The Relationship Between the Curve of Spee,

Relapse, and The Alexander Discipline

Sal Carcara, C. Brian Preston, and Ossama Jureyda
Exaggerated curves of Spee are frequently observed in dental malocclusions
that present with deep vertical overbites. During orthodontic treatment
such excessive curves of Spee are usually leveled and, in most instances,
this leveling will result in a reduction of the anterior overbite. The Alexander
Discipline provides a good example of modern straight-wire orthodontic
techniques that purport an ability to treat abnormal variations in the depth
of the occlusal plane. The records of 31 randomly selected patients treated
by nonextraction with the Alexander Discipline were studied. The results
show that the Alexander Discipline levels the curve of Spee in Class II,
Division I deep-bite cases and that when relapse occurs, the curve of Spee
returns to a lesser extent than was present before orthodontic treatment.
With the Alexander Discipline, a pretreatment curve of Spee that is not
completely level posttreatment has a slightly higher incidence and magnitude of relapse than a pretreatment curve of Spee that is completely level
posttreatment. This study indicated that, based on the pretreatment curve
of Spee, there is no ability to predict relapse in mandibular intercanine
width, overbite, overjet, mandibular incisor irregularity, and arch length in
Class II, Division I deep-bite cases treated with the Alexander Discipline.
(Semin Orthod 2001;7:90-99.) Copyright 2001 by W.B. Saunders Company

xaggerated curves of Spee 1,2 are frequently

observed in dental malocclusions that
present with deep vertical overbites. As a part of
orthodontic treatment, such excessive curves of
Spee are usually leveled during orthodontic
treatment, and, in most instances, this leveling
will, in turn, result in a reduction of, if present,
deep anterior overbites. Clinicians who adhere
to the Tweed I philosophy of orthodontic treatm e n t use continuous arch wires that incorporate
reverse curves of Spee to produce flat occlusal
planes. Accordingly, arch leveling occurs mostly
by an extrusion of the lower premolar teeth in
conjunction with a minimal intrusion of the
mandibular incisor teeth. In contrast to the ear-

From the Department of Orthodontics, State University of New

York at Buffalo, Buffizlo, NY," and Private practice, New York, NY.
Address correspondence to C Brian Preston, BDS, Dip Orth, M
Dent, PhD, Department of Orthodontics, School of Dental Medicine,
Squire Hall, 3435 Main St, Buffalo, N Y 14214-3008.
Copyright Q 2001 by 14(B. Saunders Company
1073-8746/01/0702-0006535. 00/0
doi: 10.1053/sodo. 2001.23550

90

lier approach, advocates of sectional arch orthodontic mechanics z,~ treat deep curves of Spee
by intrusion of mandibular incisors while, usually, allowing the lower premolars to erupt into
occlusion.
A review of the literature reveals that there is
disagreement a m o n g the p r o p o n e n t s of the various orthodontic techniques that are used to
level deep curves of Spee. 4-s The discussion revolves a r o u n d which leveling technique produces the most effective overbite correction as
well as the most stable long-term treatment outcomes. Those orthodontists who primarily use
sectional arches to p r o d u c e fiat occlusal planes
believe that leveling with continuous arch wires
tends to extrude the posterior teeth, which, in
most instances, will cause an increase in the
lower facial height. They further believe that, in
individuals with strong muscles of mastication,
the orthodontically extruded buccal segments
will tend to relapse after the orthodontic treatment. 4,5,9 This relapse would lead to the recurrence of anterior deep bites. W h e n a reverse

Seminars in Orthodontics, Vol 7, No 2 ([une), 2001: pp 90-99

The Curve of Spee, Relapse, and the Alexander Discipline

curve of Spee is placed in a continuous arch wire

for the purpose of arch leveling, this results in
an almost automatic tendency for the mandibular incisors to flare labially. 1,11 Contrary to this
viewpoint, Ferguson a2 states that a reverse curve
of Spee in an arch wire does not in itself cause
the lower incisor teeth to flare unless the arch is
allowed to act beyond the stage at which the
occlusal plane is flat. Orthodontists who use
Tweed's leveling technique 6,13-15 argue that the
extrusion of premolars and molars provides a
stable change while, on the other hand, the
intrusion of the lower incisors often relapses to
produce an increased overbite.
Radiographic cephalometric studies showed
that both the Ricketts and modified Tweed techniques can successfully correct deep dental overbites. 16,a7 These studies concentrated on overbite correction only and neither analyzed study
models to evaluate how effectively the curves of
Spee were leveled, n o r did they evaluate the
long-term stability of the results that were produced.
The present article reflects the findings of a
study that was designed to evaluate the longterm outcomes of a representative sample of
orthodontic patients who were treated according to the Alexander Discipline. Irrespective of
the philosophy and mechanical principles of the
orthodontic technique used, one of the primary
objectives of orthodontic treatment is to obtain a
level occlusal plane, is In this article, leveling will
be defined as the process of bringing the incisal
edges of the anterior teeth and the buccal cusp
tips of the posterior teeth into the same horizontal plane. 19
The anatomic definition of the anteroposterior curve of occlusion is generally accepted by
orthodontists as describing the curve of
Spee. 2-94 Some studies in the orthodontic literature propose other ways to define and measure
the curve of Spee on orthodontic study models. 25-27 Three-dimensional digitizers 2-~,26 have
been used to calculate the depth of the mandibular curve of Spee mathematically. Koyama, 27 in
a more practical approach to the problem, used
a caliper to measure the curvature of the occlusal plane in both jaws and f o u n d the greatest
pretreatment depth of the curvature to be located in the bicuspid region.
In a mechanical sense, the presence of a
curve of Spee may make it possible for a denti-

