt ernscan best be treated with a cervical facebow (Fig 5-4). During the treatment of a skeletal Class 111 patient using a face mask, the force Fig 5-2 To determ ine Class 111 skeletal patterns cephalom etrically in high-angle cases, the Wits appraisal is aften more accurate than point A-nasian-paint B(AN B). vector is often directed at 45 degrees in relation to the occlusal plane, depending on the smile line. 2. If the SN-MP angle is 36- 4 1 degrees (Fig 5-5), the vertical dimension is best managed wit h the use of a combinat ion-pull facebow (occipital and cervical straps) in patients with a skeletal Class 11 relat ionship (Fig 5-6). The elast ic force vector of a face mask used to treat high-angle Class I1 I patients should be directed parallel to the occlusal plane to prevent the ext rusion of the maxillary teeth. 3. If the SN-MP angle is 42 degrees or greater (Fig 5-7), 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 1I pattern (Fig 5-8). If the diagnosis is a high-angle skeletal Class 1I1 pattern, the elastic force vector of the face mask is directed almost parallel to the occl usal plane. For high-angle patients with arch length discrepancies, extract ion therapy may be indicated.

1ncisor position
The third factor analyzed with the cephalometric tracing is the posi tion of the incisors

Mandibular incisors
As stated in chapter 4 of The Alexander Discioline" control of the mandibular incisor position is critical for long-term stability. Tweed and others have demonstrated that the outcome is unstable when these incisors are advanced. Yet in contemporary orthodontics, the desire to t reat all patients without extractions has led to the routine, indiscriminate flaring of mandibular incisors. In a future volume of this series, the danger of such treatment wit h regard to postorthodont ic stability will be thoroughly explored. Clinical experience wit h both extremes of incisor position indicates that:

1. In most cases, the best and most stable position for

mandibular incisors is the position in which the Fig 5-4 Soft tissue profile of the same patient wearing a cervical facebow. Fig 5-6 Sot tissue profile of the same patientwearing a combina tion facebow. Fig 5-8 Soft tissue profile of the same patient wearing a high-pull facebow. Notice how the outer bow is bent at the firstmolar area. pat ient presents. Maintaining these teeth in their origin al positions is the goal. In high-angle cases, the incisors may be more upright. Treatment of lowangle deep bite cases may require that these incisors be proclined from their original position. 37

5 Plan Your Work


2. In extraction cases, mandibular incisors are usually uprighted . If an adequ ate interincisal angle is also achieved, this t reatment is stable. The soft tissue profile must be evaluated carefully when the incisors are uprighted so that a concave prof ile is not produced. 3. Studies have indicated tha t mandibular incisors can be advanced up to 3 degrees and remain stable- t he 3-degree rule. Beyond that crit ical 3 degrees, instabil ity is more likely. Perhaps the on ly time that mandibular incisors are int ent ionally advanced is when they are initially abnormally lingually inclined. This situation is of ten found in patients with Class 11 division 2 or Class II division 1 deep bite. Advancing the incisors in th ese patients w ill improve the int erincisal angle and soft t issue profile. The patient must be advised of the need for lifetime retenti on to ensure long-t erm stability because th e 3-degree rule has been violated.

Maxillary incisors
With the exception of Class II division 2 malocclusions, most maxillary incisors are posit ioned almost normally at the beginning of treatme nt. As with the mandibular incisors, the goal is to keep them in that original position. Maintenance of good torque cont rol of the maxillary incisors, along with the mandibular incisors. will result in a balanced int erincisal angle. This is critical for acceptab le functiona l occlusion and long -term stability. Often in patients with Class 11 division 1 patterns, these incisors are flared and spaced. When the spaces are closed and the arch is consolidated, the incisors will be uprighted to norm al position s.

Study Casts
Maxillary intermolar width
The maxillary intermolar width (t ransverse discrepancy) is measured from the lingual central groove s at the cervical line on th e maxillary fir st molars. If th e maxillary tran sverse dim ension is narrow (iess than 33 mm), th en rapid palata l expansion is routinely performed to provide adequate arch width. Moreover, addition al maxillary arch leng t h is gained, so that a bor derline extraction case often becomes treatable without ext ract ion.

