ORIGINAL ARTICLE

Prospective clinical trial comparing the effects

of conventional Twin-block and mini-block
appliances: Part 1. Hard tissue changes
Daljit S. Gilla and Robert T. Leeb
London, United Kingdom

Purpose: The aim of this prospective clinical trial was to compare the dentoskeletal effects of a conventional
and a modified Twin-block (TB) appliance. The conventional TB appliance was constructed with a large,
single-step advancement. The modified appliance, termed the mini-block (MB), was incrementally advanced,
incorporated a maxillary incisor torquing spring, and had a reduced bite-block height. Material: Seventy
patients were placed into age- and sex-matched pairs. Patients in each pair were allocated to opposing
appliance groups. Active treatment lasted 9 months, irrespective of the final overjet attained, and final
cephalometric records were taken at 12 months (⫾1 month). Both groups showed pretreatment equivalence
for age, sex, overjet, and cephalometric variables. Results: The TB group experienced a significantly greater
reduction in overjet (median, ⫺8 mm; P ⫽ .02) compared with the MB group (median, ⫺4 mm). This improved
overjet reduction was associated with significantly greater forward movement of pogonion (median change,
TB: 3.3 mm; MB: 2.1 mm; P ⫽ .02) and greater retroclination of the maxillary incisors (median change, TB:
⫺5°; MB: ⫺1.9°; P ⫽ .04). No significant intergroup difference was found for changes in total anterior facial
height (median change, TB: 4.4 mm; MB: 4.3 mm) and mandibular incisor proclination (median change, TB:
1.3°; MB, 2.4°). Conclusions: Progressive mandibular advancement was not associated with greater
mandibular growth compared with single-step advancement. The maxillary incisor torquing spring seems to
be effective at reducing maxillary incisor retroclination. Reduced bite activation in the MB group did not result
in less mandibular incisor proclination. There was considerable individual variation in appliance effects within
both groups. (Am J Orthod Dentofacial Orthop 2005;127:465-72)

T
he Twin-block (TB) appliance, originally devel-
oped by Clarke,1 is a widely used functional
appliance for the management of Class II mal-
occlusion. Its popularity is attributable to its high
patient acceptability and its ability to produce rapid
treatment changes. However, it can produce undesir-
able treatment effects, such as mandibular incisor
proclination,2,3 an increase in the vertical facial dimen-
sion, which is detrimental in high-angle patients,2-4
clockwise rotation of the maxillary plane,4 and a
limited increase in mandibular growth, which might not
be sustained in the long term.5
A modified version of the TB appliance, termed the
mini-block (MB) appliance, has been developed in an
attempt to overcome some of these limitations. Modi-
fications incorporated into this appliance include a
a downward and backward rotation of the mandible. A
Acting consultant orthodontist, The Royal London Hospital.
b
Consultant and head of department, The Royal London Hospital.
Reprint requests to: Dr Daljit Gill, The Eastman Dental Hospital, Orthodontic
Department, 256 Grays Inn Rd, London WC1X 8LD, United Kingdom; e-mail,
daljit_s_gill@yahoo.co.uk.
Submitted, October 2003; revised and accepted, March 2004.
0889-5406/$30.00
Copyright © 2005 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.11.012
facility to incrementally advance the mandible, the use
of bite-blocks of reduced vertical dimension, and the
incorporation of a maxillary incisor torquing spring.
The potential benefits of progressive mandibular ad-
vancement include gradual training of the protractor
muscles of the mandible, enhanced mandibular growth
due to repeated stimulation of the lateral pterygoid
muscle, and reduced tooth movement due to the gen-
eration of reduced viscoelastic forces compared with
large, single-step advancement.6 Teucher7 described
how reducing the vertical dimension of the bite-blocks
produces a more favorable reactive force vector, which
passes closer to the center of maxillary resistance. Such
a force vector is less likely to produce significant
rotation of the maxillary plane; this can result in an
increase in the vertical dimension secondary to a
maxillary incisor torquing spring is incorporated to
reduce retroclination of the maxillary incisors caused
by Class II traction forces.8,9
The aim of this prospective clinical trial was to
compare the dentoskeletal effects of the TB and MB
appliances.