91

tion to resist the forces of occlusion during mastication. 2s-~-~ Although several theories have
been proposed to explain the presence of a
curve of Spee in natural dentitions, its role during normal mandibular function has been questionedY 9,~4,35 It has been proposed that an imbalance between the anterior and the posterior
c o m p o n e n t s of occlusal force can cause the
lower incisors to overerupt, the premolars to
infraerupt, and the lower molars to be mesially
inclined. ~6,37 According to Root 2s and Fidler et
al, 3s when a skeletal o p e n bite is not present, the
curve of Spee in Class II malocclusions is deeper
than in other malocclusions. Although an exaggerated curve of Spee is often obsmwed in Class
II, Division I relationships, it is not unique to this
type of malocclusion. -~9
Andrews as n o t e d that the occlusal planes in
120 nonorthodontically treated and ostensibly
normal occlusions varied from being generally
flat to having a slight curve of Spee. This finding
led him to believe that the presence of a curve of
Spee could be associated with postorthodontic
treatment relapse. Andrews concluded, "even
t h o u g h not all of the orthodontic normals had
flat planes of occlusion, I believe that a flat plane
should be a treatment goal as a form of overtreatment. ''is A deep curve of Spee may make it
almost impossible to achieve a Class I canine
relationship ls,28 t h o u g h it may also result in occlusal interferences that will manifest during
mandibular function. -~2,$4
To date, there are little or no data that quantify the a m o u n t of arch leveling that occurs with
orthodontic treatment, or the long-term, postorthodontic treatment relapse of the curve of
Spee. It is perhaps worthwhile noting that very
little research has been u n d e r t a k e n to determine the most effective, and stable, m e t h o d of
leveling a deep curve of Spee.
N u m e r o u s studies have been performed to
quantify the a m o u n t and type of postretention
relapse that occurs after orthodontic treatm e n t . 6A5-17,38,42-52 In general, these studies have
noted posttreatment increases in overjet, overbite, mandibular incisor crowding, along with
decreases in arch length and arch width. Investigations have also been undertaken to determine whether untreated normal occlusions undergo the same changes that are observed in
treated cases. 5,51 At the same time, very little
research has been p e r f o r m e d to evaluate the

92

Carcara, Preston, and Jureyda

long-term stability o f leveling the curve of Spee,

and few, if any, studies have attempted to correlate the pretreatment curve of Spee with postretention changes in other aspects of the occlusion.
The primary purpose of the present investigation was to determine the effectiveness of the
Alexander continuous arch wire technique in
leveling the curve of Spee in Class II, Division I
deep bite cases. A second purpose of the study
was to determine the long-term stability of the
leveling of the curve of Spee achieved with the
Alexander Discipline. A third objective of the
research was to determine whether a relationship exists between the presence of a deep curve
of Spee before orthodontic treatment and the
relapse that takes place in a n u m b e r of occlusal
traits. The traits studied included the mandibular intercanine width, overbite, overjet, mandibular incisor irregularity, and arch length.
The sample for this retrospective study consisted of 31 patients, 22 female and 9 male,
randomly selected from the records of orthodontic patients treated in the private practice
of Dr. R.G. "Wick" Alexander, in Arlington,
Texas. The average age of the patients at the
start of treatment was 12 years and 6 months.
The average treatment time for the sample was 2
years and 1 m o n t h whereas the average time
from T1 to T2 record taking was 2 years and 5
months. Each case was treated by nonextraction
and met specific criteria for inclusion in the
study. These selection criteria included the presence of a Class II skeletal (ANB > 4 ) and at
least a half-cusp Class II molar relationship, an
overbite of 50% or greater as measured from the
initial (T1) study models, and a curve of Spee
measuring 2 m m or more. 37 Only cases with
complete records were selected for this study.
These records consisted of dental casts taken
pretreatment (T1), post-treatment (T2), and
postretention (T3). The posttreatment (T2)
records were taken 2 months after d e b o n d i n g at
a mean age of 14 years and 11 months. The final
(T3) records were taken at an average of 7 years
and 5 months after the removal of the fixed
retainer, which was at an average of 11 years and
5 m o n t h s after the d e b o n d i n g of the patient. All
31 patients were treated by a single operator, Dr.
R.G. "Wick" Alexander, who used a fully preadjusted fixed orthodontic appliance with a 0.018"
slot size according to the Alexander Discipline.

Dr. Alexander's patients were selected for this

study because he is the recognized authority for
this technique, a goal of his treatment is to level
any curve of Spee that is present in the mandibular arch, and complete long-term records were
available for the present study.
The Alexander technique was also selected
for this study, over other preadjusted appliance
techniques, because of its unique prescription,
and its biomechanical principles that assist with
mandibular incisor control during arch leveling.
The unique features of the prescription include
a - 5 torque built into the mandibular incisor
bracket base to maintain the lower incisors upright over the basal bone. In addition, a - 6
distal tip is incorporated into the mandibular
first molar buccal tube to facilitate molar uprighting, 1 and to create arch length to help reduce lower incisor flaring. The early use of rectangular wire, as is required in this system, makes
it easier, than is the case with some other orthodontic techniques, to control the position of
the lower incisors from the outset of treatment.
After the initial leveling phase of treatment
the u p p e r and lower first arch wires are replaced
with "working arch wires" constructed from
0.016 0.022 inches or 0.017 X 0.025 inches
stainless steel. The maxillary arch wire has an
accentuated curve of Spee, and the mandibular
arch wire has a reverse curve of Spee, placed into
it to facilitate arch leveling. O t h e r than the initial arch wires, all remaining arch wires include
omega loops placed 1 to 2 m m anterior to the
first or second molar tubes. These o m e g a loops
allow all of the arch wires, after the initial arch
wires, to be actively tied back with 0.014-inch
stainless steel ligatures. The finishing arch wires
in both arches are constructed from 0.017 X
0.025 inch stainless steel wires. The u p p e r and
lower arch wires are bent to incorporate an accentuated or a reverse curve of Spee respectively. A goal of the Alexander technique is to
have the 0.017 0.025 inch stainless steel finishing arch wire placed in both arches as early as
possible during treatment. The early placement
of this relatively heavy lower arch wire makes it
possible for the curve of Spee to be flat during
most of the active treatment. Each stainless steel
arch wire is heat-treated before insertion to increase the stiffness of the wire. 5S At the end of
treatment the bands are removed and retention
appliances are inserted. In all of the 31 patients

