1

TWIN BLOCK

Presented By Mohd Abdul Wajid

 INTRODUCTION
2

Functional appliances by altering the position of the

teeth and supporting tissues, establish a new and
more optimal functional behavioral pattern which
leads to adaptive changes in the bone form and
helps the dentofacial complex achieve, its optimal
genetic growth potential.
 TWIN BLOCKS
3

Twin block appliances are simple bite blocks designed for

full time wear that achieve rapid functional correction
of malocclusion by the transmission of favourable
occlusal forces to occlusal inclined planes that cover
the posterior teeth.

The goal in developing the twin block technique was to

maximize the growth response to functional
mandibular protrusion by using an appliance that is
simple, comfortable and esthetically acceptable to the
patient.
 PHILOSOPHY BEHIND TWIN BLOCK
THERAPY
4

Occlusal inclined plane :-According to Clarks the

occlusal inclined planes were the fundamental
functional mechanism for the natural dentition.
And the inclined planes play an important role in
determining relationship of the teeth as they erupt.
If the mandible inclined planes are in a distal relation
to that of maxilla then the force acting on the
mandibular teeth will have a distal force vector
leading to a class II growth tendency.
5

The aim of the inclined planes of the bite blocks in

twin block is to modify these inclined planes and
cause more favorable growth pattern. Hence the
unfavorable cuspal contacts of the distal occlusion
are replaced by favorable proprioceptive contacts
on the inclined planes to correct the malocclusion
and free the mandible from its locked distal
position.
6
7

Use of masticatory force :- one major advantage in

twin blocks was that it could be worn 24 hours,
hence the masticatory forced can be transmitted via
the appliance to the dentition from where they are
transmitted to the bony trabaculae according to
wolfs law, influencing the rate of growth and the
trabaculae structure of the supporting bone.
8
 DEVELOPMENT OF TWIN BLOCK
9

On 7th September 1977, DR Williams J Clark

developed Twin blocks.
Name :- Colin Gove
Age / Sex :- 7yrs 10 months / Male
Chief Complaint :- Luxated upper central incisor
On Examination :- Class II div 1 malocclusion with
a 9mm overjet and a midline shift to right.
10

Treatment :- The tooth was re-implanted but due to

class II; lower lip was trapped lingual to the
luxated tooth causing mobility and root resorption
to prevent this the appliance with a Occlusal plane
which could place the mandible forward into a
edge to edge bite was made later a fixed treatment
was done. Later the re-implanted tooth was
crowned and a stable result was obtained at age of
25 years.
11

Before Treatment Post Treatment IOPA

IOPA Showing Showing An
Luxated 11 Endodontic Pin To
Stabilize 11
12

Different Stages
Of Treatment
Using Twin
Block
Combination
Therapy With
Fixed Appliance
In Later Stage
 ADVANTAGES OF TWIN BLOCKS
13

Twin Blocks have many advantages compared to

other functional appliances:

Comfort. Patients wear Twin Blocks 24 hours per day

and can eat comfortably with the appliances in
place.

Aesthetics. Twin Blocks can be designed with no

visible anterior wires without losing any efficiency
for correction of arch relationships.
 Function. The occlusal inclined plane is the most
14
natural of all the functional mechanisms. There is
less interference with normal function because the
mandible can move freely in anterior and lateral
excursion without being restricted by a bulky one-
piece appliance.

Patient compliance. Twin Blocks may be fixed to the

teeth temporarily or permanently to guarantee
patient compliance. Removable Twin Blocks can be
fixed in the mouth for the first week or 10 days of
treatment to ensure that the patient adapts fully to
wearing them 24 hours per day.
 Facial appearance. From the moment Twin Blocks
15
are fitted the appearance is noticeably improved.
The absence of lip, cheek or tongue pads, as used
in some other appliances, places no restriction on
normal function, and does not distort the patient's
facial appearance during treatment.

Speech. Patients can learn to speak normally with

Twin Blocks. In comparison with other functional
appliances. Twin Blocks do not distort speech by
restricting movement of the tongue, lips or
mandible.
16 Clinical management. Adjustment and activation is
simple- The appliances are robust and not prone to
breakage. Chair side time is reduced in achieving
major orthopedic correction.

Arch development. Twin Blocks allow independent

control of upper and lower arch width. Appliance
design is easily modified for transverse and sagital
arch development.
 Mandibular repositioning Full-time wear consistently
achieve rapid mandibular repositioning that
17
remains stable out of retention.

Vertical control. Twin Blocks achieve excellent

control of the vertical dimension in treatment of
deep overbite and anterior open bite. Vertical
control is significantly improved by full-lime wear.

Facial asymmetry Asymmetrical activation corrects

facial and dental asymmetry in the growing child.
 Safety Twin Blocks can be worn during sports
activities with the exception of swimming and
18 violent contact sports, when they may be removed
for safety.

