The Principles of the Alexander Discipline
Richard G. Alexander
The Alexander Discipline is based on the premise of a number of principles.
This article lists and briefly describes these principles and the reason each is
considered important in the management of the orthodontic patient in the
Alexander Discipline, (Semin Orthod 2001;7:62-66,) Copyright © 2001 by
W.B. Saunders Company
nY e n d u r i n g principle must be built on a
A solid foundation, on certain beliefs that
have b e e n tested a n d proven by time a n d expe-
rience. In the M e x a n d e r Discipline, a certain
n u m b e r of principles are followed that give this
technique its uniqueness. T h e first three princi-
ples focus on the philosophic nature and the
attitudinal a p p r o a c h to the delivery of the Disci-
pline.
O n e of the original goals of the technique is
to m a k e t r e a t m e n t easy and m o r e comfortable
for the patient. For any technique in o r t h o d o n -
tics to be successful, the patient must be involved
in the procedures. Even though some appliances
are said to be noncompliant, the reality is that
no such thing is possible. Each patient must be
willing to keep their teeth clean, take care of the
appliances, watch what they eat, and be present
for their appointments. Allowing the patient to
b e c o m e a p a r t n e r in the t r e a t m e n t p r o c e d u r e s
not only gives t h e m some ownership in the pro-
cess, but it ensures that the results will reach a
higher level.
Patient compliance is critical to the success of
this technique. T o o often, other techniques fo-
cus on the mechanics of treatment. Mechanics
are important, however, mechanics alone will
not p r o d u c e the optimal result without patient
cooperation. In orthodontic education, p e r h a p s
the forgotten skill is teaching the student moti-
vational techniques for successful results. 1,2
From Arlington, TX.
Address correspondence to IL G. leVi&Alexander, DDS, MSD,
840 West Mitchell, Arlington, TX 76013.
Copyright © 2001 by W.B. Saunders Company
1073-8746/01/0702-0001535.00/0
doi:l O.1053/sodo. 2001.23536
62 Seminars in Orthodontics, Vol 7, No 2 (June), 2001: pp 62-66
W h e n the n e e d for this skill is understood, the
clinician will accept the responsibility to learn
techniques that will e n h a n c e their ability to mo-
tivate their patients while p r o d u c i n g high-quality
results.
Principle n u m b e r 1 is taken f r o m Allen's 3
b o o k A s a M a n Thinketh, "In all h u m a n affairs
there are efforts and there are results, and the
strength of the effort is the measure of the re-
suit." F r o m this sentence comes the formula,
Effort = Results.
Principle n u m b e r 2 is based on a n o t h e r
quote, "Sometimes when I consider what tre-
m e n d o u s consequences c o m e f r o m little things,
I am t e m p t e d to think, there are no little
things. ''4
Principle n u m b e r 3 comes f r o m World War II
and is used in m a n y variations today, "keep it
simple stupid. ''3 O f course, the acronym is KISS.
Principle n u m b e r 4 states that you should
plan your work. Accurate diagnosis and treat-
m e n t planning is critical. No matter what ceph-
alometric analysis (Fig 1) is used, three basic
questions must be answered f r o m the cephalo-
metric tracing before a p r o p e r t r e a t m e n t plan
can be produced:
1. Sagittal skeletal pattern: D e t e r m i n i n g the
Class I, II, or III growth pattern will help
decide what type of orthopedic force is pre-
ferred.
2. Vertical skeletal pattern: Determining
whether the case has a high-, medium-, or
low-angle skeletal pattern will influence
t r e a t m e n t decisions.
3. Incisors position: (a) In most cases, in the
a u t h o r ' s opinion, the best and most stable
position for lower incisors is the position in
which the patient presents. To keep lower
 Alexander Discipline
POINTS OF MEASUREMENT
Figure 1. Cephalometric measurements used to determine sagital and vertical skeletal patterns and incisor
positions.
incisors in their original positions is often
our goal. (b) In extraction cases, lower inci-
sors are almost always uprighted. (c) O u r
studies 5-7 have shown that lower incisors can
be advanced up to 3 ° and remain stable.
Beyond that degree, instability is more
likely. The only time the lower incisors are
advanced beyond this degree is when they
are abnormally retroclined. The latter situa-
tion is commonly seen in Class II, Division 2,
and Class II, Division 1 deep-bite cases.
