THE 20 PRINCIPLES OF THE

ALEXANDER
DISCIPLINE
THE 20 PRINCIPLES OF THE

ALEXANDER
DISCIPLINE
R.G. "Wick" Alexander, DDS, MSD
Clinical Professor of Orthodontics
Baylor Couege of Dentistry
Dalas, Texas
Private Practice Limited ro Orthodontics
Arlington, Texas

-bookr
Quintessence ~ublishingCo, lnc
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 I'rinciplr 1 Case Study

Figs 1-14a to 1-14c Posttreatment, age 30 years,

Fgs 1-15a to 1-15c ClinM uiew 15 pars posttreatment.

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There Are N o
Little Things

A
popular motivatirrnalbook published in the United
States is entitled, Don't S m t the SmalI Stu%.' In
the world of orthadontics, howwer, this is poor
advice. On the opposite end of the spearum, Stephen R,
Covey captured the nation's attention with the principtes
he espoused in his book, The 7 HabiB of Highly Effeciive
People, which was first publiohed in 1989.2 Covey
fwused on speQfic habits that anyone could adopt to
become more effectjve. i agree with most ef Covey's
ideas, but a favorite is the following (based on a quote
ftom Amerkan author Bruce Barton): "Sometimes when
I consider what tremendous consequencescome from lit-
tle thii-rgs, I arn tempted to think then are no little
things."
In my firct book,3 chapter 2 was dmted to a dixussion
of the "little things" that make al1 the difference in ortbo-
dontic praaice. AltRough tomputers have replaced pen
and paper, the basic concepts remain the carne.
OrthodontisB must mvision the "big piaure" in their prac-
tice and yet to be successful, they must also tend to al1 of
those little things that, when pul together properly, give
the final rewarding result,
This lwok &uses on the bíomechanics of orthodontic
treatment as well as patient compliance. However, for
 - -
0
Fig3-1 Di Charles Tweed.
The KlSS principk prmeates ewry principie w u s e d in
this b k . Occasionally, orthodontists ask, "Why band
omega loops?" or "WRy ligate with stwI ligature wire?"
These ptocedures take additional time whan initially per-
formed; in the end, however, it is much more effetctive to
have omega loops availabk so that the añhwire can be
tied back 2nd kept consolidated throughaut tfeatrnent.
The use af steel llgature wire allows better engagement
of the orchwire ln the braket slot and eliminates the
needto change the orthodontic elastomers at e a h appoint-
rnent. The idea is tg expend a small, extra effort eadier
that will pay big dividen& throughout the rest of the
treatment.
Good patient cornplanca is vitd for successful treat-
rnent. Sirnplifid techniques reduce the complexity and
nurhhr of insti'uctions necemy for the patient to follow.
The patient can more mly phmi the duties m i y
for successful resdts, rnokirq tk success rate signifimtíy
preater.
If things are kept sfmgie, al1 involved-patient,
dontist, and stáff-can do tbt jobs more ektively.
Conclusion
Simple does not necessarily equal easy. Keeping things
simpie tan be hard work. A gmd deal of time and effort
musr be dwoted to allow tíeatrnint to Row rrooüily and
sucessfuliy to the desired goal.
Tóo often in orthodontk rnanagement thm is confu-
sion between-e and eFéctivenes. Steph~nCweyl
did not choose to refer to -le who were "highly efíi-
cient" in the tiüe of his M ; he <hose the words "Righly
sffectiw," Effickncy is doing thlngs right. f mi ven^^ iS
doing the right things. The Alexander Discipline Is designed
for effectivewss, todo the right things.
Emergihg tecknology will surely allow our mtMSand
appliance daign to be more effkient and effective; how-
m r , the fundamental truths of final b i h positioning for
functional, healthy, attractive, and stable m l t s will stay
the -me.
Referentes
1. Wmd tH. Clinical Qxaiodanti~s.St hub: M*, 1966.
2. Cwey S, T k 7 HaM# of Highly EffeCtíve -te. Nwv Yo&:
Sirnon SchW@r,'98%
 Prunciple 3 Case ~niciy m

oumiw g&g
111

-;:T this ?im,.a lip burnper was placed in the mandibular akh>
to gain moderate space.
This case dernonstrates how a To addresr the skelétal problern, a cornbination fa&-
sion and Class It skdetal pattern can be treated using the bow was worn at night. After iull bracket placemefii:a@d,
KISS prindple. routine archwire seqirencing, elast ¡a were wpfn - ,
%Q'
achieiie'final ocdusion.

Ewtmination and diagnosis

A 1 Osyear-old girl presented with a medium Angle Class
II d ~ s i o n1 skeletal pattern. Her molars were Class II, and Althwgh the patimt had only one loose band,~she.,
she had an overjet of 10 mm and an overbite of 5 mm. break 11 appointments, This, along with dd+d bon
F4er mhillary intermlar width peasured 32 mm,@d;i+> '?f$.j$ 9:e n~d i~ ~ ,second
bular l mdars, unnec
- M the.ne&dior+&mp$on.
6 deA,--. $ - . . . The mandibdlar arch s h o ~ d extended her treatment time. At the end d
'Zoderate crowdng otjnore han4 rn&~he b v e r mid- rnent, she was having problems wearing her mid
line was shifted 2 h k k t h e bkeYf.Herbsoft tisws profik tics. After I told her the "wedding s t h q k e
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showed a promin,ent-inme 201,h o w e v e r g
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~n$a&efIcient mandible.

Because of the patient's thin lips and pointed nose, ii This young lady is an e x a q l e oí a typicatpatient treated
w m e d unadvisable to cansider extractihg téeth, ltir ~
h'~u!%ffice. Acceptahle gaowth and eventual comPli-
decision was made to treat this patientdth nondkac? anke combined the finirhed result, 'She
tion. Initialiy, a rapid palatal expander <wasplacM,'arid kcentlywsn a
the palate was expandd approximateiy 7 mm.-buring ; : .
 3 The KISS Principie

I
Figs 3-2a to 3-2c Preueatment facial viewc, age 10 years, 8 months. (a) Soft tissue profile: Protrusive, short upper Ilp; Iips sepamed; defi-
cient rnandible. (b) Frontal view: Nice eyes and facial symmetry; iips sepamted when relaxed. (cl Smile: Prominent maxillay central indsors.

A# 3-3a to 3-3c lntraoral views. (al RQht side: Errd-on Ciass II pattern. Frontal; Narrow maxilbry ara. (4LeR dde: End-on Chss II pattem.

Fig 3 4 a Tapsred V-shaged arch fom, Fig 3-5 Pretreatment lateral cephalometric
txclusal view. tracing.

Fig 3-4b 1, .. rch f m , 4+ mm _ _ . 4; Fig 3-6 Pretreatment panommic radiograph,

occlusal W.
 Principie 3 Case Study m

Figs 3-7a to 3-7c firee-mnth progress view. Rapid palatal expander activad 7 mm, arid Class II molar pattern resuking from sleeping in
a facebow,

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Figs 3-8a to 3-81 Fiíteen-month progress view. Maxillary 0.017 X 0.025-i~hstainless steel finishing archwires. Molars and. caning are.in
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Class 1, and the werjet has been recluced significantly.

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tembhation PweW 15
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Active lreatrñew Ws: 25 months C bMWlnc .3
m i ba 3
tin*&iq 2

Fig 3-9b Mandibular sepamtars placed

ptior to banding a bracketing, outusal
view.
 3 The n S S PRnciple

Figs 3-10a to 3-lOc Final iesult at age 12 years, 9 months. (a) Soft tiswe profile: Short upper lip makes lower lip slightly protrusive,(lj) Frontal
víew: Balanced Ilps together; no straln. (4 Smlte: Big and shows much enamel.

riEp 3-1l a to 3-11c Finai occlusion is normal,

Flg 3-13a Flnal cephabmetric tracing. Flg 3-13b Pretreatment 0 md final

(red) mphlometric trdcing cornparison.

Figs 3-12a and 3-1 215 Ovoid arch forms, fig 3.1 4 Final panoramic radiogragh.
ocdusal v i m .
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Establish Goals for

S tabilitv J
"We should look to &e end in all things."
-Jem L4 Fowkne

F
ew things in orthodonria are truiy new. The basic
method o#tooth mement has changed little since the
early 1900s. Of course, the Alexander Discipline has
benefitd greatly from impmments in rnateriak and pro-
cedures, such as nwer metallurgy and bracket bnrfing.
5pecific approach~,techniques, and materials wiH mntinu-
ally change, but the fundamental mths will always remain
ti-te same.
Early in the history of arthodontics, just getting the
teeth to mwe must have been very exciting. The idea w x
to get the teeth "straight." History has shown, however,
that this goal is not enough. That word relapse has contin-
wlly raised its ugly head. Getting the teeth straight was
very important, but time has shown that keeping them
straight is another challenge. Therefore, the next leve1 of
orthodontia is to keep the teth straight.
have learned some
Ruring this past century, orthodontkt~
facts regarding the placement of teeth at the end of treat-
ment that will affect the total outcome of the treatment.
One truth that cannot be debted is the precept "Primurn
non m e r e " ("First, do no hami"). R is posible for ortho-
dontic treatment to cause plenty of ham: werexpansim,
flaring, extrusion, poody tipped roots, and the list gaes an.
It is the responsibility of the orthodontist to position the
teeth so that the chances for healthy, stabte resuk are more
favorable. For example, orthopdic forces should control
anoVor encourage good growth. Orthodontic force5 sbould
not mwe the teeth into positions that will b unstabk.
There are many unresolved issues in orthohntics:
Are then lirnits or boundariec in orthodontics?
What is the "standard of care"?
How much of orthodontia has become a science,
rather than remaining an art?
Has the specialty of orthodontics matured to the point
at which the majority of orthodoritistswould examine
the sane patient and agree on the goals and specific
areatment plan?
Role of the Patient
The most important factor in the formula for suecas is thc
patient. Three f a c t ~will~ ahays prevent orthodontics
from being an exact science: the patknt's growth, habits,
and compliance.
Predicting the cephalometric skeleel changes that will
result from orthodontic or orthopedic f o w is at bmt an
erratic science. Treating growing children is like attempting
to hit a moving target. The amount and direaion of
growth will have a slgnificant role in determining h e
result. When a specific orthopedic farce is applied, each
human h i n g can respond differently.
ln general, orthopedic improvement can be accom-
plished in most g w i n g patients. The sagittal skeletal
dímension can be altered favarably in growing patients.
Vertically grwving gatients with a high mandibular plane
angle can be irnproved, although their direction of growth
is not as favorable as that of patients with a lower
mandibular plane angle. The most predictable orthopedic
irnprwement can be obsenied when the transverse dimen-
sion is expanded.
Habits su& as thumbsucking, mouth breathing, brux-
ism, and tongue thrlrsting can haw dstrimental effects on
the treatment outcome, regardless of tke skeletal pattern.
In most patients, however, the key to success is patient
comptiance. As discussed in principie 20, orthodontists are
only as gmd as their patients.
Evidente-Based
Orthodontics
In one of his lectures many years ago, Dr Fred Schudy from
Houston, Texas,jokingly stated, "Figures don't tie , . , but
liars figure." When diccussing the goals in wthodontic
treatment, ! rely on very spcific remrcti performedby var-
ious people. Residentsfrom the Bagor College of Dentistry
orttiodontic department have performed much of my
researeh, many times using patient recds from my office.
This could create a conflia of interest if I had perconally
setetted these records. To prwent this fmm occurring, I
have adopted some rules for use of my case records.
The nsident is given complete ac- to al1 records.
There is no "cherry picking"; I have never selected the
patient records to be used in any study. The residents select
tbe cases that thy will átudy based on their study pmto-
col. They are not permitted to remove any records frorn the
office. Orthodontic residents from other unkrsities in the
United States and from arwnd the world have studied
these records. This is important so that the dactors around
the k r l d who hear the results af these studiles can be con-
fident of their objectivity.
It is incumbent on al1 orthodontiststo practice evidence-
based orthodontics, whenever that evidence exists. Al!
resuits discussed in resea~chmust be accompanied by Sta-
tictical data. It is the goal to arrive at a statistically valid
mean. Ttiat mean will aiways have a range, howewr (the
standard deviatim). The numlirers and rneasurements pre-
sented in research are often just guidelines, not absoiute
valuec. As Dr Peter Buschang says, "There is no such thing
as a 'mean' patient." As always, then will be exceptions to
ewry nile; however, the principies advocated in this bmk
are an attempt to make orthodontin more of a science
and las of an art.
The following goals, when ad-i'kved, have been fwnd to
k l p mate healthy; estfietically pteasing, and staMe results:
Mandibular incisors balanced an basa1 b n e
Maxilbry incisors pasitioned to create'a gmd
interincisal angle
Canine expamion prwented
Proger artistic root positioning
Ugright mandibular first molars
Normal overbite and overjet
Functional ocdusion in centric relation
The 15 Keys to
Orthodontic Success
Throughout the history of modern orthdontics, the diag-
nostic record5 of the patimt have been used tu evaluate
the patient's problems and determine the resuttant treat-
ment plan. These records consist of a lateral cephalogram,
panoramic radicgraph, study mts, intraoral photagraphs,
and facial photqraphs. From e& of these records, criti-
cal fnformation is obtained and then eval~rated.After
much resea~hand evaluation of particular measurementc
from many patients' tong-ten records, certain noms
appear wident; these noms have helped to establish set
goals for the treatment of patients.
Among al1 of the possibilities, 15 measurements taken
from the diagnostic m r d s can provide a brief yet accu-
rate determination of goals necessary to achieve success-
ful treatment and long-terrn stability for the individual
pa tient,

Rg4-1 Tbiem:seHa-nasion-mandibular Fig 4.2 Mandibular incisor Indination:
plane (SM-MP); maitillary imisor-sellanasision m a d h l a r incisor (L1); mandibular hasor-
(U1-$N);maxillary inasorinandibularincisor mandibular plane (MPA); mwKUtwlar ptane
{Ul41);mandibularinasOr~ibularplane M?).
(IMPA).
Cephalome~re'cs:
The tetmgon-plw awlysis
Certain established cephalornetric measuremenl can be
influenced andlor controlled during tmtment. Among
these are the mandibubr inciso-mandibular plane (IMPA),
or the mandibukir in&r indinatian; sellaíiasiormiandibular
plane (SN-MP), or the mardibular plan@angle; maxillary
incisw+ella-nasion (U 1-SN),rir the rnaxiIIaty indw inclina-
tion;and maxillary incisor-mandi bular iricisor (U 1-L1), or the
intdncsal angle. WRen these four measurementsare mm-
bined, a four-sidcd figure, or tetragon, ir formed (Fig 4-l), A
key to successful treatment can be the control of these
angles or change to more ideal positions.
1. Mandibular incisur inclinatian
Three possibilities exkt for an ideal posttreatment value for
IMPA (Fig 4-2):
l . ln most nonextraction treatments, the mndibular
incisors sbutd be maintained within 3 dqrees of
their original position (the 3-degree nile).
2. In patients with a deep bite, especidiy a division 2 deep
b i , the mandibular i&rs are o&n indined lingually
and s hId be advanced, sometimes sr'gnificandy.
3. In patients with bimaxillary protrusion, the incisors
are often cígnificantly flard. In these patients, the
incisoa should be retraaed more than 3 degrees,
Because the majority of paüents are treated without
extraction, it is critica1 to control the position of t
h SN angle. ln contrast, when a patient ha5 a low-angle pat-
mandibular incisors and pnvent labial flaing. This is perhaps
The 15 Keys u> Orthodontic S w a s m
Fig 4-3 Mandibular pbne angle (skeletal
vedcal contrd): dla-nash-mndlbularplane
(SN-M?).
m e of the most common mistakes made in orthodontics
because many dinicians fail to address this i w e . Almost al1
studies indicatethat vidating the 3-degree rule (indining the
inci~rs more than 3 degrees from their original position) will
result in a h i g h incidente of relapse in the long ter~n.'-~
Ctinically, -S-degree toque in the mandibular incisor bradret
will help to contrd this uitical position. This is discussed in
greater detail in principie 17.
2. Mandibular plane aipolle
The goal is to maintain the mandibular plane angle [SN-
MP) as close as posible to the pretreatment value (Fig 4-
3). In very low-angie cases, the mandibular plane may have
to be inaeased during treatment. tn patients with average
vertical dimensions and g d growth potential, ortl-iopedic
forces, if managed properiy, can be very successful without
significanily increasing the vertical plane.
The problem arises when the patient presents with a
high-angk vert ¡cal pattern. In such cases, maxillary molar
control is critica1 to prevent molar extru~ion.~
For exarnple,
if headgear is misused and only a cervical neck strap is pre-
scribed for high-angle patients, the maxillary molars rnay
be extruded, causing vertical openings. Specific controls
are discussed in later principies.
3. MaxiOIaty incisor inclinatkn
ln normal sketetal patterns, t k maxillary incisor should be
inctined 101 to 105 degrea relative to SN {Fig 44). An
exception to this nile applies to patienb w'&h a high
mandibular plane angle. Often in these types of cases, the
incisor can be positioned more vertically, decreasing the U1-
tern, the maxillary incimr tnclination can often be greater.
Fig 4.4 Maxilfaryincisor indination: maxil- Fig 4-5 Interindsal angle: maxilary inci-
bry inciar-selh-nwion(U1-$N). sur-mandlbular inusor (U1-111.
tontrolling the inclination (torque) of the mxillary inci-
sor is critica[ to the creation of adequate incisal guidance,
which I d s to the fourth angk in the tetragon. With the
Aleander bracket prescriptlons, incisor inrltnation (toque
~ontmt)can be accornplisheel with a 0.017 x a.025-inch
staintes st& archwire in the pretorqued 0.018-inch slat
anterior brackets,
4, Inaftrindd angle
The accepted mgle ktween the mailhry and rnandtbular
inckors(U1 -Lí) is from 730 to 134 degreea. (Fig 4-5). As
with the other memrments, U1-L1 may vary, depending
on an irtdivldwal'sskeletal verticat pattern. Aithough ortho-
dmtists have limited options for pgsitbning af the
mgndhlar in&rT, the riaaxilla aHows more fredom in
the posiüonmg of the maxillary inriwrs. Howmr, the final
position 05 the maxillary iixisors is directly related to the
position of the mandibular tnci5ors.
5. Tatragon plus
Additional hformati~ngarnered fmrn the cephalognrn is
reerred to az tetragm vw.
" T b e data include the mas-
Fig 4-6 Sagittal control: sella-nasion-point
A (SNA); sella-nasion-pojnt8 {SNB); pint
A-nasio+@nt 8 (AMB); sella (S); nwion
(N); point A O; point 8 (3).
urernentsto determine sagittal skeletal dirnsnsionsand the
cephaiometric sqft tissue prof[le.
5a. Saqittd skeletal dimansiam
Ideally, treatment of a skele@I Class 1, 11, or lll mal~clu-
sion will result in a sagittál jaw relationship (sella-
nasion-paint B) of 1 to 3 degrees (Fig 4-61, In Ciass tl chl-
dren who are in a growth psriod and exhibit good m-
pliance, su& resulb can be arhiewd with the use ef
facebw. Class 111 skeletal pattefns, howwer, do not
always show a successful response to treatmen-t mwhan-
ia.Use of the Wits app~aisalcan elso be helpful in forrn-
ing a diagnmis for patients with this t y p af malocclu-
sion. I l x s 111 treatment mechaniais dixussed in detail in
subsequent v o l u m in this seji.er.
eh. Ccphdornaric S& tbsw pmfik
Ideatly, Holdaway's harrnony line, conneaing the caft tis-
sue pogonixin with the upper lip, shauld touch the bwer
lip and b'wd the m e (Fig 4-7). Howeve~,many variations
of Wiis esthetic measurement lan exist, depemding on the
size 05 tho chin and nae.For exarriple, in hiari patients,
 T h e 15 Keys to Orthodontic Success

Fig 4-7 (le@ M a l profile. The hamony

line connects soft t i a pogonion with the
upper lip. tdeally, the line touches the lower
lip and bisects the nose.

Fig 4-8 (@he Telragon plus: sella-

naslon-point A (SNA); sella-nasioti-poirit 0
(SNB); point A-nasion-point B (ANB); Ala-
nasion-mandibular gane (SN-M?); maxl-
larj imisor-sella-nasion (U1-SN); maxillary
Msar-madidibular lnasor {U1-U);&Bu-
la imisor-mandibular plane (IMPA) .

Fig 4-10 (righo Measurement of the inter-

canine width on the pretreatment stody
a5t.

an ideal line might tauch mft tissue pogonion, the lips,
and the tip af the nose.
fhe tetmgon "plus" combines al1 of these cephalomet-
ric measurements (Fig 4-8).
Plaster study mts are used throughout the world as a mmary
diagnostic aid (Fig 4-9), In reality, it is impossible to reah a
diagnosis oniy thmugh the use of study casts. However, ttiere
are four vey imprtant factors ~ h acan t be rneasured on tbe
study a t s ; these factors mwt be controlled if successful
orthodontk treatment is to be acmmplished.
6. Mandibular intercanine width
The treatment goal for this critica1 measurement is to
maintain the original intercanlne width (Fig 4-10).Long-
term studies have shown that any expansion of more
than 3 mm will invariably ~ l a p s e . ~
No rnatter how often the research nmnfirms this fact,
orthodontists continually look for excuses to break this
rule. A cornmon belief is that, with extraction treatment,
the mandibular canines can be retracted to a wider part of
the arch; therefore, canine expanshn is acceptable. If this
were true, the long-term studies of extraction treatment
would sl-iow the stability of canine expansion. The litera-
ture does not suppart tt1is.4~
T k only exception to this rule might be wtien the
canines have aupted lingually, inside the normal arch. ln
Fig 4-11 Occusal views. (a) Pretreatment cast showirig the lingual position of the rnandlbular canlnes. {bl Posttreatrnent cast after the canines
have been expanded to fit tk arch form. (4 Clinical view 15 pars postreteniion M n g mi relapse in the intercanine width.

m Fig 4-12 Ifar W Placemeni of 0.017 x

0.025-inch rtahless rteel finirhinp arcilwiie

tfii canines will not be expanded,

Fig 4-13 0 Final archwire is then tliiris-

ferred to the patlent's mandibular arch.

Fig 4-14 Pretreatment measurernent of the Fig 4-15 (al Pretreatment a t s demonstrating a V-shaped maxiilafyarch tom and a noma1
maxillay intermolar width to help determine mandibular arch form, (bl Posttreatment casts demonstrating an owid maxillary arSi fom
if additional expansjon is posible. and a normal mandibular arch fwm. lz) Twentyfive-year pomreatment casts demonstrating
stability of thc arch forms.

t h e ~ ec a m , ttie canines can be expandd inb that normal
arch form [Fig 4- 1 1).
Ctinicaliy, the intercanine wiúth is finalized by refening
b c k to the originat mandibular study cast (Fig 4-12} and
stlperimpmlng the final archwire aver the mardibular arch
IFig 4-13).
7. Maxillaty interm~larwidth
When measured from the lingual groove at t k cervical line
of the maWllary first m o b , the maxillary internalar d k
tan= should be htwm 34 and 38 mm (Fig 4-14). If the
sizs of t b individual teeth are close to nomal, thic width is
sufficient to allow space for cKnvded teeth and improve the
appearance in the buccal corridors, ln most cases, if thic
wi&h is 33 mm or less, the treatrnent plan wil4 include
palatal expansion with a rapid palatal expandcr or archwires.
Whlle expansion of the mandibular intercanine dimension
should be awided, the rWIbry molars a n be expanded,
which in turn will allow the uprighting or the expansion of
mandibular mobrs. This implies that it is ako possibie to
slightiy expand the premola~(a line bemeen the mandibu-
lar canines and first molar$. This is supgorted by a long-term
stlpdy of stabilitys The differen~b e w n tbse reghs
might hexplained by the balance ktween the facial mus-
 The 15 Keys to Orrhodontic Success m
Fig 4-16 (al Pretreatment smile. (b) Post-
treaunent denwnsirating a beautiful smile
that filis the buccal corridors.
5
1

Fig 4-17 M Severe mrve of Spee before

treatment. Leveledmandibular arch post-
treatment. (4 Twenty-fwe-year posttreat-
ment cast demonsuating excellent stability
of rfie aiwe of Spee.

Fig 4-18 (a) Pretreatment study casts

demonstrating severe malacclusion. {b)
Posttreatment msts shawing normal occlu-
sion. (4 Twenty-fivwear posttreatment
casts showing bng-term stabillty of the
occlusion.

culature and tha tongue. The orbiilaris oris places sufficient
pressure on the anterior teeth to resist e x c s s h flaring or
eicpansion. The buccinator rnusdes, hwever, offerless pres-
sure,albing more stable expansionin the buccal qments.
8. Arch form
An owid a ~ form h design will providethe most estheticand
stable form for most paiients (Fig 4- 1 5). Th is conclusion is
b a s d on the following ratronale: if the mandibular canine
area is not expandd and the positions of the mandibular
íncisors are contrdled, the maxillary and mandibular anterior
arch forms will be m t i y predetermined. tí the maxillaty
intermdar width is made to be approximately 36 mm, the
maxillary and mandibular posterior widths and arch foms
are ttten detmined. Thus, a line formed between t h health, and stability, Excelht ocdusion consists of a good
canines and the molars resuits in an ovoid arh form.
rhi omid arch form will also be very esthetic because
the posterior teeth (buccat segrnerrts) are sequentially
expanded, filling the patient's buccal corridars (Fig 4-16). A
detailed analysis of arch form is presented in principle 9.
9,Leveteal mandibular arch
Leveling the cunie of S p e in tke mandibular arch is eitical
to the correction of deep bites and tt-~ernaintenance of
wrbite correction, Leveling is often overlooked in case
evaluation, but my studies show that the better the lwel-
ing, the better is the stability (Fig 4-17).a9 Clnically, this
arch leveling is accomplished by placing a reverse cum in
the archwire. The exception to this rule is in the treatment
of open bitype malocclusions. In these patients, a clight
curve of Spee in the mandibular arch is desired. Principie
14 elabrates on the mechanics of IeveHng the archa.
10. tkclusion
Everyone agrees that gmd occlusion is critica1 for functim,
Chss I canine relationship, normal intemispation of pocter-
br twth, normal overbite and m r j e t relationships, canine
protection in lateral movements, anterior guidance, and a
centric relation that coincides with maximum intwcuspation
(Fig 4-18).
Fig 4-19 Panoramic radiograph reveals excellerir m1divergenein
the maxilary and mandibudar teeth. These positions are critial for
Iwig-termstability. Also,notke the uprighted mandibular first mdars.
Fig 4-21 Obmting the interproximalbone 1mls is an hitial means
of diagnosing the hearth of the periodantal tissues.
11. R a a t psitiodng
As displayed in the panoramic radiograph, the rmts af the
anterior teeth, canine to canine, should be diwrgent in
both the maxilla and the mandible (Fig 4-19). The angula-
tions ta accomplish this root positioningare integrated into
the bracket prescriptions.
After treatment of patients with deep bite, the mandibu-
lar frst mdars sh~uldbe upright. A -6 degree angulatian
an the mandibular fitst molar tube is designed to help
acmplish this resuk (Fig 4- t 9).
In extraction cases, t h roots of the teeth adjacent to
the extractian cites should be paralle1 to each other at the
end of active treatmcnt (Fig 4-20). Proper bracket place-
ment will accomplish f h i ~goal; this subject is addressed in
principie 7.
12. Periodonbl h l t h
Althwgh periapical radiographs are necessary to show
specific bone l a s , careful obsewation of the interproxirnal
Fig 4-20 In thi ase, four first premdars were extracted. The roots
in the extraction space are parallel to each ather.
Ag 4-22 Okmaion of the con$jlaki ih@ p w a m i c dbgraph is a
prel'minaty mgthod of d i h g tempwomandibular jwnt proBlems
bóne; root apices; and unusual conditions such as
irnpactions, abscesses, and roút resorption can be accom-
plished in cfetailed examinationof a highqualrty patwramic
radiograph (Fig 4-21).
t3. TemporummdJbuhr jotnt
Depending on other fa-, initial diagnosis of the tem-
paromandibular joint conditions can be made by obewing
the size and shape of the condyies on a panoramlc r a d i
qraph of gwd quality ( F i 4-22). If jdnt symptoms are
present, a more thorough investigation is required.
14. S& tisisue grofilé
The final position of the lips is dependent on the position
of the maxillary and mandibular anterior teeth that create
the interincisai angle (Fig 4-23). If these teeth are posi-
tioned too far labial or lingual, an unfamabis faaal profle
can result.
Fig 4-23 Balanad wft tissuc proflle,
As rnentioned earlier, the ideal profile ln a whlte individ-
ual is represented by a line muching h e l w e r soft tissue
chin and the upper lips and bisecting the nose. Because
most profiles tend to flatten with age, when a compromise
regarding the patient'c profile is necessary, it 6 always
preferabk to finish treatment so that the patient has a
more protrusive prdile.
15. Smile
The Alaander Discipline is intended to produce the follow-
ing results at the end of orthodontic treatmeril (fig 4-24):
Coincident dental midlines
Coincid~ntfacial midlines
Esthetically positloned teeth
A balanced smile line
A balanced srnile arc
Absence of dark buccal corridors
U n l a the patient has skeletal groblems, such as verti-
cal maxillary excw or asymmetric growth patterns, these
goals should be attainable in most patients.
There is an old saying: "All roads lead to Rome."
However, in onhodontics Rome may be dÍfficult to find.
because there are many different roads to take. It is
important to identify the goals and objectives for achiev-
ing an ideal orthodontk result. If the 15 goals discussed
here can be obtained through treatment, then treatment
will routinely produce healtl-iy, functional, esthetlc, and
stable results.
Fig 4-24 The smite demonstrates al1 of ihe goals reached in trat-
ment
The sysematic procedura needed to corred
malocdusions are addressed in other principies in this
bok, Consistencyin hatment mechanicswill lead to con-
sistent recults.
1. Glenn G, Sindair PM,Alexander KG. Monextraction orthodon--
tic ttierapy: Porttreatment dental and skeletal stability. Am 1
W o d Oentofacial Orthop 1987;92:321-3.28.
2. Ekns TN, Burdiang PH, Alexander RG. Lwig-temi stability of Class
it, D k i i 1, m a c t i m mmkd facdmw therapy. l. Model
analysis. Am J Orthcd OentofadalOrthog 1996;109:271-276,
3. Elms TM, Buxhang PH, Alexander RG. Long-term stabllity of
Class It, Oivision 1, nonextracth cervical facebow therapy. tl.
Cephalometric analysis. Am J O r W Oentofaciat Orthop
1996;109:386-392.
4. Parlcs LR, Buxhang PH, Alexander RA, Dediow P. Rossww E.
Masticatoryemise asan adjunctive tmtment for b y p e d i r -
g n t patients. Angle Orthod 2007;77:457-462.
S. Ferk T, Alexander RG, Bolq 1, Buxhang PH. Long-term stabil-
ity of corhined rapid palatal expansicn-llp bumper therapy
followed by full fmed appliances. Am J Orthod Dentofacial
Orthop 2005;128:310-325.
6,Alwander JM. A Comparative Study of Orthodontk Stability In
Clw I Extraaiori Cases (thesic). Oallas: Baylor Univ, 1995.
7. Bdey IC,Mark JA, Sachdwa RCL, Buxhang P. tong-term Sta-
b i l i af das I premobr extraction treatment. Am 1 Orthod
Dwitofwal Orthop 2003;,24:277-287.
8. Carean PRrton CB, lureyda O. The relatianihip
the mrve of Spee, relapse, and the Alexander Dixipline. Sernin
Orthod 2001;7:90-49.
9. swmin ~ cur\~e
CB, bmpsm J. L M I ~ tfie of SW
with a continuous ardrniire technique: A bng term cephalomet-
tic study Am J Orthod Dentofacial Orthop 2007;1 3 1 :363-371.
 viRrile propetly lylig~hg
prafile. T k -m

W CIO&I WBS ro mmt the rpandikyhr Jnc&qs ami

mine width hile trpating tly .qmtracMn,
TIih w@- a of jEIdid6iis me of
. d s
tbrqlbe mtroi,ifitwpWmaI e ~ l ' d u c t i o nand A I A m .
-, -1

'
Force
-
Maxillary Mandibular
1 . 0.016 MiTi 3 Nonw 3 C ~ S 3C
2.0.01 7 X 0.025NiTi 3 l . 0.017 X 0.025 Cufdifi 6, Clas 1feft
3.0.01 7 X 0.025 SS 14 2. 0.016 X 0.022 SS 2 Lateral b x
Active treatment time: 20 months 3. 0.017 x 0.Q25 SS 9 finishing elqsti~
Actiw veatmeuit time: 17 months
 Principie 4 Case Smdy

Flg 4-25 Pretreatrnent frontal vi% age 18 years, 7 months. (al Soft tissue profik shows very bala& no= lips, and &n. t;bl B a l a ~ e d
frontal view. Ir$ Smile shqw g d lip line and n a m bucal eorridon

Fig 4-26 (al IntFaoral right side shows Ckss I pattern with flrst molar in cross bite. 0 Midline dismpncy wiah anterior uowdhg. (0 Left-
side canine is partially block4 our; note unusual shape of the canine cusp.
I -Y-

Figs 4.26d and 4-26e Pretreatment Fig 4-27 Pretreatment cephalometric aac- Fig 4-28 hetreatment panoramic radi-
occlvsal views. Mandibular intercanine ing shows excellent skeletal and dental ograph shows nothing unusual.
width: 24.9 mm. nurnbers.
Flg 4-29 Ww1vlms (al M t pkrnent and initial Od17 x O.OZ5-inch CuMm archwir~. m
bracket winp r e d wi rght laterol
lndm bra&et. Class 3 e W wom night. m) 6 wek slenderlle a
nW M;actabate&al wing Mank bm&. Ici 14 week stop
ck 3 el&; slenderi.
1
W'
-
. --c<
'f.

Flgs 4-30a to 4-30c Facial uiews, 18 months: fhia8zlng arcb forms and oodusiarl.

Fig 4-31 Fid lephabmetric tracing show- Fig 4-32 Pina1 panorarnk t a e i p h .
kig control d all rwurements.
 Principle 4 Case Study u
Principle 4 Case Study 1

,-,,4-33 Pwttreatment frontal view, age 20 years, 3 manths la) Soft tissue profile. (61Soft tissue frorriai diew. (cl Soft tissue smile.

Figs 4-34a to 4-34c Pwttrwtment úcdwion. Note rnidline cor~ectionand reshaped maxillary left canine.