The Crave of Spee, Relapse, and the Alexander Discipline

selected for this study the mandibular canine-tocanine fixed retainer was removed after the
third molars were either extracted or had
erupted normally into occlusion. This occurred
at a mean time of 3 years and 4 m o n t h s after
appliance removal. At the time of the removal of
the fixed retainer, selective interproximal stripping was p e r f o r m e d on each patient to decrease
the tendency for relapse of lower incisor crow&
ing. 42
Three sets of study casts (T1, T2, and T3)
were collected for each of the 31 randomly selected patients. The 93 sets of study models were
each assigned a r a n d o m n u m b e r that made it
possible for a single investigator to measure each
set in a r a n d o m blind fashion. The curve of Spee
in this study was measured in the mandibular
buccal occlusion between the center of the incisal edge of the central incisor anteriorly and
the distobuccal cusp tip of the first molar posteriorly. 27 By using a standard palatometer (GPM,
Switzerland), the depth of the curve of Spee was
measured on each side of the mandibular arch
as being the vertical distance from the buccal
cusp tip of the most infraoccluded premolar, to
the occlusal plane previously described. 97
The curves of Spee were measured on both
the left, and the right, sides of each of the 93
mandibular models included in this study. The
resulting sets of 93 left and 93 right measurements were c o m p a r e d statistically by means o f a
paired t test. The results indicated that there
were no significant statistical differences (P >
.05) between these pairs of measurements, curve
of Spee on the right side versus curve of Spee on
the left side, for each of the 31 patients at T1,
T2, and T3. The average of the right and left
cmwes of Spee for each patient at the three
different time intervals was therefore used for
further definitive statistical analysis and comparison.
The following measurements were made by a
single operator in a r a n d o m blind fashion and
directly on study casts for each patient at three
time intervals (T1, T2, T3): mandibular intercanine width, 46 overbite, 46 overjet, 46 mandibular
incisor irregularity index, 4:~ and mandibular
arch length. 44
To test whether the curve of Spee remained
u n c h a n g e d from T1 to T2, and from T2 to T3,
paired t tests were calculated. To compare the
incidence of relapse (T2-T3) of the curve of

93

Spee in the patients that were completely level at

T2 with those that were not completely level at
T2, a two-sample t test was calculated to compare
the p r o p o r t i o n of relapse occurrence. To compare the magnitude of relapse (T2-T3) of the
curve of Spee in the patients that were completely level at T2 with those that were not completely level at T2, two i n d e p e n d e n t samples' t
test was calculated.
The treatment effects (T1 vs. T2) and relapse
(T2 vs. T3) of five variables (mandibular intercanine width, overbite, overjet, mandibular incisor irregularity, and arch length), were calculated with paired t tests. A Pearson correlation
coefficient and regression analysis was then performed to determine the predictive power of the
pretreatment curve of Spee (T1) on the relapse
of the five variables studied (T2-T3).
The mean pretreatment (T1) curve of Spee
for the 31 patients included in this stud}, was
2.41 m m with a standard deviation of -+ 0.48 m m
and a range of 2.00 to 3.75 mm. The mean
posttreatment (T2) curve of Spee for this sample
was 0.11 m m with a standard deviation of _+ 0.19
m m and a range of 0.00 to 0.50 mm. The differences between the pretreatment (T1) and posttreatment (T2) curves of Spee were highly
statistically significant (P < .0001). It was coneluded that in this sample of patients a meaningful degree of arch leveling was achieved with
the Alexander Discipline.
The mean treatment-induced reduction in
the curve of Spee was 2.30 m m with a standard
deviation of _+ 0.47 mm. The range of reduction
of the depth of the curve of Spee from T1 to T2
was 1.50 to 3.75 mm. This corresponds to a
95.43% average reduction in the curve of Spee
during treatment. Twenty-two of the 31 patients
studied (approximately 71%) were completely
(100%) level after treatment (T2), whereas 9
patients (approximately 29%) had a residual
curve of Spee at the end of the orthodontic
treatment.
The mean posttreatment (T2) curve of Spee
for the 31 patients treated with the Alexander
Discipline was 0.11 m m with a standard deviation of -+ 0.19 m m and a range of 0.00 to 0.50
mm. The mean postretention (T3) curve of
Spee for this sample was 0.48 m m with a standard deviation of + 0.50 m m and a range of 0.00
to 1.75 mm. The mean increase in the curve of
Spee from T2 to T3 was 0.37 m m with a standard

94

Carcara, Preston, and Jureyda

- 1 . 9 3 mm, which represents a m e a n 80.62%

reduction in the original depth of this curve.
The means and standard deviations for each
of the five variables measured on the study casts
(mandibular intercanine width, overbite, overjet, mandibular incisor irregularity, and arch
length) at T1, T2, and T3 are reported in Table
1. The means and standard deviations for treatm e n t changes (T2-T1), posttreatment changes
(T3-T2), and overall changes ( T I - T 3 ) are
shown in Table 2.

