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/RTHODONTICS
$ALJIT 'ILL
!SHVIN 3HARMA &ARHAD .AINI AND 3TEVEN *ONES
4HE 4WIN "LOCK !PPLIANCE FOR THE
#ORRECTION OF #LASS )) -ALOCCLUSION
!BSTRACT ! NUMBER OF TREATMENT APPROACHES ARE AVAILABLE FOR THE MANAGEMENT OF #LASS )) MALOCCLUSION &UNCTIONAL
APPLIANCES ARE COMMONLY USED FOR THE MANAGEMENT OF MANDIBULAR RETROGNATHIA IN GROWING SUBJECTS 4HE TWIN BLOCK
APPLIANCE IS THE MOST POPULAR FUNCTIONAL APPLIANCE IN USE WITHIN THE 5NITED +INGDOM 4HE AIM OF THIS ARTICLE IS TO REVIEW THE
CLINICAL MANAGEMENT OF THE TWIN BLOCK APPLIANCE AND TO DISCUSS SOME OF THE HARD AND SOFT TISSUE CHANGES THAT ACCOMPANY
TREATMENT WITH THIS APPLIANCE
#LINICAL 2ELEVANCE 4HE TWIN BLOCK APPLIANCE IS NOW WIDELY USED IN THE TREATMENT OF #LASS )) MALOCCLUSION
$ENT 5PDATE
4HE TWIN BLOCK APPLIANCE WAS DESCRIBED A B
BY #LARK IN AND IS THE MOST POPULAR
FUNCTIONAL APPLIANCE USED WITHIN THE
5NITED +INGDOM )TS POPULARITY ARISES
FROM ITS HIGH PATIENT ACCEPTABILITY AND ITS
ABILITY TO PRODUCE RAPID TREATMENT CHANGES
4ABLE OUTLINES THE MAIN ADVANTAGES AND
DISADVANTAGES OF THE TWIN BLOCK APPLIANCE
4HE AIM OF THIS ARTICLE IS TO REVIEW THE
DESIGN CLINICAL USE AND TREATMENT EFFECTS OF
THE TWIN BLOCK APPLIANCE C
PERMANENT MOLARS AND FIRST PREMOLARS OR
FIRST DECIDUOUS MOLARS IF PRESENT &IGURE A
2ETENTION OF THE LOWER APPLIANCE MAY BE
$ALJIT 'ILL "$3(ONS "3C(ONS -3C DIFFICULT BECAUSE OF THE MINIMAL UNDERCUTS
&$3 2#3%NG -/RTH &$3/RTH ,OCUM PRESENT ON PARTIALLY ERUPTED TEETH AND
#ONSULTANT /RTHODONTIST 4HE 2OYAL BECAUSE THE TONGUE TENDS TO DISPLACE THE
,ONDON /XFORD 2ADCLIFFE AND 3TOKE APPLIANCE DURING FUNCTION -ETHODS OF
-ANDEVILLE (OSPITALS !SHVIN 3HARMA IMPROVING RETENTION INCLUDE THE USE OF BALL
&IGURE AnC 4HE TWIN BLOCK APPLIANCE CONSISTS
"$3(ONS -3C -&$3 -/RTH 2#3 0ART
ENDED CLASPS BETWEEN THE LOWER INCISORS OR
OF A MANDIBULAR COMPONENT A AND A MAXILLARY
TIME CLINICAL LECTURER 4HE 2OYAL ,ONDON THE INCORPORATION OF AN ACRYLATED LABIAL BOW
COMPONENT B WHICH INTERDIGITATE TO CAUSE
(OSPITAL AND IN PRIVATE PRACTICE &ARHAD 3OME CLINICIANS REPLACE THE !DAMS CLASPS
FORWARD MANDIBULAR POSTURING C
.AINI "$3 -3C &$3 2#3%NG -/RTH WITH THE $ELTA CLASP AS THEY FEEL THIS OFFERS
&$3/RTH #ONSULTANT /RTHODONTIST SUPERIOR RETENTION 4HE $ELTA CLASP REPLACES
+INGSTON (OSPITAL AND 3T 'EORGES (OSPITAL THE ARROW HEAD OF THE !DAMS CLASP WITH
AND 3TEVEN *ONES "$3(ONS -3C ,$3
!PPLIANCE DESIGN &IGURE A CLOSED LOOP 4HE ADVANTAGE OF A CLOSED
$/RTH -/RTH 2#3 &$3 2#3%DIN ),4- 4HE MANDIBULAR COMPONENT LOOP IS THAT THE CLASP DOES NOT OPEN WITH
#ONSULTANT(ONORARY 3ENIOR ,ECTURER IN 4HE MANDIBULAR COMPONENT REPEATED REMOVAL AND IS THEREFORE LESS LIKELY
/RTHODONTICS %ASTMAN $ENTAL (OSPITAL CONSISTS OF AN ACRYLIC BASEPLATE WITH TO FRACTURE DURING USE
5#, (OSPITALS .(3 4RUST !DAMS CLASPS OFTEN PLACED ON TO THE FIRST 4HE BASEPLATE INCORPORATES
$ENTAL5PDATE !PRIL
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/RTHODONTICS
A B ON TO THE INCISORS IT IS OFTEN ALSO BENEFICIAL
TO HAVE TORQUING AUXILIARIES TO HELP CONTROL
THE INCLINATION OF THE MAXILLARY INCISORS
DURING TREATMENT USING HEADGEAR &IGURE
!S WELL AS CORRECTING THE
SAGITTAL RELATIONSHIP IT IS ALSO POSSIBLE TO
ADD ADDITIONAL ACTIVE COMPONENTS SUCH
AS SPRINGS TO HELP IMPROVE THE GENERAL
ALIGNMENT OF THE ARCHES
&IGURE AnB 4ORQUING SPURS A OR TORQUING SPRINGS B CAN BE USED TO CONTROL UPPER INCISOR INCLINATION 4HE RELATIONSHIP BETWEEN THE MAXILLARY AND
DURING 4WIN BLOCK TREATMENT MANDIBULAR COMPONENTS
/NCE THE APPLIANCES ARE
INSERTED IN THE MOUTH THE RELATIONSHIP OF