Figs 4-35a and 4 3 5 b Posttreatment Fig 4-36 Pretrsatment FbM

i and posttreatment (red cephalometric tmcing comparison.
ocdusal views. Final mandibular intercanine
width: 25.8 mm.
Plan Your Work,
Then Work Your Plan
'Vmcenmte onfindingylcr goal . .. then concmtrcéte m reaching it.
T
he history of diagnosis and treatment planning has
followed an interesting trail wer the past 1100 years.
From Angle's early commitment to nonextr-n
treatment and his battles with Calvin Case'.2 to Twed's
extraction philosophy in the midtwentieth century, the dis-
cussions have continued. More recent appliances (fixed
and removable) and treatment philosophies are promoting
nonextraction treatmcnt. Today, the debate mncerning
nonextraction treatment versus extradon treatment con-
tinues.
In our practice in Arlington, Ta&, approximately 85%
of patients are treated without extraction. The average
number of extraction cases in the United States is about
20% of ali patients treated, witk some individual ortho-
dontists extractlngup to 50%. A percentage of these cases
might be considered borderline. Of course, worldwide dif-
ferences in patient chatacteristics, such as skeletal pat-
terns, tmth sizes and shapes, and soft tissue prafiles, etc,
could change these percentages signifilantty.
The fdowing eight factors help to clarify the sometimes
dlfficuk tleatment decision between extraction and nonw-
tractíon:
1, Facial and rnusde patterns
2. Mandibular functional patterns
3. Tooth size and form
4. ArcR Iength discrepancy
5. Unusual eruption patterns
6. Growth
"
- Col Michael Friedson
7. Habits
8. Compliance
"Eegin with the end in mind," is another Stephen
Cm$ truism. However, it is necessary to f i ~ establish
t
goals and underctand how they can be achieved. The ends,
or goak, of tnatment weré discuss&d in detail in principie
4. To ensure that these gods can be ad-iieved, orthodon-
tists must discipline t hernseha t~ compile high-qua6ty
diagnostic records. The qwlity of patients' records can be
a direct reflection of the quatity of tke treatment provided
(Fig 5-1).
Chapter 4 in my original book4 details the fundamentals
of diagnosis and treatment planning. T k remainder of the
present prinaple díscusses additional factors that help to
complete the process.
No matttor what cephalmetrlc analpis is u&, t h e b a k
measurements must be obtained fcom the cephalometric
tracing befare a propr m t m e n t plan can b produced:
1. Sagittal skeletaf pattem
2. Vertical skeletal pattem
3. lncisor pocition
1 5 Plan Your Work
Fig 5-1 A bright and colorhit room displaying a Peter Max palnting
of the American flag se- as a positive setting for the patient dur-
ing diagnosdc record taking.
The first cephalometric determinatiori ta be made is the
patient's skeletat type: Class I, II, or lll skeletal pattern,
Addfessing the skeletal diwepancy at the beginning of
treatment will enable the clinician to determine the neces-
sary type and direction of orthopedic force. The measure-
ments sella-nasion-point A (SNA), sella-nasiorr-poin t 0
(SNB), point A-nasion-poin t 0 (ANB), and nasion-point A-
porion (NA-Po) and the Wits appraisal can help ta provide
the a n m r .
In most cases, the ANB angle will provide the needed
information. For a patient with a Class II skeletal pattern, it
is nelessary to determine if the patient exhibits maxillary
protrusion or mandibular deficiency. The angies SNA. SNB,
and ANB are wry helpful in this diagnosis. For C l a $ I1
patients, the Wits apgraisal may be more meaningful, espe-
dally in hose with high-angk Clas II rnatocclwioris (fig E 2).
Whether the patient has a high-, medium-, or low-angte
skdetal pattern will also influence treatment decisions. The
sella-nasion-mandibular plane (SN-MP), Frankfort
rnandibular plane angle, occlusal plane-mandibular plane,
and y-axis are measured and cornpared ta provide an accu-
rate aswssment of the patient's skeletal vertical pattern.
In keeping with t k "keep it simple, stupid" (KISS) prin-
ciple, 5N-MP is routinely used as the referente measure-
ment. A simple analysis follows:
1. When the SN-MP angle is 35 degrees or less (Fig
5-31, Class IIskeletal patterns can best be treated with
a cervical facebw (Fig 5-4).During the treatment of
a skdetal Class III patient using a face mask, th fforce
Fig 5-2 To detemine Class 111 skeletal pamrns cephalometrically in
high-angle cases, the Wits appmisai is often mofe auurate than
point A-nasion-point 6 (ANO).
vector is often directed at 45 degres in relation to the
occlusal plane, hpending on the smile line.
2. If the SN-MP angie is 3 H 1 degrees (Fig 5-5), the
vertical dimension is best managed with the use of a
combination-pul1 facebow (occip&l and cervical
~traps)in patients with a skeletal Class II relationship
(Fig 5-6). The elastic f o ~ veckor
e of a face mask used
to treat high-angle Class 111 patknts sbuld be directed
parallet to the wdusal plane to prevent the extrusion
of the maxillary teeth,
3. 1f the SN-MP angle is 42 degrees or greater (Fig 5-71.
every effwt is made to inhibit f u d w vertical gmwth
of the maxilla, A tiigh-pul1 facebow combination is pre-
saibed for patients with a high-angle skeietal CIas II
pattern (Fig M),If the diagnosis is a high-angle skele-
tal Class IIIpattern, the elastic force w o r of the face
mask is directed almost parallel to the ocdusal plane.
For Righ-anglepatients with arch Iength dkrepancies,
extraction therapy may be indicated.
Incumposition
The third factor analyed with the cephalometric tracing is
tt-ie position of the incisors,
Mandihlar incisors
As stated in chapter 4 of T k Aiwnder Discipline,4 control
of the rnandibular irnisor position is critica1 for long-term
stabifity. Tweed and othors have demonstrated that the
outcome is unatable when thqe incisors are advanced. Yet
in conternporay orthcdontktics, the desire to treat all
patients without extractions has led to the routine, indic-
criminate fiaring of mandibular incisorr. ln a future valume
of this series, the danger of such treatment with regad to
postorthodontic stability will he thoroughly exptofed.
Fig 5-3 Cephalome~ctracing of a patimt with a skeletal Class II
low-angle pattern.
Fig 5-5 Cephaiometf~tracing of a Class ll medium-angle patient.
Fig 5-7 Cephalometric tracing of a Class II h'ih-anglepatierat.
Clinial experience with both extremes of inc'mr pai-
tion indicates that:
1. In rriosf cases,
'the best and most stable position for
mandibular incisors is the position in w h i i the
Fig 5-4 Soft tiswe profile of the same patient waring a ceniicat
facebow.
Rg 5-6 Soft tissue proíile of the same patknt w r i n g a combina-
tlon facebow.
facebow. Hodce how the outer bow is bent at the first molar area.
patient presents, Majntaining these teeth in their
original posirions is the gwi. h high-angle cases, the
inckors may be rno# upright. Treatment of b-
angle deep bite cases my require that these incisors
be prodi@ fr:mt h e ~ original position.
 2 . In extraction cases, mandibular incisors $re usually
uprighted, If an adequate interimisal angle ir also
achieved, this treatment is stable. The soft tissue pro-
file must be evaluated carefully when the inlisors are
uprighted so that a concave profile is not produced.
3. Studies have irrdirated that mandibular incisors can
be advanced up to 3 degrees and remain stablethe
3-degree de. Beyond that critical 3 degrees, instabii-
ity is more likely. Perhaps the only time that mandibu-
lar indsors are intentionally advanced is when they
are initially abnormally lingually inclined, This situa-
tiori is often found in patients with Ciass II division 2
or Class II division 1 deep bite. Advancing the incirors
in these patients will improve the interlncisal angle
and sofí tissue prafile. The patitnt must li>e advised
of the need for I¡#etime retention to ensure long-term
stability because the 3-degree rule has been violated.
Maxillaty incisors
With the emeption of Class II dividon 2 malocducims, most
maxillary incisors are positioned almost nomally at the
beginrring of treatment. As with the mandibular incisors, the
goal is ta k e p them in that original position. Maintenance
of g d bque control of the maxilbry incisors, along witb
the mandibular incisors, will result in a balanced interincisal
angle. This is critical for acceptable functional d u s i o n and
long-&m stability. Often in patients with Class II divisian 1
p a w s , these in- are fared and spaced. When the
spaces are closed and the arch is consolidated, the incisors
will be uprighted ta normal gositions,
Study Casts
The maxillary intermolar width (transverse discrepan@ is
measured from the lingual ~entralgrooves at the cervical
line on the maxillaiy first molaiu. If tke maxillary transverse
dimension is narrow (less than 33 mm}, then rapid palatal
expansion ir routinely performed to prwide adequate arch
width. Moreover, additional maxillary arch length is
gained, so that a borderlineextraction cace often becomes
treatable without extraction.
Too often, tbe decision to extract teeth is focused only on
the tooth size-arch kngth discrepanq, Alt hough a critical
issue, other factors must be considered k f o r e an irre-
versible extraction decisbn is made. These factors are dis-
cussed in principies 17 and 18.
Assessment of the panoramic radiograph must focus on
areas where problems can occur. The interproximal bone
I dmust be checked, especially in adult patients. The root
shape and position are critica1 to observe. Occasionally, an
angulated or cuwed root ia revealed by the radiograph (Fig
5-9). The roots must also be examined for any signs of pos-
sible root ~sorption.
The eruption patterns can alx, reveal that teeth rnay
be erupting eetopically (Fig 5-10). The panoramic radi-
ograph should also be used to check for any supernumer-
ary or missing teeth. The radiograph mwt: include the
areas well beyond the apices of primary teeth to allow the
observer to ensure that the permanent replacement tooth
is present.
Sometimes, the panoramic radiograph may not clearly
shaw an area of concern. In this ase, a regionalor complete-
rnouth periiapical series is indicated. If nece#ary, the patient
rnay be referred back to his or her general dentist or to a
radicgraphic laboratory for these additional diagnostic radie
graphs,
It is very important to obserw the patient's third mobrs
throughaut treatment. Tracking of the eruption of third
molars during treatrnsnt is not only enlightening but nec-
essary ín the decisiún-making process. Compariron of suc-
cessive panoramic radiographs can allow an infomed deci-
sion, at the appropriate time, about whether it is necessary
to extract these teeth.
In addition, observation of thie shape of the condyles in
the panoramic radiograph can help to prwide an initial
diagnosis of potential joint problems. If other temporo-
mandibular joint dysfunctions are found, special radi-
ographs and treatment rnay be indicated.
Facial Photographs
Soft t k u e p f ; k
6f al1 the changa that can wcut as a. result of orthodon-
tic treatment, the soft tisrue píofile is the most important
for the orthodontist to consider. Orthodontic treatment

Ftg 5-9 During the diagnostic exam, a c w e d root (arrow) was
noted on the panoramic radiograph.
Fig 5-10 W Panoramic radlograph showing a labially impacted canine. 0 lntraoml view at an early stage of treatment.
can affect the lips and soft tissue pogonion. The goal for
the lips should be that they touch lightly, without strain,
when ths patient's mouth is cfosed, When the facebow is
properly worn, the diin will come forward in profile in
growing patients.
Although orthdontic treatrnent ncat difectly influ-
ente the gmwth of the m,tlw outcome can affect the
apparent size of the nose relative to the upper lip. For
exarnple, extradon therapy can reduce upper lip protru-
sion, making the nasolabial angle more obtuse and result-
ing in an inuease in the apparent size of the nose, The size
and shape of the parents' noses may also be an indication
of the patient's ptential nwe growth and an additionat
factor in the diagnosis and treatment-planning pmess.
Saft tissuefTonta1 appemnce at rest
Caeful observation of facial symmetry is yet another part
of a thorough diagnosis. Aithough no face is perfectly sym-
rnetric, any major acymmetry must be addiwsed. If the
patient's lips are apart a t repose, it may indicate that the
teeth are protrusive in relatianship to the lips or that a sig-
nificant vertical problem exists.
Facial Photographs m
A primary reason parents bnng their child to the orthodon-
tlst is a concern about the child's smile. It is important to
observe the facial midline in relation to the dental rnidline
as well as the smile line and the amount of rnaxillary gin-
gival tissue revealed. The ideal position af the smiling lip is
at the gingival tine, plus or minus 2 mm. The srnile arr.
is the shap of the lower lip in relation to the maxillary
incisal edges when the individual ¡S smiling. Ideally, the
smiling lower lip should follow and contact the maxillaiy
incisal edges.
A wry important consideration is the buccal corridors.
Narrow ardies will mresu tl In dark buccal corridors that are
rewaled when the patient is talking or smiling. In the
Alemnder Discipline, the finished ámile is intended to show
the mesiobuccal cusps of the rnaxillary first molars within
tke buccaI corridors. Thir outcome ir routinely accom-
plished as a result of the specific arch form developed and
the distobuccal rotation of the first molars,
 Treatrnent decisions: Extraction versus nonextraction
- .
- - .- -
Factor Extraction Borderline Nonextraction
Soft tissue profile

Mandibular incisor position

Attached gingiva

- - -
- ~ r o G potential-
h

Vertical skeletal pattern

High angle

Mediurn angle

Low angle

Mandibular arch length discrepancy

Madllary intermolar width

Patient corngliance

Total

Fig 5-1 1 b r m used for documenting Vmtrnent considelations.

Fig 5-12 Convex profile or bimaxillary pro- Fig 5-13 Normal profile. Flg 5-14 Concave profile.
tnision.

Fig 5-15 Cephalometric tracing showing Fig 5-16 Cephalometric trxing shwving Fig 5-17 Cephalometric tracing showing
proclined incirors, normally inclined incisors. retroclined incisors.

Treatment Decision
Paradigm
Al1 the drfferent analyses used throughout the world can
help to grovide the infomiation needed to establish a diag-
nosis, These analyses can also become very complex, In
keeping with the KlSS principie, h ~ r a very , simple
approach has evolved that will summarize and qukkly yield
the irlforrnation necessary to set goals and to assist in
developing the treatment plan (Fig 5-1 1).
For each factor listed, the orthodontist should place a
mark in the appropriate column, as dictated by the param-
eters defined in the following sections. When filling out
this f m , you should bcus only on the sgecific factor
under consideration, independent of al1 other factors.
Convex pmfile or bimaxillary protrusion: extraction
(fig 5-12)
Normal (Fig 5-13) or Class II profile: nonextraction or
brderline
Concave profile: nonextraction (Fig 5-1 4)
Mdndjbuldr inckorpoghn
Proctined inctsors: extraaion (Fig 5-1 5)
Normally inclined incisors: nonextraaion or bordedine
(Fig 5-16)
Retroclined incisors: nonextraction (Fig 5-17)
 5 Plan Your Work
Attdchedgiagiztd
Thin, narrow attadied glngiva or gingival recession:
extraction (Fig 5-18)
Compromised gingiva: borderline (Fig 5-19)
Healthy gingiva: nonextraction (Fig 5-20)
Pa;ist gniwlh potgntial: extraction
End of peak grmvth period: bwderline
Within QrMore p u W l gilowth period: nonextraction
High-ringle (ddichocephalic): extraction (Fig 5-21)
Mediurn-angle (mesxephalic): nonextraction or bor-
derline (Fig 5-22)
tow-angle (brathycephdic): nonextradian (Fig 5-23)
Severe (more than 6 mm): extraction (Fig 5-24)
Moderate (4 to 6 mm): borderline (Fig 5-25)
Slight (less than 4 mm): nonextraction (Fig 5-26)
(Cdst dndY~k)
mNamxu;iessthan33mmcanbeexpanded:change
borderline into nonextraction (Fig 5-27)
Normal; expansion not a factor {Fig 5-28)
ln a bordedine case:
Poor cmperation: extraction
Moderate coopera tion: brderline
Excellent cooperatlon: nonextraction
After each factor is assessed independently, the
columm are totald. The cohimn with the greatest number
of marks suggests the final deásion in fawr of or against
extraction.
The dilemma OCCUi'S when the borderline COlumn Ras
the highest score. To resolve this situation, tht practitioner
should disruss the findings wlth the patient and parents.
In these borderline cases, if the patient is willing, a nonex-
traction m t m e n t plan is initiated, and the progres is
reevaluated 6 to 9 manths into the treatrnerit. The dqree
of compllance could determine whether extractions will be
necessaty.
Assuming that every effort has been made to treat a
patient without extradims, several things can t x done in
the prsence of significant rnandibular Mcisor crowding to
help control the mandibular inckcirs and prevent exassive
labial flaring.
First, the Alexander bracket prescription assists by
includingthe-5 degrws (lingual crown-labial m t ) torque
in the mandibular incisor brackets and the -6 degres of
angutation (dista1 crown tip) in the mandibutar first molar
bucal tubes. The bracket prescription is supplemsnted by
placement of an in!tial resilient rectangular archwire, In
addition, interproximal enamel reduction, prior to bracket
plxement, can create space and allow the teeth to rotate
more readily.
If there is so much d n g that the initial a t M r e
must be a round wire (thus eliminating toque control),
class 3 elastics can be used to reduce mandibular incisor
flaring. C lass 3 maxillomandibularelastics are prexribed to
be worn for 72 hours(3 days), This wiii also k l p to upright
the mandibular first molars, thus créating additional space.
Conclusion
After al1 the possibilities of extracting or not extracting
teethareevaluated,thefinalquestionthatshouMbecon-
sidered is, "Where should the teeth be at the and of treat-
merit for this particular patient?"
1, Bwnstein 1, Edward H. Angle vems Calvin S. Case: Extraction
versus nmexh'action. Histarical revisioniwn. Patt II. Am J Orihd
ümtofacial Orthop 1992;1 02546-55 1.
2, Berristein L, Edward H. Angk versur CaMn S. Case: Extractlon
vem nonextraction. Histwical revhionim. Part l. Arn 1 Orthod
Dentofacial Orthop 1992;102:46l470.
3. Covey Habns of Highly EH* Peopfe, York:
Miurtc 1989.
4. Alexander RG, The Alexander Discipline: Conternprary
compt, and Philooophes. Glendora, CA: or-, 1 % ~ .
Fig 5-18 Thin narrow attached gingiva or Fig 5- 19 Compromised gingiva. Fig 5-20 Healthy glngiva.
gingival recession.

Fig 5-21 Cephalometric tracing showing Fig 5-22 Cephalometric traring showing Fig 5-23 Cephalometric tmcing showing
high-angle (dolichocephalic) skeletal pattern. mdium-angle (rnesocephalic)skeletal pattern. tow-angle (brachycephalic) skeletal pattern.

--

Fig 5-24 Severe (more than 6 mm) mandi- Fig 5-25 Moderate (4 to 6 mm) mandibu- Fig 5-26 Slight (les~than 4 mm) mandibu-
bular arch length discrepancy, occlusal view, lar arch length dislregancy, acclusal view, lar arch length discrepancy, ocdusal view,

Fig 5-27 (left)Narrow maxillary internolar

width, occlusal view; less than 33 mm can
be expanded 6 x 6.

Fig5-28 (right)IUormal6X 6maxillary 1

fntermolar width, occlusal view,
 S Plan Your Work

4
Table S-'
hdiwidm8 m e s

Duration
) S _ _. -.
, . ---
- -...,-
(months)
- --- .

Maxillary Mandibular Rapid palatal expander 5

1. 0.01 6 NlTi 6 Mone 4 Cervical facebow 19
2, Q.017 X ,025S5 14 1.0.017 x .O25 CuNiTi 3 Elastics
Active t m m n t time: 20 mnths 2.0.016 x ,022 SS 3 Class 2 8
3.0,017 x ,025 SS 10 Lateral box 1
AaFw trmtment t i m 16 months Finishing elastia 3
 - -
1 Principie 5 Case Study (

I
Fig 5-29 Pretreatment facial vlews, age 11 years, (a) Soft tissw facial profile shows obtuse nasolabial angle with skeleeal mandibular deficiency
and a large pogonion, Severe submental fold, (b) Smlling photo shows tow lip line; maxillary midline is mimaal, but the mandible is shifted
sllghtly to the left, (Courttsy of Dr J. Moody Alexander.)

Fig5-M Intraoral photos. Ia) Class II molars, psterior right. (b) Overbite, 100%; midline shift of 3 mrn. 0 End-on molars, posterior left,

division 2,lGangle.

Fg 5-31 Ocdusal vieinrr (a) Narrow maxik

Iwy arch width of 31.7 mm; partially
bhked-wt canines. (b] Normal rnandilar
arch M;large airve af 5p; intermhe
width of 26.6 rnm,
 5 Plan Yoir Work

Fig 5-34 Final facial views, age 13 years. (a) lmproved facial protile, lncluding rhe ~ s d a b i aarigle,
l submental fold, and a less protrusive pogo-
nion. 161 Beautiful smile!

fig 5-35 Final oalusion. (aJ Normal posterior occlusion. (bl Midline is slightly off-center. (c) Normal posterior occlusion.

Fig 5-37 Final cephalometric Fig 5-38 Panoramic radiograph showing ideal rmt
positioning.

Fig 5-36 Occlusal views. {a) Maxillary arch

form changed from tapered to ovoid. (b)
Excellent mandibular arch form; no 3 x 3 Fig 5-39 Pretreatment Iblack)
eicpansion. Final intermolar width: maxillary, and final (red} cephalometric trac-
35.7 rnm; mandibular, 26.7 mm. ing comparison,
 Principie 5 Case Study

d Principle 5 Case Study

Fig 5-40 Circumferential maxillary retainer. Flg 5-41 ftie adjustment loop is smaller Fig 5-42 labial bour of wtainer wire is flat
Notice how acryllc Is relleved adjacent to lin- and more comfortable for the patient. adjjent to teeth and murid labially.
gual surfaces of posterior teetti,

Frg 3-w mntal. Fig 5-45 Smiiing.

m - :.: ' , -

Flg 5-46 Rlght lateral. Fig 5-47 Frontal. Flg 54 31.

Figs 5-43 to 5-50 Thm-par p w m t -

mt v k A maxilbry reiainw is worn
onceaweekat night,Theiwnded3 x 3can
be removed 3 m 5 years pwtreamnt. Flg 5-49 Maxilla, occlusal view. flg S-5Q Mandible, ocdusal view.
Use Brackets Designed
for Specific Prescriptions
"Creative thinking involves breaking out of established patterns
in order to look at things in different ways."
-Edwurd de Bono
p Alexander Diipline bracket prescflption dates back
k t 370s. Prior to introduang pretoqued brackets in
to t
the 197& 1 began saving finishing archwires to rraeawre
for tques, o M Iand angulationsthat had been hand h t
in each case. These mewurements w m the basis for the
design of the fiw appliance gresolptbm. This design strategy
-tht is, beginning with the end result and wotking back-
ward-has been furtRer refiwd throughout pan of trial,
error, and clinical rwsardi, and it has allowed the piaement
of t&h in specific pmitions that will fwe h greamt poten-
tial for optimal &tia aand long-term sbbitity.
Distinctive Bracket Design
Bracket slot size rmd t-w m h ~ l
To obtain effeciike torque control, three options are available:
1. "Fill up" the bradtet slot. In a 0,022-inch slot, the
lqical archwire is a 0.02 1 x 0.025-inch archwire,
whidi would provide the same torque control as a
0.01 7 x 0.025-inch archwire in a 0.018-inch slot.
2. Place certain torque in the archwire.
3.Place certain torque in the bracket slot.
k should be understood that for every 0.001 inch of
freedom between the archwire and the vertical bracket
slot, approximateiy S degrees of e f f d v e torque is lost.
This means that if the final aKhwire is a 0.019 x 0.025-
inch archwire in a 0,022-inch dot, 15 degrees of toque is
lost. A 0.017 x 0.025-inch archwire in a 0.018-inck slot
w u l d mate a loss of 5 degrees.
The 0,018-inch slot dimendn was selecteti wer the
0.022-inch slot dimensh for three reasons: better torque
control, bever Ieveling mechanics, and patient cornfort.
First, m r a t e torque control for the maxillaiy and mandibu-
lar anterior teeth is adíiewd by finishing ea& case with a
0.017 x 0.025-ind-i stainless steel archwire, which results in
nearly complete engagement of the bracket slot to the arch-
wire, Eliminating the 5 degrees of Teedom from the brack-
et4 tarque value results in more effective transmish of
toque to the tooth. Second, the additional interbracket
space (diussed later) allom stiffer archwires Mth accentu-
a t d curves to be placed earlier in treatment. rhe rewlt is
more effiient leveling mechanics. Third, the patient's dis-
comfort is reduced by use of the smaller ardiwires in the
O,Ol &inch slot lwacket with greater intehracket space.
Use +ingle kkts i n ~ ~ofacwin
l
bmkm
Whereas some bracket prscriptions use twin brackets on
al1 teeth except for tke malars, it seems to make more
 6 Use Bnckecs Desigaed for Speufic Prescriprion~
Hg &1- 1 iRtdra& Amm
i t 50% n@rk i n t e ~
&&ained with.l;ih$bv~WMI^ bm&e%
b&t,cMar~~
sense to use single brackets rpecifically designed to fit the
shape of each tooth.
In the Alexander Discipline, twín brackets are used only
on large, flat-surfae teeth. The use of single brackets with
rotation wings ori larger, flat-nirface teeth may be benefi-
cial if these teeth require significant rotation. Single brack-
ets, which mate more interbracket space (Flg 6-11, are
ahays u& on small, flat-surface teeth and on cuwed-
surfale teeth (Fig 6-2).
increasing the distance between brackets has a significant
impact an treatment: The teeth quickly come into aiign-
ment early in treatment with little discomfort to t k patient.
Everyone knows that a smalt change in archwire
iength or diameter produce significant change in the
wire's load-defleaion rate. Fcir exampte, doubling the
intehracket distance-and hence the interbradcet win
tengti-can result in an eightfold reduction of the force
ddivered by Ares of the same type and size. Similarly, if
the same kind of archwire is used in twa patients, one
with twin brackets and the other with single brackets
with wings, the interbracket distance is effectively dou-
bled in the second patient relative to the first.
Consequeritly, the amount of force detivered to the teeth
Fig 6-2 Singlwving brackets. These are used on small, fbt-surface
teeth and on al1 curved-surface teeth.
Fig 6-4 Rotatbn wing remwal.
could be eight times lower in the patienz with the single
brackets with ratarion wings. Such a sizeable reduction in
force levels could also reduce the extent of undermining
resorption and related discomfon experienced by the
patient.
As interbracket distance increases, larger-diameter rec-
tangular archwires can be engaged with no additional
force. Because of the resulting decrease h the interbradret
load-def lection rate, fewer archwire changes are needed,
and finishing archwires may be used sooner iri treatment.
A relatlve reductian in torsional stiffness allows earlier
placement of rectangular ard-iwires, providing greater and
faster torque control.
Single brackets with wings offer other advantag~as
well. The archwire ís simpler to engage and ligate, and a
larger archwire may be placed without additional discom-
fort to thc patient.
Rotation wings provide specific advantages not found with
twin brakets: faster rotational wrrection; more precise
rotationai control; wing activation for c o n t M deactiva-
tion andbr overcorrection (Fig 6-3);and wing removal for
more accurate bwc-ket placemerrt in crowded dentitbns
(fig 6-4).
 Flg 6.5 @ No need to replace a bracket
when a wing has been remwed, (blWeingart
pliers for activation of a rotation wing.
Because the force is applied only to the active wing,
there is no need t~ replace the bracket to hotd the rota-
tional correction if a wing has been removed (Fig 6-Sa).
Contrary to what some orthodontists believe, rota-
tion wings do not r~quireroutine activation. If the
bracket is property positioned, there is usually no need
to activate or remove a rotation wing. When activation
of a rotation wing is necessary, the following technique
is r~ornmended.A Weingart pliers or other similar pliers
is placed so that its beaks are at an angle on the wing to
be activated (Fig 6-54}. As the pliers are squeezed, the
rotation wing will bend a t the hole in the wing. Rotation
wing activation wilt not cause bracket debonding.
Generally, aIl rotations should be corrected while the
patient is &ng the initial archwires, which are more
resilient. If a rotation still remains when the patient is wear-
ing the sliffer finishing archwire, minor rotational correc-
tions cansometimesbe made; to correct a more significant
mtation,however,itmayben~e~rytoreturntoamon
resilient archwire.
Fig 6 6 &cima1 uim (a) Maxlllaryarch,
bracket in-out offsefs. (bl Mandibular
arch, bracketin-out ofbetr.
Bracket Pres~ripti~n
OfFsek, angulations, and toques are designed into the
Alexander brxket prescription appliances, which pocition
the teeth in esthetic, functional, and stable positions
regardless of the original malocdusion. lñe prexription b r
uslng the bracket system follows.
Ofiets @iMlingtuI base va&&@
Offsets built into the bracketc are designed so that the
faciolingual interproximal contad points are properly
algned and positioned when a straight archwire witk no
offset bends is futly engaged in the bracket slots.
Prescription brackets eliminate the onerous work of plac-
ing numerous offset bends in the wire (Figs 6-6a and
6-6b).
 6 Use Brackets Designed for Sppeciñc Prescriptisns
S d molar
fig 6-7 Maxillav mdar distal ofísets used in Class 1 molar relatlon-
ships.
Fig 6-9 Band burnished to molar anatomy after the tube has been
reposiloned to be more distal.
The buccal tubes on the maxillary flrst molars b v e a 15-
degree distal offset. In a Class I molar relationship, disto-
buccal rotation produces maxillary first molars that m g y
the least amount of arch tength and provide the best
occlusion. By design, the dista1 offset achieves these aims
and minirnizes the posible need for second-order A r e
bends. Buccal tubes on the maxillary second mhrs have a
1 2-degree distal offset (fig 6-71.
if the final occlusion resJ# in a Clas ll or III molar rela-
tionship, the maxllary molars ocdude best when they are
rotated in the opposite dimction-that is, toward the
mesial. This mesial rotation can be accmglished by posi-
tioning thebracket and tube more to the diistal, toward the
distobuccal cwp, rather than at the mesiobuccat cusp of
the maxillary molars (Fig 6-8).When a buccal taibe has to
be positioned more distally, the band is compressd diag8-
nally, f i around the tmth, and burnished to the molar
anatomy (Fig 6-91,
The mandibular first and second molars haw a O-degree
disal offset and a 6-degree distal offset, respmively(Fig S-
1 O). The mandibular molar pmitions remajn unchanged
when the molar relationships are Class II or III.
Fig 6-8 Differences in brricket h t i m to rotate the molar in a Class
II or III relatlonship.
Fig 6-10 Mandibular molar dlstal ofFsets.
Advacates of twin brackets hypothedze that single brxk-
ets do not adequately control long-axis angulation. My
many years of experience and ctinsistent results disprsve
that idea. I have found that a twin bracket is nut necessary
to obtain proper iang-axis angulation. Single brackets with
wings ddiver proper root angulation with sup- efficiency.
tf a tmth is not angulated properly, the cause h more likdy
to be incorrect bracket piacement than the design of the
bracket itseif.
The so-called artistic-positioning bends advxated by Dr
Tweed for the maxillary and mandibular anterior teeth
have been incorporated into the design of the brackets.
lñe angulations of the incixir bracket are desjgned to
spread the roots in the rnaxinary and mandibular anterior
teeth, improving the esthetics and stability of the results.
Angulating the roots crf the six a n i i o r mandibdar teeth is
a very important step in achiwing long-&mstability in the
mandibular arch,
A 4-degree distal poot tip angulation is required for the
maxillaty second premo(ars; othenuise, the m&will tip
mesially when the bracket is placed parallel to the long axis
of the te. In an extraah case, thiangulatinn is not used.
Fig 6-t 1 Bracket angulations {degrees).
A-6 degree dista1 crown tip angulation on the mandib-
uiar first rnolars will help in lweling the mandbutar arch. A
more detailed discussion of this requinment is pranted
in principia 14 on the treatment af deeep bite malocclusions
and the leveling of the mandibubr arch. Fig 6-11 shaws
typKal angulatatlons in normal and deep bite cases, Macement
tdniques are discuaed in principie 7.
Torpe
The dnysical interaction between the archwire and the
bracket slot creates torque, which corrects the faciolingual
indination of the teerh. To create and contro'ol torque, a
wtangular archwire, or a square archwire of sufficient
diameter, must be used in the rectangular bracket slot.
The degree of toque control is determined by the size of
the archwire relative to the bracket slot. Assuming that
the bracket and archwire manufacturing tolennces are
constant, fw every 0.001 inch of space between the slot
and the archwlre, appniximtely 5 degrees of effective
toque control may be lost. For example, a 0.0'19 x 0.025-
inch archwire in a 0.022-inch slot will have about 15
degrees of mtational fr~edom:0.022 inches minus 0.019
inches equals 0.003 inches crf cpace, times 5 degrees of
toque, which equals approximately 15 degrea.
Fig 6-1 2 Brackettoque val= (@re&,
Figure 6-12 shws recommendeci toque values for
each bracket. To obtaln the actual toque expressed rou-
tinely in our finished treatment, simply subtract 5 degrees
from the value given for each bracket. i ñ i s witl give you
the effective torque.
Mandibular antenox incisor torgue
The trademark of the Alexander Discipline prescription is
the -5 degrees of toque in tho mandibular anterior Inci-
sor prescription. The torque values in the 0.018-indi slot
brackets are designed to compensate for the 5 degrees of
archwin k d o m when a 0.017 X 0.025-inch stainles
steel archwire is used. As explained previously, this results
in O degrees of torque expressed on these teeth. The -5
degrees of lingual crowdabial root torque compensates
for the 0.001 inch of tolerante between the 0,017 x
0.025-inch archwire and the O.Ol&inch bracket siot.
Regadless of tRe original position of die anterior teeth,
the incimrs will be cbse tothe ideal position after placement
of the 0,017 x 0.025-inch stainlea cteel archwire, whether
the patient has bimaxillary protrusion being treated with
extrxtion or a Class H dision 2 deep bite being treatecl
without extradon, For exampk, the cases shown in Figs
6-13 and 6-14 demonstrate Row the -5 dqrees of torque
responds in two different t p e s of rnalocdusion.
 6 Use B&ea Designed fbr Specific Prescriptions

II

Fig 6-13a Pretreatmentprofile. Fig 6-13b PrPtreatment smite. Fig 6-1 3c Preueatment frontal v i ¡ ,

Fig 6-13f Posttreamient frontal Jew,

Fig 6-13g Premment cephalometric trae Fig 6-13h P ~ s t t r e a f m@ometrickc-

~ Fig 6-131 Compite oephalmetrictracnig.
.
ing ing.
 g 4 Patient with open bite.
~ i 6-1

Flg 6-14a Pretreabnentprofile. Flg 6-14h Pretreatment smile. fig 6-14c Pretreatment frontal view.

m
Fig 6-14d Posttreatment profile,

Fig 6-14g Pretreatment cepMomebk trac- Fig 6-14h Posmmient c e p h a h t n c irac Fig 6-14 Comp4te ~ephahrrretmctracing.
ing. .
ing
 Bracket Height m

Fig 7-6 (al Pretreatment and (b)treatment views showing gingival height discrepancies,

riy I - r ~ aisr:
i yariri ir ~ I I U V V I I 11I riy ,-u. at the end of treatment and (b) f o l l o ~ ~ ai i par-
i~

tial gingivectomy and bonding.

FIY 1-0 r>idcneip ~ d ~ ~ r nforcanine

ent rise. b,bI SStrt of treament. (cdl During treatment.

- .--.-- --- ..- - .--.... - -. -- - -- ... -.- -. .

W r b i 4 e retapse as m
.
~ ~ ~ ) . ~ { ~ . ,-
m
-
.;:~::?~~~~!~~~4:..:i~-;
+:*h. A:
,. '
<<:. , ,-:,, (:, , ,- -
3
&.+..
" ,
, ., .,e . m.
t $i M,,..-
,;
, 1
-
-,,
-
11, aftw (T-21, and post- (T-3) treatmnt (mm
-;;y$$$T:?:-3p ~ ~ ~ ~ , + ~ . 7. . +. .L2yp$hrga$;tm:erj -y=--m,--

-':'-e. ., ,,- ' , . '. .-. /

28 (Glend) 4.60 2.70 3.00 7 years, 11 months

42 (Elms2J} 4.80 2.00 2.50 8 years, 6 months
31 (Carcara5) 4.76 2.09 2.84 1 1 years, 5 monthr
Total; T01
Mean 4.89 2.20 2.80

recontoured before fhe canine bracket is glaced, The risk
af hypersensitivity assodated with enamel contauring is
reduced when ir is pedormed h small incremenrs over sev-
eral appointments.
One of the rnost cammon rnistakes m d e when brackets
are piaced on the rriandibular inciso6 Is to place the brack-
ets too far incisally. lo avoid this rniQake, the iridsor brack-
et first shauld be placed in the center of the dinical vcrwrí
and then measured and m m d t6 the specified heght.
In general, the cusp tip of tk fiat premolar is larger
than that of the recond premolar. Ta o%et this difference,
the bncket is placed 0.5 mrn lovver on the second premiar.
Fig 7-9 Anrerior bracket plament in open Flg 7-10 Paterior bracket placement, right
bhe fase. side.
Fig 3-12 gracket pbment, horizontal ref-
erem.
in patierits d d h ópen bite, the bradet'hdghtfor the max-
illafy anterior i t h , which are out of mlusbn, is
inueased by 0.5 mm (Fig 7-9). The bracket Wght for pos-
terlm te&, which are tn ocdusion, is decreased by 0,s
'mm (m 7-10 and 9-1 1). This height mudification ior
tmatment of W n bite is ngt ajways applied to the
mandibular teeth because only the maxillary anterior teeth
usually rquire extrusion. The arnount of curve of Spw in
the mandbular xch can be used ro detemlns if aily
change in bracket height is nemsary. If there is significant
werse amature to the mandibular acdusl plane, then
the bracket heights are adjusted in both the maxillary and
the mandibular archa.
Flg 7-11 PaQeriiorbratket glrrrement, M
side.
Fig 7-13 plaament, vertical refet-
Bracket Angulation
ñoper angdation of the brackee on the teefh will bring
the rmts and crowns d w r to !heir ideal positions iit the
md of treatment, To promote =cura@, the brackets are
4signed so that the horizontal aspeck (¡e, bracket sbt
and rotajion wingd are aiigned parallel ts the incisal cdge
of t k tooth (Fig 7-12). Howver, mamelon ridges, attri-
tion, and fractures resuk in irmc$lar h&ál edges that can
interfere with thb visual refemce. For this reason, the long
axis of the crown sem as a taetter and mom consistent
guide for garallel rwt alignmelit. If the vertial a s w of
the bracket are a@& with the long gxis af the crown,
exceltent ruot positioning can be achiwd (FQ7-13).
T k angulation of the maxillary and mandibular anterior
bradcets is designed for root dwrgence. The maxillary m-
arrd premolars are angutated to tip tbe mts dictalb 4
degrees (swFig 611). The mandbular h t molarsare mgu-
lahed to tip hcrown d5mlly by 6 deg~k-sbe@Fpg 6-í 1).
 Fig 7-15 Irigh6 Relapde of lateral [ncisor
due to insuffdtentswulation.
Fig 7-18 {E#() Mandlbular fim molar band
angulatition in apen bite.
Proper angulation of the rnaxillary incisors significantly
improves the estktk apparance of the smile and there-
fwe merits special attention, Dr Charles Tweed introduced
the concept of incorporatingartistic positioning bends i n t ~
the brackets of maxilaty and mandibular anterior teeth.
However, a search of the literature found only one refer-
ente to angulating the mandibular incisors, by Wiltiams6
(Fig 7-14).
The frequent relapses that resulted when the
mandibular lateral indsor was not sufficiently angulated
(Fig 7-15) first led me to k g i n angulating the old, non-
prescription brackets at the time a7 banding (Fig 7-16).
Later, the Alexander Discipline apgliance was the first to
incorporate these angulatians into the incisor bracket
prescription (Fig 7-17). When the incisors are properly
angulated, however, the incisal edges often are nnot par-
allel to each other. To address this problem, rninor incisal
recontouring of these teeth is required to align all of the
incisal edges.
I
1
When I first entered priwate practice, I routinely angulated
the mandibular first mlars by -6 dcgrees (¡e, a tipback end)
as prexribed by Dr Twecd. This dista1 crown tip angulatian
helped level the mandibular arch witbut tipping back the
cecond molar. Tday, this uprightingof the mandibular first
molar represents an important factor for success in achiw-
ing lorrg-term stability in the treatment of deep bite maloc-
clusions, as confirmed by hnw st~dies.3,~When the
mandibular first molars are uprighted, the second premo-
lars are exttuded, and this ako promotes leveting af the
mandibular arch. Because the uprighted f i molars are
generally stable, correction of the overbite in deep bite
cases achiwes lonpterm stability as well.
An exceptian to h e practire of dista1 tipping of the
mndibular first d a r is made when an open bite p a t k t is
treated. The mal ir, bite cases is to maintain.or inct'e*
rather than remove-the mandibular arch curvature to aast
in dosing the bite. TRerefore, the buccal tube of ti7e f irst d a r
bradcet is set at O degrw angulation, wtiid-i is the opposlte
of the treatment p m h d for a deep bite Fg7-18).
 7 Build Trrptmenc into Brack-t Placemenr

Fig 2-19 W t áncpilatbbw i fi#~ premolar e $ f w t i m ~ Fig 7-20 Bracket angulatbns with smnd p r e d a r eicttactions
tb anguM ofw thegwd prsmd~by-3 degreeriOmm4, &%e the angulaion of m& ttíe firsk p W a r by +3 degrees
M m n t ii)mm (amws). (a) P r e t r m ~ l t(ri)
. Pomfeatmeiit.

