Review Article

Alexander Discipline: Concept & Philosophy

Dr Nabil Muhsen Al-Zubair

Assistant Professor, Department of Orthodontics, Faculty of Dentistry, Sana'a University, Sana'a, Yemen

Correspondence: Dr Nabil Al-Zubair; Email: [email protected]

ABSTRACT
Due to the distinctive orthodontic treatment methodology of the Alexander Discipline; thousands of clinicians around the world
perform its 20 master principles. An outgrowth of the Tweed technique, these basic principles has been established over many
years in author’s own practice. This review presents evolution of the appliance, the concept of Vari-Simplex Discipline, as well
as Alexander orthodontic philosophy. This paper concisely describes finishing and retention procedures in Alexander Discipline
and will be of interest to anyone involved in the study and practice of orthodontics.

Key Words: Alexander Discipline, biomechanics, Vari-Simplex Discipline

INTRODUCTION proper position. Instead of archwire bending; the first,

second, and third-order bends placed in the bracket,
Richard G. Wick Alexander designed an appliance to which simplified archwire fabrication and offer easier
deliver excellent treatment results in an easy organized ligation and activation with fewer archwire changes.
manner. Simplicity, to encourage cooperation,
comfort and control, was his main concern. His major Tweed to Vari-Simplex2
goals include high quality results, patient comfort and
reduced chair-side time. He developed an appliance The Discipline maintains many of Tweed technique,
known as Vari-Simplex Discipline, a system of brackets and was developed from its principles. It has benefited
placed on teeth, which is used by orthodontists around from growth dynamics while remaining true to its three
the world.1 In Alexander Discipline; certain number goals: high quality result, ease and convenience for
of principles are followed that give this technique its the patient, and minimized chair-side time.
uniqueness.2
In Alexander Discipline, the patient ends up with
EVOLUTION OF THE APPLIANCE 3 balanced facial proportion consistent with skeletal
pattern, which is the key objective to treat the case.
It has originally grown from many proven ideas and Non-extraction therapy is preferable whenever
concepts that have been put together in a unique possible.
package (Table 1). In 1977, Alexander described Vari-
Simplex Discipline; which includes a specific bracket Vari-Simplex philosophy retains following three
system used in case treatment. fundamentals of Tweed technique:

1. Anchorage preparation (uprighting mandibular

Although 0.022” brackets can also be used, the
molars)
advantages of using 0.018” bracket slots and 0.017”
2. Positioning of mandibular incisors over basal bone
wire were: reduced treatment time, improved patient
3. Orthopedic alteration with headgear
comfort, and enable easy movement of teeth into

Table 1: Evolution of the appliance

1977 The original appliance was developed and called as Vari-Simplex Discipline.
Generation 2: Mini Wick appliance: In this design, a stronger metal alloy was used, brackets were reduced in size,
1985
and the wings were redesigned to be more efficient.
1997 Generation 3: Alexander Signature appliance.

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 Al-Zubair NM: Alexander Discipline: Concept & Philosophy

2. Single brackets create increased inter-bracket

space as compared to twin brackets, which will
allow more flexibility with stiffer archwires, resulting
in easier engagement and fewer archwire
changes (Figure 1).

