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The Twin Block traction technique

Article  in  The European Journal of Orthodontics · June 1982

DOI: 10.1093/ejo/4.2.129 · Source: PubMed

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 CHAPTER 11

The Twin Block reinforce the functional component for correction of a Class
II buccal segment relationship.
A method was developed to combine extraoral and

Traction Technique intermaxillary traction by adding a labial hook to a

conventional facebow and extending an elastic back to attach
to the lower appliance in the incisor region (Clark, 1982).
This development was based on previous experience of
ORTHOPAEDIC TRACTION functional appliances that were worn part time and were slow

In most cases, full functional correction of occlusal

relationships can be achieved with Twin Blocks without the A
addition of any orthopaedic or traction forces. Where the
response to functional correction is poor, the addition of
orthopaedic traction force may be considered.
In the early stages of development of the Twin Block
technique a method was devised to combine functional
therapy with orthopaedic traction. This approach should be
limited to the treatment of severe malocclusion, where
growth is unfavourable for conventional fixed or functional
therapy. Functional therapy combined with traction achieves
rapid correction of malocclusion.
The indications are confined to a minority of cases with
growth patterns where maxillary retraction is the treatment of
choice. For example:
• In the treatment of severe maxillary protrusion.
• To control a vertical growth pattern by the addition of
vertical traction to intrude the upper posterior teeth.
• In adult treatment where mandibular growth cannot assist
the correction of a severe malocclusion.
B
C

The Concorde facebow

Before Twin Blocks were developed, the author used extraoral
traction with removable appliances as a means of anchorage
to retract upper buccal segments to correct Class II
malocclusion (Cousins & Clark, 1965). In the early years
using Twin Blocks, tubes were added to clasps for extraoral
traction on the upper appliance to be worn at night so as to Fig. 11.1 A–C  Concorde facebow.
151
 and unpredictable in correcting arch relationships. headgear effect caused unneccessary maxillary retraction.
11  •  the twin block traction technique

The Concorde facebow is a new means of applying Occasionally (Orton, 1990), high pull traction may be
intermaxillary and extraoral traction to restrict maxillary indicated to intrude the upper posterior teeth in cases with a
growth and, at the same time, to encourage mandibular severe vertical growth pattern, in an effort to achieve a
growth in combination with functional mandibular forward mandibular rotation by intruding upper molars. The
protrusion. A conventional facebow is adapted by soldering a same objective can be achieved more simply by using vertical
recurved labial hook to extend forwards to rest outside the intraoral elastics to intrude the posterior teeth.
lips as an anchor point to combine intermaxillary and
extraoral traction. Patient comfort and acceptance is similar
to a conventional facebow. Intermaxillary traction was added
to the appliance system to ensure that if the patient postured
out of the appliance during the night, the intermaxillary
traction force would increase. This ensured that the appliance
was effective 24 hours per day (Fig. 11.1).
The labial hook is positioned extraorally, 1 cm clear of the
lips in the midline. This enables an elastic back to pass
intraorally to attach anteriorly to the lower appliance to
apply intermaxillary traction as a horizontal force vector. This
has the advantage of eliminating the unfavourable upward
component of force in conventional intermaxillary elastic
traction, which can extrude lower molars and cause tipping
of the occlusal plane.
When distal extraoral traction is applied to a removable
appliance, the outer bow of the facebow should be adjusted
to lie slightly above the inner bow in order to apply a slight
upward component of force to help retain the upper
appliance. Fixation of the appliance must be excellent before
any orthopaedic force is applied to a removable appliance,
and poor fixation contraindicates the addition of traction,
except to a fixed attachment.
The traction components are worn at night only to
reinforce the action of the occlusal inclined plane. If the
patient fails to posture the mandible to the corrected occlusal
position during the night, the intermaxillary traction force is
automatically increased to compensate and to ensure that
favourable intermaxillary forces are applied continuously.
The aim is to make the appliances active 24 hours per day to
maximise the orthopaedic response.
Careful case selection is essential before using a
combination of Twin Blocks with orthopaedic traction. This
is a very powerful mechanism for maxillary retraction and, as
the majority of Class II malocclusions are due to mandibular
retrusion, it is contraindicated in most cases. The headgear
effect tends to tip the occlusal plane and palatal plane down
anteriorly and to retrocline the upper incisors, which may
cause unfavourable autorotation of the mandible. Extraoral
traction should be used selectively, bearing in mind that
most patients respond to treatment without the addition of
traction components.
Later experience in using Twin Blocks confirmed that the
addition of a traction component was not necessary to
achieve correction of the buccal segment relationship, and
extraoral traction is no longer used to reinforce the action
152 of the inclined planes. Study of early cases showed that the
Case report:  K.A.
Fig. 11.2 Treatment:

