THE PRINCIPLES OF

ALEXANDER
DISCIPLINE
 Contents
• Introduction
• Principles
• Appliance design
• Conclusion
 INTRODUCTION

• Orthodontics in the Alexander family began with the older brother, C. Moody Alexander. Followed by Dr. R.G.
Wick Alexander(Gted ib orthodontics in1964 Huston University ,Tx.).

• The Legacy continues to the next generation of the alexander family by the son of C. Moody Alexander ; Cliff
Alexander and Dr. R.G. Wick Alexander's sons J. Moody and Chuck.

• They continue to live the tradition of The Discipline in their own private practices in Texas and Colorado and
advancing the study of orthodontics through the lectures that they regularly conduct around the world.

• The Alexander Discipline is based on the premise of a number of principles.

Any enduring principle must be built on a solid foundation, on certain beliefs that have been tested and proven by
time and experience.
Tweed to Vari-Simplex:
The Discipline maintains many of Tweed technique, and was developed from its principles. It has benefited from
growth dynamics while remaining true to its three goals: high quality result, ease and convenience for the patient,
and minimized chair-side time. In Alexander Discipline, the patient ends up with balanced facial proportion consistent
with skeletal pattern, which is the key objective to treat the case. Non-extraction therapy is preferable whenever
possible.

Vari-Simplex philosophy retains following three

fundamentals of Tweed technique:
1. Anchorage preparation (uprighting mandibular molars)
2. Positioning of mandibular incisors over basal bone
3. Orthopedic alteration with headgear
 PRINCIPLE NUMBER 1
PRINCIPLE NUMBER 1 is taken from Allen's book As a Man Thinketh, "In
all human affairs there are efforts and there are results, and the strength of
the effort is the measure of the result."
From this sentence comes the formula,

According to Alexander , The Keys to Success are Self-confidence , Persistence , Pragmatism and Discipline.
When persistence and discipline can be channeled in the right direction, positive results will always be produced.
 PRINCIPLE NUMBER 2
There Are No Little Things
Optimum Treatment Timing & Issues to Consider Stage of growth: From the orthodontist’s perspective, the best time
to treat patients is when they are in a period of maximum growth.

Age: girls begin growth at an earlier age than boys. For example, an 8-, 9-, or 10-year-old girl usually responds better
to headgear treatment than does a boy of the same age.

However, girls also complete their growth at an earlier age. Boys, therefore, respond best to orthopedic changes
between 12 and 14 years of age.

Orthodontic diagnosis:The clinician must weigh the advantages and disadvantages of orthodontic treatment while
giving equal consideration to the patient’s psychological health and the total treatment time.

General rule: Ideally, Wick prefer to initiate treatment once patients have lost all primary teeth, with the exception of
the primary mandibular second molars (the E’s). This usually occurs when patients are about 11 to 12 years old and
experience a period of rapid growth.
 PRINCIPLE NUMBER 3

• KISS A popular maxim is “Keep it simple, stupid” (KISS). The idea is to avoid
unnecessary complexity. With a desire to reduce the complexity of biomechanics.
• According to Wick, it is much more effective to have omega loops available so that
the archwire can be tied back and kept consolidated throughout treatment. The use
of steel ligature wire allows better engagement of the archwire in the bracket slot
and eliminates the need to change the orthodontic elastomers at each appointment.
 PRINCIPLE NUMBER 4:Establish Goals for Stability
orthopedic forces should control and/or encourage good growth. Orthodontic forces should not move the teeth
into positions that will be unstable.

Role of the Patient:

The most important factors are the patient’s growth, habits, and compliance.