deviation of + 0.40 m m and a range of 0.13 to

1.25 mm. The differences between the posttreatm e n t (T2) and postretention (T3) curves o f
Spee, t h o u g h small, were statistically significant
(P < .0001).
The posttreatment (T2) curve of Spee data
for the sample (N = 31) revealed two subpopulations. Twenty-two patients at T2 had curves of
Spee that were completely leveled whereas nine
patients had residual curves of Spee at this time.
A comparison of the occurrence of relapse in
the curves of Spee in these two subpopulations
was calculated by using a two-sample t test. The
results of this test revealed that there was a statistically significant difference (P < .05) in the
occurrence of relapse of the curve of Spee in
these two subpopulations. A statistically greater
occurrence of relapse (88.9% vs. 50%, P < .05)
was seen between those patients that were completely leveled at T2 and those that were not
A comparison of the magnitude of relapse in
the curve of Spee that takes place in these two
groups between posttreatment and postretention was calculated by using two i n d e p e n d e n t
samples' t test. The results of this test revealed a
statistically significant difference (P < .0001) in
the a m o u n t of relapse of the curve of Spee in
these two subpopulations (P < .0001). Eleven of
22 patients that were completely level at T2 subsequently relapsed an average of 0.28 m m at T3,
which is equal to a relapse of 11.68% of the T1
curve of Spee. By comparison, eight of the nine
cases that were not completely leveled at T2
relapsed an average of 0.39 m m at T3, which is
equal to 22.46% of the T1 curve of Spee.
The overall m e a n period of the time that
elapsed from taking the initial records (T1) to
taking the final records (T3) was 14 years and 4
months with a range of 7 to 28 years, 8 months.
Over this period (T1-T3) the overall effect on
the curve of Spee was an average reduction of

Table

Mandibular Intercanine Width

A total o f 77.5% of the cases showed statistically
significant increases in the mandibular intercanine width during treatment (~ = +1.37 mm,
P = .0002). The same 24 cases (77.5%) in which
intercanine widths were increased during treatmerit showed a marginally significant postretention reduction (9` = - 0 . 6 2 ram, P = .0505) in
their intercanine widths. It should be noted that
when the mandibular fixed cuspid-to-cuspid retainer was removed, interproximal enamel reduction was performed.

Overbite
In all 31 patients, the overbite was reduced significantly during treatment (9` = - 2.67 mm, P <
.0001). In 74% of the cases the overbite increased significantly postretention (9, = +0.75
mm, P < .0001). The posttreatment mean overbite was 2.09 mm, and the postretention mean
overbite was 2.84 mm.

Overjet
In all 31 cases the overjet was r e d u c e d significantly during treatment (9` = - 4 . 0 9 mm, P <
.0001). In 87.1% of the cases the overjet increased significantly postretention (9` = + 1.09

1. P r e t r e a t m e n t (T1), P o s t t r e a t m e n t (T2), a n d P o s t r e t e n t i o n (T3) M o d e l M e a s u r e m e n t s

Pretreatment (T1)

Posttreatment (T2)

Postretention (T3)

Measure (mm)

Mean

SD

Mean

SD

Mean

SD

Mandibular width intercanine

Overbite
Overjet
Mandibular incisor irregularity
Arch length

25.75
4.76
6.27
3.97
62.22

2.1
0.95
2.97
3.35
4.64

26.11
2.09
2.18
0.31
64.01

1.4
0.65
0.56
0.46
3.17

25.5
2.84
3.27
1.28
61.85

2.36
0.85
0.93
1.35
3.41

Abbreviation: SD, standard deviation.

95

The Curve of Spee, Relapse, and the Alexander Discipline

Table 2. Treatment, Posttreatment, and Total Changes in Model Measurements

Treatment Changes
(T2- T1)
Measure (mm)

Mandibular intercanine width

Overbite
Overjet
Mandibular incisor irregularity
Arch length

Postt~atment
Changes (T3- T2)

Total Changes
(T3- T1)

Mean

SD

Mean

SD

Mean

5~

1.37
- 2.67
-4.09
- 3.66
1.79

1.85
1.05
2.96
3.25
4.57

-0.62
0.75
1.09
0.98
-2.16

1.69
0.89
0.84
1.19
2.11

0.75
- 1.92
-3.00
- 2.69
-0.37

2.38
1.06
2.93
2.94
4.42

Abbreviation: SD, standard deviation.

m m , P < .0001). T h e p o s t t r e a t m e n t m e a n overj e t was 2.18 m m a n d the p o s t r e t e n t i o n m e a n
overjet was 3.27 m m .
Irregularity Index
T h e m e a n p r e t r e a t m e n t incisor irregularity was
3.97 m m ; 54.5% o f cases h a d m i n i m a l irregularity 52 before t r e a t m e n t ( < 3 . 5 m m ) , 35.5% h a d
m o d e r a t e incisor irregularity (3.5-6.5 m m ) , a n d
9.0% h a d severe incisor irregularity ( > 6 . 5 m m ) .
T r e a t m e n t p r o d u c e d a significant decrease in
the incisor irregularity (z~ = - 3 . 6 6 m m , P <
.0001). Incisor irregularity increased significantly p o s t t r e a t m e n t (:~ = + 0 . 9 8 ram, P <
.0001). However, 90% o f cases at T3 h a d minimal incisor irregularity, a n d 10% h a d m o d e r a t e
irregularity. All 31 cases s h o w e d a n e t improvem e n t in incisor irregularity f r o m T1 to T3.

Arch Length
A total o f 64.5% o f the cases s h o w e d a slightly
significant increase in arch l e n g t h because o f
t r e a t m e n t (:~ = +1.79 m m , P = .04) whereas
87.1% o f the cases s h o w e d a significant decrease
in arch l e n g t h p o s t r e t e n t i o n (g: = - 2 . 1 6 , P <
.0001).
T h e P e a r s o n correlation coefficient was calculated by c o m p a r i n g the T1 curve o f Spee with
the p o s t t r e a t m e n t c h a n g e s ( T 3 - T 2 ) observed
for each o f five variables ( m a n d i b u l a r intercanine distance, overbite, overjet, m a n d i b u l a r incisor irregularity, a n d arch length) a n d revealed
n o statistical correlation (P > .05). Follow-up
regression analyses revealed n o ability to p r e d i c t
relapse in any of the five factors m e n t i o n e d earlier based o n the T1 curve o f Spee (P > .05).

