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Contents
• The Principles of the Alexander Discipline
• Vari-Simplex Appliance Design & Construction
• Non-Extraction Treatment
• Face Bow Correction of Skeletal Class II Discrepancies in
the Alexander Discipline
• The Orthodontic Management of Vertical Deficiencies
• Extraction Treatment
• Finishing & Detailing

"Nothing is really new. We only rediscover
for ourselves."
……..Socrates


Introduction
• It grew out of the Tweed Technique, and today
maintains many of its principles. The present
technique incorporates ideas found from other
teachings and techniques, and much was gained
from trial and error.
• Its originality has grown from many proven ideas
and concepts that have been put together in a unique
package “The Alexander Discipline”

Salient features
• The specifics that make this technique different
include:
A unique bracket selection with specific designs created
for specific teeth.
Increased inter-bracket space is created from single
brackets to allow more flexibility with stiffer arch wires,
resulting in easier engagement and fewer arch wire
changes, and
Rotational wings give controlled guidance and direction
to the teeth.
Arch forms have been developed that fit most patients
within one standard deviation.

Treat one arch at a time, beginning in the upper arch; in
extraction cases treat the upper arch while allowing the
crowded mandibular arch to "drift" before placing appliances
(driftodontics).
Use is made of a cervical face bow to a tied-back arch wire to
create an orthopedic response in normal and low-angle
skeletal Class II cases.
Control lower incisor flaring by -5 ° torque in the incisor
brackets and placing an initial rectangular flexible arch wire.
Upright the lower first molars with -6 ° tip.
Spread lower anterior roots with specific angulated brackets.

Successfully level lower arches by using a reverse curve in
the arch wire employing the specific prescription.
Attach Class II and Class III elastics on lateral incisors rather
than on cuspids to produce a more horizontal vector of force
on the arches.
Specific arch wire sectioning and elastic attachments finalize
posterior occlusion, and by using a unique maxillary wraparound retainer wire design, post-treatment settling is
controlled.

•

The treatment philosophy retains three fundamentals of
the Tweed technique:
1. Anchorage preparation (uprighting mandibular first
molars)
2. Positioning of mandibular incisors over basal bone
3. Orthopedic alteration with headgear

•

Diagnosis and Treatment Planning :
 Case diagnosis is generally reduced to two steps:
•
•

determine the desired position of the mandibular incisors,
and
then determine the treatment needed to position the
maxilla and maxillary dentition over the desired
mandibular arch position.

•

The object of treatment is to position the mandibular
teeth within the mandibular trough, with four goals in
mind :
1.
2.
3.
4.

•

Incisors upright over basal bone
Cuspids not expanded
Curve of Spee level
Nonextraction therapy whenever possible

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 the treatment goal.

• In extraction cases, lower incisors are almost always kept up
righted.
• According to the author, 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, a situation
commonly seen in Class II, Division 2, and Class II, Division
1 deep-bite cases.
Richard G. Alexander
(Semin Orthod 2001;7:62-66)

• Others factors affecting diagnosis:
• Age of the patient
• Diagnostic records taken like the intra-oral x-rays, models,
cephalograms, photographs, etc

• Facial, Skeletal, Dental tissues should be evaluated in all three
dimensions i.e. vertical, transverse, and sagittal.
• Dentally, the key to sagittal control is the position of the
mandibular incisors. In this discipline their position is
determined by the A-Po line, the Holdaway ratio, and IMPA
(relationship of mandibular incisor to mandibular plane).
• The decision to extract or not to extract obviously affects the
position of these teeth and, therefore, it is the most important
decision made by the orthodontist.

• Certain factors observed in the patient himself :
• Palpation of the temporomandibular joint while the patient is
opening and closing his jaw.
• Patient's gingival health is described in words from observation
and, sometimes, from probing
• Tendency for tongue thrusting.

• Laminagraphic x-rays are taken on every patient who exhibits
abnormal TMJ function.
• Treatment of a tongue thrust is to first make the patient and
parent aware of the problem, then to give the patient simple
instructions in proper swallowing.

• The most important factors in determining the design of the
Vari-Simplex Discipline are the size and shape of the teeth,
especially the mesiodistal width and curvature.
• These affect inter-bracket width, which, in turn, affects the
ability to rotate the teeth and level the arches. So, in some
instances, the optimal bracket design was a single bracket with
wings and, in other situations, a twin bracket design was most
advantageous.

• Another major factor is the accessibility of the tooth and
whether it is located in a curved or straight area of the arch.
•

Finally, the design must take into account patient comfort and
the frequency of bracket wing breakage.

• The system evolved around five factors related to
brackets:
–
–
–
–
–

bracket selection,
bracket height,
bracket angulation,
bracket torque, and
bracket in-out.