465
466 Gill and Lee American Journal of Orthodontics and Dentofacial Orthopedics
April 2005

MATERIAL AND METHODS

Ethics committee approval was granted before this
study began. A total of 70 patients meeting specific
inclusion criteria were enrolled into this trial. Briefly,
the patients had to have a Class II Division 1 incisal
relationship associated with mandibular retrognathia
and a minimum overjet of 7 mm. They were all white;
the boys were aged 12 to 14 years, and the girls were
aged 10 to 13 years. Fig 1. MB appliance, showing maxillary incisor torquing
All patients were placed into age- (⫾6 months) and spur with incisor capping.
sex-matched pairs. A patient from each pair was ran-
domly selected and allocated to the TB appliance
group. The other patient of each pair was automatically
allocated to the MB appliance group.
For the MB, all appliances were constructed by a
senior dental technician at The Royal London Hospital.
An occlusal record was taken with a wax wafer, in the
intercuspal position, and the working models were
articulated on a plasterless, hinge-type articulator. The
bite-blocks, meeting at a 90° interface angle, were then
activated both sagittally and vertically by 3 mm in the
laboratory. In this way, the block activation was stan- Fig 2. MB appliance. Progressive mandibular advance-
dardized for all patients. The maxillary central incisors ment achieved by addition of 2-mm Perspex spacers to
were capped with acrylic, and an incisor torquing front of maxillary blocks.
spring, as described by Bass,8,9 was incorporated (Fig
1). Clinically, progressive mandibular advancement
was achieved by the addition of 2-mm-thick Perspex
spacers (Acorn Polymers, Bolton, United Kingdom) to
the front of the maxillary blocks (Fig 2).
For the TB, all appliances were constructed in 1
commercial laboratory (Monarch, London, United
Kingdom). To standardize the appliance activation
vertically, the construction bite was taken with an
Exactobite stick (Forestadent, Milton Keynes, United
Kingdom), with the incisors in an edge-to-edge position Fig 3. Construction bite registration for TB appliance
and separated by 4 mm (Fig 3). No labial bow was taken in edge-to-edge position with Exactobite stick.
incorporated into the appliance.
Table I outlines the treatment and records protocol. Figure 4 illustrates the main linear and angular cepha-
Height measurements were recorded with a Harpenden lometric measurements. The tracings were completed
stadiometer and the stretched technique. Clinical over- in a blind manner, with the facial profile orientated to
jet measurements were taken from the midpoint of the the right and with the horizontal plane at 7° to the
maxillary incisal edges to the labial surface of the sella-nasion (S-N) plane. The cephalometric points
mandibular incisors, with the Frankfort plane orientated were then digitized and duplicate recordings made for
horizontally, by using a digital caliper gauge. each point to obtain a mean value. Any replicate point
A lateral cephalogram was taken with the same that did not lie within 0.2 mm of the original value was
cephalostat, within 1 month before appliance placement rejected and redigitized. All linear measurements were
and at the 12-month (⫾1 month) review appointment. reduced to life size.
A 3-month period was left between appliance removal Twenty radiographs were selected randomly, re-
and the final cephalometric record, to minimize man- traced, and redigitized to determine the cephalometric
dibular posturing for the final record. The pretreatment error. Random and systematic error was calculated with
and posttreatment cephalograms were traced on good- Dahlberg’s estimation,10 Houston’s coefficient of reli-
quality acetate paper under optimal lighting conditions. ability, and the paired t test.11
American Journal of Orthodontics and Dentofacial Orthopedics Gill and Lee 467
Volume 127, Number 4

Table I. Treatment and records protocol

0 mo 3 and 6 mo (⫾1 mo) 9 mo (⫾1 mo) 12 mo (⫾1 mo)

Treatment Appliance inserted MB advanced by 2 mm Appliance withdrawn Review

Records Lateral cephalogram, Height and overjet Height and overjet Lateral cephalogram,
height, and overjet height, and overjet

Fig 4. Linear (left) and angular (right) cephalometric measurements. S, sella; N, nasion; TAFH, total
anterior face height; A, A-point; Pog, pogonion; Me, menton; U1-Max. Pl., maxillary incisor
inclination relative to maxillary plane; L1-Mand. Pl., mandibular incisor inclination relative to
mandibular plane.