BITEBLOCKS IN THE REGION OF THE PREMOLARS FORWARDS THE UPPER INCISORS COME UNDER THE BITEBLOCKS ENCOURAGES THE PATIENT TO
WHICH BY OCCLUDING WITH THE MAXILLARY CONTROL OF THE LOWER LIP WHICH ALSO PROVIDES POSTURE THE MANDIBLE FORWARDS IN ORDER
BITEBLOCKS ENCOURAGES THE MANDIBLE TO BE A RETRACTING FORCE TO ACHIEVE LIP CLOSURE 4HE BLOCKS ARE OFTEN
POSTURED FORWARDS 4HE BASEPLATE CAN BE !DDITIONAL COMPONENTS WHICH MADE TO INTERDIGITATE AT AN INTERFACE
FURTHER MODIFIED WITH THE INCORPORATION OF MAY BE INCORPORATED TO HELP REDUCE ANGLE OF DEGREES AS CLINICAL EXPERIENCE
LOWER INCISOR ACRYLIC CAPPING 4HE POTENTIAL UNWANTED INCREASES IN FACE HEIGHT DURING HAS SHOWN THIS ANGLE TO BE EFFECTIVE IN
BENEFITS OF LOWER INCISOR CAPPING INCLUDE TREATMENT INCLUDE TUBES FOR THE INSERTION OF MAINTAINING AN ANTERIOR MANDIBULAR POSTURE
)MPROVED APPLIANCE RETENTION HEADGEAR IN THE UPPER PREMOLAR REGION AND &IGURE C )T IS ALSO IMPORTANT THAT THE
)NHIBITION OF LOWER INCISOR ERUPTION AND OCCLUSAL RESTS TO PREVENT OVERERUPTION OF BLOCKS ARE OF SUFFICIENT HEIGHT TO MAINTAIN
THEREFORE IMPROVED OVERBITE CONTROL THE SECOND MOLARS IF THESE ARE NOT PRESENT ANTERIOR MANDIBULAR POSTURING
2EDUCED LOWER INCISOR PROCLINATION AT THE TIME OF APPLIANCE CONSTRUCTION )N
! POTENTIALLY REDUCED INCIDENCE OF LOWER PATIENTS WHO HAVE EXCESS GINGIVAL EXPOSURE 0ATIENT SELECTION
APPLIANCE BREAKAGES IN THE MIDLINE AS ON SMILING THE UPPER INCISORS MAY ALSO BE &UNCTIONAL APPLIANCE TREATMENT
THE CAPPING INCREASES THE RIGIDITY OF THE CAPPED WITH ACRYLIC SO THAT THE HEADGEAR IS APPROPRIATE FOR THE MANAGEMENT OF WELL
APPLIANCE IN THIS REGION APPLIES AN INTRUSIVE FORCE TO THE ANTERIOR MOTIVATED GROWING PATIENTS WITH MODERATE
,OWER INCISOR CAPPING MAY BE DETRIMENTAL DENTITION !S THE INCORPORATION OF HEADGEAR MANDIBULAR RETROGNATHIA 4HE TWIN BLOCK
IN PATIENTS WITH POOR ORAL HYGIENE AS TENDS TO APPLY ADDITIONAL RETRACTION FORCES APPLIANCE IS ESPECIALLY APPROPRIATE FOR THE
DECALCIFICATION CAN OCCUR ON THE TIPS OF THE
LOWER INCISORS
4HE MAXILLARY COMPONENT A B
4HE MAXILLARY COMPONENT
CONSISTS OF AN ACRYLIC BASEPLATE WITH A MID
SAGITTAL EXPANSION SCREW INCORPORATING
!DAMS CLASPS IN A SIMILAR ARRANGEMENT TO
THE MANDIBULAR APPLIANCE &IGURE A 4HE
BITEBLOCKS COVER THE OCCLUSAL SURFACE OF THE
PREMOLARS AND MOLARS INCLUDING THE SECOND
MOLARS IF THESE HAVE ERUPTED AT THE TIME OF
APPLIANCE CONSTRUCTION
3OME CLINICIANS INCORPORATE A C D
LABIAL BOW TO AID RETRACTION OF THE UPPER
INCISORS AND IMPROVE APPLIANCE RETENTION
4HE INCORPORATION OF A LABIAL BOW MAY
ADVERSELY AFFECT COMPLIANCE AS PATIENTS
OFTEN DO NOT LIKE THE APPEARANCE OF THE
ADDITIONAL WIREWORK 4HE UPPER INCISORS
TEND TO RETROCLINE AND RETRACT EVEN
WITHOUT A LABIAL BOW OWING TO THE #LASS )) &IGURE AnD %XAMPLES OF APPLIANCE DESIGNS THAT CAN BE USED TO DECOMPENSATE THE MAXILLARY INCISORS
INTERMAXILLARY FORCES PRODUCED BETWEEN BEFORE FUNCTIONAL APPLIANCE TREATMENT A B C D %XAMPLES OF #LASS )) DIVISION CASES WHICH HAVE BEEN
THE BITEBLOCKS !S THE MANDIBLE IS POSTURED DECOMPENSATED TO ALLOW FORWARD MANDIBULAR POSTURING FOR TWIN BLOCK APPLIANCE CONSTRUCTION
!PRIL $ENTAL5PDATE
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/RTHODONTICS
SCREW CANNOT BE INCORPORATED USING A
SECTIONAL FIXED APPLIANCE
&ABRICATING THE TWIN BLOCK APPLIANCE
CONSTRUCTION BITE
)N THE MAJORITY OF CASES THE
CONSTRUCTION BITE CAN BE MADE WITH THE
INCISORS IN AN EDGE
TO
EDGE POSITION
AND THE BUCCAL SEGMENTS SEPARATED BY
APPROXIMATELY MM )F THE OVERJET IS VERY
&IGURE 0ROGRESSIVE MANDIBULAR ADVANCEMENT &IGURE ! SECTIONAL FIXED APPLIANCE MAY ALSO BE LARGE MM IT MAY BE NECESSARY TO HAVE