3. Rotational wings give controlled guidance and

direction to the teeth. Wings can be activated
or deactivated for increased rotation. The
Figure 1: Single brackets create increased inter-bracket advantage of rotation wings is that the force is
space
exerted on the “active” wing (Figure 2). Using single
DIAGNOSIS AND TREATMENT PLANNING4 brackets with wings creates an advantage that is
not possible with twin brackets. The prescription
The desired mandibular incisors position is determined, allows for controlled and effective mandibular
which ascertains the treatment needed to position the arch leveling, especially in non-extraction cases.
maxillary dentition over the desired mandibular arch This is accomplished by first placing the brackets
position, with four goals in mind: Incisor upright over and ligating each tooth with a rectangular wire.
basal bone, cuspids not expanded, curve of Spee
level, and non-extraction therapy whenever possible.4 4. The special prescription of torques and angulations
in Alexander discipline makes the resulting straight
Lower incisors position:5 The best and most stable wire appliance unique. If one believes that control
position for lower incisors is the position in which the of inter-canine width and mandibular incisor flaring
patient presents. Lower incisors can be advanced is important, maximum effort should be made
upto 3° and remain stable. Instability is more likely to control this area. Possibly the most important
beyond that degree. When the lower incisors are unique design elements of this bracket system is
abnormally retroclined (Class II Division 2 and Division I expressed in lower mandibular anterior brackets
deep-bite cases); they can be advanced beyond this (Figure 3).
degree. In extraction cases, lower incisors are almost
kept uprighted. The position of the mandibular incisors The incisors resistance to tipping labially, caused by the
is considered the key to sagittal control; determined by minus 5° torque, places a distal force on the first molars
the A-PO line, IMPA (relationship of mandibular incisors angulated at minus 6°, causing them to upright. This can
to mandibular plane), and the Holdaway ratio. gain 2–3 mm of arch length without flaring the incisors.
The unique biomechanical principles of actively tying
Other factors affecting diagnosis are: age of patient
back a heat-treated, curved, rectangular stainless-
and diagnostic records.
steel archwire contributes to successful and stable
THE CONCEPT OF VARI-SIMPLEX DISCIPLINE3 arch leveling.

Following factors make Alexander Discipline different

Unique arch form:6,7
from others:

Unique bracket selection and prescription: The arch form used in Alexander Discipline was
developed as a result of the compilation of hand-bent
1. Specific bracket designs are created for specific
archwires that provide individualized archforms. This
teeth.

Figure 2: Rotational wings Figure 3: Special prescription of torques and angulations

32 Orthodontic Journal of Nepal, Vol. 5, No. 1, June 2015

 Al-Zubair NM: Alexander Discipline: Concept & Philosophy

arch form has been compared to other commercially 13. Controlling the post-treatment settling by a unique
available arch forms and found to be more stable. maxillary wrap-around retainer worn at night only.

For long term stability of the mandibular anterior; teeth THE APPLIANCE DESIGN AND CONSTRUCTION13
positions are very important. With rare exceptions,
The system grew around five dynamics related to
inter-canine width must stay within 1 mm of its original
the brackets; viz: bracket selection, bracket height,
position. Mandibular incisors can be advanced not
bracket angulation, bracket torque and bracket in-
more than 2 mm. Thus the anterior portion of the
out.
maxillary and mandibular archforms should be built
around the mandibular six anterior teeth.
Bracket selection: Each tooth has a particular bracket
that is most effective.
Regarding the posterior teeth, it is well known that the
inter-molar width of ± 36 mm is stable in the long term. 1. Twin Brackets (Diamond brackets) - Used on large,
When combining these goals, the resulting archform flat-surfaced teeth i.e. maxillary central and lateral
shall be ovoid regardless of the patients’ beginning incisors.
archform.
2. Lang Brackets - Invented by Howard Lang, used
Treatment mechanics: 8-12 with the Diamond design on large, round-surfaced
teeth at the corners of the arch, i.e. maxillary and
The Alexander Discipline is much more than a bracket mandibular cuspids.
system or arch form. Following specific mechanics
3. Lewis Brackets - Used on large, round-surfaced
were first created or popularized by this technique:
teeth that are not at the curve of the arch i.e.
1. Treat maxillary arch before mandibular arch.8,9 maxillary and mandibular bicuspids and on small
flat-surfaced teeth i.e. mandibular incisors.
2. Allow crowded mandibular arch to “drift” before
placing brackets; in extraction cases, while 4. Other Attachments - Twin brackets with convertible
maxillary arch is treated “Driftodontics”. sheath are used on maxillary and mandibular first
3. The low and average angle skeletal Class II cases molars, which are usually banded. The convertible
corrected orthopedically by a tied-back arch wire sheath is easily removed when second molars are
attached to a cervical facebow. banded, converting the attachment to a bracket.