Mandibular arch length discrepancy


Too often, the decision t o extract teeth is focused only on the tooth size-arch length discrepancy. Although a criti cal issue. other factors must be considered befo re an irreversible extraction decision is made. These factors are discussed

in principies 17 and 18,

Panoramic Radiograph
Assessment of the panoramic radiograph must fo cus on areas where problems can occur. The interproximal bone level must be checked, especially in adult patients. The root shape and position are critical to observe. Occasionally, an angulated or curved root is revealed by the radiograp h (Fig 5-9). The roots must also be examined for any signs of possible root resorption. The eruption patterns can also reveal that teeth may be erupt ing ectopically (Fig 5-10). The panoramic radi ograph shou ld also be used to check for any supern umerary or missing teeth. The radiogra ph must include t he areas wel l beyond th e apices of primary teeth to allow the observer to ensure tha t the permanent replacement tooth is present. Sometimes, the panoramic radiograph may not c1early show an area of concern. In this case, a regional or complete mouth periapical series is indicated. If necessary, the patient may be referred back to his or her general denti st or to a radiographic laboratory for these addit ional diagnostic radiographs. It is very important to observe the patient's thi rd molars throughout treatment. Tracking of th e erupt ion of th ird molars during t reatm ent is not only enlighten ing but necessary in the decision-making process. Comparison of successive panoramic radiographs can allow an informed decision, at the appro priate t ime, about whe t her it is necessary to ext ract these teeth. In addition, observation of the shape of the condy les in the panoramic radiograph can help to provide an init ial diagnosis of potential jo int prob lems. If other temporomandibular jo int dysfunct ions are foun d, special radiographs and treatm ent may be indicated .

Facial Photographs
Soft tissue profile
Of all the changes that can occur as a result of orthodontic treatment, the soft t issue profile is the most imp ortant for the orthodont ist to consider. Orth odontic treatmentcan affect the lips and soft ti ssue pogonion . The goal for the lips should be th at they touch lightly, w ithout strain, w hen the pati ent's mouth is closed. Wh en the facebow is properl y worn, th e chin will come forward in profile in growing pati ents. Although ort hodontic treatment does not direct ly influ ence the growth of the nose, the outcome can affect the apparent size of the nose relative to the upper lip. For example, ext ract ion therapy can reduce upper lip protrusien. making the nasolabial angle more obtuse and resulting in an increase in the appa rent size of the nose. The size and shape of the parents' noses may also be an indication of the patient's pote nt ial nose growth and an additional factor in th e diagnosis and treatment-planning process.

Soji tissue fro ntal appearance at rest


Careful observat ion of facial symmetry is yet anoth er part of a thorough diagnosis . Although no face is perfec tly symmetr ic, any major asymmetry must be addressed. If the patie nt's lips are apart at repose, it may indicate t hat the teeth are protrusive in relationship to the lips or th at a significant

vertica l prob lem exists.

Sojt tissue smile


A prima ry reason parents bring th eir child to the orthodontist is a concern about the child' s smile. lt is important to observe the facial midline in relat ion to the dental mid line as well as the smile line and the amount of maxillary gingival tissue revealed. The ideal position of the smiling lip is at th e gingival line, plus or minus 2 mm . The smile arc is the shape of the lower lip in relati on to th e maxillary incisal edges when the individual is smiling . Ideally, the srrulinq lower lip should follow and contact the maxillary incisal edges.

Buccal corridors
A very impo rta nt consideration is the buccal corridors. Narrow arches will result in dark buccal corridors that are revealed when the patient is talking or smiling. In the Alexander Discipline, the f inished smile is intended to show the mesiob uccal cusps of th e maxillary fi rst molars wi thin th e buccal corridors. This outcome is rout inely accom plished as a result of th e specif ic arch form developed and the distobuccal rotat ion of the first molars.

Treatment Decision Paradigm


AII the different analyses used throughout the world can help to provide the information needed to establish a diagnosis. These analyses can also become very complex. In keeping with the KISS principie, however, a very simple approach has evolved that will summarize and quickly yield the information necessary to set goals and to assist in developing the treatment plan (Fig 5-11) For each factor listed, the orthodontist should place a mark in the appropriate column, as dictated by the parameters defined in the following sections. When filling out this form, you should focus only on the specific factor under consideration, independent of all other factors.

