ORIGINAL RESEARCH

Comparative Evaluation of Twin Block Appliance and

Fixed Orthodontic Appliance in Early Class II Malocclusion
Treatment: A Randomized Controlled Trial
Eman Saad Radwan1, Ahmed Maher2, Mona A Montasser3

A b s t r ac t
Aims: To compare skeletal, dentoalveolar, and soft tissue changes between Twin block and early fixed orthodontic appliance for class II division
1 malocclusion treatment through a randomized controlled trial.
Materials and methods: Sample and randomization: This study was a randomized controlled trial with a 1:1 allocation ratio in which 40 patients were
divided equally into two groups: control and experimental; each group had an equal number of boys and girls. Randomization was achieved using
random blocks of 20 patients with allocation concealed in sequentially numbered, opaque, and sealed envelopes. Blinding was only applicable for
data analysis of radiographic measurements. Intervention: Twin block appliance was used in the experimental group for 1 year. However, control
group was treated with fixed appliance. Inclusion criteria: Skeletal class II division 1 malocclusion with mandibular retrognathism; cephalometric
angular measurements: SNA ≥ 82, SNB ≤ 78, ANB ≥ 4; overjet ≥6 mm; and patient in circumpubertal stage cervical vertebral maturation (CVM2
and CVM3). Parameters for evaluation: Cephalometric skeletal, dental, and soft tissue angular and linear measurements were used for evaluation.
Results: SNB increased remarkably by 4° in the Twin block group, but only by 0.68 in the control group. There was a significant decrease in
vertical dimensions (SN-GoGn) in the Twin block group compared to control group (p = 0.002). Significant enhancement in the facial profile
of the patients was observed.
Conclusions: The Twin block appliance induced significant skeletal and dental changes. These changes were more obvious relative to the slight
changes induced by natural growth.
Clinical significance: Early treatment of Class II due to mandibular retrusion with Twin block functional appliance is recommended due to its
favourable skeletal effect. Early treatment with fixed appliance affects mainly the dentoalveolar component. Long term follow-up is needed
for further insights.
Keywords: Mandibular retrusion, Skeletal class II, Twin block.
The Journal of Contemporary Dental Practice (2022): 10.5005/jp-journals-10024-3426

Introduction
Class II malocclusion is one of the most common problems in
orthodontic practice, accounting for approximately one-third of the
patients seeking orthodontic treatment in some populations.1 Class II
had a global distribution of 19.56% in permanent dentition. Europe
has the greatest incidence of class II (33.51%). African population
showed the lowest occurrence of class II malocclusions (7.5%). Class II
division 1 malocclusion is the most frequent orthodontic issue. It
accounts for approximately 12 to 49% of all orthodontic difficulties.2
Class II malocclusion, like other types of malocclusions, causes
esthetic, functional, and psychological problems, the severity of
which depends on the amount of anteroposterior discrepancy and
its interaction with the surrounding soft tissue structures.3
Various factors contribute to the development of class II
malocclusion, but mandibular retrognathism is the most common.3
Different functional appliances are used to correct a class II
malocclusion by utilizing, eliminating, or directing muscle function
forces, tooth eruption, and growth modification.4
The debate over the mode of action of functional appliances
is about the efficacy of the appliances in increasing mandibular
growth, which leads to a long-standing improvement in the skeletal
pattern. 5–10 Although research results showed that functional
appliances could increase mandibular unit length (Co-Gn),5 other
researchers concluded that functional appliances did not affect
mandibular growth.6,7 The mandibular changes need to be evaluated
1–3
Department of Orthodontics, Mansoura University, Mansoura,
Egypt
Corresponding Author: Eman Saad Radwan, Department of
Orthodontics, Mansoura University, Mansoura, Egypt, Phone:
+01094233462, e-mail: emansaad@mans.edu.eg
How to cite this article: Radwan ES, Maher A, Montasser MA. Com­
parative Evaluation of Twin Block Appliance and Fixed Orthodontic
Appliance in Early Class II Malocclusion Treatment: A Randomized
Controlled Trial. J Contemp Dent Pract 2022;23(11):1111–1121.
Source of support: Nil
Conflict of interest: None
carefully. According to Johnston, what might be interpreted as
growth is in fact mandibular displacement or a combination of the
two types of change.8,9 This could be seen in measurements that
use point articulare (Ar), because the measurements are unable to
discriminate between growth and displacement.10 Distalization of
the upper buccal segment and retroclination of the upper anterior
teeth, along with mesial movement of the lower buccal segments
and proclination of the lower labial segments helped in the
establishment of class I relationship.10
Treatment timing is a critical factor for the successful treatment
of any skeletal malocclusion. There is controversy about the best
time for correction of class II malocclusion. Some researchers
preferred orthodontic therapy in the mixed dentition period,11

© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
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 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance
Flowchart 1: CONSORT diagram showing the patients’ flow in the study
while others contended that early treatment is sometimes a waste
of time and resources.12 Early treatment of class II malocclusion
is suggested to result in more stable results because the skeletal
growth is adjusted and enhanced.13 Baccetti et al.14 reported that
the best time to treat class II malocclusion is in circumpubertal
cervical vertebral maturation (CVM) stages 2 and 3.
The Twin block appliance has become the most popular
removable functional appliance during the last few decades.15
Additionally, systematic reviews found it to be the most efficient in
producing skeletal changes.16 It has been proven to be comfortable,
efficient, and esthetic,17,18 and can be used in both permanent and
mixed dentition.19 There are several studies that evaluated the
dental and skeletal effects associated with the Twin block appliance
and compared them with a control group or with other appliances
such as the Herbest or the Activator appliances.20 However, there are
few studies that compared the Twin block to the fixed orthodontic
appliance in the treatment of class II malocclusion.
The target of the Twin block appliance is to enhance mandibular
growth. The main functioning mechanism in the normal dentition is
the occlusal inclined plane. This plane is crucial in determining the
final occlusal relationship. If the mandible occludes in distal relation to
the maxilla in normal function, the forces of occlusion acting on
the lower teeth have a distal component of force. Additionally, the
mandible is locked in a distally occluding functional position by the
inclined planes created by the cusps of the upper and lower teeth.15
The aim of this study was to compare skeletal, dentoalveolar,
and soft tissue changes between Twin block and early fixed
orthodontic appliance for class II division 1 malocclusion treatment.
M at e r ia l s and Methods
Trial Design
The study design was a randomized controlled trial in which control
group and experimental group were assessed as parallel groups
1112 The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)
with a 1:1 allocation ratio. The study protocol was approved by
the Research Ethics Committee of Faculty of Dentistry, Mansoura
University (No. A09061119).
Participants, Setting, and Eligibility Criteria
Participants were selected from the outpatient clinic of
Orthodontic Department, Faculty of Dentistry, Mansoura
University. The inclusion criteria were: (1) skeletal class II
division 1 malocclusion with mandibular retrognathism,
(2) cephalometric angular measurements: SNA ≥ 82, SNB ≤ 78,
and ANB ≥ 4, (3) overjet ≥6 mm, and (4) patient in circumpubertal
stages 2 and 3 (CVM2 and CVM3).14 The exclusion criteria were:
(1) previous orthodontic treatment, (2) craniofacial anomalies or
temporomandibular joint (TMJ) disorders, (3) systemic disease or
syndromes, and (4) presence of oral habits. They signed a consent
form after clarifying the purpose of the intervention and the
associated risks and benefits. At the beginning of the trial, the
age of the patients was 10 ± 1.35 years.
Sample Size Calculation
The sample size was calculated using an independent samples
t-test, with an alpha level of 0.05, and a power of 90%. Assuming
a medium effect size difference between groups (effect size d =
0.5), the power analysis showed that 17 patients were required for
each group. To account for possible dropouts, the sample size was
increased to 20 participants in each group, for a total of 40 patients.
Participant Flow
A total of 110 patients were screened, with 70 being excluded
from the study owing to selection criteria. A total of 40 patients
participated in the study. Two patients in the control group
discontinued treatment due to some difficulties related to the
COVID-19 pandemic (Flowchart 1).
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance
Table 1: Descriptive data of patients included in Twin block and control groups
Demographic data Twin block group (n = 20)
Weight (kg) Mean ± SD 36.05 ± 8.46
Height (cm) Mean ± SD 139.05 ± 10.60
BMI kg/m2 Mean ± SD 18.51 ± 3.10
Overjet (mm) Mean ± SD 9.75 ± 1.61
Gender
Male 10 (50%)
Female 10 (50%)
CVM
CVM2 10 (50%)
CVM3 10 (50%)
*Significant p ≤ 0.05
Randomization (Random Number Generation,
Allocation Concealment, Implementation)
Patients were randomly selected using a computer-generated
random list (www.Sealedenvelope.org). Block randomization was
designed with two blocks (experimental and control). Each block
contained two groups (male and female) in random order to allow
a random allocation of the patients and to ensure equal number in
comparison groups throughout the research.21 Stratification factor