Discussion
T h e i m p o r t a n t c o n t r i b u t i o n that leveling the
curve o f Spee makes toward the success o f orth-

o d o n t i c t r e a t m e n t has b e e n well d o c u m e n t e d in
the literature. 18,19,25-2s,~9,34,4 T h e r e is, however,
n o g e n e r a l a g r e e m e n t as to the m o s t appropriate b i o m e c h a n i c a l principles that s h o u l d be
used to accomplish stable long-term arch leveling. Two i m p o r t a n t studies have b e e n perf o r m e d to c o m p a r e the use o f sectional versus
c o n t i n u o u s arch leveling m e c h a n i c s in the treatm e n t o f deep-bite cases. 16,17 Dake a n d Sinclair 1~
in a c o m p a r i s o n o f Ricketts' a n d S c h u d y ' s treatm e n t s o f a d o l e s c e n t Class II deep-bite low-angle
n o n e x t r a c t i o n cases, c o n c l u d e d that b o t h operators' t e c h n i q u e s were effective in overbite correction, a n d that these c h a n g e s r e m a i n e d stable
after an average p o s t t r e a t m e n t p e r i o d o f 4 years
and 6 months.
W e i l a n d et al, 17 in a study o f 50 adult lowangle deep-bite cases, c o n c l u d e d that in adult
patients the B u r s t o n e 4-~' segmental arch techn i q u e is s u p e r i o r to c o n v e n t i o n a l c o n t i n u o u s
arch wire t e c h n i q u e s w h e n arch leveling by incisor intrusion is indicated. T h e earlier-ment i o n e d studies 16,~7 c o m p a r e d the effectiveness o f
overbite c o r r e c t i o n as m e a s u r e d o n c e p h a l o m e t ric radiographs. N e i t h e r study used study m o d e l s
to m e a s u r e the curve o f Spee n o r to m e a s u r e the
effectiveness or long-term stability o f leveling the
curve o f Spee. T h e p r e s e n t study was p r o m p t e d
by the r e c o g n i t i o n o f a n e e d for a long-term
study-model analysis o f the effectiveness a n d stability o f leveling the curve o f Spee.
Findings r e p o r t e d in the literature dealing
with the stability o f o r t h o d o n t i c t r e a t m e n t are
often contradictory, in large part, because o f the
fact that investigators g r o u p malocclusions that
require different t r e a t m e n t strategies together.
Further, the o r t h o d o n t i c r e c o r d s that are used
in o u t c o m e s studies often b e l o n g to patients
w h o were treated by b o t h e x p e r i e n c e d a n d inexp e r i e n c e d operators. It is also an u n f o r t u n a t e
fact that detailed o u t c o m e s goals are n o t regu-

96

Carcara, Preston, and Jureyda

lady established for orthodontic patients before

the start of their treatment. Lastly, assessments
of relapse are often qualitative and do not allow
for quantitative comparison. By defining strict
guidelines for the selection of cases treated by a
single experienced operator with clearly defined
goals, the present study attempted to overcome
at least some of the earlier shortcomings.
The effectiveness of arch leveling achieved
with the Alexander Discipline was determined
by comparing T1 and T2 curve of Spee data by
using a paired t test. Results of the paired t test
indicated a statistically significant change (P <
.0001) in the curve of Spee during treatment. It
was concluded that the Alexander Discipline is
an effective preadjusted continuous arch wire
technique for leveling a curve of Spee in Class II,
Division I nonextraction deep-bite cases in
which the initial curve of Spee was in the range
of 2 to 4 mm. Seventy-one percent of the cases
studied were leveled completely, whereas 29%
had a slight residual curve of Spee at T2. For the
latter cases the mean curve of Spee remaining at
the end of treatment was 0.11 mm. A residual
curve of Spee of 0.11 m m is probably clinically
insignificant based on the qualitative observations of the posttreatment study models. The T2
models all exhibited Class I molar and canine
relationships with properly finished buccal occlusions, and normal overjets and overbites. 18
A question that c a n n o t be answered by this
study is how the curve of Spee was leveled. Several investigators 4,5,9,1,u,16,~7 have reported on
the negative effects of continuous arch wire mechanics. These effects include a flaring of the
lower incisors, an extrusion of the mandibular
molars, and an o p e n i n g of the occlusal mandibular plane. Some features of the Alexander Discipline, including the - 5 of torque in the lower
incisors and the - 6 of distal tip in the mandibular molars, are specific and probably unique
a m o n g the preadjusted appliance prescriptions.
These unique features, along with biomechanical principles such as the use of heat-treated
arch wires with omega stops tied back to the
molar tubes, could play a role in preventing the
untoward side effects seen with some other
straight-wire techniques.
The long-term stability of arch leveling
achieved with the Alexander Discipline was determined by c o m p a r i n g the T2 and T3 curve of
Spee data by using a paired t test. A statistically

