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ALEXANDER ORTHODONTIC PHILOSOPHY

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DOI: 10.13140/RG.2.1.1879.4404

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 ALEXANDER ORTHODONTIC PHILOSOPHY
Nabil Muhsen Al-Zubair

Department of Orthodontics, Faculty of Dentistry, Sana’a University,

Sana’a, Yemen

E-mail address: dr.nabilzubair7@gmail.com

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 ALEXANDER ORTHODONTIC PHILOSOPHY

ABSTRACT

The Alexander Discipline represents a unique approach to orthodontic treatment; today,

legions of clinicians around the world apply its 20 master principles in their practices. An
outgrowth of the Tweed technique, these basic principles has been developed
empirically over many years in the author’s own practice. This review presents evolution
of the appliance, the concept of the Vari Simplex Discipline, as well as Alexander
orthodontic philosophy. This paper concisely describes finishing and retention
procedures in Alexander Discipline and will be of strong interest to anyone involved in
the study or practice of orthodontics.

Key Words: Alexander Discipline, Vari Simplex Discipline, biomechanics

INRODUCTION

Richard G. Wick Alexander designed an appliance to deliver

excellent treatment results in an easy organized manner. Simplicity,
to encourage cooperation, comfort and control, was his main
concern. His major goals include high quality results, patient comfort
and reduced chair side time. He developed an appliance known as
the Vari-Simplex Discipline, a system of Brackets placed on teeth,
which is used by orthodontists around the world (Box 1).

In the Alexander Discipline, a certain number of principles are followed that give this
technique its uniqueness. The first three Box 1: Vari-Simplex Discipline
principles focus on the philosophic nature and
- Vari –Variety of the bracket types
the attitudinal approach to the delivery of the
Discipline (Appendix 1). - Simplex – Concept of keeping all
aspects of the treatment as simple
Evolution of the appliance as possible
Its originally has grown from many proven (KIIS principle -Keep It Simple, Sir)
ideas and concepts that have been put
- Discipline – Orthodontists must be
together in a unique package (Box 2). In 1977,
knowledgeable and regular in
Dr. Wick Alexander described the Vari-Simplex
2

follow up
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Discipline; which includes a specific bracket

 system used in case treatment. Box 2: Evolution of the appliance

- The original appliance was developed in

The discipline is innovated for 0.018”
bracket slots and 0.017” wire, although
0.022” brackets can also be used. The
0.018” slot improves patient comfort,
reduce treatment time, and facilitate easy
movement of teeth into their proper
positions.
Instead of archwire bending, the first,
second, and third-order bends placed in
the bracket, which simplified archwire
fabrication and offer easier ligation and
activation with fewer archwire changes.
1977 and was called the Vari Simplex
Discipline.
- Generation two, called the Mini Wick
appliance, was developed in 1985. In this
design, a stronger metal alloy was used,
the brackets were reduced in size, and the
wings were redesigned to be more
efficient.
- In 1997, generation three evolved as the
Alexander Signature appliance.

From Tweed to Vari-Simplex

It grew out of the Tweed technique, and today maintains many of its principles (Box 3).

The Alexander Discipline has benefited from

these growth dynamics while remaining true
to its three goals: high quality result, ease and
convenience for the patient, and minimized
chair time.
Box 3: Treatment philosophy retains three
fundamentals of the Tweed technique:
1.Anchorage preparation (uprighting
mandibular molars).

In the Alexander Discipline, the patient ends 2.Positioning of mandibular incisors over
up with balanced facial proportion, consistent basal bone.
with skeletal pattern, which is the key
3.Orthopedic alteration with headgear.
objective to treat the case. Non-extraction
therapy is preferable whenever possible.

DIAGNOSIS AND TREATMENT PLANNING

Case diagnosis is generally reduced to two steps:

The desired mandibular incisors position is determined, and then ascertains the
treatment needed to position the maxilla and maxillary dentition over the desired
mandibular arch position, with four goals in mind: Incisor upright over basal bone,
cuspids not expanded, curve of Spee level, and non-extraction therapy whenever
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possible.
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 Factors affecting diagnosis:

A. Lower incisors position

The best and most stable position for lower incisors is the position in which the patient
presents. Lower incisors can be advanced up to 3° and remain stable. Instability is more
likely, beyond that degree. When the lower incisors are abnormally retroclined (Class II,
division 2, and division I deep-bite cases), they can be advanced beyond this degree. In
extraction cases, lower incisors are almost kept up righted.