Efficiency. Twin Blocks achieve more rapid correction

of malocclusion compared to one-piece functional
appliances because they are worn full time. This
benefits patients in all age groups.

Versatility . Arch relationships can be corrected from

early childhood to adulthood. However, treatment
is slower in adults and the response is less
predictable.
 Integration with fixed appliances. Integration with
19 convention fixed appliances is simpler than with any
other functional appliance. In combined techniques.
Twin Blocks can be used to maximize the skeletal
correction while fixed appliances are used to detail the
occlusion. Because Twin Blocks need have no anterior
wires, brackets can be placed on the anterior teeth to
correct tooth alignment simultaneously with correction
of arch relationships during the orthopedic phase.
During the support phase an easy transition can be
made to fixed appliances.
 Treatment of temporomandibular joint dysfunction. The
20 Twin Block may at times also be used as an effective
splint in treatment of patients who present
temporomandibular joint dysfunction due to
displacement of the condyle distal to die articular disc.
Full-time wear allows the disc to be recaptured, when
disc reduction is possible in early stage TMJ problems,
and at the same time sagital, vertical and transverse
arch development proceeds to eliminate unfavorable
occlusal contacts.
 CASE SELECTION
21 Ideal requisites for twin block appliance are :
Class II div 1 with a good arch form.
Lower arch uncrowded
Upper arch aligned.
Overjet 10-12 mm and a deep bite.
Full unit distal occlusion.
On models when the lower model is advanced to edge to edge
bite the distal occlusion should get corrected.
Patient should be growing actively preferably should be in
pubertal growth spurt.
VTO positive.
 APPLIANCE DESIGN
22

Twin blocks were originally conceived as simple

removable appliances with interlocking occlusal bite
blocks designed to position the mandible forward to
achieve functional correction of CI. II Div. I
malocclusion. However, many variations in appliance
design have been incorporated to extend the scope of
the technique to treat all classes of malocclusion.
23
 The earliest twin blocks were designed with the
following basic components.
24

1. Occlusal bite blocks

2. Midline screws to expand the upper arch.
3. Adam's clasps on upper molar and premolar.
4. Adam's clasps on lower first premolars
5. Inter dental clasps on lower incisors.
6. Labial bow to retract the upper anteriors.
7. Springs to move individual teeth and improve the arch
form as required.
8. Transmission for extra oral traction in cases of
maxillary protrusion.
 Labial bow
25

In its earlier stages all twin blocks incorporated a

labial bow to retract the upper anteriors.
However, it was observed that if the labial bow
engaged the upper incisor during functional
correction, it tended to overcorrect incisor
angulations, retracting upper incisors prematurely
and limiting the scope of functional correction with
mandibular advancement.
26

This led to the conclusion that a labial bow is not

always required unless it is necessary to upright
severely proclined incisors and even then it must
not be activated until full functional correction is
complete and a class I buccal segment relationship
is achieved.
 Clasps
27

Though the early design of twin blocks incorporated

Adam's clasps (modified arrowhead clasps), Clark
introduced the Delta Claps in 1985 to enhance
appliance fixation. It is similar in principle to the
modified arrowhead clasp but includes new
features to improve retention, minimize adjustment
and reduce metal fatigue, thereby reducing
breakage.
28

The Delta clasp retains the basic shape of the Adams

clasps with its inter-dental tags, retentive loops,
and buccal bridge. However, the difference is in the
retentive loops which are shaped as a closed
triangle (from which the name delta clasp is
derived) instead of the open V shaped loop of the
Adams clasp.
29
 Subsequent modifications has produced circular
30
loops which are easier to construct. Both types
of Delta clasps have similar retentive
properties. Depending on the anatomy of the
tooth, 2 methods of retention can be used if the
tooth is favorably shaped with good undercuts
mesially and distally. The retention loops are
angled to follow the curvature of the tooth into
mesial and distal undercuts. If the tooth is not
favorably shaped, the loops are directed
interdentally to gain retention from the inter-
dental undercuts.
31

Delta clasps are generally constructed from 0.70 to 0.75

SS wire. Their advantage is that they do not open with
repeated insertion and removal and therefore give
better retention with less adjustment and hence are less
subject to fatigue. They give excellent retention on
lower premolars and can be used on most posterior
teeth.