4. Rapid palatal expansion and lip bumpers can Bracket height: Brackets are positioned in the center
often be used for gaining space in borderline of the tooth mesio-distally at a predetermined position.
cases treated without extraction.11 Placing a bracket higher or lower affects the amount
5. The -5° torque in the bracket and first rectangular of torque and angulation, and the inciso-gingival
flexible archwire control the flaring of mandibular position of the tooth. The bracket height will vary to fit
incisors.12 the clinical crowns.

6. Uprighting mandibular first molars with a -6° tip.

Bicuspid bracket height is the key. Its normal height is
7. Roots of mandibular anterior are spread with 4 mm for small crowns; 4.5 mm for average-sized
precise angulated brackets. crowns; and 5.0 mm for large crowns (Table 2).
8. Leveling the mandibular arches by using a definite
reverse curve in the archwire.
9. The lateral brackets are supplemented with ball Table 2: Guide to bracket height
hooks for the attachment of elastics. Maxillary Arch Mandibular Arch
10. More horizontal vector of force on the arches Centrals X X - 0.5mm
created by attachment of Class II elastics on Laterals X - 0.5mm X - 0.5mm
lateral incisors rather than canines.
Cuspid X + 0.5mm X + 0.5mm
11. Retraction of maxillary canines with 0.016 stainless-
Bicuspid X X
steel archwire and power chains.
1st Molars X - 0.5mm X - 0.5mm
12. Finalization the posterior occlusion by sectioning
2nd Molars X - 1.0mm
particular archwire with elastic attachments.

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 Al-Zubair NM: Alexander Discipline: Concept & Philosophy

Table 3: Maxillary and mandibular archwire force systems

Sequence Purpose Archwire type Size (inches) and alloy
Maxillary
Initial Eliminate rotations Flexible round 0.016 NiTi

Or rectangular 0.017 x 0.025 CuNiTi5

Transitional Close spaces: Intermediate 0.016 SS
Non-extraction round Power chain
Close spaces: Intermediate 0.018 x 0.022 SS
extraction rectangular 0.017 x 0.025 SS
with closing loops TMA T-loop
Finishing Final arch form, Stiff rectangular 0.017 x 0.025 SS
leveling, torque

Mandibular
Initial Eliminate Flexible round 0.016 NiTi
rotations,
Or rectangular 0.017 x 0.025 Turbo
control torque CuNiTi, D Rectangular

Transitional Close spaces: Intermediate 0.016 SS

Non-extraction round Power chain
Close spaces: Intermediate 0.016 x 0.022 SS
extraction rectangular Closing loops

Finishing Final arch form, Stiff rectangular 0.017 x 0.025 SS

leveling, torque

Bracket in-out (First order bends): The appliance the mandibular arch may however prevent unraveling
incorporates a system of interrelated, compensating and uprighting of the lower anteriors. The “slenderizing”
bracket base thicknesses to replace the usual first- is used for the selective interproximal reduction of the
order bends or offsets. enamel.

ARCHWIRE SELECTION AND SEQUENCE7 Bonding /banding on the mandibular arch is delayed
in non-extraction case for the following reasons:
Bracket is only a “handle” placed on the tooth. Proper
archwire selection and sequence allow the discipline • It avoids interference of mandibular brackets with
to deliver the desired results. The first step in most cases maxillary teeth
is the elimination of rotations. This is done by the newer, • If a bite plate is needed, it fits better and is more
flexible, more resilient wires i.e. multistranded round comfortable after the maxillary arch has been
and rectangular TMA and Nitinol. Leveling and space properly aligned
closure are accomplished next, usually with TMA or
stainless steel rectangular wire. The last step is final • Total time needed to treat the mandibular arch is
leveling and arch form, which are always performed 6-9 months
with stainless steel wire (Table 3). • It allows more time for the second mandibular
molars to erupt.
NON-EXTRACTION TREATMENT14, 15
EXTRA ORAL FORCES APPLICATION16-18
Modern technology and materials allow the
orthodontist to treat more borderline cases without The posterior transverse dimension is controlled better
removing teeth. Non-extraction treatment begins with with the attachment of a retractor to the maxillary first
maxillary arch. molars and offers successful orthopedic results. When
mandibular plane to SN angle is greater than 42o, a
The mandibular arch is the key to non-extraction high-pull is used, while cervical-pull is used when this
treatment with Vari-Simplex Discipline. Control lower angle is equal to or less than 35o, and a combination
arch using -5o torque on incisors, -6o tip on first molars pull is used when the SN to mandibular plane range
and initial flexible rectangular archwire. Crowding of from 36-42o.