was the gender of the patient,22 the actual list length was 40 and
the block size was 20.
The number of the subjects (0–20) were written on papers
inside opaque sealed envelopes and kept in a box. At the time
of intervention, the subject was allowed to choose one of the
envelopes to detect his/her number in the randomization sequence,
thus detecting the group to be joined.
Blinding
It was done only for the assessors by coding the cephalometric files.
It was not possible for the subjects or the operator.
Interventions
Twin block appliance was used to correct mandibular retrognathism
according to the procedures described by Clark.23 The mandible was
guided anteriorly 4 mm by the exacto bite. If the overjet was greater
than 4 mm, and after correcting the 4 mm overjet, another wax bite
was taken, that is, sequential technique of construction bite. The
patients were instructed to wear the device 24 hours a day for a year
to get the most out of all functional forces acting on the dentition,
including mastication forces. Follow-up visits were planned once
every 4 weeks. The anteroposterior dental arch relationship was
examined, with and without the appliance, at each appointment.
All patients in the experimental group received phase 1 treatment
during the growth spurt. However, the control group received fixed
orthodontic appliance using metal orthodontic brackets 0.022
inch slot Roth prescription (Dentaurum Co., Pforzheim, Germany);
patients with mixed dentition received two by four appliance;
and patients with permanent dentition received initial leveling
and alignment until insertion of 0.016 × 0.022 inch stainless steel
archwire to begin active treatment. This lasted about a year, with
patients being followed up on every 4 weeks.
Lateral Cephalometric Radiographs
It was used for the analysis, which was performed using Onyx
TM (Onyx Ceph® Version 2.6.24). Skeletal, dental, and soft tissue
measurements were made.
The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)
Control group (n = 20) Test of significance p-value
33.80 ± 5.27 t = 1.008 0.320
135.45 ± 7.60 t = 1.234 0.225
18.42 ± 2.56 t = 0.094 0.925
  8.60 ± 1.53 t = 2.305    0.027*
10 (50%)
10 (50%) χ2 = 0 1
14 (70%)
6 (30%) χ2 = 1.67 0.197
Outcomes
Primary outcomes were skeletal and dental changes of the maxilla
and mandible after 1 year of treatment or observational period.
Statistical Analysis
Statistical analysis was performed using the statistical package
for social sciences (SPSS) software, version 21 (IBM Corp.,
Armonk, NY, USA) for windows. Qualitative data were described
using numbers and percentages. To ensure the reliability of the
measurements of cephalometric, interobserver and intraobserver
reliability were assessed. Ten pretreatment and posttreatment
cephalometric images were selected randomly and measured
by the same examiner on two occasions within a 2-week interval.
Then comparing these measurements with another examiner was
done to assess interobserver reliability. Continuous variables were
presented as mean standard deviation (SD) for normally distributed
data and median (minimum–maximum) for non-normally
distributed data. Comparison of pretreatment and posttreatment
measurements was accomplished using the paired t-test (or
Wilcoxon signed-rank test). A comparison of both groups regarding
pretreatment and posttreatment values was accomplished using
the Student’s t-test (or Mann–Whitney test). The results were
considered significant when p ≤ 0.05.
R e s u lts
The patients in both groups were well matched according to
gender, weight, height, body mass index, and finally CVM. Except
for overjet, no statistically significant difference was found between
the control and Twin block group (Table 1). For cephalometric
measurements, intra-class correlation coefficient ranged from
0.85 to 1.0, while the inter-class correlation coefficient ranged from
0.87 to 0.99. Except for U1-NF and Ar angle, the initial values of all
cephalometric measurements of patients in both groups showed
similar values with no statistically significant differences (p ≥ 0.05).
Twin block group showed statistically significant differences
nearly in all skeletal measurements (Table 2, Fig. 1). Regarding
skeletal maxillary, mandibular, and maxillomandibular relationship,
all variables (Co-A, SNB, SND, and ANB) showed significant change
after treatment or an observational period between two groups.
SNB increased remarkably by 4° in the Twin block group, but only by
0.68 in the control group. Twin block group showed also an increase
in Co-A by 5.48 mm comparable to 2.38 mm in control group. As a
consequence of the forward advancement of the mandible in Twin
block group, facial convexity (N-A-Pog) decreased by 2.68 mm.
1113
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Table 2: Comparison between pretreatment (T0) and posttreatment (T12) skeletal measurements among Twin block and control group