MAY BE ACHIEVED BY THE ADDITION OF ACRYLIC TO THE USED TO DECOMPENSATE THE MAXILLARY INCISORS TO A LESS ACTIVATION INITIALLY AND THEN ADVANCE
FRONT OF THE MAXILLARY BLOCKS MORE FAVOURABLE INCLINATION THE BITE DURING TREATMENT AS THE OVERJET IS
REDUCED !DEQUATE SEPARATION OF THE MOLARS
IN THE VERTICAL DIMENSION IS ESSENTIAL SO
THAT THE BLOCKS CAN BE CONSTRUCTED WITH
TREATMENT OF PATIENTS WITH A REDUCED LOWER REDUCTION BY LEVELLING THE LOWER CURVE OF SUFFICIENT HEIGHT 4HE CONSTRUCTION BITE CAN
ANTERIOR FACIAL HEIGHT AS TREATMENT TENDS TO 3PEE /NE DISADVANTAGE OF UNDERTAKING BE TAKEN USING WAX ALONE OR WITH THE AID OF
INCREASE THIS FACIAL DIMENSION 4REATMENT PREFUNCTIONAL EXPANSION IS THAT IT INCREASES AN %XACTOBITE STICK &ORESTADENT ,TD -ILTON
IS OFTEN STARTED ONCE THE FIRST PREMOLARS THE TOTAL TREATMENT TIME BY APPROXIMATELY +EYNES 5+ &IGURE
HAVE ERUPTED AS THESE TEETH CAN BE CLASPED SIX MONTHS WHICH MAY AFFECT PATIENT
TO IMPROVE RETENTION #URRENT EVIDENCE COMPLIANCE LATER IN TREATMENT ! MODIFIED 4HE ACTIVE PHASE OF TREATMENT
SUGGESTS THAT THE GREATEST SKELETAL RESPONSE APPROACH HAS RECENTLY BEEN DESCRIBED 4HE ACTIVE PHASE OF TREATMENT
OCCURS IF TREATMENT IS UNDERTAKEN DURING THE FOR THE MANAGEMENT OF #LASS )) DIVISION MAY BE COMMENCED BY ASKING THE PATIENT
PUBERTAL GROWTH SPURT MALOCCLUSION WHICH INVOLVES THE USE OF TO WEAR THE APPLIANCE INITIALLY ONLY A FEW
MAXILLARY INCISOR TORQUING SPURS ON THE TWIN HOURS A DAY AND THEN TO INCREASE WEAR TO
4HE STAGES OF TREATMENT BLOCK APPLIANCE AND IS CONSTRUCTED WITH FULL
TIME OVER A TWO
WEEK PERIOD 4HIS MAY
0REFUNCTIONAL EXPANSION MINIMAL MANDIBULAR POSTURING !S THE MAKE IT EASIER FOR THE PATIENT TO TOLERATE
)N PATIENTS WITH A #LASS )) TORQUING SPURS CAUSE INCISOR PROCLINATION THE APPLIANCE PARTICULARLY AS SPEECH AND
DIVISION INCISAL RELATIONSHIP OR INSTANDING THE TWIN BLOCK CAN BE PROGRESSIVELY MASTICATION CAN BE ADVERSELY AFFECTED
MAXILLARY LATERAL INCISORS TREATMENT MAY ACTIVATED WITH THE ADDITION OF ACRYLIC TO THE INITIALLY #LARK ADVISES THAT THE APPLIANCE BE
COMMENCE WITH AN UPPER REMOVABLE FRONT OF THE MAXILLARY BITEBLOCKS &IGURE WORN FULL
TIME INCLUDING DURING MASTICATION
APPLIANCE TO PROCLINE THE MAXILLARY INCISORS !N ALTERNATIVE APPROACH TO ALTHOUGH MANY PATIENTS MAY NOT TOLERATE
INTO ALIGNMENT &IGURE 3UFFICIENT DECOMPENSATE THE MAXILLARY INCISORS IN EATING WITH THE APPLIANCE IN SITU )T IS
OVERJET CAN BE CREATED TO ALLOW FORWARD #LASS )) DIVISION MALOCCLUSION IS WITH THE IMPORTANT THAT THE PATIENT REMEMBERS TO
POSTURING FOR THE CONSTRUCTION OF THE USE OF A SECTIONAL FIXED APPLIANCE BETWEEN TURN THE EXPANSION SCREW TURN WEEKLY
TWIN BLOCK APPLIANCE 4HE REMOVABLE THE MAXILLARY CANINES OR FIRST PREMOLARS IN ORDER TO MAINTAIN ARCH CO
ORDINATION
APPLIANCE CAN ALSO INCORPORATE A MIDLINE &IGURE 4HE DISADVANTAGE OF USING THIS IF THIS IS REQUIRED 4HE PATIENT SHOULD BE
EXPANSION SCREW TO BEGIN EXPANSION AND AN APPROACH COMPARED TO USING A REMOVABLE REVIEWED ON A SIX
WEEKLY BASIS IN ORDER
ANTERIOR BITE PLANE TO COMMENCE OVERBITE APPLIANCE IS THAT A BITE PLANE OR EXPANSION TO MONITOR TREATMENT CHANGES CHECK ORAL
HYGIENE AND ENSURE THAT THE APPLIANCE HAS
ADEQUATE RETENTION )T IS IMPORTANT THAT THE
OVERJET MOLAR RELATIONSHIP AND TRANSVERSE
A B RELATIONSHIPS ARE RECORDED AT EACH VISIT
3OME CLINICIANS PREFER TO MONITOR TREATMENT
CHANGES BY MEASURING THE MAXIMUM
REVERSE OVERJET ACHIEVABLE BY THE PATIENT
WHEN POSTURING AS IT CAN BE DIFFICULT TO GAIN
A TRUE OVERJET READING BECAUSE THE PATIENT