By maintaining good torque control of the
u p p e r incisors, along with the lower incisors, a
balanced interincisal angle is created. This is
critical for long-term stability, s
Principle n u m b e r 5 describes our goals for
stability. Objectives include mandibular incisors
that are balanced on basal bone with a good
interincisal angle, cuspids not expanded, p r o p e r
root artistic positioning, upright mandibular
molars, normal overbite and overjet, and a func-
tional occlusion in centric relation. These goals,
when achieved, have b e e n f o u n d to create
healthy, aesthetically pleasing, and stable re-
sults.5.6.s-10
63
Principle n u m b e r 6 describes specific brack-
ets designed for increased interbracket space;
wings for rotation and correction, then control;
precision p r e t o r q u e d slots; and precision base
variation. Details of the bracket system are dis-
cussed by Bagden on page 74 in this issue of
Seminars in Orthodontics.
Principle n u m b e r 7 r e c o m m e n d s "building
treatment" into the bracket placement. In plac-
ing brackets, three dimensions are considered:
bracket height, bracket angulation, and mesio-
distal bracket position. This is also described
later.
Principle n u m b e r 8 is to obtain predictable
orthopedic correction by using a face bow, face
mask, rapid palatal expansion, lip bumper, or
other auxiliary appliances such as the transpala-
tal arch, the Nance, lingual arch, magnets, and
distalizing mechanics.
Face bow treatment is discussed in a n o t h e r
article in this issue. In the M e x a n d e r Discipline,
a face bow and face mask are used primarily for
orthopedic forces. This means that these forces
are placed on consolidated, tied-back arch wires
in growing patients. If arch wires are not tied
64 Richard G. Alexander

back, the facebow forces are changed to orth-

ORMCO ®
odontic forces, resulting in tooth m o v e m e n t .
Principle n u m b e r 9 discusses the use of a
proven arch form design 12 (Fig 2) and a contem-
porary arch wire force system. 13 Most patients
are treated by using continuous arch wires be-
ginning with the maxillary arch. T h e initial arch
wire is r o u n d and flexible (.016 NiTi). T h e tran-
sitional arch wire has intermediate stiffness (.016
stainless steel or 17 × 25 titanium alloy). T h e
final wire is stiff, 17 × 25 stainless steel. T h e only
difference in the m a n d i b u l a r sequence is that
the initial arch wire is a flexible rectangular wire,
for initial torque control. T h e functions of the
arch wires include: elimination of rotations, de-
v e l o p m e n t of arch form, leveling the arches,
control of torque, a n d final arch form.
Principle n u m b e r 10 is to consolidate
arches early in t r e a t m e n t . T h e p u r p o s e of clos-
ing spaces is to c h a n g e 10 to 12 i n d e p e n d e n t
force units (the teeth) into 1 unit. W h e n this
has b e e n a c c o m p l i s h e d , o r t h o p e d i c forces,
such as a face bow or a face mask, can create
skeletal c h a n g e s r a t h e r t h a n dental changes.
Also, iutraoral elastics, w h e n a t t a c h e d to the
ball h o o k s o n the brackets, will n o t m o v e in-
Part No 20%0060
dividual teeth or cause spaces to o p e n b e t w e e n
the teeth. C o n s o l i d a t e d arches are a goal o f Figure 2. Most maxillary arch forms will fall
this t r e a t m e n t . within 1 SD of this template. Two mandibular arch
Principle n u m b e r 11 is to obtain complete forms are needed to accomplish this. (Courtesy of
Ormco Corp, Gleudora, CA.)
bracket e n g a g e m e n t w h e n placing arch wires,
ligating with steel ligatures, and maintaining
consolidation with o m e g a loops "tied back."
O n e o f the most i m p o r t a n t concepts of the dis- q u i r e m e n t s are p l a c e d into the stainless steel
cipline is using tied-back arch wires. finishing a r c h wire: a r c h f o r m , torque, curve,
Principle n u m b e r 12 is to level arches a n d a n d o m e g a loops. After this wire has b e e n
o p e n the bite with accentuated and reverse p r o p e r l y tied in (full-bracket e n g a g e m e n t a n d
curves of Spee. Clinical experience and re- tied b a c k with steel ligature wires), time is
search 1:~,14 have substantiated that leveling the n e e d e d for the g e n e r a t e d forces to have their
arches and o p e n i n g the bite with the M e x a n d e r effects a n d to m o v e the teeth into their final
Discipline is not only successful, but also stable positions. O f t e n this wire will r e m a i n in place
(Fig 3). until fixed appliances are r e m o v e d .