Advantages of the Alexander Discipline Bracket System
• Bracket selection :
– The system is composed of a no. of brackets designs. By
creating a variation (hence Vari-) in types of brackets
selected, the advantages of each design are used in a singleslot (0.018" X 0.025") design.

Frontal view showing bracket selection. Lateral view showing bracket selection.

• Interbracket space:
– Using single brackets with
wings in the lower anterior
and buccal segments allows
maximal inter-bracket
distance.
– This, along with the newer
Maxillary occlusal view showing interbracket space and rotational wings.
metals available, enables the
practitioner to engage stiffer
(larger) wires faster, which
allows for faster leveling,
less discomfort, and
improved torque control.
This also allows the
orthodontist to get into their
Mandibular occlusal view showing interfinal arch wires faster.
bracket space and rotational wings.

• Rotational control:
– Rotation wings on cuspids, bicuspids, and lower
anteriors provide for improved rotational control
and individual activation of particularly involved
teeth.
– In those situations in which a single tooth does not
respond to conventional mechanics, individual
forces can be applied by activating, deactivating, or
removing individual wings.

• Torque:
– Each bracket has a 0.018 × 0.025 inch wire slot.
Slot sizes do not vary from anterior to posterior
brackets and, realizing that 5 ° of torque is lost for
each 0.001-inch "play" in the slot, final ideal wires
(0.017" × 0.025") are constructed to fill the slot as
much as possible.


• Lower incisor torque:
– (- 5 °) torque is incorporated into lower incisor
brackets.
• This allows for more efficient control of these teeth
during the leveling process
• Sets up anterior anchorage in those situations where
the mandibular posterior teeth are to be protracted in
the correction of Class II malocclusions.
• The - 5 ° torque also aids in ideally maintaining the
position of these teeth over the mandibular basal
bone.

– The use of a flexible rectangular arch wire in the
lower arch is recommended as soon as possible to
optimally control torque in this critical area.

• Lower first molar tip:
– The mandibular first molar is
also constructed to have a - 6 °
tip incorporated into its design.
– This is essential in establishing
posterior anchorage in Alexander
cases.
– This allows the mesial aspect of
mandibular molars to be up
righted, which, in turn,
incorporates leveling mechanics
with attention to anchorage
demands.

– The - 6 ° tip of the molar bands also positively contributes
to a non-extraction philosophy in that it allows distal
movement of the molar crowns, which can create
additional arch length where needed.

– Band placement is also critical on the first molar.
• For a typical case the band must be placed, as always, with
the occlusal margin of the band parallel with the occlusal
surface of the molar at the marginal ridges.
• In open bite situations, care must be given to tip the distal
aspect of the band gingivally so that the mesial cusp is not
supera-erupted and the distal aspect is supported, which
minimizes the bite opening effect of the - 6 ° tip of the
bracket placement.

Bracket Selection
• Twin Brackets:

– Used on large, flat-surfaced
teeth (namely, maxillary
central and lateral incisors).
– The flat surfaces of these
teeth permit full arch wire
engagement in the twin
brackets.
– There is little trouble tying
the wire into these brackets
because of their ease of
accessibility, and

Diamond Twin Brackets


• Ball hooks for elastic
placement are usually
placed on lateral incisor
brackets.
• The brackets allow for 5 to
6 mm of inter-bracket
width, which is sufficient
for flexibility, rotational
control, and torquing.
• Also, these brackets are
smooth and minimize
irritation on labial tissues

Twin Brackets are Convenient for Ligating
Teeth Together & Placing Hooks


• Lang Brackets:

– Originally developed by
Dr. Howard Lang.
– Used on large, roundsurfaced teeth at the
corners of the arch i.e.
maxillary & mandibular
cuspids.
– The pad is contoured,
which fits on most
cuspids.

– The straight wing eliminates interference with complete
arch wire engagement. Thus, the bracket is easily ligated
and inter-bracket width is maximized.
– The wings can easily be activated for rotational control.
Lewis

Lang

When a Lewis or Steiner Bracket is completely tied into a cuspid, there is a
tendency to flatten the curvature of the archwire. A Lang bracket avoids this
effect, while retaining the rotation wing capability.

• Twin brackets on cuspids are not the brackets of
choice because:
– They decrease the inter-bracket width, making it
more difficult to ligate & control rotations.
– It is often impossible to get full- bracket engagement
on these teeth early in treatment and,
– They can interfere with opposing cusps on occlusion
(actually often causing cusp attrition).


• Lewis Brackets:

– Used on round-surfaced teeth not located at the corners of the
arches (maxillary and mandibular bicuspids) as well as small,
flat-surfaced teeth (mandibular incisors).
– The Lewis bracket is a fixed-wing single bracket that again
contributes positively to the concept of increased inter-bracket
width. The wings provide a distinct advantage in having a
built-in auxiliary for rotational control, much in the same
fashion as those on the Lang brackets.