EXPERIENCES PAIN WHEN THE MANDIBLE IS
FORCIBLY RETRUDED INTO THE RETRUDED CONTACT
POSITION
&IGURE !N %XACTOBITE STICK A MAY BE USED TO RECORD THE CONSTRUCTION BITE FOR APPLIANCE CONSTRUCTION !FTER A FEW WEEKS OF WEAR
B 4HE %XACTOBITE IN THE MOUTH WITH THE INCISORS IN AN EDGE
TO
EDGE POSITION AND SUFFICIENT SEPARATION PATIENTS WHO ARE COMPLIANT WILL OFTEN
OF THE BUCCAL SEGMENTS TO ALLOW ADEQUATE BLOCK HEIGHT SHOW A SIGNIFICANT REDUCTION IN OVERJET AND
$ENTAL5PDATE !PRIL
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/RTHODONTICS
A B C
&IGURE A 0RETREATMENT OVERJET B TWIN BLOCK APPLIANCE IN SITU AND C THE END OF THE FUNCTIONAL APPLIANCE STAGE WITH THE INCISORS IN AN EDGE
TO
EDGE
POSITION AND THE PRESENCE OF LATERAL OPEN BITES
THE PRESENCE OF LATERAL OPEN BITES 4HIS IS CROWDED ARCHES /WING TO THE DIFFICULTY IN A NON EXTRACTION BASIS IT MAY BE PRUDENT
BECAUSE THERE IS INCREASED RESTING ACTIVITY CLOSING LATERAL OPEN BITES SOME CLINICIANS TO REINFORCE ANCHORAGE WITH THE USE OF
IN THE PROTRACTOR MUSCLES OF THE MANDIBLE PREFER TO USE FIXED APPLIANCES IMMEDIATELY HEADGEAR
AND HYPERPLASIA OF THE CONDYLAR CARTILAGE AFTER THE ACTIVE PHASE OF FUNCTIONAL
4HIS EARLY EFFECT MUST NOT BE CONFUSED WITH APPLIANCE TREATMENT TO EXTRUDE THE BUCCAL 2ETENTION
TRUE OVERJET REDUCTION AS THE MANDIBLE SEGMENTS ACTIVELY !N ANTERIOR CLIP OVER !FTER TREATMENT THE PATIENT
WILL RAPIDLY ADOPT ITS ORIGINAL POSITION IF BITEPLANE WITH A REVERSE SLOPE CAN BE WILL OFTEN REVERT TO HISHER ORIGINAL GROWTH
THE APPLIANCE IS KEPT OUT CONTINUOUSLY !S USED AT THIS STAGE TO MAINTAIN THE SAGITTAL PATTERN AND THERE IS THEREFORE A RISK OF
A GENERAL RULE WITH GOOD COMPLIANCE ONE CORRECTION UNTIL #LASS )) INTERMAXILLARY RELAPSE OF THE CORRECTED MALOCCLUSION
CAN EXPECT APPROXIMATELY MM OF TRUE TRACTION IS COMMENCED &IGURE !LTHOUGH VERY FEW STUDIES HAVE BEEN
OVERJET REDUCTION PER MONTH 4HE ACTIVE UNDERTAKEN TO IDENTIFY THE IDEAL RETENTION
STAGE OF TREATMENT IS USUALLY COMPLETE &IXED APPLIANCE PHASE REGIME FOLLOWING FUNCTIONAL APPLIANCE
AFTER n MONTHS WHEN THE INCISORS ARE &OLLOWING THE USE OF FUNCTIONAL TREATMENT SOME CLINICIANS RECOMMEND
IN AN EDGE TO EDGE RELATIONSHIP AND THE APPLIANCES PATIENTS MAY UNDERGO A PERIOD THE USE OF ACTIVE RETAINERS 4HESE MAY
MOLARS ARE IN A #LASS ))) RELATIONSHIP &IGURE OF FIXED APPLIANCE THERAPY TO DETAIL THE BE IN THE FORM OF A SLOPED ANTERIOR
)T IS DESIRABLE TO ACHIEVE A DEGREE OCCLUSION "EFORE MAKING A DECISION ABOUT BITEPLANE ON A STANDARD RETAINER TO HELP
OF OVERCORRECTION AS THERE WILL ALMOST THE SPACE REQUIREMENT OF THE CASE IT IS MAINTAIN AN ANTERIOR MANDIBULAR POSTURE
CERTAINLY BE SOME REBOUND WHEN THE IMPORTANT TO TAKE A LATERAL CEPHALOGRAM OR STANDARD FUNCTIONAL APPLIANCES WITH
APPLIANCES ARE REMOVED TO CHECK HOW MUCH PROCLINATION OF THE REDUCED BITEBLOCKS WHICH ARE WORN ON A
LOWER INCISORS OCCURRED DURING TWIN BLOCK @NIGHTS ONLY BASIS 4HERE IS ALSO EVIDENCE
4HE SUPPORTIVE PHASE OF TREATMENT THERAPY 4HIS IS IMPORTANT IN ORDER TO TO SUGGEST THAT A WELL INTERCUSPATED
!T THE BEGINNING OF THE MAKE A DECISION ABOUT THE IDEAL PATTERN OCCLUSION AT THE END OF TREATMENT IS
SUPPORTIVE PHASE THE OVERJET WILL HAVE OF EXTRACTIONS IF THESE ARE INDICATED /THER MORE LIKELY TO LEAD TO A STABLE SAGITTAL
BEEN CORRECTED BUT THE PATIENT WILL FEATURES WHICH MUST BE TAKEN INTO ACCOUNT CORRECTION
HAVE LATERAL OPEN BITES 4HE AIM OF THE BEFORE MAKING THIS DECISION INCLUDE THE
SUPPORTIVE PHASE IS TO MAINTAIN THE FACIAL PROFILE THE DEGREE OF CROWDING THE 4REATMENT EFFECTS OF THE TWIN