Clark has evaluated that the breakage rate of Delta clasp

(1 %) was significantly less than that of Adam's Clasp
(10%).
 The Delta clasp can be adjusted in 2 ways
32

By placing pliers on the wire as it emerges from the

acrylic. A slight adjustment extends the retentive
loop of the clasp into the gingival or interdental
undercut.
By grasping the arrowhead from the buccal aspect
and twisting the retentive loop inwards towards the
tooth to adjust into the mesial and distal undercut.
33

Ball shaped interdental clasps may be placed for

increased retention. They are generally placed on
lower anteriors to provide control over lower
anterior segment but clasps mesial to lower
canines are equally effective. Ball shaped clasps
are specially useful when removable twin blocks
are combined with fixed appliances and no other
clasps can be used.
 Base Plate
34

The base plate and occlusal bite blocks may be made

from heat cure or cold cure acrylic. The main
advantage of heat cure acrylic is additional strength
and precision (as blocks are first made in wax) .
Cold cure acrylic has the advantage of speed and
convenience but strength is less Breakage is a problem
in later stages of treatment, when blocks are trimmed
for allowing eruption in deep bite cases and hence a
top quality acrylic should be used.
35

The inclined planes can lose their definition if a soft

acrylic is used. Preformed bite blocks made of good
quality heat cure acrylic are being manufactured
for incorporation into cold cure appliances to
combine convenience with strength and accuracy.
 Occlusal Inclined planes:
36

The position and angulation of the occlusal inclined

planes are crucial to efficiency in correcting inter
arch relationships. The earliest twin blocks had bite
blocks articulating at a 90 degree angle. This
forced the patient to make a conscious effort to bite
in a forward position. 30% of patients failed to bite
forward consistently and tended to bite back to
their retruded position. As a result, posterior open
bites developed as the bite blocks occluded on their
flat surfaces and the sagittal correction was
hampered.
37

So, the occlusal inclined plane was developed based

on the functional mechanism of the natural
dentition. Initially 45 degree angulation was used
which was immediately successful.
However 45 degree angulation leads to an equal
downward and forward stimulus to growth. Taking
this into account,
38

clinicians decided on a 70 degree angulation to

increase the horizontal component of force,
reasoning that this may cause more horizontal
mandibular growth. This is generally used by most
clinicians now. If the patient has difficulty
posturing forward, the inclined planes may be
trimmed to reduce the angulation as well as the
amount of protrusion.
39

The position of the inclined plane is determined by

the lower block. In deep bite cases, the upper bite
block has to be trimmed to allow eruption of the
lower molars. Since, the inclined planes should not
be disturbed during trimming, it is necessary to
place them anterior to the lower molar.
 Screws:
40

These can be used for arch development. Normally

the upper arch has a midline screw to enable
expansion to accommodate the advancing lower
arch.
Lower midline screws can also be used for transverse
development of the lower arch. Screws may also be
used for sagittal development especially if upper
incisors are retroclined with deepbite. Two screws
are placed aligned anteroposteriorly in the palate.
 Standard twin blocks and
41
modifications
They are used for uncomplicated CI. II Div I
malocclusion. The upper appliance has a midline
screw and delta clasps on upper first molars.
Additional ball shaped clasps may be placed
interdentally distal to the canines or between the
premolars or deciduous molars.

The lower appliance has delta clasps on the

1stpremolars and ball clasps mesial to the canines.
42

Twin blocks have the gift of versatility of design. They

can be modified by the addition of screws, springs
and bows to move individual teeth. Screws can be
used for independent control of upper and lower
arches and for asymmetrical movement to suit the
need for individual patient
43

The twin block Crozat appliance has minimum

palatal and lingual coverage and is useful for adult
treatment.
 DIAGNOSIS AND TREATMENT PLANNING:
44

The essential orthodontic records are a diagnostic

report supported by study models, x-rays and
photographs.
 Clinical Guidelines
45

If the facial profile improves when the mandible is

advanced with the lips tightly closed, then
functional mandibular advancement is the treatment
of choice. The change in facial appearance is a
preview of the anticipated result of functional
treatment.
 Photographs:
46

Profile and frontal photographs with the mandible in

retrusive and advanced position, are used to assess
the changes that can occur during treatment
 Study models:
47

They serve as adjuvant to direct examination in the

mouth. Occlusal changes can be checked by sliding the
lower model forward and observing the articulation of
the mandibular dental arch with that of the upper
model.
In uncrowded CI II Div. I with 10 mm or more overjet, it
can be seen that good buccal segment occlusion will
result from advancing the mandible and at the same
time, laterally expanding the maxilla to match the
width of the mandibular dental arch in the projected
advanced position.
48

If the arches are crowded with irregular teeth, the

upper and lower models will often not fit on
advancement of lower model. If the irregularity is
severe, a first phase of arch development with fixed
appliances may be necessary before fitting twin
blocks. If the irregularity is less severe, modified
twin blocks with springs, screws or bows may be
used to correct the arch form during the twin block
phase.
 Radiographs:
49

OPG is vital to study the dentition and condition of

alveolar bone and periodontium. This may be
supported with intra oral films of certain teeth as
required. TMJ X-rays may also be required to
assess the joint condition before treatment. A hand
wrist film may be taken to assess the developmental
status of the patient. Finally, lateral cephalograms
are necessary to support and confirm the clinical
diagnosis.
 CONSTRUCTION BITE
50

