5principios de Alexander Ingles

7/29/2019 5principios de Alexander Ingles

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Effort Equals Results"Talent plus knowledge plus EFFORT accountf orsuccess."

The first principie of the Alexander Discipline isEffort EqualsResults (E= R). This basic formula or philosophy is thefoundat ion on which all else is built and is an out growthof a philosophy of life. This equat ion was derived

from the bookAs aMan Thinketh, by JamesAllen1 (Fig 1-1)More than 100 years ago, Allen stated that. " In all human

affairs, there are efforts and there are results, and thestrength of the effort is the measure ofthe result. Chance isnot ." Such simple words can have a powerfu l inf luence onthose who apply th is philosophy to the irown lives.No one can expect his or her life to be completelysmooth, without bumps in the road. In general, however,

- Gertrude Samuelsthe atttude with which the individual approaches thesebumps wi ll have a great impact on the outcome. The hardera person works on a problem, the " luckier" he or shebecomes. This is so t rue in orthodontics. Whether the challengeis learning to bend omega loops ormotivating apatient, the more effort given, the better the results wi llalways be.The concept ofE = R has been the theme of our officesince its inception . Whe n patients and parents enter, thefirst thing they see is the sign on the wall (Fig 1-2).AII educationalmaterial has been prepared with t his thought inmind (see also Fig 20-3).

Keys to SuccessAfter40 years ofc1 inical practice, I have ident if ied severalkeys to success. Systems come and go, technology changes,but certain truth s remain that are independent of the timesand can lead to success . . . whetherin orthodontics or in life.

SelfconfidenceOne of the most imp ortant elements in each person's lifeis the concept of self-confidence.Although t his outlookcan be misinterpreted as conceit, every orthodontist musthave t his attitude if he orshe expects to be successf ul. Inthe children's story The Little Engine ThatCould, the littlet rain kept itself motivated by saying, "1 thi nk I can; I thinkI can." Like the train in th e fable, orthodontists must give

t heir very best with each patient. Alt hough clinicians mayfall short occasionally, the y keep tryin g. Baseball immortalBabe Ruth was asked what he thought abo ut when hestr uck out. He replied, "Every strike brings me closer to thenext home run ." What a posit ive attitude!

PersistenceThe informat ion presented in the fo llow ing chapters is aprod uct ofmy curiosity and persistence.As Calvin Coolidge,the 30th president of the United States, said :Not hing in the world can take the place ofpersistence.


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Talent w ill not . . . noth ing is more common thanunsuccessful men with talent. Genius wi ll not . . .unrewarded genius is almost a proverb. Educat ionwill not ... the world is full of educated derelicts.Persistence and dete rmination alone are omnipotent.

Fig 1-2 The first thing patients see when they enter the autho r'spractice is theprincipie upon which it is built.

The slogan "Press on" has solved and always w illsolve th e problems of the human race.

PragmatismWhen the E = R formula is applied to orthodo ntic results,every pat ient should be treat ed as ifhe orshe were t heort hodontist's own child or spouse. Nevertheless, althoughI strive to produce the very best results possible, after treatingmore than 14,000 patie nts, I have yet to produce the

perfect result. Clinicians must be realistic when it comes toworking w ith human beings.It has been said, "To strive for excellence is goo d; tost rive forperfect ion is a terrible waste of tim e." This aphorismis not to be interpreted as an excuse for not deliveringthe highest quality treatm ent possible. Rath er, it represents

an acceptance of the realization that human beings aresimply not perfe ct. There comes a t ime at the end of everypatient's treatment when practical, realistic decisions mustbe made to finalize the results. The orthodontist mustweigh the advant ages of continuing treatmen t with theconsequences of removing the appliances. If th e results donot come up to the c1inician's standards, the patient andparent s shou ld be informed of th e reasons w hy the treatmentgoals were not achieved.

DisciplineEvery teacherhas asked him selfor herselfwh ether disciplinecan even be taught. I believe that it can be. The bestdef initi on ofdisciplin e I have heard was taught to me byWalterHaley:

Discipline: Do what you ough t to do, when you oug htto do it. whetheryou wan t to do it or not! No debate:2

Fig 1-3 Dr Moody Alexander,modeling good patientcom munication.When persistence and discipline can be channeled inthe right direction , positive results will always be produced.Characterhas been def ined as "what you do when no one15 looking." This idea also applies to discipline.

PrincipIe 1 Case StudyOverviewSevere Class 11 skeletal pattern corrected by facebow,compliance, and growth.

Examination and diagnosisA 13-year-old girl presented with a convex profile, lipst rain, minimal soft tissue pogonion, and asevere Class 11medium-angle skeletal pattern. Her maxillary incisorswere flared, resulting in an 11-mm overjet; her overbitewas 4 mm. Slight spacing was found in the mandibularincisor area, and an extremely large gingival display uponsmiling was observed.

Treatmentplan


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Usually such patients would be treated by extraction .Because of the spacing in the anterior mandibular arch,however, a decision was made to attempt treatmentwithout removing teeth .Based on the lateral cephalogram, SN/MPwas normalat 33 degrees, and yet it was evident c1inically that thepatient had a more vertical skeletal pattern . Sometimes

the " numbers" do not tell an accurate story. Therefore, aPrinciple 1 Case Study _

ConcIusionAlth ough every orthodontist loves to treat patients whofollow the rules, pat ients who do not comply represent achallenge (Fig 1-3). The tendency may be to give up andattempt "noncompliant " treatment. Instead, it is hopedthat th e reader will feel and absorb theAlexanderDiscipline approach and then apply this attitude to allpatients and especially to problem cases, where extraeffort equals improved results. Principie 20 presents adetailed discussion about patient compliance.

PrincipIe 1 Case StudyOverviewSevere Class 11 skeletal pattern corrected by facebow,compliance, and growth.

Examination and diagnosisA 13-year-old girl presented with a convex profile, lipst rain, minimal soft tissue pogonion, and asevere Class 11medium-angle skeletal pattern. Her maxillary incisorswere flared, resulting in an 11-mm overjet; her overbitewas 4 mm. Slight spacing was found in the mandibularincisor area, and an extremely large gingival display uponsmiling was observed.