The 15 Keys to Orthodontic Success:

Among all of the possibilities, 15 measurements taken from the diagnostic records can provide a brief yet accurate
determination of goals necessary to achieve successful treatment and long-term stability for the individual patient.
• Cephalometrics: The tetragon-plus analysis
1. Mandibular incisor inclination:In most nonextraction treatments, the mandibular incisors should be maintained
within 3 degrees of their original position (the 3-degree rule)
2. Mandibular plane angle:The problem arises when the patient presents with a high-angle vertical pattern. In
such cases, maxillary molar control is critical to prevent molar extrusion.
3. Maxillary incisor inclination:In normal skeletal patterns, the maxillary incisor should be inclined 101 to 105
degrees relative to SN. An exception to this rule applies to patients with a high mandibular plane angle.
4. Interincisal angle:The accepted angle between the maxillary and mandibular incisors (U1-L1) is from 130 to 134
degrees.
5. Tetragon plus:
a. Sagittal skeletal dimensions:Ideally, treatment of a skeletal
Class I, II, or III malocclusion will result in a sagittal jaw
relationship (sellanasion–point B) of 1 to 3 degrees.
b. b. Cephalometric soft tissue profile: Ideally, Holdaway’s
harmony line, connecting the soft tissue pogonion with the
upper lip, should touch the lower lip and bisect the nose.
Tetragon plus: sellanasion–point A (SNA); sella-nasion–point B
(SNB); point A–nasion–point B (ANB); sellanasion–mandibular
plane (SN-MP); maxillary incisor–sella-nasion (U1-SN); maxillary
incisor–mandibular incisor (U1-L1); mandibular incisor–mandibular
plane (IMPA) .
The tetragon ”plus” combines all of these cephalometric
measurements.
6. Mandibular intercanine width: studies have shown that any
expansion of more than 1 mm will invariably relapse. with
extraction treatment, the mandibular canines can be retracted to a
wider part of the arch; therefore, canine expansion is acceptable.
7. Maxillary intermolar width:
When measured from the lingual groove
at the cervical line of the maxillary first
molars, the maxillary intermolar distance
should be between 34 and 38 mm.
8. Arch form: An ovoid arch form design
will provide the most esthetic and stable
form for most patients . This conclusion is
based on the following rationale: If the
mandibular canine area is not expanded
and the positions of the mandibular
incisors are controlled, the maxillary and
mandibular anterior arch forms will be
mostly predetermined.
9. Leveled mandibular arch:
Leveling the curve of Spee
in the mandibular arch is
critical to the correction of
deep bites and the
maintenance of overbite
correction.
10. Occlusion:Everyone
agrees that good occlusion
is critical for function, health,
and stability. Excellent
11. Root positioning:
As displayed in the panoramic radiograph, the roots of the anterior teeth, canine
to canine, should be divergent in both the maxilla and the mandible . The
angulations to accomplish this root positioning are integrated into the bracket
prescriptions.
12. Periodontal health: Observing the interproximal bone levels is an initial
means of diagnosing the health of the periodontal tissues.
13. Temporomandibular joint:Observation of the condyles in the panoramic
radiograph is a preliminary method of diagnosing temporomandibular joint
problems.
• 14. Soft tissue profile: As mentioned earlier, the
ideal profile in a white individual is represented by a
line touching the lower soft tissue chin and the
upper lips and bisecting the nose.
• 15. Smile:The Alexander Discipline is intended to
produce the following results at the end of
orthodontic treatment
• Coincident dental midlines
• Coincident facial midlines
• Esthetically positioned teeth
• A balanced smile line
• A balanced smile arc
• Absence of dark buccal corridors
 PRINCIPLE NUMBER 5
Plan Your Work, Then Work Your Plan
“Begin with the end in mind,” is another Stephen Covey truism.
three basic questions must be answered from the cephalometric
tracing before a proper treatment plan can be produced.
1. Sagittal skeletal pattern: Determining the Class I, II(low
angle cases), or III(high angle cases) growth pattern will help
decide what type of orthopedic force is preferred.

2. Vertical skeletal pattern: Determining whether the case has a

high-, medium-, or low-angle skeletal pattern will influence
treatment decisions.
When the SN-MP anagle is 35 degrees or less (Fig 5-3), Class II
skeletal patterns can best be treated with a cervical facebow (Fig
5-4). During the treatment of a skeletal Class III patient using a
face mask, the force vector is often directed at 45 degrees in
relation to the occlusal plane, depending on the smile line.
 PRINCIPLE NUMBER 5
3.Incisors position:
(a) In most cases, in the author's opinion, the best and most stable position for lower incisors is the position in which
the patient presents. To keep lower incisors in their original positions is often our goal.

(b) In extraction cases, lower incisors are almost always uprighted.