Because both groups were age- and sex-matched,
the data for both sexes were pooled. Pretreatment
equivalence and treatment changes were tested for
significance with the Wilcoxon matched-pairs signed
rank test. P values of less than .05 were considered
statistically significant.
RESULTS
The Dahlberg value for all measurements was less
than 1. The only significant systematic error, as shown
by the t test, was associated with determination of the
maxillary and mandibular incisor inclination (Table II).
This is most likely associated with the error in deter-
mination of the maxillary and mandibular incisor apical
positions.
A total of 60 (85.7%) of the original 70 patients
completed this trial. Five patients dropped out from
each treatment group. The reasons for these dropouts
include failure to return midtreatment (n ⫽ 6), refusal
to wear appliances from the outset (n ⫽ 2), loss of a
permanent tooth (n ⫽ 1), and moving to a different
geographic area during treatment (n ⫽ 1).
Both treatment groups showed pretreatment equiv-
alence for starting age, height, overjet, and all cepha-
lometric variables (Table III).
Table IV summarizes the treatment changes in both
groups. There was no significant difference between
groups in increase of standing height or the distance
S-N during treatment. This suggests that the general
growth rate between the treatment groups was matched.
Therefore, it was assumed that any differences in facial
growth could be attributed to appliance effects.
There was a significantly greater reduction in over-
jet in the TB group (median change, ⫺8 mm; P ⫽ .02)
compared with the MB group (median change, ⫺4 mm)
during treatment. Between appliance removal and re-
cording of the final cephalometric measurements (ie,
between 9 and 12 months), there was a similar relapse
in overjet in both groups (median, TB: ⫹2 mm; MB:
⫹1 mm) (Table V).
The significantly greater reduction in overjet in the
TB group was associated with significantly greater
forward movement of pogonion relative to the S-
vertical. When the results of both groups were com-
bined, there was a significant correlation (P ⫽ .015; r ⫽
0.31) between the increase in standing height and
forward movement of pogonion (Fig 5). There was no
significant difference between appliances in effects on
the maxilla and changes in total anterior facial height.
There was no correlation between start maxillary-
468 Gill and Lee American Journal of Orthodontics and Dentofacial Orthopedics
April 2005

Table II. Cephalometric error study

Houston’s coefficient
Dahlberg value of Reliability (%) t test

S-N (mm) 0.253 99.6 1.14

A to S-vertical (mm) 0.358 99.5 0.98
SN-Max. Pl. (°) 0.349 99 0.38
Pog to S-vertical (mm) 0.481 99.7 1.17
TAFH (mm) 0.34 99.6 0.55
U1-Max. Pl. (°) 0.766 98.5 2.14*
L1-Mand. Pl. (°) 0.939 98.3 2.19*

*Significance at 10% level.

Table III. Median age, height, overjet, and cephalometric values at start
TB MB

Start Minimum Maximum Start Minimum Maximum

Age (y) 12.1 10.7 13.9 12.2 10.3 13.8

Height (mm) 1492 1330 1711 1521 1359 1725
Overjet (mm) 10.5 7 16 10 7 15
S-N (mm) 65.1 58.5 71.8 63.6 58.2 72.5
A to S-vertical (mm) 60.9 56.6 71.8 61.1 56.3 71.5
SN-Max. Pl. (°) 9.3 4.8 14 7.6 0.1 16.5
Pog to S-vertical (mm) 51.4 37.4 66.4 50.2 39 64.8
TAFH (mm) 102 86.8 115.2 102.3 90.1 116.5
U1-Max. Pl. (°) 115.8 100.9 140.6 114.7 103.4 128
L1-Mand. Pl. (°) 94.1 78.6 109.6 95.6 79.1 105.6