The construction bite determines the degree of

activation built into the appliance, aiming to
reposition the mandible to improve jaw
relationship. The degree of activation should
stretch the muscles of mastication sufficiently
to provide a positive proprioceptive response.
At the same time, activation must be within the
physiologic range of activity of the muscles of
mastication and the ligamentous attachments
of the temporomandibular joint.
51

In CI II Div I malocclusion, a protrusive bite is

registered to reduce the overjet and distal occlusion
by 5 to 10mm on initial activation depending on the
freedom of movement in protrusive function.
52

Roccolideo observes that the position of

maximal protrusion is not a physiologic
position. The range of physiologic movement
of the mandible is no more than 70% of the
total protrusive path. Hence, the maximal
forward positioning of the mandible should
not exceed 70% of the total protrusive path of
the patient.
53

Forward positioning into a edge to edge

relationship is preferred for twin blocks as this
is a most easily reproducible position for the
patient. Generally horizontally growing young
patients have a maximal protrusive path of
about 13 mm and hence, up to 10mm of
forward positioning can be done for these
patients. If overjet is greater than 10mm,
initial activation of 7 -8mm is done followed
by reactivation later.
54

The amount of activation should not

significantly exceed the mandibular growth
potential, otherwise unfavourable
dentoalveolar compensation -protruding lower
incisors -might occur. Hence, young patients
who are horizontally growing can withstand a
single large activation. On the other hand,
stepwise activation with small increments are
preferred in adults or those who are vertically
growing (unfavourable growth pattern).
55

The vertical activation is determined by 2

factors. Firstly adequate vertical clearance
must be available between upper and lower
teeth to accommodate blocks of sufficient
thickness to activate the appliance.
Secondly, the vertical activation must open the
bite beyond the freeway space to ensure that
the patient cannot drop the mandible into rest
position and negate the proprioceptive
functional response to inclined planes.
56

Generally, vertical activation is done to achieve

2mm of interincisal clearance. This normally
leads to opening the bite beyond the free way
space and achieving 5-6mm opening in the
premolar region and about 2mm in the molar
region.
57

In CI II Div 2 malocclusion, edge to edge bite may be

sufficient to achieve 6mm of opening in premolar
region. While in anterior openbite, generally
incisal clearance of 4-5 mm is required.
 BITE REGISTRATION:
58

The centric position is checked and the desired

degree of activation decided. The patient is then
trained to bite in the desired position by giving him
a mirror.
For accurate control the Exactobite registration
device is recommended.
59

This gauge allows the clinician to choose variable

amounts of sagittal activation by selecting the
appropriate groove to engage the upper incisors
when the mandible closes into the incisal guidance
groove.
The wax is softened in a water bath and adapted. The
patient is instructed to bite into the desired
position. After the wax has hardened sufficiently, it
is removed and chilled.
60
61

The models with the bite are articulated and the twin
blocks constructed.
 PROGRESSIVE ACTIVATION:
62 This is indicated in the following conditions:
If overjet is greater than 10 mm, initial activation is 7-8 mm. The
second activation brings the incisors in edge to edge
relationship.
If full correction is not achieved by initial activation.
If the direction of growth is vertical, gradual advancement is
preferred to allow adequate time for compensatory
mandibular growth.
In adult patients in whom muscles and ligaments are less
responsive to a sudden, large displacement of the mandible.
In the treatment of TMJ dysfunction, activation should not be
beyond the level of tolerance of injured tissue.
 REACTIVATION
63

Reactivation of the twin block can be done as a

simple chair side procedure by the addition of cold
cure acrylic to extend the anterior incline of the
upper twin block mesially as the clinician inserts
the appliance to record a new protrusive bite before
the acrylic is fully set.
64

Thank You…!!!
65

GOOD MORNING
 STAGES OF TREATMENT
66

Twin block functional therapy is divided into 3

stages:
1. Active phase 6-9 Months
2. Support phase 3 -6 months
3. Retention. 9 months to reducing the
wear time gradually
Total time Average 18 months inclusive
of retention period
 Active Phase:
67

During the active phase, twin blocks are worn full time.
The objective is to correct to the arch relationship in
the sagittal, vertical and transverse dimensions.
Normally, overjet and overbite are corrected within 6
months and the lower molars erupt into occlusion in
9 months.
68

 The average wear time for twin blocks is 6 to

9 months though sagittal correction may be
obtained in 2 to 6 months. At the end of the
active phase, there should be a three point
contact in the incisor and molar region and
the sagittal relationship should be in a slightly
overcorrected position.
 Support Phase
69

The objective of the support phase is to retain the

corrected incisor relationship until the buccal
segment occlusion is fully established.
The lower twin block is left out at this stage and
posterior bite blocks are removed. The appliance of
choice is a steep anterior inclined plane borne on a
removable appliance.
70