TreatmentplanUsually such patients would be treated by extraction .Because of the spacing in the anterior mandibular arch,however, a decision was made to attempt treatmentwithout removing teeth .Based on the lateral cephalogram, SN/MPwas normalat 33 degrees, and yet it was evident c1inically that thepatient had a more vertical skeletal pattern . Sometimesthe " numbers" do not tell an accurate story. Therefore, a

Principle 1 Case Study _

ConcIusionAlth ough every orthodontist loves to treat patients who

follow the rules, pat ients who do not comply represent achallenge (Fig 1-3). The tendency may be to give up andattempt "noncompliant " treatment. Instead, it is hopedthat th e reader will feel and absorb theAlexanderDiscipline approach and then apply this attitude to allpatients and especially to problem cases, where extraeffort equals improved results. Principie 20 presents adetailed discussion about patient compliance.

Reference


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1. Allen J.As aMan Thinketh . 1902.

combination facebow was worn 9 to 12 hours daily for19 months .

DiscussionNote that the maxillary arch was banded while themandib ulararch was bonded; the patient was treated

during the period (1978) when my practice was transitioningfrom bands to brackets.The patient was extremely compliant as good growthtook place, which accounts for the relatively brief(20month)

treatment periodo This isa great example of effort =results!

EvaluationLong-term records (15 years posttreatment) show goodstability throughout with the exception of the rotation ofthe mandibularleft lateral incisor. This can be attributedto the poor angulation of the lateral incisorresultingfrom poor bracket placement. I soon learned to angulatethe brackets when bonding .

The patient pursued a successful career as an internationalmodel, for wh ich her smile proved a valuable asset.

ThereAreNo

Little Things"Tr if les make perf tction and perftction is not a tri fl e."

- Michelangelo

APoPu,ar motivational book published in the United tle things, I am tempted to think there are no littleStates is entitled, Don't Sweat the SmallStuii.'In things. rr

the world of orthodontics, however, this is poor In my firstbook.' chapter 2 was devoted to a discussionadvice. On the opposite end of the spectrum, Stephen R. of the "little things" that make all the difference inorthoCoveycaptured the nation's attention with the principies dontic practice. Although computers have replaced penhe espoused in his book, The 7 Habits of Highly Effective and paper, the basic concepts remain the sarne.People, which was first published in 1989 2 Covey Orthodontists must envision the "biq picture " in their

pracfocusedon specific habits that anyone could adopt to tice and yet to be successful, they must also tend to all ofbecome more effective. I agree with most of Covey's those little things that, when put together properly, giveideas, but a favorite is the following (based on a quote the final rewarding result.from American author Bruce Barton): "Sometimes when This book focuses on the biomechanics of orthodonticI consider what tremendous consequences come from lit- treatment as well as patient compliance. However,for

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2 There Are No Little Thngstreatment to be successful, office management and


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patient treatment mechanics cannot be separated. Themore efficient an orthodontist is in treatment mechanics,the more smoothly the whole office can function.The following chapters describe and illustrate each of thelittle things that should be routinely performed for consistentlyhigh-quality results. The outcome of any therapeuticorthodontic procedure depends on proper diagnosis, treatment

planning, and management of any skeletal problems.Then it is possible to begin the process of treatment,including selection of the right bracket system, detailedplacement of brackets, archwire sequence, use of elastics,finishing, and finally, retention. If the principies involved ineach of these steps are understood and performed properlyand routinely for each patient, the final results will includeconsistently beautiful smiles, good functional occlusion,healthy hard and soft periodontal tissues, and long-termstability.

Optimum Treatment

Timingf all the little things that influence the outcome of treatment,

timingmay be one of the most important. Howdoes a c1inical orthodontist make the very important decision

as to when to initiate treatment?

Issues to ConsiderWhile observing cervical maturation can be helpful, oneday the profession may have a simple test to accuratelypinpoint a patient's stage of growth. For now with growingchildren, the orthodontist must approach every appointmentas if the child is a new patient, because new growthand the treatment mechanics being employed will havealtered the prior condition.

StageOfgrowthFrom the orthodontist's perspective, the best time to treat

patients is when they are in a period of maximum growth.It is always satisfying to see very difficult cases managed

8with beautiful results that are achieved partly because ofgood timing between treatment and growth. Excellentresults can often be attributed as much to growth as to theskill of the treating practitioner. The converse situation alsooccurs too often-that is. orthodontists tend to blame"bad growth" for poor results.

AgeGenerally, girls begin growth at an earlier age than boys.For example, an 8-, 9-, or 1O-year-old girl usually respondsbetter to headgear treatment than does a boy of the sameage. However, girls also complete their growth at an earlier

age. Boys, therefore, respond best to orthopedic changesbetween 12 and 14 years of age. Figures 2-1 and 2-2demonstrate the gender difference in dental maturity oftwo patients of the same age.

Nevertheless, the window of opportunityfor capitalizingon growth in children has great individual variationthat must be recognized and taken into consideration.Questions asked during the initial examination can elicitvaluable information for determining a patient's stage ofgrowth:


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Is the patient growing now? Are the patient's feet growing? Are the patient's pant legs getting short? Has the female patient started her menstrual cycle? Does the patient more closely resemble the father orthe mother? How tall is the patient's father?

For Class 111 patients: Does anyone on either side ofthe family have a strong lower jaw like that of thepatient?

OrthodonticdiagnosisAnother factor that affects the timing of treatment is thepatient's specific problem. If the problem involves excessivelyprotruding teeth susceptible to traumatic injury, misalignedteeth that negatively affect a patient's self-imageor desire to smile, or impacted or poorly erupting teeth, itis difficult to justify a delay in treatment. Early treatmentmight therefore be necessary for patients with these problems.The c1inician must weigh the advantages and disadvantagesof orthodontic treatment while giving equal considerationto the patient's psychological health and thetotal treatment time.

PrincipIe 2 Case StudyOverviewA borderline, moderate Class II skeletal pattern with maxillaryanterior crowding corrected with combination facebow.Long-term stability was acceptable.

Examination and diagnosisThis ll -year-old girl presented with a medium-angle, Class1I skeletal pattern. Molars were in Class 11 positions, and shehad a 6.5 mm overjet and a 3.5 mm overbite.A 2-mmmidline shift and a slight arch length discrepancy were

observed .AII four primary second molars were present.TreatmentplanWhen first examined, this patient was diagnosed as a firstpremolar extraction case.Aftershe wore a combinationfacebow for 10 months while waiting for the second premolarsto erupt , the decision was changed to treat hernonextraction.