significant change (P < .0001) was seen in the

curves of Spee after the removal of the mandibular retention appliances. The curves of Spee
increased fi'om a mean of 0.11 m m posttreatm e n t to a mean of 0.48 m m postretention. In
other words, the curve of Spee relapsed on average 0.37 m m over a period of 7 years and 5
months after the fixed lingual canine-to-canine
mandibular retainer was removed. Although the
relapse in the curve o f Spee may be statistically
significant, it has been explained, in a clinical
sense, by several investigators as being a normal
physiologic process. 18,27,~x,~2 It was concluded
that the Alexander Discipline efficiently "over
treats" Class II, Division I deep-bite malocclusions so that when the relapse occurs the curve
of Spee returns to a lesser extent than was initially present. The overall long-term (T1-T3)
effect of orthodontic treatment with the Alexa n d e r Discipline is an average of 80.62% reduction in the pretreatment curve of Spee. Twelve
of the 31 cases studied remained 100% level over
a time span of 5 to 25 years after the conclusion
of orthodontic treatment. This study shows that
in this sample the observed relapse of the curve
of Spee (:~ = 0.48 mm) was minimal and that it
occurred slowly over an extended period of
time. The effects of this degree of relapse of the
curve of Spee are probably clinically insignificant with regard to p r o p e r mandibular function,
esthetics, and occlusion.
The results of a two-sample t test used to
compare the p r o p o r t i o n of relapse that took
place revealed a significant difference in the
incidence of relapse that occurred in the 22
cases that were completely leveled at the end of
treatment (T2) and the 9 cases that were not
(P < .05). In addition, the results of the two
i n d e p e n d e n t samples' t tests also revealed a significant difference in the magnitude of relapse
that occurred in the 22 cases that were completely leveled and the 9 cases that were not (P <
.0001). Half of the 22 cases that were completely
leveled at the end of treatment showed some
relapse at T3. The a m o u n t of this relapse was
11.68% of the original curve of Spee (T1) or
0.28 mm. In contrast, eight of nine (88.9%) of
the cases that were not completely leveled at T2
relapsed, and the a m o u n t of relapse was 22.46%
(0.39 mm) of the original curve of Spee. It was
concluded that in those cases treated with the
Alexander Discipline that were not completely

The Curve of Spee, Relapse, and the Alexander Discipline

leveled posttreatment, there is a slightly higher

incidence and m a g n i t u d e o f relapse than in
those cases that were completely leveled.
To establish whether significant t r e a t m e n t
and posttreatment changes h a d taken place in
m a n d i b u l a r intercanine width, overbite, overjet,
m a n d i b u l a r incisor irregularity, and arch length,
preliminary statistical analyses were p e r f o r m e d .
Paired t tests were calculated to c o m p a r e the
p r e t r e a t m e n t and p o s t t r e a t m e n t data and the
posttreatment and postretention data.
For each of the five variables m e a s u r e d f r o m
the study casts, statistically significant changes
occurred during t r e a t m e n t with the Alexander
Discipline (P < .05). An evaluation of the effects
of t r e a t m e n t on these five variables was not the
primary goal of this research project. T h e findings did, however, detect that in association with
the treatment there was a general decrease in
overbite, overjet, and incisor irregularity, and an
increase in m a n d i b u l a r intercanine width a n d
arch length. With one exception, arch length,
these results are similar to those r e p o r t e d by
Elms et al. 46 T h e increase in the arch length
during orthodontic t r e a t m e n t that was observed
in the present study was not statistically significant in the Elms et a146 study. In the present
study, four of the five variables (overbite, overjet,
incisor irregularity, and arch length) showed statistically significant (P < .05) p o s t t r e a t m e n t
changes. In the present study, the m a n d i b u l a r
intercanine width showed marginally significant
(P = .0505) posttreatment changes. Although it
was not a major goal of this study to investigate
the relapse of m a n d i b u l a r occlusal traits, significant p o s t t r e a t m e n t changes were detected for
all five variables studied. Although these results
are similar to those f o u n d by Elms e t al, 46 the
p o s t t r e a t m e n t changes n o t e d for overbite, overjet, and the irregularity index were marginally
greater in the present study than are those reported by Elms et al. 46
Most of the p o s t t r e a t m e n t changes n o t e d in
the m a n d i b u l a r intercanine width and arch
length were small and probably reflect n o r m a l
physiologic changes that occur with increasing
age, as r e p o r t e d in the literature. 44,5,51 It must,
however, not be overlooked that overexpansion
of the intercanine arch width in the mandible is
a potential source of relapse after orthodontic
treatment. Although a statistically significant
posttreatment increase in incisor irregularity was

97

observed, it is a fact that 90% of the cases at T3

had minimal incisor irregularity (<3.5 m m ) , ~2
and all 31 cases showed a net i m p r o v e m e n t in
m a n d i b u l a r incisor crowding f r o m T1 to T3.
T h e increase in the p o s t t r e a t m e n t overbite
may be attributed to a physiologic gradual return o f the curve of Spee over time, as well as to
other factors such as attrition and overeruption
of the maxillary incisors. T h e latter p a r a m e t e r s
were not investigated in this study and, furthermore, it should be emphasized that the changes
in overbite n o t e d in this study were less than
previously reported. 97
T h e p o s t t r e a t m e n t changes in the overjet that
were n o t e d in this study were not m u c h different
than those r e p o r t e d previously for Class II, Division I malocclusions. 16,17,47 It is i m p o r t a n t to
emphasize the fact that very few studies dealing
with p o s t t r e a t m e n t orthodontic changes have
used postretention records that could m a t c h this
sample in the length of time covered (:~ = 11
years a n d 5 months; range: 7 years to 28 years
and 8 months). In this respect the longer postretention time span of the cases included in this
study provided m o r e time for p o s t t r e a t m e n t relapse to take place.
Because it was shown that relapse had occurred in the five variables previously mentioned, a Pearson correlation coefficient was calculated to c o m p a r e the p r e t r e a t m e n t curve of
Spee with the p o s t t r e a t m e n t changes observed
for each of the five variables studied. T h e results
of this test revealed that no statistical correlation
existed between the original cmwe of Spee and
each of the five factors of relapse (P > .05).
Follow-up regression analyses revealed no ability
to predict relapse in m a n d i b u l a r intercanine
width, overbite, overjet, m a n d i b u l a r incisor irregularity, a n d arch length based on the d e p t h
of the p r e t r e a t m e n t curve of Spee. It should be
n o t e d that in each of these cases, interproximal
enamel reduction was p e r f o r m e d on the mandibular anterior teeth. T h e variable with the
highest correlation was overjet r = - 0 . 2 6 8 ) , yet
only 7.2% of the variability seen in the overjet
change can be accounted for by the pretreatm e n t curve of Spee (r 2 = 0.072). It is possible
that if a sample with larger p r e t r e a t m e n t curves
of Spee were studied, a positive correlation
could be seen between the larger p r e t r e a t m e n t
curves of Spee, and the relapse in other aspects
of the occlusion posttreatment.