The position of the mandibular incisors is considered the key to sagittal control;
determined by the A-PO line, IMPA
(relationship of mandibular incisors to
mandibular plane), and the Holdaway
ratio.
B. Age of Patient
C. Diagnostic records taken like intraoral
and/or panoramic x-rays, models,
facial photographs, cephalograms, etc;
to study the three tissues (facial,
skeletal, dental) in their three
dimensions (sagittal, vertical,
transverse).
THE CONCEPT OF THE VARI SIMPLEX
DISCIPLINE
Box 4: Factors determining the design of the
appliance
1. Size and shape of the teeth, especially the
mesiodistal width and curvature. These affect inter-
bracket width, which, in turn, affects the ability to
rotate the teeth and level the arch without using
vertical springs, multiloops, or extra arch wires.
2. Selection of proper bracket style to fit the size
and shape of each tooth.
3. Accessibility of the tooth and whether it is
located in a curved or straight area of the arch.
4. Patient comfort. The design must take into
account patient comfort and the frequency of
bracket wing breakage.

Three specific factors make the Alexander

Discipline different from others: unique
bracket selection and prescription; unique
arch form; and the treatment mechanics
(Box 4).

Unique bracket selection and prescription

1. Specific bracket designs are created for

specific teeth.

2. Single brackets create increased interbracket space, as

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compared to twin brackets, which will allow more flexibility

 with stiffer archwires, resulting in easier
engagement and fewer archwire changes.

3. Rotational wings give controlled guidance

and direction to the teeth. Wings can be
activated or deactivated for increased rotation.
The advantage of rotation wings is that the
force is exerted on the “active” wing.

4. The special prescription of torques and

angulations) in the Alexander discipline makes
the resulting straightwire appliance unique. If
one believes that control of intercanine width
and mandibular incisor flaring is important, as
shown in the literature, maximum effort should
be made to control this area. Possibly the most
significant and important of the unique design
elements of this bracket system is expressed in
the lower mandibular anterior brackets.

Using single brackets with wings creates an advantage that is not possible with twin
brackets. The prescription allows for controlled and effective mandibular arch leveling,
especially in nonextraction cases. This is accomplished by first placing the brackets and
ligating each tooth with a rectangular wire.

The incisorsʼ resistance to tipping labially, caused by the − 5° torque, places a distal force
on the first molars angulated at − 6°, causing them to upright.
This can gain 2–3mm of arch length without flaring the incisors.
The unique biomechanical principles of actively tying back a
heat-treated, curved, rectangular stainless-steel archwire
contributes to successful and stable arch leveling.

Unique arch form

The arch form used in the Alexander Discipline was developed

as a result of the compilation of hand-bent archwires that
provide individualized archforms , that will fit most patients
within one standard deviation. This arch form has been
compared to other commercially available arch forms and found
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to be more stable.
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 For long term stability in orthodontic treatment the mandibular anterior teeth positions
are vitally important. With rare exceptions, inter-canine width must stay within 1mm of
its original position. Mandibular incisors can be advanced not more than 2mm if long
term stability is the goal. Exceptions exist but this is the general rule. Therefore, it makes
sense that the anterior portion of the maxillary and mandibular archforms should be
built around the mandibular six anterior teeth.

Regarding the posterior teeth, it is well know that an intermolar width of ± 36mm is
stable in the long term. When combining these goals, the resulting archform will be
ovoid, regardless of the patientʼs beginning archform.

Treatment mechanics

The Alexander Discipline, however, is much more than a bracket system or arch form.
Certain specific mechanics were first created or popularized by this technique. Among
them:

1. One arch is treated at a time, beginning with the maxillary arch.

2. Driftodontics: In extraction cases, the maxillary arch is treated while allowing the
crowded mandibular arch to “drift” before placing brackets.

3. A cervical facebow is attached to a tied-back arch wire to create an orthopedic

correction in low and average angle skeletal Class II cases.

4. Borderline cases can often be treated without extraction by using RPE (rapid palatal
expansion) and lip bumpers for gaining space. The long-term stability of this technique
has been verified.

5. Mandibular incisor flaring is controlled by − 5° torque in the bracket and the initial
rectangular flexible archwire.

6. Mandibular first molars are uprighted with a − 6° tip.

7. Mandibular anterior roots are spread with specific angulated brackets.

8. Mandibular arches are leveled by a reverse curve in the archwire, using a specific
prescription for each patient.

9. Ball hooks are placed on the lateral brackets for elastic attachment.

10. Class II elastics are attached on lateral incisors rather than canines in order to
6

produce a more horizontal vector of force on the arches.

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 11. Maxillary canines are retracted on 0.016 in. stainless-steel archwire with power
chains.

12. Specific archwire sectioning and elastic attachments are used to finalize posterior
occlusion.

13. The unique maxillary wrap- Box 5: Twin Brackets

around retainer wire design controls
posttreatment settling. A maxillary
retainer is worn at night only.
THE APPLIANCE DESIGN AND
CONSTRUCTION
The system grew around five
dynamics related to brackets:
bracket selection, bracket height,
bracket angulation, bracket torque
and bracket in-out.
Bracket selection
- Diamond shape: horizontal
lines are placed parallel to the
incisal edge of the tooth
- Rhomboid: make it possible to align the
vertical lines parallel to the long axis of the
tooth
- Flat surface: permit full arch wire engagement
- Inter-bracket width: 5-6 mm, which is
sufficient for flexibility, rotational control, and
torquing ability

Each tooth has a particular bracket that is most effective.