Lewis Brackets

• The design of the bracket is wedge shaped which
puts the tie wing closer to the tooth occlusally and
far out gingivally
–
–
–
–

This makes it easy to tie
To use as hooks for elastics
To keep clean and
Often in this technique, up & down elastics on
posterior teeth are used for settling, and this wedge
shape is excellent for that purpose.


An additional benefit offered by the single bracket
with wings is that, on a tooth that is badly rotated,
the wing in the direction of the rotation can be
removed. The bracket can then be positioned
properly, with the remaining wing serving to rotate
the tooth into proper position


• Molar bands:
– Twin brackets with
convertible sheaths are
used on the first molars.
– Headgear tubes are used
on the maxillary molars
and are manufactured to
be on the occlusal aspect
of the band. The latter
allows for superior
hygiene and accessibly
for headgear where
indicated.

– The mandibular first molar bands can be constructed with
convertible arch wire tubes and lip bumper tubes (if
necessary) placed on the gingival aspect of the bracket. This
allows the convertibility of the tubes as well as allowing for
the placement of lip bumpers in indicated situations.
– Single buccal tubes are used on both mandibular and
maxillary second molar teeth.
– Elastic hooks are located on all first and second molar
brackets, and also as distal offsets used for tying back arch
wires.
– Lingual elastilugs are placed on all molar bands.

Specifications of the Appliance
• Bracket Height :
– Bracket height in this Discipline, as in any other
technique, is extremely important in the construction of
the appliance.
– Bicuspid bracket height (x) is the key because of its
clinical crown height is so variable.
– Other bracket heights are calculated in relation to x

Maxillary Arch

Mandibular Arch

Centrals

X

Centrals

X – 0.5mm

Laterals

X – 0.5mm

Laterals

X – 0.5mm

Cuspids

X + 0.5mm

Cuspids

X + 0.5mm

Bicuspids

X

Bicuspids

1st Molars

X – 0.5mm

2nd Molars

X – 1.0mm

1st Molars


X
X – 0.5mm

Special Considerations in Appliance Construction
• Deep Bite Cases :
– The true Alexander Discipline dictates that the
maxillary arch have appliances placed first, with the
mandibular arch having appliances placed when an
adequate bite opening has been achieved in order to
prevent bracket interference.
– However, in some instances, particularly in adult
patients, reverse curve wires alone are not sufficient to
adequately open the bite. In these situations, the use of
a maxillary bite plate is strongly recommended.

• The bite plate allows immediate placement of
mandibular appliances and also hastens bite
opening by allowing simultaneous molar-bicuspid
eruption along with incisor intrusion.
• A bite plate can also be used on those patients in
whom early initial treatment of the mandibular
arch is desired.


• Open Bite Cases :
– Special bracket placement of anterior brackets in
an exaggeratedly gingival fashion and more
occlusal placement of posterior brackets is
indicated.
– Additional placement of vertical elastics also
contributes to open-bite closure.
– Mandibular first molars should be placed with the
distal aspect seated more gingivally to offset the
-6° tip incorporated into the band. This prevents the
mesial cusp from supra-erupting, which would be
counterproductive in an attempt to close the bite.

• Extraction Cases :
– The bicuspid brackets adjacent to the extraction
sites should be tipped so that the roots of the teeth
are up righted toward the extraction area allowing
for improved parallelism with resulting easier
retraction of the cuspids.
– In molar protraction situations the - 6 ° tip of the
molar band is extremely advantageous during the
process in that the mesial aspect of the tooth is not
"dumped" in a mesial fashion during protraction;
hence, ideal uprighting can be facilitated.

• Bracket Angulation :
• To allow the roots to be properly positioned at the end of the
treatment, care is taken during the bracket placement to
ensure that the brackets are placed parallel to the long axis of
the clinical crowns.

• BRACKET ANGULATIONS
Maxillary Arch
Banding
(Incisal edge
Reference)

Centrals
Laterals
Cuspids
Bicuspids and
Molars

Mandibular Arch
Banding
(Incisal edge
Reference)

Bonding
(Long axis
Reference)

3°
6°
6°

5°
8°
10°

0°

0°

Centrals
Laterals
Cuspids
Bicuspids
1st Molars
2nd Molars


2°
2°
6°
0°
– 6°
0°

Bonding
(Long axis
Reference)

2°
2°
6°
0°
– 6°
0°

• Mesiodistal Position :
• On flat-surfaced teeth, the bracket
should be placed in the center of
the clinical crown.
• The bracket is placed at the height
of the contour on all roundsurfaced teeth.
• The molar tubes are placed so that
the mesial end of the tube is placed
parallel to the mesio-buccal cup of
the molar