11  •  the twin block traction technique

A
A  Profiles at ages 9 years 6 months (before treatment) and 10
years 7 months (after 8 months of treatment).
B, C  Occlusion before treatment at age 9 years 6 months (note
the anterior open bite).
D  Occlusion after 8 months of treatment.

B C D

TWIN BLOCKS COMBINED WITH

ORTHOPAEDIC TRACTION

Treatment of maxillary protrusion

CASE REPORT: K.A. AGED 9 YEARS 6 MONTHS

A severe Class II skeletal base relationship is due to maxillary

protrusion. A previous thumb sucking habit has resulted in
an anterior open bite which is perpetuated by a tongue thrust
and the lower lip is trapped in a 14 mm overjet. The addition
of the Concorde facebow with extraoral and intermaxillary
traction applied a retraction force to the maxilla, while the
action of the occlusal inclined planes advanced the mandible.
This combination of mechanics resulted in a rapid response
to treatment, in spite of spasmodic appliance wear (Fig. 11.2).

Twin Blocks and Concorde facebow: 8 months

Support and retention: 6 months.

153
 Case report:  K.A.
9.6 10.7

28ϒ
29ϒ

32ϒ
29ϒ 1
4
6 4
53ϒ 51ϒ 18
19

-5 -4 -4
-6

24ϒ 23ϒ

Maxillary Plane at ANS

Corpus Axis at PM Nasion Basion at Nasion Basion Superimposition

K.A. Age 9.6 10.7

Cranial Base Angle 29 28

Facial Axis Angle 29 32
F/M Plane Angle 24 23
Craniomandibular Angle 53 51
Maxillary Plane 4 1
Convexity 6 4
U/Incisor to Vertical 27 24
L/Incisor to Vertical 29 28
Interincisal Angle 124 128
6 to Pterygoid Vertical 19 18
L/Incisor to A/Po −6 −4
L/Lip to Aesthetic Plane −5 −4

Nasion Basion at CC

154
Case report:  W.F.
Fig. 11.3 Treatment:

11  •  the twin block traction technique

A
A  Profiles at ages 9 years 5 months (before treatment) and 9
years 11 months (after treatment).
B, C  Occlusion after 5 months of treatment at age 9 years 11
months.

B C

Case report: W.F. aged 9 years 5 months

This patient presents a 12 mm overjet and deep overbite with

a full unit distal occlusion in the mixed dentition. At this
stage of development there may be a resting phase in growth,
when the patient does not gain significantly in height. The
mandible follows the growth pattern of a long bone, therefore
mandibular growth is also limited. In appropriate cases
maxillary retraction may be required to contribute to the
correction of a distal occlusion. The Concorde facebow with
intermaxillary and extraoral traction is effective in accelerating
correction to compensate for a lack of mandibular growth
(Fig. 11.3).

Twin Blocks and Concorde facebow: 9 months

Support and retention: 9 months.

155
 Case report:  W. F.
9.5 9.11 13.11

27ϒ
24ϒ
25ϒ

29ϒ -3 33ϒ 1
32ϒ 1
44ϒ 11 5 3
5 46ϒ 16
44ϒ 14
-2
-2
0 1
-3 1

21ϒ 19ϒ
19ϒ

Maxillary Plane at ANS

Corpus Axis at PM Nasion Basion at Nasion Basion Superimposition

W.F. Age 9.5 9.11 13.11

Cranial Base Angle 25 24 27

Facial Axis Angle 32 29 33
F/M Plane Angle 19 21 19
Craniomandibular Angle 44 44 46
Maxillary Plane 1 −3 −1
Convexity 5 5 3
U/Incisor to Vertical 32 18 16
L/Incisor to Vertical 30 34 39
Interincisal Angle 118 128 125
6 to Pterygoid Vertical 14 11 16
L/Incisor to A/Po −3 0 1
L/Lip to Aesthetic Plane 1 −2 −2