Principle n u m b e r 13 advocates p r o g r e s s i n g Principle n u m b e r 14 focuses on creating sym-
into finishing a r c h wires rapidly a n d allowing metry. Coordination of the arches is essential to
sufficient time for the a r c h wire to m o v e the establish occlusal symmetry. T h e maxillary and
t e e t h to their desired position. By following m a n d i b u l a r arch forms have now b e e n individ-
the previous principles a n d s e q u e n c i n g the ually finalized and the goal then is to get the
t r e a t m e n t plan, the finishing a r c h wire is usu- maxillary and m a n d i b u l a r arches coordinated.
ally p l a c e d in 6 to 9 m o n t h s in n o n e x t r a c t i o n Coordination is accomplished by using pre-
patients. In e x t r a c t i o n t r e a t m e n t p r o c e d u r e s , f o r m e d arch wires in b o t h arches as well as sym-
p r o g r e s s i n g into finishing arch wires m a y take metrically adjusting the inner bow of the face
9 to 12 m o n t h s All o f the final finishing re- bow and the lip b u m p e r . Final symmetry is es-
 Alexander Discipline
Figure 3. Mandibular heat-treated 17 x 25 ss arch wire with reverse curve of Spee tied in and tied back (A).
Six months later with both arches level (B).
tablished by specific elastics in finishing arch
wires.
Principle n u m b e r 15 r e c o m m e n d s that finish-
ing arch wires be in place before initiating elastic
wear. By establishing arch form and p r o p e r
torque controls before using intraoral elastics,
the elastic forces act more orthopedically, mov-
ing the entire arches without adversely affecting
the teeth. The exceptions to this rule include:
the use of cross-bite elastics when necessary;
Class III elastics may be used when the lower
arch is initially b o n d e d to prevent flaring of the
lower incisors, a n d / o r while closing lower ex-
traction spaces with a closing loop arch wire in
m a x i m u m anchorage situations; and Class I1
elastics may be used when closing lower extrac-
tion spaces with a closing-loop arch wire to move
lower molars forward in m i n i m u m anchorage
situations.
Principle number 16, in nonextraction cases, u~
r e c o m m e n d s initiating treatment in the u p p e r
arch and progressing into finishing arch wires as
soon as possible. Because the major goal in non-
extraction treatment is to control the position of
the lower anterior teeth, total focus can then be
placed on these teeth when the lower arch is
b a n d e d / b o n d e d . The lower anterior teeth are
controlled by - 5 ° torque in lower incisor brack-
ets, - 6 ° tip on lower first molars, the use of
initial flexible rectangular arch wire, slenderiz-
ing teeth if necessary, and Class II1 elastics if
necessary.
Principle n u m b e r 17 r e c o m m e n d s that, in
extraction cases, treatment be initiated in the
u p p e r arch. The objective is to remove potential
bracket interferences by improving the overbite
with an accentuated cmwe of Spee and retract-
65
ing the cuspids before b o n d i n g / b a n d i n g the
lower arch.
U p p e r cuspid teeth are retracted with power
chains on .016 stainless steel arch wire. This
procedure usually takes 6 to 8 months.
Principle n u m b e r 18 r e c o m m e n d s that, in
extraction cases, 17 treatment is delayed in the
mandibular arch to allow time for driftodontics
(Fig 4). This is the term the author coined to
describe the spontaneous unraveling of the
lower anterior teeth, making it m u c h easier
to place brackets after 4 to 6 months. W h e n
the u p p e r cuspids have been retracted to a
Class I relationship, the lower arch should be
bonded/banded.
