The 20 Principles of the Alexander Discipline, Volume 2. R.G. "Wick" Alexander
used for 3 × 3s and each tooth is bonded to the 0.0215 multistranded wire.
5 The mandibular intercanine width was expanded approximately 5 mm.
6 No interproximal enamel reduction was performed on the mandibular anterior teeth.
Final analysis
As stated earlier, we can always learn from our mistakes. This patient displayed some very challenging problems and positive changes were achieved during her treatment. But relapse occurred in certain areas.
Overall, the positive factors of this case include the patient’s compliance and favorable growth response, the soft tissue profile, the smile, the final occlusion, the maxillary intermolar width change, the maxillary arch form, and the leveled mandibular arch. The negative factors include the poor mandibular anterior root positioning, the expanded 3 × 3, the lack of interproximal enamel reduction, and the poor mandibular arch form.
Summary
With some exceptions, the goal for orthodontic treatment should be to (1) keep the mandibular anterior teeth as close as possible to their original positions, and then (2) build the rest of the occlusion around the mandibular anterior teeth. This book will expand on this very simple concept and demonstrate by research and examples that there is such a thing as long-term stability!
Enjoy the trip!
Acknowledgments
Writing a book has many challenges. Probably the most important factor is the subject material. Spending my professional career studying and practicing orthodontics has been the dream of a lifetime. Having two sons, Chuck and Moody, to continue the “tradition” has been a father’s dream. Knowing classmates and close friends, we have always wanted to share with each other our knowledge and new concepts.
Behind the scenes is my understanding wife, Janna, who has given me the wings to fly around the world.
This book would have been only a dream without the support and efforts of Dr Elisa Espinas-San Juan, my associate for orthodontic research, lectures, and publications, who was responsible for case images and organization, and Becky Davis, my administrative assistant, who coordinated the manuscript. My appreciation to our clinical staff: Ellie Oginski, Angie R. Knight, and Nancy McInnis. Additional professional support from Quintessence provided the means to an end.
A final “thank you” to all the orthodontists around the world who have heard the “message” and have become loyal supporters. And I might say some of the best orthodontists in the world.
And now… on to the future.
Author’s Note
The reality is that not every patient treated orthodontically can have long-term stability without retention. Some clever person once said that “rules are made to be broken.” In this book, a great effort has been made to identify certain facts that affect the stability of orthodontic treatment. We must realize that in dealing with individual human beings, specific circumstances may prevent us from reaching our goals.
For example, it may be that for stability’s sake teeth should be extracted, but extraction might create an unattractive soft tissue profile. Generally speaking, if I have to choose between esthetics and stability, I choose esthetics. Luckily, this situation seldom occurs.
In a particular case, because the anterior occlusion is a Division 2, the mandibular incisors are excessively lingually uprighted. After improving the torque in the maxillary anterior teeth, the mandibular anterior teeth can and should be advanced beyond the “3-degree rule.” A more normal interincisal angle can be created that is definitely more functional. However, is it stable? My answer is a restricted yes. If the mandibular arch is properly leveled, little overbite relapse should occur. Controlling intercanine width, spreading the incisor roots, and interproximal reduction all play a large part in stability success.
Many years ago at a Texas Tweed meeting, my brother Moody was grading a case that was treated with the extraction of four first premolars. In discussing this with the clinician, Moody observed the concave profile that had resulted. The clinician agreed with the analysis, but very defiantly said, “But I satisfied the triangle,” meaning the Tweed Triangle diagnosis.
Today, in diagnosing borderline extraction cases, the decision depends on appearance rather than stability. Borderline cases will be treated with nonextraction by the vast majority of orthodontists, although the teeth will be moved into unstable positions. So, this brings forth a significant question: Should the patient and parent be told that the teeth are being moved into unstable positions?
At the annual 2011 AAO meeting in Chicago, I had the privilege of being on the program. With a theme of “Finishing, Retention and Stability,” I chose to entitle my presentation “It’s Time to Stand Up for Stability.” The material I presented is found within the pages of this book. In this small way, I am standing up for stability! May my thoughts and suggestions help you treat your future patients with long-term stability as a treatment goal.
CHAPTER 1
Introduction: Begin with Stability in Mind
“We are what we repeatedly do. Excellence, then, is not an act, but a habit.”
–Aristotle
Orthodontics has been a creditable specialty within dentistry for more than 100 years. And yet, after all these years and millions of patients treated, universal guidelines that can be taught and practiced on a daily routine have not been established. The phrase “begin with the end in mind” is well and good if we know where the end should be. A phrase better suited to this book is “begin with stability in mind.”
For many years, the world of orthodontics has been searching for the “golden horseshoe” when addressing the subject of long-term stability. So many factors must be included: growth, habits, treatment technique, application of forces, and compliance. Webster’s New World Dictionary defines stable as “not likely to change” and “firm, fixed, lasting.” When this subject is related to entities in the oral cavity, especially the teeth, is it realistic to think that they can remain firm and last throughout a patient’s life? Several variables exist, including eruption patterns, eruption direction, skeletal pattern, musculature, and habits, many of which cannot be controlled by the orthodontist throughout the patient’s life. Dr Little arbitrarily stated that any occlusion with less than a 3-mm irregularity index can be considered stable.1
The reality is that we are not dealing with teeth set in concrete. Perfection is not a realistic goal. Living hard and soft tissues place pressures on the teeth that can cause changes and movement. Our challenge is to find certain positions in which the teeth can be placed in the oral cavity so that the balancing intraoral forces will allow the teeth to be firm and lasting.
After all this time, are we as a specialty in orthodontics any closer to identifying the keys that are necessary to achieve adequate functional occlusion, acceptable esthetics, and stability? Historically, by not learning from our past mistakes, the pendulum has swung from nonextraction to extraction and then back to nonextraction.
Currently in the world of orthodontics, fantastic technology and new and different ways of viewing mechanics, such as cone beam imaging and controlling vertical anchorage with mini-implants, have shown great promise. But few things in life come without a price. The question is: Are we smart enough to know who has control of what? And is it worth the price?
In reading the history of the Roman Empire, one is amazed by the advanced technology the Romans created in the construction of their roads. During that special time in history, literally all roads did lead to Rome. In the world of orthodontics, wouldn’t it be wonderful if we had a Rome? No matter our technique or bracket system, our goals for the finished result would be the same, and we could expect good long-term