Fq 7-21 RdesiWl tira& p@$oning al mmiodkial a n @ r on F¡g 7-22 Me5idistal bracket podtianing at height of contour on
lhe rrraxllhy and mdwlar m t n b ~ , the mandibular Qntne and maxihry flrst prern*

In extraction cases, t kteeth adjacent to the extraction cite
tend to tip into the extraction space, causing the roots to
diverge. To compensate for this ten- and to align the
roob, the brackets In extraaion cases are specifically angu-
lated, In first premolar extraction tmtment, the secomi
premolar bradtet is angulated by -3 degrees (¡e, a mesial
root tip) (Fig 7-19). In second prernolar extraction treat-
ment, the first premolars are angulated by +3 degrees (ie,
a dista1 root tip) (fig 7-20). These bracket angulations are
made at the time of bracket placement. As desuibed ear-
lier, ths bracket is first aligned with the long axis of the
tmth and then rotated or tipped by the spcified arnwnt.
All other bracket anguhtions are identical in extraction and
nonextraction trea tment.
Mesiodistd Position of
Bracket
nie mesiUdistal position of the brxkets on ttiefacial surface of
the teeth influences how and ta what mknt the Mets and
archwire rotate the teeth. VMng h e teeth from the i&
and ocdusal aspectc with a muuth m i m is esserutial for wn-
firming progea mesiodistal bracket placenient.
On flat-surface t e t h (¡e, maxillaiy and mandibular cen-
tral and lateral incisors), the bracket is placed in the r n ~ i o -
dista1 center of the tooth (Fig 7-2 1).
On curved-surface teeth (ie, maxillary and mandibular
canines arid premolars), the bracket is placed at the height
of contour ( F g 7-22), which is often mesial to t k center
of the twth. Bracket bonding pads are designed to accom-
modate this curvature, making the bracket easier to pbce.
Owing to its unique nwrpho!ogy, the mandibular canine
is often the most dificult tmth on which to mesiodirtally
Fig 7-23 Poor bracket placement, causing rota- Fig 7-24 Position of ;he max- Fig 7-25 Palatally erupted lateral incisor,
tiwi of the mandibuiar
- v right
. canine. illaty first molar tube,

position a bracket. Because the bbkl surface of this tooth Furthemore, when a twin bracket is placed on a signif-
oftenKI~~con~xmesiodistalqithantheothertecth,cli- icantlyrotatedtooth,itshouId bepsitionedtowardthe
nicians rend to place the bracket in the center of the tooth, rotation rnesiodistally. This will allow overcsrmtion of the
which 1s too far distal, resulting in mesial rotation of the rotated tooth.
canine (Fig 7-23).
Molar tubes, which are pomond so that the entry af
the tube bisects the mesiobuccal cwp (Fig 7-24), have a
15-degree dista1 offset for proper distcbuccal rotation in a
Class I malwdusion. The tubes are wlded to the buccal The maxillary lateral incisor has more anatomic variabitity
side of the molar bands so that the position is corredwhen from one person to the next than any other tooth. To
the band is properly seated on the tooth. accommodate the varying sizes, shapes, and eruption pat-
If the final occlusion ic a Class II or Class HI malocclusion, terns encountered among maxillary inciwrs, creative
the rnaxillaty molar tubes should be repositianed toward bracket positioning is sometimes necessary:
the distobuccal cusps of the molars instead of applying
standard mesiobuccal positioning (see Fig 6-7), This Srnall lbteral inciso: The angulation is increased to
negates the distal offset in the molar tube and rotates the mcupy more space mesiodistat ly.
maxillary molars rnesially. To make this adjustmnt, recon- Pahcally erupted lateral incD01: The bracket Is inverted
touring of the band may be necessary before it is seated ta reverse the toque. Generally, rio change in the
with the molar tuba repositianed distobucally. inverted bracket is required bter in the treatment (Fig
7-25),
Wigh (ie, la bialiy erupt& or partial& erupted) lateral
inGiso: The bracket height on the lateral incisor is*
increased to align the iñcisal edge with the central
incisor.

The previous precuiption has been applied worldwide Ni

the treatment of patients of every ethnicity. Thuu~ndsof
patients have been treated with successful resutts in Asia,
Africa, Latin America, South America, and Australia, as
well as h r t h America and Europe. Nevertheless, individual
differences sometimes require the brackets to be adjusted
andfor repositioned to add res5 specific wriations. For
example, on significantly rotated teeth, the interfering
rotation wing can be removed and/or tbe bracket posi-
tioned toward the rotation, as discussed earlier, This
adjustment is made before the brackets are bonded by
placlng the brackets on the study cast and removing the
interfering wing (see FIg 6-4).
Canine stlbstitationfor missing
mmillaty luteml incisors
When the maxillary lateral incisors are missing, a popular
treatment aption is to mwe the canina into the lateral
incixir positions, whkh requires special consideration dur-
ing the selection and placement of brackets.
.
1 Bracket sekction: To make the canine b k more like a
lateral iiacisor (Fig 7-26), the canine bracket (on the
same side of the arch) is invefted, thus reversing the
torque. A canine bracket is placed on the first premolar.
 Fíg 7.29 W s t d plxe Fig 7-30 Canifie bradret
me# oq gnhe m, on first pmdar.
flg, 7-32 Ename! r m n -
towlng of the canlm
2. Bracket height: The invertedcanine br&t is positiod
mwe gingivally the cabe (Rg 7-27). (ihe same
adjwtment # m& when ths cuy tip of W mine
h l o p -gmimtkaIíy,as diwxissed earlier.) To extrw
the canine mid a l b for ageqwte atsp reduaion, á
canine bracket is &o placed on the firsi pernolar at the
sam height at w k h it is on the canirte
3. B d e t angulation: T i m k e the canine look more
like a lateral incicor, the anguiation of the canine
bracket is d~reasedby approximately 3 to 4 degres,
giving it a more vertil alignrnent (Fig 7-28).
4. MsMstal bracket placement: b mako the &ni¡'@
appear las c w d and more like a lateral incisor, the
bracket b placed rnes'odistaíly in the crenter oi the
canine rather than at the height of contwr (Fig 7-29),
In AdiIion, a m i n e bracket ¡S pplaced on the first pre-
Flg 7-31 loaip&iitingwire k n d fi% anSne substh-
ticm.
Hg 7-33 Enamel mn-
t0WCKlg of che flrst $remo-
lar fur anine s&titution,
molar in the same mesiodistal poaition in whch it
placed on the can¡ne (Fig 7-30),
5. Archwire &s@n: To irnprove the tnterproxlmal con-
tact p o k , offset bends (iníiut) may be n d e d
between the central inuw and canine (Fig 7-31).
6. Enamd r e d ~ ~ E mn :g m l is recon~oured(4 to flatten
and create m incisal Mge on the m i n e cusp tip; (b)
tb eliminate traumatic ~climsionof t h mandihlar
lateral i&rs with the Ilngual curfac~ofthe canines
(Fig 7-32); and (c) to Irnprm the mhetitics of the first
prmolar (lingual cusp) (Fig 7-33). In addition, l o q
andlbr unusually h a @ canhe msp tips should be
reduce$ and recontoured prior to hnding to elirni-
nate the enlarged incisal ambrwure be- the
caniw and @clateral iricispr (Figs 7-34 and 7-35).

Fig 7-34 Canine r~ontarring,pretreatment view.
Flg 7-36 k n d position in relation to Fig 7-37 Cheek and tongue retractor used
ocdusal plarre. during bonding of ihe brackets.
Banding and Bonding
Preparing the
ing is aitical r
o p r envimnment for banding and bond-
Qsums. When banding, separators, or
wcm, are pbced betlveen the teeth for a periM of 2
weeks. At the end of the 2 weeks, dequate space has
been and the wth ae iw lwger sensitive from
the m c w e m t a m e d by the spamrs, which allow the
bands to be pked with litde additional dlscomfort to the
patient. Fm a u r a t e pwitioning of the molar tube, the
band must fit mugly arauml the tooth; it shouid not a&
back and fo*. The mesia-xclusal and dito-ocdusal
qspects of tiw band should be seated at the height of h e
Banding and Bonding m
*. -.
*"*i 23.
f?;,
e*.m - -
Fig 7-35 Canine recontouring, pasttreatment.view.
Fig 7-38 Magnifrcatim loupes for use dur-
ing banding and bondíng.
marginal rldges. Qn the buccal wrfxe, the occlusal side of
the band should Ix paraflel to the mesiobuccal and disto-
buccal cww aM to the accluwl plane (Fig 7-36).
During bnding, the patient st-iould not experience dis-
comíort because of &E&retraaion. TRe Nola Dry Field
Sfitem (Great d es 0rth;ctdantial allows the patient to be
~omfortabieand also funcriém vely well (fig 7-37).
The use of special magnifying loupes is strongly recom-
mended during b d i n g and banding pmedures, regard-
les of the praetitioner's age (Fig 7-38]. Magnification
loupes are alsd useful when the prxütiúmr is reducing
interproximal enamel, or slenderkhg, aand removing adhe
sive at the time ~f deban$ing.
Years of trial and error involving the methodical evaluation
of the results of rny treatment have led me to condude
that the specific final positions of the teeth and final occlu-
sion are factors that are critica1to long-term stability. The
prexription b r d e t s are desiged to produce outstanding
design, toques, and in-outs. Bu1 the treatment will only be
as effective as the quality of the bracket placement. In
ewnce, Iam offering you knowledge that is the accumu-
lation of al1 my years fine-tuning the appliance, attempting
to g@tit eloser to perfection, Your responsibilityis to place
the brackets and tubes conalyaWhether you use a direct
or indirect technique, allow yourself adequate time to
place the brzickets in their proper positians.
After a patient has worn appliances for 12 to 15
months, take a progres panoramic radiograph to check
root positions, Repositioning brackets may add 2 months
and an extra archwire to the overall scheme, but long-term
success ¡S worth the effort.
&bly ~h~mosf8ff1cdt of ~a&tu5ionsnis theCIajSc
II
o p n b i t d i f f i c ú l t to be&, dobtsn good resulb, and
kpve lmg-tem sbitity.
.!
' 7 were placed, followed by a face mask, and finished with
'l;
'L.- '
iylljb ,a Cbjr III o G bite, a high a&, and a posterior
*bite malocdusig.
-
Cammmts -
According to ANB, thi patient has a Class 1, not a Class
111 skeietal pattern. If Wits a d y s i s were u d , the meas-
urement would be -8 mm, ind'cating a C l m 111 pattern.
In patients su& as this, ttie Wits analysis b more accurate
in determining the trua skeletal pattwn.
Note the larga size of rhe mandibular arch in me ini-
tid presentation, This is a result of "tangue posture." It
also means the patient is a mouth breather.
1. Clenn G, Sinclair PM, Alexander RG. Nonextraction orthodon-
tic therapy: Post-twtment dental and skeletal stability. Am 1
Or$iod 1987;92:321-328.
2. Elms TN, Busthang PH, Aiexander RG. Long-term stability of
Class II d i o n 2 nonextraction cervid facebow therapy: l.
Model anaiysls. Am J Orthod hntofacial Orthop 1996;109:
27 1-276.
3. Elm TN, Buschang PH, Aexandw RG. tong-term stability of
Cfass II division 2 mmxtractioíl cervical facebow therapy: il.
Cephahtric analpis. Am J Orthcd Dentofaaial Orthop 1996;
109:38&392.
4. Bernstein RI. Levellng the cuwe of Spee with a continuous
a d w i r e technique: A Iong-term cephalometric a n a m . Am 1
Orthod Dentofacial Orthop 2007:13 1 :36%37 1.
5. Carcara 9.Leveling the cuwe of Spee with a continuous arch-
wire bxhnique: A long-&m study cast analysii. Semin Orthad
2001 ; 7 : m 9 .
6, Wiliiams R. EliminaüngImer retention. 1Clin Orthod 1W5;I9
342-349,
with th& major p b b l e m k l & ' 111, high angle, and'
opeh 'bit- decision was made to attempt noñextrac-
tion treatment. Afier rapid palatal expansion, brackets
.Gelastia. The patient was asked to practice tongue exer-
cises throughout treatment.
DbMISSiOn
ment after expansion. The face mask was wo@ fm-10
months with the elastics a W e d to the maxiilary lateral
ball haok in a 45-degm angle to the accluml plane.
Thh, a h g with other vertical helastics, a l h d more
extruslon of the maxillary anbrior teeth, tkus imprwing
the patimt'r smile line.
ti^^
Final resutts s b w a normal occlucion. The 3-par post-
keatrnent appwance shows a slight anterior bite relapse
and an improved soft tissue profile.
 Principie7 Case Study m

Fig 7-39 Pretreatment facial vi% age 14 years. (al Soft tissue profile showing a vertical pattem, long face anteriorly, 161 Lips open when
relaxed. (c) Smile llne shows more than one half of clinical crown covered by upper lip.

Fig 7-80 {al Right intraoral view showing a n w i i open bite and Ctass 111 tendency. 01 Frontal view dlsplaying anterior open bite and left
posterior crosrbie. Ici Left intraoral view showing anterior open bite and posterior crmbite.

Fig 7-42 Pretreatment cephatometric

tracing.

Fig 7-41 Pretreatment ocdusai ulews.

(8) Consiaed mwiliary and (bl wpanded
manditwlar arch {common in open bite mal-
-gdusionsl.
v.7..." Fig 7-44 Rapid palatal expander.
 -
--

Fig 7 4 5 Two-manth views. Special bracket placement for treatment of oope bite. (a,d Postersor hackets and bands p l a d more ocdusaliy.
(blAnterior brackets placed mote ginglvally, (Archwin:0.01binch nidtel titaniurn.)

Figs 7-46a tu 7-46c Slx-month views. Open bite rewaion rmuinngrrom race masi; merapy, [~rchwires:m i i a r y , u.u i J n u.ur,incn
stainless steel; mandibulw 0,017 x 0.0251nch nidrel tltaniwn.)

Figs 7-4751to 7.47~Nine-month views. Box elastics and face mask therapy for open-bite reduction, (Ardiwires: maxiliarj, 0.017 x 0.025-
inch stainless steel; mandibular, 0,016 x 0.022-ki& stainless 5t
e .
A

Fips 7-48a and 7-48b Occlusal views

show the dramatic improvements in arch
fms.
 Pnnciple 7 Case Sriidy m

m
Principie 7 Case Study
,..A -

, . %f:

Figs 7-49a to 7-49c Twelve-month views. Finishing archwires with reverse curves of Spee. (Archwires: 0.017 x 0.025-inch stainless steel.)

Figs 7-SOa to 7-SOc Fiftm-moirtR views. Finishing elastics ("M " with a tail) for Class 111 rnalocclusion. Both arches sectioned,

Figs 7-51a and 7-5 1b Fifteen-month viwvs.

ccc
Figs 7-52a to 7-52c Final views following 18 months of active treatment.
- .
'ir'"1

Figs 7-53a to 7-53c Final views f o h n g 18 months of active treatment.

 I Figs 7-54a and 7.54b Final occlusal
views showi
.. .ng normal
- .. woid ach forrns.
..-m

Flg 7-55 Cepblometrlc tracingr, (a) Posttreatment. (b) Pntreatment @a& and psttreat- Fig 7-56 Final panoramlc radiqraph. Note
ment (red) cornparison. maidly tipped mandibular first rndars.
Figs 7-57a to 7-57c Four-year pstbeamient views,

.. .
Flgs 7-59a and 7-59b Four-year posttreatment ricclusal views.
Exploit Growth to
Obtain Predictable
Orthopedic Correction
O
ne of the most intriguing subjects in orthodonticsis the
growth and d&pment of the maxillofacial complex.
Dunng the last 40 years, krtcwiriledge and understand-
ing of this subgect have changed greatiy Tbday it is dear that
u&r certain cirniwnces, pa&ular forces can be used to
affect or control growth of the maxillofacial camplex with
exdlent w l t s . In orthodontk treatment, the affected areas
ir#& the maxilla, the mandible, and the dentoakieolaP com-
pkx.
I first discovered this possibility in graduate school
when studying the effects of scoliosis treatment with the
Milwaukee brace on tooth position and maxillofacial
growth. Dr Fred Schudy (Fig 8-1) provided valuable coun-
se1 as I attempted to interpret the findings of this study.
For the first time in orthodontic literature,' it was concluded
that force applted to the mandible (through the
Milwaukee brace) "demonstrates a directionat change
of growth in the lower face of a growing child" (Fig 8-2).
The occlusal forces created by the brace flared the maxil-
lary and mandibular incimrs and depressed the molars.
These forces also depressed the total anterior facial height
(Fig 8-3).
The gmd news from this study was that maxillofadal
growth can be altered. However, it is impossible, in ortho-
dontic treatment, to create the same force levels as t h o ~
achieved by patients wearing the Milwaukee brace,
because the brace was worn almost 24 h u r s a day. The
cballenge, Zhen, was to find a way to apply this newfound
knowledge to treating the abnormal skeletal patterns of
orthodontic patients.
For orthopedic forces to have an opportunity to control
or change growth, a patient must have the potential fw
significant growth. In generd, a good rute to follow is that
females grow earlier and males grow later. Therefore, early
treatment in the mixed dentitian is usuatly more successful
with females. If possibte, delayed treatrnent in males is pre-
fernd. Sweral methods to determine g r m h potential
have been used; hand-wrist radiographs and cervical verte-
brae radiographs are useful but tend to be les rreliable in
the borderline stages, when it FS not known if the patient
has any growtb Ieft. The old-fashioned rnethd of absw-
ing the size of the parents and siMings and talking wiih
parents about the growth petential of their &ild may be as
good indicators as o t k r approaches.
 Fig 8-1 Dr Fred Schudy, who
shared his understanding of
growth and development, tiad
considerable influence on the
authofs prokssional life.
Fig 8-3 Pretreatment 0and final (re4 cephalometrictracings, Mihvaukee
brale patient.
Possibilities fur Growth
Growth takes place in three planes of space: transverse,
vertical, and sagittal. Of the t h m directions, the transverse
dimension is the most predctable. A narrow maxilla in a
growing chlld can usually be expanded with rapid palatal
expansion and have predictable and stilble resulb. This is
considered an orthogedic correction. Similar changes of les5
magnitud@can be actijevd with expanded archwires. In
nongmwing patients, rronsurgilal palatal qansion is also
posible, alfhough the bng-term sbbility is les certain.
To a lesser extent, a n a r m mandibuhr dental arch can
be expanded with controlled stability, usually with a lip
bumper or other functional appliance. This w u l d be con-
sidered dentoahala r expansion. Orthopedic expansion of
the mandible K not pmsible without surgery.
Flgs 8-2a to 8-Zc Milwaukee brace.
The maxilla ic a very malleable h e . The foward grow-th
of the maxilla can be controlled effmively by the use of
orthopedic appliancei;, such as a facebow w other func-
tional appliancer. As shown in many studies, grwvth oF the
maxilla is actually inhibited while !&e mandible continua
to grow ta reach its genetic potentia1.I-3 In addition, in a
skeletal Ciass III patient, the maxilla can be advanced
slightly by the use of a face mask.
There are few if any appliances that can be used to
affect mandibular growth. lhe clairn that certain appli-
mces can "grow" mandibles b o n d their genetic poten-
tial lacks long-term evidence4
TRe debate among orthodontists is whether it is possi-
ble to "stimulate" the growzh of the mandible, as claimed
by advocates of certain functlanal appliances. The reality,
based on many studies and dinical experience, is that no
type of orthopedic force can stimulate mandibular
 Transverse Skeletal Correction m

F¡g 8-17 5udy w t with first premo- Fig 8-18 Hyrax placed parallel to
lars and first molars banded. Notice ficst molars, approxlmately 3 mm from
bra&s and tulties on the bands. the pabtal tisue.

Fig 8-19 Hyrax angulated 20 d egw Ffg8-20 The 0.032-incfiround wires FIg 8-21 Finished rapid palatal
to the occlusal plane for easier view of are contoured to connect premolar expander ready for p tacement.
the hole that must be accased for acti- and molar bands.
vation.

Fig 8-22 Mlxed-dentition expander. Only Fig 8-23 Primary dentition expander.
the first molars are banded. Acrylic resln-bwided material c m the
posterior teeth,

while inserting the key. Furthemiore, when tRe kv is inseW banded. TRe anterior extension wires, off the Hyrax, extend
and turned, it d o e not mknd as far toward tbe t h a t to the lingual surfaces of t h Wmry
~ mnines, where they
On the stone -51, a 0.032-inch rwnd wi& is contoured are c d M to We Iingual bars (FIg &-22).
lingually f m the premdar to the molar and contoured
amund the m n d prem~larat the lerv'kal line, on each Prlmaty dantftion. Although seldom used, the rapid
side of the arch (Fi8-20), Thk wirg stabflizes tbe appliance, palhtal expander design for the píimary dentition is an
t h 5 applrng a more horizontal fosze t~ the feeth when aoytic fesin-bmded appliance. The dcsign of the
expander is the same except for the acrylic resin wer-
activated. After these wires are soldered to the bands (Fig
8-21), the apyipliance is cleaned and reaciy for placemnt.
age on the posterior teeth, which replaces the bands.
TRis appliance is cfesigrred in such a manner because it is
Mixed dentition. h the mixed dentition, when the f i ~ t very difficult to band grimary beth in young patients (Fig
prernolars have not wupted yet oniy the first moim are 8-23).
 The uppr jaw is made ug of two bunes. There is a w t u n in thc mi&b 0f the jaw that will sepatate as the screw
is tumed.
Twrn the screw one time (one-quarkr turn) each day. lf the dmmfbrt is excasive, it can be turned once w r y
ottw day. This is more mmmm with adult patients.
You will feel an instant pressure that will dbapigpar In las than a rninute.
. ::
Holding warm salt water in tRe mouth for 3 minMes will elieve the dbmfart in most cases.
G u d oral hygisne b tritical, Mod can lodge b e h e e n the palate and the vviw eütensions of the appliance. H not
removed by inigatian, this debrls will cause umvanted irrflammatian,
Bruch your teeth thmughly and t k n use a water jet (for exam ple, Waterpik) wery night before Mto remove
any food caught in the expandtr,
When the appliam is acüvated as yrou tvrn the key, a small y ~ c will e apwl be-en the two upper fpnt teeth,
the maxillay central Indxirs, This uwally appears after the firct w k of turnlng. .*
Pleaw return to the office in 2 weeks fd'r check-up appointrnent. The total number of wrns du.rina thb~fint 2
weeks should be ap~roxirnateiy14. .. -:a* -
.
.
. - -k
.. -_ 1
7

The acrjlic resin occlusal coverage around the posterior
teeth is alro used in paknts with anterior crossbk as
well as constricted maxillae. Hooks are placed above the
canines where the face mark elastics are attached.
This particular Hyrax design was setected primarily
because it is very effedive at opening tt-ie midpalatal
suture. In my opinion, plxement of the Hyrax posteriiorly
and high in the palate mults in the agplication of addi-
e the maxilla and ~ t hThis
tional transverse f o ~ to . gen-
erates more horizontal and less vertical force, which will
mult in less tipping of the teth and greater separation of
the suture. Ako, because the appliance is al1 metal, it is
easy to keep clean with a water jet-type unit. This will
allow the device to be maintained in the patient's mouth
foi 6 months, g i n g t k midpalatal suture arnpte time to
fill in normally. In essence, tke rapid palatal expander
becornes a transverse spam maintainer after activation is
completed.
lnstru&lons for the patient
After the appliance is c e m t e d on the teeth, it is turned me
time by the at3hadsrrtist to emre that it turns freely. The
aduk patient or the ckild patient3 parent is t k n instructed
about the function of the expander and how to activate it
(Box 8-2). This important rtep ensures that the user is well
educated rqarding h e actiifatbn of the appliam.
Two weeks after delivery of the expander, the patient is
checked for progress. compliance, and hygiene.
Exarnination of the expansion screw will indicate the
amount of opening that has taken place. Thc orthodontist
hould turn the smw one time to be sure it is tight. If it
turns easity, in mast instantes, the appliance has not been
activated daily as instructed. This can be a noncompliance
appliance. If the patient (or parent) d w nat tum it, the
orthodontist can hwe the padent come in to the office
w k l y and turn the screw several t i m a until the desired
expansian is achieved.
If al1 is progressing m a l l y , the patient is instwcted to
turi? the screw once a day for another 2 weeks, At 4 weeks,
the appliance should h m k n turned a total of 30 tu 32
times. i ñ e actual expmsh, therefore, WW h dose to 7
mm (each turn of the expansion screw equals 0.25 mm). In
most situations, the lingual cusps of the maxillaryfirst molars
should be located at ahe width of the buccal cusps of the
mandibular first d a r s . In certain cases where the mandibu-
lar molars Initiallywere tipped Iingually, it may be prudent to
continue expansion of bhe millary arch, because additional
uprlghting wll be needed in the mandihular arch.
When the expansion goal has been achiwed, the screw
is sealed with a Hght-cured adhesive (Fig 8-24) to prevent
it from loosening or unscrewing in the following m n h .
me appliance then becomes a fixed transversespace main-
tainer and remains in place for 6 months. The parents aand
patient are totd that the appliance is Ieft in the mouth for
such a long time because, after the mldpalatal wpration,
it ta kes time for "new bone" to grow back.
Because there are brackets and buccal tuba on the
bands, orthdontic treatment can be performed during
this 6-month period. If the patient also exhibits a Class II
skeletat problem, tht facebow can be placed as soon as
 Flg 8-24 When the expanslon goal is
achieved, the saew access hde is sealed
with light-cured adhesiw.
~ i g6-26 [al up bumpw mes designM to M used in tmee p n a m ot mmnt.
{b)Distal extmslon designed for dass-2 elastic attachment.
ths expansion is completed. In a Cl a s HI case, the elastics
to the face mask can be attached to the first prernolar
brackets on the rapid palatal expander, Some 6 to 8 weeks
after active expansion is completed, brackets can be placed
on the anterior teeth, and an archwire can be pIaced to
align these teeth (Fig 8-25). Brackts should not, however,
be placed on the separated maxillary antwior teeth until 2
to 3 months after the expansion is completed. During this
time, these teeth will drift together spontaneously as bone
is being created in the expanded suture.
After 6 months, h e ecpansion applianm is removed. At
th'i point, the expanion is not stable. To reta:n the expansh,
the remaining brackets, bands, and a~hwtrescan k placed.
If a suffiaent number of permanent teeth have not yet fully
erupted, a ~tainermay be used to hold the expansion.
Lip kmper
The lip bumper is the appliance oof choice to gain space in
the mandibubr arch, because it can create space in three
areas: the posterior, the anterior, and the trasisverse.
Mevant et ali4 demonsated this in their study of lip
burnper treatment.
Fip 8-25 Brackets are plad on anterior
teeth.A O.Ol&imh NiTi archwire is piaced8
w k s after the expanslon goal 1s achiewd.
Lip bumpers are d t e n placed shortly after the maxilla
has been expanded. An important factor in tbe timing
and use of the lip bumper is the eruption of the mandibu-
lar second molars. If they are unerupted and appear opi
the mdigraph to be tipped mesially, the dista1 tipping of
the first molars caused by the lip bumper could compro-
mise normal eruption of the second molars. If the
mandibular second rnolars are empting mesiatly, place-
ment of a separator Cspacer) between the motars will usu-
ally prewnt them from becoming impacted and alIow
them to erupt. If mandibular second molars have already
erupted, the lip bumper tubes are stjll ccmented on the
first molars.
The rnandibular first mdar bands, with special lip
bumper tubes attached, ai.e cementd first (Fig 8-26).
These spedfic tubes were designed to be used in three
phases of treatment: (1) as a lip bumper tube; (21 as an
archwire tube when the anterior teeth have been bonded;
and (3) as a twjn bradtet after the second molars have
been bandcd or bonded. The first molar bracket must be
converted tu a ligated bracket by removal of the convert-
r
ible sh h on the archwire tube when the second mulars
are ba ded or bonded, The lip bumper is then adjusted to
the mandibular first molar lip bumper tubes.
 Fig 8-27 Wust the Up bumpr to slie passively
into the tubes.
Fig 8-29 After adjustment, the auylic resln
shield shaild be p~itlonedat least 3 mrn labial
to the incisors.
nie iip burnper is designed wiih an arch form similar to
he a& form on t kAlmnder archwire template. The lip
Burnper wire is 0.045 inches in diameter, yhi& makes
insertbn and removal easler,
A4-a
Similar to a f a c e h I the lip bumper is. adjusted in faur
planes of space:
1. The ends of the lip burnper w i e on ea& side, when
inserta inta the lip bumpr tube, must slide in par,-
siveiy (Fig 8-27).
2 . in the banniersiedimension, the lip bumper is expanded
appmimately 4 mm, 2 mm per side (Fig 8-28).
3. taioiotingually, the loop are adjusted so that the
actyiic resin pad is 3 mrn in 'frontof the mandibular
incisors (Fq 8-29).
4. Incisoginglvally, the acrjlic resin pad is adjusted to be
at the gingival line, plus or mirius 2 mm (Fig 8-3Q).
1-ioiu fw th paüePit
Patimts are itxtructed to wear &e Ep bumper full time, 24
hgua a day, and to take it out oonly at night while they
brwsh thdr wth. If patient campliance b m h e e an issue,
the 6p bumper may be tied in, Patients a- advised to keep
fig 8-28 üp bumper e x p a d in a
manner similar to that of the inwr bow
of the f a d m .
Fig 8-30 The a@k shield is adjusted every 4
weeks fw vertical positiming at the ginght
line.
their l i p togethw when the lip bumper is in place. The
prescure fmm t h periaral musdes, girnarily the rnentaHs
muscle, exem the dlstal brce on the lip bwmper and is
most effective when the lips are dosed. The pat'wt is
examined at 4-week Intervals to monitor progress.
R the Ilp bumper k worn properi), at rhe LGweek apoint-
ment, the lig bumper will n d adjmtment in two areas:
1. The labial acryiic resin pad may be close to cmtacting
h e anterior teeth. To gain additional length, the
adjuqment loops are opsned to again m m the pad
out 3 mm frm El-ieincisors. Tkis pasitive change rig-
nifies that the mnlars have uprighted and the incisors
have f l a d , thus increasing arch Imgth.
2. Additi~nalexpanrion shoM also be plxed in the lip
bumper as the molars hawe m d buclally while
being uprlg hted.
It is important ta examine lip bumper patiank w r y 4
week's tb keep the appliance pmpertyadjusted. If the tabiai
acrjlic resin pad comes in mntact lFljth the gingival tissue,
it could cause gingival recession, if this contact ocrurs, the
patients are hskructed to wear t k lip h m p w at night only
and to cal1 the office imdiatety fwan adjustment
agpointment,
 -
Fib 31 Lip t,,.,$er therapy. (a) Pretreatmentand (b}6 months psttreatment.Thischanged
from an extraction patiem to a nonextraction patient.

Flg 8-32 The lingwl arch is a 'fixd" il1,,,- , , "-33 Nance palatal arch. This mnnlllary Fig 8-34 Trampalatal arch is seldom used
dlbular spare maintainer. It is commoniy fixed space maintainw can also ix fof in 5qday's tpII~-p&@g,
used to presene "Eu space, or the $pace anchorage in selaed patients.
gained with the lip bumper.

Generally, a lip bumper takes approximately 6 months anre and the incidente of kist removable appliane are
to create the desired space. A typical response to the lip two good reasons for limiting tkeir use, However, certain
bumper appliance is shown in Fip 8-31. appliances a n of great benefit to the technique.

Six mixiths inta treatment, space created by the rapid
palatal expander and lip bumper is not stable. In addition
to the orthopedic changes, buccal tipping of the teeth
Ras taken place. It is critica1to maintain the newly gained
space with full bracket placement and archwires or a
retainer andior a lingual arch. Before this treatment can
be considered stable, the rmts must later be properly
aligned and the arch form estalolished. This is best accom-
ptished with 0.018-inch slot preadjusted fixed appliances
and finishing in 0.017 x 0.025-inch staintess bteel arcfi-
wires.
Lingual arcti
The tingual arch can be very useful as a fixed space main-
tainer in the mandibular arch (Fig 8-32). Whether for sav-
ing "E" space (the discrepancy between the widthsof the
primary second molar and the permanent second p m o -
lar) ar for maintaining gains achieved with a lip bumper,
this appliance can k very useful.
Namce palaid w ~ h
The Nance palatal arch is a commonly used fixed appliance
for maintaining space, maintaining trancverse expansion,
or preseniing anhorage in the maxillary arch (Fig 8-33).

Trampalatal arch
Years a&, the transpalatal arch wac used much more com-
Auxiliary Appfiances
m

monly than it is today for treatment gaajs su& as molar

The ktexander Discipline incorporates very limited use of
auxiiiary appliances. In keeping with princlple 3, "keep it
simple, stupid, " very small numbers of removable appli-
anmsareused.Thedifficultyofensuringpatientcompli-
raration and expansion. Atthough it can carry out these
functions, other methods can accomplish these procedura
more simply. Today, the transpalatal arch is used only to
maintain the maxillay tranmrse dimension-and vey_$l-
domevenforthatpurpose(Fig8-34).
Ftg 8-35 Pendulum appljance 1s an excel- FIg 8-36 Remable acrylic ocdusal plate, Fig 8-37 Bite Turbos bonded to the lingual
Ient 'molar distaiizing" fwd appllarlce constructed after the maxillarj ardi fm surfaces of the maxlllary anml incisors.
used In selected patients. has k n esta bllshed. They serve as an excelknt fixed bite opener
for Class 1 cases,

:igs 8-38a to 8-38c Guray bite opners, attached over the maxillary firg y~~~gar~xcellwit for opening t b ,.- ..,Class II deep bite cases.