DiscussionThe patient was treated in the early 19705, befo re thedays of bonded brackets, which made mandibularincisorcont rol in nonextraction treatment more difficult. Thiswas accomplished with c1ass 3 elastics early in treatment.

EvaluationExaminatio n of the patient's chart reveals that she haddifficulty wearing the facebow. With good growth, persistencefi nally wo n, and acceptable results wereachieved with herfinal occlusion and facial pattern.More than 31 years later, this patient appeared in theoffice with her 8-year-old daughter in need of orthodontictreatment. In evaluating our former patient's longtermresults, it was noted that heroverbite and overjethad been very stable. Buccal occlusion is excellent (no


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temporomandibularjoint issues), and arch forms are stable.After the mandibular fixed retainer had beenremoved 4 years posttreatment, there was some minorshif ting, especially between the left lateral incisorandcanine. In the author's opinion, this was a result of poorroot angulation on the left lateral incisor. Remember, thiswas before the days of pre-angulated brackets.Also, no

interproximal enamel reduction was performed on theanteriordentition .

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The KISS PrincipIeI n al l thi ngs, the supreme excel lence is simpli city."- Henry Wadsworth Longfellow

In graduate schoo l, at t he University ofTexas Denta lBranch in Houston, I was taug ht the Tweed Technique.'I took the Tweed typodont cou rse twice whi le in schoo land again while in private practice when my study club: 'aveled to Tucson, Arizona, to hear from the master(Fig3-1). I was taught structured, systematic sequences thatallow orthodont ists to achieve certain goals in treatment.This basic educat ion, although very difficult, was anexcellent way to learn t he fundamen tals of orthodontics.

Vhen I began private practice, however, I asked myselfif:here could be a betterway to achieve t he same highualityresults using mechanics t hat were gent lerand less:omplicated. Therefore, I began my search by quest ionngthe mechanics of the Tweed technique.

A pop ular maxim is "Keep it simple, stupid" (KISS). Theidea is to avoid unnecessary comp lexity. Wi th a desire toreduce th e comp lexity ofbiomec hanics, I attempted tocreate treatment mechanics tha t could be performed in asimple, straightforward, and routine format. This wasaccomp lished by a process of questioning most ofth e conceptsI had learned, keeping those concepts that werenecessary, and removing those that were not. The goalwas to develop a treatment plan that would progressin the most direct course possible. In keeping with theKISS principie, treatment sequencing in theAlexanderDiscipline is so predictable and simple that fo rmostpatients the c1ini cal assistants can determ ine the nextappointment's procedure.

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3 The KISS Prin cipleFig 3-1 Dr Charles Iweed.

BenefitsThe KISS principie perm eates every prin cipi e espou sed in


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thi s book. Occasionally, orthodo nt ists ask, "Why bendomega loops?" or"Why ligat e w it h steel ligature vvire?"These procedures take additional time when initi ally performed; in the end, however, it is much more effect ive tohave omega loops available so that th e archwire can betied back and kept consolidated th rou ghout treatrnent .The use of steel ligature wi re allows better engagement

of the archwire in the brac ket slot and eliminates theneed to change the ort hodont ic elastomers at each appointment.The idea is to expend a small, extra effort earliert hat wi ll pay big divid end s throughout the rest of thet reatment.Good patient compliance is vital for successful treatment.Simp lifie d techniques reduce the complexity andnumberof instructions necessary for the patient to follow.The patient can more easily perform the duties necessaryfor successful results, makin g the success rate significantlygreater.If thin gs are kept simple, all involved-patient, orthodontist,and staff- can do theirjobs more effectively.

Conclu sionSimple does not necessarily equal easy. Keeping thi ngssimple can be hard work .A good deal of time and effortmust be devoted to allow t reatment to flow smoothly andsuccessfully to th e desired goal.Too often in orthodont ic management, t here is confusion

between efficiencyand effectiveness. Stephen Coveyldid not choose to refer to peopl e who were " highly eff icient" in th e ti t le of his book; he chose the words " highly

effective." Efficiencyis doing thin gs right. Effectiveness isdoing the righ t th ings. TheAlexanderDiscipline is designedfor effectiveness, to do the right th ings.Emergin g technology wi ll surely allow our methods andapp liance design to be more eff icient and effective; how ever,the fundamental truths of final tooth positioning forfunctional , healthy,

Prin ciple 3 Case StudyOverviewThis case demonst rates how a ratherdifficult malocclusionand Class 11 skeletal pattern can be treated using theKISS principie .

Examination and diagnosisA 1O\


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th is time, a lip bumper was placed in the mandibular archto gain moderate space.To address the skeletal problem , a combination facebowwas worn at night. After full bracket placement androutine archwire sequencing, elastics were worn toachieve final occlusion.

DiscussionAlthough the patient had only one loose band, she didbreak 11 appointments. This. along with delayed bondingof the mandibular second molars, unnecessarilyextended her treatment time. At the end of active treatment,she was having problems wearing her midline elastics.After1 told her the "wedding story" (see principie20), however, she corrected the midlines perfectly.

Follow-upThis young lady is an example of a typical patient treatedin our office.Acceptable growth and eventual compliancecombined to produce the finished result. Sherecently won a beauty contest.17

Estab ish Goals for

Stability'We should look to the end in all things."

-Jean La Fontaine

Few things in orthodontics are trul y new. The basicmethod of tooth movement has changed little since theearly 19005. Of course, the AlexanderDiscipline hasenefited greatly from improvements in materials and pro::edures, such as newermetallurgy and bracket bonding.Specific approaches, techniques, and materials will continuellychange, but the fundamental truths will always remain:he same.Early in the history of orthodontics,just getting the

:eet h to move must have been very excitin g. The idea was:0 get the teet h " st raiqht ." History has shown, however,

:hat thi s goal is not enough. That word relapse has contin.rally raised its ugly head. Getting the teeth st raight was:ery important, but time has show n that keeping the mstraight is anothe r challenge. Therefore, the next level of

orthodont ics is to keep the teeth straight.During this past century, orthodontists have learned some:acts regarding the placement of teeth at the end of treat-nent that wil l affect the total outcome of the treatment.