CORRECTIONS THAT HAVE BEEN ACHIEVED WHILE SIZE OF THE OVERJET AND THE DEPTH OF THE BLOCK APPLIANCE
CLOSING THE LATERAL OPEN BITES CURVE OF 3PEE )N CASES THAT ARE TREATED ON ! NUMBER OF CLINICAL TRIALS HAVE
! NUMBER OF DIFFERENT
TECHNIQUES MAY BE USED TO CLOSE THE
LATERAL OPEN BITES WHICH CAN TAKE BETWEEN A B
AND MONTHS 4HESE INCLUDE REMOVAL OF
THE LOWER FIRST MOLAR CLASPS AND TRIMMING
OF THE UPPER BITEBLOCK TO ALLOW FREE
ERUPTION OF THE LOWER MOLARS OR ASKING
THE PATIENT TO WEAR THE APPLIANCE FOR
ONLY HOURS PER DAY )T IS IMPORTANT
TO REMEMBER THAT THERE IS A SPACE
REQUIREMENT TO LEVEL THE LOWER CURVE OF
3PEE AS IT CONSISTS OF A SERIES OF SLIPPED
&IGURE A #LIP OVER ANTERIOR BITEPLANE WITH A STEEP INCLINED PLANE CAN BE USED TO RETAIN #LASS ))
CONTACT POINTS AND THE LATERAL OPEN BITE CORRECTION AND CLOSE THE LATERAL OPEN BITES B 4HE BITEPLANE IN SITU
CAN BE EXTREMELY DIFFICULT TO CLOSE IN
!PRIL $ENTAL5PDATE
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/RTHODONTICS
BEEN CARRIED OUT TO ASSESS THE EFFECTS OF THE
!DVANTAGES $ISADVANTAGE TWIN BLOCK APPLIANCE 4HE DESIGNS OF THE
TRIALS ARE DESCRIBED IN 4ABLE
2APID OVERJET CORRECTION -INIMAL MANDIBULAR GROWTH BENEFIT
$ENTO
SKELETAL EFFECTS
4WO PIECE DESIGN ALLOWS FREEDOM OF 4ENDENCY TO INCREASE THE FACE )NCREASED MANDIBULAR LENGTH
MANDIBULAR EXCURSIONS HEIGHT IN PATIENTS WITH INCREASED %VIDENCE FROM PROSPECTIVE
FACE HEIGHTS CEPHALOMETRIC STUDIES SUGGESTS THAT
&ACILITY TO CONTROL UPPER ARCH WIDTH MANDIBULAR LENGTH INCREASES BETWEEN
,ATERAL OPEN BITES CAN BE DIFFICULT AND MM MORE THAN CONTROLS
%ASE OF INCORPORATING ADDITIONAL TO CLOSE DURING TREATMENT WITH THE TWIN BLOCK
ACTIVE COMPONENTS APPLIANCE /NE FACTOR IN COMMON
,OWER INCISOR PROCLINATION WITH ALL STUDIES IS THE LARGE VARIABILITY IN
TREATMENT RESPONSE AND CURRENTLY THE
2ETENTION MAY BE POOR DURING THE BEST PRE
TREATMENT INDICATOR OF POSSIBLE
MIXED DENTITION TREATMENT SUCCESS IS A DEEP OVERBITE
4HIS MAY BE BECAUSE THE MANDIBLE IS
$IFFICULTY IN INCORPORATING FIXED RESTRICTED BY THE DEEP BITE IN SUCH CASES
APPLIANCES AND FUNCTIONAL APPLIANCES HELP TO REMOVE
4ABLE 4HE ADVANTAGES AND DISADVANTAGES OF THE TWIN BLOCK APPLIANCE THIS OBSTRUCTION ENCOURAGING EXPRESSION OF
3TUDY $ESIGN 2ANDOMIZED -ATCHED 3AMPLE 3IZE
#ONTROLS
)LLING ET AL 0ROSPECTIVE 9ES .O 4"
#
,UND AND 3ANDLER 0ROSPECTIVE .O .O 4"
#
-ILLS AND -C#ULLOCH 2ETROSPECTIVE .O 9ES 4"
"URLINGTON #
GROWTH STUDY
-ORRIS ET AL 0ROSPECTIVE 9ES .O 4"
#
4OTH AND -C.AMARA 2ETROSPECTIVE .O 9ES 4"
-ICHIGAN #
GROWTH STUDY
4àMER AND 'àLTAN 0ROSPECTIVE .O 9ES 4"
#
-C$ONAGH ET AL 0ROSPECTIVE 9ES .O 4"
4" ('
/"RIEN ET AL 0ROSPECTIVE 9ES 9ES 4"
#
4ABLE 3UMMARY OF TRIAL DESIGNS USED TO EVALUATE HARD AND SOFT TISSUE CHANGES DURING TWIN BLOCK APPLIANCE TREATMENT 4" TWIN BLOCK APPLIANCE # #ONTROL
GROUP (' (EADGEAR
$ENTAL5PDATE !PRIL
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/RTHODONTICS
UNDERLYING GROWTH POTENTIAL -ILLS AND -C#ULLOCH 4OTH AND -C.AMARA n MM MORE THAN CORRESPONDING CONTROLS
2ETROSPECTIVE STUDIES TEND AND 4àMER AND 'àLTAN FOUND THAT THE TWIN 7HEN CONSIDERING VERTICAL MOLAR
ONLY TO CONSIDER SUCCESSFULLY TREATED BLOCK APPLIANCE RETROCLINED THE MAXILLARY CHANGES IT HAS GENERALLY BEEN FOUND THAT
CASES 4HESE SUGGEST THAT MANDIBULAR INCISORS ON AVERAGE BY THE MAXILLARY MOLARS ARE RESTRAINED AND
LENGTH INCREASES BY APPROXIMATELY MM AND DEGREES RESPECTIVELY ,UND AND THE LOWER MOLARS ARE EXTRUDED UP TO MM
MORE THAN CONTROLS AND THE CHIN MOVES 3ANDLER INCORPORATED A LABIAL BOW INTO MORE THAN CONTROLS ,OWER MOLAR ERUPTION
SIGNIFICANTLY FORWARDS BY A MEAN OF THEIR APPLIANCE AND THIS MAY ACCOUNT FOR HELPS IN THE CORRECTION OF A CLASS )) MOLAR