(c) studies have shown that lower incisors can be advanced up to 3° and remain stable. Beyond that degree, instability
is more likely. The only time the lower incisors are advanced beyond this degree is when they are abnormally
retroclined. The latter situation is commonly seen in Class II, Division 2, and Class II, Division 1 deep-bite cases.

By maintaining good torque control of the upper incisors, along with the lower incisors, a balanced interincisal angle
is created. This is critical for long-term stability.
 PRINCIPLE NUMBER 6
Use Brackets Designed for Specific Prescriptions

To obtain effective torque control, three options are available:

1. “Fill up” the bracket slot. In a 0.022-inch slot, the logical archwire is a 0.021 × 0.025-inch archwire, which
would provide the same torque control as a 0.017 × 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. It should be understood that for every 0.001 inch of freedom
between the archwire and the vertical bracket slot, approximately 5 degrees of effective torque is lost. This
means that if the final archwire is a 0.019 × 0.025- inch archwire in a 0.022-inch slot, 15 degrees of torque
is lost. A 0.017 × 0.025-inch archwire in a 0.018-inch slot would create a loss of 5 degrees.

The use of single brackets with rotation wings on larger, flat-surface teeth may be beneficial if these teeth
require significant rotation.
• Offsets (faciolingual base
variation):
• Molar offsets:
 PRINCIPLE NUMBER 7

Build Treatment into Bracket Placement

Recommends "building treatment" into the bracket

placement. In placing brackets, three dimensions
are considered:

1. bracket height,
2. bracket angulation, and
3. Mesiodistal bracket position
 PRINCIPLE NUMBER 8
Exploit Growth to Obtain Predictable Orthopedic Correction
Is to obtain predictable orthopedic
correction by using

• A face bow,
• Facemask,
• Rapid palatal expansion,
• Lip bumper,
• Auxiliary appliances such as the
transpalatal arch, the Nance lingual
arch, magnets, and distalizing
mechanics.
 PRINCIPLE NUMBER 9
Establish Ideal Arch Form
 His conclusion about the ideal arm forms are:-
 First. the anterior segment of any arch form should be dictated by the
mandibular intercanine width and the position of the mandibular incisors.
 Second, the mandibular incisors should be kept in an upright position. This
anterior segment of the mandibular arch form was taught by Tweed with the
Bonwell-Hawley arch form.
 Because little variation in arch form can take place in the mandibular anterior
segment, the maxillary anterior arch form, from canine to canine, must then
conform to the mandibular arch form
 Third, the final shape of the posterior segments of the maxillary arch form is
dictated by the maxillary intermolar width .
 PRINCIPLE NUMBER 10
Follow a Logical Archwire Sequence
Discusses the use of a proven arch form design and a contemporary arch wire force system. Most patients are treated
by using continuous arch wires beginning with the maxillary arch.

•The initial arch wire is round and flexible (.016 NiTi).

•The transitional arch wire has intermediate stiffness (.016 stainless steel or 17 X 25 titanium alloy).
•The final wire is stiff, 17 X 25 stainless steel.

The only difference in the mandibular sequence is that the initial arch wire is a flexible rectangular wire, for initial
torque control.

The functions of the arch wires include: elimination of rotations, development of arch form, leveling the arches,
control of torque, and final arch form.
 PRINCIPLE NUMBER 10
ARCH WIRE TYPES D-rect
rectangular arch
wire
D-Rect is an
eight-strand
braided stainless
steel wire. It can
be used
throughout
treatment where
lighter forces with
dimensional
control are
indicated.
Archwire Functions
The functions of the archwires, in sequential order,
include:
1. Elimination of rotations
2. Development of arch form
3. Leveling of the arches 232
4. Control of torque
 ARCH WIRE SELECTION AND SEQUENCE
Non extraction cases Non extraction cases
Maxillary arch Mandibular arch
•o.o175 multistranded •o.o17X0.025 multistranded
•0.016 stainless steel •0.016X0.022 stainless steel or 0.017X0.025” beta titanium
•00.017X0.025” stainless steel finishing •00.017X0.025” stainless steel finishing