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One trut h that cannot be debated is the precept " Primumnon nocere" (" First, do no harrn" ). It is possible for orthodontictreatment to cause plenty of harm: overexpansion,flaring, extrusion, poorly tipped roots, and the list goes on.It is the responsibility ofthe orthodontist to position theteeth so that the chances fo rhealthy, stable results are morefavorable. For example, orthopedic forces should control

and/orencourage good growth . Orthodontic forces shouldnot move the teeth into positions that vvrll be unstable.There are many unresolved issues in orthodontics: Are there limits or boundaries in orthodontics? What is the "stan dard of care" ? How much of orthodont ics has become a science,rather than remaining an art ? Hasthe specialty of orthodontics matured to the pointat which the majority of orthodontists would examinethe same patient and agree on the goals and specifictreatme nt plan?

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4 Establish Goals for Stability

Role ofthe PatientThe most imp ort ant factorin the formula for success is thepatient. Three factors wi ll always prevent orthodonticsfrom being an exact science: the patient's growth, habits,and compliance.Predicting the cephalometric skeletal changes that wi llresult from orthodontic or orthopedic forces is at best anerratic science. Treating growing children is like attempt ingto hit a moving target. The amount and direction ofgrowth wi ll have a significant role in determining theresult. When a specific orthopedic force is applied, eachhuman being can respond differently.In genera l, orthopedic improvement can be accomplishedin most growing patients. The sagittal skeletaldimension can be altered favorably in growin g patients.

Vertica lly growing patients with a high mandibular planeangle can be improved, although their direction of growthis not as favorable as that of patients with a lowermand ibularplane ang le. The most predictable orthopedicimprovement can be observed when the transverse dimensionis expanded .Habits such as thumbsucking, mouth breathing , bruxism,and tongue thrusting can have detr imental effects onthe treatment outcome, regardless ofthe skeletal pattern.

In mostpatients. however, the key to success is patientcomp liance.As discussed in princ ipie 20, orthodontists areon ly as good as theirpatien ts.

Evidence-Based

OrthodonticsIn one of his lectures many years ago, Dr Fred Schudy fromHouston, Texas, joking ly stated, "Figures don't lie . .. butliars figure." When discussing the goals in orthodonti ctreatment, I rely on very specif ic research performed by variouspeople . Residents from the BaylorCollege of Dentistryorthodontic department have performed much of myresearch, many times using patient records from my office.This could create a conflict of interest if1 had personallyselected these records. To prevent this from occurring, I


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have adopted some rules for use of my case records.The resident is given complet e access to all records.There is no " cherry picking"; I have never selected thepatient records to be used in any study. The residents selectthe cases that they wi ll study based on th eir study protocol.They are not permitted to remove any records from theoffice. Orthodontic residents from oth eruniversities in the

United States and from around the world have studiedthese records. This is import ant so that the doctors aroundthe world who hearthe results ofthese studies can be confidentofthe irobject ivity.It is incumbent on all orthodontists to practice evidencebasedorthodontics, w henever that evidence exists. AIIresults discussed in research must be accompa nied by statistical data . lt is the goal to arrive at a stat ist ically validmean. That mean will always have a range, however (thestandard deviation). The numbers and measurements presentedin research are often just guidelines, not absolut evalues.As Dr Peter Buschang says, "There is no such thingas a 'me an' patient."As alway s, th ere will be exceptions toevery rule; however, the principies advocated in this bookare an attempt to make orthodonti cs more of a science

and less of an art.The following goals, when achieved, have been found tohelp create healthy, esthetically pleasing, and stable results: Mandibularincisors balanced on basal bone Maxillary incisors positioned to create a goodinterincisal ang le Canine expansion prevented Proper artistic root positioning Upright mandibularfirst molars Norma l overbite and overjet Functional occlusion in centric relat ion

The 15 Keys to

Orthodontic SuccessThroughout the history of modern orthodontics, the diagnosticrecords of the patient have been used to evaluatethe patient's problems and determine the resultant t reatmentplan. These records consist of a lateral cephalogram,panoramic radiograph, study casts, intraoral photographs,and facial photographs. From each of these records, crit icalinformat ion is obtained and then evaluated .Aftermuch research and evaluat ion ofpart icularmeasurementsfrom many patie nt s' long-term records, certa in normsappearevident; these norms have helped to establish setgoals forth e treatment of patients.

Among all ofthe possibilities, 15 measurements takenfrom the diagnostic records can provide a briefyet accuratedetermination ofgoa ls necessary to achieve successfui treatment and long-term stabi lity for the individua lpat ient.Cephalometres:

The tetragon-plus analyss:::ertain established cephalometric measurements can be-ifluenced and/orcontrolled during treatment.Among.nese are the mandibular incisor-mandibular plane (IMPA),J fthe mandibular incisorinclination ; sella-nasion-mandibularolane (SN-MP), or the mandibular plane angle; maxillary


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-icisor- sefa-nasion (Ul-SN), or the maxillaryincisor inclination;and maxi llary inciso r- mandibularincisor(U 1-L1), or the''lterincisal angle. When these four measurements are comoined.a four-sided figure, ortetragon, is formed (Fig 4-1). A


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stainless steel archw ire in th e pretorqued 0.018-inch slotanter iorbracke ts.

4. Interincisal angleThe accepted angle between the maxi llary and mandibular

incisors (U1-L1) is from 130 to 134 degrees (Fig 4-5).Aswith the othermeasurements, U1-L1 may vary, dependingon an individual's skeletal vertical pattern . Alt hough orthodontists

have limited options for positioning of theman dibular incisors, th e maxilla allows more freedom int he positioning of the maxillary incisors. However, t he finalposition of the maxillary incisors is direct ly relate d to the

position ofth e mandi bularincisors.

S. Tetragon plusAdd it ional information garnered from the cephalogram is

referred to as tetragon "plus."These data include the measurementsto det ermine sagitta l skeleta l dime nsions and thecephalometric soft tissue profile.

Sa. Sagittal skeletal dimensionsIdeally, treatment of a skeletal Class 1, 11, or111 malocclusion

w ill result in a sagi ttaljaw relat ionsh ip (sellanasion-point B) of 1 to 3 degrees (Fig 4-6). In Class 11 children

who are in a growth period and exhibit good compliance, such results can be achieved w it h th e use offacebow. Class 11 1 skeleta l patterns, how ever, do notalways show a successful respon se to t reatment mechanics.Use of the Wits appraisa l can also be helpfu l in forminga diagn osis for patients with t his type of malocc lusion.Class 1I I treatment mech anics is discussed in detail insubsequent volumes in thi s series.