• Bracket Torques:
– The torque prescriptions used in this technique are
derived from measurement of the torques in the
rectangular archwires used to finish well treated
orthodontic cases.
BRACKET TORQUES
Mandibular Arch

Maxillary Arch

Centrals
Laterals
Cuspids
Bicuspids
Molars

14°
7°
– 3°
– 7°
– 10°

Incisors
Cuspids
1st Bicuspids
2nd Bicuspids
1st Molars
2nd Molars

– 5°
– 7°
– 11°
– 17°
– 22°
0° or – 27°

• These measurements differ from commonly used torques
in three major respects:
• The -3º torque on the max cuspids compared to
extremes of +7º to -7º in other appliances,
eliminates the need for adjusting the torque later in
the treatment.
• No torque is placed in the mandibular second molar
tubes, because of the use of omega stops, which are
always bent out to avoid impingement on gingival
tissue & to avoid food trap. This automatically
incorporates torque in the wire
• -5 º of lingual crown torque or labial root torque in
the mandibular incisors.

• In Alexander’s discipline a typical non-extraction treatment,
begins with the maxillary arch.
• The incisors, cuspids, and first bicuspids are bonded, and the
second bicuspids and first molars are banded. Second molars are
banded near the end of treatment only if they are in poor
position.
• Initially round, multistranded archwires are placed, because
maxillary torque control is not critical at this stage.
• Two weeks later a facebow, which he calls – the retractor- is
given to the patient.
• At the third appointment, usually four or five weeks later,
rotations are tied, and the retractor is adjusted.

• Soon an .016" round wire with omega stops mesial to
the terminal tubes is placed, so that the archwire can be
tied back.
• This wire further eliminates rotations and continues
leveling the arch.
• If the case involves a closed bite, enough excess curve
of Spee is placed in the archwire to enhance the
opening of the bite.

• Purpose of tying back the archwire :
• To consolidate the arch, so that the extra-oral forces act
orthopedically instead of dentally; and intra-oral elastic
forces act on the arch and not on individual teeth.
• A consolidated arch eliminates the need to ligate teeth
together or to solder hooks to the archwire.

• The omega stop, placed 1-2mm mesial to the buccal
tube, enables placement of an active tieback force on
the archwire.
– This can close small spaces that could have developed
if the elastic hook were placed on the bracket.

• All spaces should be closed while the .016" archwire is in place.
In addition to tying back, power chains can be used from molar
to molar to close all spaces.
• After all rotations & spacing have been corrected, an .017" x .
025" rectangular stainless steel finishing archwire is placed.
• f the bite is still closed at this stage, a bite plate is used so that
the mandibular anteriors occlude on the bite plate and free the
occlusion
• This improves the effectiveness of the maxillary arch wire
• Allows the posterior teeth to erupt into a more level occlusion
• The pressure of the mandibular anterior teeth on the bite plate
will tend to depress them. This will begin to open the bite and
level the mandibular arch before it is bonded and banded.

Mandibular Arch
•

Bonding/banding the mandibular arch is delayed for the
following reasons:
1. It will avoid interference of mandibular brackets with
maxillary teeth.
2. As the maxillary arch improves, the mandibular curve of
Spee improves naturally.
3. If a bite plate is needed, it fits better and is more
comfortable after the maxillary arch has been properly
aligned.
4. Total time needed to treat the mandibular arch is 6-9
months.
5. It allows more time for the mandibular second molars to
erupt.

•

The mandibular arch is the key to non-extraction treatment with the
Vari-Simplex Discipline and therefore, holding the lower incisors in
place is very important.

•

This is achieved by :
1. A -5° torque on the mandibular incisors that resists anterior
flaring of these teeth.
2. Bonding, which eliminates the need for interproximal band
space.
3. The use of .017" x .025" D-Rect multistranded, braided archwire
which permits torque control in the anterior segment with the
initial archwire.
4. A -6° tip on the mandibular first molars which allows distal
movement of the molar crowns, which can create additional arch
length.
5. Selective inter-proximal enamel reduction.

• Cases wherein crowding of the mandibular arch prevents unraveling
and uprighting of the lower anteriors— despite the five factors listed
above—Class III mechanics should be considered.
• If Class III elastics are used, they must be initiated at the time of the
placement of the first wire.
• This wire must be round and multistranded because of the excessive
anterior crowding.
• Without Class III mechanics, the mandibular anteriors will advance
labially. A combination of the distal force from the Class III elastics and
the uprighting tip on the mandibular first molars will control this
advancement.
• The angulation of the -6° tip built into the first molars creates an
uprighting force, serving the same purpose as a tipback bend. Together
with Class III elastics, this allows the first molars to upright farther
distally, creating additional arch length and allowing the anterior
discrepancy to unravel with little or no advancement.