34 Orthodontic Journal of Nepal, Vol. 5, No. 1, June 2015

 Al-Zubair NM: Alexander Discipline: Concept & Philosophy

Depending on the diagnosis, the patient should wear with extreme deepbite, the overbite will be corrected
the retractor 8-14 hours per day. 8 hours a day during with reverse curve in the lower archwire and box
night if the patient’s ANB is less than 3o, 12 hours a day if elastics to the bicuspids. After the lower arch has
the ANB is 3-5o, and increase to 14 or more hours a day leveled and the bite has opened, Class II elastics will
if the patient’s ANB is 5o or more. then be employed.

LEVEL ARCHES AND OPEN BITE WITH REVERSE CURVE FINISHING AND RETENTION PROCEDURES23
ARCHWIRES
By understanding definite verified mechanics and
In case of close bite, excess curve of Spee is placed to mastering the order of their application for the specific
enhance the opening of the bite. It is necessary to tie patient, accomplishment of excellent results with
this archwire back.19-21 long term stability can usually be obtained. When the
patient is ready for retention, certain criteria must be
CONSOLIDATE ARCHES EARLY IN TREATMENT, THEN TIE
met, that include:
BACK3
• Ideal occlusion: Cuspids protected with centric
Tying back the archwire is utilized to consolidate the occlusion and centric relation coincident
arch to change the archfrom several units to a single
unit. It is important for the arch to be in one unit for • Normal overbite and overjet
the extra-oral forces to act orthopedically instead of • Spread out incisor roots, especially the lower incisor
dentally, and instead of acting on individual teeth, roots
intraoral elastic forces must act on the arch.
• Correct torque of the upper incisors to allow for a
There are three methods for tying back; power chain, good inter-incisal angle
the traditional Omega stop or ligature wire from molar • Lower incisors balanced over basal bone within 3°
to molar, and bending the archwire at an angle of their original position
distal to the molar tube. The Omega stop, set 1-2 mm
mesial to the buccal tube, empowers placement of a • Original lower inter-cuspid width must be
dynamic tieback force on the archwire. maintained

• Lower first molars should be upright to maintain a

PROPER TIMING WITH CLASS II ELASTICS22 leveled mandibular arch and overbite correction

As in most things in life, “timing is everything.” • Habits should have been eliminated
Diagnostically, Class II malocclusions can be classified
• Optimal and coinciding midlines.
as either skeletal or dental. In Alexander Discipline,
treatment of a skeletal Class II case begins with In addition, two months before removal of the fixed
headgear wear 8-10 hours each night. Proper timing appliance; a circumferential supracrestal fiberotomy
for elastic wear is critical during orthodontic treatment is done for adults with severely rotated teeth. A
in the Alexander Discipline. It is very important that the frenectomy also performed for those who have heavy
final archwires in both arches, 17×25 stainless steel in an diastema with familial traits.
.018 slot, are fully engaged, tied back and have been
in the mouth at least one month before Class II elastics When all the treatment objectives are achieved and
are initiated. It is also important to attach elastics to fixed appliance removal time is approaching, four
the appropriate teeth. In Alexander Discipline, Class II arrangements are made with specific purposes for
elastics are not employed to open the bite. In a case each appointment (Table 4).

Table 4: The countdown to retention24

Appointment 1 Sectioning of wires and finishing elastics
3 weeks later: Occlusal check and final adjustments, and possible sectioning of the opposing arch wire and
Appointment 2
removal of molar bands
Appointment 3 3 weeks later: Fixed appliance removal
Appointment 4 2 days later: Seating of the retainers

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 Al-Zubair NM: Alexander Discipline: Concept & Philosophy

CONCLUSION outcome results in easy systematized manner. Its uniqueness

accomplished through the application of a certain number
Alexander orthodontic philosophy is a unique orthodontic of principles.
treatment approach designed to provide excellent OJN

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