The anterior inclined plane, without interfering with

occlusion, should engage the lower incisors and
canines which should occlude at the base point of
the upper incisors and canines.
For this purpose the inclined plane should have an
angulation of 70-80 degree to the occlusal plane
and should have a thickness of 6 to 8 mm.
71

If the molars have fully settled, an upper Hawley

type of retainer with clasps on molars can be
used to bear the inclined planes. If the molars
still requires some settling, the inclined plane
can be borne on a Begg type retainer. If fixed
appliance therapy is to be instituted after the
twin block stage, a simple "clip- over"
removable retainer or a fixed anterior bite
plane can be used.
72

Rick-A-Nator Appliance -This fixed orthodontic

appliance is the treatment of choice since it is fixed
and virtually guarantees patient cooperation and
treatment success. The Rick-A-Nator Appliance are
utilized to hold the mandible in a forward position
and also to help erupt the bicuspids to complete the
orthopedic correction of the overbite
73
 Retention
74

A normal period of retention follows treatment after

occlusion is fully established. The same appliance
used during the support phase is used, where in
appliance wear is gradually reduced to night time
wear.
Support phase and retainers are vital to ensure
stability of results achieved with twin blocks. For
stable changes, the total treatment time should not
be less than 15 to 18 months.
75

Support phase and retention are especially prolonged

if twin blocks have been used for correction in the
mixed dentition and final detailing of the occlusion
is to be done in the permanent dentition.
 CLINICAL MANAGEMENT
76

Class II Div. I with deep overbite.

Protrusive bite record is taken according to the
principles mentioned before and the appliance
fabricated. The upper bite block is trimmed occluso
-distally to allow the lower molar to erupt and
reduce the deep bite with increase in lower facial
height.
77
78

The occlusion is cleared over the lower molars progressively

at each visit by I to 2 mm only to facilitate eruption. This
prevents the tongue from protruding between the teeth and
interfering with eruption. The inclined plane must be
maintained intact during trimming to preserve the active
mechanisms for functional correction.

At the end of the active phase, incisors and molars are in

correct occlusion and deep bite corrected. However the
presence of bite blocks leads to openbite in the premolar
region. The lower block is then trimmed slightly to allow
the premolars to erupt with the appliance.
 Management in mixed dentition
79

Though the standard design can be used, retention is

generally limited by deciduous teeth that are
unfavorably shaped.

So C clasps may be used on deciduous molars. Retention

can be enhanced by bonding composite on tooth
surfaces to create undercuts. Alternatively C clasps
may be bonded directly to the teeth for 7 to 10 days.
The clasps may then be freed .and the edges of the
composite that remains attached to the teeth rounded
off to improve retention.
80
 After treatment in the mixed dentition, a final
81 detailing of the occlusion with fixed
appliances is generally required in the
permanent dentition. So, there is generally a
prolonged phase of support and retention. A
night time functional appliance like
Occlusoguide, resembling a positioner can be
used to overcome the diminished occlusal
support that is normally present during the
transition to permanent dentition.
 Combination therapy -permanent
82
dentition
An initial phase of functional correction by twin
blocks is generally followed by final detailing of
occlusion with fixed appliances.
This combination of orthopedic and orthodontic
therapy generally leads to optimum treatment
results. The versatility of design of twin blocks
allows it to be easily integrated with fixed
appliances.
83

Several approaches are possible. First, a preliminary

stage of treatment with fixed appliances may be
indicated before fitting twin blocks if upper and
lower arch form does not match, crowding is
moderate or severe and alignment and leveling is
needed before functional correction.
Depending on the severity of the problem lingual
appliances may be fitted for arch development and
interceptive Treatment or a fully bonded appliance
may be used.
84

In cases with vertical growth pattern (high mandibular

angle) with deep bite, VTO does not improve as
functional protrusion further increases facial height.
In these cases anterior intrusion is done initially with
fixed appliance to reduce the overbite and then twin
blocks are used to advance the mandible.

Secondly, as no anterior wires are used in twin blocks,

brackets may be fitted in the anterior segment and
the anteriors aligned with a sectional wire during
twin block stage of treatment.
85

Finally, twin blocks may be combined with

fully bonded fixed appliances by 2
approaches. Simple removable twin
blocks may be designed to fit over the
fixed appliance, using ball end
interdental clasps for retention. Another
option is to design fixed twin blocks for
full time wear.
 Twin blocks with extra oral traction.
86

In most cases, full functional correction can be

achieved with twin blocks without extra-oral
forces. However, extra-oral force with twin
blocks can be indicated in the following
conditions..
In the treatment of severe maxillary protrusion,
high pull, cervical pull or combination pull
headgear may be combined with twin blocks to
restrain maxillary growth and cause maxillary
retraction. The choice of headgear depends on
the individual case.
87

To control a vertical growth pattern. High pull

headgear may be used. This restrains vertical
maxillary growth and applies intrusive force
on upper posteriors.
In adult treatment where mandibular growth
cannot assist the correction of severe
malocclusion.
88
89

