The 20 Principles of the Alexander Discipline, Volume 2. R.G. "Wick" Alexander
California, New York Univeristy, Loyola University, and other schools in Canada, Germany, Mexico, Brazil, and other countries. A large number of these theses have been published. An open-door policy concerning these records has always been in force. Any student in the world is welcome to come study these diagnostic records (Fig 1-1c). The only stipulation is that no records be removed from the office.
Throughout this book, I quote many statements from these research studies that changed some of our concepts on long-term stability from anecdotal to evidence-based information.
In volume one of this series, I attempted to identify the 15 keys to orthodontic stability. Although the keys have not changed, I have consolidated them into six guidelines. Hopefully this book presents to the reader a more precise approach to identifying the goals for long-term stability.
Six Guidelines to Building Facial Harmony and Stability
1 Surrounding tissuesPeriodontal healthTMJ
2 Anterior torque controlIMPANasolabial angleInterincisal angle
3 Skeletal controlVerticalSagittal
4 Transverse controlMandibular 3 × 3 widthMaxillary 6 × 6 widthArch form
5 OcclusionRoot positionLeveled mandibular archInterproximal reductionFinal occlusion
6 Soft tissue profile and smile
Presented with most guidelines are:
Evidence: As often as possible, research from graduate orthodontic students using the author’s diagnostic records directly addresses the question related to the specific subject.
Mechanics: Throughout my 45-year practice of treating more than 15,000 patients with full orthodontic appliances, specific mechanical techniques have been created to address specific issues. These mechanics are explained and demonstrated. More detailed explanations can be found in volume one of this series.
Exceptions: Someone once said, “There is an exception to every rule.” In orthodontics, this statement is partially true; I attempt to distinguish the differences.
During a presentation on posttreatment changes during and after retention, Dr Asai (Crazyhorse) Yasuhiko, one of Japan’s outstanding orthodontists, said the following: “It has been said that the biggest cause of relapse is inappropriate treatment, above all other factors causing posttreatment changes, such as growth, jaw position, function, and habits. This is a matter of common sense.”12
Conclusions
1 The human body grows, matures, and ages; none of its parts stay unchanged. The dentition is no exception. It will continue to change little by little, even during retention.
2 There are many possible causes of orthodontic relapse that preclude us from accurately predicting long-term posttreatment changes with the current scientific standards in orthodontics.
3 The current difficulties facing orthodontics should be no excuse for poor treatment. Orthodontic treatment makes an important contribution to patient quality of life through marked esthetic enhancement, various functional improvements, and creation of an environment conducive to more favorable jaw growth and oral hygiene.
4 Minor changes occurring after quality orthodontic treatment seem to be mostly unavoidable and should therefore be tolerated. In reality, these changes are unlikely to develop into major problems.
5 The orthodontist should inform the patient of relapse potential prior to treatment and raise patient awareness of sharing responsibility for stability of treatment results. Based on this shared responsibility approach, it is desirable for the orthodontist to be flexible to retreatment needs.
In an article about the future of orthodontics, Mark Hans made the following statement: “A disturbing trend in the last few years has been the willingness of the specialty to accept that the treated case is less stable than the original. If we as a specialty give up on stability as a treatment goal, then it is likely the specialty will not survive. So, we must embrace stability as a treatment goal.”13p1 This statement is quite appropriate to the purpose of this book. Yes, I agree that we should embrace stability as a goal. Continued evaluations and studies on future patients will bring us closer to creating accurate diagnoses, treatment planning, and treatment results that demonstrate long-term stability.
References
1 Little RM. The irregularity index: A quantitative score of mandibular anterior alignment. Am J Orthod 1975;68:554–563.
2 Turpin, DL. The case for treatment guidelines. Am J Orthod Dentofacial Orthop 2007;131:159.
3 Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy: Posttreatment dental and skeletal stability. Am J Orthod Dentofacial Orthop 1987;92:321–328.
4 Alexander JM. A Comparative Study of Orthodontic Stability in Class I Extraction Cases [thesis]. Dallas: Baylor Department of Orthodontics, 1995.
5 Elms TN, Buschang PH, Alexander RG. Long-term stability of Class II, Division 1, nonextraction cervical facebow therapy: I. Model analysis. Am J Orthod Dentofacial Orthop 1996;109: 271–276.
6 Elms TN, Buschang PH, Alexander RG. Long-term stability of Class II, Division 1 nonextraction cervical face-bow therapy: II. Cephalometric analysis. Am J Orthod Dentofacial Orthop 1996;109:386–392.
7 Boley JC. An extraction approach to borderline tooth size to arch length problems in patients with satisfactory profiles. Semin Orthod 2001;7:100–106.
8 Buschang PH, Horton-Reuland SJ, Legler L, Nevant, C. Nonextraction approach to tooth size arch length discrepancies with the Alexander Discipline. Semin Orthod 2001;7:117–131.
9 Carcara SJ. Leveling the curve of Spee with a continuous archwire technique—A long-term study cast analysis. Semin Orthod 2001;7:90–99.
10 Ferris T, Alexander RG, Boley J, Buschang PH. Long-term stability of combined rapid palatal expansion–lip bumper therapy followed by full fixed appliances. Am J Orthod Dentofacial Orthop 2005;128:310–325.
11 Bernstein RI, Preston CB, Lampasso J. Leveling the curve of Spee with a continuous archwire technique—A long-term cephalometric study. Am J Orthod Dentofacial Orthop 2007; 131:363–371.
12 Yasuhiko A. Posttreatment changes during retention. Presented at the Southwest Component of the E.H. Angle Society Annual Meeting, Dallas, 5–7 Mar 2009.
13 Hans M. Future of orthodontics. Orthod Select 2009;23:1.
Case 1-1
Overview
A mature adult previously treated (at least four premolars extracted) presented with a severe overbite (8 mm). Lingual brackets were discussed, but labial Alexander brackets were decided upon.
Examination and diagnosis
A 39-year-old woman presented with a Class I skeletal pattern. All four first premolars, the maxillary left second molar, and four third molars were missing. Even though premolars had been previously extracted, mandibular crowding of 5 mm was present. The patient’s occlusion demonstrated a Class I molar relationship with overjet of 4 mm and overbite of 8 mm. The mandibular midline was shifted 2 mm to the right, and the left first molars were in reverse articulation. Cephalometrically, the patient presented with a low-angle Class I skeletal pattern with a Division 2 torque on the anterior teeth.
Treatment plan
Do not remove additional teeth. This patient seeking treatment before the days of implants, the missing second molar allowed open space for a maxillary left second premolar partial denture. Band and bond the maxillary arch first, create a normal arch form, and then place a maxillary bite plate before bonding the mandibular arch. The reverse articulation found with the mandibular left first molars was corrected by expanding and constricting