Sb. Cephalometric soft tissue profileIdeally, Holdaway's harmony line, connect ing the soft tissuepogonion with the uppe r lip, should touch the lowerlip and bisect the nose (Fig 4-7). However, many variationsof this esthetic measurement can exist, depend ing on t he

size of the chin and nose. For example, inAsian patients, an ideal line might toueh soft tissue pogonion, the

lips, 6. Mandibular intercanine widthand the tip ofthe nose. The treatment goal forthis crit ieal measurement is toThe tetragon "plu s" combines all of these eephalometmaintainthe original intereanine wi dth (Fig 4-10). Long'e measurements (Fig 4-8). term studies have shown that any expansion ofmorethan 1 mm will invariably relapse.?No matterhow often the researeh reeon firms this fact ,

Study castsorthodontists eontinually look for excuses to break thisrule.A eommon beliefis that, with extraetion treatment,Jlaster study easts are used throughout the world asa primary the mandibulareanines can be retraetedto a wider part ofiagnost ie aid (Fig 4-9) In rea lity, it is impossible to reaeh a the areh; therefore, eanine expansion isaeeeptable . Ifthisdiagnosis only through the use of study easts. However, there were true. the long-term studies of extraetion t reatmentare fourvery important factors that can be measured on the wo uld show the stabr lity ofeanineexpansionoThe literastudyeasts; these faetors must be controlled if sueeessful ture does not support this.6.7orthodontie treatment is to be aecomplished. The only exeept ion to this rule might be when theeanines have erupted lingually, inside the normal areh. Inthese cases, the canines can be expanded intothat normal sufficient to allow space for crowded teeth and improve thearch form (Fig 4-11). appearance in the buccal corridors. In most cases, ifthisClinically, the intercanine width is finalized by referring width is 33 mm or less. the treatment plan willinclude


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back to the original mandibular study cast (Fig 4-12) and palatal expansion with a rapid palata l expanderorarchwires.superimposing the final archwire over the mandibular arch While expansion of the mandibularintercanine dimension(Fig 4-13) should be avoided, the maxillary molars can be expanded,which in turn will allow the uprighting or the expansion of

7. Maxillary intermolar width mandibular molars. This implies that it is also possible toWhen measured from the lingual groove at the cervical line slightly expand the premolars (a line betweenthe mandibuofthe maxillary first molars, the maxillary intermolar dislarcan ines and first molars). This is supported by a long-termtance should be between 34 and 38 mm (Fig 4-14). Ifthe study of stability.? The difference betweenthese regions

sizes ofthe individual teeth are dose to normal, thiswidth is might be explained by the balance betweenthe facia l mus.ulature and the tongue. The orbicularis oris places suff icientoressure on the anterior teeth to resist excessive flaring orexpansionoThe buccinatormuscles, however, offerless pressure.allowing more stable expansion in the buccal segments.

8. Arch form.-\n ovoid arch form design will provide the most estheticand

stable form for most patients (Fig 4- 15). This conclusion isoased on the following rationale: Ifthe mandibular caninearea is not expanded and the positions of the mandibularncisors are controlled, the maxillary and mandibularanteriorarch forms will be mostly predetermined. If the maxillary.nterrnolarwidth is made to be approximately 36 mm, themaxillary and mandibularposterior widths and arch formsare then determined. Thus, a line formed between thecanines and the molars results in an ovoid arch formoThis ovoid arch form will also be very esthetic becausethe posteriorteeth (buccal segments) are sequentiallyexpanded, filling the patient's buccal corridors (Fig 4-16).Adetailed analysis ofarch form is presented in principie 9.

9. Leveled mandibular arch

Leveling the curve of Spee in the mandibulararch is criticalto the correction of deep bites and the maintenance ofoverbite correction. Leveling is often overlooked in caseevaluation, but my studies show that the betterthe leveling,the better is the stability (Fig 4-17 )8.9 Clinically, thisarch leveling is accomplished by placing a reverse curve inthe archwire. The exceptio n to th is rule is in the treatmentof open bite-type malocclusions. In these pat ients, a slightcurve of Spee in the mandibulararch is desired. Prin cipie14 elaborates on the mechanics of leveling the arches.

10. OcclusionEveryone agrees that good occlusion is critical for function,health, and stability. Excel lent occlusion consists of a goodClass I canine relationship, normal intercuspation of posterior

teeth, normal overbite and overjet relationships, canineprotection in lateral movements, anteriorguidance, and a

cent ric relation that coincideswith maximum intercuspation Panoramicradiograph11. Root positioningAs displayed in the panoramic radiograph, the roots oftheanteriorteeth, canine to canine, should be divergent inboth the maxrlla and the mandible (Fig 4-19). The angulationsto accomplish this root positioning are integrated intothe bracket prescriptions.


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After treatment of patients with deep bite, the mandibularfirst molars should be upright.A - 6 degree angulat ion

on the mandibular first molartube is designed to helpaccomplish this result (Fig 4-19).In extract ion cases, the roots of the teeth adjacent tothe extraction sites should be parallel to each other at theend of active treatment (Fig 4-20). Proper bracket placement

will accomplish t his goal; this subject is addressed inprincipie 7.

12. Periodont al healthAlthough periapical radiographs are necessary to showspecific bone 1055, carefu l observation of the interproximalFig 4-20 In this case, four first premolars were extracted. The rootsin the extraction space are parallel to each other.Fig 4-22 Observation of thecondyles in the panoramicradiograph isapreliminary method of diagnosing temporomandibularjoint problems.bone; root apices; and unusual conditio ns such asimpactions, abscesses, and root reso rption can be accomplishedin detailed examination ofa high-quality panoramicradiograph (Fig 4-21).

13. TemporomandibularjointDepending on other factors, initial diagnosis ofth e temporomandibularjoint conditions can be made by observingthe size and shape of the condyles on a panoramic radiographofgood quality (Fig 4-22). If joint symptoms arepresent, a more thorough investigation is required.

Facial photographs14. Soft tissue profi leThe final position ofthe lips is dependent on th e positionofthe maxillary and mandibularanteriorteeth that createthe interincisal angle (Fig 4-23). Ifthese teeth are positionedtoo far labial or lingual, an unfavorable facial profi lecan resul t.

As mentioned earlier, the ideal profile in a white individ_a l is represented by a line touching the lower soft tissue=1in and the upper lips and bisecting the nose. Because, ost profiles tend to flatten with age, when a compromise-egarding the patient's profile is necessary, it is always: referable to finish treatment so that the patient has a- ore protrusive profile.