Sojt tissue profile


Convex profile or bimaxillary protrusion: extraction (Fig 5-12) Normal (Fig 5-13) or Class II profile: nonextraction or borderline Concave profile: nonextraction (Fig 5-14)

Mandibular incisor position


Proclined incisors: extraction (Fig 5-15) Normally inclined incisors: nonextraction or borderline (Fig 5-16) Retroclined incisors: nonextraction (Fig 5-17) 41

5, Plan Your Work

Attached gingiva
Thin, narrow attac hed gingiva or ging ival recession: ext ract ion (Fig 5- 18) Compromised gingiva: borderline (Fig 5-19) Healthy gingiv a: non extract ion (Fig 5-20)

Groioth potential
Past growth potenti al: ext ract ion End of peak growth period: borderline W it hin or before pubertal growth period: nonextraction

Vertical skeletal pattern


High-angle (dolichocephalic): extract ion (Fig 5-21) Medium-angle (mesocephalic): nonextraction or borderline (Fig 5-22) Low- angle (brachycephalic): non ext ractio n (Fig 5-23)

Mandibular arch length discrepancy


Severe (more than 6 mm): ext ract ion (Fig 5-24) Moderate (4 t o 6 mm): borderline (Fig 5-25) Slight (Iess th an 4 mm): nonextra ct ion (Fig 5-26)

Maxillary intermolar ioidth (cast analysis)


Narrow; less than 33 mm can be expanded: change borderline into nonext ractio n (Fig 5-27) Normal; expansion not a factor (Fig 5-28)

Patient compliance
In a borderline case: Poor cooperation : extraction Moderate cooperatio n: bord erline Excellent cooperation : nonextr action Aft er each factor is assessed independently, the columns are totaled. The colum n with the greatest number of marks suggests th e f inal decision in favor of or against extract ion. The dilemma occurs wh en the borderline column has the highest score. To resolve thi s situ ati on, the pract ition er should discuss th e f indings with th e pat ient and parents. In these borderline cases, if the patient is willing, a nonextract ion treatme nt plan is initiated, and the progress is reevaluated 6 to 9 months into the treatment. The degree of comp liance could determ ine whether extract ions will be necessary. Assuming th at every eff ort has been made to treat a patient with out ext ract ions, several things can be done in the presence of significant mandibu lar incisor crowd ing to help cont rol the mandibul ar incisors and prevent excessive labial f laring. First, the Alexand er bracket prescripti on assists by including the -5 degrees (lingual crown-Ia bial root ) torque in the mandibular incisor brackets and the - 6 degrees of angulation (distal crown t ip) in the mandibular fi rst molar buccal tu bes. The bracket prescription is supplemented by placement of an initial resilient rectangul ar archwire. In addit ion, interproximal enamel reduction, prior to bracket placement , can create space and allow th e teet h to rotate more readily. If there is so much crowd ing th at the initi al archwire must be a round wi re (thus eliminat ing torque control), c1ass 3 elast ics can be used t o reduce mandibular incisor flar ing. C\ass 3 maxillomandibular elastics are prescribed to be worn for 72 hours (3 days). This will also help to upright th e mandibular first molars, thus creating additional space.

Conclusion
After all the possibilit ies of ext ract ing or not extract ing

teeth are evaluated, the final question that should be considered is, "Where should t he teeth be at th e end of tr eatment for this part icular pat ient?

PrincipIe 5 Case Study


Overview
A retrusive mandible and excessively prominent pogonion created a difficult problem to solve.

Examination and diagnosis


This ll-year-old girl presented with a severe mandibular retrusive Class I1 division 2 malocclusion. The maxillary transverse dimension was constricted . Her early permanent dentition displayed partially blocked out maxillary canines and unerupted premolars. The maxillary incisors were excessively uprighted. No crowding was found in the mandibular anterior teeth. The midline was shifted 3 mm to the left.

Treatment plan
Initially, the maxilla was expanded with the rapid palatal expander (RPE). The cervical facebow was placed on the same day that turning of the RPE was completed . Five months later, the RPE was removed and the maxillary brackets were placed. Seven months after that, the

~
mandibular brackets were placed. Four months later, c1ass 2 elastics (with an additional elastic on the left side) were worn with the facebow. Typical fin ishing elastics were used at the end of active treatment.

Discussion
In retrospect, it might have been preferable to have delayed treatment unti l more of the permanent teeth had erupted , thus potentially reducing the total treatment time.

Evaluation
In reviewing the patient's chart, it is obvious that she had many difficulties throughout her treatment time . She had 15 extra appointments. In the middle of treatment during a conversation with her mother, the patient cried. (Mean orthodontist! ) Every motivational technique known was attempted with this young lady . . . and it fina lly worked. (Effort =Results!) The facebow and c1ass 2 elastics achieved the anticipated "headgear effect."