Principle n u m b e r 19 advises the use of a spe-
cific retention plan ls,-~ incorporating retainer
design, time sequence, and resolution of third
molar teeth in an effort to ensure long-term
stability. The u p p e r "wrap-around" retainer wire
is fabricated to a specific design and has proven
to be extremely effective according to the au-
thor. Also r e c o m m e n d e d is the fixed lower cus-
pid-to-cuspid retainer design using an .0215 Tri-
ple-Flex wire (Ormco, Glendora, CA) b o n d e d to
each tooth. After bracket removal, the u p p e r
retainer is worn only 8 to 10 hours per 24-hour
period, being placed after dinner and removed
the next morning. The patient is instructed not
to wear it out of their home. The resulting re-
duction of lost and broken retainers has been
remarkable.
Principle n u m b e r 20 is "to work your plan."
A l t h o u g h every case is u n i q u e in some ways,
in m a n y ways every case is also the same. The
general t r e a t m e n t plan in most cases as out-
lined in these principles is to treat the u p p e r
66 Richard G. Alexander
Figure 4. Pretreatment mandibular occlusal view (A). Four months later, showing driftodontics (B).
arch first by using a specific series o f arch
wires. If the case requires o r t h o p e d i c correc-
tion, it is initiated o n the maxillary arch with
an rapid palatal e x p a n d e r (RPE) a n d / o r face
b o w or facemask. A p p r o x i m a t e l y 6 m o n t h s af-
ter c o m m e n c i n g maxillary arch treatment,
t r e a t m e n t is initiated in the lower arch. A
specific series o f arch wires are used to posi-
tion the m a n d i b u l a r teeth. After the finishing
arch wires are in place, appropriate elastics are
used to c o o r d i n a t e the arches and finalize the
o c c l u s i o n . Retainers are then placed.
Following these basic step-by-step procedures
allows the clinician to control treatment
progress. By being able to anticipate treatment
objectives o f the next appointment, future
scheduling is simplified and treatment progress
can be easily m o n i t o r e d so that the treatment
can be c o m p l e t e d on schedule.
The ultimate objective is a well-treated pa-
tient, c o m p l e t e d in a timely fashion, with a sat-
isfied patient, parents, and doctor.
References
1. Alexander RG, Alexander CM, Alexander C, et al. Cre-
ating the compliant patient. J Clin Orthod 1996;30:493-
497.
2. Stroud J. The psychosocial effect of orthodontic treat-
ment [master's thesis]. Dallas, TX: Baylor College of
Dentistry, 1996.
3. AllenJ. As a man thinketh. Classics of inspiration. Kansas
City, MO, Halhnark Cards, Inc, 1971, 57.
4. Covey S. First things first. New York, Simon and Schus-
ter, 1994, 287.
5. Glenn G, Sinclair PM, Alexander RG. Non-extraction
orthodontic therapy: Post-treatment dental and skeletal
stability. AmJ Orthod 1987;92:321-328.
6. Ehns T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 1, model
analysis. AmJ Clin Orthod 1996;109:271-276.
7. Elms T. The long-term stability of class II, division 1,
nonextraction cervical face-bow therapy: Part 2, cepha-
lometric analysis. Am J Clin Orthod 1996;109:386-392.
8. Nevant CT, Bnschang PH, Alexander RG, et al. Lip
bumper therapy for gaining arch length. Am J Orthod
1991;100:330-336.
9. Alexander JM. A comparative study of orthodontic sta-
bility in class I extraction cases [master's thesis]. Dallas,
TX: Baylor College of Dentistry, 1995.
10. Alexander RG. Treatment and retention for long-term
stability. In: Retention and stability in orthodontics. Phil-
adelphia, W.B. Saunders, 1993.
11. Alexander RG. The quest for long-term stability. In:
Sachdeva R (ed). Orthodontics for the next millennium.
Glendora, CA: Ormco, 1997.
12. Alexander RG. A practical approach to arch form. Clin-
ical Impressions 1992;1:3-5.
13. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986.
14. Bernstein R. Leveling the curve of Spee with a continu-
ous archwire technique-a long-term cephalometric anal-
ysis. Master's Thesis, State University of New York at
Buffalo, Buffalo, NY, January, 1999.
15. Alexander RG. The Alexander Discipline. In: Engel GA
(ed). Glendora, CA: Ormco, 1986, chap 7.
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(ed). Glendora, CA: Ormco, 1986, chap 9.
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(ed). Glendora, CA: Ormco, 1986, chap 10.
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(ed). Glendora, CA: Ormco, 1986, chap 14.
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down to retention. J Clin Orthod 1983;18:214-218.