15.Smile- neAlexander Discipline is intended to produce the follow19results at the end of orthodontic treatment (Fig 4-24): Coincident dental midlines Coincident facial midlines Esthetically positioned teeth A balanced smile line A balanced smile arc

Absence of dark buccal corridorsUnless the patient has skeletal problems, such as verti:al maxillary excess or asymmetric growth patterns, theseqoals should be attainable in most patients.

Con clusionThere is an old saying: "AII roads lead to Rome."How ever, in orthodontics Rome may be difficult to find,

oecause there are many different roads to take. It isimportant to identify the goals and objectives for achieving


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an ideal orthodontic result. If the 15 goals discussedhere can be obtained through treatment, then treatmentvill routinely produce healthy, functional, esthetic, andstable results.The systematic procedures needed to correct specificmalocclusions are addressed in other principies in thisbook. Consistency in treatment mechanics willlead to consistent

results.

PrincipIe 4 Case StudyOverviewThe challenge is to align the crowded teeth properlywithout changing thi s beautiful profile .

Examinationand diagnosisThis young adult (18 years, 7 months) presented with a

borderline nonextraction skeletal elass I occlusion and abeaut iful soft tissue profile, but a moderate curve ofSpeeand an arch length discrepancy of 5+ mm.

Treatment planOur goal was to control the mandibular incisors andcanine width wh ile treating the patient nonextraction .This was accomplished by means of judicious use ofto rque control, interprox imal enamel reduction , and class

DiscussionThe challenge was to treat the patient nonextractionwhile properly aligning the teeth and maintaining theprof ile. The sequence of mandibularocclusal photosdemonstrates how the anteriorcrowding was resolvedand how the position of the incisors and the intercaninewidth were controlled.The patient was extremely compliant, which accounts

for the relatively brief (20-mont h) treatment period oEvaluationThe patient's profile was maintained while the malocclusionwas successfully t reated in a simple manner.

Plan Your Work,

Then Work Your Plan"Conc ntrate on finding your goal . . . then concentr ate on reachingit."The history ofdiagnosis and treatment planning hasfollowed an interesting trail overthe past 100 years.From Angle's early commitment to nonextracti on


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treatment and his battles with Calvin Case1,2 to Tweed'sextract ion philosophy in the midtwenti et h century, the discussionshave cont inued. More recent app liances (fixedand removable) and treatme nt philosop hies are promotingnonextraction treatment. Today, the debate concerningnonext ract ion treatment versus extraction t reatment continues.In ourpractice inArlington, Texas, approximately 85%

ofpatie nts are t reated w ithout extraction . The averagenum berof extract ion cases in the United States is about20% of all pat ients t reated, w it h some individual orthodontistsextracting up to 50%.A percentage of th ese casesmight be considered borderline. Of course, worldwide differencesin patient characteristics, such as skeletal patterns,toot h sizes and shapes, and soft tissue profiles, etc,could change these percentages significantly.The following eight factors help to c1 arify the sometimesdiffic ult t reatment decision between extraction and nonextract ion:1. Facial and muscle patterns2. Mandibular functional patterns3. Tooth size and form4.Arch length discrepancy

5. Unusual erupt ion patterns6. Growt h

- Col Michael Friedson7. Habits8. Compl iance"Begin with the end in mind," is another StephenCovey3 truism . However, it is necessary to first establishgoals and understand how they can be achieved. The ends,or goals, of treatment were discussed in detail in principie4. To ensure that these goa ls can be achieved, orthodontistsmust discipline themselves to compi le high-qualitydiagn ostic records. The quality of patients' records can bea direct reflection of the quality of the treatment provided(Fig 5-1).

Chapte r4 in my originalbook" detai ls the fu ndamentalsofdiagnosis and t reatment planning . The remainderof thepresent principie discusses additional factors that help tocomp lete th e process.

CephalometricsNo matter wh at cephalometric analysis is used, three basicmeasurement s must be obtained from the cephalometrictracing before a proper treatment plan can be produced:1. Sagittal skeletal pattern2. Vertical skeletal pattern3. Incisor position

Sagittal skeletal pattern

The first cephalometric determination to be made is thepatient's skeletal type: Class 1, 11, or I1I skeletal pattern.Addressing the skeletal discrepancy at the beginning oftreatment will enable the clinician to determine the necessarytype and direction of orthopedic force. The measurementssella-nasion-poi nt A (SNA), sel la-nasion-po int B(SNB), pointA-nasion-point B (ANB), and nasion-po intAporion(NA-Po) and the Wits appraisal can help to providethe answer.

In most cases, theANB angle will provide the needed


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information. For a patient with a Class 11skeletal pattern, itis necessary to determine if the patient exhibits maxil laryprot rusion or mandibular deficiency. The angles SNA, SNB,and ANB are very helpful in this diagnosis. For Class 111patients, the Wits appraisal may be more meaningful, especiallyin those with high-angle Class1I1 malocclusions (Fig 5- 2).

Verti cal skeletal patternWhether the patient has a high-, medium-, or low-angleskeletal pattern will also influencetreatment decisions. Thesella-nasion-mandi bular plane (SN-M P), Frankfortmandibularplane angle, occlusal plane- mandibularplane,and y-axis are measured and compared to provide an accurateassessment ofthe pat ient's skeletal vertical pattern.In keeping with the "keep it simple, stupid" (KISS) principie,SN-MP is routinely used as the reference measurement.A simple analysis follows:1. When the SN-MP angle is 35 degrees or less (Fig5-3), Class 11 skeleta l patt ernscan best be treated witha cervical facebow (Fig 5-4). During the treatment ofa skeletal Class 111 patient using a face mask, the force

Fig 5-2 To determ ine Class 111 skeletal patterns cephalom etrically inhigh-angle cases, the Wits appraisal is aften more accurate thanpoint A-nasian-paint B(AN B).vectoris often directed at 45 degrees in relation to theocclusal plane, depending on the smile line.2. If the SN-MP angle is 36- 4 1 degrees (Fig 5-5), the

vertical dimension is best managed wit h the use of acombinat ion-pull facebow (occipital and cervicalstraps) in patients with a skeletal Class 11 relat ionship(Fig 5-6). The elast ic force vector of a face mask usedto treat high-angle Class I1 I patients should be directedparallel to the occlusal plane to prevent the ext rusionof the maxillary teeth.3. If the SN-MP angle is 42 degrees or greater (Fig 5-7),

every effort is made to inhibit furthervertical growthof the maxilla.A high-pull facebow combination is prescribedfor patients with a high-angle skeletal Class 1Ipattern (Fig 5-8). If the diagnosis is a high-angle skeletalClass 1I1 pattern, the elastic force vectorof the facemask is directed almost parallel to the occl usal plane.For high-angle patients with arch length discrepancies,extract ion therapy may be indicated.