The Concorde face bow was designed for combined

extraoral and intermaxillary traction. This was made
by soldering a labial hook to the conventional face
bow. While restrictive or intrusive influence is
applied to the maxilla, elastics can be given from the
labial hook to the ball shaped interdental clasps or
hooks on the anterior part of lower appliance. This
applies a orthopedic traction on the mandible in
addition to the functional protrusion achieved by
twin blocks.
90
91

The advantage is that if the patient tends to

posture out of the appliance at night, the
intermaxillary traction force would increase
and ensure 24 hours effectiveness of the
appliance. Moreover, compared to CI. II
elastics, a more horizontal intermaxillary
force is exerted and extrusive mechanics is
avoided.
92

However, twin blocks combined with extraoral force

are very powerful mechanics to retract the maxilla
and should be used in extremely selected cases. The
headgear effect tends to tip the occlusal and palatal
plane down anteriorly and retrocline the upper
anteriors which may lead to unfavourable rotation
of the mandible. Most patients can be treated
effectively without extraoral traction, with twin
blocks alone.
93

The attachment of face bow can be done on tubes

soldered to clasps on upper posteriors or using
modified arrow head clasps with tubes. If fixed
appliances are in place with twin blocks, face bow
may be inserted into the headgear buccal tubes
welded on upper molar bands.
 Treatment of reduced overbite and
94
anterior open bite.
Patients with dolichofacial growth patterns show a
vertical tendency of growth with increased lower
facial height associated with reduced overbite and
anterior open bite. In these patient's careful
management is needed to prevent posterior
eruption and try to achieve intrusion of posterior
teeth:
95

a. All posterior teeth must be in contact with

opposing bite blocks to prevent eruption. No grinding
of posterior bite blocks should be done during
treatment.
b. If second molars erupt distal to the appliance"
eruption should be controlled by placing occlusal rests
or extending upper twin block distally over the upper
second molars to contact the lower second molars.
c. Intrusive orthopedic forces can be applied to upper
posterior teeth with extra oral force as described earlier.
96
97

d. MiIls introduced an extremely effective modification to intrude

posterior teeth by using vertical elastics (Intra oral traction).
These elastics are applied bilateraIly and pass from upper to
lower arch in the premolar region.
They are attached to the twin block appliance or brackets on
opposing teeth. They force the patient to bite consistently into
the appliance and hence apply intrusive forces to the molars
(especiaIly upper molars)" thus reducing anterior open bite.
This method has proven to be extremely effective and is now
being preferred over extra oral force in a majority of cases.
98
99

e. Magnetic twin blocks are also being used

in anterior openbite problems" as wiIl be
discussed later.
100

f. Greater interincisal opening (4-5mm) is

required to make it difficult for patient to
disengage from the blocks in openbite cases.
g. A tongue guard or palatal spinner (lead) may
be added to train the tongue in case of tongue
thrusting habit. Also" a labial bow may be
used to retract extremely proclined incisors
and reduce the anterior openbite.
 Management of CII Div. 2
101
Malocclusion
In severe cases" a preliminary phase of fixed
appliances therapy may be needed to align the
arches before functional therapy.
However" arch development can be done
simultaneously with functional correction
using the sagittal twin block appliance. 2
screws are put in the palate for arch
development in antero posterior direction.
102

They act by 75-80% advancement of anteriors and

20-25% distalization of posteriors.
In cases where transverse expansion is required a
third screw may be put transversely in the midline
or alternatively a 3D expansion screw may be used
(central sagittal twin block).
103
 Management of Cl III malocclusion.
104

Functional correction of CI.III malocclusion is achieved in twin

block technique by reversing the angulation of the inclined

planes and harnessing occlusal forces as the functional

mechanism to correct arch relationship by maxillary

advancement while using the lower arch as anchorage. The

position of the bite blocks is reversed compared to twin blocks

for class II treatment.

105
106

The occlusal blocks are placed over upper

deciduous molars and lower first molars. The
reverse inclined planes are angled at 70
degrees and drive the upper teeth forward by
the forces of occlusion and at the same time,
restrict forward mandibular development.
107

Bite registration is done with 2 mm interincisal clearance

and mandible in fully retruded position.

Reverse twin blocks can be modified by incorporating

two way or three way screws in the upper plate for
sagittal and transverse development. The opening of
the screws has the reciprocal effects of driving the
molars distally and advancing the anteriors. Distal
movement of upper molars is restricted by occlusion of
the lower bite block on the reverse inclined planes
108

Night wear of reverse pull face mask may be used for

4-6 months to apply orthopedic traction on upper
block and enhance CI. III correction.
 Extraction / Non -Extraction therapy
109

The treatment of patients presenting a combination of

crowding, dental irregularity and skeletal discrepancy
acquires more time compared to the treatment of
uncrowded cases with good arch form.