Extraction cases Extraction cases

Maxillary arch
•o.o17X0.025 or 0.0175” multistranded
•0.016” stainless steel for retracting cuspids
•0.018X0.025” stainless steel with closing loops
•0.017X0.025” stainless steel finishing
Mandibular arch
•o.o17X0.025 or 0.0175” multistranded
•0.016” stainless steel or o.o17X0.025 multistranded
•0.016X0.022” stainless steel with closing loops
•0.017X0.025” stainless steel finishing
 PRINCIPLE NUMBER 11
Consolidate Arches Early in Treatment
Is to consolidate arches early in treatment. The purpose of closing spaces is to
change 10 to 12 independent force units (the teeth) into 1 unit. When this has
been accomplished, orthopedic forces, such as a face bow or a face mask, can
create skeletal changes rather than dental changes.

Also, intraoral elastics, when attached to the ball hooks on the brackets, will not
move individual teeth or cause spaces to open between the teeth. Consolidated
arches are a goal of
this treatment.
 PRINCIPLE NUMBER 12
Ensure Complete Bracket Engagement and Maintain Consolidation
Principle number 12 is to obtain
complete bracket engagement when
placing arch wires, ligating with steel
ligatures, and maintaining
consolidation with omega loops "tied
back.“
One of the most important concepts of
the discipline is using tied-back arch
wires.
PRINCIPLE NUMBER 13

Let It Cook!
 The archwire requires time to
fully express its forces and
become passive in the
brackets.

 The sequencing advocated

allows each archwire used to
be optimally effective,
improving treatment results.
 PRINCIPLE NUMBER 14
Level the Arches and Open the Bite with Reverse-Curve Archwires
• Principle number 14 is to level arches and open the bite with accentuated and reverse
curves of Spee.
• Clinical experience and research have substantiated that leveling the arches and opening
the bite with the Alexander Discipline is not only successful, but also stable.
• By following the previous principles and sequencing the treatment plan, the finishing
arch wire is usually placed in 6 to 9 months in nonextraction patients.
• In extraction treatment procedures, progressing into finishing arch wires may take 9 to 12
months
Creation of the curve
• In stainless steel and titanium-molybdenum alloy archwires (0.016-inch, 0.016 × 0.022-
inch, and 0.017 × 0.025-inch), the curve begins just mesial to the omega loop and is
extended to the distal side of the canine in both maxillary and mandibular archwires.
• In stainless steel wires, the curve is created by sliding the wire over the index finger (Fig
14-5).
• Titanium-molybdenum alloy may require more bending with appropriate pliers.
 PRINCIPLE NUMBER 15
Create Symmetry
Principle number 15 focuses on creating symmetry.

Coordination of the arches is essential to establish occlusal

symmetry.

The maxillary and mandibular arch forms have now been

individually finalized and the goal then is to get the maxillary and
mandibular arches coordinated.
 PRINCIPLE NUMBER 16
Use Intraoral Elastics to Coordinate the Arches
Principle number 16 recommends that finishing arch wires be in place before initiating elastic wear.

By establishing arch form and proper torque controls before using intraoral elastics, the elastic forces act more
orthopedically, moving the entire arches without adversely affecting the teeth.

The exceptions to this rule include: the use of cross-bite elastics when necessary; Class III elastics may be used
when the lower arch is initially bonded to prevent flaring of the lower incisors, and/or while closing lower
extraction spaces with a closing loop arch wire in maximum anchorage situations; and Class II elastics may be
used when closing lower extraction spaces with a closing-loop arch wire to move lower molars forward in
minimum anchorage situations
• In general, the use of elastics in the Alexander
Discipline system of biomechanics is divided into
three sequences:
• 1. Early in treatment
• Crossbite elastics
• Class 3 elastics after bonding of the mandibular arch
to prevent incisor flaring
• 2. Midtreatment
• Box elastics to help close open bites and/or level the
mandibular arches
• Class 2 elastics for minimum mandibular anchorage in
extraction cases
• Class 3 elastics to maximize mandibular anchorage in
extraction cases
• 3. Finishing archwires
• Class 2 elastics to achieve occlusion in centric relation
• Midline elastics with class 2 or class 3 elastics (never
combine midline and maxillomandibular elastics
because they can cant the occlusal plane)
• Box elastics to improve occlusion • Finishing elastics
 PRINCIPLE NUMBER 17
Use Nonextraction Treatment When Possible
Principle number 17, in nonextraction cases, recommends initiating treatment in
the upper arch and progressing into finishing arch wires as soon as possible.