1ncisor positionThe third factoranalyzed with the cephalometric tracing isthe posi tion of the incisors

Mandibular incisorsAs stated in chapter 4 ofThe AlexanderDiscioline"controlof the mandibular incisorposition is critical forlong-termstability. Tweed and others have demonstrated that theoutcome is unstable when these incisors are advanced. Yetin contemporary orthodontics, the desire to t reat allpatients without extractions has led to the routine, indiscriminateflaring of mandibular incisors. In a future volumeof this series, the danger of such treatment wit h regard topostorthodont ic stability will be thoroughly explored.

Clinical experience wit h both extremes of incisor positionindicates that:


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1. In most cases, the best and most stable position formandibularincisors is the position in which theFig 5-4 Soft tissue profile of the same patient wearing a cervicalfacebow.Fig 5-6 Sot tissue profile of the same patientwearing a combina tionfacebow.Fig 5-8 Soft tissue profile of the same patient wearing a high-pull

facebow. Notice how the outer bow is bent at the firstmolararea.pat ient presents. Maintaining these teeth in theirorigin al positions is the goal. In high-angle cases, theincisors may be more upright. Treatment of lowangledeep bite cases may require that these incisorsbe proclined from their original position.37

5 Plan YourWork2. In extraction cases, mandibularincisors are usuallyuprighted . If an adequ ate interincisal angle is alsoachieved, this t reatment is stable. The soft tissue profilemust be evaluated carefully when the incisors areuprighted so that a concave prof ile is not produced.3. Studies have indicated tha t mandibularincisors can

be advanced up to 3 degrees and remain stable- t he3-degree rule. Beyond that crit ical 3 degrees, instabil ityis more likely. Perhaps the on ly time that mandibularincisors are int ent ionally advanced is when theyare initially abnormally lingually inclined. This situationis often found in patients with Class 11 division 2or Class II division 1 deep bite. Advancing the incisorsin th ese patients w ill improve the int erincisal angleand soft t issue profile. The patient must be advisedof the need forlifetime retenti on to ensure long-t ermstability because th e 3-degree rule has been violated.

Maxillary incisorsWith the exception of Class II division 2 malocclusions, mostmaxillary incisors are posit ioned almost normally at thebeginning oftreatme nt.As with the mandibularincisors, thegoal is to keep them in that original position. Maintenanceof good torque cont rol of the maxillary incisors, along withthe mandibularincisors. will result in a balanced int erincisalangle. This is critical for acceptab le functiona l occlusion andlong -term stability. Often in patients with Class 11 division 1patterns, these incisors are flared and spaced. When thespaces are closed and the arch is consolidated, the incisorswill be uprighted to norm al position s.

Study CastsMaxillaryintermolar widthThe maxillary intermolar width (t ransverse discrepancy) ismeasured from the lingual central groove s at the cervicalline on th e maxillary first molars. If th e maxillary tran sversedim ension is narrow (iess than 33 mm), th en rapid palata lexpansion is routinely performed to provide adequate archwidth. Moreover, addition al maxillary arch leng t h isgained, so that a borderline extraction case often becomestreatable without ext ract ion.

Mandibulararch length discrepancyToo often, the decision t o extract teeth is focused only onthe tooth size-arch length discrepancy.Although a criti calissue. other factors must be considered befo re an irreversibleextraction decision is made. These factors are discussed


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in principies 17 and 18,

Panoramic RadiographAssessment ofthe panoramic radiograph must fo cus onareas where problems can occur. The interproximal bone

level must be checked, especially in adult patients. The rootshape and position are critical to observe. Occasionally, an

angulated or curved root is revealed by the radiograp h (Fig5-9). The roots must also be examined for any signs of possibleroot resorption.The eruption patterns can also reveal that teeth maybe erupt ing ectopically (Fig 5-10). The panoramic radi ographshou ld also be used to check for any supern umeraryormissing teeth. The radiogra ph must include t heareas wel l beyond th e apices of primary teeth to allow theobserver to ensure tha t the permanent replacement toothis present.Sometimes, the panoramic radiograph may not c1earlyshow an area of concern. In this case, a regional or complete mouthperiapical series is indicated. If necessary, the patientmay be referred back to his or her general denti st or to aradiographic laboratory forthese addit ional diagnostic radiographs.

It is very important to observe the patient's thi rd molarsthroughout treatment. Tracking ofth e erupt ion of th irdmolars during t reatm ent is not only enlighten ing but necessaryin the decision-making process. Comparison of successivepanoramic radiographs can allow an informed decision,at the appro priate t ime, about whe t her it is necessaryto ext ract these teeth.In addition, observation of the shape of the condy les inthe panoramic radiograph can help to provide an init ialdiagnosis of potential jo int prob lems. If other temporomandibular

jo int dysfunct ions are foun d, special radiographsand treatm ent may be indicated .

Facial Photographs

Softtissue profileOfall the changes that can occur as a result oforthodontictreatment, the soft t issue profile is the most imp ortantforthe orthodont ist to consider. Orth odontic treatmentcan affect the lips and soft ti ssue pogonion . The goalforthe lips should be th at they touch lightly, w ithout strain,w hen the pati ent's mouth is closed. Wh en the facebow isproperl y worn, th e chin will come forward in profile ingrowing pati ents.

Although ort hodontic treatment does not direct ly influ encethe growth of the nose, the outcome can affect theapparent size ofthe nose relative to the upper lip. Forexample, ext ract ion therapy can reduce upper lip protrusien.making the nasolabial angle more obtuse and resultingin an increase in the appa rent size of the nose. The size

and shape of the parents' noses may also be an indicationof the patient's pote nt ial nose growth and an additionalfactor in th e diagnosis and treatment-planning process.

Soji tissue fr ontalappearance atrestCareful observat ion offacial symmetry is yet anoth er partof a thorough diagnosis .Although no face is perfec tly symmetric, any major asymmetry must be addressed. If thepatie nt's lips are apart at repose, it may indicate t hat theteeth are protrusive in relationship to the lips orth at a significant


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vertica l prob lem exists.