1. Twin Brackets (Diamond brackets) - are used on large, flat-surfaced teeth –

maxillary central and lateral incisors (Box 5).

2. Lang Brackets – were invented by Howard Lang, used with

the Diamond design on large, round-surfaced teeth at the
corners of the arch – maxillary and mandibular cuspids.

3. Lewis Brackets - are used on large, round-surfaced teeth

that are not at the curve of the arch - maxillary and
mandibular bicuspids – and on small flat-surfaced teeth –
mandibular incisors.
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 4. Other Attachment – Twin
Box 6: Buccal tube brackets with a convertible
- Headgear tubes: sheath are used on maxillary
placed occlusally; and mandibular first molars,
makes it easier to use, which are usually banded. The
minimizes food traps, oral hygiene convertible sheath is easily
problems, and gingival impingement; and removed when second molars
it eliminates blockage when omega stops are banded, converting the
are used attachment to a bracket (Box
6).

Bracket height

Brackets have to be positioned in the center

of the tooth mesiodistally at a
predetermined position. Placing a bracket
higher or lower affects the amount of torque
and angulation, and the incisogingival
position of the tooth. The bracket height will
vary to fit the clinical crowns. Bicuspid
bracket height is the key. Its normal height is
4mm for small crowns; 4.5 mm for average-
sized crowns; and 5.0 mm for large crowns.

Bracket in-out (First order bends)

The appliance incorporates a system of interrelated, compensating bracket base

thicknesses to replace the usual first-order bends or offsets.

Archwire selection and sequence

Bracket is only a “handle” placed on the tooth. Proper archwire selection and sequence
will allow the discipline to deliver the desired results. The first step, in most cases, is the
elimination of rotations. This is done by the newer, flexible, more resilient wires –
multistranded round and rectangular TMA and Nitinol.

Leveling and space closure are accomplished next, usually with rectangular wire – TMA
or stainless steel. The last step – final leveling and arch form – are always performed
8

with stainless steel wire.

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 NON EXTRACTION TREATMENT

Modern technology and materials now allow the orthodontist to treat more borderline
cases without removing teeth. Initiate treatment in Upper Arch (Non-extraction
treatment begins with maxillary arch), Table 1.

Table 1: Maxillary and mandibular archwire force systems

Sequence Purpose Type Size (inches) and alloy

Maxillary

Initial Eliminate Flexible round 0.016 NiTi

rotations
Or rectangular 0.017 x 0.025 CuNiTi

Transitional Close spaces: Intermediate 0.016 SS

Non-extraction round Power chain

Close spaces: Intermediate 0.018 x 0.022 SS

extraction rectangular 0.017 x 0.025 SS

with closing loops TMA T-loop

Finishing Final arch form, Stiff rectangular 0.017 x 0.025 SS

leveling, torque

Mandibular

Initial Eliminate Flexible round 0.016 NiTi

rotations,
Or rectangular 0.017 x 0.025 Turbo
control torque CuNiTi, D Rectangular

Transitional Close spaces: Intermediate 0.016 SS

Non-extraction round Power chain

Close spaces: Intermediate 0.016 x 0.022 SS

extraction rectangular Closing loops

Finishing Final arch form, Stiff rectangular 0.017 x 0.025 SS

leveling, torque
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 - The mandibular arch is the key
to non-extraction treatment with
the Vari-Simplex Discipline.
Control lower arch using minus 5
degree torque on incisors, minus
- 6 degree tip on first molars and
initial flexible rectangular
archwire (Box 7).
- In non-extraction cases but
crowding of the mandibular arch
may prevent unraveling and
uprighting of the lower anteriors.
The term “slenderizing” is used,
rather than “stripping”, for the
selective interproximal reduction
of the enamel.
EXTRA ORAL FORCES
APPLICATION
Box 7: Bonding /banding on the mandibular arch is
delayed in a non-extraction case for the following
reasons:
- It will avoid interference of mandibular brackets
with maxillary teeth.
- As the maxillary arch improves, the mandibular
curve of Spee improves naturally.
- If a bite plate is needed, it fits better and is more
comfortable after the maxillary arch has been
properly aligned.
- Total time needed to treat the mandibular arch
is 6-9 months.
- It allows more time for the second mandibular
molars to erupt.

Successful orthopedic results are achieved with a retractor attached to the maxillary
first molars. The retractor offers better control of the posterior transverse dimension. A
high-pull is used when the angle SN to mandibular plane greater than 42 degree,
cervical-pull is used when this angle of 35 degree or less, and a combination pull is used
when the SN to mandibular plane range from 36-42 degree.