n MM MORE THAN CONTROLS )N BOTH THE GREATER RETROCLINING EFFECT FOUND BY RELATIONSHIP AIDS OVERBITE REDUCTION AND
PROSPECTIVE AND RETROSPECTIVE STUDIES THERE THESE AUTHORS (OWEVER IT IS CLEAR THAT THE HELPS MINIMIZE THE EXTENT OF LATERAL OPEN
WAS A LARGE AMOUNT OF INDIVIDUAL VARIATION UPPER INCISORS BECOME RETROCLINED EVEN BITES FOUND AT THE END OF TWIN BLOCK THERAPY
IN TREATMENT RESPONSE IN THE ABSENCE OF A LABIAL BOW /"RIEN ET
AL SHOWED THAT UPPER INCISOR RETRACTION 3UMMARY
%FFECTS ON MAXILLARY GROWTH CONTRIBUTED SIGNIFICANTLY TO OVERJET 4O SUMMARIZE IT APPEARS
4HE MAJORITY OF STUDIES HAVE CORRECTION $ATA FROM CLINICAL TRIALS SUGGEST THAT THE TWIN BLOCK APPLIANCE ACHIEVES
FOUND NO SIGNIFICANT ORTHOPAEDIC EFFECT THAT TORQUE CONTROL AUXILIARIES ARE EFFECTIVE SAGITTAL CORRECTION IN #LASS )) MALOCCLUSION
EXERTED ON THE MAXILLA WITH THE USE OF THE AT LIMITING RETROCLINATION OF THE MAXILLARY PREDOMINANTLY BY DENTO ALVEOLAR CHANGE
TWIN BLOCK APPLIANCE 4HE RESULTS OF INCISORS -ANDIBULAR GROWTH ENHANCEMENT
ONE LARGE MULTICENTRE STUDY CONDUCTED IN AND MAXILLARY RESTRAINT EFFECTS MAY BE
THE 5+ FOUND A SMALL MAXILLARY RESTRAINING 0ROCLINATION OF THE MANDIBULAR INCISORS STATISTICALLY SIGNIFICANT IN SOME PROSPECTIVE
EFFECT USING TWIN BLOCKS WHICH CONTRIBUTED 0ROCLINATION OF THE LOWER LABIAL STUDIES BUT IT IS QUESTIONABLE IF THESE
ONLY TO THE OVERALL SKELETAL CHANGE SEGMENT DURING TREATMENT IS UNDESIRABLE IN CHANGES ARE CLINICALLY RELEVANT 4REATMENT
AND WAS THEREFORE CONSIDERED CLINICALLY NOT MOST CASES BECAUSE IS ALSO ASSOCIATED WITH AN INCREASE IN
SIGNIFICANT )T CONTRIBUTES TO OVERJET REDUCTION AND THE VERTICAL FACIAL DIMENSION WHICH MAY
THEREFORE LIMITS THE POTENTIAL FOR FURTHER BE DETRIMENTAL IN CASES STARTING WITH AN
)NCREASED FACIAL HEIGHT SKELETAL GROWTH INCREASED FACE HEIGHT BUT ADVANTAGEOUS
"OTH PROSPECTIVE AND 4HE LOWER INCISORS ARE SUSCEPTIBLE TO IN PATIENTS WITH REDUCED FACE HEIGHT )N
RETROSPECTIVE STUDIES ARE CONSISTENT IN RELAPSE THE LONGER TERM EVIDENCE WOULD SUGGEST
SHOWING THAT TREATMENT WITH THE TWIN 3UBSEQUENT FIXED APPLIANCE TREATMENT IS THAT THE EARLY GROWTH BENEFIT MAY NOT BE
BLOCK APPLIANCE RESULTS IN AN INCREASE MORE LIKELY TO INVOLVE EXTRACTIONS AS SPACE MAINTAINED IN THE LONG TERM WITH TWIN BLOCK
IN TOTAL ANTERIOR FACE HEIGHT RANGING ON IS REQUIRED IF THE LOWER INCISORS ARE TO BE APPLIANCE TREATMENT
AVERAGE BETWEEN AND MM MORE RETRACTED TO THEIR PRETREATMENT POSITION
THAN CONTROL GROUPS !S WITH ,UND AND 3ANDLER -ILLS AND
CHANGES IN MANDIBULAR LENGTH THERE IS A
3OFT TISSUE CHANGES
-C#ULLOCH 4OTH AND -C.AMARA AND
! NUMBER OF STUDIES HAVE NOW
LARGE VARIABILITY IN TREATMENT RESPONSE 4àMER AND 'àLTAN FOUND THAT THE LOWER BEEN UNDERTAKEN TO ASSESS THE EFFECTS OF
)N PATIENTS WITH AN INCREASED FACE INCISORS PROCLINED ON AVERAGE BY TWIN BLOCK APPLIANCE TREATMENT ON THE FACIAL
HEIGHT WHERE IT WOULD BE ADVANTAGEOUS AND DEGREES DURING TREATMENT SOFT TISSUES
TO PREVENT ANY FURTHER INCREASE THE RESPECTIVELY )LLING ET AL FOUND NO SIGNIFICANT
ADDITION OF HIGH PULL HEADGEAR MAY BE CHANGE IN THE LOWER INCISOR INCLINATION 4RANSVERSE FACIAL CHANGES
EFFECTIVE AT REDUCING THE PROPORTIONATE FOLLOWING TWIN BLOCK THERAPY 4REATMENT &ACIAL THREE DIMENSIONAL OPTICAL
LOWER FACE HEIGHT BUT NOT THE OVERALL EFFECTS ON THE LOWER INCISORS MAY NOT HAVE LASER SCANS HAVE BEEN USED TO STUDY THE
FACE HEIGHT BEEN DETECTED BECAUSE THE MEAN CHANGE EFFECTS OF TWIN BLOCK THERAPY ON TRANSVERSE
WAS SMALL AND THERE WAS A LARGE INDIVIDUAL FACIAL GROWTH 4HESE STUDIES HAVE FOUND