Nasion Basion at CC

156
Case report:  K.S.
A
B C
E F
Case report: K.S. aged 11 years 6 months
The growth response slows significantly in girls after the onset
of menstruation. This tends to reduce the mandibular
response to functional treatment. The addition of orthopaedic
traction may be required to achieve correction of a severe
distal occlusion.
This is an early example of Twin Block treatment for a girl
with a severe Class II division 1 malocclusion with excessive
overbite. The case was complicated by previous loss of 6 ,
and was treated by extraction of 4 4 and 4 to achieve better
11  •  the twin block traction technique
Fig. 11.4 Treatment:
A  Profiles at ages 11 years 6 months (before treatment) and 14
years 2 months (after treatment).
B, C  Occlusion before treatment.
D  Occlusion 2 years out of retention.
E  Facial appearance before treatment.
F  Concorde facebow used during treatment.
G  Facial appearance after treatment: aged 14 years 2 months.
D
G
symmetry (Fig. 11.4). Treatment was effective in reducing an
overjet of 12 mm and an excessive overbite of 9 mm to
produce an acceptable occlusion. A Concorde facebow
resulted in flattening of the profile by maxillary retraction,
combined with a favourable mandibular advancement. The
skeletal correction reduced the convexity from 8 mm before
treatment to 3 mm out of retention at age 18.
157
 Case report:  K. S.
11.6 13.0 17.9

28ϒ 28ϒ
27ϒ

28ϒ 2 29ϒ
26ϒ 2 0

8 5
3
50ϒ 53ϒ 48ϒ
17 22
20
-1 -1 0
-1 -3
-2

24ϒ 20ϒ
25ϒ

Maxillary Plane at ANS

Corpus Axis at PM Nasion Basion at Nasion Basion Superimposition

K.S. Age 11.6 13.0 17.9

Cranial Base Angle 27 28 28

Facial Axis Angle 26 28 29
F/M Plane Angle 24 25 20
Craniomandibular Angle 50 53 48
Maxillary Plane 2 2 0
Convexity 8 5 3
U/Incisor to Vertical 32 14 17
L/Incisor to Vertical 26 20 17
Interincisal Angle 122 146 146
6 to Pterygoid Vertical 17 22 20
L/Incisor to A/Po −1 −1 −1
L/Lip to Aesthetic Plane −2 0 −3

Nasion Basion at CC

158
DIRECTIONAL CONTROL the appliance in the mouth. This produces an effective

11  •  the twin block traction technique

OF ORTHOPAEDIC FORCE
Additional orthopaedic forces may help to control vertical
growth by applying an intrusive orthopaedic force to the
upper posterior teeth. A high pull headgear is used to apply
an intrusive force to the upper molars to resist the vertical
component of growth and to reduce the anterior open bite.
The Concorde facebow is a unique method of delivering an
intrusive force to upper molars and, at the same time, a
protrusive force to the mandible and the lower dentition.
The direction of extraoral force is especially important in
the treatment of patients with a vertical growth pattern. A
vertical orthopaedic force to the upper appliance applies an
intrusive force to the upper posterior teeth and palate, and
limits downward maxillary growth.
Intrusion of the upper posterior teeth allows the bite to
close by a favourable forward rotation of the mandible, and
facilitates correction of mandibular retrusion in vertical
growth discrepancies.
The addition of traction is optional in reduced overbite
cases, and many cases respond well to treatment without
traction. Traction is indicated in severe discrepancies with
vertical growth which are unfavourable for functional
correction. A vertical component of traction force is
particularly effective in controlling this type of malocclusion.
The Concorde facebow is adjusted so that it lies just below
the level of the upper lip at rest, with the ends of the outer
bow sloping slightly upwards above the level of the inner
bow. The resulting extraoral traction applies an upward
component of force that helps to retain the upper appliance.
anterior oral seal, whereby it is more economical for the
circumoral muscles to form the seal by lip closure than by lip
to tongue contact.
The overjet reduced from 10 mm to 2 mm in 3 months.
During this period a slight posterior open bite developed. To
maintain an intrusive occlusal force on the posterior teeth,
Twin Blocks continued to be worn full time without reducing
the occlusal blocks. This helps to resolve an anterior open
bite. The Concorde facebow was worn at night for the first 6
months of treatment. During the support phase an anterior
inclined plane was designed for retention with the lower
incisors occluding on the cingulae of the upper incisors as the
buccal teeth settle into occlusion.
The rapid correction occurred in this case mainly by
mandibular advancement, and was accompanied by an
increase in the upper pharyngeal space from 3 mm to 10 mm
after 4 months of treatment.
Twin Blocks and Concorde facebow: 4 months
Support phase: 6 months
Retention: 4 months
Treatment time: 14 months
Final records: 6 years 9 months out of retention
(Figs 11.5, 11.6).