Cephalometric Twin block group (n = 20) Control group (n = 18)

measurements T0 T12 p-value Mean difference T0 T12 p-value Mean difference
Anteroposterior relationship
SNA (°) 81.06 ± 3.26 80.89 ± 2.61 0.687 −0.17 (−1.07–0.71) 81.75 ± 2.50 81.92 ± 2.82 0.591 0.16 (−0.47–0.79)
Co-A (°) 103.04 ± 11.76 108.51 ± 10.57 ≤0.001* 5.48 (3.79–7.17) 106.78 ± 14.42 109.04 ± 14.37 ≤0.001* 2.38 (1.71–3.04)
SNB (°) 74.55 ± 3.19 78.55 ± 2.74 ≤0.001* 4 (3.22–4.78) 75.02 ± 2.03 75.70 ± 2.45 0.01* 0.68 (0.18–1.17)
SND (°) 71.24 ± 3.06 74.21 ± 3.33 ≤0.001* 2.98 (2.24–3.71) 72.07 ± 2.46 71.88 ± 3.00 0.724 −0.26 (−1.42–0.91)
N-A-Pog (°) 15.50 ± 5.32 12.81 ± 5.65 ≤0.001* −2.68 (−3.66–1.71) 15.05 ± 3.93 15.55 ± 3.72 0.349 0.5 (−0.6–1.61)
ANB (°) 6.51 ± 2.13 2.34 ± 1.30 ≤0.001* −4.17 (−4.91–3.44) 6.73 ± 1.74 6.21 ± 1.74 0.018* −0.52 (−0.93–0.1)
Vertical relationship
SN-GoGn (°) 35.48 ± 5.66 34.04 ± 6.42 0.007* −1.44 (−2.44–0.43) 35.58 ± 6.89 36.15 ± 6.62 0.214 0.57 (−0.41–1.56)
FMA (°) 23.89 ± 5.58 22.54 ± 5.68 0.024* −1.34 (−2.5–0.19) 24.47 ± 4.84 24.77 ± 4.79 0.129 0.3 (−0.1–0.7)
AFH (mm) 137.02 ± 6.35 141.29 ± 7.01 ≤0.001* 4.27 (2.93–5.61) 138.62 ± 9.60 142.97 ± 9.79 ≤0.001* 4.48 (2.45–6.5)
UAFH (mm) 61.32 ± 5.02 63.85 ± 5.48 ≤0.001* 2.53 (1.74–3.31) 61.37 ± 7.28 67.19 ± 8.23 ≤0.001* 5.98 (3.47–8.49)
LAFH (mm) 78.15 ± 2.63 81.51 ± 4.22 ≤0.001* 3.36 (1.84–4.87) 78.82 ± 4.56 84.78 ± 5.72 ≤0.001* 6.05 (3.82–8.27)
PFH (mm) 83.90 ± 8.77 86.82 ± 9.48 ≤0.001* 2.92 (1.67–4.16) 85.53 ± 11.20 91.40 ± 11.48 ≤0.001* 5.9 (4.16–7.65)
Cranial base measurements

The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)

N-S-Ar (°) 129.66 ± 6.39 126.27 ± 5.26 0.006* −3.4 (−5.69–1.1) 126.69 ± 5.12 128.63 ± 5.26 0.053 2.1 (0.04–4.16)
S-Ar-Go (°) 138.82 ± 9.56 141.91 ± 9.32 ≤0.001* 3.09 (1.73–4.45) 144.45 ± 5.11 145.47 ± 5.09 0.007* 1.06 (0.32–1.79)
N-Se (mm) 81.36 ± 7.05 83.58 ± 7.61 ≤0.001* 2.22 (1.24–3.19) 81.64 ± 9.70 85.01 ± 9.67 0.002* 3.53 (1.51–5.54)
S-Ar (mm) 38.70 ± 4.75 40.94 ± 4.82 ≤0.001* 2.24 (1.56–2.92) 39.68 ± 5.88 43.10 ± 5.86 ≤0.001* 3.4 (1.8–4.99)
Mandibular measurements
Ar-Go-Me (°) 124.28 ± 6.65 126.29 ± 7.29 0.002* 2.01 (0.85–3.17) 124.24 ± 5.98 125.73 ± 6.29 0.008* 1.56 (0.45–2.67)
Co-Go (mm) 64.09 ± 6.18 67.32 ± 6.23 ≤0.001* 3.23 (1.69–4.78) 64.62 ± 8.91 69.70 ± 11.23 ≤0.001* 5.16 (2.9–7.41)
Co-Gn (mm) 127.69 ± 14.31 135.46 ± 12.84 0.001* 7.78 (3.45–12.11) 130.46 ± 14.12 139.56 ± 17.04 ≤0.001* 9.49 (4.82–14.16)
Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