The Ritcher scale for crowding is as follows:

Mild crowding 1-3mm
Moderate Crowding 4-5mm
Severe crowding 6mm or more.
The more the crowding, the more difficult it is to treat the case
non extraction.
110

Two factors improve the prognosis for a non-

extraction approach in moderate to severe
crowding cases.
If premolars and permanent canines have not
erupted, arch width can be increased and space
gained by arch development due to early
intervention.
If the lower dentition is lingually positioned
relative to the skeletal base, space can be gained by
proclining the lower incisors.
111

Non-extraction treatment of irregular dentition is

done in 2 phases depending on the age of the
patient at the start of treatment and the degree of
severity of the skeletal and dental problems.
 Magnetic twin blocks
112
The role of magnets in twin block therapy is specifically to
accelerate correction of arch relationships. Two types of rare
earth magnets are used - samarium cobalt and neodymium
boron with the latter delivering greater force from a smaller
magnet. Two types of magnetic forces have been proposed.

(a) Attracting magnets:

This helps in pulling the appliance together and encourages the
patient to occlude actively and consistently in a forward
position. This allows greater activation to be built into the
initial construction bite, with the patient being encouraged to
bite in the new position. This increases occlusal contact in
both working and sleeping hours, thus increasing functional
stimulus to growth.
113
 They can be used in the following
114
situations:
1. Rapid correction of CI. II Div I malocclusion with a large
overjet.
2. Resolve mild residual CI. II molar relationship, especially if it
is
unilateral.
3.Patients with weak musculature who fail to engage the
appliance consistently.
4. Adult patients with TMJ pain with severe CI II Div II
malocclusion or unilateral CI. II malocclusion.
5. Severe class III malocclusion.
6. Facial Asymmetry -magnets may be added on inclined planes
on the affected side to increase unilateral contact.
 Repelling magnets
115

These may be used when less activation is built into

twin blocks. The repelling magnetic force applies
additional stimulus to forward posturing as the
patient closes into occlusion. They induce
additional forward mandibular posturing without
reactivation; however, the degree of activation
induced by magnetic forces is not ascertained. .
116

Moss and Shaw (1990) reported that there is a 100%

increase in rate of overjet correction when
repelling magnets are used. However,
improvements in growth response could not be
established and significant changes were produced
in incision angulations
117

However, magnetic twin blocks cannot be reactivated

by addition of acrylic to the inclined planes as this
deactivates the magnets. Screws may be needed on
the bite blocks for progressive activation of
magnetic twin blocks.
 Adult Treatment
118

Twin blocks can be used in treatment of adults if

the skeletal discrepancy is not severe. There is
generally a dentoalveolar response with
limited skeletal adaptation. However,
significant facial changes can be produced in
mild to moderate discrepancy cases by
dentoalveolar compensation. However, in
severe skeletal discrepancies, twin blocks are
contraindicated and orthognathic surgery is
the treatment of choice in adult patients.
 Fixed twin blocks
119

To increase patient compliance, twin blocks may be

temporarily or permanently fixed to the teeth.
Temporary fixation of removable blocks is done by
either of the following 2 methods.

a. The clasps can be bonded to the teeth using composite

resin.
b. The twin blocks can be cemented on to the occlusal
surface of the teeth.

This is generally done in the initial stages of twin block

therapy for 7 to 10 days to gain patient compliance.
120

Clark has designed fixed twin blocks with the help of

Wilson 3D modular attachments to be used as fixed
attachments, removable only by the operator.

Wilson's 3D lingual tube is used as a retentive

component on molar bands and provides a mode of
attachment for occlusal twin block elements, which,
in turn, may be fixed or fixed removable under the
direct control of the operator. A TPA or lingual arch
can be added
121
122

Though fixed twin blocks ensure patient compliance, their

management is more difficult than removable twin blocks.
Their disadvantages are:

1. They can be detached from the teeth, requiring immediate

repair.
2. If lower molars are used for fixations, they cannot be
erupted to correct deepbite.
3. After fitting, adjustment for control of the vertical
dimension is limited.
Hence removable twin blocks are preferred for compliant
patients.
123

OTHER MODIFICATIONS
Twin Block with a Spinner to control tongue thrust.
124

Fixed Twin Block: - is essentially used in cases where

patient is not motivated enough to wear the twin
block twenty four hours.
 RESPONSE TO TWIN BLOCK
125
TREATMENT
A series of growth studies have been done on
monkeys and rodents to study the effect of fixed
inclined planes. The results of these studies indicate
that functional mandibular protrusion with fixed
inclined planes has a profound effect on the whole
of the dental arch, the condylar head, glenoid fossa
and muscle attachments. Even in the adult animals,
the whole stomatognathic system, including the soft
tissues, adapt to establish an efficient masticatory
system.
126

These tissue changes are reflected in the clinical

signs after fitting twin blocks. The patient
experiences adaptation of muscle function in
response to altered occlusal contacts within a few
days. He/she experiences pain behind the condyle
when the appliance is removed and the mandible
retracted.
127