• However, the extrusive effect of the Class III elastics on the max
molars should be given due consideration, especially in open bite
or high angle cases.
• A high-pull force is added to the face-bow during Class III
mechanics to prevent molar extrusion. The high-pull force should,
however, be initiated before placement of the first mandibular
wire.
• Cases with severe discrepancy, slenderization is carried out.
• The D-Rect wire is left in place for 2-4 months. However, if all
rotations cannot be eliminated,.017" x .025" D-Rect wire may be
followed with an .016" x .022" TMA or stainless steel archwire.

• The next wire is an .017" x .025" stainless steel finishing
archwire. If additional leveling is needed, a reverse curve of Spee
is placed in this final archwire.
• With finishing archwires in both the arches, and extra-oral forces
continued thru-out, Class I molar relationship should have been
achieved.
• For final detailing, Class II elastics may be added, if necessary,
until normal centric relation is achieved.
• Note that Class II mechanics are not initiated until finishing
archwires are in place.

• Premature use of Class II elastics can cause
•
•
•
•

loss of torque control,
bite closure,
tipping of the occlusal plane, and
a false bite.

• To correct a midline shift, a midline elastic with a Class II
elastic on one side and/or a Class III elastic on the other
will help shift the arches into their final positions.
• Up-and-down elastics may be used to correct any open
bite, or for overcorrection.
• Occasionally, one may need crossbite elastics on the
posterior teeth to achieve the normal buccal overjet.

Brief History
• Alexander’s interest in the orthopedic forces developed
from the study of the effects of the Milwaukee Brace on
scoliosis patients.
• During this same time, the Kloehnn headgear was gaining
popularity in distalizing maxillary first molars.
• One of the negative side effects of the Kloehnn headgear
was the tipping and extrusion of the molars, causing an
opening of the mandible plane angle.

• In an attempt to prevent this undesirable effect, Alexander
advocated a continuous upper arch wire to prevent molar
tipping while adding tied-back omega loops to reduce their
extrusion and keep the arch consolidated
• Although this approach prevented the distal movement of the
maxillary first molars, another effect was observed:
– Results from patients wearing the cervical face bow with the tiedback arch wires indicated that very little maxillary distal
movement took place, however, the Class II skeletal problem was
being corrected by the forward movement or growth of the
mandible.

• This effect has been widely recognized and used in the
treatment of patients.

Effects On the Three Dimensions
• Sagittal Dimension
– The Class II sagittal discrepancy can be positively
affected by the cervical face bow.
– In a growing patient requiring a Class II skeletal
correction, the face bow can be used to modify the
skeletal development by inhibiting anteriorly directed
maxillary growth.
– The result is an expression of the genetic potential for
mandibular growth and skeletal correction of the Class
II skeletal discrepancy.

• Vertical Dimension :

– The goal of the combination and high pull face bow is to
maintain the vertical relationship of the maxillary
posterior teeth and modify maxillary skeletal growth by
inhibiting vertical maxillary development.
– The vertical relationship can often be difficult to control
during orthodontic tooth movement, however, it is
imperative that this be done.
– In general :
• When the mandibular plane angle, (SN-MP), is 36 ° to
41° then a combination headgear is used, but when SNMP is greater than 42 °, a high-pull facebow is
recommended to control maxillary molar vertical
position.

• Transverse Dimension :
– Developing or maintaining
the maxillary transverse
dimension is accomplished
with the inner bow of the face
bow.
– The inner bow is routinely
expanded 3 to 4 mm when a
cervical or combination
headgear is being used for
Class II correction.
– Face bows can also be used to
hold cross bite corrections.

Inner bow expansion.

Advantages of Face Bow Therapy
• It places only a distal force on the maxilla without any
undesired mesial effects.
• No negative affect on the maxillary and mandibular incisor
torque, as seen in other intra-oral appliances like Herbst, Jasper
Jumper, etc.
• The face bow is cost effective and is easy to fit and adjust.
• Does not adversely affect speech.
• The authors also believe that there is no relapse with successful
face bow therapy because it does not posture the mandible
forward, the latter which may result in relapse resulting from
the muscular action. Correction is accomplished by the forward
growth of the mandible, when the headgear is appropriately
used, and favorable growth occurs.

Face Bow Adjustment
• For mesio-lingually rotated 1st
molars, the inner bow can be
adjusted over a period of 6
months to effect de-rotation of
the molar.
• In the cervical or combination
face bow, the innerbow and
outerbow are adjusted to be
parallel to the occlusal plane
• This important adjustment allows
the forces to be effective
sagittally while not causing
undesirable vertical forces to the
molars.