Go-Gn (mm) 86.86 ± 5.78 90.74 ± 7.39 ≤0.001* 3.88 (2.03–5.74) 85.79 ± 11.14 92.59 ± 13.04 ≤0.001* 7.01 (3.75–10.26)
Go-Pog (mm) 87.19 ± 7.46 91.77 ± 8.21 ≤0.001* 4.59 (2.92–6.25) 87.01 ± 12.10 93.98 ± 13.58 ≤0.001* 7.09 (4.91–9.28)
Go-Me (mm) 85.85 ± 7.20 91.28 ± 8.32 ≤0.001* 5.43 (3.26–7.6) 84.64 ± 10.87 92.79 ± 12.40 ≤0.001* 8.26 (5.5–11.02)
*Significant p ≤ 0.05
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

Fig. 1: Pretreatment and posttreatment skeletal measurements among Twin block group

Fig. 2: Pretreatment and posttreatment skeletal measurements among control group

However, the decrease in facial convexity in control group was
insignificant (p ≥ 0.05) (Fig. 2). Mandibular plane angle showed
a significant decrease by 1.34 mm in Twin block appliances after
treatment. All facial heights anterior facial height, posterior face
height, upper anterior face height, and lower anterior face height
(AFH, PFH, UAFH, LAFH) showed a significant increase in both groups
after treatment or observational periods.
Additionally, Twin block group showed statistically significant
difference either increase or decrease in all dental parameters
except L6-MP as shown in (Table 3, Fig. 3). Control group showed
significant decrease in U1-NA (°), U1-NA (mm), U1-NF (°), Z angle
after observational periods by 3.24°, 1.44 mm, 3.28°, and 2.99°,
respectively (Fig. 4).
There was a significant decrease in vertical dimensions
(SN-GoGn) in the Twin block group compared to the control group
(p = 0.002). The Frankfort-mandibular plane angle (FMA) showed a
significant change between both groups (p = 0.001). However, face
height (PFH, UAFH, and LAFH) increased significantly after Twin
block treatment. These changes were significant and remarkable
in Twin block group over control group (2.53 mm, 3.36 mm, and
2.92 mm, respectively). Among cranial base variables, N-S-Ar and
S-Ar-Go showed significant change between the groups (p = 0.030
and p = 0.006), (Table 4, Fig. 5).
Among dentoalveolar variables, U1-NF and L6-MP showed
significant changes (p = 0.033 and p = 0.036) between groups either
by a decrease or increase in their values respectively. In comparison
to the control group, overjet decreased significantly by 7.09 mm,
while overbite showed a significant decrease by 2.19 mm. Among
soft tissue variables, the nasolabial angle and Z angle showed
significant change (p ≤ 0.001*) between groups. The nasolabial
angle and Z angle showed increase in Twin block group by 1.39°
and 2.75°, respectively. However, they showed a decrease in control
group by 8.15° and 1.28°, respectively (Table 5, Fig. 5).
Finally, there was a significant and remarkable enhancement
of anteroposterior relationship in Twin block group in comparison
to control group. Additionally, there was a significant decrease
in vertical dimensions (SN-GoGn) in Twin block group compared
to control group (p = 0.002). Also, significant enhancement
in the facial profile of the patients in Twin block group was
observed.

The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022) 1115
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Table 3: Comparison between pretreatment (T0) and posttreatment (T12) dental and soft tissue measurements among Twin block and control group

Cephalometric Twin block group (n = 20) Control group (n = 18)