2ETROCLINATION OF THE MAXILLARY INCISORS
VARIATION IN TREATMENT RESPONSE MEAN THAT THERE IS A GENERAL WIDENING OF THE LATERAL
#LASS )) TRACTION FORCES ARE
PROCLINATION ² 3$ ² #URRENTLY THERE EXTREMITIES OF THE FACE IN PATIENTS TREATED WITH
TRANSMITTED TO THE MAXILLARY DENTITION
ARE NO CLINICAL DATA ON THE EFFECTS OF LOWER BOTH THE TWIN BLOCK AND TWIN BLOCKHEADGEAR
DURING FUNCTIONAL APPLIANCE TREATMENT
INCISOR CAPPING ON CONTROLLING LOWER INCISOR COMBINATIONS
4HESE FORCES IN ADDITION TO THOSE
MOVEMENT DURING TWIN BLOCK THERAPY
TRANSMITTED TO THE UPPER INCISORS AS THEY #HANGES IN LIP POSITION
ARE BROUGHT UNDER THE CONTROL OF THE LOWER %FFECTS ON THE BUCCAL SEGMENTS 3TUDIES HAVE FOUND NO SIGNIFICANT
LIP DURING MANDIBULAR PROTRUSION RESULT 'ENERALLY CHANGES IN MOLAR CHANGES IN THE SAGITTAL POSITION OF THE UPPER
IN PALATAL MOVEMENT OF THE INCISORS !S POSITION ARE DIFFICULT TO ASSESS AS THESE TEETH LIP IN PATIENTS TREATED WITH THE TWIN BLOCK
OVERJET CORRECTION IS OFTEN TAKEN AS THE END ARE OFTEN POORLY DEFINED CEPHALOMETRICALLY APPLIANCE DESPITE LARGE REDUCTIONS IN THE
POINT OF FUNCTIONAL APPLIANCE TREATMENT A 7ITH REGARDS TO THE HORIZONTAL OVERJET
DISADVANTAGE OF RETROCLINATION IS THAT A LARGE MOLAR POSITION THE MAJORITY OF STUDIES HAVE 4HE LOWER LIP BECOMES MORE
COMPONENT OF OVERJET CORRECTION IS DUE TO FOUND THAT THE UPPER MOLARS ARE DISTALIZED PROTRUSIVE WHEN MEASURED CEPHALOMETRICALLY
INCISOR MOVEMENT RATHER THAN MANDIBULAR UP TO MM MORE THAN CONTROLS AND THE OR USING OPTICAL SCANS 4HIS MAY BE RELATED TO
GROWTH LOWER MOLARS MOVE FORWARD ON AVERAGE PROCLINATION OF THE MANDIBULAR INCISORS DURING
,UND AND 3ANDLER )LLING ET AL
!PRIL $ENTAL5PDATE
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/RTHODONTICS
TREATMENT AND FAVOURABLE MANDIBULAR GROWTH THERAPY !M * /RTHOD $ENTOFAC /RTHOP EFFECTS OF THE TWIN BLOCK APPLIANCE
WHICH MAY BE FOUND IN SOME PATIENTS n ! CEPHALOMETRIC STUDY !M * /RTHOD
$YER &-6 -C+EOWN (& 3ANDLER 0* $ENTOFAC /RTHOP n
#HANGES IN SOFT TISSUE CHIN POSITION 4HE MODIFIED 4WIN "LOCK APPLIANCE 4OTH ,2 -C.AMARA *! 4REATMENT
3TUDIES INDICATE THAT CHANGES IN THE IN THE TREATMENT OF #LASS )) DIVISION EFFECTS PRODUCED BY THE 4WIN BLOCK
SOFT TISSUE CHIN POINT TEND TO REFLECT THOSE FOUND MALOCCLUSIONS * /RTHOD APPLIANCE AND THE &2 APPLIANCE OF
CEPHALOMETRICALLY WITH CHANGES IN THE HARD TISSUE n &RËNKEL COMPARED WITH AN UNTREATED
CHIN POSITION 4HE LONG TERM NATURE OF THESE #LARK 7* 4HE TWIN BLOCK TECHNIQUE #LASS )) SAMPLE !M * /RTHOD $ENTOFAC
CHANGES HAS YET TO BE STUDIED !DDITIONALLY IT IS ! FUNCTIONAL ORTHOPAEDIC APPLIANCE /RTHOP n
WORTH NOTING THAT -C$ONAGH ET AL DID NOT NOTICE SYSTEM !M * /RTHOD $ENTOFAC /RTHOP 0ARKIN .! -C+EOWN (& 3ANDLER 0*
ANY FURTHER MOVEMENT OF THE SOFT TISSUE POGONION n #OMPARISON OF MODIFICATIONS OF THE
MM IN A TWIN BLOCK GROUP WEARING HEADGEAR 3ANDLER * $I"IASE $ 4HE INCLINED 4WIN BLOCK APPLIANCE IN MATCHED
BITEPLANE n A USEFUL TOOL !M * /RTHOD #LASS )) SAMPLES !M * /RTHOD $ENTOFAC
3OFT TISSUE TOTAL ANTERIOR FACIAL HEIGHT
$ENTOFAC /RTHOP n /RTHOP n
4HE CHANGES IN THE SOFT TISSUE
0ANCHERZ ( 4HE NATURE OF #LASS (ARRADINE .74 'ALE $ 4HE EFFECTS
DIMENSIONS APPEAR TO BE WELL CORRELATED TO
)) RELAPSE AFTER (ERBST APPLIANCE OF TORQUE CONTROL SPURS IN TWIN BLOCK
THE UNDERLYING SKELETAL CHANGES )T SHOULD
TREATMENT ! CEPHALOMETRIC LONG TERM APPLIANCES #LIN /RTHOD 2ES
ALSO BE NOTED THAT THERE IS LARGE VARIATION IN
INVESTIGATION !M * /RTHOD $ENTOFAC n
TREATMENT RESPONSE FOR MOST OF THE PARAMETERS
/RTHOP n (ANSEN + +OUTSONAS 4' 0ANCHERZ (
MEASURED