mandibular plane angle and increase in lower face
height in both treatment groups.
There was significantly more retroclination of the
maxillary incisors in the TB group (median, ⫺5°; P ⫽
.04) compared with the MB group (median, ⫺1.9°).
There was no significant difference between the 2
groups in mandibular incisor proclination. There was a
large individual variation in mandibular incisor procli-
nation in both treatment groups. Only in the TB group
was a significant reverse correlation found between
increase in mandibular incisor proclination and the start
mandibular incisor position (Fig 6). There was a ten-
dency for the mandibular incisors to procline less in
patients in whom they were proclined from the start of
treatment.
Figure 7 illustrates the variability in treatment
response within and between both groups. Most pa-
tients in the TB group showed a highly favorable or a
favorable change in the ANB angle during treatment.
However, in the MB group, more than 40% showed no
response or an unfavorable change in the ANB angle.
DISCUSSION
The weaknesses of previous studies used to evalu-
ate growth modification techniques were reviewed.12 A
prospective design was used in this study, so that the
treatment protocol could be standardized between all
patients and so that all patients, including those unsuc-
cessfully treated, would be considered in the final
analysis.
In this study, the patients were placed into age- and
sex-matched pairs rather than being randomly allocated
to the treatment groups. Previous studies that randomly
allocated relatively small samples of patients have
resulted in treatment groups that did not necessarily
show pretreatment equivalence for variables such as
age and sex.13,14 Because the groups in this study did
show pretreatment equivalence for age and sex, data for
the male and female patients were pooled and not
analyzed independently. Nonparametric analysis was
used because the data were not normally distributed.
This is most likely because of the relatively large
individual variation in each group.
The treatment effects of the TB appliance have been
relatively well established.2-4,15,16 Because of this, and
because the primary aim of this study was to compare
the effects of a modification of the TB with the
conventional appliance, a control group receiving no
treatment was not enrolled. The conventional TB ap-
pliance group effectively acted as a positive control
American Journal of Orthodontics and Dentofacial Orthopedics Gill and Lee 469
Volume 127, Number 4

Table IV. Median treatment changes compared between groups

Median change
during treatment Maximum Minimum
TB vs MB
TB MB TB MB TB MB (Wilcoxon test)

Height (mm) 43 43 93 97 13 11 n.s

S-N (mm) 1.2 0.9 1.8 3.2 ⫺0.4 ⫺0.1 n.s
Overjet (mm) ⫺8* ⫺4* 14 9.5 3 0 P ⫽ .02
Pog to S-vertical (mm) 3.3* 2.1* 8.8 8.7 0.9 2.4 P ⫽ .02
A to S-vertical (mm) 0.6 0.8 2.8 3.7 ⫺1.1 ⫺2.1 n.s
SN-Max. Pl. (°) ⫺0.2 ⫺0.1 2.8 1.7 ⫺3 ⫺2.2 n.s
TAFH (mm) 4.4 4.3 8.5 6.5 3.3 0.4 n.s
U1-Max. Pl. (°) ⫺5* ⫺1.9* 5.4 9.1 ⫺13 11.9 P ⫽ .04
L1-Mand Pl. (°) 1.3 2.4 17.8 7.5 ⫺7.6 ⫺4.7 n.s

n.s., not significant.

*P ⬍ .05.

Table V.Median overjet changes (in millimeters) 0 –9 months and 9 –12 months and significance
of changes between groups
TB MB TB vs MB (Wilcoxon test)