Depending on the diagnosis, the patient will wear the retractor 8-14 hours per day. 8
hours a day during night if the patient’s ANB is less than 3 degree, 12 hours a day if the
ANB is 3-5 degree, and increase to 14 or more hours a day if the patient’s ANB is 5
degree or more.

LEVEL ARCHES AND OPEN BITE WITH REVERSE CURVE ARCHWIRES

In case of close bite, enough excess curve of Spee is placed to enhance the opening of
the bite. It is greatly vital to tie this archwire back.

CONSOLIDATE ARCHES EARLY IN TREATMENT, THEN TIE BACK!

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Tying back the archwire is utilized to consolidate the arch to change the arch from
several units to a single unit. It is important for the arch to be in one unit for the
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 extraoral forces to act orthopedically instead of dentally, and instead of acting on
individual teeth, intraoral elastic forces must act on the arch.

There are three methods for tying back, power chain, the traditional Omega stop or
ligature wire from molar to molar, and bending the archwire at an angle distal to the
molar tube. The Omega stop, set 1-2 mm mesial to the buccal tube, empowers
placement of a dynamic tieback force on the archwire.

PROPER TIMING WITH CLASS II ELASTICS

As in most things in life, “timing is everything.” Diagnostically, class II malocclusions can

be classified as either skeletal or dental. In the Alexander Discipline, treatment of a
skeletal class II case begins with headgear wear 8 – 10 hours each night. Proper timing
for elastic wear is critical during orthodontic treatment in the Alexander Discipline. It is
very important that the final archwires in both arches, 17×25 stainless steel in an .018
slot, are fully engaged, tied back and have been in the mouth at least one month before
class II elastics are initiated. It is also important to attach elastics to the appropriate
teeth. In the Alexander Discipline, class 2 elastics are not employed to open the bite. In
a case with an extreme deep bite, the overbite will be corrected with reverse curve in
the lower archwire and box elastics to the bicuspids. After the lower arch has leveled
and the bite has opened, class 2 elastics will then be employed.

FINISHING AND RETENTION PROCEDURES IN ALEXANDER DISCIPLINE

By mastering specific proven techniques (mechanics) and understanding the sequence

of their application for the individual patient, quality results with long term stability can
routinely be achieved. Certain criteria must be met before the patient is ready for
retention. These criteria include:

- Ideal occlusion – Cuspids 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
11

- Lower incisors balanced over basal bone within 3° of their original position.
When proclined excessively, the lower incisors tend to upright over time.
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 - Original lower intercuspid width must be maintained. Expanded lower
cuspids typically constrict after removal of retention appliances.

- Lower first molars should be upright to maintain a leveled mandibular arch

and overbite correction.

- Habits should have been eliminated.

- Midlines should be coincident and correct.

- Correct curve of Spee and curve of Wilson should be optimal.

In addition, a circumferential Box 8: The countdown to retention

suprscrestal fiberotomy is performed on
all adults with severely rotated teeth Appointment 1: Sectioning of wires and finishing
two months before fixed appliance elastics
removal. Removal of hyperplastic tissue Appointment 2: (3 weeks later): Occlusal check and
in the maxillary central incisors area is final adjustments, and possible sectioning of the
also performed where heavy diastemas opposing arch wire and removal of molar bands
are present, especially if they are
Appointment 3: (3 weeks later): Fixed appliances
considered to be familial traits.
removal
The countdown to retention
Appointment 4 (2 days later): seating of the retainers
When all the objectives of the optimally
treated patient are achieved and fixed appliance removal time is approaching, four
arrangements are made with specific purposes for each appointment (Box 8).

CONCLUSION

If the mandibular arch is properly positioned –the arch level with the incisors not tipped
forward, the molars uprighted, and the canines not appreciably expanded –and the
maxillary teeth interdigitate with the mandibular teeth in good centric relation,
significant relapse is limited.

REFERENCES
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1. Alexander CD, Alexander JM. Facebow correction of skeletal Class II discrepancies in the
Alexander Discipline. Semin Orthod. 2001; 7(2): 80–84.
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 2. Alexander JM. A comparative study of orthodontic stability in Class I extraction cases.
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 19. Bernstein RI. Leveling the curve of Spee with a continuous archwire technique —a long-
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length. Am J Orthod. 1991; 100: 330–336.

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 32. Papandreas S. Physiologic drift of the mandibular dentition following first premolar
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 Appendix 1: Alexander Principles

Principle 1 Effort Equals Results

Principle 2 There Are No Little Things

Principle 3 Keep it Simple, Sir

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

Principle11 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, Followed by Retention, Will Improve Stability

Principle 20 Create Compliance

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