From animal studies, it may be reduced that retraction of

the condyle results in compression of connective tissue
and blood vessels and the resulting ischaemia is the
principal cause of pain. Hence, a new pattern of
muscle behavior is quickly established whereby the
patient finds it difficult and later impossible to retract
the mandible into its former retruded position. This
change in muscle activity is described by McNamara
as the "pterygoid response" due to altered activity of
the medial head of lateral pterygoid. This response is
extremely rare with appliances not worn full time.
128

Clark investigated the changes in CI. II Div. I

malocclusion with twin block traction technique in
43 girls and 31 boys aged from 9 years 6 months to
14 years. He compared it with Michigan growth
studies and Neijmagen growth studies as controls
and found the following changes due to twin block
treatment.
 Michigan growth control (Riolo et
129
a11979)
(i) Maxillary protrusion reduction by retraction of A point.
(ii) Correction of antero posterior skeletal discrepancy by a combination of
maxillary retraction and to a lesser extent, mandibular advancement.
(iii) Retraction of upper incisors.
(iv) Increase in interincisal angle
(v) Reduction of convexity by retraction of A point relative to facial plane.
(vi) Advancement of lower incisor tip relative to A- pogonion.
(vii) Retraction of upper molars relative to pterygoid vertical.
(viii) Increase in mandibular length, except in age group above 13 yrs.
(ix) Increase in ramus height.
(x) Increase in facial height N-Me
 Neijmagen series control (Prahl
130
Andersen et aI, 1979)
i) Reduction of maxillary protrusion by retraction of A
point.
ii) Reduction of anteroposterior skeletal discrepancy by a
combination of maxillary retraction and to a lesser
degree, mandibular advancement.
iii) Retraction of upper incisors and reduction of the
overjet.
iv) Increase in mandibular length (Ar-Gn) in the age
group 10-12.5 years.
v) Increase in facial height (N-Me)
vi) Increase in gonial angle but not throughout the age
range.
 OTHER RELEVANT STUDIES
131
REGARDING TWIN BLOCKS
Mills and Mcculloch (Ajodo, 1998 July) used a
modified twin block with an acrylic labial bow on
lower incisors on 28 CI. II patients and compared
the results with age and sex matched untreated
class II controls. Results indicated that mandibular
growth in the treatment group was on the average
4. 2mm greater than the control group over the 14
month treatment period. Some dento alveolar
effects in both arches contributed to the overjet
reduction. No significant increases in SN-
mandibular plane angle occurred during treatment.
132

Lund and Sandler (AJODO 1998 Jan) treated 36 CI II

subjects, mean age 12.4 yeas with twin blocks and
compared the changes to an appropriate control group.
The data was annualized. In the treatment group, there
was a reduction in ANB by 2 degrees largely due to 1.9
degrees increase in SNB. No statistically significant
restraint of maxillary growth was observed.
Treatment resulted in net increase in Ar-Pog by 5.1mm
compared with control group increase of 2. 7mm
leading to a net gain in mandibular length by 2.4mm.
133

The overjet was reduced by combination of net

maxillary incisor retroclination of 10.8 degree, net
mandibular incisor proclination of 7.9 degrees, and
forward movement of the mandible.
Buccal segment relationships were corrected by
means of lower molar eruption, restraint in the
eruption of upper molars and forward growth or
repositioning of the mandible. Any possible fossa
adaptation was not assessed.
 ADVANTAGES OF TWIN BLOCKS
134

Twin blocks have a number of advantages over other

functional appliances belonging to the monobloc
series. As the upper and lower components are
separated, there is freedom of jaw movements in
anterior and lateral excursion. This also allows the
operator independent control of the upper and
lower arches. Speech is minimally affected as there
is no restriction to movements of the tongue, lip or
mandible.
 CONCLUSIONS
135

In the pursuit of ideals in Orthodontics, facial balance

and harmony are of equal importance to ideal and
occlusal perfection. The role of functional jaw
orthopedic techniques is widely acknowledge in
achieving these goals by growth guidance during the
formative years of facial and dental development.
Twin blocks are extremely patient and operator friendly
functional appliances. They have the gift of versatility
of design, which allows their use in a variety of clinical
situations to effectively correct different types of
malocclusions.
136

1. Twin Block Functional Therapy,

by William J Clark.
2. Orthodontics & Dentofacial Orthopedics
by McNamara & Brudon.
3. Dentofacial Orthopedics with Functional Appliances
by Graber , Rakosi & Petrovic.
4. Orthodontics Current Principles & Techniques
by Graber , Vanarsdall.
5. Removable Orthodontic Appliances
by Graber & Neumann.
6.Mills et al.Post treatment changes after successful correction of class
II malocclusion with Twin block appliance. AJODO2000;118:24-33