Molar rotation 1s accomplished by the 15degree distai

offset built into the rnaxlllary first molar tubes and the use
of a 0.01 6-inch stainless steel archwire with the wire "toed
in." This molar rotation creates cortical anchorage with the
meslobuccal roots, preventing the rnolars from moving
rnesially.
mkr &stdiZingprc@
., Ci
Pendulum appliaruce
Devetoped by Dr James Hllgers, the pendulum 'appiiáikie
(Fig &35) is a good molar distatizing appliance when the
patient exhibits a skeletal Clws I relatiamhip and the
molan cxhibit a Class tl malwdusion. ln rny opinion, this
appliance should not be u x d in a skdetal Ctass II patient.
The pendulumappliance is also very technigue sensitiw.
Great care rnust be taken to avoid palatal soft tissue
irripingernent by the wires.
Mickel-titaniurn coi1 springs
In certain cazs, nickel-titanium coi! springs can be used
effectively to move molars distally.
bit^ plate
For many years, removable acrylic resin bite plata have
k e n suaessfully used for bite opening (Fig 8-36). The key
is to delay the fabrication for 2 to 3 months afkr the start
of therapy until the maxillary arch fom has been created.
Then the impression is taken, and the appliance is con-
swcted. As a mult, wry little adjustment af the bite plate
is necessary. The anterior bite plane is adjusted so that,
when the muth is cloced, the anterior overbite is apgrox-
imately 2 mm and wíthout occlusal interferences of the
mandibular bradcets.
Bite Turbas
Bite Turbos (Orrnco), which are lingual bradcets without a
slot, are hnded to the lingual surface of the maxillarycen-
tral incisors (Fig 8-37). Thk fixed appliance works very well
for bite opening in patients with Class I deep bite.
However, if there is an excessiw overjet when the patient
closes, the mandibular incisors will be llngual to the Bite
T u b s , The appliance is thcn ineffeaive.
Guray bite opener
The Guray bite opener (GAC) fits civer ahd around the
maxilbry molar5 (Fig 838). This fixed appliance wo&s
very well to open the occlusion in patients with Class II
deep bite. It is ako very effectiw for correcting anterior
crossbite problems.
Conclusi: -I
In most growing children, the maxiltofacial h l e t a l pattwn
can ansistently be influenced in a gmitive way. The max-
''lahas
potenoal for change'It can be expanded.
moved forward, and inhibited from moving forward. The
rnaxillary dentoalveolar mmplex can be extruded, inhibited,
and even lntruded.
The mandible has many more limitations. Without sur-
gery, the most positiw orthopedic effect that can be
a m p l i s h e d in the mandibie is to mate an "atmospbere"
to allow the mandible to grow and reach its genetic poten-
tial. lhe mandibular dentaalvecrlar complex can be changed
within certain limitatiorrs. ümited expansion of the p r e w
lars and molar5 is posible, and leveling of the aKh by extru-
sion or mption of the p n d a r s is quite stable.
Armed with this knowledge and an understanding of
the biomechanics used to affect maxiltofacial gtowth,
0dhodonti* can a a m ~ l i s hwccesful ortho~edic treat-
ment for mast growing patients. Principk 8 has described
the varbtrs appliances used to obtain predictable orthope-
dic mtrectlon. In my eariier t e x t b k , l l I discussed in detail
how the facebow is successfu!ly u d . Twenty years and
several thousand patients later, my beliefs have remained
the same.
References
RG. meeffectr on mtion maxillofacial
Mnical grwvth during rcoliosir treatment with the
Mlwaukee Brace: An iniiial study, Am J Orthod 1966;52(3):
161-189.
2. English 1. functional appiiiances and long term effects on
mandibular growth. Am J Orthod Dentofacial Orthop 2005;
118:120.
3. Sproul PW, English J. Corbett JA, Gallerano RL, Mlnkoff RA.
Cephalometric C~nparisonof C&l Headgear Treatmnt
ln Maxillary Protrusive versus Mandlbular Retrlisive Class II
Patients (theis). Hourton: Unlv oi Texas, 2000.
4. Kassi5'eh *g@ Oif ferenta in Uie mse to MaxillafY
ProtradionTherapy (t hesls). Dallas: BayBoF Univ, 19%.
5. Parl<r LR, BuwhanpPH, *lexander RG,D e o w Rmuw E.
Masticatory exercise as an adjunctlve treatmmt for hyperdi-
vergent patients. Angk Orthod 2007;77:457462.
6.Romine L. A Cephalometrk Evaluation of thc E- of
Cervical Facebow on the Craníofaciat Complex (thesis).
Dalias: 3aylor Univ, 1982.
7. Plunk MD. A Cephalometric Evaluationof the Effects of Early
Headgear Therapy (thesis). Dalbs: Baylor Univ, 1985.
8. Glenn G, Sinclair PM, Akxander RG. Non-extractbn arthu-
dontic therapy: post-mment dental and M e t a l staliiitg!
Am J Orthod Dentofacial Oi-tkop 1987;92:321-328.
9. Elms TN, Buxhang PH, Alexander RG. Long-mmstablity of
Model analy.r. ,
Clas II division 2 non-extraction cerWcal facebow ttaeragy: l.
Orthod Dentofacial 1996;
109:271-276.
10. Umr Buwhang m, Alexander RG. Long-tem stability of
CIass 11 cüvision 2 non-extraion cervical facebw therapy: 11.
Lephalometric analpis. Am J O r t M Dentofacial Orthop
1996;1W:38&392.
11. Alexander RG. The Alexander Discipline: Contem porary
Concepts and Philosophies. Glendora, CA: ürmco, 1986,
12. Aiexander CD, Alexander 1M. Facebwv mrrection of Jceletal
Class II discrepancies in the Atexander Dixipline. Sernin
Orthod 2001;7:80-84.
13. Ferris f; Buschang P, Alexander RG, Boley J. Long-tenn stabil-
ity of cmbined rapid palatal exparision-lip bumper therapy
followed by fuH fixed appliances, Am Orthod Oentofacial
Orthop 2005; 1 28:3 10-325.
14. Nevant C, 811xhang PH, Alexander RG, Steffen 1M. Lip
bumper therapy for gaining arch length. Arn J Qrthod Dentc-
facial Orthop 1991;100:330-336.
P
8 Exploit Growth to Obtain Predictable Orthopedic Conection

Principie 8 Case Study -

O u ~ Maintenance phase: Invisible maxillary retainer; lingual

Orthopedic first-phase treatment can change extraction
treatment into nonextraction in certain patients. Special
note: no serial extractbsl --
fidmdndti~nand d k f l 0 k
This 9-par-old girl presented with a mixed dentition, a
deep bite, a Class I division 2 tendency, a lingually impacted
rnandibular right lateral incisor, a severe arch length dis-
crepancy, and a narrow rnaxillary intermolar width.
Tredtmentp h leveling of mandibular arch.
arch. Diagnortic record5 were taken before the second
phase of treatment was inithted, and an intwesting phe-
nomenon was foud. Notice that, cephalwnetriaiiy IMPA
hanged from89 to 96 degreesduring phase 1, even though
no orthodontic force was put on the anterior te&. Four
are responsible. (1) Opening the bite and (2) i m p w
ing the toque in the maxillary anterior teeth relieved the
p m u on ~ the mandibular anterior teeth. (3) The iip
bumper relieved the muscular pressure of the lips a the
mandibulwanterior teeth. Now, (4) the tongue p u r e can
move the teeth into their phiblogically balanced pwiüons.
Phase II: Full bracket placement M h normal sequence
of treatment, as shown. Progress photos show effective
. ..
a

Because of the patient's excellent skeletal low-angk pat-

tern, soft tissue profile, and young age, the decision was
made to gain arch length by maxillary and mandibular
X)ficasSZm; -I -o . --
- .- .,
- .
transversc expansion d q i t e the presence af a severe Note the gingivaI height of h e mandbular right lateral ind-
mandibular arch length discrepancy. The goal was to sor at the end of treatment; it "Af-adapted" to a normal
treat with nonextraction, pwition as shown in the 2-year posttmtment photos. This
Although tempting, serial extrartion was not used in is probabpa resuit
, .of normal t q.t.h Fnishing.
. .
the mandilwlar anterior area. Note that keeping the pri- . & ,.; , , . - - - ,: *
c .- -1 e

mary premoiars preserved the alveolar b n e in that area. d.?1

m-r

EV#lwhn h-. . --. . !m mi- II ,

- , . . I
AL

I ,
I

Two-pkase ~ e d h n e n t
Phase 1: Expand the maxilla via rapid palatal expansion.
tncrease the mandibular arch Iength using a lip bumper.
Bracket the maxillary indsrxs to increase torque and
improve the alignment.
Overall results were excellent. The dental and facial com-
p a r i ~ n sreveal many Improwlments. The s e e r i t y nf the
original malocdusion and intercanine width dmges dur-
ing treatment, h o m r , giw me concerm rqarding long-
tem stability of the mandibular incimrs. This ptient woukl
benefit from long-term retention.
 Pnnciple 8 Case Study m

Fig 8-34 hewamt facial views, age 9 years. (a) Soft tissue profile shows a n m l nose, pmtnislve upper lip, and normal chin, Ib)Frontal view
s h w s balance and symmetry; the upper lip droops dightly. (c) Smiling shows glnglval display of 2 mm,

Fig 8-40 PretreaMt intrqral photos. {a) End-on molar relationship, right side. (b) Oeep werbite (8 mm); rnidllire shift, lower to the rigfit by-
3 mm. 0 N o m l Class I dusiori, left side.

Fig 841a Maxillaiy arch form: square with

crowding o5 erupting lateral incisors, Narrow
htemrolat width: 3 1.7 mm,

Fig 8-42 Pretreatment cephalmetric trx-

ing showing a bw angle wiih a division 2
Inclsor relationship.

.:ig 8-41 dandi bular arch demons,,.,~

extreme arch length dimepancy. A'iht lateral
indsor is m p l e t d y b W out lingually.
 8 Exploit Growth to Obtain Predictable Orthopedic Correctian
m

- -
Principie 8 Case Smdy

kig 0-94 After rapid palatal expansion, Ilp burnper expansion, and 2 x 4 brackets: (a) profile shows slight improvement; (b) les drooping of
upper lip; (0smile Qnegreatly i m p r d .

FIgs 8-45a to o-45c IntTaOlal pmW5 SnOw nlre opening am space gain ror maxiiiary iaarai inasws. venmi mtaiirie is sriti uii uy r nirri.

9
Flg 8-46 Ocdusal views la) Maxilla shows ovoid arch forrn wlth adequate spacing fa per-
3. Q.017 X ,025 SS
Active treatment time:
11
15 monthr

tnanent teeth. Ib) Mandibular arch shows space gained by lip bumper. üngual arch is placed Mandibular
to rraaintain"E" space. Note eniptisn and Yabial mwement of right lateral incisor, None

Rapid palatal expaqdq 5

Up bumper 20
Lingual arch 22
 Fig 104 (al Pretreatment mandibular
ocrlusal view. Ibl F i minths: driftodonfrcs.
{4 Ten months. Seconú archwire: 0.016 x
0.022-imh SS dosing loops. Id) Twelve
months, Thlrd arcRwire: 0.01 7 x 0.015-incli
SS Wnishing, 5econd d a r s bandd.

Purpose. This archwire is placed tu close spaces. The clos-

lnltial
~Flexibteround or rectangular (0.017-inch rnulüstranded
SS ar 0.016-indi Ni'lf, 0.017 X 0.025-inch D-Rett). In
exlraction treatment, the initial focus on torque control of
the mandibular incisors is not n m r y . AKhwires are
cinched bark to keep them from sliding around the arch,
Purpose. The initial archwire provides comction of rota-
tion and initial leveling,
ing loops are placed mesially in the extraction cite. In addi-
tion to the dosing loops arid omega loops, a reverse curve
of Spee is placed in the archwire. !f the second molars are
not banded, the archwire can be activated by cinching
back dista1 to the first motars.
Duration. 4 to 8 months. Closing loops are aaivateifevkry
4 to 5 weeks.
Finishing (Fig 1 0 4 )
Stiff rertangular wire (0.017 X 0.025-inch SS). Omega
loops are tied back with appropriate curve.

Duration. 1 to 3 months. Patients are examined wery 5 to Purpose, This archwire is intetided to finalize leveling,
6 weeks. toque control, and arch form.

Ttansitional Duration. Through the end of treatment.

lntermediate (0.01dinch SS or 0.017 x 0.025-inch TtViA).

Purpose. These wires continue lewling, toque control,

and arch forrn development. The archwire is bent with
omega -1 and the appropriate curve. Although there is a definite gattern for sequencing of arch-
wires, the practitioner must be able to make individual
Duration. 2 to 4 months. The patient is examind every 5 to choices that vary from the nomal, routine sequence,
6 weeks. In some cases, this archwire may not be necessary. Possible variations fmm a routine archwire sequence
include the foltbwhg scenarios:
. Space closing (Fig 1 0 4 )
lntermediate rectangular wire with teardrop closing
loops (0.0 t 6 x 0.022-inch SS).
 If the treatment objdve is to advance the rnandibular
incisors (¡e, a ,Class II division 2 case), then the mitial
rnandibular wire choice would be a round wire.
If the ocdusion has opened and adeqlrate toque is pres-
ent an the maxillary aích, it may not be necessary to
change to the final, high-stiffness archwire.
&&r b k & ~ ~ ~ k w %
~ 'er eq ~ m e
Because the metal rotation wings are not as stiff In the
esthetic clear bracket as they are in the all-metal brarkef,
it is important to use flexible archwires langer to eliminate
al1 rotations before intermediate archwires are placed. It
m a y be advisable to begln with a CuNiTi in the mandibu-
lar arch for a few months and then progres to another
flexible wire, su& as a 0.017 x 0.025-inch D-Rect.
In addition, rectangular TMA wires are a good choice
for intermediate torque control. lhe 0.017 X 0.025-inch
TMA clming loop wlre is used to retraa h e maxillary ante-
Fior teeth in an extraction case, when the case is bnnded
with the clear bradrets.
Because the poiymeric material of the clear bracket can
wear down from occlusal forces, it is important to begin
treatment in the maxillary aiLh and then use a b i p e n i n g
appliance, if necessary, ta prwent premame contact on
the mandibular clear brackets. Three options are availabk
for a biteopening appliance: a removable bite plate, blte
t u h , or Guray Blte Opners (GACJ, as diccussed in prin-
ciple 8.
Heat treating the archwire
After every stainless aeel archwire has been properly
s h a ~ d , t t s h o u l d k t e m p e ~ t o r e a r r a n g e t h e ~ e c u l e cw m i n e d m o r e o f i e n ( e v e r y 4 t ~ 5 ~ k s ) t o e r i n i r e t h e
in the wire and give It a perrnanent "fix." It will then have success and m-time comgletkn of the active tfeatment.
more spring md will bounce back to its original form eas-
Ay. This is be5t accomplkhed with a special appliance
deslgned to heat-treat archwires. A dgarette lighter, flight checklist (the diagnosis and treatment plan). nie
although not as effective, can be used if nothing else is
available. The wire murt not be ailowed to turn black or
red; this will ruin the wire.
Appointment Scheduling
Sweral factow are cansidered when the next appointment returns to high al^,
isscheduledfor the patient; the agpointrnents must be not
only effident but also effective.
With the n w e r titanium alloy archwires to go along
wlth newer bracket designs, less chair time is required to
bend the archwin. Elastomeric ligatures and self-ligation
make ligation faster. Because titanium alloy archwires can
retain t k i r activations oVer longer petiods of time, a
greater intewal between apgointments can be scheduled.
Fewer archwlres during treatment and longer intervais
between agpointrnents can be very time eficient.
Howewr, in general, it ir recommended that the patient be
examined more often during t k first 6 months of treat-
ment. If the patient is wearing a rapid palatal expander,
facebow, facemask, andíor a lip bumper, these appliances
must he dosely monitored, more frequently.
In addiiion to the adjwtments tRat a patient requirw, time
lm to be spent with the patient and parents, educating and
motivating thern. Getting the p a t i t off to a gaadstart and
expbiningwfrj he or she is askd ta do these produres will
hdp ensure that treatment will progress effectively.
After the first 6 to 8 months, treatment has usually S&-
tled inta a pattern. Often the appointment intenials can
then he extended, because treatment is n w under good
control. This usually m r s when the patient has fínishing
a M r a (0,017 x 0,025-inch 55) and the ind~duatarches
are wll established,
During the next 6 io 8 mnths, the interim perM, the
patient can k put on "cruisecontrol" and examined every
6 to 8 weeks. During Ihis period, facebow wear 1s contin-
ued, aflowing the mandible to grow into position. Various
elastitia are worn to mrrect midlines, centric relation, and
so cm,during this time.
A third stage of treatrnent o~currin the lost 6 months
of treatment. At this point, the patient may be wearing
elastics continuousiy to cborciinate the archa. tlass 2 etas-
tia, midline, b x , and fínishing elastia are used, as wc&-
saty, to estabtish the final occlusicrn. The patient now is
An analogy to orthodonüc treatment is that of fly ing an
airplane. T k pilot first musf study the flight plan and pre-
takeoff is a critical time wben ewryone k on high alert,
ensuring trafic control, runway clearance, equipment
monitoring, etc. This is similar the first 6 months in
M o n t i c treatment. When the pilot reaches the cruising
altitude (the interirn period of orthodontic treatment), he
or she switches to autopilot and monitars the always at a
reduced leve1 of alert, until iz is time to begin the descent.
On destent and landing, a critica1 time of the flight (simi-
lar to the end of adv; orthodontic treatment1,the pilot
Thus, during the tlmes of high alert, a t the beginning
and end of treatment, the patient has to be obsemed more

notedaand the archwire is then tied back on the side to
which the midline is shifted. Next, the a~hwireis tied back
tightly on the opposite side to cause the midline to shift
toward the center.
After the complete sted ligation of the finishing arch-
wire, It is very likely that this archwire will never have to be
adjusted again. Because most finishing archwires stay in
the mouth for 6 to 12 months, in the long term, tbis
approach is ext rwnely effective.
maxilbry first premolars were in rever% crosbite,
hces sgacUrg was present in the maxillary atch while
tk rnandikbr areh display& minor mtations and a
sewre cume of Spw.
The palient was treabd nmextrattion with a cetvical
facebow and a series of elastia.
Principie 12 Case Smdy m
To ensure that the a~hwiresare allmved to dev&p their
kill force potential it is important that they be fully
engaged in the bracket slots. Steel ligatures are the best
means to accomplish this goal.
Another irnportant principie in the Alexander Discipline &
tying back the a~hwiresto maintain tbe progress ackiwed
during treatment. As stated earlier, the advice t give to my
students is, "When in doubt, tie badr !" Together, these two
p r d u r e s helg to ensure ttiat the aKhwires successfully ful-
fill their functions. As yau examine and evaluate t4e case
studies that f o l b most of the chapters, h t v e h m the
sequeming of archwires and the methods of ligation follow
a pattem.
eg&tim
Althaugh atypical ndnextraction a~hwiremquenc& *re
foltowed, the p t b t wwe Rer f a b w and tlibsi'i very
well. Secgnd d a f i w e r e banded late ki h m e n t , mis-
ing an WeA5hn in the treatment time. AlthougR mi&
line w a afigwd or~the day the applianm *re removed,
h r e was e rninor &iFt after the twth settled. Ewything
e k has mmained a l e 4 years pmttrewtrnent.
11 12 h u r e Complete Bracht Bngagemrnr and Maintain Comoliduion

Fig 12-8 Fretreatment tacial víews, age 12 years. (a) Soft t i w e profile shows a protrusive upper lip but a well-dweloped mandible and a
weli-shaped mfiksue pogonion. (4Soft tissue frontal view show a symmeaic facial pattern with lips parted because of tRe procliried max-
illary teeth, Ic) Smiling photo shows he protrudirag incison but a good maxillary lip line.

Ftgs 12-9a to 12-9e Pretreatment intraoral viw show Class I rnolars but Class II canines and premdars, first premolars in mrse cross-
bite, a a l i w spacing, and a were anterior owjet (-11 mm). The over4ite k 6 mm. Note the cuwe of Spee In the mandibular a&.

Fig 12-10 UefO Pretreatment ocdusal

vicws. (a) Maxilla shows modemte spadng
and dlghtly tapered arch forrn. Ibl nie
mandibular arch shows mhor rotations,

12-12
~ i g Pretreatment
grap~s h m nothing unusidal. Arnple
for m a l eruption is prerent in the d a r
regias,

4 Fig 12-11 Pretreatment cephalometric

t racing.
 Principie 12 Case Study m

Fig 12-13 (a,d lñe initial archwire Is O.01S-mch nidcel-titanium. (b) Patient weafing awkal facebw.

Figs 12-14a to 12-14c Three mnths: fxcess spacing in ihe maxlllary arch was codidated between the lateral incisars and the canina via
O.Ol&inlh stainles steel archwire,

to ctose spaces.
Figs 12-15a to 12-1 5c Eigh t months: Maxllary 0.017 X 0.025-inch TMA T-loap archwire k USA

Figs 12-16a to 12-16c Eleven months: Mhxillary spaces closed; ready b r finishing archwire. Mandibular archvvire 0,016 x 0.022-inch SS.

Figs 12-1l a to 12-17c Eighteen months: tn both ames, u.u i 1 x u,u~s-incnsraniess steel finishing archwires were used. Overcorrection
of werjet with dass 2 elastics. m6 is ~r goal with every patient who presents widr excessive wetjet.) Semnd mabrs were banded late

Figs 12-18a to 12-1 8c Twnty-twomonths: 30th arches are sectioned, mdar bands are removed, and the patient is wearing finishing elas-
tics (a W shape with a tail).
 12 Hnsure Complete Bmcket Engagtment md Maincain Consolidation

Figs 12-19a to 12-19c Final facial views, age 14 years. Balanceti soft tissue profile, symmtry, and smile.

Figs 12-20a to 12-20c Final intraor;. .,?ws. Normal buccal Class 1 o ~ c l u s i ~Midline
n slightly si...,-3.

- . -. -.

Fig 12-22 Final ceptialonaecrictraaq. Ftg 12-23 P~treatmentWkl anh final

M aphdmwtrk W n g comparison.

Figs 12-ala and 12-21b Final occtusal

view show b o d anterior fixed retainers.
The maxlllary bonded retainer was placed
because of the original diastema b m e n
the central incisors, Fig 12-24 Final pancxamk di*.
 m
Principie 12 Case $ ~ d y

:igs 12-25a to 12-2Sc Four-year posttreatrnent facial Wews,age 18 years. Maxlllarj bonded retainer r d .

Figs 12-26a to 12-26c FOM-year posttreatmcnt intraoral vlews. Class I canine and molar relationships.

Force
, ..
Y.' ,
.
'
. bo'nrn]
Cervicalfacebow 12
Elastia
C$W 2XMidline 4
Chrts 2 3
Lateral box 2
Finkhlng 1
Let It Cook!
&Timing is emything*It is as impmtant b know when as to k w bow."
- Amold Glason
o neof tRe primary advantagesof additional interbracket
distanceafforded by the single-wing brackets is that
larger-diameter, stiffer archwires can be placed ear-
lier in treatrnent. When the interbracket distance is
increased, the relative stiffness of the wire between the
brackets is reduced by a factor ofthe length of the wire (L)
to the third w r (lll-9,making tRe wire more flexible and
easier to engage.
W e n the initial flexible archwire is plmd in a crowded
arch, this added distance between the bracketc allows the
wire to be deflected without creating a permanent set in
the wire. The advantages of this ihclude (1) a reductim in
patient dixomfort, (2) the ability to begin with a larger-
diameter archwire, and (3) the use of fewer total archwires.
To use these advantages to their fullest potential, the
archwire must be given time to fully express the forces and
moments within. As an atcfiwire is engaged in the bracket
stots, any deflection or distortion (nonpermanent) of the
wire is stared within the wire (Fig 13-1). Oependingon the
properties af the wire-elastk modulus, resiliency, and
springback-this stored energy is transferred to the teeth
via the brackets, and the teeth move, resutting in a disipa-
tion of the wire's forces (Fig 15-21. The pro- takes time,
a requirement that is conveyed M the phrme, "letit cook."
This maxim implies that orthadontists must not be too
hasty in hanging archwires. Rather, they should allow the
time necessary for the archwire to fully exgress its forces
and become passive in the bracketc before proceeding to
the next archwire.
 13 Let It Cookl
m
Fig 13-3 Occtusal views, rionextraction case, la) Pretreatmnt. Ibl Three months: Maxllary 0.017 x 0,025-indi rnultistránded stainless sWl
archwire shwving Mleai~1 labidingually, {d Flve months: Maxlllaiy O.dl64nch stainleis steel archwire is used.
As discumd in detail in principie 10, must nonextraction
treatment will require a sequence of no more han thw
arhwires per arch. In the rnaxillary arch, placement of the
first flexible archwire (0.016inch nldcel-titanium) will elirni-
nate most rotations in 1 to 3 rnonths (Fig 13-3). The second
archwire is often 0.016-inch stainless steel, c u d , heat
treated, and tied back. This second archwire will irnprove
the leveling and alignment. It will remain in place for 2 to 4
months. The third and final arcbwire, a 0,017 X 0.025-inch
stahless steel wire, is then placed after approximately 6
months of Mive treatrnent.
Early placement of the final wire has m n y advantages.
11allw-mretíme for ~ k f i n awirel (9.0175 x 0.0250-inch
Fig 13-1 Ocdusal views, extradon case. (4
Pretreanent maioilla. (b) Six months: Vlwv
M i a g O.Ol&inch stainless steel archwire,
elimination of rotations, and retraction oí he
canines.
Flg 13-2 Ocdusal views, extraction case. (al
Mandible showing inldal glacernent of brack-
ets and 0.01 6-inch nickel-titaniurn archwire.
0 Fwr months: Mandible Wh the same
archiw.
stainless steel) to e x p m itself, particularly in the final
detailing stage. It is uitical that this a~hwirebe bent to
exact standards, becau* the torques, angubüons, and off-
sets built into the brackets, as well as the c u w and shape
of this wire, will be almost fully expressd on the teeth.
Because the archwire is tied back, the maxillary teeth
now become a single unit, rather than 12 to 14 individual
teeth. The force of a facebow andlor elastia is now
applied to this one unit, the entire maxillary arch. Because
the teeth are moved gently and quickly to one position and
then held firmly throughout the remaining treatment,
there is no continuous movernent or jiggling of teeth.
Consequently, root resorption has not been an isue in the
Alexander Dixipline.
Because of the increased interbracket space and rota-
tional wings, rotations can be elimixiated, spaces closed,
 Archwire Sequencing m

Figs 1 3 4 and 13-4b Fwr months: Right

and left viwvs, respctively. Maxillaty arch-
Are: 0.016-inch stainless steel. Mandlbular
archwin:0.01dinch nichl-titanium.

ngs 13-4c and 13-4d Eleven months:

Right and left views, respectively, Maxlllarj
archwire: 0.017 X 0.025-lnch stalnless
steel. Mandibdar archwire: 0,016 x 0,022-
lnch nlckel-titanium,
C
Figs t 3 4 and 13-4f Foumn monihs:
Right and left views, respectkly. Maxillary
and mandibular ardiwires: 0.017 X 0.025-
imh stainless stwl.

Figs 13-4g and 13-4h Twnty-four

months: Rght and left views, respeaively.
Both arches are leveled by letting the atch-
Ares "cook."

and arches Iweled, predictabLy and quickly. Thus, the key
principle, especially in nonextractfon treatment, is to
place the finishing archwire as quickly as posible and
t k n let it cmk. Figure 1 3-4 is an example of how severe
deep bite rnalocclusion was treated with t h r e archwires
in each arch.
The " let it cook" principk is somewhat different in extrac-
tion treatment than in nonextraction treament. Since most
extraction malocclusianc have arch length discrepan€&
allowing the teeth to drift a few months after the extrac-
tion(s) will dften make it easier to place M@. Mormlly,
canina will drlft Kito bhe exbxüon sites. Wben brackets are
d a d , the teeth wül tend to mow to the area of least mist-
anc+ie, the extraaion sites. The exception to this nik is in
a maximum anchwage case wken the treatment plan is to
move t k anterior teeth as far distally as possible (see
PrinQple 18b Case Study), and ea* bracket placement in
both a ~ h e sis usually recammended in thk type of case.
F g 13-5 ~h~rxtion . ,b) PretreV, ,,nt view. b}blur ~..,,,rii>.
a
, .,
I~IIW. 9 .,.h O,Ol&inch nickel-titanium archwires.0 Eight mnths: Caniw
re- with rm tipping. {dT h i m monttEs: Closing loop for a n W remctiwi. (4 Finishing archwirs: 0.017 X 0.025-inch stalnbs steel. #
Final results

'
kt it c&" M& true whm d l l a y csninró are
being Mracted in wttaction irreapmwt (Fq T3-5). The pf@ COII&&O1l
&m is wken the eldorneric &¡m and
archwh qm a t l d b m&fUr 5 wds More they are ~ t i ea r t M f mi =Tuw -&@Sik M a"nd
&m&.&km the d a m e & dainr are r e p k d in IW tiewn~pasive in the b@&. T h e ~ r n n dmateíd
g
hair S-week inteivals, masirre tippjw qfl#,tq@f@q gf3.h a l h w&qchwre used w I sgptimaily é M e , iroiprw-
c a d n can
~ wr. ing mment ~~. sur g m l l ~ gel into #e flnishhg
a m i as quickly >eposcible,t k n . . . *let rt &."
 Primiple 13 Case Srudy m

Examination dad diagnosis a combiiation facebow worn throughout the remainder

of treatment. "Squeezing" exercices were used in the
A 10-year. Cmonth-old girl presented with a skeletal hope of controlling thg ,qpy:<,b,ite aqd ,vertic$ s,&JgL
Clasr II high-angle malocclurion, Dentally1a full-step Class pattern. T&C~I; arhwireba-nd-qlbdcrequences f o i opeil
II molar and canine relatiortship was noted. A V-shaped bite treatment,
maxillaiy arch form also i,ncluded a 6-mm arch length dis- ,dgrz-
Li
crepancy.. The mandibular &h had mode'rate crowding. - c--h
The patient exhibited a 9-mm.,%~erjetand no pssitiv
$~eI-bif:+.&~ignifica~i~tongu$~tM<$t
-. ,+, wa$:gjSe$ed , J

-
Archwire sequence

~Juration Archwire Duratiorr: Fw~e Ouration

(months):, (months)
Maxiliary .Aandibular Rapid pal--- expander 6
1. 0.016 NiTi 4 1. 0.016 NiTI 5 Combination facebow 1O
Z 0.026 45 2 2. 0.01 7 x 0.025TMA '3 Elastia
3.0.017Y 0,625: S$ 20 3,Q.Q17 x 0.025SS 9 Clas~2 5
Active treatment time: 26 months Active treatment time: 17 mmths Lateral box 2s 6
Anterior box 3
Finishing 2
Fig 13-6 Pretrearment facial views, age 10 years, 4 months. {a) alft tissue profile: upper lip is slightly protrusive. (bl Frontal view: features are
generally symmetrical. (c) Smile exhihts an unusual lip posture.

kig 13-7 Prerreamienr innaomi wews. (a)Right side: ciass ii wirn a siignr paerior uossoite. b) rronrai; open oire ana a mmiine aiscrepanry
are revealed. (4 Left si&: Class II with a posterior croshite.
Fig 13-8 Pretreatment occlusal views. (a)
Maxillary arch is V-shaped with significant
d i n g (6 mm) and a constrictd intermo-
lar width. Maxillary 6 X 6 = 24 mm. {b)
Mandibular arch shows moderate crowding
(4 mm), Mandibular 3 x 3 = 26 mrn,

b
Fig 13-9 (le& Pretreament aphalometrk
tradng, Hlgh-angle Class H hletal gattern,
Ftard rnaxillarj irnisors. Open bite.

Fig 13-10 (r9ht) Pretreatment panoramic

radiograph.Normal development.
 W c i p l e 13 Case Study m
Principie 13 Case Study 1

fig 13-12 Final frontal and profile views, age 13 years, 6 months. 0 Balanced profite and (b)frontal symmetry. (d Smile reveak excessive
gingival display.

Figs 13~13ato 13-13~fid intraoral Y¡&dudon

= iS exdhnt.

Fig 13-15 Final qhtmtric Sracing Fig 13.16 Pretreatmnt 0 and final
Excellent skeletal and dental mtml Ir@ ~ephalmetrktmdng amparims.

Figs 13-14a and 1 3 . 1 ~Final ~ occtusal

view Typical arch forms in b t h maxilla and
mandible. Maxilary internolar width: 36
mm; rnandibular intercanine width: 28 mm. Fig 13-17 Final panommK radiagmph.
Leve1 the Arches and
Open the Bite with
Reverse-Curve
"An investmmt in knowledge pays the best interestmD
- Ben Ft&
ne of the most common maldusions found
throughout the wodd is the deep bite malocdusion. In
a true deep bite case, the patierrt exhibi an ex&
anterior d i and an excaive curve of Spee in the
mandibular arch (Fig 14-1). In addition, the indsal edges of the
mandibular inchrs contxt the lingwl surfaces of the rnaxil-
lary anterior te& or the palatal time (Fg14-2).
To Ievel the mandibubr arch in patients with deep bite,
clinicians may hoose to use utility or base (intruúon) arches
or place a reverse curve of Spee in tbe archwires. Clinical
experience and evidente-bed research h a w substantiated
that use of the Alexander Discipline approach to lwel the
arches and open the bite is not only simple and successful
but also stable (Figs 14-3 and 14-4). Using patient ncords
from rny office, researchers were able to demonstrate
what happens when the rnandfbular arches are leveled
with a reverse curve in the archwire':
The Alexander Discipline is an effmive continuous
archwire technique for leveling the curve of Spee in
Clas 11, division 1 deep bite cases treated nonextrac-
tion. The method of leveling the curve of Spee with
the Alexander Discipline Is by a mmbination of mainly
bispid extrusion, and minor incisor intmion. The
Alexander Discipline effectively controls the mandibu-
lar incisor position during the Ieveling pmcess and
does not =use excasive flaring of the mandibular
incisors as a side effea of leveling. The -6" angulation
ln the molar band does cause the mandibular moIar
to tip back at least that amount during treatment
although there is a 30% loss after treatment. The
Alexarrder Discipline does not cause excessive open-
ing af the vertical dimension during treatment. There
is an alteration of the angulation of the fundtional
ocdusal plane which appars to be stable wer time.
These results are stable in the long-term.
 14. MI.the Arches and Open &e Bite with RwerseCurve AKhwires
Fig 14-1 Curve of Spee typically fouml in
diviciwi 2 deep Me patients.
Fig 14-3 Treatment e aof reverse curve of Spee in
f Fig 14-4 At an average posttreamnt period ef 1 1
archvitires as demonstrated ln d% studies by Bernsteinl
ami Carcara.2
Technique
Crerimt ofthe cwve
In stainless steel and titanium-molybdenum alloy archwires
(0,016-inch, 0.016 x 0.022-inch, and 0.017 x O.OZEinch),
the curve begins just mesial to the omega loop and is
extended to the dirtal side of the canine in both maxillaty
and mandibular archwires. In stainlesz steel wires, the
curve is created by sliding the wire over the index finger
(Fig 14-91. Titanium-molybdenum alloy may require more
bending with appropriate ptiers. This pracedure is repeated
on the opposite side to giw horizontal syrnmetry to the
archwire (Fig 1 4 4 ) .
Amottnt ofcz~rve
The amount of curve placed iri the maxillary afchwire
depends an tke m h i t e and the patient's smile line. If the
patient Ras exressive soft tissue show (gingival display)
when smiling, a larger curve is placed in the archwire. If a
patient reveals only part of the clinical uown when smiling,
Fig 14-2 nie inckal edges of the mandibu-
lar i n d m mntaa the linmal surfaces of
the m i l l a r j anterior teeth or palatal iissue,
creating a w e r e &rte.
years 5 manths, the results show no relapse in the pre-
molar area, and thus the lweled arch is maintained.
the archwire will receiw no curve. Correction af the over-
bite in t h a patients is accomplished mainly in the Ieveling
of the mandibular a d . When the time comes to treat the
mandibular arch, the anterior werbite and amount of
curve are assessed; these factors determine how rnuch
reverse curve is placed. In deep bite cases, the mandibular
arch should always be completely lweled to prevent over-
bite relapse at a later date.
Whm the time comes to place the cunie h the archwire,
the patient is first asked to smile. Rardy, in such a case, will
he or she g k a full, natural mile. iñis caild mult in a fatse
appraisal. To rectify this pdiem, the "goochee goolhee"
tedinique 1s used. The orthdntist asks the patient to smile,
xratches the patient behind the eaí, and says, "goochee
goochee." The resuit will akvays be a full smite, and the
orthodontist will be aMe tú determine the proper amount of
curve.
The average cutve ptaced in a 0.016-inch stainless steel
archwire is approximately 5 to 6 mm. This cuwe can be
measured by placing the archwire in the molar tubes with-
out fully engaging tf-ie archwire in the anterior brackets,The
anterior portion of the archwire should be approximately at
the gingival line (Fg 14-7) or about 5 mm from the bracket
slot. The same amount of cuwe can also be placed in a
 Fig 14-5 Cuw of b, ptaad in the
archwire in four st* {?} Using a rectangu-
lar wu'&nding pkerr, b l d the wlre just
m-l to the omega loop # Place a finger
beside the pllmand gen* 'niveep' it over
the wire. B)Stop the cuwe at the dista1 of
hmine.M) Repeat the RNeeplng m o t h
on tke -he siside.

Fig 144 T
h 11111sheci
ityht and left c
um Fig 14-7 Note urdt when he archwire is Fig 14-8 Exarnple of the ,,,dd far a minor
coindd- loosely pbced in zhe molar tube tohll cumof Spee in the archwfre bewusg ilirf the
engagmwit), the anterior part 6f iChe &- aaentuated cuwe In the mandibrilar srch,
w1re is dose to the ging'il margino

Fig 14-9 Treatment of deep bites with 0.017 x 0.026-inch stainless *l wire may require
r e d d archwire curve.

Fig 14-9a Typical prewatment Class II

division 2 makdusion.

Fig 14-9b Treatment progress of 8 m h

ts
and two arcRwlres (0,016 MiTi and 0.016 SS).