Because the major goal in nonextraction treatment is to control the position of the
lower anterior teeth, total focus can then be placed on these teeth when the lower
arch is banded/bonded.

• The lower anterior teeth are controlled by —5°

• torque in lower incisor brackets, — 6°
• tip on lower first molars,
• the use of initial flexible rectangular arch wire,
• slenderizing teeth if necessary,
• Class III elastics if necessary.
 PRINCIPLE NUMBER 18
Use Extraction Treatment When Necessary
Principle number 18 recommends that, in extraction cases, treatment be initiated in the upper arch.

The objective is to remove potential bracket interferences by improving the overbite with an accentuated curve of
Spee and retracting the cuspids before bonding/banding the lower arch.
In extraction cases, treatment is delayed in the mandibular arch to allow time for driftodontics.
This is the term the author coined to describe the spontaneous unraveling of the lower anterior teeth, making it
much easier to place brackets after 4 to 6 months.

When the upper cuspids have been retracted to a Class I relationship, the lower arch should be bonded/banded.
The principles are provided; they must be applied to the specific needs of each particular patient:
• Extract all premolars at beginning of treatment.
• Initiate treatment in the maxillary arch.
• Ensure early retraction of canines into a Class I relationship .
• Delay treatment in the mandibular arch until the canines are in a Class I relationship.
• Allow the mandibular anterior teeth to drift (“driftodontics”). The exceptions to this rule include adults and
patients with Class III occlusions. Often, the mandibular arch is bracketed early in treatment in these cases.
 PRINCIPLE NUMBER 19
Careful Appliance Removal, Then Retention Will Improve Stability
Principle number 19 advises the use of a specific retention plan incorporating retainer design, time sequence, and
resolution of third molar teeth in an effort to ensure long-term stability.

Certain criteria must be met before the patient is ready for retention. These criteria include
• Ideal occlusion.
• Cuspid protected, with centric occlusion and centric relation coincident.
• Normal overbite and overjet.
• Proper artistic positioning.
• Spread out incisor roots, especially the lower incisor roots.
• Correct torque of the upper incisors to allow for a good interincisal angle.
• Lower incisors balanced over basal bone within 3° of their original position. When proclined excessively, the
lower incisors tend to upright over time.
• The upper "wrap-around" retainer wire is fabricated to a specific design and has proven to be
extremely effective according to the author.

• Also recommended is the fixed lower cuspid- to-cuspid retainer design using an .0215 Triple-
Flex wire (Ormco, Glendora, CA) bonded to each tooth.
 PRINCIPLE NUMBER 20
Create Compliance
Somehow the orthodontist must communicate with the patient and parents that the discomfort experienced after
almost every appointment will be worth it in the long term. This can be called delayed gratification. This principle
suggests techniques for improving the compliance exhibited by patients. The effectiveness of these techniques is
dependent on the positive attitude and efforts of the orthodontist.
Adopting and Adapting Motivational Techniques
Creating Compliance
Personality profile
 Treatment mechanics
The Alexander Discipline, however, is much more than a bracket system or arch form. Certain specific mechanics were
first created or popularized by this technique. Among them:
1. One arch is treated at a time, beginning with the maxillary arch.
2. Driftodontics: In extraction cases, the maxillary arch is treated while allowing the placing brackets.
3. A cervical facebow is attached to a tied-back arch wire to create an orthopedic correction in low and average angle
skeletal Class II cases.
4. Borderline cases can often be treated without extraction by using RPE (rapid palatal expansion) and lip bumpers for
gaining space. The long-term stability of this technique has been verified.
5. the bracket and the initial rectangular flexible archwire.
6. Mandibular first molars aƌe upƌighted ǁith a − ϲ° tip.
7. Mandibular anterior roots are spread with specific angulated brackets.
8. Mandibular arches are leveled by a reverse curve in the archwire, using a specific prescription for each patient.
9. Ball hooks are placed on the lateral brackets for elastic attachment.
10. Class II elastics are attached on lateral incisors rather than canines in order to produce a more horizontal vector of
force on the arches.
11. Maxillary canines are retracted on 0.016 in. stainless-steel archwire with power chains.
12. Specific archwire sectioning and elastic attachments are used to finalize posterior occlusion.
13. The unique maxillary wrap_x0002_around retainer wire design controls posttreatment settling. A maxillary retainer is
worn at night only.
 Appliance Design
The Alexander design maximizes the concept of straight wire appliances.