measurements T0 T12 p-value Mean difference T0 T12 p-value Mean difference
U1-NA (°) 25.51 ± 4.65 20.07 ± 6.42 ≤0.001* −5.44 (−7.39–3.49) 25.52 ± 7.67 22.10 ± 8.30 ≤0.001* −3.42 (−5.08–1.75)
U1-NA (mm) 8.78 ± 1.66 6.59 ± 2.04 ≤0.001* −2.19 (−3.07–1.31) 9.02 ± 2.17 7.58 ± 2.30 ≤0.001* −1.44 (−2.12–0.75)
U1-SN (°) 107.27 ± 5.24 103.47 ± 7.79 0.002* −3.8 (−5.99–1.61) 106.90 ± 7.63 103.48 ± 7.85 0.001 −3.56 (−5.49–1.63)
U1-NF (°) 115.60 ± 4.19 110.28 ± 3.95 ≤0.001* −5.32 (−7.1–3.54) 114.61 ± 7.11 111.32 ± 7.51 ≤0.001* −3.28 (−4.83–1.73)
U1-NF (mm) 34.39 ± 1.99 35.80 ± 2.82 ≤0.001* 1.4 (0.15–2.64) 35.79 ± 2.05 38.32 ± 2.52 ≤0.001* 2.53 (1.4–3.65)
U6-NF (mm) 25.33 ± 2.5 23.87 ± 2.70 ≤0.001* −1.47 (−1.8–1.14) 25.40 ± 2.06 28.27 ± 2.92 ≤0.001* 2.89 (1.46–4.32)
L1-NB (°) 32.22 ± 7.22 35.55 ± 7.37 ≤0.001* 3.34 (1.75–4.92) 32.77 ± 5.01 34.54 ± 4.60 0.007* 1.84 (0.55–3.14)
L1-NB (mm) 7.04 ± 1.98 8.45 ± 2.08 ≤0.001* 1.41 (0.82–1.99) 8.06 ± 1.88 9.00 ± 1.84 0.004* 0.99 (0.36–1.61)
L1-MP (°) 98.91 ± 8.12 102.49 ± 7.12 0.027* 3.57 (0.46–6.68) 100.77 ± 7.33 102.07 ± 7.08 0.168 1.3 (−0.6–3.19)
L1-MP (mm) 48.14 ± 3.43 49.53 ± 4.06 ≤0.001* 1.38 (0.65–2.12) 48.51 ± 3.85 51.75 ± 4.22 ≤0.001* 3.24 (1.7–4.79)
L6-MP (mm) 35.13 ± 2.78 35.39 ± 3.07 0.615 0.26 (−0.79–1.31) 35.27 ± 3.08 37.28 ± 4.00 0.005* 2.11 (0.72–3.51)

The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)

Overjet (mm) 12.30 ± 3.07 5.21 ± 3.98 ≤0.001* −7.09 (−9.17–5.02) 10.75 ± 2.79 10.25 ± 2.36 0.222 −0.5 (−1.34–0.33)
Overbite (mm) 4.54 ± 0.99 2.34 ± 1.55 ≤0.001* −2.19 (−3.03–1.35) 4.67 ± 3.19 3.78 ± 2.36 0.073 −0.88 (−1.86–0.09)
U1-L1 (°) 114.69 ± 6.61 119.35 ± 8.22 ≤0.001* 4.66 (3.11–6.22) 115.08 ± 9.77 117.22 ± 9.91 0.011* 2.21 (0.54–3.89)
Nasolabial angle 113.44 ± 11.50 117.48 ± 11.45 0.001* 4.04 (1.86–6.22) 121.21 ± 11.25 112.84 ± 14.14 ≤0.001* −8.37 (−11.28–5.45)
Z angle 65.94 ± 8.37 69.21 ± 8.10 ≤0.001* 3.26 (2.46–4.06) 64.26 ± 5.86 61.27 ± 8.11 0.015* −2.99 (−5.33–0.65)
Gl’SnPog’ 23.05 ± 3.78 19.32 ± 3.34 ≤0.001* −3.73 (−5.18–2.29) 24.67 ± 3.92 26.22 ± 3.96 0.002* 1.56 (0.66–2.46)
FH to N’-Pog’ 88.36 ± 3.33 90.86 ± 3.67 ≤0.001* 2.5 (1.59–3.4) 87.99 ± 2.37 89.25 ± 2.45 ≤0.001* 1.26 (0.75–1.77)
Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

*Significant p ≤ 0.05
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

Fig. 3: Pretreatment and posttreatment dental and soft tissue measurements among Twin block group

Fig. 4: Pretreatment and posttreatment dental and soft tissue measurements among control group