98

Carcara, Preston, and Jureyda

Although this study has shown the clinical

effectiveness of using continuous arch wire mechanics to level the curve of Spee, it must be
kept in mind that not every straight-wire appliance has the unique prescription that is part of
the M e x a n d e r Discipline, namely the - 5
torque in the mandibular incisor and the - 6
distal tip built into the molar tubes. These
unique appliance features may play a large role
in allowing for an effective, and controlled, mandibular arch leveling as shown in this study. In
addition, the mechanical principles of actively
tying back a heat-treated curved arch wire may
contribute to the success of the arch leveling
achieved with the Alexander Discipline. It is unwise to assume that every straight-wire appliance,
using continuous arch wire mechanics to level
the curve of Spee, will be as successful as the one
studied here. Furthermore, this study investigated the cases of not only an experienced clinician but also the authority on the Alexander
Discipline.
Because only study models were evaluated,
this investigation was unable to ascertain the
exact process by which the curve of Spee is leveled with the continuous arch wire mechanics of
the Alexander Discipline. Also, the exact process
by which the slight relapse of the curve of Spee,
noted in this study, occurred was not ascertained. A comprehensive cephalometric appraisal of the mechanism of arch leveling and
relapse of the curve of Spee in this sample has
been u n d e r t a k e n by Bernstein. 54 Additionally,
study model and cephalometric investigations of
the curve of Spee leveling process by using incisor intrusion mechanics should also be performed. If the sample of such a study is carefully
matched to the present one, valid comparisons
could be made to ultimately determine the most
effective biomechanics necessary to level the
curve of Spee and to maintain it level in the long
term.

Conclusions
1. The Alexander Discipline is an effective continuous arch wire technique for leveling the
curve of Spee in Class II Division I deep-bite
cases treated by nonextraction in which the
initial curve of Spee is 2 to 4 mm.
2. The Alexander Discipline efficiently overtreats a pretreatment curve of Spee of 2 to 4

m m in Class II Division I deep-bite cases

such that when relapse occurs, the curve of
Spee returns to a lesser extent than was
present before orthodontic treatment.
3. Postretention changes in overbite, overjet,
and irregularity index were small and
showed net improvement.
4. With the Alexander Discipline, a pretreatm e n t curve of Spee of 2 to 4 m m that is not
completely level posttreatment has a slightly
higher incidence and magnitude of relapse
than a pretreatment curve of Spee that is
completely level posttreatment.
5. There is no ability to predict relapse in mandibular intercanine width, overbite, overjet,
mandibular incisor irregularity, and arch
length in Class II Division I deep-bite cases
treated with the Alexander Discipline based
on the pretreatment curve of Spee.

References
1. Tweed CH. Clinical orthodontics. St. Louis: CV Mosby,
1966, pp 84-180.
2. Ricketts RM. Bioprogressive therapy as an answer to
orthodontic needs. Part I. A m J O r t h o d 1969;70:241-268.
3. Ricketts RM. Facial a n d d e n t u r e c h a n g e s d u r i n g orthodontic t r e a t m e n t as analyzed from the t e m p e r o m a n dibular joint. A m J O r t h o d 1955;41:163-167.
4. Wylie WL. Overbite a n d vertical facial dimensions in
terms o f muscle balance. Angle O r t h o d 1944;14:13-17.
5. B e n c h RW, Gugino CF, Hilgers ~ . Bioprogressive therapy. Part 2. J Clin O r t h o d 1977;11:661-682.
6. Merritt J. A cephalometric study of the t r e a t m e n t a n d
retention of deep overbite cases [master's thesis]. Houston, TX: University of Texas, 1964.
7. Schudy FF. T h e association of anatomical entities as
applied to clinical orthodontics. Angle O r t h o d 1966;36:
190-203.
8. Graber TM. Orthodontics: Principles a n d practice. Philadelphia: W.B. Saunders, 1969.
9. Otto RE, A n h o l m J M , Engel GA. A comparative analysis
of intrusion of incisor teeth achieved in adults a n d child r e n according to facial types. A m J O r t h o d 1980;77:437446.
10. B e r m a n MS. Straight wire myths-BJO Interview. Br J
O r t h o d 1988;151:57-61.
11. W o o d s M. A reassessment of space r e q u i r e m e n t s for
lower arch leveling. J Clin O r t h o d 1986;20:770-778.
12. F e r g u s o n J W . Lower incisor torque-the effects of rectangular archwires with a reverse curve of Spee. BrJ O r t h o d
1990;17:311-315.
13. Schudy FF. Cant of the occlusal plane a n d axial inclination o f teeth. Angle O r t h o d 1963;23:69-82.
14. Schudy FF. Vertical growth versus antero-posterior
growth as related to function. Angle O r t h o d 1964;34:
756-793.
15. Lett RL. Overbite correction a n d relapse as analyzed by

The Curve of Spee, Relapse, and the Alexander Discipline

16.

17.