Sojtti ssuesmileA prima ry reason parents bring th eirchild to the orthodontistis a concern about the child' s smile. lt is important toobserve the facial midline in relat ion to the dental mid lineas well as the smile line and the amount of maxillary gingival

tissue revealed. The ideal position of the smiling lip isat th e gingival line, plus or minus 2 mm . The smile arcis the shape of the lower lip in relati on to th e maxillaryincisal edges when the individual is smiling . Ideally, thesrrulinq lower lip should follow and contact the maxillaryincisal edges.

Buccal corridorsA very impo rta nt consideration is the buccal corridors.Narrow arches will result in dark buccal corridors that arerevealed when the patient is talking or smiling. In the

Alexander Discipline, the finished smile is intended to showthe mesiob uccal cusps ofth e maxillary fi rst molars wi thinth e buccal corridors. This outcome is rout inely accom plishedas a result of th e specif ic arch form developed andthe distobuccal rotat ion of the first molars.

Treatment Decision

ParadigmAII the different analyses used throughout the world canhelp to provide the information needed to establish a diagnosis.These analyses can also become very complex. Inkeeping with the KISS principie, however, a very simpleapproach has evolved that will summarize and quickly yieldthe information necessary to set goals and to assist indeveloping the treatment plan (Fig 5-11)For each factor listed, the orthodontist should place amark in the appropriate column, as dictated by the parametersdefined in the following sections. When filling outthis form, you should focus only on the specific factorunder consideration, independent of all other factors.

Sojttissue prof il e Convex profile or bimaxillary protrusion: extraction(Fig 5-12) Normal (Fig 5-13) or Class II profile: nonextraction orborderline Concave profile: nonextraction (Fig 5-14)

Mandibularincisor posit ion Proclined incisors: extraction (Fig 5-15) Normally inclined incisors: nonextraction or borderline

(Fig 5-16) Retroclined incisors: nonextraction (Fig 5-17)41

5, Plan YourWork

Attached gingiva Thin, narrow attac hed gingiva or ging ival recession:ext ract ion (Fig 5- 18) Compromised gingiva: borderline (Fig 5-19) Healthy gingiv a: non extract ion (Fig 5-20)


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Groiothpotential Past growth potenti al: ext ract ion End of peak growth period: borderline Wit hin or before pubertal growth period: nonextraction

Vertical skeletalpattern High-angle (dolichocephalic): extract ion (Fig 5-21)

Medium-angle (mesocephalic): nonextraction or borderline(Fig 5-22) Low- angle (brachycephalic): non ext ractio n (Fig 5-23)

Mandibulararch length discrepancy Severe (more than 6 mm): ext ract ion (Fig 5-24) Moderate (4 t o 6 mm): borderline (Fig 5-25) Slight (Iess th an 4 mm): nonextra ct ion (Fig 5-26)

Maxillary intermolar ioidth

(cast analysis) Narrow; less than 33 mm can be expanded: changeborderline into nonext ractio n (Fig 5-27) Normal; expansion not a factor(Fig 5-28)

Patient complianceIn a borderline case: Poor cooperation : extraction Moderate cooperatio n: bord erline Excellent cooperation : nonextr action

Aft ereach factor is assessed independently, thecolumns are totaled. The colum n with the greatest numberof marks suggests th e final decision in favoroforagainstextract ion.The dilemma occurs wh en the borderline column hasthe highest score. To resolve thi s situ ati on, the pract ition ershould discuss th e findings with th e pat ient and parents.In these borderline cases, if the patient is willing, a nonextraction treatme nt plan is initiated, and the progress isreevaluated 6 to 9 months into the treatment. The degree

ofcomp liance could determ ine whetherextract ions will benecessary.

Assuming th at every effort has been made to treat apatient with out ext ract ions, several things can be done inthe presence ofsignificant mandibu larincisor crowd ing tohelp cont rol the mandibul ar incisors and prevent excessivelabial flaring.First, the Alexand er bracket prescripti on assists byincluding the -5 degrees (lingual crown-Ia bial root ) torquein the mandibularincisor brackets and the - 6 degrees ofangulation (distal crown t ip) in the mandibularfi rst molarbuccal tu bes. The bracket prescription is supplemented byplacement of an initial resilient rectangul ararchwire. Inaddit ion, interproximal enamel reduction, priorto bracketplacement , can create space and allow th e teet h to rotatemore readily.Ifthere is so much crowd ing th at the initi al archwiremust be a round wi re (thus eliminat ing torque control),c1ass 3 elast ics can be used t o reduce mandibular incisorflaring. C\ass 3 maxillomandibularelastics are prescribed to

be worn for 72 hours (3 days). This will also help to uprightth e mandibular first molars, thus creating additional space.

ConclusionAfter all the possibilit ies of ext ract ing ornot extract ing


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teeth are evaluated, the final question that should be consideredis, "Where should t he teeth be at th e end of treatmentforthis part icularpat ient?

PrincipIe 5 Case StudyOverviewA retrusive mandible and excessively prominent pogonioncreated a difficult problem to solve.

Examination and diagnosisThis ll-year-old girl presented with a severe mandibularretrusive Class I1 division 2 malocclusion. The maxillarytransverse dimension was constricted . Her early permanentdentition displayed partially blocked out maxillarycanines and unerupted premolars. The maxillary incisorswere excessively uprighted. No crowding was found inthe mandibular anterior teeth. The midline was shifted 3mm to the left.

Treatment planInitially, the maxilla was expanded with the rapid palatalexpander(RPE). The cervical facebow was placed on thesame day that turning of the RPE was completed . Fivemonths later, the RPE was removed and the maxillarybrackets were placed. Seven months after that, the

~

mandibular brackets were placed. Four months later,c1ass 2 elastics (with an additional elastic on the left side)were worn with the facebow. Typical fin ishing elasticswere used at the end of active treatment.

DiscussionIn retrospect, it might have been preferable to have

delayed treatment unti l more of the permanent teeth haderupted , thus potentially reducing the total treatmenttime.

EvaluationIn reviewing the patient's chart, it is obvious that she hadmany difficulties throughout her treatment time . She had

15 extra appointments. In the middle of treatment duringa conversation with her mother, the patient cried.(Mean orthodontist! ) Every motivational techniqueknown was attempted with this young lady . . . and it

fina lly worked. (Effort =Results!) The facebow and c1ass2 elastics achieved the anticipated "headgear effect."

Documents

5principios de Alexander Ingles