)LLING (- -ORRIS $/ ,EE 24 ! ,ONG TERM EFFECTS OF (ERBST TREATMENT
PROSPECTIVE EVALUATION OF "ASS ON THE MANDIBULAR INCISOR SEGMENT
#ONCLUSION "IONATOR AND 4WIN "LOCK APPLIANCES ! CEPHALOMETRIC AND BIOMETRIC
4HE TWIN BLOCK APPLIANCE IS A 0ART n THE HARD TISSUES %UR * /RTHOD INVESTIGATION !M * /RTHOD $ENTOFAC
POPULAR APPLIANCE FOR THE TREATMENT OF #LASS n /RTHOP n
)) MALOCCLUSION BECAUSE OF ITS HIGH PATIENT ,UND $) 3ANDLER 0* 4HE EFFECTS OF 4WIN 4ULLOCH *&# 0HILLIPS # 0ROFFIT 72
ACCEPTABILITY AND ITS ABILITY TO PRODUCE RAPID "LOCKS ! PROSPECTIVE CONTROLLED STUDY "ENEFIT OF EARLY #LASS )) TREATMENT
TREATMENT CHANGES 4HE APPLIANCE WORKS !M * /RTHOD $ENTOFAC /RTHOP 0ROGRESS REPORT OF A TWO PHASE
PRINCIPALLY BY INDUCING DENTO ALVEOLAR CHANGES n RANDOMIZED CLINICAL TRIAL !M * /RTHOD
WITH A SMALL AMOUNT OF FAVOURABLE SKELETAL 4àMER . 'àLTAN !3 #OMPARISON OF $ENTOFAC /RTHOP n
CHANGE IN THE SHORT TERM #HANGES IN THE SOFT THE EFFECTS OF MONOBLOCK AND TWIN -ILLS #- -C#ULLOCH +* 0OSTTREATMENT
TISSUES TEND TO ACCOMPANY HARD TISSUE CHANGES BLOCK APPLIANCES ON THE SKELETAL AND CHANGES AFTER SUCCESSFUL CORRECTION OF
PERHAPS APART FROM CHANGES IN THE UPPER LIP DENTOALVEOLAR STRUCTURES !M * /RTHOD #LASS )) MALOCCLUSIONS WITH THE 4WIN
POSITION $ENTOFAC /RTHOP n "LOCK APPLIANCE !M * /RTHOD $ENTOFAC
/"RIEN + 7RIGHT * #ONBOY & ET AL /RTHOP n
%FFECTIVENESS OF EARLY ORTHODONTIC -ORRIS $/ )LLING (- ,EE 24 !
2EFERENCES TREATMENT WITH THE 4WIN BLOCK PROSPECTIVE EVALUATION OF "ASS
#LARK 7* 4HE TWIN BLOCK TRACTION APPLIANCE ! MULTICENTER RANDOMIZED "IONATOR AND 4WIN "LOCK APPLIANCES
TECHNIQUE %UR* /RTHOD n CONTROLLED TRIAL 0ART $ENTAL AND 0ART )) THE SOFT TISSUES %UR * /RTHOD
SKELETAL EFFECTS !M * /RTHOD $ENTOFAC n
#HADWICK 3- "ANKS 0 7RIGHT *, 4HE /RTHOP n -C$ONAGH 3 -OSS *0 'OODWIN
USE OF MYOFUNCTIONAL APPLIANCES IN THE #ALDWELL 3 #OOK 0 0REDICTING THE 0 ,EE 24 ! PROSPECTIVE OPTICAL
5+ A SURVEY OF "RITISH ORTHODONTISTS OUTCOME OF TWIN BLOCK FUNCTIONAL SURFACE SCANNING AND CEPHALOMETRIC
$ENT 5PDATE n APPLIANCE TREATMENT A PROSPECTIVE ASSESSMENT OF THE EFFECT OF FUNCTIONAL
"ACCETTI 4 &RANCHI , 4OTH ,2 -C.AMARA STUDY %UR * /RTHOD n APPLIANCES ON THE SOFT TISSUES %UR *
*! 4REATMENT TIMING FOR 4WIN BLOCK -ILLS #- -C#ULLOCH +* 4REATMENT /RTHOD n
!BSTRACT
$/ "%44%2 "523 2%35,4 ). "%44%2 RESINS ARE APPLIED TO DENTINE PREPARED SIGNIFICANT DIFFERENCE BETWEEN SPECIMENS WITH
2%34/2!4)/.3 BY A HIGH SPEED BUR 4HE DENTINE ON THE ONE OF THE RESTORATIVE MATERIALS IN THE OTHER
%FFECTS OF DIAMOND BUR PARTICLE SIZE ON DENTIN BUCCAL SURFACE OF THREE GROUPS OF TEETH WERE GROUP A STATISTICALLY SIGNIFICANT DIFFERENCE IN
BOND STRENGTH 9 (OSOYA ( 3HINKAWA # 3UEFIJI PREPARED WITH RESPECTIVELY BURS BURS BOND STRENGTH WAS ACHIEVED USING THE SUPER
+ .OZAKA AND 'ARCIA 'ODOY !MERICAN *OURNAL AND THE STANDARD SILICONE PAPER 4WO SETS OF FINE GRIT BUR WHEN COMPARED TO THE
OF $ENTISTRY n TEETH WERE PREPARED FOR COMPARISON OF TWO COARSER BUR %NSURING THAT CAVITY MARGINS ARE
4HE AUTHORS OF THIS INTERESTING ADHESIVE SYSTEMS &OLLOWING APPLICATION AS SMOOTH AS POSSIBLE MAY GIVE A SIGNIFICANT
PAPER REALIZED THAT MOST DENTINE BOND OF THE ADHESIVE MATERIAL ACCORDING TO THE IMPROVEMENT TO THE QUALITY OF YOUR ADHESIVE
STRENGTH STUDIES ARE PERFORMED ON SPECIMENS MANUFACTURERS INSTRUCTIONS SHEAR BOND RESTORATIONS
THAT HAVE BEEN GROUND WITH GRIT SILICONE STRENGTH TESTING WAS PERFORMED 0ETER #ARROTTE
CARBIDE PAPER WHEREAS CLINICALLY ADHESIVE !LTHOUGH THE RESULTS SHOWED NO 'LASGOW $ENTAL 3CHOOL
$ENTAL5PDATE !PRIL
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