0–9 mo 9–12 mo 0–9 mo 9–12 mo 0–9 mo 9–12 mo

Overjet change 8 2 4 1
Minimum 3 0 0 0 P ⫽ .02 n.s.
Maximum 14 4 9.5 3

group. Previous studies have not necessarily ensured
that untreated control groups were matched to the
treatment groups for age, sex, and other measure-
ments.2-4,15,16 Therefore, changes in facial dimension
might be due to differences in normal growth as well as
to appliance effects.
The discontinuation rate in this study was 14.3%. A
similar number of patients dropped out from each
appliance group. Bias might be introduced when pa-
tients discontinue during the study period. Patients who
are not achieving rapid treatment changes might be
more likely not to return for follow-up appointments.
Problems of compliance with functional appliances
have previously been recognized.17
Previous studies have reported discontinuation rates
of 21%,18 14%,19 and 10.7%15 for the TB appliance.
These figures compare favorably with discontinuation
rates reported for other appliances, such as the Bass
(28%),19 Bionator (25%),20 and the functional regulator
appliance (42% boys and 24% girls).21 This supports
the viewpoint that the TB is generally well tolerated.
It was considered that progressive mandibular ad-
vancement might result in greater mandibular growth in
the MB appliance group. One possible explanation
for the less-favorable mandibular growth response
achieved could be that some patients failed to posture
their mandibles forward because of the reduced vertical
dimension of the appliance bite-blocks. This might
explain why a number of patients in this group showed
no change or a negative change in ANB angle (Fig 5).
Another reason for the less-favorable response in the
MB group could be that these patients were not as
compliant as those wearing the TB appliance. Patients
in the MB group might not have liked the appearance of
their appliances because of the labial incisal coverage
produced by the torquing spring. Ideally, microelec-
tronic monitoring should have been used to assess
compliance in both treatment groups.
It has been proposed that progressive mandibular
advancement might result in repeated stimulation of the
lateral pterygoid muscle, which might be important for
the stimulation of condylar growth. Evidence has ac-
cumulated both for6,22,23 and against24-26 the impor-
tance of the lateral pterygoid muscle during functional
appliance therapy. Voudouris and Kuftinec26 believe
that the tensile forces generated in the retrodiscal
tissues during mandibular protrusion are most impor-
tant for condylar growth modification. This would
predict that larger mandibular advancements during
treatment might result in greater mandibular growth, as
found in the present study.
The results of this study showed no significant
difference in total face height change between the
treatment groups. The median changes in face height
470 Gill and Lee
Fig 5. Correlation between change in statural height
and forward movement of pogonion in both treatment
groups combined.
Fig 6. Correlation between change in mandibular inci-
sor proclination and initial mandibular incisor proclina-
tion in TB group.
found in this study are similar to the mean changes
reported by others.2-4 It was hoped that reducing the
vertical dimension of the TB appliance bite-blocks
would result in a smaller increase in facial height due to
reduced rotation of the maxillary plane. However,
minimal rotation of the maxillary plane was noted in
this study. This might be because all patients were not
necessarily treated to completion or because the
3-month interval between appliance removal and the
final cephalometric measurements allowed some time
for relapse of the orientation of the maxillary plane.
This study showed the maxillary incisor torquing
spring to be effective at reducing retroclination of the
maxillary incisors. These results are in accordance with
those of Harradine and Gale,27 who found torquing
spurs to also be effective during TB appliance therapy.
They found a mean retroclination of 6.9° in the pres-
ence of torquing spurs, whereas in the present study the
median retroclination was 1.9°. This would suggest that
torquing springs are more effective than spurs at
reducing incisor retroclination. One possible explana-
tion for the greater effectiveness of the torquing spring
American Journal of Orthodontics and Dentofacial Orthopedics
April 2005
could be that it has a greater area of contact with the
gingival portion of the maxillary incisor crown or that
the bite blocks had a smaller dimension and therefore
generated smaller Class II forces in the MB appliance
group.
This study found no significant difference in man-
dibular incisor proclination between the TB and MB
groups. It was considered that reducing the bite activa-
tion of the TB appliance might result in less dental
movement due to reduced Class II traction forces. The
results of this study would be in accordance with those
of DeVincenzo and Winn,28 who studied the effects of
a TB-type appliance with different amounts of protru-
sive activation. They found no significant difference in
mandibular incisor proclination between a group
treated with 3 mm of continuous protrusion and one
treated with an average of 5 to 6 mm of continuous
protrusion.
The degree of mandibular incisor proclination
found in this study seems to be smaller than the amount
typically reported by others during treatment with the
TB appliance. For example, Lund and Sandler2 re-
ported a mean mandibular incisor proclination of 8°
during TB treatment. Possible explanations for smaller
median changes found in our study could be that
patients were not necessarily treated to completion, and
the 3-month delay between appliance removal and the
final cephalometric measurements might have allowed
the mandibular incisors to relapse.
An interesting observation noted in both treatment
groups was that in some patients the mandibular inci-
sors seemed to have uprighted between the start of
treatment and the observations 1 year later. A possible
explanation for this response could be that these pa-
tients shed deciduous molars during treatment. Because
mandibular arch length was effectively maintained
during treatment with appliance wear, the additional
leeway space allowed the mandibular incisors to up-
right between appliance removal and the final cephalo-
metric measurements.
There was also a significant reverse correlation
between the start mandibular incisor inclination and
treatment-induced incisor proclination. The mandibular
incisors might be expected to procline more in patients
who start with retroclined mandibular incisors because
treatment might abolish unfavorable lip activity that
maintains the pretreatment incisor position. It can also
be concluded that mandibular incisor proclination
might not be a contraindication to functional appliance
treatment because these patients might experience less
unfavorable change during treatment.
The patients treated with a TB appliance achieved a
significantly greater reduction in overjet during active
American Journal of Orthodontics and Dentofacial Orthopedics Gill and Lee 471
Volume 127, Number 4