Discussion
The results of the current trial confirmed the findings of Lund and
Sandler,24 Mills and McCulloch,25 and Trenouth26 that the Twin block
appliance produced an orthopedic effect in both the anteroposterior
and vertical directions, resulting in an improvement in the facial
profile. In the current trial, a significant increase in mandibular
length (Co-Gn) was observed in Twin block group as reported in
other studies.27 Illing et al.28 found an increase in mandibular unit
length measured from point condylion (Co) and Ar to gnathion (Gn).
Toth and McNamara29 found an increase of 5.7 mm in mandibular
unit length (Co-Gn) during a 16-month period when compared with
controls which increased by 2.7 mm. This increase in mandibular
length was a net result of an increase in both ramal (Co-Go) and
body length (Go-Gn). Many studies asked whether the increase of
mandibular length was due to actual growth of the mandible or
forward posturing of the mandible which affects cephalometric
points as point (Ar) and the (B) point.30 In the current trial, there were
no significant differences regarding the mandibular length change
between the two groups; therefore, the increase in mandibular
length is supposed to be due to the actual natural growth of the
mandible. Early intervention with the Twin block appliance increased
the SNB angle by 4.0° which is greater than the increase reported
in previous studies. 31,32 Illing et al. 28 reported 0.8°, while Mills
and McCulloch25 reported 1.9° increase in Twin block group. The
larger change of SNB in the current trial could be attributed to
the longer duration of wearing the Twin block or to a difference in
skeletal age between the studies. Twin block postures the mandible
forward, which explains the increase in the SNB angle; in the current
study, the SNB angle increased by 4.0° in the Twin block group while
it increased by 0.5° in the control group.
In the present trial, besides the stimulating effects of Twin
block on the mandible, there was an insignificant inhibitory effect
of Twin block on the maxilla as reported by previous studies.28,31–33
This conclusion is based on the similar change in the effective
maxillary length in the Twin block and the control groups.
Thus, the Twin block may have no effect on the anteroposterior
maxillary position (point A). The labial bow in Twin block restricted
proclination of upper anterior teeth and this may result in an
inhibitory effect on point “A”. Sagittal jaw discrepancy, therefore,
significantly improved in the Twin block group. The increase in SNB
and decrease in SNA lead to a significant decrease in ANB by 4.17°

The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022) 1117
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

Table 4: Comparison of the changes of skeletal parameters obtained in Twin block and control group

Cephalometric Twin block group (n = 20) Control group (n = 18)

measurements Median Min Max Median Min Max p-value
Anteroposterior relationship
SNA (°) −0.14 −4.00 3.35 −0.02 −2.26 2.52 0.599
Co-A (°) 4.48 1.104 17.249 2.21 0.083 4.564 ≤0.001*
SNB (°) 3.96 0.87 7.73 0.50 −0.96 3.57 ≤0.001*
SND (°) 2.92 0.55 6.67 0.61 −6.51 3.243 ≤0.001*
N-A-Pog (°) −2.28 −7.72 1.48 0.47 −3.90 4.66 ≤0.001*
ANB (°) −4.57 −5.97 0.86 −0.66 −2.48 1.09 ≤0.001*
Vertical relationship
SN-GoGn (°) −1.61 −6.277 3.293 0.29 −2.234 7.664 0.002*
FMA (°) −1.07 −8.37 3.03 0.29 −1.33 2.57 0.001*
AFH (mm) 4.89 0.083 9.443 2.17 0.078 13.298 0.877
UAFH (mm) 1.91 0.595 7.604 4.98 −0.416 17.013 0.030*
LAFH (mm) 2.65 0.349 13.287 5.03 0.706 17.661 0.006*
PFH (mm) 2.26 −0.315 9.632 5.28 −0.625 11.864 0.002*
Cranial base measurements
N-S-Ar (°) −1.02 −18.798 −0.13 0.66 −3.167 10.994 ≤0.001*
S-Ar-Go (°) 2.21 0.106 10.928 0.48 −0.875 4.5 0.009*
N-Se (mm) 1.39 −0.076 8.137 1.77 −0.556 16.559 0.536
S-Ar (mm) 1.81 −0.315 5.578 2.27 0.504 12.093 0.565
Mandibular measurements
Ar-Go-Me (°) 1.21 −0.928 9.884 1.03 0.016 10.181 0.346
Co-Go (mm) 2.12 −0.558 12.37 3.50 −1.546 14.168 0.116
Co-Gn (mm) 2.34 −0.658 28.124 5.20 −0.952 32.596 0.391
Go-Gn (mm) 2.15 0.066 14.874 5.31 0.741 24.051 0.089
Go-Pog (mm) 4.75 −0.3 11.367 6.04 0.38 20.83 0.064
Go-Me (mm) 4.31 −0.67 15.557 6.45 2.738 23.121 0.056
*Significant p ≤ 0.05

Fig. 5: The changes of skeletal, dental, and soft tissue measurements obtained in Twin block and control group

1118 The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance

Table 5: Comparison of the changes of dental and soft tissue parameters obtained in Twin block and control group