18.
19.
20.
21.
22.
23.

24.
25.

26.
27.

28.
29.
30.
31.
32.
33.

34.
35.
36.
37.

some cephalometric and treatment related variables

[master's thesis]. Minneapolis, MN: University of Minnesota, 1969.
Dake ML, Sinclair PM. A comparison of the Ricketts and
Tweed-type arch leveling techniques. AmJ Orthod 1989;
95:72-78.
Weiland FJ, Bartleon HP, Droschl H. Evaluation of continuous arch and segmented arch leveling techniques in
adult patients: A clinical study. Am J Orthod 1996;110:
647-652.
Andrews LF. The six keys to normal occlusion. Am J
Orthod 1972;9:296-309.
Baldridge DW. Leveling the curve of Spee: Its effect on
mandibular archlength. J Clin Orthod 1969;64:26-41.
Spee FG. The gliding path of the mandible along the
skull. J Am Dent Assoc 1980;100:670-675.
Gysi A. The problem of articulation. Dental Cosmos
1910;52:1-19, 148-169.
Christensen C. The problem of the bite. Dental Cosmos
1905;47:1184-1195.
Orthlieb J. The curve of Spee: Understanding the sagittal organization of mandibular teeth. J Craniomandib
Pract 1997;15:333-340.
The Academy of Prosthodontics. Glossary of prosthodontic terms. J Prosthet Dent 1994;71:50-112.
Germane N, Staggers JA, Rubenstein L, et al. Arch
length consideration due to the curve of Spee: A mathematical model. A m J Orthod 1992;102:251-255.
Braun S, Hnat WP, Johnson BE. The curve of Spee
revisited. Am J Orthod 1996;110:206-210.
Koyama T. A comparative analysis of the curve of Spee
(lateral aspect) before and after orthodontic treatmentwith particular reference to overbite patients. J Nihon
Univ Sch Dent 1979;21:25-34.
Root T. Level anchorage. Monrovia, CA: Unitek Corp,
1988.
Sicher H. Oral anatomy. St. Louis: CV Mosby, 1949.
Hemley S. Orthodontic theory and practice (ed. 2). New
York: Grune and Stratton, 1953.
Wheeler RC. A textbook of dental anatomy and physiology (ed. 2). Philadelphia: W.B. Saunders, 1950.
Ash MM. Wheeler's dental anatomy, physiology and occlusion (ed. 6). Philadelphia: W.B. Saunders, 1984.
OsbornJW. Orientation of the masseter muscle and the
curve of Spee in relation to crushing forces on the molar
teeth of Primates. Am J Phys Anthropol 1993;92:99-106.
Dawson P. Evaluation, diagnosis and treatment of occlusal problems. St. Louis: CV Mosby, 1974.
Diamond M. Dental anatomy (ed. 3). NewYork: McMillan, 1952.
Strang RH. A textbook of orthodontia (ed. 3). Philadelphia: Lea and Feibiger, 1950.
Gresham H. A manual of orthodontics. Christ Church,
New Zealand: N.M. Peryer, 1957.

99

38. Fidler BC, Artun J, Joondeph DR, et al. Long-term stability of angle class II, Division I malocclusions with
successful occlusal results at the end of active treatment.
A m J Orthod 1995;107:276-285.
39. Braun ML, Schmidt WG. A cephalometric appraisal of
the curve of Spee in class 1 and class II division I occlusion for males and females. Am J Orthod 1956;42:255278.
40. Hellsing E. Increased overbite and craniomandibular
disorders-a clinical approach. AmJ Orthod 1990;98:516522.
41. McNamara JA, Seligman DA, Okeson JP. Occlusion,
orthodontic treatment, and temporomandibular disorders: A review. J Orofac Pain 1995;9:73-90.
42. Williams R. Eliminating lower retention. J Clin Orthod
1985;22:342-349.
43. Little RM. The irregularity index: A quantitative score of
mandibular anterior teeth. Am J Orthod 1975;68:554563.
44. Bishara SE,JakobsenJR, TrederJE, et al. Changes in the
maxillary and mandibular tooth-size-archlength relationship from early adolescence to early adulthood.
Am J Orthod 1989; 1:46-59.
45. Burstone CJ. The mechanics of the segmental arch technique. Angle Orthod 1966;36:99-120.
46. Elms TN, Buschang PH, Alexander RG. Long-term stability of class II division I nonextraction cervical face-bow
therapy: I. Model analysis. Am J Orthod 1996;109:271276.
47. Glenn, G, Sinclair PM, Alexander RG. Nonextraction
orthodontic therapy: Postreatment dental and skeletal
stability. Am J Orthod 1987;92:321-328.
48. Little RM, Reidel RA, Artun J. An evaluation of changes
in mandibular anterior alignment from 10 to 20 years
post-retention. Am J Orthod 1988;5:423-428.
49. Puneky PJ, Sadowsky C, BeGole EA. Tooth morphology
and lower incisor alignment many years after orthodontic therapy. AnlJ Orthod 1984;10:299-305.
50. Sinclair PM. Little RM. Maturation of untreated normal
occlusion. A m J Orthod 1983;2:114-123.
51. DeKock WH. Dental arch depth and width studied longitudinally from 12 years of age to adulthood. Am J
Orthod 1972;62:56-66.
52. Little RM, Wallen TR, Reidel RA. Stability and relapse of
mandibular anterior alignment-first premolar cases
treated by traditional edgewise orthodontics. Am J
Orthod 1981;80:349-364.
53. Alexander RG. The Alexander Discipline, contemporary
concepts and philosophies. Glendora, CA: Ormco, 1986.
54. Bernstein: Leveling the curve of Spee with a continuous
archwire technique-A long-term cephalometric analysis
[master's thesis]. Buffalo, NY: University of Buffalo,
1999.