Fig 7. Percentage of children in each group demonstrating different amounts of change in ANB
angle.

appliance therapy. The median reduction in overjet was
8 mm and 4 mm in the TB and MB groups, respec-
tively. The greater reduction in overjet in the TB group
is probably the result of greater maxillary incisor
retroclination, as well as more sagittal mandibular
growth. The reduction in overjet in the MB group is
more than might be expected from the effects of growth
alone.4
Statistically, there was no difference between the
groups in overjet relapse after appliance withdrawal.
The median overjet relapse in the MB and TB groups
was 1 mm and 2 mm, respectively. An interesting
finding was the large variability in the amount of
relapse in both treatment groups. Many factors might
be responsible for this short-term relapse in overjet,
including a tendency for teeth to move back to their
pretreatment positions, atrophy of the hypertrophied
condylar cartilage and disc,29-31 and a reduction in the
postural activity of the protractor muscles of the man-
dible after appliance withdrawal. In the medium and
long term, continuation of the pretreatment growth
pattern is probably a dominant factor in causing re-
lapse.32
After functional appliance treatment, patients often
undergo a second phase of treatment involving fixed
appliances. At this stage, anchorage requirements are
often assessed and extraction decisions made. Because
there is a large variability in the degree of relapse
between patients, it might be prudent to allow a short
period to elapse after functional appliance treatment so
that anchorage requirements can be assessed more
accurately. Randomized controlled trials are required to
determine the best retention regimen after functional
appliance therapy.
CONCLUSIONS
● Progressive mandibular advancement is not associ-
ated with greater mandibular growth compared with
a large, single-step advancement with the TB appli-
ance.
● There was great individual variability in the mandib-
ular growth response to both appliances.
● Reducing the vertical dimension of the TB appliance
bite-blocks does not seem to be associated with a
lesser increase in the vertical dimension.
● The maxillary incisor torquing spring is effective at
reducing maxillary incisor retroclination.
● Progressive mandibular advancement used in con-
junction with bite-blocks of reduced vertical dimen-
sion does not seem to result in less mandibular
incisor proclination. Functional appliance treatment
might not be contraindicated in patients who start
with a proclined mandibular labial segment.
● A short interval (2-3 months) should be left between
functional and fixed appliance treatment, to better
assess anchorage requirements for phase II.
REFERENCES
1. Clarke WJ. The Twin block traction technique. Eur J Orthod
1982;4:129-38.
2. Lund DI, Sandler PJ. The effects of Twin Blocks: a prospective
controlled study. Am J Orthod Dentofacial Orthop 1998;113:
104-10.
472 Gill and Lee
3. Mills CM, McCulloch KJ. Treatment effects of the twin block
appliance: a cephalometric study. Am J Orthod Dentofacial
Orthop 1998;114:15-24.
4. Illing HM, Morris DO, Lee RT. A prospective evaluation of
Bass, Bionator and Twin Block appliances. Part 1—the hard
tissues. Eur J Orthod 1998;20:501-16.
5. Mills CM, McCulloch KJ. Posttreatment changes after successful
correction of Class II malocclusions with the Twin Block
appliance. Am J Orthod Dentofacial Orthop 2000;118:24-33.
6. Falck F, Fränkel R. Clinical relevance of step-by-step mandibu-
lar advancement in the treatment of mandibular retrusion using
the Frankel appliance. Am J Orthod Dentofacial Orthop 1989;
96:333-41.
7. Teucher U. A growth-related concept for skeletal Class II
treatment. Am J Orthod 1978;74:258-75.
8. Bass NM. Early treatment of skeletal II malocclusion involving
preliminary incisor root torquing. Trans Eur Orthod Soc 1975:
191-200.
9. Bass NM. Innovation in skeletal II treatment including effective
incisor root torque in a preliminary removable appliance phase.
Br J Orthod 1976;3:223-30.
10. Dahlberg G. Statistical methods for medical and biological