Outerbow parallel to innerbow, both
parallel to occlusal plane.


• When the high-pull face
bow is considered
necessary in the treatment
of the patient, the
outerbow is bent in such a
fashion as to direct the
forces in a more vertical
fashion (eg, 45 ° to the
occlusal plane).
High-pull face bow with special adjustment
to outerbows.

Treatment Time
• Depending on the diagnosis, the patient will wear the retractor
8-14 hours per day.
• As a general rule,
– if the patient's ANB is 5° or more, the retractor is worn 14 or
more hours a day.
– If the ANB is 3-5°, retractor wear can be reduced to 12 hours.
– If the ANB is less than 3°, the retractor is worn at night only, 8
hours a day.

Keys to Optimal Face Bow Results
• Cooperation:
– The face bow should be worn consistently. Eight to 10 hours
every night is usually adequate. In extreme antero-posterior
and vertical discrepancies, more wear can be beneficial.

• Growth:
– If the patient is not growing, no skeletal changes will occur.

• Tie back on continuous arch wire:
– If the upper arch wire is not consolidated into one unit, the
face bow will individually tip molars distally, resulting in the
loss of effective anterior growth expression of the mandible
and possible extrusion of upper molars.

Lower anterior vertical facial deficiencies are often
accompanied by over-eruption of anterior teeth
and under-eruption of posterior teeth. The result is
an excessive curve of Spee in the mandibular arch
and a reverse curve in the maxillary arch. This
presents as an abnormally increased overbite. The
freeway space in such cases is often excessive.


Principles in the Treatment of Vertical
Deficiencies
• Three modalities
– intruding the anterior teeth,
– extruding the posterior teeth, or
– a combination of the two.

• Factors of special importance in Alexander’s philosophy include
the final position of the lower incisors.
• It is considered most important by advocates of this orthodontic
approach to avoid the advancement of the lower anteriors.
• The one exception to this rule, however, is in the deepbite
patient where the incisors are excessively upright. Increasing
anterior torque in both arches is necessary to achieve a normal
interincisal angle.

• Most deep bite cases can be treated non-extraction
• In cases of moderate crowding, consider
• Inter-proximal enamel reduction

• For minor crowding in Class II patients, extraction
of maxillary bicuspid teeth only may be
appropriate.
• Extraction of a single mandibular incisor in a
severe, lower arch length, discrepancy situation
could also be a consideration.

• Maxillary Arch Development
– Accomplished by eliminating rotations, closing spaces,
accentuating the curve of Spee, and establishing proper
torque in the anterior teeth.

• Maxillary Bracket Height
– In some cases, the maxillary six anterior brackets are
placed 0.5-mm more incisally and the posterior brackets
are placed 0.5-mm more gingivally.

• Curve of Spee
– After the initial arch wire, an
accentuated curve of Spee is
placed to open the bite
– The curve should be placed in
the arch wire from mesial to
the Omega loop forward to
the cuspid area and not
beyond.
– In the flexible wires (0.016
stainless steel [ss], titanium
molybdenum alloy) excessive
curve can be placed to
encourage bite opening.

• When determining the amount of curve to place in the arch
wire, it is important to look at the patient's "smile line."
• If the incision-stomion measurement does not show a full clinical
crown, then great care must be taken with the amount of curve
placed in the arch wire.
• When gingival tissue is exposed when smiling, more curve can be
placed in the arch wire.

• The arch wire is "toed in" slighdy distal to the omega loop to
help rotate and control the first molars.
• All ss wires are tempered (heat-treated) before inserting.
• After the initial wire, all arch wires are tied back by using
omega loops.

• Bite Plate
– If the bite has not opened adequately after a few
months of treatment in the finishing arch wires, a bite
plate is placed.
– It is not placed until the maxillary arch form is close to
completion, usually the month before the lower
brackets are placed.
– By delaying bite plate placement, fewer bite plate
adjustments are needed.
– The bite plate is adjusted so that the upper teeth do not
touch the lower brackets on closure.
– In some cases, special lingual brackets can be bonded
to upper incisors to achieve the same bite opening
result.

• Mandibular Arch Development
– Treatment initiated approximately 6 months after
the maxillary arch.
– Lower anterior brackets must not be placed more
incisally than is usual because this would result in
premature con tact with the maxillary incisors
when occluding.
– Torque control should be maintained from the
beginning.

• Coordination of the Arches
– Both the maxillary and mandibular arch forms are
established by using the Alexander Archform
Template
– The maxillary first molars have been derotated and
mandibular second molars have been constricted,
and curves of Spee placed in the arch wires to level
the arches.
– If the overbite is not opening adequately, the arch
wire may be removed after 2 to 4 months for
recontouring and/or increasing the amount of curve
in it.