This is a Discipline that not only uses a force delivery system that has been well conceived and tested, it also has a
system of Principles that guides the practitioners through each case with a level of conformity, ensuring predictable
final results.

Once a case is well constructed with the Alexander system, the Principles serve as a guide throughout the treatment of
the case.
This was the intent of Dr. Alexander when he first introduced his "Vari-Simplex" bracket system in 1978.
"Vari" referred to the variety of bracket types used and
"Simplex" related to the concept of keeping all aspects of the Discipline as simple as possible.
Arch wire fabrication and the incorporation of many aspects of treatment options into the brackets (ie, elastics hooks
and rotational wings on the brackets) added up to the "simplex" concept.

"Discipline" rather than "appliance" was chosen to reflect that the orthodontist must be knowledgeable in all aspects of
edgewise mechanics and must play an active role in the application and follow-up treatment of each patient.

As previously mentioned, the Vari-Simplex Discipline was developed as a conglomeration of other brackets designs.
 Bracket selection
Bracket selection.The first, and most important, advantage of the Alexander Discipline is that the system is composed
of a number of bracket designs. Each tooth has a particular bracket that is most effective.
1. Twin Brackets 3. Lewis Brackets 4. Other Attachment – Twin
- Diamond shape: horizontal lines are - are used on brackets with a convertible
placed parallel to the incisal edge of the large, round-
tooth surfaced teeth sheath are used on maxillary
- Rhomboid: make it possible to align the that are not at the and mandibular first molars,
vertical lines parallel to the long axis of the curve of the arch -
tooth which are usually banded. The
maxillary and
- Flat surface: permit full arch wire convertible sheath is easily
engagement mandibular
- Inter-bracket width: 5-6 mm, which is bicuspids – and on removed when second molars
sufficient for flexibility, rotational control, small flat-surfaced are banded, converting the
and torquing ability teeth –
attachment to a bracket .
2. Lang Brackets – were invented by Howard mandibular
Lang, used with incisors.
the Diamond design on large,

round-surfaced teeth at the

corners of the arch – maxillary and mandibular
cuspids.
Bracket placement in
first bicuspid & second
bicuspid
extraction cases
 Conclusion

Alexander orthodontic philosophy is a unique orthodontic treatment approach designed to provide excellent

outcome results in easy systematized manner. Its uniqueness accomplished through the application of a certain

number of principles.
 REFERENCES
1. Alexander RG. R.G. “Wick” Alexander, DDS, MSD. J Clin Orthod 2012;
46(6):329-43.
2. Alexander RG. The Principles of the Alexander Discipline. Semin Orthod 2001;
7(2):62–66.
3. Alexander RG. The Vari-Simplex Discipline. J Clin Orthod 1983; 17(6):380–
392.
4. Alexander RG, Alexander CM, Alexander CD, Alexander JM. Creating the
compliant patient. J Clin Orthod 1996; 30(9):493–497.
5. Alexander RG, Sinclair PM, Goates LJ. Differential diagnosis and treatment
planning for the adult nonsurgical orthodontic patient. Am J
Orthod 1986; 89(2):95-112
6. Felton JM, Sinclair PM, Jones DL, Alexander RG. A computerized analysis of
the shape and stability of mandibular arch form. Am J Orthod
1987; 92:478–483.
7. Alexander RG. A practical approach to arch form. Clinical Impressions 1992; 1
(3):2–5.
8. Alexander RG. Retention, a practical approach to that critical last step to
stability. Clinical Impressions 1997; 6(3):14–17.
9. Alexander RG. Treatment guidelines. Am J Orthod Dentofacial Orthop.
2007;131(6)