students. New York: Interscience Publications; 1940.
11. Houston WJB. The analysis of errors in orthodontic measure-
ments. Am J Orthod 1983;83:382-90.
12. Tulloch CJF, Medland W, Tuncay OC. Methods used to evaluate
growth modification in Class II malocclusion. Am J Orthod
Dentofacial Orthop 1990;98:340-7.
13. Illing HM. A prospective cephalometric evaluation of the hard
tissue effects of differing functional appliances and their rele-
vance to the visual head horizontal thesis]. London: University of
London; 1994.
14. Muniandy SD. A prospective cephalometric and laser scanning
study of two different functional appliance systems: the Twin block
and the Silensor [thesis]. London: University of London; 1999.
15. Tumer N, Gultan AS. Comparison of the effects of monoblock
and twin-block appliances on the skeletal and dentoalveolar
structures. Am J Orthod Dentofacial Orthop 1999;116:460-8.
16. Toth LR, McNamara JA. Treatment effects produced by the
Twin-block appliance and the FR-2 appliance of Frãnkel com-
pared with an untreated Class II sample. Am J Orthod Dentofa-
cial Orthop 1999;116:597-609.
17. Tulloch CJF, Proffit WR, Phillips C. Influences on the outcome
of early treatment for Class II malocclusion. Am J Orthod
Dentofacial Orthop 1997;111:533-42.
18. McDonagh S. A prospective cephalometric and optical scanning
assessment of the effects of functional appliances on the hard and
soft tissues [thesis]. London: University of London; 1996.
American Journal of Orthodontics and Dentofacial Orthopedics
April 2005
19. Morris DO, Illing HM, Lee RT. A prospective evaluation of
Bass, Bionator and Twin Block appliances. Part II—the soft
tissues. Eur J Orthod 1998;20:663-84.
20. Hunt NP, Ellisdon PS. The bionator: its use and ‘abuse’. Part 2.
Problems and progress. Dent Update 1985;12:129-32.
21. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster
LL. Headgear versus function regulator in the early treatment of
Class II, Division 1 malocclusion: a randomised clinical trial.
Am J Orthod Dentofacial Orthop 1998;113:51-61.
22. McNamara JA. Neuromuscular and skeletal adaptations to al-
tered function in the orofacial region. Am J Orthod 1973;64:578-
606.
23. Petrovic A, Stutzmann J, Oudet C. Control processes in postnatal
growth of condylar cartilage of the mandible. In: McNamara JA,
editor. Determinants of mandibular form and growth. Mono-
graph 4, Craniofacial Growth Series. Ann Arbor: Center for
Human Growth and Development; University of Michigan;
1975. p. 14-57.
24. Sessle BJ, Woodside DG, Bourque P, Gurza S, Powell J,
Voudouris J, et al. Effect of functional appliances on jaw muscle
activity. Am J Orthod Dentofacial Orthop 1990;98:222-30.
25. Yamin-Lacouture C, Woodside DG, Sectakof PA, Sessle BJ. The
action of three types of functional appliances on the activity of
the masticatory muscles. Am J Orthod Dentofacial Orthop
1997;112:560-72.
26. Voudouris JC, Kuftinec MM. Improved clinical use of Twin-
block and Herbst as a result of radiating viscoelastic tissue forces
on the condyle and fossa in treatment and long-term retention:
growth relativity. Am J Orthod Dentofacial Orthop 2000;117:
247-66.
27. Harradine NWT, Gale D. The effects of torque control spurs in
twin-block appliances. Clin Orthod Res 2000;3:202-9.
28. DeVincenzo JP, Winn MW. Orthopedic and orthodontic effects
resulting from the use of a functional appliance with different
amounts of protrusive activation. Am J Orthod Dentofacial
Orthop 1989;96:181-90.
29. Charlier JP, Petrovic A, Herrmann-Strutzmann J. Effects of
mandibular hyperpropulsion on the prechondroblastic zone of
young rat condyle. Am J Orthod 1969;55:71-4.
30. Stöckli PW, Willert HG. Tissue reactions in the temporoman-
dibular joint resulting from anterior displacement of the mandi-
ble in the monkey. Am J Orthod 1971;60:142-55.
31. McNamara JA, Carlson DS. Quantitative analysis of temporo-
mandibular joint adaptions to protrusive function. Am J Orthod
1979;76:593-611.
32. Pancherz H, Fackel U. The skeletofacial growth pattern pre- and
post-dentofacial orthopaedics. A long-term study of Class II
malocclusions treated with the Herbst appliance. Eur J Orthod
1990;12:209-18.