• Elastics
– Elastics are used to further coordinate the arches.
– No elastics should be used until finishing arch wires are in place.
– To help level the mandibular arch, box elastics can be used in the
bicuspid area.
– Class II and midline elastics are used after the overbite
approximates normal if the headgear has not resolved the Class II
condition.
– Finishing elastics are used to finalize the posterior occlusion for
long-term stability

• Retention
– Retention for vertically deficient patients is similar to
that of other patients except that a bite plate is placed on
the maxillary retainer and is adjusted so that the posterior
teeth are just out of occlusion.
– The patient sleeps in the retainer for 2 to 3 years.
– The mandibular cuspid-to-cuspid bonded 0.0215
multistranded wire can be worn indefinitely.


A typical treatment sequence for a Class II
division 1 case with a 5-8mm discrepancy in the
mandibular anterior arch is described.


• Maxillary Arch :
– After the extraction of the four premolars, separators are left in
place for two weeks to create adequate space and to allow
initial discomfort and soreness of the teeth to dissipate.
– The initial archwire— .0175" Respond or .017" x .025" DRect braided wire.
– Except in a Class III or bimaxillary protrusion maximum
anchorage case, where the mandibular incisors are protrusive
and the canines are Class I, we will begin treatment in the
maxillary arch and allow the mandibular arch to drift
(driftodontics) for six to eight months.
– By the time the mandibular arch is ready for bonding and
banding, the anteriors will have unraveled by themselves and
the mandibular second molars will often have erupted enough
for banding.

• Four to five weeks later an .016" stainless steel round wire is
placed, usually with omega stops 1-2mm anterior to the molar
tubes and canine retraction started. Canine ligation should be
done properly to avoid rotation & tipping of the canine.
• Face bow is adjusted to ensure adequate anchorage.
• In a closed bite case (overbite greater than 3mm), treatment of
the mandibular arch is begun as soon as the canines are Class I,
to help open the anterior bite.
• If the bite is not closed, canine retraction is completed (canines
touching second premolars) and incisor retraction is initiated
prior to proceeding to the mandibular arch.

•

Reasons for separate canine retraction :
1. less posterior anchorage is lost because fewer
teeth are being retracted, and, since it's early in
treatment, the patient will be more cooperative in
wearing his extraoral appliance;
2. by obtaining a Class I canine relationship before
the mandibular arch is banded there is no concern
for cuspal interference, loose bonds on the
mandibular canine, or attrition of the maxillary
canine cusp tip; and
3. after canines have been retracted, torque on the
maxillary incisors is more easily controlled during
their retraction.

• After maxillary canines have been retracted on the
.016" round wire with the power chain, an .018"
x .025" stainless steel closing-loop archwire is
placed for incisor retraction.
• This archwire is bent in an ideal arch form with
large, teardrop-shaped loops just distal to the
maxillary twin lateral bracket. Omega stops are
not used, but the wire extends through the first
molar tubes and the archwire distal to the closing
loops is reduced approximately .001" in the anodic
polisher, so that part of the wire can slide through
the brackets easily during activation.

• After all maxillary spaces are closed, the fourth
and final archwire is placed. This .017"x .025"
stainless steel wire is bent with ideal arch form
and omega stops and may or may not incorporate
an accentuated curve of Spee, depending upon the
overbite.


• Mandibular Arch :
– Treatment in mandible is begun after 6-8 months into active
treatment.
– The advantages of delay in banding the mandibular arch in
extraction cases are that:
• it allows physiological drifting of crowded mandibular
anterior teeth,
• little posterior anchorage is lost since maxillary molars are
being held distally,
• while retracting maxillary canines there is no interference
and/or attrition on the cusp tips from the mandibular canine
brackets,
• it allows additional time for the second molars to erupt more
fully, and
• total time needed to complete mandibular arch treatment is 912 months.

• As the maxillary spaces are closed and the canines are
in a Class I relationship, the mandibular arch is
banded/bonded with an .017" ´ .025" D-Rect
rectangular braided archwire or an .0175" Respond
multistranded wire
• Next an .016" round stainless steel wire with omega
stops 1-2mm anterior to the second molar tubes is used
to eliminate rotations, and level the curve of spee.

• The omega stops are not used if only a small amount of
extraction space remains that can be closed with a power chain
stretched from molar to molar.
• If there is too much space to close with a power chain, an .016" x
.022" stainless steel rectangular closing-loop archwire is used.
• A Bull loop is placed in the extraction site, and omega stops are
placed at the distal of the twin brackets on the first molars.
• Care must be taken to avoid overactivation of this closing loop,
which will cause dumping of the mandibular arch.
• If the mandibular arch has a deep curve of Spee, a gable bend is
placed at the closing loop.
• Space closure takes from two to six months, depending on the
amount of space to be closed.