Fig 14-9c Overcorrection af oiierbite

resulting from an excessive cum of Spee in
the 0.017 x 0.025-i~hSS archwires,

Fig 1 4 4 Final owrbite result after removal

of the excessh wrve in the archwirer

0.016 x 0.022-inch stainless stwl wire. if the rnandibular
arch hasan xcerltuated cum of Spee, only a minor amount
of i.everse euwe ic placed in the a r d w i i (Fig 14-8). f the
arch has no1 levekd aciequarely after 6 ~o 8 weeks, the arch-
wire iz mwedand additional cuw is placed*
When a significan1curve is pláced in 9.017 x 0.025-inch
stainless steel wire, h m v e r , more care must be taken
because this is a stiffer wire. The amount of cum placed in
the wjre wil be replicated dmost 100% in t k arch. When
I first staired incorparatifis a curve tn this archwire, I was
taking &ep bltes and almost tuning them into open bit&>
tt was often necmary to i e m m the a~hwireand reduce
the curw (Fig 14-4-91.
, 14 Lwel t h e Arches and Open the Bite with ReverseCurve Archwires
S~btleopen bite
Regadless of the amount of anterior overblte, if there is no
contact 6f these anterior teeth-that is, if be incisal eciges
of the rnandibular Msors are not touching the lingual sur-
face of the maxillaty inciso-then a space is present
between these te&. According to Dr Fred Schudy, this is
calied a subtle bite (personal communication).
Although a positive overbite is present, these patients usu-
aliy have a more n m a l mandibular cuwe of Spee and may
even exhibit a high-angle pattern. When an orthodontist
encounters this particular situation, he or she should be
very careful in placing a reverse cuwe in the mandibular
archwire. The s p c e between the anterior teeth must be
the rewlt of a tongue thrust. lf túo much cunie is created
in the wire, the tongue can accentuate the force of the
wire and create an open bite very quickly.
Heat tre&ment of the archwks
All stainless steel archwires are heat treated k f o n they are
ligated In the arch. The heat treatment relieves stress in thc
wire and improves its elastic properties. This is espcially
me when large curva are present in the mandibular arch.
The wire is then allowed to "cook" over several rnonthsof
treatment. If the wire has to be remwed and adjusted and
an additional curw has to be placed, the archwire shduld
then be heat treated again.
Conclusion
The argument against using a reverse curw in mandibular
archwires is that it fiares the mandibular incisors as it lev-
eB.This can happen if rousrd rather than rectangular arch-
wim are used. Three factors mmt be considered in Ievel-
ing the mandibular a&:
1. Torque of -5 degrees must be placed in the 0.018-inch
slot mandibular incisor txackets-
2. Angulatisn of -6 degres rnust be placed in the
mandibular first mdar brackets.
3.Oniy fectangular archwires should be used,
With this prescription, the mobrs upright distalb while
the toque controls the incison. Tbis placa an extrucive
force on the prernolars, cadng them to extiude (sr enipt)
and aid in lewling of the arch-without flaring the Inci-
sors.
By controlling e& tooth wid-i full archwire engage-
ment (rather than .segmented archa), positioning of the
teeth within the arch form is completed much faster. Most
important, the use of this approacb in rexilving deep bite
rnalocclusions has been proven to be stable.
l.Bwnwin RI. Leveling tbe cuw d Spee with a continuas
aKhwire technique: A kng-tem e p h a W c anal*. Am J
Otthod Dentofaclal O&pp 2007;131:363-371.
2. C w a r a 9. W P n g the cuwe of S
m with a cmtinubus arch-
win techniqw: A long-term study wt an-. SerPiin Orthod
2001;7:90399,
 Principie 14 Case Saidy m

d Principie 14 Case Stiidy

I were exceedingly flared h i l e mandibular inciso~swwe

exceedinglv uwriahted. There was also a l w r rnidline
6notas g
g m iwhtalk as wuid
~ he mandibk
. di¡ not
b e b n s&n in su$i 1
 14 bvel h e Aeches and Open the Bite with Rwerse-Cume Archwires

Fig 14-Id Pretreatment facial views, age 13 years. (a) Soft tissue profile showing extreme skeletal Class II defickncy with a large pgonion.
(bl Frontal view showing normal symmetty and protruslve Ilp,(4 Smile vim showing protniding teeth, acceptable smite Ilne, and da& bucal
mrridors.

Figs 74-lla to 14-11c Pretmtment intraaral views demonstrate Class II molars,a large arw ot Spee, and an excesslw owlbite (5.5 mm}
and ove j e t (1 1 mm).
Fig 14-12 f k j Pretsatmwt d u s a l
viewa @ tlaxiiia showc a -red V~stiaped
,aral. IXi1 MandiM~shtw a normal a%$i
forirt.*re is rnodetata mndibular antelrúr
mWng,but all b w 'Es" 84 pwnt
Maxillary
1. 0.0175 lhistflex 1
2.0.016 SS 7
3.0.017 X 0.025SS 16
Aaivetreatmenttirne; 24mntb

Fip 14-13 Pre'treatment aphalametric

mdng M y =re & b l i ~ m g l s 3.0.017 X 0.025 SS 5
Ctw H and Mrnmillary i d m mmt rime:
~ctiw u mwths
 Principie 14 Case Srudy m
Principie 14 Case Studv

Fig 14-14 Final faaal views, age 15 years, 8 rnonths. (a) Soft ttssue profile shwving enlarged me,obtuse nasoiabiai angie, a more normal
t pogonion. (b) Lips are balanced and show no smin on closure. The frontal view ir symmettical. (c) Big
submental fold, and a m a l ~ ftissue
smite view shoM a normal rnaxillary lig line and twccal corridors,

Figs 14-1Sa to 14-1 5c Flnal lntraoml phatos shawing normal Class I ocdusion with corrected overbfte and civerjet.

Fig 14-17 Final cephalometric tracing. Flg 14-18 Pretreatment and final
{d) cephalomeiic üacing comparim.

M
Fig 14-16 Fhal occlural iew rhowing (a) Cervical facebow 20
o\roid maxillary and (bl normal mdlhhr EWcr Fig 14- 19 Final panoramic radiograph.
arch fonns. Ctw 2
Figs 14-20a to 14-20c Twenty-five-year posttreatment facial views.

Ffg 14-23 Posttreatment cephalometric

Figs 14-22a and 14-22b Posttreatment Fig 14-24 Posttreatment panorarnic radio-
occlusal views. graph.
Create Svmmetrv d 1
'Tommon seme is the kluack of seein thin S as thq, are,
and doing thingsar they oicght to be me. f 4
- Harriet Beecher Stowe
A
ll patientswith mdocdusbnspresent with carne asym-
metries, b t h skeletd and dental. The i m p h and
b& M o d to comedthese pmbiems is to agply sym-
metric forces to the teeth and jmivs. This statement is based
solely on the resultsof my clinical experience. To my knowl-
edge, this issue has not ken addressed in the clinical liter-
ature. In a future volume af this series, an entire chagter
wiil be devoted to the trea trnent of major wymmetries that
require more comptex treatment plans, such as asymmetri-
cal extractions or surgery, which usually occur in adult
pa tients.
When treating growing patients, however, the *eletal
and dentoakieolar resplonse to various orthodontic and
orthopedic forces will rwtinely produce symmetric, esthet-
ically pleasing, stable results.
Rationale for St&g
Treatment in the Maxilla
After having been taught to hegin treatment in the
mandibular arch, I experimented with banding the maxil-
lary arch first. This change in treatment procedure, in
whkh the maxiltary arch was treated before the mandibu-
lar arch, carne as a result of the following obswvations:
lf the rnaxillaryarch is treated first, t k bite opens, and
the mandibular curve of Spee begins to level, making
it simpler to band and bond the mandibular arch later
(Fqs t 5- 1 and 15-2).
Because there are fewer opposing occlml forces, the
mandibular arch routinely is corrmed faster.
k a u s e it is no longer restricted by the occlusion, the
mandible may begin to grow, making the f a c e h
more effective,
Maxillary incicors face less occlusal interference from
mandibular anterior brxkets because the occlusion
has opened.
6 The patient experiences less discomfort because the
archa are not treated simultaneously.
Patients and parents are happier whsn maxjllary
brackeb are placed first so that they can "shaw off"
their new braces.
It is ttierefore preferable to treat the maxilla first and
create an ideal maxiliary arch, w n though it is in an asym-
rnetric environment,
Facebow is more effective when the maxillary arch is
treated first because the occlusion is changed and inter-
 Fíg 15-1 Pfetreatment frontal view. Note
the deep werbite and midline disuepancy.
Fig 1 9-3 Facebow on template W r r g Fig 154 The f a & ~ ' ~outer bows restna
symmetry of inner bow. the patient h m skping on either side of
the face.
ferences removed, thereby unlocking the mandible and
allowing it to better express its potential growth. In addi-
tion, the orthopedic effect of the facebow on the tied-back
maxillary archwire holds the maxilla in position while the:
mandible grows downward and forward. In patients withc
severe deep bite, a bite plate (remwable retainer), Guray
Bite R a i r s (GAC), or bonded lingual brackets (Bite Turba,
Ormca) can be used to facilitate this pmess.
W h n moderate asymmetries are present in the original
malocctusion, first establishing symmetry in the maxillary
nch prornpts tbe rnandible to respond taward greater
rymmetry without special treatment. Tke following three
hypotheses may explain this effect:
1, lf the maxiltaty arch is treated first, the therapy will
simulate a splint effect by rnoving these teeth out of
their original occlusbn, thercby allowing the
mandibular ocdusion to be unlscked from asymmet-
ric occlusal forces. TRis will allow tke mandible to
"relax" and grow into better symmetry. Ceritric rela-
tion shifts often are redved with bracketing of the
rnaxilbry arch.
Fig 15-2 One month: Frontal view. Note
the ovehite anrl midline imprwements.
Fig 15-5 Llp bumper on kmplate showlng
symmetíy.
2. When facebow b used in a patient with a Class IIsub-
division malocclusion, although tbe occtusion i5
asymmetric, the syrnmetric design of the facebow
(Fig 15-3) will apply more force to the Class II side,
thus encouraging corredion on thot side, The asym-
metric molar positions will make the syrnmetric face-
bow fit asymmetrically, thereby causing the auter
bow on the Class II slde to be positioned more out-
wardly. This will increase the f o ~on e the Class IIside,
3. An asymrnetric fme is definitely king applied to the
side of the face if the patient sleeps on one side. tf this
posture is repeated over rnany months, it k feasible
that it could affed the patient's growth pattern and
make it more asymetric. The outer bows of the face-
bwv compel the patient to sleep on his or her back
instead of the side of the face, whidi can wicourage
or allw symmetfic grawth of the rnandible (Fig 15-4),
In addition to the facebow, the lip bumper is also sym-
rnetrically designed (Fig 15-5) and can provide similar
forces. If the patlent sleeps on his or her side, the lip
bumper wire can irritate the inside of that cheek.

Treatment Sequence
As detailed in prlnciple 9 on arch form, coordination of
a ~ h e sis essentiai to create occlusal symrnetry. Maintaining
the original mandibular intercanine width is critica1 to sta-
bility. The Alexander preformed archwire template is effec-
tive in coordinating the maxillary and mandibular anterior
canine-toíanine relationships, thus maintaining interca-
nine width (Fig 15-6).
Almost wery Class II malocclusian requires maxillary
canine, premolar, and molar expansion, but it is necessry
to determine the amount of expansion required, A simple
procedure to anwer this question is to ask the patient to
protrude the mandible forward until the incisor teetk are
atmbst edge to edge and then observe how much maxil-
lary posterior overjet expansion would be needed to bring
these t e t h into good nlaüwiship with the untreated
mandibular posterior teeth.
The maxillary arch form is then created to coordinate
with the anticipated Class I relatlonship of the currently
untreated mandibular arch. This archwirr! is shaped in an
ideal arch form.
Treaunent Sequence m
Fig 15-7 Maxillaty and mandibular arch-
wíre coordination.
Likewise, when the fínal ideal mandibular arch form is
established, the original intercanine width is maintained
and tbe posterior region shaped to coordinate with the
treated maxillaty arch form. If this procedure is followed,
the final mub will be coordinated archwires (Hg 15-7)
refleaing normal and stable buccal werjet.' Only rarely will
it be necessaty to cmrdinate both archwires by removing
and replacing them, as was taught in the Tweed techrrique.
After the maxillary arch is deueloped to within one stan-
dard deviation of the maxillary prefoformed template, it is
time to initiate treatment In the mandibular arch. This arch
is treated independently of the maxillary arch with a
sequence of symmetric archwires, in accordance with the
mandibular Alexander template. Care must be taken to
control the intercanine widtk. The Alexander preformed
mandi bular archwires are helpful in accomplishing this
h the rec-
goal. In addition to creating the correct a ~ form,
tangular mandibular archwire (like the maxillary archwire)
will control torque dnd the curw of Spee.
 rig I 3-6 Arcacnmenr OT rnioiine ana ctass r dastics, la) MMlirw elastlc attachment Ibl Clas
2 elastic, left side only.
- -
Rg 15-9 {a) Befon elastia: 0.017 x 0.025-inch sainkss steel aKhwirw tied back. Signlfiant midline shift; end-on lncisor bii. @O Elastic
attachment: C k 3 left, rnidline. Note the paralkl v e m (4 Three monthr: Overbite and midline are gready ImprwPd.
After the maxillary and mandibular arches are both individ-
ually symmetric, they do not as yet d u d e properly. The
midlines may not be aiigned. The molar-canine relationship
may still be asymmetric. The buccal segments may be in
cmsbite on one side and excessive bucal werjet on the
other.
To coordinate these arches, the patient must wear mid-
line elastics. Either dass 2 or class 3 elastia may be wed ta
supplement this correction (Figs 15-8 md 15-91. Howevw,
use of both class 2 and c l a 3 elastia along with the mid-
line elastic can create a cant in the ocdusl plane. With
m e exceptions, midline elastics are used when both of the
0.017 x 8.025-inch stainlesssteelarchwiresare t i d back. A
uossbite elastic, extending from the Iingual surface of the
maxillary first d a r to the buccal surfaced the mandibular
first molar, may k added, A l three elastia tclass 2, midline,
and crossbite) should have the =me vector.
Patients are instructed to wear these elastics 24 houa a
day, 7 ddys a week. I tell patients to remve the midine
elasüc when they are eating, jokingly suggesting that they
place it around their little finger, and to continue to wear
the class 2 elastic. By the time they have completed their
meal, their little finger will have turned blue, reminding
them tu replace the midline elastic. This joking with
patients seems to work well as a reminder to replace their
elastig after eating.
A midline elastic may be troublesome for patients to
wear because it is so visible. The g d news is that they
can aIso easily monitor it. The patient is shown, in the mir-
ror, where the problem is, and the goal of the elastic is
explained. The patient is assured that the midline will mow
if the elastia are worn as instructd.
A 0.5-mm corrmion can routinely accur each month
with this agproach (see Fig 15-9c). Because there is a ten-
dency for a slight relapse, wrcomction of the midline is
critical. When the overcorrection (approximately 0.5 mm)
has been accomplished, the patient is instruaed to wear
the elastics only at night to maintain the correction.
Finishing
When the maxillary and mandibular midlines coincide,
class 2 elastics are used to obtain the final centric acclu-
sio~enintricrelation relationship. Finishing elastia then
create the final posterior occlusion.
The importante of this final step cannot k overernpha-
sized. The last 6 months of treatment can make al1 the dif-
ference in the quality and stability of the finishéd result. It
ir vital to set goals for patients and their parents and to
educate them as to why finishing elactics are so imponant
for a beautiful and stable resultaSpending a few extra
appointments to finalize the occlusion is well worth the
effort for all concerned'

Conclusion
In gmwing patients, when symmetric forces are applied in
an asymmetric envimnment wer a p e f i of time, the
teeth and jaws tend to become symmetric. Treatrnent pro-
ceeds in the bllowing sequence:
1. Creation of an ideal maxillary aKh with facebow (if
necessary) and archwires.
2, Creation of an ideal mandibular arch with a lip bumper
(if necessary) and archwires.
J. Coordination of the arches with elastia,
Principle 15 Case Smdy m
improved environment in the oral cwity o# a growing
patient and appiy forces that encourage favorable tooth
mwement and skeletal improvement.
While mderate asymmetric rnalodusiwis in growing
patients can tx routinely treated with simple mechanics,
asymmetry in nongrowing patients is a tatally d i n t situ-
atim. Without the benefit of growth, the options for treat-
ment are fimited. Often, asymmetrk extracths are n e c e
=y+More sewre pmblems may require surgicxil sdutions.

Many years ago, Creekmore' wrote an article entitled

"Teeth Want to Be Straight." This staternent is so true. 1. Creekmore TD. Teeth want to be straight. 1 Clin Orthod
Good things happen when an orthadontist can create an 1982;16;745-764.

i'Principle 15 Case Study

I
: Ouewiew
1
... .- .... 1 - - I
I.
Discussion
.avmetricCiaa il wbdiuirion rnalocduiion is treated Thb patieh~:ii6hexceiidt $xamPle of treating asymrne-
"

kih , s i ~ symmec
e - -. try wi~symrri,tjy" fter her brackets were placed, she
, ri
t
;
, : N

A,.,
-- . .- .
e -. - K, r$
was @ven s"p etq, archwires and a symmeiric cervical
fac-. &.Mr mjjillary teeth conformed to the arch-
.,
:&&i&tion & hP* wi%,;the facebow a tomatically placed more pressure on
,-.-, .y -,t. . a j- the Clair II side.1
~ h i s11~y&~6idm
%S-
id+preented with a Claa II !ubdivhion
J Note.that in'the $rnonth views, the midline is aligned
e
atrd a mandibo r,,MMve .-. a *letal pattern. ni'
m h c md,Gl&ionhad a signjficant midline qd-
gnd tjkhdars a r e b t h in Clarr l. No elartics or othe
1
.,p. forcer wen ~ w i r e dto adiieve these results. Also note in

-
ovwte, ex&¡? pandibular arch;ler@Q . *- the sama v i w s that.the maxillaiy arch has been leveleda
overjet, ,. .gl di a. ..
dkcrepangof a nim.' - -
4.
r
first, creating occludl spacer rnd t q @ iteFK&leyed
.h., v-. * --
-:--
-the mandibqtar a ~ h ,
.
?

- ?-"y -t@igg %ti* a t ' h e

, ,- .. whlle the
~rilafiilla
I &,

The patienrg~cpatedn~nextron, . face-"

h h cervical
1 bow and c b i 2 elastio.
+ > -, .
:,- --
-
m
-1

- -

Thls eatiehf 'lacked compliance after ine first 6 monps;

'e yet thk firii&ed smiie al1 the eritda eiptwqd by
leadlng esthetic tea&rs today. And this patlent was
treated 20 y e a ~befofe we knew such terms as buccat
c o r r i i , smile line, and smlle erc.
 principie IS case S+ 1

Fig 75-10 Pretreatment faciat views, age 11 years. (a) Soft tissue profile: poimed nose, obiuse nasolablal angle, and deficht mandlble.
Frontal view: rninor asymmetry. Id Normal smile.

Fig 15-11 Pretreatment intraoral views. Ouerbite af 4 mm, overjet of 6 mm. (a} End-on molar and canine relationship. (b)Significant crowd-
ing and midline shift. (4 Class I motacs, end-on canines.

Fig 15-13 Pretreatment

cephalometric tracing.

Fig 15-12 Pretreatment occlusl views. (a) Fig 15-14 Ptetreaiment panoramic radiograph,
Maxillary arch, 5+ rnm of crowding. (b)
Mandibular arch, 4 mm of crowding.
 Principie 15 Case Smdy m

Figs 1S-15a to 15-15c One montk Maxillaiy 0.0175-inch rnulrirtrandedardrwln. Note midline imprwement.

Figs 15-16a to 15-16c Nine months: Maxillaiy G." 1 7 x 0.025-inch stainless steel ardnvire; mandibular 0.017 x 0.025-inch muttistranded
archwlre. Note corrected midline; Class 1 mdars; leveling of maxillary arch; lack of occlusal mtacts in the premola-area.

Figs 15-17a to 15-1 7c Two years: Maxillary and mandibular 0.0 17 x 0.025-inch stainless steel archwire. Ready tu begin finishing dasticr.

%?"!
,-
Ir'

Figs 15-18a and 15-18b One month:
Occlusal views. Maxillary OaO175-inch multi-
stranded archwire,
Figs 15-t9a and 15-19b Nine months:
Occlusal vi- Maxillary 0.017 X 0.025-inch
stainless steel finishing archwire. Mandibular
0.017 x 0.025-inch muitistranded archwire.
Anterior enamel rediiction.
Figs 15-20a and 15-2Ob Tw years:
Occlusal views. Finishing archwires and arch
forms.
Fig 15-21 Final facial views, age 13 years. W Soft tissue profile is nicely balanced. Nose is larger; nasolabial angle is improved; soft tissue
pogonion is normal. (NFrontal view shoM excellent syrnmetry. (d Excellent srnile line, Iip line, facial and dental rnidlines, and buccal covidors.

Fig 15-22 , ,,ial intraoral view. Frontal view: Fig 15-23 Unal M L , ~ ~ I(a) ~Iltaxllla:ovoid arcl. .-......b} Mandible: handed -.....-
views. --
midline ymmetrj.
.. ,. canine.

Flg 15-24 Final cephalometric trachg, Fig 15-25 Pretreatment (biack) arrd final Flg 15-26 Flnal panoramic radiograph.
(red) cephatometric tracing comparison.
 Principie 15 Case Smdy m

Figs 15-27a to 15-27c Six-year posttreatment views of the soft tissuk4 age 19 years.

e.'p .m-&#
7,- =
--*& - -

. .m

Figs 1 S--- to 15-28c Six-year posttreatment intraoral views following artistlc recontouringof the maxilIav incisal edges.

Mandibiilar
m e
1.0,016 re 0,03i2
~ltistmd
2. &M7 X P P a 5
Muitbtránd
3.0.017 X 0.025 TMA 3
4.0.017 X 0.42555 11
~ ~ t i i m e2ümmths :
Figs 15-29a and 15-29b Six-year post-
treatment, three-year posttetention occlusal
views. Note the minor rotations of the
mandibular right central and lateral Indws.
Use Intraoral Elastics to
Coordinate the Arches
"Greatness Iies not in b&g strong, but in tbe ~ & h u
t se of mgtk."
- Henry Ward Beecher

I
n the Alexander Discipline of orthodontic treatment,
intraoral elastics are most commonly used to coordinate Sequence of Elastics
the arches. Nthwgh sorne orthodontists may use intra-
a ~ elastia
h for space clowre, this approach is seldom In general, the use of elastia in the Alexander Discipline
used in the Alexander Discipline. With the exception of fin- system of bimechmics is divided into three sequences:
ishing elastics, which will be dixussed later in the section,
dastics are used to reposition entire arches, not individual 1, Early in treatment
teeth. * Cmsblte elastics
As with any intraoral functional appliance, elatics are CIass 3 elastia after bonding of the mandibuhr
subject tto Newton's third law of motiok-for mry actim, arsh ta prevent inasw flaring
there is an egual and opposite reaction. This opposite reac- S. Midtreatment
tion is most critica1 when the onhodontist is attempting to Box elastics tu help cl& Mén bites andlor IevGlt h ~
control the position of the mandibular incixirs. mandibular archa
Class 2 elastics for ninimum mwrdibularamorage
in extraction cases
Class 3 dasticr to mwirnlze mandkukar andwage
in ~ b a c t i o nases
Fig 16-1 Elastics attadied to ball haoks on Figs 16-2a and 16-2b Crossbite elztics attachment.
lateral indsor brackets can dellwr four tima
more horizontal (red m w ) than vertical
(b,ue armw) fm.

Fig 16-3 (al Class 3 dastia attachrhent.

Wwded mandibular arch. k d, 4Class 3
elasiics used eariy in treatment (72 hours) to
prewnt mandibular incisors ftom advanang.

Fig 16-4 Class 2 ekstjcs attachnwnt flg 16-5 CIass 2 dada can be used in this Fig'164 Midlineeh!Note how tFfe das-
slaiation to mwe mansli'bubr& mesialiy. tk goes m the.central I n h r bradaet befom
anguldng bthe mandibubr hml i n c h
Use Nonextraction
Treatment When
Possible
"lfyou can dream it, yoil can do it."
- Walt Disney

r e previocls chapters have outiined in detail s

mfci prin-
uples that are necessary to f d l w in ordw to mnsis-
tently produce h i h - q u l i stabie results. T k e next
two principk will put it al1togethw as the micaltreabnent of
m t r a c h and extractiwi cases is dinmed.
The question is how to c o m the skeletal Class II prob-
lern. In growing children, thi is best accomptkhed Mth face
bow and das 2 elastia. In adub (nongrowingpatients), the
sdution is either to extra maxitary premolars úr to corrcidw
surgical mandibular aduancement. Principie 14 clws4ed
It is important to understand the basic Alexander how the mandibular arch is Ieeled in nonextradon treat-
Disciplirie p h i b g h y of treating skeletal malocclusions. In ment of deep bite patiem, bath children and adults.
mt cases, a skeletat tlass II patient presenting with a
Class II molar relationship is corrected by control of
growth, not by the mesial andior dista1movement of teeth
to obtain the proper ocdusion. Occasionally, in patients
with a skeletal Class I pattern and dental Class II malorclu- Assessment of Barderline
sion, maxillary molan may be dirtalized. However, the
teeth must fit within tRe alveolar trough. Although this
PadentS
trough can be widcned in the posterior afeas, the
mandibular anterior wgrnents alfow only limitcd changes, In determining if a patient can be treated without extrac-
Therefore, the ftaring of mandibular anterior teeth to tion, the primary question is whether the mandibular arch
reduce overjet in most patients is unstable and unwise. crowding can be resolved while the anterior teeth are main-
In typical patients virho are to be treated with rionextrac- tained in acceptable positions. This decision is based partly
tion therapy, the mandibular arch has rninimum to moder- on the extent of the mandibular tooth sitegarch length dis-
ate crowding. As stated earlkr, the arches are treated inde- crepancy. In general, 4-6 mm of arch length can be "con-
pendently. troled" with good mechania. This additional 4-6 mm of
 17 Use Nonexaaction Truanenr Whui Possible
+
spce can be gained by slightly advancing the inasors and
uprighting the molarr. More spxe can be gained if the pas-
tdor transverse dimensions can be expanded.
ln my experimce, approximately 15% to 20% of
patients are definiteiy extraction cases. Another 50% defi-
nitely do not require extradon. The critica1 area is the
ather 30% or so of patients wRo are brderline tases. tn
Qur prxtice, nearly al1 of these borderline patienb are
treated without extraction. five factors allow the use of
nonextraction therapy a nd enable the mandibular inciso^
to remain posirioned upright over baral bone:
1. Space gaind by transverse expansbn with rapid
palatal expanders and lip bumpers. Studies by Adkins
et al1 and Chung and Font2 show that there is a
0,6-0.7m m perimeter increase for evefy millrneter
of posterior expansion.
2. The -5 degrees of torqw buiit into the mandibular
inciw bratkeb rnaintains proper uprighting, while,
at the same time, tRe-6 degnw of angulation in the
msndibular first molar brackets will upright the
mandibular molars, creating more arch length in the
dista1 sqments.
3. The use of rectangular flexible archwires such as
haided stainless sterrl, nickel, capper, and titanium
wires allows mandíbular anterior torque control,
beginning with the initial archwire.
4. Judidom use of class 3 elastics with the initial arch-
wire can prevent tRe mandibular incisors from exas-
siw labial tipping. The elastia can also i n m s e avail-
able space by helping to upright the mdars.
5. interproximal enamel reduction of the dentition can
create Several extra millimters of space in each arch,
At Ieast 0.25 mm of enamel can be removed from
ea& interpíoxjmal surface of the mandibular anterior
reeth. If the teeth are large, wen more w m e l can
be safety removed.
Interproximal enarnel reduction, also called siendenziing, is
ehe removal of interproximal enarnel. Atthough slenderiz-
ing is most oftftenpracticed ln the mandibular anterior den-
tal segment, it is not confin& strictly to this area. tt is pos-
sible to slendedze in any segrnent af either atch.
lt is perbctly safegto remove up ta 0,25 mm from e&
interpmximal sudace, which translates to 0.50 mm per
tooth. Therefore, the tooth mass of h e six anterior teeth
Can be reduced up tu 3,Oü mm. lf mandibular pnmolars
and first molará are ako slenderized, tmth mass can be
reduced by a total of 6.00 mm.
In h s i n g speOfic teeth to be slenderlzed, the ortho-
dontist may have to perform a Bolton analysis. A visual
impection of the mandibular arch to examine the anatomic
design of ea& 100th can also help the orthodontist to
cleady define which teeth can afford mwe reduction in
the interproximal areas.
The mesiodistal width of the maxillary incisors has a
major effectan the amount of posible mandibular anterior
slenderizing. If the maxiilary central and lateral incisors are
owrsiid and the mandibular incixirs are not espdally
large,' mandibular anterior slenderizing should no2 be per-
formed alone as this wuld increase the tooth size discrep-
ancY It is possible in such cases to slenderiie in botR the
maxillary and mandibular archa.
More commonly, the rnaxillary lateral hciisors are usually
found to be narrowr, mesidistally, than the ideal. This
canifition allows more enarnel reduaion in the mandibular
incisors.
The initiation of rndndibular interproximal enamel
reduction can occur at the begjnning of treatment or dur-
ing treatment (Fig 17-1a). Furtherrnore, slenderizing
remodels the mandibular anterior interproximal contact
points into broader contact surfaces. The larger interproxi-
mal contact areas hdp to maintain the mandibular anterior
alignment.
Sleriderizing is performed with steel carborundum
saips (Fig 17-It}, a diamand di*, or an air mtor hand-
piece. The diamond disk is used prirnarily m maxillary and
mandibular anterior teeth that are large and bell shaged.
The diamond disk removes enamel faster than carkrun-
dum strips, so it must be used with care, The abrasive
strips can be u s ~ don al1 anterior &&h. Ifind them easier
to use on crowded t e ~ during
h the early stages of treat-
ment.
fluoridated prophylaxis gaste is used M i l e slenderizing
is prformed (Fig f 7-1b). The paste increases the life of the
abrasive irrstniment because the paste becomes a part of
the abrasive surface. When the diamwd di& is used, the
paste mates a smmther enamel surface. A rough nirface
cwld tallect bamria, which might cause interproximal
Caries.
Treating the newly e>~posedenamd with Ruoride gel is
important because h e fluoride-rlch enarnel has been
removed, Having pehrmed this procedure on several
thousand patients as well as myself, I have never seen
i nterproximal caries develop.
In addition, the mandibular anterior teeth may be slen-
krized at the end of retention, imrnedtatdy foll~wing
removal of the fixed canine-t~ninereainer (Fig 17-2).
This praedure allows for future anterior and lingnial migra-
tion of the canines without concurrent mndihular anterior
relapse.
rig 11-1 mntienzrng p&ure (a} ~rowdedmandiouiar a r a requinng sienderiiring. Archwire is removed antefiorly for better alces,
W Prophyiaxispaste with fluoride is p k e d bebre the p r d u r e beglnrIntwproPiimalenamd redudion with a stet carbonindum strip (Dome).
fig 17-2a Aiter removal ot 3 x 3, gener-
ow mame1 reduction is peiformed with rhe
Dome stripper.
Compliance
Another factor to consider in the treatment of a borderline
case is patient cooperation. This type of case requires
excellent cooperation to achiew the desired resulb. When
such a case is to be treated, the pamts must be thwoughly
informed as to the treatment options a t the consultation.
In almost every situation, if the patient is willing to coop-
erare and is still growing, the case can be successfully
treated without extraction of the prmanent teeth. If,
however, the patient is not willing to wear the exttaaral
and intrwral appliancec as instructed, it may be best ro
perfom the extractions.
In my early years in orthcdontics, I had a tenckncy to be
toa idealistic and impose my beliefs on the patient and
parents, without prwiding alternative treatrnent choices.
However, over the years I have learned to be more reafistic
and to present al1 o p t i m to the patient and parents, If
Eig 17-2b lmmediately after slenderizing,
nate the Rat mtact surfaces from canine to
canine.
they are allowed to help make the decision, treatment
becomes more of a team effart.
There are times whwi treatment will begin without
extraction, but the patient is not ableto fulfill his or her part
of the agreement. As a result, extraaions must ultimately
be performed. ln nich instantes, ir is dtical that the ortho-
dontist ctosely monitor the progress of the patient. if not, 2
years,can elapse before the dinkian realizesthat extractions
are the only way to successfully complete the treatment.
By initially giving the borderlinepatient 6 to 9 months in
treatment, the orthdontist can detennine if the nonex-
traction therapy will be successful. If after that time the
progress is not suffkient, extractions are recommended.
Extraction choices in such cases are dixusxd in principie
18. A detailed desctiptim of treatment of brderline cases,
whicb often inciudes expansion of both ardes, will be pre-
sented in a future volume of this series.
 17 .UseN o n e x d o n Treatment When PossibIe
I
F I ~ S17-3a to 17-3c When exessive space is present a closing loop archwire rather than elastomeric chains is wed to consotidatethe rnax-
tllary h.
Typical Nonextraction
First, the maxillary arch is banded and bonded. At the
same appointment, a 0.01 4- or 0.016-inch nickel-titanium
archwire is placed to begin the process of unraveling the
crowding, correcting rotations, and leveling the arch. At
the next appointment 5 weeks later, the facebow is
placed, if needed, to k g i n sagittal and/or vertical skele
tal mrrection. At the third appointment, the initial wire
is replaced with a 0.016-inck round stainless steel arch-
wire to com~ imgroving the dental alignment a@
leueling.
If the maxillary arch has any spacing, the 0.016-inch aK1-i-
wire is formed with curve of Cpee (unless open bite) but
witkut omega loops. Elastomericchain is placed from first
molar to first molar to dose these spaces. As discussed in
principie 11, the arches should be consolidated eariy in
treatment. TRis pimedure is repeated until al1 sgaces are
closed in the maxillary arch.
Hower, mt wthodontists were taught nwer to dose
maxillary anterior spaces with mund wire k a u s e t k teeth
could tip. Thii is an excdlent point; ,h- the reality in non-
extraction cases is that wtien the 0,016-inch nickel-titaniurn
wire aligns the anter'ir te&, these teeth will flair slightiy,
possibly causing some spadng. lhe elastomeric chains will
then return the teeth to their original positioris, without
excesively tipping them or losing significant torque.
Ocaionally, if too much space is present to dose with
elactomeric chain alone, tha patient is treated as if it were
an extraction case, and the spacing is consolidated dista1 to
the la teral inciwrs. Then a closlng Imp archwire is used to
dose that space (Fig 17-3).
lf no spadng is piwent, omega lmps are placed approxi-
mately 1 mm anterior to the first molar tubes, and the arch-
wire is tied bxk. The approprii accentuated c u m of Spee
is placed in this 0.016-inch stainlñs *el archwire, depend-
ing on the patient's overblte and smile line, Tkc stainless
steel aKhwire k always heat W e d before it is placed.
The purpose of the 0.016-indi stainless steel archwire is
to eliminate any rernaning rotations, to consotidate the arch
by dosing al1 spacn,and to hdp in l d i n g the arch. Ijiing
back the achwire is aitical to afow the mbpedic effm of
the facebow to take place, If the arch is not ti& back or held
by elastomeric chain, the facebow can m- the first rnolars
distalb, opening spaces anterior to the molm.
After al1 rotatiom have been resolved and al1 spaces
dosed, the faciolingual inclination of the teeth (torque) is
addressed. In most situations, the faúolingual lndinations
of the anterior teeth are well aligned so that treatment can
proceed directly to the finishing 0.0175 x 0.025inch
stainless steel archwire. mis wire is always constructed
with omega loops so that it can be tied k k . The appro-
príate curw of Spee and final a ~ forrn h are placed in this
wire,
If the indination (torque) In the anterior teeth is not ade-
quate, it may be necessary to p k e a tramitional wire such
as a 0,017 x 0.025-inch nickel-titaniurn, 0.016 x 0,022-inch
staintess steel, or 0.017 x 0.025-inch titanium-waolybdenum
alloy. After 6 to 8 weeks, the teeth should be ready for the
0417 x 0.025-inch stainless steel finishing archwire.
In any Class II nanextraction case, treatment is initiated in
the maxillafy arch Rrst, for the following reasons:
l . Plaang brackets on the mandibular te& early in treat-
ment creates unnecessary acclusal interferences.