CASE REPORT: L.G. AGED 9 YEARS 1 MONTH

This girl presented a severe mandibular retrusion with 10 mm

convexity and mild maxillary protrusion. An overjet of 10 mm
was perpetuated by a tongue thrust and a tooth apart swallow,
resulting in an incomplete overbite. The lower incisors
normally erupt into contact with the upper incisors or the
soft tissue of the palate, unless they are prevented from doing
so by intervening soft tissues or by a thumb or finger sucking
habit. Reduced overbite may present as a small separation of
the lower incisors from the palate. This is due to an atypical
swallowing pattern as the tongue thrusts between the teeth to
contact the lower lip to form an anterior oral seal in a ‘tooth
apart’ swallow. The soft-tissue pattern improves when the
mandible postures forwards and an anterior seal is formed by
closing the lips together over the teeth. The soft tissues adapt Fig. 11.5  Vertical extraoral traction force to intrude upper posterior teeth.
quickly to full-time appliance wear as the patient eats with

159
 Case report:  L.G.
Fig. 11.6 Treatment:
11  •  the twin block traction technique

A
A  Profiles at ages 10 years 8 months (before treatment), 10
years 11 months (after 3 months treatment) and 18 years 4
months.
B  Occlusion before treatment.
C  Twin Blocks.
D  Occlusion before treatment.
E–G  Occlusion after 3 months of treatment.

B C D

E F G

160
Case report:  L.G.

11  •  the twin block traction technique

H J K

L M N

P Q R

Fig. 11.6  Treatment (cont.):

H  Concorde facebow and combination headgear with high pull.
J  Occlusion after 9 months of treatment.
K  Addition of an anterior inclined plane.
L–N  Occlusion at age 11 years 6 months.
P  Facial appearance before treatment at age 10 years 8 months.
Q  Facial appearance after 3 months of treatment.
R  Facial appearance at age 18 years 4 months.

161
 Case report:  L.G.
10.8 10.11 15.4

25ϒ
26ϒ 26ϒ

27ϒ -1 26ϒ 26ϒ 0

1
52ϒ 10 8
22 52ϒ 9 52ϒ
20 23

0 1 -1
3 3
4

27ϒ
27ϒ 27ϒ

Maxillary Plane at ANS

Corpus Axis at PM Nasion Basion at Nasion Basion Superimposition

L.G. Age 10.8 10.11 15.4

Cranial Base Angle 25 26 26

Facial Axis Angle 27 26 26
F/M Plane Angle 27 27 27
Craniomandibular Angle 52 52 52
Maxillary Plane −1 1 0
Convexity 10 9 8
U/Incisor to Vertical 19 18 17
L/Incisor to Vertical 46 47 41
Interincisal Angle 115 115 122
6 to Pterygoid Vertical 22 20 23
L/Incisor to A/Po 0 4 3
L/Lip to Aesthetic Plane 1 3 −1

Nasion Basion at CC

162
References

11  •  the twin block traction technique

Clark, W.J. (1982). The twin-block traction technique. Eur. J. Orthod., 4: 129–38.
Clark, W.J. (1988). The twin-block technique. Am. J. Orthod. Dentofac. Orthop., 93:
1–18.
Cousins, A.J.P. & Clark, W.J. (1965). Extra-oral traction. Theoretical considerations
and the development of the removable appliance system. Trans. BSSO, 29–38.
Orton, H.S. (1990). Functional Appliances in Orthodontic Treatment. London,
Quintessence.

163
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