• During this period, the amount of extraoral force used depends
on the molar relationship. In a severe Class II, active headgear
force for 14 or more hours a day is needed; in a Class I, only
night wear is required to hold the maxillary molars in position.
• After spaces have been closed in the mandibular arch, the
fourth and final archwire is placed— an .017" x .025" stainless
steel ideal arch with omega stops 1-2mm anterior to the
second molar tubes.
• If the arch is not adequately level after one or two months, this
archwire is removed, a reverse curve of Spee is placed, and the
archwire is retied, being sure it is tied back.

• Detailed finishing takes three to six months.
• Rotations are tied and the wings on the Lang or
Lewis brackets are activated to finalize rotations.
• Midline, Class II, or Class III corrections are
made with elastics.


• Elastic Wear :
• Class III elastics are often worn early in treatment either
to correct an anterior crossbite or to prevent
advancement of the mandibular incisors during the
initial elimination of rotations in nonextraction
treatment.
• Class II elastics are rarely worn until both arches have
rectangular archwires. Early indiscriminate use of Class
IIs can cause loss of anterior torque control, rotation of
the occlusal plane, and a deepening of the bite.
• Normally, Class II elastics are worn during the last few
months of treatment, when both arches have finishing
archwires.

• Midline correction is achieved after all spaces are closed
and final archwires are in place. A midline elastic,
connected from a maxillary lateral to the opposite
mandibular lateral, is worn in conjunction with a Class II
or Class III elastic to achieve the desired correction.
• Crossbite elastics are worn as early as possible, so that the
correction can be maintained during treatment. Lingual
lugs are placed on all molar bands for this purpose.
• Special elastics are worn during the finishing stages of
treatment. Anterior and posterior up-and-down elastics are
worn to finalize the cuspal interdigitation and overbite.

• ELASTIC SIZES

•
•
•
•
•
•

Class II
Midline
Class lIl
Up-and-down
Crossbite
Finishing

1/4"
1/4"
1/4"
1/4"
3/16"
3/4"

6oz
6oz
3– 1/2oz
6oz or
6oz
2oz


3/16" 6oz

• Palatal and Lingual Arches
– Normally not used because of the use of face bow thru-out the
treatment.
– Palatally, two designs are preferred.
• The Nance palatal arch, designed with an acrylic button placed in the
anterior center portion of the palate, is used in a case with an extreme
discrepancy, a Class I molar relationship, and anterior teeth that are in
normal positions. The purpose of the Nance is to hold the anterior
and posterior teeth in place while the canines drift into their position.
• A transpalatal arch with a Goshgarian design is used on all high angle
cases. In addition to maintaining the transverse dimension, the TPA
can inhibit vertical alveolar growth, which is desperately needed in
high angle cases. The arch bar is designed to be removable, so that it
can be expanded, constricted, or adjusted to rotate the molars during
treatment.

• In the mandibular arch a lingual holding appliance
is used to preserve the "E" space when needed.
This occurs in nonextraction cases frequently. In
extraction cases, it would be used in a maximum
anchorage situation with crowding, while waiting
for the remaining teeth to erupt. This lingual arch
is used specifically as a holding appliance


The problem of retention must be solved during
treatment or it will not be solved at all.
Dr. Fred Schudy


• Treatment goals are the same today as they were when
Tweed a wrote them in 1955.
– Pleasing balance and harmony of facial lines: no lip
strain should be present after treatment. Often lip strain
is the determining factor in an extraction decision. Facial
maturation, facial growth, and treatment changes in
nonextraction treatment can correct lip strain, and, of
course, are considered.
– Correct occlusion.
– Healthy tissues.
– 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.

– Original lower intercuspid width must be maintained. Expanded
lower cuspids typically constrict after removal of retention
appliances.
– Lower first molars should be upright to maintain a leveled
mandibular arch and overbite correction.
– Habits should have been eliminated.
– Midlines should be coincident and correct.
– Correct arch form.
– Correct curve of Spee and curve of Wilson should be optimal.

• In addition, a circumferential supracrestal fiberotomy is
performed on all adults with severely rotated teeth 2 months
before fixed appliance removal. Removal of hyperplastic tissue
in the maxillary central incisor area is also performed where
heavy diastemas are present, especially if they are considered to
be familial traits. www.indiandentalacademy.com

• The Countdown to Retention :
– When all the goals of the optimally treated patient are met
and fixed appliance removal time is approaching, four
appointments are made with specific objectives for each
appointment.

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

Preformed wraparound retainer wire.

"C" clasp not touching distolingual
cusp of second molar.

Maxillary retainer ready for deliver},.


Thank you
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