Traumatic ocduim, often the result of mastication
while the patknt consumes items such as hard f&,
ice, or chewing gum, can Boosen brackets andbr bands
and h k archwires. In a patient with deep bite, at the
outset, the overbite rnay be tea m r e to altow the
rnandibular dentitial to be h d e d without dental
impingment.
2. As the maxillary arch imgroves, the mandibular cuwe
of Spee irnproves naturally.
3. If a bite plate is needed in gatients with deep bite, it
fits better and is more comfoítatile after the maxillary
arch has been properly aligned,
4. The original, untreatedmandibular arch form is main-
tained longer. The undisturbed mandibular arch can
k used as a guide for developing the maxillary arch.
5. In most instances, only 6 to 9 months, from first to
last archwire, are required to treat a mandibular arch
without extraction. Even an extraction case should
not require more than 1 year of treatment.
6,More time is allowed for mandibular secmd molars
to empt. This approacb rnakes it more likely that
these teeth can k banded at the outset oF mandibu-
lar arch therapy.
Mandibular aKh treatment usually is initiated 4 to 6 months
after maxillary arch treatment has begun. When the maxil-
lary arch is under control, the mandibular t e t h are more
fully erupted {esperialiy second molars, if possible), and the
mandibular orthopdic response is taking effect. The
mandibular arch is now ready for appliance placement.
Treatment in the mandibular arch is not always
delayed. The rule is to band and bond the mandibular
arch when the canines are in a Class I relationship. This
means that Class 111 gatients and Class I patients with
bimaxillary protrusion rnay begin treatment in the man-
dibular arch early.
When the time comes to begin treatment in the
mandibular arch, ernghasís is given to controlling the ante-
rior teeth immedialely. The mandibular arch should be
treated aggressively from the day it is bonded and banded,
If possible, a 0.077 x 0.025-inch braided stainless steel
wire or a rectangular nickel-titanium wire is placed as the
first archwire, to eliminate rotations and begin leveling the
arsh while maintaining torque control in the anterior den-
tition. The archwire selected is depencknt on the degree of
crowding. In a routine case where there is l e s than 4 mm
of anterior arch length discrepancy and the goal is to hold
the incisars in their original gositions, the aforementioned
scenario will suffice.
Class Ii Division 2 Mechanics m
A greater discrepancy or the need to upright the incisors
rnay require one or both of the following:
1. Slendering f o l l d by a 0,016 X 0.022-inch nidrel-
titanium wire or a round 0,016-inch nickel-titaniurn
or stainless steel archwire
2. Controlled use of class 3 elastics
After 2 to 4 months, if needed, a rectangular titanium-
molybdenum alloy wire ora 0.016 x 0.022-inch stainless
steel wire is used as an intermediate wire to continue
toque control, correct rotatbns, and for leveling, These
wires are constructed with omega loops and tied back to
eliminate dental drifting and space opening. In most cases,
a reverse curve of Spee is incorporated to help leve1 the
mandibular arch.
At times, if the initial braided stainless steel wire has
performed nearly a l the required alignment, leveling, and
rotation correction, the finishing archwire (0.017 x 0.025-
inch stainless steel) is placed immediately following the
braided stainleiis steel wire.
Class 2 elastics andror midline elastics are emplayed
after the finishing archwins (0.01 7 x 0.025-inch stainless
steel) are in place on both arches to finalize any Class IIcor-
m'on. The total treatment time, depending on growth
and compliance, is approximalely 18 to 24 months.
Class 11 Division 2
Mechanics
Most Class II division 2 patients exhibit more dental pmb
lems than sagittal skektal probfems. Often, hswewr, there
exists a wrtical maxillary deficiency. When smiling. the
patient does not show an adquate display of dinical m.
The first step in treatment is to change the Class II divi-
sion 2 malocclusion into a Class II division 1 relationship.
This action is initiated with a 0.Olbinch nkkel-titanium
wire for several months. A O.Oló-inch stainless steel arch-
wire follows for 2 to 3 months to provide space closure, if
needed, and continued leveling and arch f m imprwe-
ment. The maxillary central inciso^ that wen originally
indined lingually are tipped labiallyby tbese archwires until
they are aligned in the maxillary arch. tn most cases, a fin-
ishing 0.017 x 0.025-inch stainless steel archwire with an
accentuated curve of Spee is then placed.
At that time, a bite-openíng apgliance rnay be inserted
in the maxillary arch. Mast Class IIdivision 2 gatients have
deep bites and iow anterior facial height. The bite plate
1 17 Use Nonextraction Tmtrnent When Possible
constructed after final maxillaty ardi form is
created, a1lwvii-qa more accurate fit.
allows the mandibular prern&f$ ahd molars t~ exkurie,
helping the arch to level, the bite to open, and the profile
to impme (Fig 17-4).
Class II division 2 patients also generally h w e a signifi-
cant cunie of Spee in the mandibular arch (Fig 17-5; sw
also Fig 14-1). As the patient occludes on a bite plate, only
the mandibular indsors come in contact with the bite
plate. This preswre applies an intrusive force to these teeth
and atlows the prernolars to begin to erupt spontoneously.
The remainder of the maxillary aKh treatment is identi-
cal to treatment used in patients with a Class II division 1
relationship. However, further differences remain in the
mandibular arch.
ln Class II divicion 2 patients, the rnandibular imisors aie
often pacitioned too far lingually and h m tu be gosjtioned
more labially. When this c d i t i o n occurs, a rectangulitr wire
with the -S-degree mandbuIar incisor bracket toque will
amally create an anterior fme on the teth and result in a
mesial movemnt. The advancemcnt can m m e t i m be
!accomplished wkh round wire rather than rectangular Are.
This produre negates the -Edegree toque built into die
mandibular anterior bracket i l o t ~
A possible wire sequence is a 0.01 Binch nickel-titaniwm
:ard.iwire foklowed by a 0.01Gnch stainless steel round
wire with no stops and a Iarge reverse cuwe of Spee. fhe
:finisRing wire may be a 0.016 x 0.022-inch staintess steel
wire rather than O.QI7x 0.025, sa that the built-in bracket
4orque is minimal. Appropriate reverse curve is placed Ni
$bis wire.
In divlsion 2 patient.
Open Bite ~ e c h d c s
.- -L -
Certain variations in bracket placernent and treatment
sequencing can help the treatment of open bite malocclu-
sions. The anterior brackets are placed more gingivally on
those rnaxillary teeth that are out of occlusion. The brack-
ets are p l x d more occlusaliy on the posterior teeth that
are in ocdusion, Also, the mandibular first molar buccal
tubes are set at O degrees of tip rather than the. custornary
., .. , ,
-6 degrees.
Often in open &te cases, there is no advantage'in delay-
ing treatment In the mandibular arch, Treatment in the
mandibular arch can begin at the same time as or soon
after bonding in the maxillary arch.
Vertical b x elastics can usually k w r n early in treat-
ment, and the patient is prescribed squeezing exercises.
Conclusion
ln~n6neitYráaion therapy, treithientls usuaiiy initiated in
the maxillary arch; then, severa1 months later, the
mandibular arch is treated aggressively. Treating the
maxillary arch first estabiishes the ideal arch fonn early.
Because a major goal of nonextractlon treatment is to
control the posirion of the mandibular anterior teeth,
the total focus of treatment can then be directed a t
these teeth when the mandibular arch is banded and
bonded.

The mandibular anterior teeth are controlled by:
1. A -5-degree toque in mandibular incisor bracket3
2. A -6-degree tip on mandibular first molars
3. An initial, flexible rectangular archwire
4. Slenderizing, if neci-ssary
5. Claa 3 elastics, if necessary
The pattern is to treat the maxillary arch to its ideal fom
and then do the same to the mandibular arch. Orthopedic
forces are applied as needed early in treatment, After two
ideal arches are created, they are cwrdinated with maxil-
lomandibular elastics.
üetailed dexriptions of PRe treatment of deep bltes,
open bites, and Class Ill malocclusions will be included in
subsequent volumes of this series.
Principie 17 Case Smdy
UV&W
Haa
-:% . l twt$ aiipatient early-ia.*
+.ra.
career, I w l d have Spee to level the arch and open &e &@.$lasi & @ - $
exttaaed!themaxí/~a'~firstpremel~rsand~emandibular
second premolars. Today, with the sirnyln mechania aod
stabilty of this heatment it is aiways a r - , -.A
-
a+ u.-
Ewmination and k p o s i s
This 14-year-old girl presented with a mild Class II but a
swere division 2 malocclusion. Her molar relationship
was e n d a , and she exhibited a 4-mm werjet and a 5-
mm overbite. The midline was shifted 2 mm r n r , t o the
right. The maxillary and mandibular incisors tipped lin-
gwlly. Moderate crowding was seen in both ardies. T k
nyndibular left centrat incisor had severe incisal attrition
of almost 2 mm.
. Tredtmentphn
Nonextraction therapy with a cervical facebow was rec-
ornmended. The patient's treaúnent fallowed the typical
mechanics for this type of malacclushn. The maxillary
Principie 17 Case S tudy m
1. Adkins MD, Nanda RS, Currier GF. Arch peflmeter changcs on
rapid palatal expandon. Am J Orthod Dentofacial Orthop
1990;97:194-199.
2. Chung CH, Font B. Skeletal and dental changa in tha sagittal,
vertical, rind trarinierse dimensioris after rapid palatal expan-
sion. Am J Orthod ümtofadal Orthop 2004;126:569-575.
3. Sparks A. lnterproximal Enamel R e d d o n and Its Effect on
the Long-term Stability of the Mandibular lncisor Position
(thesii). Bimingham; Univ of Alatiama, 2001.
$
\: 7 -.
arch wis tkated first to deveiop g m i incisai tmue.mT
mandibular a ~ was h then treated using revet&;cy@''E2
and finishing.lelasticswreworh the'last 7 mofi&$,. - ..
active treatment. -r
,
d4
a 4
Ukcussion ,
A declsion war m a b to resolve the attrition problem by,
F
extrvding the mandibular flghtccentdincisor. This can be!
abserved wheri looking at the Iinguál bonded canine-t+
canine retainer. The wire had -be bent around the anf
gulum of that tooth.
This b a gmd example where IMPA can be advan
to achieve a better interincical angle and improve u
patient's mft tissue prrifile.
Ev~htbn
When we can combine good growth, excellent patient
compliance, and proven mechanics, these results can be
predicted and achiewd routinely.
I - 17 Use Nonextraction Treatment When Possible

Fig 17-6 Pretreatment facial vi% [U) n VI 1101 view: nice symmetry. (4
age 14 years, 1 month. (a) Soft tissue profile: slightly protrusbe upper 11~.
M i l e has great wtential,

Fig 17-7 Preueament intraoral views. (a) Right d e : end-on molar relationship. lb)Frontal view: 5 mrn oveiwre; rnicllJll~shift, lower llylmL
by 21- mm, (4 Left si& viw:Maxillary left first premolar 1s in re- te;..,, ,., > . qr.$l,aCI,
..rh • FT

I
Fig 17.8 Pretreatment ocdusat views. {a) Fig t 7-9 Pretreatment cephalometric trac- Fig 17-10 Pretreatment panmmic radi-
Maxillary arch shows moderate aowding and Ing. agraph.
an m i d arch fom. (6) Mandibular arch has
a 4-mm arch length disuepancy and the riiht
central incisor shows severe incisal attrition.
 Principie 17 Case Smdy m
Principie 17 Case Stiidy E 1

Figs 17-11a to 17-11c Three months: 0.016-inch SS archwire with omega loops and curve.

Figs 17-12a to 17-12c Seven months: maxillary 0.01 7 X 0.025-inch SS fínishing archwire; rnandibular 0.01 7 x 0.025-inch NiTi archwire,

Figs 17-13a to 17-1 3c Fourteen months: 0.017 x 0.025-inch SS finishing archwire in both arches. Note midline and overbite imprwements.

Figs 17-14a and 17-l4b Three-month Figs 17-1 5a and 17-1 5b Seven-month Flgs 17-16a and 17-16b Fourteen-month
ocdusal view: maxillary arch is treated firit. occlusal view of maxilla; four-month occlusal occlusal view finishiy archwires. Note the
view of mandible. slght discrepancy caused by ttie attritiwi wi
the mandlbular right central kisor.
 17 Use Nonextraction Tmmienr Whm Possible

Fig 1717 Rnal soft tissue views, age 15 years. 8 months, (a) E x c e h t Asian proflle, m) Balanced, rebxed rnusculatur~(d Smile is al1 enamel.

Figs 17-183 to 17-18c Final occlusion: Overbite and werjet are normal, ciass I occlusion; mldline is dightly oft.

Fíg 17-19 Final occlusal viewc. (a) Typical Fig 17-20 Final cephalometric tracing. Fig 17-21 Final panoramic radiograph,
ovoid arch form. 0)Bonded 3 x 3. Note
wire adapted to tMc!er labiolinguat right
-... .... incisor.
central
, .. ..- . . .
 Principlc 17 Case Study m

Figs 17-22a to 17-22c Three-year posttreatment views, age 19 yeaB The appearance is gening k t t e r with age.

Figs 17.2% ta 13-23~ArtMc rewntouririg on kisl edge of centrd incisors.

Force m Duration

Magillary Cervical facebow 9

1. Q;Dl6NiTi 3 Elastia
2.0:01655 3 Ciass 2 5
finishing ebstics 2

Mandibular
None 3
1.0.076 NiTi 2
2. K017 % 0.025 NiTi J
3.0.01 6 X 0.022 SS 4
4.0.0 17 X 0.025 SS 7
Active t r e a t m t time: 16 months

Figs 17-24a and 17-24b No changes in fig 17-25 PretreBtrrzent and pwt-
occlusal a ~ foms.
h -en t 0aphidamtnctraung m p a r -
ison shows mical stability while maxillary
and mandibular a m h eorqut?remiahs pmp
eriy comlled.
 ..
S:. . .. PRINCIPLE

Use Extraction
Treatment When
Necessary
"Let m one be ashumed to say yes today $yestm&y he said no.
Never to have changed-what a pitiuble t h g of whiCh to boastl "
- JohannWolfgang von Goethe

roughout the history of orthdontia, the pendutum
has swung back and forth regarding the extracüon of
permanent teeth. Clearly, it Al1 never swing back tward
the percentageof patients being treated with eKtractions dur-
ing the 1950s and 196Qs.
In addition to the bonding of bradrets, rather than the
placement of bands on each tooth, another m e t h d to
gain space is interproximl enamel reduction, If techniques
for transveae expansjon are used, 6 to 7 mm of arch
length can be gained in selected patients. Therefore, with-
out question many patients who would have been treated
with 'extractians i i ihe past will be treated without extrac-
tions today.
The problern now appears to be that some orthodon-
tists have the attitude that evety patient, regardless ofthe
swerity of crowding, should be treated without extrac-
tions, even though the teeth might be placed in unstable
positions; these clinicians contend that lifetime retention
can resohe this problern, Granted, come patients' treat-
ment must be compromised when the choice is ktween
esthetics and stability. Happily, this situatiún does not h p -
pen often.
It is true ttaat extraction of any permanent dentition dur-
ing the course of arthodontic treatment shwld be avdded
whenever passible. Howe\rer, rny experiwice suggests that
approximaely 20% of orthodontic pabents require extrac-
tion of some permanent teeth (other than third molars).
Diagnosis
Two types of malocclusion almost always require premalar
extractians. tn the first type, patients with extreme man-
dibular arch length discrepancy have more tooth mas than
the dental arch can accommodate (Fig 18-1). Regardlessof
the mechanics used, it wwld be impossible to gain an ade-
quate amount of space for the dentition to be properly
aligned in the arhes without extracting teeth.
T k mandibular arch is most often the limiting factor in
this type of case. In most growing patients, if the rnandibular
1 18 Use Bx&ofi Treatment When Necmsaty
Flg 18-1 Extreme mandlbular arch length
discrepancy normally requires extrattiúns to
create space,
arch can be treated IhEithout extraction, so can the rnaxil-
hry arch. The only routine exception is in a nongrowing
Class II patient who does not want surgery. The mandibu-
lar arth may be treated as a nonextraction case, h i l e the
rnaxillary prernolars are extracted. Thls treatment elirni-
nates any overjet; the rnaxillaty canines are rxeated until a
Class 1 relationship is reached, while the malars remain in
a Class II relationship (see Principie 18a Case Study).
Although it is possible to correct an end-on molar rela-
tionship C n some patients, it is impractkal to attempt sig-
nificant distalization of molars in most nongrowing
patients.
The smnd type of malocclusion that alrnost ahays
requires premolar extractions is severe bimaxillary prag-
nathism, In these patients, h e mandibular incisors are
indinedso far labially that the patient carrnot cioce his or her
lips, and the profile is fithetically unappealing (Fig 18-2). In
cases, first grernalaa are extracted from boh arches
to mate spxe to retract the maxillary and mandibuhr ante
rior teeth into more esthetic ~ositions.Generally, in a patient
with birnaxillary prottusion, h e indsors can be k ~ e sig- d
nificanthwithout causina the face to "dish in.* Class 3 elas-
t i a are Dften used to ~ecracth e mandibular anterior teeth.
In any extraction cwe in whi& the possibility of a post-
treatment concave soft tissue profile appearance exists,
extraction of the rnandibular second premdars should be
considered. This extraction pattern allows for the ctosure
of additional extraction space from the posterior, which
prevents the mandibular incisors from moving as far lin-
gually. This treatment regimen may require clss 2 eiastics
Fig 18-2 Convex soft tissue profiie caused
by flard maxlllaty and mandibular anterlor
teeth.
during dosing mechanics irr the mandibular arch to
advance the molars, and it is often successful in patients
exhibiting slight pretreatment facial ccinvexity and thin
attadied gingival tissue.
OtbeB.
Over the years, t have extracted many differerit teeth for
different reasons. Moct often, these extractirins haw been
perfwmed in adult patients,
A single rnandibular incisor extncüon may be an
aceptable treatment option when severe mandibular
crowding or flared inlisorsare present in a patient who has
a full Clasc I mdar tendency and small maxillary lateral inci-
sorc. Oetailed discussion of this topic will be presented in a
subsequent volume in this series.
Managment ofthe
Exmd.don Patient
Bsause of the excessive number of extraction cases treated
in the past, the publk níay be wary when the orthodontist
recommends the extrxtion of twth. At the initial appoirit-
ment, a visual examination can determine whether the
patient is like!y to wquire extrartion. If the pdlern rnay
Figs 1&3a to 18-3c Canine' retractim on O.01Mnch stainks steel cuwd archwire wlth power h...-.
require extractions, this information 1s relayed to tfie par-
ents and patient immediately. The patient and parents are
then prepard if the final prefetred treatment plan indudes
extractions. As with every patient, intraoral phoiographs
are presented at the consuitation to illwtrate the uowd-
ing. it is usually obvious to the family that thwe is no room
for al1 of the teeth. The precise teeth to be extracted are
then indicated,
If the patient exhibits Mrnaxiltary prognathism, the
patient's soft tissue profije is emphasized on the bteral
view facial photograph and an the cephalometric tracing.
he severe flaring of the incisors is shown. The famiiy ¡S
told that after the premolars are removed, the incisors kn
be uprighted and retracted to achievs a more balanced
face and a more stable dental relationship,
The patient and parents must tx involved in the extrac-
tian treatment decision. If the patient or garent is reluctant
to accept extrxtion treatment, the advantages and disad-
vantaga of each treatment option are expbined, For
patients w ith birnaxillary prognathism, there are thne
advantages to treating the case with extractions:
1. lmprwed long-term stability of the teeth. The teeth
can be straightened without extractions, but the
diances of relapse are extremely high.
2. Cosmetic appearance. Without extractions, the
results will not be as esthetic a t the end of treatment
kcause the twth will be protruding fartha fian
they should.
3. The heaith of the teeth and gingival tissue. If the
mandibular anterior teeth have to be advarrced to
avaid extracticxis, it is possible they could actualiy be
pushd into areas in wtikh tess h e and penodon-
tal tissue are available,
After al1 is said and done, the best way to demonstrate
the advantaga of extractions for patients with bimaxillary
prognathism is to show facial pbtographs of another
patient to demonstrate dramatic profile chanps before
and after treatment.
After these facts are presented, if the response to
extraction treatment is stlll negative, it is important to
write the family's dedsion on the treatment card and ask
the paren& to sign ít. TRus, the famlly has been infomed
of the potential risks and limitations of nonextraction
treatrnent and has consented to the alternative treatmmt
option. This pracedure is a safeguard for the orthodontist.
Typicd Bxtraction
In treating grawing children, the orthodontist must always
keep in mind that patients are "moving targetc." Whether
an extraction OF a nonextractioncase, tthe patient is a new
person at every appointment. First, he or she is growing;
second, ortkoriontic and orthopedk rnechanics are affect-
ing the teeth and h e f a . Although step-by-step instruc-
tions for treatment are provided in this book, aheratiuns in
these procedures may be neessary from visit to visit,
depending on the patient's response. The principies are
grwided; they must be applied to the speufic needs of
ea& particular patient:
Extract al1 premlars at beginning of treatment.
lnitiate treatment in the rnaxillary arch.
Ensure early retraction of canires into a Class 1 rela-
tionship (Fig 18-3).
Delay treatment in the mandibular arch until the
canines are in a Class 1 relationship.
Allow the mandibular anterior teeth to drift
("driftodontics"). The exceptions to this rule include
adults and patierrtr with Class IIIocclusions. Ofien, the
mandibutar arch is bracketed early in treatment in
these cases.
 18 Use Bxtraaion Treatmmt When Necessary
Fig 18-4 Lw-Mctian, figure-eight tigature FCg 18-5 Accentuatad curve of Spee,
tie. 0,016-inch stainless steel with omega loops.
Initial archwire
As in nonextraction cases, in extraction treatment the ini-
tial rnaxillary archwire is usually a 0.016-inch nickel-tttaniurn
wire. Because extraaion patients often exhibit more inithl
crowding in the rnaxillary arch ?han do nonextraction
patients, this flexible wite is oflen used for one to two
additional appointments. mis archwire will correa the
aowding, reduce the rotations, and k l g leve1 the teeth.
Because the point of least resistan= is toward the extrac-
tion site, there is little flaring of the incisors as they align.
Most of the tooth movement is Into the extraction sites. To
make this even more effective, the special low-friction lig-
ation (Fig 18-4) can be placed on those teeth that need the
greatest amount of movement.
Second archwire (canine retractkn)
The secoiid archwire Is a heat-treated 0.01 6-inch stalnless
steel round wire with omega loops. An accentuated cuwe
of Spee may be added to help i m p m or maintain the
overbite (Fig 18-5). The purpose of this wire is to continue
a ~ leveling
h arid eliminate rotations. In addition, this is an
excellent wire for retraction of rnaxillary mines. The distw
buccal segmene of the archwire entering the first molar
buccal tubes are h t parallel to each other (Fig 186).
These bends, along with the 15 degres of dista1 offset
built into t8-ie first molar tubes, will rotate the molars disto-
buccatiy. This will provide cortical anchorage because of
the position of the mesiobuccal m t s of the fiwt molars in
the buccal cortical plate. This anchorage is sufficient to
allow the canines to be moved distally while little or no
anchórage is lost. Sekdom is a transpalatal arch or facebow
needed for anchorage.
Maxiliary canine retraction has several advantages wer
en masse retraction:
Fig 18.6 Maklng ttie tifstal ends of t k
archwire parallel to ea& other wlll rotate the
maxillary ftrst rnolars easily and accurateq?
Canine rettaction can be initiated as eady as 2 to 3
rnonths into treatrnent, rather than a t the time of dver-
bite correction.
There is less anchorage strain and, therefore, no need
for a transpalatal arch.
Later retractiún of the four maxiilary indsors, as a unit,
will control torque much better than en masse move-
ment of all six anterior teeth.
The amount of space clmre is wry predictabk when
cbsing loop are w d , allowing symmetnc movement
on bath sides.
€anins positwing
Maxillary canines are ~etractedbefore the incisors. As just
mentimed, there are several r e a m s for this pmedure.
First, there 1s greater control over molar ancbrage. Only
the canines are pittedagainst the premolars and molars, as
o p p d to al1six anterior teeth. When al1six anterior teeth
are opposed to four posterior teeth, there is a tendency to
lose posterior anchorage. hcond, because h e canine has
the latgest root of any taoth in the mouth, it is important
to gosition it as quickly and accurately as posible. The
basic goal in this eady stage of treatment is to move the
canines into a Class I relationship. A f t e ~that bsk has been
accornplished, if is a matter of bringing al1 of the remain-
ing teeth tagether, as the final occlusion is built araund the
canine position.
Canines can b e retraaed appmximately 1 mm per
appointment, wery 4 to 6 weeks. Complete canine retrac-
tion requires 4 to 6 months on average, Elastomeric chain,
attached on each side of the arcb from first molar to
canine, is used for canine retraction (Fig 18-71, Normally
the 'short" elastomeric chains are used. kiitially, if there is
a greater distance frorn the first molar buccal tube ta the
canine bracket, four segments of chain are used; other-
wise three segments are ideal.

6 8 - 17 When recond rnolars are banded, U place omega lwpr dista1 to the first mobr bracket {a-),
aaivate archwire. (4Archwire is aaivated after belng tied back
5 -
Flgs 18-18a and 18-18b Example of different dminbp,,
As in the maxillary arch, the closing loop shauldbe arti-
vated approximately 1 mm per appointment. Often, if a sig-
nificant cuwe of Spee exists, t k eMng loap b not activated
when the wire is engaged for the first time, which allows
the archwire to initially serve as a lewling archwire. In the
mandibular arch, closing lmgs are required for less time,
usually a total of 4 rnunths, than in the rnaxillary arch
because there is less extraction space after the drifting
phase (Fig 18-1 8).
Occasionally in a severe arch length dixrepancy case,
unraveling of the cknüüon leaves an extraction space of
only 1 rnm or less. In these instánces, rather than using a
closing b p wire, final space docure can be accomplished
with a 0.016-~KR stainless steel round wire, with a re-
cunie and elastomeric chain attached from first molar to
first molar.
In previous artides that appeared in orthdontic jour-
nals, I advocated the use of other types of loops tto close
mandibular extraction sites. Over the years, 1 have used vir-
tually every tyge of loop ever designed. All of them wark.
A praaitioner can be quite successful wing several types
of clming loops. In particular, I used bull l w p s for years,
and they were very effective. However, I have changed to
teardropihaped Imps prinapally because there is more
archwire in the loop, resulting in less discomfort for the
patient when the loop is activated.
Typid Extraction Mechanics m
and (b) tie back omega loop to
designs on same patient.
Finishing archwire
After al1 the spaces in the mandibular arch are ctosed with
the closing loop wire, the 0.017 X 0.025-inch stainless
steel finishing wire is placed. This wire ¡S identical to the
finishing wire used in nonextraction cases.
Often in an extraaion case, a large cuwe of Spee is
present in the arch after spaes are dosed. It may then be
difficult to engage !he routine 0.017 X 0.025-inch finish-
Ing iirchwire, An " intermediate" wire, 0.016 x 0.022-indi
stainless steel, can then be used to k g i n Ieveling. Also, if
iz is not feasible to place the desired reverse cuwe in the
archwire, tt may be added at subsequent appointments.
Two or t h r e months later, the archwire is removed, and
the reverse cuwe of Spee is increased, always tied loa&.
This tieback procedure is very important, If a reverse curve
is placed in the archwire and not tied back, anterior fiaring
and spacing rnay occur.
If the second molars are bnded, omega Ioops are bent
approximateiy 1 to 2 mm mesial to die second molar tu bes
tu allow tieback. The stainless steel archwires are always
heat treated,
Elartics
Ac detailed earlier, selected elastics are used to coordinate
the arches and finalize the ocdusion.
1-
18 Use Extraction Treatmerit When Necessary

Condusion
Even though the use of extraction therapy in orthodontia
has dedined dramatically oirer the last 40 years, in a select
number of patients the laeed still exists, TRe question gaes
beyond whether or not to extract. lhe most Important deci-
sion ¡S to determine where ir the most esthetic, funaional,
and stable dental positions for the individual patient. lf
extractlons are necessary to achieve this goal, so be it.
Some colleagues have speculated that one reason the
number of extradion cases has declined so sharply is the

Prhciple 18a Case Study

OVWV~W

lar arch.

&dmikdOfl d d
. A

d2psi~
..
A special opportunity 6xists when a -nongrowing z
presents with a protrusive maxilb but a good .ma'nc
-

,
den

Our .advice was to extract the rnaxillary ...A premolar,

and the >remaining;third mzrlars; -howevgr, the patient
refuced to Raw her third molars extrack ihe canines
-
+->-

2.0.017 x 0.025 $5
Active mmt time:
dapter, if studted canfully, will

results of nonextraction.

&U!$

*
7
,
. .+,
2
.
-

-
,
+A

.-*J
.

+,
difficulty of extraction mecbania. It is hoped that this
demmstrate the simple
sequence of archwires that can be used to produce fin-
ished occlusion that is every bit as- high in quafity as the

Y-
-. -

be finkh~d:ih *ci--!I olavonrhip and the rnolan

in.a Class IIrelationship

The maxillary molar bands fiad special placement to give

a Ctass II rotation for better final ~dusion.Class 3 elas-
tics were used to advance tt.ie maxillary mdars while con-
~ ~ a k Lthe
A 2ó-year-old wornan p r ~ e n t d ~ w i w i t ~ y l r k g i l e ~ ~ ~trnlling
Jendency but edge-toledge miar relati~nshii;rs:
~ l mandibular Incisors (IMPA). "Squwzing"
exercises rep~ibedthroughouttreatmenttohelp
In ceritric relation, she had an overjet qf 47 1mrn.4naan , control tt lpen bit
overbite of O mm. The maxillary:indsors wewgtremsly

,e-*
The'shft tissue profile was nicely improved. Final ,occlu-
sion showed imprwed overjet, owrbite, and buccal
occlusion. By rotatlng the rnaxillary molars distobuccally,
the distobuccal cusps fit nicely in the ,!&el central
g m of the mandibular molars.

17
$0 mmtb
Y + i h
 Principie 18a Case Study m

m, 10- 13 facial views, age 26 years, 20 months. (al Soft tissue profile showing mnvex profile with protrusive lips, Cb) Frontal
rieueauiieiit
view shows strained lips on chure. (4 Smile shows p~tpsj_i_i$gg.gd, mipor gingival evosure.

Fg 18-20 Pretreatment intraoral views. (a) End-on molar relationship. Ib) Ovejet, 7 mm; overbite, O mm. ld tnd-on molar relatjonship,

'.. .., ir.

:.
.,:,
m . .
'1 <
, , <

Fig 18-21 Pretiearment ctdusal viowi. (a) Fig 18-22 Pretreatment cephalom*ric trac- Fig 18-23 Pretreatment panoramis radie)
Maxillary tapered arch fom. (NMandibular ing shows severe flaring of the maxillary ind- ograph.
ovoid arch form with minor crowding. MIS with open bite.
 1S Use Extmctiod Tmatmerit When Necessary

Principie 18a Case Study 1

rig 1 4 ~ ~rlnal4 racial vi- (a) Soft tissw profile shows miama nose, iips, and diin. (b/ h t a i view s t r reiaxea
~ iips on aosure. (Q
Despite e x m i o n of teeth in the maxlilary arch, the buccal cwridors are nicely filled.

Figs t 8-25a to 1&2Sc Ffnal i n t m a l views. Ocduslon shows Class 1 canine and Class II molar relationhips with normal midline, mrbite,
ami mrjet.

Fig 18-27 Final cephalometric tracing. Fig 18-28 Pretreatment IbibcW and final
(reo) aphalometic tracing comparison.

Figs 18-26a and 18-26h Find occlusal

m.Maxilfary mid arch fm with f i ~ ~
molar$ rmtd for Class lt dusion. Fig 18-29 Fmal pmoramic radiagraph.
 Principie 18b Case s u i d y a

Principie 18b Case Study 4

 18 Use htraction Treatment When Necessary
m

Principie 18b Case Smdy 1

Fig 1 % ririrwrrr~iit
~ facial views, age 9 years. (4Severe rnaxdlornei~u~vuu~
~ I U I Iubion. (b) Symmetricfrontal view, which appears strained
on lip dosure, (c) Normal smile,

Figs 18-31a tc , ,-31c Pretreatment intraoral views. Class I occlusion with anterior spacing and rotation of the maxiliary left lateral incisor:

rig 18-32 Pretreatment occlusal views. fa) Fig 18-33 Pretreatment cephalernetric Fig i a-= rretrearmenr panorarnic raoio-
Maxlla shows supernumerary 100th lingual tmcing shows sewfe anterior protrusion. graph.
to the left lateral incisor. (B) Mamlible shows WiU analysis woufd show a Class 111 skeletal
normal develapment. pattern.
1Priiiciple 18b Case S N d y 1

Fjg 18-35 Phase l posttreatment facial views after 12 m t h s age 10 years, (al Profile remains sewrely protruded, (b) Strained rn~sculature
.. . . (4
on,, closiq. . Nice smile.
-.. ..

FIgs 18-36a to 18-36c Phw I posttreatment Intraoral vi- All views s h normal occluslon.

2.0.016 SS 4
3.0.017 X 0.025 SS 5
Actiw treatment time: 10 months

Figs 18-37a atid 1837b PRase I post-

treatrnent occlusal views. kmal arch foms
wi$i mmor crowding in the maridibularanter-
ior.
 18 Use Extraction Treamient When Necessary

Priiiciple 18b Case Smdy 1

.. .
.
t.'
\ .?
Phase I I prareatrnent facial views, age 12 years, 9 mttis, reveal yrotrusive profile, large lips, a d a nice mile.
Figs 18-38a to 18-~OL

Figs 18-39a to t 8-39c Phase II prematment intraoral views. Ocdusion is normal.

&nrAm fla e h w 9
1.0.016 NiTi 2 Ei&kb
2.0.016 $51 12 F M n g ektím 2
3 , O d I T X 0.025 TMA 5
Ct&ng loop
4, D.017 x 0.025 Nrri 3
5. 0.016 $5 4
A& treatment time: 26 m t h s

1 Mzbular

1.0.017 X 0.025 4
S

CuNiii

L 1
Figs 18-40a and 1840b Phase II pre-
2.0.016 X 0.022
CiMingimp
3. 0.017 x 0.025 NiTi
9

1
treatment occlusal views. Good mid arch 4. 0.017 x 0.025 SS 7 Fig 18-41 Phase II pretreatment panoramic
forms and a minor arch length dimpancy. Active t r e m t time: 2 t months rwP@'.
 ~rinciple18b Case Study m
r Priiiciple 1% Case Study

Figs 18-42a to 18-42c Phase 11, 5 months: lntraoral views show typical canine retraction with 0.016-inch stainless steel archwire.

Flgs 18-43a to 18-43~Phase 11, 10 mrinths: lntraoral wews show hliy retrmed canines in th maxilla and 0.016 x 0,022-lnch stainless
steel dosing loop in the mandible.

Figs 18-44a to 1 8 4 Phase

~ 11,18 months: Inttaoral views. Maxilia:0.0 17 x 0.025-inch TMA T-loop; mandible:0.016 x 0.022-inch stain-
less sted closing loop.

Fig 18-45 Phase II occlusal vWs of the maxilla and mandible at la,bl 5 months, Icdf 10 months, and (e,t3 18 months.
Fh@s 18#a to 1846c Rare II final facial vi-,
rri
I
I

age 14 pan, 11 mnths.Balanced profije, W e r reiaxed iips, ana "aii-enarne mile.

Hgs 18-47a to 18.47~phase It final lntraoral viwrs. Normal Class Ibucal ocdusion, overbite owrjet, and mibRne.

Fig 18-38 Phase II final ocdwal viewc. (a) Fig 1 D ?ha$ H finzll pnorarr
Maxillaty ovold ard h. &) Mandibular graph mparalle! reats at m n nrez
fixed retainer extends to the amnd premo.
lars to maintain space dosure.
 Principie 18b Case Study m
-.- .. .

I>ririciplr 1% Case Stiidy

Fig 18-51 Fourqar postb-eatment fadal vi* age 19 years, 3 monthr (a) Balan& soft t i profile. 0Symmetric frontal wew.Id Great smile.

Fus 18-52a to 18-52c Four-year posttreatment intraoral vlews, tmproved buccal ocdusion, stable avemire, ana s w e oveqet.

Figs 18-53a and 18-53b Four-year post- fig 18-54 Phase I pretreatment and phase 1 posttreahnent (red) qhalomettic uacing
treatrnent occlusal views show stabillty in comparison shows ihe changes in inciwr positbns and soft tissue proles
arch forms.Third molars erupting.
Careful Appliance
Removal, Then
Retention Will
Improve Stability
'Tbeyears teach m ~ c thar
h the &y nmm knows."
- Ralph Waldo Emerson
A
spedfic retention plan that incocporata sound
retainer design, a re'easonabletime sequence, and rer-
olution af ttie third molars will improve the chances
far long-term stability.
The longanticipated day finally arrives-the day the
appliances are removed, It is a day of celebration, This
appointment can be a positive, memorable occasion for
al1 concerned,
First, the brackets are remov@dwith direct bond
remover pliers (Fig 19-1), and bandc are removed with pos-
terior band removal pliers (Fig 19-2) {Hu-Friedy}.
The use of special magnifying eyeglassesduring debond
ing procedures ic rtrongly recornmended fig 1 9-3). These
magnifying loupes enlarg~the area and enabte the practi-
tioner ta better perform the necessaly tasks, and they pro-
vide eye protection. Théy can also be used to great aduan-
tage (r'egardless of age) when brackets are bonded and
when interproxirnal enamel teductian is prfomed,
After the bracketc are removed, the excess adheive lis
removed with a multiflured carbide finishing bur in a high-
speed handpiece (Fig 19-4). Polishing cups are then used
to remave any stain and to polish the enamel (Fig 19-5).
A diamon-d bur is used to provide s m e artistic reton-
touring and to align the uneven incisal edges of the anterior
inusors. The dlamand 1s also used to even the lingual sur-
faces of the mandihular six aoterior teeth in gregaration for
the bonded canine-to-canjne (3 X 3) retainer tFig 79-61.
This techriique is ako helpful in reducing bonding failure.
Fig 19-1 Removal of brackets wlth dha
bond remover pliers. Gen* squeeze ptiers
until the bracket "snaps"off the tooth. Note
that h e archwlre remains engaged during
this procedure.
Fig 19-2 Remwal of bands with posterior
band remwal pliefi Loosen first frwn the
bucal surfa@, then complete the remwal(if
necessary) from the Ilngual.
Fig 19-3 Use of optic loupes durlng
debonding procedures. Magnifying ioupes
are strongly recomrnended during tfie
remwal of excess adhesiw and stain from
the labial swface of the enamel,

Fig 194 R m a l of excess adhesíve with Fig 19-5 The next step is to remow stams Fig 1$6 Use of a d a d bur to roughen
a finishing bur in a high-speed handpiece. and polish the enamel with a pdishing cup. the lingual sub of he mandihlar anterior
teeth in prepamtion for the fixed retainer.

treatment, car-poded, f d , and otherwise mto it that

Befow the patient is dismissed, the parents are asked tci
come in to discuss the patient's treatment results. A com-
parisan is made bemeen the origina! study casts and pho-
tographs and the current results. This is a spectal occasion
to celebrate the completion of active tnatment.
The posttreatrnent panoramic radíagraph is used to
evaluate and discuss the third molars (Fig 19-7). When the
third molar issue is addressed at the end of active treat-
ment, unnecasary parental concems can be eliminated. At
thk time, any frustrations encorrntered by the doctor and
patiernt during treatment are forgotten. The diniuan
emphasizes that the importafi fact ir that doctor, patient,
parents, and staff haue al1 succeeded.
Appropriate congratulations are then bestawed by the
doctor on the patient and parents. Special ~ecognitionis
given to the "unsung heroes," the parents who paid for
the patient foltow& the niles. The patient is rerninded of
this by the orthodontist. Often, patients or parents will
start crying. It is a very emotional time for everyone,
lhe patient then receives a "Super Smile Award," which
is an orthodontic diploma (Fig 19-8). fhe orthodontist
states, "Qn behaif of the entire staff, it gives us great
pleasure ta inform you that you've graduated from haces.
Just so you never forget this wunderful experience, here is
your graduation diploma." This diploma contains the
words, 'TRe end of the road and a new beginning for
[patient's name inserted]."
The text alm reminds the patient that Re or she has
crossed the finish line as a winner, The patient and parents
are then brought to the main aperatory where they are
given balloons. candy, and bubble gum, A photograph is
then taken for the patient's scrapbuok (Fig 19-91, and a
dupliate photo is placed on the bultetin board for other
patients to admire.
the panommic radiograph. cebate when the ordiodontic diploma Is end of actiw treatmnt.
presented.

i i g 19-10 (al Retainer design showing wlres ctossing over the ocdusal surfaces. Ib)When
the retainer 5 remowd, note the spactng caused by the retainer wires. When the teeth settle
in, the retainer will RO longer fit.

times for open bite patients. TRese positiorrers are worn

Retention
As the name lmplies, the purpwe of retenflon is to
"retain" the teeth in their finalized positions. Over the
years, many retainer designs and retention techniques
have emerged as the profession attempts to discover the
ideal retainer. Actually, there is no one design that is per-
fect for al1 patients. A retainer for the mixed dentition may
differ from ahe for the permanent dentition. Some
patients, for special reasons, may need permanently
bonded retainers. Some spedaI cases may require a posi-
tloner.
In our office, the vacuum-formed invisible retainer is
used only as a provisional appliance. Tbis design is fast ami
inexpensiw to produce. The rnajor problem with this
approach is that, whion !he teeth shifi slightly, the retainer
will no ionger fit. The ntainer may cause so much dixom-
fort wben the patknt glaces it in Zhe mouth that the
gatient will stop wearing it. A b , this type of retainer is less
durable. The material can wear, chip, and crack.
In years past, I have used poskers m speafic cases
where I wanted to achieve a result doser to ideal or some-
for appmximately 3 rnonths before regular retainers are
delivered.
Chapter 14 of TAe Akvrander Dircplinel describes the
basic concepts still used today for retention. The goal of
retention is to design a retait-terthat wilt hold the teeth in
approximateiy the same pos¡tiori that h y occupied at the
end of treatmnt, while adowing them to "settle" into
their own physiologically balanced positions.
Prlnciple 18 discussed the phenomenm of "driitodon-
tics." Thls is the uninhibited, mesiodistal self-mwement of
teeth into extraction spaces. Sirnilarly, when al1 appliances
are removed from the teeth, there will be "vertical"
dfiftodontics. lf unencumbered, maxillary wd r n a d u l a r
teeth will mow vertually until they reach contact wlth each
other. This settling-in cffect will give the patient a more
ideal posterior occlusion.
No matter hwv precise the bracket placementzir the use
of fmishing elaia, ~ocdusalforces will continue to move
the teeth into more physiologic positions if the retainer
design a l l w thi to happen, Retainer wires that cross the
ocdusion will p m n t the teeth from settkng, so thk retainer
design should be auoided (Fig 19-1 0).
 Fig 19-11 Maxilbry labial hh p e d to
ctinftwm to the Alexander arch form.
rlg 19-13 Offset berids for the lateral inci-
501s.
Oesign ' The a W t be& for the hteral incicorsare prepláced in
The maxillary wraparound (circumferential) retainer wire is
designed so that no wires c r m the occlusion. Such wires
would hold the teeth in their positions, prwenting them
from responding to normal occlusal forces, OcdusaI farces
allow the teeth to mave wdusally until they xclude with
their opposing twth. At the end af treatment, if the teeth
are placed in gcad positions of torqlre, tip, and in-out (ie,
labiolirigual) relationship, thic settling effect will allow the
bucal acclusion t~ look much better 6 rnonths aftertreat-
ment than it does the day appliances are removed.
Constructkn
The rnaxillary labial wire used is now preformedto my spe-
cific design. Severa1 factors make it unique and quite effec-
tive. Fiat, the labial bow is shaped to conform to the
Alexandes. maxillary arch form (Fig 19-11).
The anterior labial wire is uniquely designed fram
adjusting loop to loop. The labial portion of tfie wire is
round, and the lingual portian 1s flat {Fig 19-12). This
allows the lingual of the wire to adhere better to tke sur-
Fig 19-12 Anterior labial wire wkh round
labial pwhn and flat liiual portion.
Fig 19-14 Small adjustment loop to pro-
vide greater control in incisogingival posi-
tioning.
face of üre teeth, pmnttng the labial bow b r n slipping
onto the gingivat ,tissue, and makes the labial af the wire
comfortable to the upper lip.
rhe wire tP "tu& in" the lateral lncirors (Fig 19-13).
&cause the locath of these bends will vary depending
on the size of &e incisor.s, this retairrer wire is adlable in
t h r e different sizes.
The adjustment loops are much srnaller than k astom-
ary (Fig 14-14). 1 haw often wondered why tlie normal
Hawtey retainér is designed with such large Ioops (see Fig
19-loa). Larger Imps create more flexibiiity, thus maklng
the labial wke more diftimlt to mntrd. Besause the b p s
in thii &ner are smaller in height arid width, there is
morestiffness in t k wire, whirh allouis greater control for
placn-ig it in the corrert incisoging&al p i t i o n . Narmally,
this positlon 1s in the middle third of the clinical crown of
thc cehtrd incison. Where the labial bqw is water than
normal, the wire is bent with a sllght rwerse urm so that
tk Are will be positianed more iwkally (fig 19-1S),
To compkte tRe retainer design, a Ctlasp is placed
ammd the tetmind molars, p~hrabiythe secgnd moiars
(Fig 19-16).This wire is bent to stay away from the dktolin-
gual msp of the ocond molar to albw space for these
Fig 19-15 (a) Reverse cuwe in labial bow to control its verticál @ition on the anterior labial surface. (b}Normal pasition of labial bow for
ideal control of anterior teeth. {a) No wires aoss h e occlusion, so teeth ocdude against themselws

Fig 19-16 (lef21C-dasp bent specifically to

m i d the distolingual cusp of the second 1
I molar.

I Fig 1917 I&hti Labial wire is soldered to

C-dasp at distobuccal cusp area. I

Fig 19-18 Removalof aaylic resin from al1 Fig 79-19 ZuffrWt m& resin has bsn.
embrasure ateas. lemovedsathiititisiiptfdihgtReteeth,
She mal1 hak in the antwiw mion d the
palatalaqlsc k for positidngoí the tmgue,

twth to drift tiqually if neded. The labial wire is then sol-
dere8 to *he C-clasp in h e area bf the distobuccal cusp (Fig
19-13.If the setond molaa have not enipted sufficiently,
tk cclasp is placed around the first rnolar. The wcllisal por-
tbn uf the lmdtre is placed exactiy parallel to the dishl mar-
ginal ridge of the first molar, This allows the second mdar
to erupt in gmd occllusion with littls or ng ocelusal inter-
ference frm the C-dasp.
When the acrylic nsin is added, oáre fhauld Be taken to
make it even and not t m thkk tkmugholrt the palatal
vadt. An anterior bite plate can be bullt F i h e etrlginal mal-
ocdusion included a deep werbite.
Adjustnient
Afkr the acryiic resin ic c u d , al1acrylic resin in the embra-
sure areas is removed during trimming (Fig 19-18). If the
patient underwent treatment with expansion mechanics,
the acrylic resin toudiing the lingwl of the posterior teeth
is maintained, besause studies have shown that some
retapx mrs in maxillary buccal expansion cases.
If expansial is not an imue or the patient has ex~essiw
buccal averjet at the end of treatment, adequate acrylic
resin is removedM that it is not touching the Wth (Fig 1%
19). Thisallows enough space to give the teetk freedom to
S& their own final occlusion, bumlingually.
Fig l S Z O Wdl bw dustment, (a} hrtyíived q m retainer pllers. b)lghten!ng d the labial bow.(4P~altelingthe gmterlar and ante-
rior parts af h e wire.

Fig 19-21 F i mandibular linguat retainer. Fig 19-22 Two views of the W e g r e e Fig 19-23 Adjustment of slight rotation
angle utllity pliers u s d m correct lnuw with the utillty p l i e ~
ratation during 3 x 3 bonding.

When the retainer is adjusted before dejivery, excess
acrylic resin is also removed from the area that touches
the lingual surfaces of the rnaxillary incisors, It is also
preferable to remove the acrylic resin fmm the anterior lin-
gual embrasures. fhis atlows more pressure to be placed
labialiy on the incisoh when the retainer is tightened.
TRe bite plate is adjusted so tbat the w l i c resin is just
out of occlusion with the mandibular incisal edges.
Occasionally, when a patient who had excessive ovehite
pretreatment still has too much overbite, a minor bite plate
is left to keep the teeth slightly out of ocdusion.
Before the retainer is detivered to the patient, the dos-
ing loops are adjusted M that the patient can feel a tight-
ness and firmnsss on the teeth (Fig 19-20).
If a slight rotqlion ic present, it can be corrected wlth a
specMI 90-degree utility pliers while the Iingual wire is
bonded (Fig 19-22). One beak of the utility pliers is placed
an the rnesiolingwl of one tmth and the other beak is
placed on the distolabial of the adjoining tooth. A gentle
squeete of the pliers will mwe t b e teeth~ into their ideal
contaa point relationships (Fig 19-23). WRile the rotated
teeth are held in this pasition, the adhesive is polymerized
with the curing light.
When patients wore banded 3 X 3 retainers. they con-
tinued to return for retainer examination appointments
until the 3 x 3 was removed. Patients tend to be so hapgy
with the current bonded lingual retainer's design that they
m m e t i m miss the retainer recall appointments and do
not return for their annual examinations.

M m d i h b v ret&ms
A f i e d mandibular canine-to-canine retainer has alwaw
been used in our ctinic. A banded 3 >5 3 retainer was u&d
beforebondingtediniquesweredewbped.Today,asection
of 0.0215indi multistranded stainless steel wire is con-
toured to fit the lingual surface of the mandibular anterior
teeth and &en directly bond4 to each twth (Fig 19-21).
I m m g o n sfw retainer wear
After bracket remwat, the rnaxillary retalner is delivered to
thepatient.Heorshekinstructedtoweartheretainer
only 8 to 10 hours per day; the retainer is to be placed
after dinner and removed the next morning. The patient is
instructed not to wear the retainer away from home. The
 Fig 19-24 Informatianal handout on
retainer use and care (Retainer Wear and
are, OREC).
resulting decrease in the incidente of lost and broken
retainers has been remarkable,
Most orthodontists have their patients wear retainers
24 hours a day for several months after the appliances
are removed, Inltially, I request that patients wear the
retainer only at night. This rationale is based on the tygi-
cal archwire sequence and length of time in the finishing
archwire followed for most of our patients. M a t
patients will have their 0.017 x 0.025-inch stainless
steel archwire in place for 6 to 12 months, with few or
no adjustrnents. In essence, after the first 2 to 3 months
in this archwire, when the teeth have been moved to
their final positions, the archwire is acting as a fixed
retainer. By the time the removable retainer is delivered,
the teeth have already been in retention for several
months.
When the retainer is removed each morning, it should be
brushed with tmthgaste, driecf with a towel or tissue, and
t h n placed in the retainer case and stored in the bath-
m.That evening, t b dean retainer is then placed in the
mouth after the patient has btushd and flossed his or her
teeth. The patient is given retainer insbuctions to be
shared with the parents (Fig 19-24).
The patient also is instructed in the tehnique for floss-
ing with the hnded mandibular retainer and is instructed
to floss every evening (Fig 19-25).
If t
htreatment goals have been achieved, the teeth are in
stable positions, w oniy minimum wtentjon is required.
The protocol for retainer wear has been established by
years of observation of patients in retention.
Fig 19-25 F k threak. Used to flass the
bonded 3 X 3 retainer.
The greatest unknown at this time is the paücnt's future
growth. Dr Schudy, wha taught us ta aiways continue
retention until al1 growth ¡S completed, gave sorne g d
advice. The maxillary retainer is to be worn only at night,
but consistently, for 1 year. The second year, the retainer
can be worn three tlmes a week. Beginning in the third
year, the patient ir asked to wear the retainer at teast
once a week, for example, every Sunday night.
Thereafter, the patient is told, "Be your own orthodon-
tist." If the retainer is very tight when it is placed, there
has been some movement of the teeth. Therefore, it
would be prudent to wear h e retainer more often.
The mandibular 3 x 3 retainer must be worn until al1
grawth has ceased. At this time, the patient is informed
that when ttiis wire k removed, there is a slight chance
that the mandibular inusors could shift. Some patients
elect to continue wearing this retainer.
I have never told a patient to stop wearing the rernov-
aMe retainer entirely and t h r w it away. However, virtually
no patients will continue to wear a retainer indefinitely.
Thus, if the teeth are placed in as seable positions as possi-
ble during treatment, the eventual movement when the
patient stops wearing the retaine~should be rninimal.
GingivaI fibrotomy is recommended routinely for ckildren
when they have teeth that are severely rotated at the
kginning of treatment, impacted teeth, or malgosed
tecth.
This grocedure is also recommended for wery adult
patient who begins treatment with mtated teeth. An anec-
dotal obsenration has been that when the maxillary central
inasors are initially rotated meciolingually/dist~bwcally,
there is a greater tendency for relap. This is especially
true for adults.
FIg 19-26 (4 Fllsorldated pumice, placed In preparatibn for Intergroximalenamel reduc-
tion. & Slendenzing tool used for interproximal enarnel reduction.
AMough third molars are often the excuse for relapse,
studies have shawn that wisdom teeth have no effeci on
the stábility of the teeth. The causes of relapse haw been
addressed in earlier principies, R is important, Rowever, to
address this issue with patientr and their pamts. Part of
the orthodontist's responsibility tto patients is to continue
seeing them until the wisdom teeth hwe been resolved,
whether that rneans extracted or erupted normally.
If the length of the mandibls is sufficient and the third
malars are pitioned in such a manner that they can enipt
into the arch normally and be functionaj, they prabably do
not have to be moved. Othenniise, leaving them in tke
mouth ~ t e n t i d l ycould cause periodontal problems later.
Often In extradion cases, adequate room for wisdom teeth
will develop.
m m e l redwtion
Inte>prox%'mul
E not perfomed during active treatment, interproximal
enamel reduction, from mandibular m i n e to canine, is a
very important procedure when the bonded 3 x 3 retainer
is removed (Fig 19-26). In addition to creating a few mil-
lirneters of spoce, the procedure, by changing contact
points to contact surfaces, gready reduces the chance for
relapse (Fig 19-2 7). This also gives the twth some space to
adjust without relapring. Fluoride should alwaysbe applied
after this procedure Is completed.
Fig 19-27 Result after interproximalenarli-
el ductlon. Note fiat, not mlinded, mnract
surfaces
Lifetime retention is a very popular t e m in orthodontics.
The basic concept is that teeth will shift ttiroughout life,
with or without orthodontics, so it is reasonable to plan to
hold them in their final orthodontic positions for the rest
of the palient's life. Although there Is no questian that
teeth will shift slightiy with time, perhaps rifetime retention
is an excuse to knowingly place the teeth in unstable posi-
tions during treatrnent and hope that patients wlll wear
retainers the rest of their Irves.
The realiry in my practice is that the handful of patients,
out of 15,000, who Rave pemanent mandibular retention
are adult patients. The challenge, then, is to place the
teeth of every patient in pssitions that will have the oppor-
tunity to be stable without "lifetime" retention,
fhe availability of pretreatment and final diagnortic
records for approximately 10,000 of my patients has given
the opportunity for many graduate students to do their
research, h i l e helping me change afiecdotal clinkal expe-
rience into evidente-based truthc. In addition to more than
50 graduate theses, no fewer han seven research t h e s
have been writkn wsing diagnmtic records of my patients
who haw been out of retention from 5 to 40 years. nie
tetragon-plus analysis and the 15 keys to orthdontic suc-
cess (principie 41 wre developed as a result af these lorrg-
term studies.
A future volume of this series wiil be devoted to the
important subject of long-term stablity.
 er, if you violated mandibular incisor control, expand~d
Conclusion mines, failed tb p i t t o n rmb properly, etc, during active
treatment, you mults will have little chance to be stabk.
After careful removal of ~rhododitkappliances, the imple-
mentation of a ~ m i f i cretention plan that incorporate
b t h a maxillary cirmfetential retainer and a PMd
mandibular retainer and that addresces the third motars
will improve the ehances f ~ tong-termr stabiity. But Refwenee
rememhier, Et is not one big "rhing." tt is many lirtle things.
(Prineiple 2: "There Are No ütüe nih~s."Shave attempted l . Alexarder RG,The Alexarder Dixipllne: Corraemporav
tu give @u a caokbook approach to finiang and reten- m rard Philosophi. Glendora, CA: Omm, 1 906.
t
t i a . You can follow thir advice in compkte detail; hawev-
Create Compliance
..
T o know m d nut to da , is not to know,"
- Chinese Proverb
A
Ithwgh ewry gatient is unique in some ways, wery
patient is also the =me in many way. In mt cases,
the general tmtment plan, as outlined in these princi-
@es, ir to treat the maxillary arch first usinga spelific sequence
of arctwvires. R the patient requires orthopedic correcücn, such
treatment is initiated in the maxillary arch with a rapid palatal
expander ancüor facebow or fdce mask.
About 4 to 6 months later, treatment is initiated in the
mandibular arch. A specific series of archwira is used to
position the mandibular teeth. After h e finishing arch-
wires are h place, appropriate elastia are used to cmrdi-
nate the arches and finalite the occkision. Retainers are
then plarcd.
Following these basic step-by-step pnxedures in a rou-
tine system, the orthodontist can stay in complete control
of each patient, Because the treatment needs at the next
appointment can be anticipated, future scheduling is sim-
plified, and pmgress can be easily monitored so that the
treatment is completed on schedule. 7he bottom Iine is a.
well-treated case, finished in a timely fashion, resulting in
happy parents, patient, and orthodontist-8 the patient is
compliant.
What makes orthodontia such a uriique profession is
the necessity to rely on tke patient to follow the orthodon-
tist's instructions. The reality is that mwing the teeth by
archwires, functional appliances, and elastks makes the
teeth hurt. Scrmehow the orthadontist must communicate
with the patient and parents that the dixomfort experi-
enced after aknost evei'y appointment will be worth it in
the long term. TRis can be t a lfed delay& gratification.
This principie suggests techniques for improving the
compliance exhibited by pa t ¡ents, The effectiveness of
these txhníques is dependent on the positive attitude and
efforts of the orthodontist.

There is no doubt that successful orthodontic results can
ix enhanced by the patient's positive mmpliance; the
question, then, becomes how to achiew this compiiance,
Various ways of achiwing patient cooperation are possible.
Howevea, the methods and techniques used will vary with
each patient and orthodontist.
While the mechanics of treatment described in this
b m k can be used for any patient in the worid, the tech-
niques of motivating pa tients can vary greatly within any
given community or country. The suggestions expressed
in this principie are based en experience with píttients
treated in rny office in Arlington, Texas, over a period of
40 years, Even within the same practice, the attitudes of
the patients have chaqed over the years, Methods of
motivation that will wsrk evety time on csne patient may
never work on another, The way a 1 2-year-old patient in
Texas thinks may be completely different from the way a
child who lives in Germany or South America thínk.
Every patient, however, deserws the opportunit)l to
accept personal responcibility and to succed in the
endeavor.
Some readers may believe that the though25 and sug-
gestions mentioned here are silly and uselw. For those
readers, that will be true. Howewr, for those who beticve
in these concepts and appiy t h m t h m g h their own
thoughts, style, and technique, these methods will work.
The reader should study this chapte~and see how the prin-
ciples described on the following pages can fit into his or
her own personality and attitude.
The gmd news is that kids are kids throuqbtit the
world. By taking a few extra minutes to educate and mti-
vate patienb, orthodontists can increase the chances for
successful orthodontic treatment, Not only will this special
time be motbational to patients during ttieir treament,
but also the thoughts and ideas learned can be internal-
ized and continue to have a positive influence on their
entire lives.
Derees of compliance
Orthdontists often seem fmsed on ~ O W ta treat the
"noncornpliant " patient, Appliances such as t k e Herbst
appliance, the pendutum appliance, and magnets may be
able to corred Class II malocdusion regardless of the
pa tient's compliance. Although these appliances or 0 t h
orthopedk approachn are effeaive in certain cases,
removing al1 resggnsibility from the patient could compro-
mise the treatrnent plan,
The reality is that there is no such thing as noncompll-
ant treatment Every patient must brush properly, avMd
certain food~,wear elastia, and come to appointmerits.
Rather, the dtfferences exhibited are in the degree of com-
pliance. Unfortunately, some patients fail to take responsi-
bility for their actlans. Although words such as efhrt,
mp~nsibility,and disipfine may not be fashíonable, they
shriuld be induded in the basic patient education program
in cvery orthodontic practice. D m r s are giwn the oppor-
tunity to have a positive influence on their patients' atti-
tudes, in addition to straightening their teeth, as patients
are encouraged ta accept personal reqmnsibilityand expe-
rience the succcss of their efforts.
One of the great joys in life for me has been seeing
patients change in both their physical appearance and
their mental attitudes. Letters f rom patients and parents,
and evei? comments from patients m n y years later,
demonstrate tl-tat these motivational efforts did not fall on
deaf ears.
The generally accepted goal of orthodontic treatment is a
high-quality finished result. Howwer, the reality is that dif-
ferent practitioners have different objectives and different
perceptions of quality in achieving this goal. For example,
in the treatment of Class II skeletal patterns, tbe nature of
a balanced profile, the proper position of the mandibular
incisors, and the desirable arnount of buccal expansio-
all of which affect long-tem stabillty-are controversia1
issues among orthodontisb of diverse opinions.
Regardless of the differencees iin tmtment approaches,
motivatirig patients to follow the instructions of the prac-
titioner will pmvide &ter results. The reality is that every
patient, regardlessof the appliances used, must be cornpli-
ant to a degree. The baricc, wch as maintaining oral
hygiene, eating proper foods, keepirag appointments, and
wearing elastics, must be followd by every patient if there
is to be any chance for successful rewlts.
Creating Compliance
It is possible to imprwe a patient's willingness to follow
instruaions. Just as orthodonticr itself remains so much an
art, the psychologiwl treatment of the patient is every bit
as important an art. This technique of compliance can be
Figs 20-la to 20-Id Finished results with great smiles.
Fig 20-2 This patient-educa-
tion booklet 1s giwn to al1
patlents at their f b t appoint-
ment. tt introduces the doctop,
discusses treatment planning,
early treatment, full rreatment,
braces, additlmal applbnas,
Invisallgip, and lingual braces, It
also indudes foods to avoid
during watment, proper care
and brushing techniques for
braces, and retention. This
booklet is available through
OREC.
taught just as can the mechanics of arthodontks.
However, certain factors must be present to rnofwate the
patient to follow instructions.
The first requirement for creating a comptiant patient is
that the clinician believe in his or her technique, and the
staff must have confidente in thc anticipated nsults when
the patient follows instroctions. Kenneth Cooper' has
said, "Your batiefs are the most powerful motivational
tmls you hme-if you can just Iearn how to use them."
Keeping t r e a w n t simple and executing a stepby-step
plan will make education and monitoring easier if the
orthodontist knows these efforts will produce the antici-
pated results. Consistent, high-quality results can be pro-
duced when the principles discussed In thir book are fd-
lowed (Fig 20-1).
The definition of qualiry is the conformance to require-
ments. The requirements for orthodontics are well k m .
If orrhodontists just do what they know they should do,
they will produce high-quality resutts.
Fig 20-3 Patient education far
adutts is completely dfierent,
and therhre a completely dif-
ferent booklet is needed.
lnduded are drárnatic results,of
surgery patients and irnportant
dikrences In d u l t treatment,
Diagnosis and keatmnt plan-
ning are d h ~ s e d abng
, wfth
treatment options. A future vol-
urne in this series will dwote a
,
full chapter to adutt orthodon-
tia.
When I discuss with patients the benefits of wearing a
facebow, they can feel my belief in these techniques.
Orthodontists must communicate, each in his or her awn
way, that t k y know the treatment wíll work if the patient
will follsw instructions.
The second requirement for ensuring cornpliance is that
patient and parents understand exactly what to do and
why it is important. Parents must be induded. The need for
parental support is critical. They need to know the costs
and benefits of treatment Iri time, money, and effort. This
education takes t i r n ~ t a f time
f and orthodontist time.
ARhough efficiency e x p m may talk about "saving " time,
people can actually only "apend" time. The question is
how to sgend that time most effectively. If tess time is
spent worrying about orthodontk mechanics, more time
can be spent on patient education (Figs 20-2 and 20-31,
Thorough patient education at tthe beginning of treatment
can eliminate many problems down the road; that is,
" inform before you perform."
 Fig 20-4 Patiem-educa- Fig 20.5 (a) O m r educatlng staff rnember.
tion kit givm after place
ment of maxiiiary bradcets.
A kit given to the patient after the maxillary bracketc are
placed includer a regular toathbrush, a travel toothbrush,
t h p a s t e , fl uoride gel, interproximal brush, travel inter-
proximal brush, flo~s,f l w threader, Superfloss (Oral-B),
disclosing tablets, and wax (Fig 20-4).
The assistant demonstrates the proper use of the tooth-
brusha, floss, and interproximal brushes. The patient tben
repeats these pracedures in fmnt of the assistant and par-
ent.
Educating the patient means more than a monotme
recitation of a set of instruaions. Orthdontists and their
staff should try hard to communicateand enjoy making new
friends with the patients and parents. Contemporary ortho-
dontic techniques allow many treatment procedures to be
taught and delegated to staff members, freeing time for tk
practit ioner to personally educate patients and paren&.
However, it is altical that 5 h f f members undestand what is
expected af them when they are assigned to educate
patients. Time mwt be spent educating the staff before the
staff pemnnel can help educate the patient. Patients must
understand exactly what to da and why it ic important.
Time must be taken to educate them (Fig 20-5).
The third requirement for creating a compllant paPient is
the ability af tke orthodontist and staff to motivate the
patíent. First, the members of the practice must accept the
prmise that peogle can change. In t h wwards of Williarn
Jarnes (sometimes alled tRe "father of American psychol-
ogy"), "Tha most important dTscovery of the 20th century
is that the a t t i t u d ~of an individual can change."2
The lescon ts tearn from a study of motivatimal tech-
n@ues3is that the one trdy successful method is self-
motivation. Pep rally speeches can fall on deaf ears, To be
effectiw, rnotivation mwt be intarnalized. The key, then, is to
determine wha t apprciach will e m p o w individual patients.
Assistant educating patient.
Differences of opinion arise as to how or whether an
individual's attitudes can be changed-the challenge of
creating the compliant patient. Thic is an inexact science
that continues ta evolve as mciety changa, but several
thoughts gathed from numerars rources and more than
4Q years of trial and error can k applied.
Personality prof ite
In patient-centered orthodonticc, the patient is the engine
that runs the system. It is the orthodontist's respnsibility
to understand the patient, not the reverse. The staff and
orthodontlst can learn techniques that enabie them to bet-
ter communicate the need to fuRow instruaions necessary
for succea. Determininga patient's personality pmfik is a
good place to start. Generaliy, four types of personality
tendencies exist:
1. Dominante: wtivated by immediate results
2.infiuence: motivatd by interactian with others
3. Steadiness: motivated by predictable, stabiling rewlts
4. Conxientiousness: motivated by detailr and precision
By determining a patient's personal9 traib, the o&o-
dontist can use specific agproaches for that particular ger-
sonality to achiwe success.
Patknt differences
Every practitionef knows that patients' degree of self-
motivation can vary substantially. Patients who come from
stable farniiies with Supportive parents often seem to be
the ones who wear their facebow and keep their teeth
clean. These patients receive positive strokes from their
parents, friends, teachers, and others. The problern is that
not al1 patients are cheerleaders or class presidents. The
gractitioner's real ckalkqe is to relate to the patient with
low self-esteem, the typical noncomptiant patient.
Most arthodontists have encountered at least one
patient who does everything wrang: He or she rnisses

iig 20-6 WRen a patient
enters the operataty, you
should imagine himlher
waring this sign.
appointments, arrives late for appointments, exhibits poor
oral Rygiene, has loose brackets, and n m r follows Instrw-
tions properly. Orthodontistsand staff memkrs often react
negatively when such a patient en- the operatory. ("Here
mmes Bill. Let's get him in and out as quickly as posible. ")
The reaction should be exady the o m i t e . Here is a
young pemn who definitely needs the help and attention
of the orthodontist and staff, He or she could be from a
broken family, ahays in trouble at school, mixed up with
the wrong crowd, and may sport unconventional clothes,
piercings, tattoos, and hairstyle. This patient protiably has
poor oral hygiene, has not worn the appliance, and
experts a reprimand as soon as someone Imk into his or
her motlth, It is difficult to be nonjudgmental in such a sit-
uatim, but the clinician does have a choice.
Attitude iKjjustment
Stephen Cwey4 describes the "space" between stimulus
and response. In this spare lía the freedom to chmse a
response. For exampte, vvhen a car cuts in front of a driver
(stimulus), the driver's instantaneous thought or attitude
(space) is to become angry and then try to get back in front
of the other car (response). The resutt is "road rage."
Howwer, if in this space the person has a positive attitude,
everything changes. While the stimdus cannot be
changed, the individual's attitude and response can
change through the self-awareness of chming how to filt
that space. IIt takes practice and forethought to anticipate
how to fill that space. In driving defensively, good drivers
learn Row to watch out for other drivers and let them go
without getting angv The same process can occur with
the noncompliant patient.
for example, the orthodontist says, "After you have
warn your elastics for a few hours, your teeth will begin
tu hurt (stimulus) just like when we put your braces on.
The difference is that you could not remove your braces,
Fig 20-7 This question-
naire is comgleted to deter-
mine the ~atient'sand par.
ent's feelhg reprding ' tha
orthodontic experience.
so you 'played through the pain,' and after a few days
the discomfort disappeared. So this is my question: What
are you going to do when your teeth srart hurting from
wearing the elastics?" The orthodontist should wait for
the patient to think (space); then he or she will make the
commitment, " 1 will kwp h e m on" (response). The
patient has predetermined what to do when the teeth
begin to hurt, so he or she will not r e m m the elastics.
The orthadontlc office may be one of the few positive
influenc~in this young person's life. If the patient can
receive positive stroks from the orthodontist and staff
h i l e learning to accept individual responsibility, his or her
attitude rnay be altered. When this noncompliant patient
enters the office, the orthdontist should picture him or
her W n g a sign that says, "Make me feet importantu
(Fig 20-6).TRe orthodontist and staff must find something
good to say to the patient, although it rnay be difficult.
These 11th things could change the patient's life,
This approach is also self-seniing in that an improved
attitude will help the patient fallow instructions and, pre-
sumably, lead to a bettcr treatment mult. A sense of suc-
cess offers tbe patient a foundation on whkh to build
other positiw experiences, and just knowing that sorneone
cares can haw a significant impact,
Mfice envirorrment
A gmd office environment is influeniial' Ín creating complt
ance because every office reflects the personality od the
orthodontist. To measure how the "office personali'ty" is
perceived, the arthodontist can ask a sales representative
who visits periodically.
When evaiuating his or her own practice, the ortldon-
tist who rmtly wants to know how it is doing will ask. In our
office, the patient and parent are givm a questionnaire the
&y appliances are removed {Rg 2Q-7).AltRough it is grati-
fying to read pMitive commnts, the negative feedback can
1- 20 Create Cornpliance
m

Flgs 20-8a and 20-8fi FJew patient and parent takfng an ofñce tour.

Fig 20-9 lreatrnent chart with patient's Fig 20-10 Patient wearing her special Fig 26-11 Display case of treatment
name. "Atexander" t-shirt x Dr Moody discusses rewards.
treatment with patient and mother.

be helpful in pointing out areas where irnprovements are
needed. The creation of an adult mrnwas a resulr of com-
ments made by adult patientr whs were being treated in
tRe " Rainbow Room."
The key ¡S to aaively create and maintain a positive envi-
ronment in the office that fits the orthodontist's personal
mmfofort zone. The goal is to maintain a friendly, retaxed,
warm, caring, professional atmdsphere in whicb patientc
know they receiw the highest quality of treatment and
understand that the best is e x p d from them. nius, the
orthodontist is building a practice full of achievers. The
enviranment exudes positive vibrations.
Creatiori of the compliant patient begins with the initial
telephone conversation. Educational informstion is sent in
the welcome letter. On the first visit, the patient is given a
tour of the office (Fig 20-8).
One of the mast beautiful sounds in the world K the
sound of a person's own name. A "hi-bye" policy is consis-
tent with the goal and simple to implement Patients'
narnes are written in large ktters on their charts so thar
ewryone can cal1 them by name when they are gmted
and dismisseci (Fig 269).
Nonwrbal ~ommunicationis an important factor in
motivating patients. On the wall next to the enirance of
our office is a sign with the motto, "Effort equals resulte''
(principie 1). This therne, adaptd from a jarnes Allen5
quotation, is carried throughout the office for staff mem-
bers as well as patients.
Reward system
In keeping with the philorophy of effort equats resulb, a
prqram that m a r d s cornpliance has been intrduced by
my son, J. M d y , A list of "ruks"is given to the patient. At
each appointment he or she ir awarded a "wooden nickd"
fw following the instructims (tules), These niles include:
Arrive on time for appointments.
Maintaln excellent oral hygiene.
Demonstrate excellent cooperation.
Wear an "Atexandw" t-shirt to appointmentr (fig 20-10).
After accurnulating enough nickels, the patient can
"purchase" a designated gift s e l d from the display
case (Fig 20-1 11,
Shaking hanas
Although this may differ in other parts of the world, a
Texas tradition that 1 was taught by rny fatber is also taught
to wry patient who gues through treatment in my office.
Shaking hands is a form of nonverbal communication and
Fig 20-12 lal Dr Alexander shaking hands
with psttient. (b) Dr Alexander in horlzonral
communication with patient.
follows a simple set of principies. Su when I shake hands
with a patient who responds with a weak grip, I will always
tell hlm or Rer what my dad taught me. He told me to
squeeze the hand tightly, lo& the person in the eyes,
stand tall, and smile. fl added the smile.) I will then say,
"When you are introduced to yaur profesor, or looking for
a job, whatever the circumstances, your first impression
will be your handshake. Make it positive!" (Fig 20-12a).
Comrnunlcation techniques
Doer positive psychology in evetyday life have the poten-
tial to change people's lives? A short book by Rath and
Clifton6asks, "How full is your bucket?" They dixuss the
theory of the dipper and the bucket. They wite that each
person has an invisible bucket and an invisible dipper. A
p e r a who says something to another in a positive man-
ner is filling the listener'sbucket. It is just the opposite when
a pemn says negative things. It not only empties the listen-
er4 bucket but the speaker's as well.
Orthcdontists are in a unique position to fill buckets al1
day lmg. Not only the patient but also their parents need
positive strokes. The same is true for the staff. By con-
sciousiy attempting to fill these buckets, orthodontists will
have a positive influence on all those witb whom they
come in contact-and imprm communication, productiv-
ity, heakh, and happiness.
L d ahem in the eps. If the patientf welfan is kegt in
mind, motivational oppMtunities present themseives from
the moment the orthodontist sits down at the patient4
chairside. Patients typically open their mouths before any-
thing is said. When this Rappens, I say, "Close your mouth
for a moment. I want to look at you." The orthodontist
should take the opportunity to lwk into the patient's eyes
before lookingin the mouth. niis simple aa helps the ortho-
dontist remember that the patient is a human being, not a
typodont. The clinician has no idea what is happeningin this
chldf life outside the office. The orthodontist has only a few
moments to mmrnunicate with the patient in a positive
manner. It is imprtant to take advantage of that time.
The conversation should ahays bqin on a personal
note. It is useful to ask questions a b u t the patient's per-
sonal life, such as xhool, sports. music, or whatewr inter-
ests the patient. Each gatient is envisioned as a star to
determine where he or she shines; then this inforrnation is
written on tke chart as a reminder. It is beneficia1 to
attempt to get a general idea of concerns in the patient's
personal life. Carefully chosen words and tone of voice are
important m n d bites that can inspire and motivate.
Horiontal communication. Horizontal communlcation
is an important comrnunkation tedinique (Fig 20-12b).
While the orthadontist sits on the stool, the patient sip up
when swious cammunication is needed. Situations in
which the orthodontist's eye level is higher than tha t of the
patiwit's hould be avoided. It is bstter to avoid standing
above the patient when speaking with him or her. Goad
communication shwld be honese and two-way, and the
orthodontist must devebp skPk as an active listener. After
explaining a procedure, t do not ask, "Do you have any
questions?" Rather, I ask,"What questians do you have?"
There is an important differeme ln h e warding. Th@n1 lis-
ten to the patient.
Progres r e p r t s . The patient and parentc must be gitrerl
current information on the trea tment progresr. Wi th mod-
ern digital photography, it is simple ta take an intraoral
photograph and give It to the patient to put on the batk-
room mirror, so he or she can monitor the progress.
Encouragement. Genuine compliments and concern can
be expressed in a variety of ways. The orthodontist must
underctand the power of wurds and use the right words at
the right time. Sharing favorite expressions with a patient
 Expressions of encouragement
Your grade k your pay.
No one k n m what he can do until he tries.
Just do ¡t. . . with a p u r g a .
DO me ight ming, at the nght time. (or the
: what y
Definitidn of d ~ c i p l hDo w ought to do,
wtien you ought to do it, whether pu'want to do
it or not. No +bate!
- - --
* - - 1C ..-e
at the right time can be very valuable. 8ox 20-1 presents
some of my favarites.
Df al1 the motivational expressions used, h e last one is
my favorite. is that because the word disc,;Oline desaibes
my tedrnique (ie, the Alexander Discipline)?
Oral Crylljieriaf
Without question, the most critica1action the patient must
perform on a mnsktent basis is proper oral hygiene meas-
ures. Regardes of the appliances used, this basic proce-
dure must be taught and then followed by the patient.
Oifferent approaches can k followed, depending an
the office and the patient. The educatiunal process can be
presented in a groqs or individually. but the mnsage is the
same. Patients should enter the operatory with no visible
plaque on their teeth.
The plaque rtory, Some children will relate to a story
about t
k effects of plaque:
What is plaque? It # the goaey substance found on
the teeth when they have not been properly cleaned.
Take a dental instrument and remove a small a m n t
of plaque and then put it on a glaa slab. Add a drop
of water, stir gentiy, and t k n place it undeí a rnicro-
scope. Do you knaw what you will see? Thousands
. ..
and thowands of bugs . . gerrns , k t e r i a . . . are
h m i n g all around. lhey are living b e ~ m
teeth.
Do p u know what their favorite f o d is? Sugar!
your
Just like you and me. So when you eat candy or a
Fig 2&13 Oral hygiéne gdes. recarded
at each visit.
cookie before you go to bed, and then forget ta
h s h your teeth, gues what happens?lhe bacteria
.
eat the sugar alt night long . . get full tummies . . .
and then . . . do you know what happem? tPause]
TRey poo-poo in your mouth! Yuck!
Bacteria are living organisrnc and, just like you and
me, must go to the bathmm. The probjem with the
bacteria is that their wste ptoducl is an aad. This
acid causes al1 the prciblem found ín the mouth . . .
bleedinq gums, cavities, and discoloration of t h
teeth. So when you use a toothbrush, you must do
..
more than Iust brush . you must clean your teeth.
Keeping your teeth free of plaque k the goal of
proper oral hygiene, It also keeps the braces shiny
and pretty., A
ivknitoring pmrer#
EacR patient's progress is monitored mnstantly to maintain
motivation and compliance throughout the treatment. At
the beginning of each appointment, the patient's oral
hygiene is graded by the chairside assistant (Fig 20-13):
green (+) = excellent; yellow (0)= acceptable; and red (-1
= pmr. This routine tracking of the patient's oral hygiene
will be used when progress is discussed with the parents:
gabd or bad repans.
ihe d d i n g &y stoty F O wme
~ young women, 1 may
present the wedding day story:
b k 10 years into the future at your wedding day.
.
White gown, perfect halr and makwp.. the perfect
day. Now you lmk into the mirror and smile! What
do your teetl-i look Yke? What you are
that day in the futurel
P tdayon
will determine how beautíkil your smile ill be

Fig Z0-14 lt-iíormed consent
form, which is signed by the
patient and parents at the
beginning af treatment
Short-term goals
Developing ackievable short-term goals, such as reduction
of the patient's overjet, is very irnportant. Overjet can be
measured at each appointment. When improvement is
seen, the staff must be sure to praise the patient and share
the achievement with the parent. Rewards for good
hygiene and cooperatiun are valuable. Fw exarnple, some
officer; award a silver dollar when a patient receives three
"plus" grades for excellent oral hygiene. Acknowledgment
and reinforcement of success are critical.
The tact ressrt
Some patients will inevitably fall behind in treatment. If it
is attributable to uncontrollable factors, such as poor skele-
tal grdwth patternr, this should he explained and treat-
ment continued as planned. If slow progresc is due to the
patientls noncornplian'ce, the first step is to have a mini-
consultation to inform the patient and parents of the situ-
ation. Explain the consequences of noncompliance-the
lack af progress.
Talking directiy with the parent can often be very valu-
able. The parent has "invested" a large arnount of money
for the child's braces, and at this time he crr she is not get-
ting a good "return" on the "investment." A business-
rninded father or mother can readily appredate this analogy.
It is important not to give up or get mad, but it is equally
important to be realistic. At this point in time, it is necessary
to determine what is best for 'the patíent and the parents,
as well as what is best for the orthodontist. The deed
should be separated from the "doer," The staff likes the
daer (the patient) but not the deed (the noncompliance).
New goals. It may be necessary to set new, dear, and
attainable goals with the patient and parents. Compramise
may be necessary to guarantee same form ~f success. For
exarnple, the patient may be told, "lf you wear elastics full
time, you can stop weartng the facebaw," The orthodon-
tist should try every rnotivational technique, take accurate
notes, and follow up with a letter to the parents when
progrriss is nbt brthcoming.
Creating Compliance u
Motivatirinal Ianguage. As a former athlete and lover of
sparts, I like to use sports-reIated phrases to communicate
with many patients as they come to the end of treatment:
It3 "crunch" time.
You are a winner (nat a loser).
We're at the 2-minute warning.
Pay me now or pay me later.
First and goal, but time is running out.
Don't yw want to cross the finish line as a winner?
Persistent noncompliance. A few patients will fail in
spite of al1 efforts, If cornpliance problems persist, another
meeting is scheduled with the patient and parents 6
months before the estimated end of treatment, At that
time, four eptions are paesentd:
1. The patient will give ultimate effúrr with facebow
andlor elastics to ad-iieve the treatment goals and
finish on time.
2. The facebow will be tiéd in, or the patient will be
switched to a noncompliant appliance such as a
Herbst apptiance, Forsus appliance (3M Unitek), or
spedal coi1 springs.
3, Treatment will contínue and applianres will be
removed a t the predeterrnined time after parents
sign a release letetter.
4. Treatment will be continued past the predetermined
time, wjth an additional manthly fee, until a success-
ful result is achieved.
Recause the parents have already invested a consider-
able sum of money, it is unfair to expect them to pay more.
Instead, patients are asked to invest some of rheir own
money in the completion of treatment, This option of an
additianal fee is íncluded in the individual responsibility
agreement that is signed by every patient in the parents'
presence at the initial consultation (Fig 20-24). Most
patients, however, elert to put more effo~tinto completing
treatment sooner.
 if treatment takes 3 to 6 months Iunger than ex'pected,
urualiy thote ir; rm addftbnalfee.
Creating a mmpliant patient begins widi the attihide of
tbe orthodontisr. Orthodontists are in h "peaple"busi-
rrm, Treatment gmls will k ahieved if orthodontists
klieve ln the delivery system, prdperly educale patients,
and eff~tiuelymotivate them to follow instmctions. This
kind of comrnunimtion takes üme M produces woutk-
h i l e results.
Mncompliant appliances have their place, but they
should n a be viewed as a solution to all problems. lf they
wen, there would be no need for patienb to maititah
goad mal hygiene, care for their appllances, keep appoint-
ments, ot do al1 the other "littk thirrgs" that make treat-
ment succ~ful.
in their bwk, Raising Sdf-ReIiant íhiId~nin a SM-
Indulgmt W d , Glenn and Neken? address the issw of
cooperation with wise wqrds that can be applied tci the
motivation of patients. TRek Ideas about panwiting can be
adapted to fhe orthodontist-patient relationship as fol-
l m : Today orthodonW must deal with patients actively
in waF that cause them t~ kli@vthote they play an irnpor-
tant mle and are not just &jxts or pmbe recipients of
úeatment, Orthsrfmtists rnm make patients feel that
they are part of the team and are given al1 the c d i t when
success is achiwd.
lohn MaWitt%sum it up with thii incredibk statement:
"In our minds, at le&# technobgy is a h a 6 aii the verge
of liberating us fram personal disciptine and responsibility.
Only it never does and never Yvlll." Patienb must still cüop-
erate in al1 areas of treatment If arthodpntisls,expect to
consictently produce htgk-qwlity mults. The law of cause
and e f f ~has
t not &ahged+ffort stlll equaIs r e s u b f ~ r
the patient wd ortRodontist.
1. m r K. It's B&ter to M h ,Nashville: M a s Nelson, 1995.
2. hale NV. My Favwite Quotations. Norwalk, CT Gibson, 1990.
3. Waitley D. ihe Pqchology of Human Motivation [audiocas-
sette tapes]. Niles, II: Nightingale Conant, 1991.
4. Covey 5. First Things First. Mw Y o k Sirnon and Schuster,
1994.
5. Allen J. As a Man ThMeth. 1902.
6. Rath T, C l i o n DO. How full Is YourBucket? *tive Strategia
for Work and Life. New York: Gallup, 2004.
7. Glenn HS, Nelsen J. Raising Wf-Reliant Children in a Self-
hddgent World, ed 2. New York: niree Riem 2000.
8. Naisbitt J. Megmnds: Ten New Directions Trandorming Our
M.New York: Warner, 1982.
Index
A& finhing, 163, 168
M ~ i p f27,27f,
, 145-146,IQ f kxible, 1 07
liqud1, &7, 8?f, 92f f o m of, 100
m d u t a r . SW MambulaFatch. f uncti~nsef, 1 08
rnaiiillm. S e MMlary d, gu& for usíng, 107
A w p a l d aKh,07, a7f i y'1 1S, 148
h ~ t - t r ~ tof,
&eoi pa*L t Arch a r i w l m n labial, 2ü6,2Q6f-207#
AkmdetQlSd@ri a w r é M to mahitaln, 129-1 31, length &a-, 50
~ ~ ~ ~ W130f B r ~ "ktpet d," ~
137-144
$qipm. ca5ebw d,? 3 1,132-135f mndibulat. See Mardibufar ar&iwi~.
d*rn d,,1, 3, 15, 39 f* for, 1m mxilbry. %? Maxiüary a.-
he* e%c&77 inn-n mes, 174 reverse cuw in, 14&14$, 147f
hiswy'af,49 raüoRal&P4r81 t 9, l2Bf M o n i n g of, 168, 1Mf
Wai&+& aPF~&!m*Ta5 Wnim of, 1 2Qf-12 1f, 123 stainles steel. %e S t a i n k sW mh-
~ ~ 171 M , MfQml w'ves.
rMuM m 29' " b d , " 101-105, iO2f-109 stiff, 107
&kx#&r Spifrlt W @ 4 , 5&5?,5?f ose st* im-105, jozf-1~5f tieba~k~ f 129-131.1JOf
,
&&ni m, lh 27 dinKal adjustmem b, S 160 titaniurn afby, 113
AiyWM,*,Xf mcidlWr, Ci*P-S,&f-BF transihai, 1Ó7
Aquidtiof), bfadek. &e B r d e t mgW m a x l k y See WbYy w4 h. Archwire sequencdsquencing
tion. mtol;&e wicli K h fom m n k n e n t scheduling, 113
h t w b r bwr eiastics~$66l W 6mkm&ies, 97, W, 1
A K ~P QD care && ~ f141, , 142f-14f
A@- Arci Iqngth d i s c r ~ w q clear br*& 112-1 13
BitMpming,- , 175 &sdptbs)msf, 1if, &; 9lf @ hite wrerted vuith, 1 39f
fa@m&, %xFa& m&. jw&m&rl mkd&m,1i9 eWact.iQn
fa* SeFxebW. m W ' r formanditrular aKh, 11 1-1 12, 1 1Zt
fQP Mdng fwpe, &M@, 87- pft3% 42 fymaxillay a&, 9 10-1 11, 4 12t
Rp bmp, Bfmf,8H7,92f, 1% iiiushtim ort, 1 1f: 42% r w T 186f-1 #f, f 86-1 88
r* pferndw mvMm ¡&a%@, W3 honeñvxth
m& b i l m n g . 88,$Bf -r% guldelim fw 138-139
mW$l a&, 87,87# fw C h II *&al p m f i , 3-6, Gwf fCjp nrandibulsr a&, 109-110,
rwld palami mnders.
@ara1 mpandem
*Rapid cbirrg, 10% 'I07,rTH, f ZBf
c i ~ Wa, 14&14?, 14H
112t
f.or maxE119ry a&, 108-1 09, I 1 2 t,
r e m a l bf, 203, ZWf euive af p W M, lWf, m,'1M 131, 133f, 174-175
retajma, ~ e cw! n e t s . deíi&m6f, 137 varialiom in, 11 2
trnWbM ~, 87,Wf Wmmirig o#*107' Archwire template, 155f
#pponanlmadiedu#ng, Y 13 @r&h'ii of, T37-la4 Artkt5c-positionihgbehds, 52
B twque
Bail hoaks, 1M, 164f
Band remaval, 169
Bandhg
illustrationof, 67, 67f
mandibular separators,p k e d before,
t9f
~f caribes, 160f
"Big pitture" approzich to t r e a m t , 7
Bimaxillary protlusion, 41f, 1Wf,
184-185, 195, 1%f-201 f
Bite. See &p bte; Open bite; Overbii.
Bite plate, 88, 88f, t 54
Blte T u b s , 638,88f
Bonding of breets, 67,67f, 103
BOX d e , 166f-167f, 166.1 67
Bbys, 8,9f, 75
Brachpphalic patte~n,43f
Bráckei(s)
Alemmder Spirit. 56-57, 57f
bondlng of, 67,67f, 183
remo\lal of, 203, 204f
rotaiion wings for, Süf-51f, 5&5 1, 57
single w twin, 49-54 Nf
Bracket angulation
dmription of, 52-%,53f
mi1lary inciwm, 63, 63f
purpm of, 62
Bracket engagemgrrt
low-frictioh liga-, 127,118f
self-ligation, 128
B r a M height
canina, 60f
for mandibubr teeth, 6ot
for maillery anterior teeth, 59
3racket height gauge, 59, 60f
%mk@t plaoement
angular considerations. See Bmckft
angulation.
Y 68,69f-73
CX@ S ? ~ ~rf,
in extraction cases, 64.64f
height msiderations. 5ee Bracket
kight.
mandibular separators placed &re,
19f
maiodistal, 646-65f. M 5
open bite treated with, 62, 62f, 68,
69f-736
Brxket pcexnptiwi
anglrlation. See Bracket anguiation.
f ~ t l ~ - u68
p,
frkaon, 56, S7f
mesiaia&taf positim, 64W5f, 64-65
offets
facioiingual base, 51, S1 f
molar, 52. 521
iilrrstration of, 41f
mandibular anterior incbr, W 6 f , lwg-term srabillty in, 29 4
53-56 rnalocdusion with, 17-20, 9 8f-2M
mandibubr pwterloc, S,56f with mdllary anterior crdtríg, 10-1 3,
8ratket slots, 49,57f 1 If-13f
Burcal box elastics, 167, l67f maxilbry arcb in, 100
-1 corrldws, 26-27,27f, 39 with moderate cum of %e?,1l f
miar ancharage Qring canine
c & d o n in, 187
Canine(s). See hbndlbular canina; C l m 111 malocclw[on
Mandibular intercani~W; m e study of, 7tf
M d h y canines. finishing elastia fa168, 169f
Caniae bracket maxillary rn&r t u k m t i o n i n g in, 65
height of, 60f, 66f Class Iii Jceiecdl pattern
inverted, in canine substitution for m& cephalometric analysis d,35f
ing maxillary lateral incisar, 65, 6 8 fa& mask for correction of
mandibular, 189 dactiption of, 81f. 81-82
Tanine guidance, 6 W 1 rapid pdlatal expanleers and, 85
C a r b r r d u m strigs, 172,173 wra'cal m i l l a r y defdenty, 81,81f
Cdasp, 206 207f vertical mdlbry extes, 81,8 1f
Centrk datibn, 154 Class 3 dartia, la,1 64f-165f
Cephalometries Class 2 elwtics, ?a, t 65f
intw*ncislande, 24.24f Clear bncket archwire seqwnre,
mandibular id-, 13,23f, 36-37 112-113
rnaxillary indmrs, 23-24, 24f, 38 Closing archwlm" 1 03f, 107, 1 l6f, 'I74f
sagittal contrd, 24,24f Cmmunication
sagittal skelaal pattem, 36, 36f horizorrtal, 219,219f
*letal wrtial eontrol, 23,23f norwerbal, 2 18
soft tissue profik, 24, Nf shaking hands as fmof, 218f,
Ceiiiical headgear, 114 218-219
C h e k wtraaion, fw bondiq, 67,67f techniques fsr,2 1 S220
Circumhntial mm*lbryretainer, 47f Comp l i a m
Cbss 1 maloccl&on, 168, 169f in borddine nonextraction c a s ,
Class 1 skeletal pattem 173-174
arch form miderations, 100 dinician'sconfihnce in techniqus and,
case study of, 31f 21 5
C las II maldusion m t i n g of, 214420
arch fm In, 100, 101, Imf-10Sf degrees of, 214
case sludies, 4447, 4 5 f 7 f , 101, descriptrwi of, 3
10261051, 114, f lSf-118f, 141, f a c e b w we, 80, $Qb
142f-1 Mf, 144, I5Of-152f, 1 57, failure in, 221-222
158f-161f, 177, 178f-181f importan# of, 22
c k 2 elastia for, 165, 1 65f,168, 169í mivatiorí-based appmadws, 2 14,
curve of Spee in mandibulw arch, 176. 2 16-222
176f o f f i i environment on, 2 17-2 '1 8,
fxebw.fw; 154 218f
mandibdar inrkar püsitming in, 176 patiient educa- fm, 2.1 5f, 21 5-2 16
maxillary expansbn n & w r y for cor- PtbgPess iepotts ~d for, 279
recting, 155 rapld palatal expandw use, 84
maxilhty molar t u k rwitioning in, 65 retainer, 209, L09f
mechanics of, 175176 reward v t e m for pmmoting, 218, 21&f
Clas II skelaral pnwn short-&m pmls for, 221
SaSe Studk . ~ d ,3-6,4f-úf, 1 0-1 3, surnmary of, 222
1 tf-13 Cmcave profile, 41f
correction of, 77-81 Condyks, 28, 28f
f a & w for correction o!, Fmbow. Conmx profile, 41f
Cweg: S k p M R, 7,16,35,217 Uastmeric chains, 18€-1.B;r, 187f First 11101ar~,&e Mandlbubr mdars, first.
Cmsbite elastics, 164, 164f EW&c ligatures, 113, t l @ F M e n e r s , 134f
ct& teeth Embrasure ams, 207,207'f Flexible ardidre, 107
case study of, 30-33,3 1f-33f Errame1 m
mandibular lateral inqisors, 93f contourlng of, 61 ase study u% of, 122, 123f-126f
maxillary lateral inllsors, 1 15f lnterproximl redwtionof, 172, 173f, hr Class Ii skektal pattem correctlon,
Cutw of Spee 183, 21M121,&211 78
in archwirti, l47f, 186,186f mtcniring of, 66,66f for Class I skektal pattern comtioh,
h U n g of, 27, 27f, 145, 146f Encwragemt, 2 1%220,22% 8142
in M i b u l a r arch, 62, 153, 176f Evi-ced orthodontics, 22 Qa%kfor, 21
moderate, tlass Il skdatd pattern wrth, Emdm treatment hdding, appliances used for, Wf-88fl
1l f arch length discmpanaies h, $39 87-88
in open bite-type maldwsions, 27,71f archwire squence in mechariismsof, 137
rewm, 71f, 145 marrdibular arch, 7 11-1 12, 1 12t FFicüon, 56, 57f
severe, 27f. 1 2 3 18&191,18!3f-1~1f
Curved mt, 38,39f W l b r y ardi, 110-11 1, 1 l 2 t G
186f-1Wf, 118&188 Gingival crest, 5g
D a r c h w i ~tiebadc in, 129, 129f G ingival f i h t o q , 2l O
oeep bite In blmaxillarjr protnision, T 845, 184-1 85 G ingival hJgRt
ardwires fbr bracket p k m t in, 64.64f case study of, 9 5 f 4 f
W i n g of, 168,168f m ~ t ~ of, d k1'92-201
~ d i in, 61f
wmrrg of, t39f in &¡bular arch length di-ricy Gtnghria lirae, 39
c K m s t i c s of, 145, t46f paüents, 183,184f Ginglval recession, 431
iHustraüon of, 88, 88f mandibubr incisors, 184 Girk, O, SI,75
Delayed gratifilation, 213 patient manageinent, 184-1 85 Gmb
Dentitkm, 9f. S e &o speciflc teeth. pnmotars, 183-184, l84f cephalomeuic mewurements for xhirev-
Diagnosis prwalence of, 183 ing. S@@ Cepblometrja.
cephalometric rneasuremenb u& in. principies of. 185 g M h variatioris' effm on, 22
Sw Cephalmetrics. surnmay of, 192 iist of, 22
dedsicm paradigm u& to establish, patient compliance prometed thmugb,
41f, 4742,43f F 221
facial photographs for, 2&29,29f Face m& G M
panoramic radiraph use in, 28, 28f C k MI skeletal pattems covstd agerelated varlations, 8
mdy cast use in. See Study casts. using, 81f, 01-82 inboys,&Sf
treatment timing based m, 8 faabw and, d i f í e m ktween, 82 in girk 8,9f
Diamond bur, 203, 204f open bite tmted with, 7M mandibular, 7&77, 89
Discipline, 2-3 Webw maxiltofacial. 5 e M&hfxial growth.
D o l i c ~ h a l i pattern,
c 43f arch condia*n aing, 120f potential for, methwls for detñrninlng,
"Driftdytb," 114, 116f,12 t f, 185, ase study of, 131, I33f 7s
188-1 8 , l m,205 CLass IIskeletal patkms m & uaing stage of, 8
adjustments, 7&80, 79f-W treatmwit $m&affected by, 22
E dewiptim of,77-78,78f Guray bite Wnec 88f, 89
"E space," 9,9f, 87,87f, 92f nMrvwtiEal mtrd,79-80
Effectiveness, 16 ayter baw adjustments, 79, 79f H
Effiuenq, 16 after rapid palatal ~ & n ,84-85 parafunctional, 22
flatiits,
EMort Equals Rewlts ((E = R), 1-2, 2f,218 definition of, 77 Hamony line, 24, 24f
Eiastics face mask and, #iff&eptces between, 82 Headgmr eWect, 77
box, 166f-l67f, 166167 m& llary ardi treatment b e f m use of, Horizontal mrnmuniration, 219.21 97
~ W d yU% ~ f157,
, 158f-l69f 153-1S4 Hyrax rapid palatal expnder, 82-83.83f
C ~ S 3,164,
S l64f-165f patient compham and instructions, 80,
ctass 2,165, 16Sf, 175 8ub
crossbite, 164, 164f resea& on, 8'1
ftnishing, 156, 168.1 69 Facid photographs, 2&29,29f, 38-39
midBne, 156, 156f, 166, 166f Fibtotomy, gingival, 210
5equence of, 163, 164f Figure-8 liwtion, 1 28f, 1Mf
timing of use, 169 ñPiihing ebstia, 156, i@-I 69
lntercanine width, d i l i u l a r Id&, 27,27f MandiMr f e t a i m , 208.208f
arch fOrm determitwdby, 9 7 , W b r i n g d 27,274,145-146,148. Maridibularqarators, 19f
d-ipüon d,2%-26f, ZSt, 25-26 midline m m ' m with e l a s t i 156, kndibular te&
tnterimisal angle, 24, 24f, 2A8,29f 196f anterior, 176. See abo spectfic teeth.
Intedar wibth, maxillary, 2@-2?f, narrsw, 76 posterior, 56, !%f. See &o Mgndibular
2&27,4,43f stahl&s 9teJ archwims in, 99* ggfi mbrs.
Intwpmximal enamel reducthn, 132, 1 24f Maxilla
i n f , iw, ~ I M2 9,~ 2 1 1 Mandibular arch f m , 97,98f-99f vertKal defdency of, 81,81f
I n w a l ebstitics. S e E h t b . Mandibufar aKti length dxrepancy v w t h l w o f , 81,81f
d-tion Of, 38,42 Maxillary anterior t&. SM also wiñc
K jllwtration of, 1 lf, 43f, 1W mth.
KISS prtnclp1e premolar extradiíon i n d d o q , 1 b r d e t helghb for, gOt
ase s t d y uzilizing, 17-20, 18f-20f MandiBular adwire bracket plmrnent m, 62,62f
.d&ptiOn ~ f 1,5-1 6 for C l w U &&tal pattern, 3-6,4f-6f Mexillary a&
m r
s ecurve in, 148 archwin sequence for
L Mandibdar canines In Wactbncases, 11&1111,1tZt,
Labial wire, 206,206f-207f bracket4, 189 l86f-l88f, 1186-188
Lateral b g d&i, 1af-t67f, 1x7 d d s t a l W e t wtioning cm,64, in m r a c t i o n c a S , lW'109, 1 126
Lateral indsors. S e Wndibutar incisw(s); 64f 131,133f, 138, 174-175
k # l a s j iineiwo. Mandibular inc*s) in Class IIskektai pattern, 1OO
"btit m&" principie, 137-144 anterior, tmque in, 53, 53f-55f ~ N W c t e d 69f.
, 100
tevstingaf mandibulararch, 27, 27f, arch fom Iiased on p l m m t d,97, cwdlng in, 1%
14Ef46 1 4 98f extracth t W m t in, 186f-IMf,
üfethne retentim, 211 br& placement m, 61,64f 186-188
hgathn ciass 3 da& applir;aüm, 165f midline c o m i o n wlth elastia, 156,
atchwl~,Vt-2&129 ria class II malwctrision, 176 156f
figulei8,128f, 186f &e of, 146f nclliexttactiont r e m t , 174-175
hfric?&n, i27, 128f extraction of, 184 space dosure in, l20f
sdf-li@M, 113, 128 inclInalisn of, 23, 23f symrnetty ih, t 54
üngual arrh, 87, 87f. 92f lateral tied-back, nM
Up bumper, 85f-83f, 8587,92f, 154, angulation of, 63 Weabmirt initiation in, 153-1 54,
1S4f c m g of, 9331 174-175
Lip lime, maxillary, 132f. 151f rmtion of, 161f V&aped, 123f. 15üf
Low-f Bctian Itgation, 127, 128f norrnally indlned, 41f Maxihíy arch fom
p o s l t i ~~ f 3&38,41
, f in Clasi Imalocdusiom, 100,117f
M prodi&, rtli finalizing of, 98-99, 99f
M a g n i f i o n loupes, Wf, 203, 204f recontwrringof, 63 ovoid, 26f. 27
Mkdusim. S e spxif~ m a l d w i o n . &trdn& 41f Maxiltarjarchwire
Maftdtk r O t M 0f, 161f for C i w IIskletel pattern, 3-6,4f4f
armding ir2, 197f Madibuhf 1 ncisM-ma~ularplaw, 23, cuwe Err, for lmling of arches, 146
dekienq af, TQ2f 23f in exwcüon treatmmt 186
grUwth of, 76-77, 89 Mmdibular intemnine width Maxillary caninies
Mafldibdararch m h farm deemiimd by, 97,98f d i n g of, 1 1Sf
axhwire saquen= for &criptian of, 25f-26f, 2% 15-26 "let it gmkaprMciple appIhtim tcr, 140
iri Mraction sasw, 11 1-1 12, 1?2t, Mandi1Puiar d r s pwitioning of, 18&187
188-191, 18%-191f dass 2 e W c s used to m-, 165, 1 65f recontourSnp bf, 67f
in nonextractbn Cases,1OS114 112t, fim wtraction of, 1 t 6f, 121, 140, 185f, 186
175 angubtion of, 6243,63f substírution of, for mxillary lateral
hnding of, 189 m i a l l y tipped, 72f intiat, 6546, 66f
in Class II makdusion, 1 7 JT uprighted, 28f,63 Maxillary inuwfi
COmtWd, 69f offset of, 52,$2f angulntion of, 63,63f
c M n g in, 1SM,171 xond edge relatiomhips fm, 59, 60f
ctirve of Spee ha6 , l S3, 176f a~hwire-ks, 129, 129f indination of, 23-24, 24f
"driftdontia," 114, 9 161, 121f, 185, lip bumpsr use and 85 la twai
188-18g1 18% 205 tw~m ~ f 56,
, 56f canina substitution for W i n g , ó m ,
¡nitiaticm of watment in, 155,175 Mardibular plam anqb, 23,23f 66f
 c t M n g nf,11sf emoura~mentof, 219-220,220b
offset hnds for, 2% 2ü6f -f imfructions foro80.8üb
palatally erupted, 65,65f goal ~ f t i n gfor, 221
rotatlan of, 7 1f, 73f, 1%f habibof, 22
variabtllty Ih, 6-5, 65f O nonmplian~ioby, 22 1-222
mesodista1wfdth of, 172 Ocdwian gersMtalw of, 216
positm d, 38 Clas 1, 11Sf, 134f, 196f rapid palatal qpander instnictions for,
retractionof, 186 normal, 27, 27f &lb, 84-85
Maxillary internolar mmdth Office emiininmt, 217-218,218f F e M wm p u ct
o
in s for, 20&209
arch form based on, 9B.W OFfsets reward system for, 218, 21 8f
description of, 26&27f, 2 M 7 ,38, 42, faciohgual base, 5 1,s 1f rote of, 22
43f mdsir, 52, 52f shaking hands whh, 21N,2228.219
W l l a t y molar$ Omega loop staff attitudes toward, 217
distalizath of, 171 in archwire M e W , 130, 1JOf Pendulum appliam 88, 88f
orrSet of, 52, S2f bendkig of, 16 Periodontal heaith, 28,28f
WIlary reta& 47f, 206f-2Wf, illuwath of, Sf,1Q3f,1Wf Mistence, 2
206-20s Open bite Photographs, facial, 28-29,29f, 3&39
Maxillofacla8 gmwth a& constwctiom wwiated Mth, 69f Pragmath, 2
de~crtpthn6, 75,89 archwin W'mIrsg for, 168,I68f Premolars
gertder differ~ces~ 75 bracket p p b m t for, 62, 62f, 68, bracket angulatiotw with maction of,
=fatal dhmsion of, 75-76 69f-?3f 64,84f
tranrvemdimm$on of, 75 Class III, 68. 6%-73f extraétbn of, 183-1 M, 1 Mf, 192-201
wrtisl djmrrsion af, 77 cuwe of h, 27 Raclined rnandibr i n c m o41f
M ~ i c d i ibrarket
l plmment, MfdSf, face mask therapy for, 70f Pmgress mrinitoring, 2 2 S 2 1
-5 nandibular first mohr angulation in, 63f Progres rema 2 19
Mesacephalic pataern, 43f mdaanics of, 176
Midline elastics. t 56, 156f, 166, 7 66f subde, 148 R
Mihniaukee brace, 7577,761 W&&tii: fom. See FoKe. Rapid @tal exparrdws
M i i d dentith, 9f owie case study &es of, 44,90-96,9 1 f-96f
Molar(s). 5 e Mandibular molars; Maxiliary É a g study lllustrationsof, 11f, i3f, 49, f x e b w pbcemeflt after, 8ú-85
molars. 9lf, 9 3 , 118 folb-up waluatiMK, M
Molar diilizing appliane, 88,Mf relapse of, 61t Hyrax, 82-83, 83f
Molar offsets treatment of, faetors that affect, 60 illustration of, 19f, 69f
desctiption of, 52, S2f Wjet inditions for, 26
for mandibular mulas 61 case study illusttaticlns of, 1 1f, f 3f, %f, for rnixed dentitiwi, 83,83f
Molar rtltation, 88 118f p a t h t tnstructions fw,84b, -84-85
Molar tu&, 65, 65f, 147f posferior buccal, 99 fos pennanent Mtition, 82-83.W
Ovoid arch fom far primary denti&, 83,83f
N case study of, 101, 102f-105f healing of screw, 84,851
hnce philatal ardí, 83, 87f illatration of, 26f, 72f, 92f-#f, IQQf, turning of, &4
NasoBbU angle, 39 ?25f, 151f, 193f-tMf, 1%f, ZOM Retainers
Nlckei-titanium arcknnm, 94f, 103f stability achieved with, 100 clcserning of, 209, 2119f
NickeLtitanium cal1 sgrinqs, '88 compliance wlfh, 209, 2U9f
NoncompSianée, 22 1-222 P design of, 205f
Nanextíaaion twatment Paled expande= See Rapid pahtal fldng of, f,09,209f
ardi consdidation, t 74 mpanders. instructions f w use d, 20%209
archwire sequence h Panriramic rdbgrapb mandtbubr, 208, 2ü8f
gddines for, 136139 ofcmw&QW. 3tf maxillary, 47f, ZDGf-20#, 206-288
mandibubr arch, 10+110, 1 12t, 175 periadontal health aswmnts, 28.28f 3 X 3,208,208f. 210
maxillary a&, 108-1 09, 11Zt, 131, rmt positioniri~whg, 28,28f Retention
133f, 138,174-1 75 P a r a f u M a i habits, 22 goal of, 205
borderline paticnts for, 17 1-1 74 Pat'mIbl lifetime, 211
W study ~ f149, , 150f-152f, 177, attihrde adjustmt for, 21 7 long-tem, u0
t m-isif Ccrrliplianle by. !ñ?e Compliance. long-tem st&I-ir/ t h r q h , 21 1
m p l a n c e issua, 173-1 74 difbmes among, 216-217 'r@taimfw. S e Retainers.
initiatim of treatmnt, 174-176 education far, 21Sf, 2 1E 2 t 6 Retrdined mandlbdar incisors, 41f
Rb~t(s) concave, 41f rapid palatal wnders for, Se Rapid
a d w t to exlnction sites, 28, 2Elf evaluations of, 28-29 patatal expamdets.
angulatd, 38,39f stainless stwl mhwires Trapezoid elastia, 167, 167f
cwed, 38,39 illustrationaf,32f, 94f, 1 l6f-117f. 133 Treatment
diverqenca of, 28f mandlbular arch km plasment with, appintment xheduling, 1 13
positbning of, 28,2%f 99, Sf, 124f, 159f "big pkture" appach to, 7
Rmt divergente, 62 Seel ligature wlre, 16, 128-1 29 M o n paradgm for, 41f. 4 1 4 2 4 3 f
Rwt tip anguiation, 52-53 Study casts dacumentation of, 40f
Rotation wlngs, 5Of-5 1f, %51,57 arch fom,26f, 27 dutation of, 1?3-114

S
illustration d,25, 25f
mandibular intercanine width, 25f-26fs
*
@ictralaon. Eittradion t r e a m t ,
goaks of, 214
Sagittal control, 24.24f 2% 25-24 nonextratrion. 5& Nonexfractlontreat-
Sagittd deletal pattern, 36,36f maxíllafy intermta asrldth, 26f-27f, mt.
Schudy, Fred, 75,76f, 148, 210 26-27,38 m t r n e n t twiw, 2ü4,205f
moleirs, Si?e Mandibular rnoiars, Success T M t m n t sequem
first. dinical pr-, keys to,2-3 arch coordination, 1 55, 155f
Self-confidena, 2 treatmeint kep tai 22-29 finkhing, 156
Self-ligatian, 113, 128 " S u p Smik Award," 204 mandibuk arch, 155,175,2 13
Sella-nasion-mandibular plane, 23, 23f, Supwnumeray te&?, 3 95,1 96f-201f maxilbry aKh,153-154, t54f
36,37f, '18 Symmktry, 154 midline correcüon with elastia, 1 56,
Mtanasion-pdnt.A 24f136 156f
Sella-nasimnt 0, 24f. 36 T Treatment tiining
Cing/esvingbrackets, 137 Temporomandbufar joint mdyles, 28, age of pawt and, 8
Skeletal pattem 28f autiwf preferente for, 9
Claa I,31f, 100 Tetrqon @S, 24,24f case gudy of, 122,123-1 26f
Class II. * Clas II skdetal patkm.
Clzm ill. a Clag III skeletal pattem.
Third das, 204,205f, 210
3 X 3 retainers, 208, 208f, 210
diagmsis influerm m, 8
g r W h stage and, 8
miltal,36, 36f 34kyee nile, 23, 38 imprtnnce af, $
vertical, 36,37f, 43f Tkbadc, adwire, 129-1 31, 130f Triangular eldg 4 67,167f
Skeletal vertical control, 23, Uf Titanium alloy a r c R w i ~ 1, 13 Tweed Principie, 15, l6f, 35
Slenderizhg, 172, 173f, 21(lf, 210-21 1 TMA Floap, 188, ?#f. 199f Twim backets, 49-50, 50f
S m k atc TMA wires, 113
defini2ion o[, 59 Tmth eruption, ea& 38,39f
m t i o n of, 39 Toque, 53f-56f, 53-56
Smiling lip, 39 Transpalatal arch, 87, 87f
Wft tissue frontal appearance, 39 T r m r s e eprtsion
Soft tissue profk characwis.lks of, 82
case study of, 31f lip bumper, 85f-87f, 85-87.92f
 y e a t dnce,Dr~lexuiderhumgqd in re=&& &y pro-
&ksn a Mw i h - fd fm t=Qupr, whidi h.rc beai cxtendvely tea&
m!m4hd.Whad< pranití itp Akxnndrr W # i m in the &*m of 20 prindpln h
t integrate
t k w y with ta%v.