Cephalometric Twin block group (n = 20) Control group (n = 18)

measurements Median Min Max Median Min Max p-value
U1-NA (°) −4.92 −11.67 −0.58 −1.66 −9.60 0.10 0.072
U1-NA (mm) −1.60 −5.93 −0.10 −0.97 −5.04 0.49 0.318
U1-SN (°) −3.46 −11.061 8.486 −1.17 −13.928 0.482 0.325
U1-NF (°) −5.84 −12.04 4.13 −2.39 −11.22 1.02 0.033*
U1-NF (mm) 1.11 −2.55 10.20 1.82 −0.98 7.57 0.064
U6-NF (mm) −1.38 −2.61 −0.34 1.45 0.091 8.5 ≤0.001*
L1-NB (°) 1.46 0.132 10.932 1.10 −3.592 7.554 0.286
L1-NB (mm) 1.38 −0.718 5.757 0.94 −0.833 4.455 0.168
L1-MP (°) 1.95 −0.73 31.18 0.63 −6.73 10.87 0.114
L1-MP (mm) 0.64 0.23 6.43 2.26 0.26 11.59 0.01*
L6-MP (mm) 0.33 −4.518 4.514 1.74 −3.719 8.318 0.036*
Overjet (mm) −7.15 −19.72 −0.62 −0.11 −5.64 1.72 ≤0.001*
Overbite (mm) −1.78 −5.01 −0.21 −0.34 −8.74 0.73 0.004*
U1-L1 (°) 3.44 −0.924 10.23 0.77 −1.145 10.522 0.009*
Nasolabial angle 1.39 −0.37 14.38 −8.15 −20.32 −0.30 ≤0.001*
Z angle 2.75 0.61 7.52 −1.28 −21.27 −0.16 ≤0.001*
Gl’SnPog’ −3.42 −13.98 0.22 0.85 −0.01 7.23 ≤0.001*
FH to N’-Pog’ 2.09 0.08 7.23 0.76 0.10 3.02 0.017*
*Significant p ≤ 0.05

in Twin block group in comparison to control group which was
0.52°. Likewise, Alhammadi et al. 32 found a statistically significant
reduction in ANB angle by 2.49° in Twin block group, while control
group increased by 0.29°.
The overjet improvement was 7.09 mm in the Twin block
group and 0.5 mm in the fixed appliance group, and there was
a statistically significant difference between the change in the
two groups (p ≤ 0.001*). Mills and McCulloch25 noted a reduction
of 5.6 mm in patients treated with a Twin block appliance for 14
months. The obvious difference in the change occurred in the
overjet between the two groups suggest a clinical significance too.
Patients in the Twin group enjoyed a large decrease in the overjet
during the 12-month follow-up which is suggested to be due to the
forward positioning of the mandible. The dentoalveolar changes
included lingual tipping and displacement of upper anterior teeth,
labial tipping, and displacement of lower anterior teeth in the
Twin block group and in the fixed appliance group as well. These
results are in agreement with the results of previous studies.25,28,34
Dentoalveolar changes in both groups contributed, in part, to the
overjet improvement. Also, there was a significant reduction of
overbite in Twin block group by 2.19 mm. This was in accordance
with findings by Illing et al.28 who reported a decrease in overbite
by 1.8 mm. However, the decrease in overbite in the fixed group
was only 0.88 mm.
According to Mills and McCulloch, 25 the improvement of
anteroposterior relationship improved facial profile as indicated
by N-A-Pog, which showed a significant reduction in Twin block
group. This, in turn, reduced the convexity of the facial profile.
The facial profile was also improved by a reduction in the
vertical growth pattern as SN-GoGn and FMA angles significantly
decreased in Twin block group and the change was significant
between the two groups. This change in SN-GoGn is in partial
agreement with those stated by Elfeky et al., 31 and Mills and
McCulloch25 who reported an insignificant decrease in SN-MP
angle. The attributed cause for this reduction in vertical dimension
is the maxillary plane rotation as reported in a previous study. 28
The insignificant increase in SN-GoGn and FMA angles in the fixed
group could be attributed to the slight extrusion of molars by the
action of a fixed appliance and might be clinically insignificant.
In the current study, AFH, UAFH, LAFH, and PFH significantly
increased after wearing Twin block appliances, there is a common
agreement in previous studies that Twin block leads to an increase
in LAFH. 28,34 Elfeky et al. 31 reported a significant increase in LAFH,
while Illing et al. 28 reported an insignificant increase. Elfeky et al. 31
and Mills and McCulloch25 reported a significant increase in the
PFH in the Twin block group over the control group. The patients
who received the fixed appliance also showed a significant
increase in AFH, UAFH, LAFH, and PFH. Comparing the changes
that happened in the AFH, UAFH, LAFH, and PFH between the two
groups showed a significant difference in the UAFH, LAFH, and PFH
and an insignificant difference in AFH. A significant increase in the
PFH that coincided with the increase in the AFH, especially in the
fixed group could explain the decreased clockwise rotation of
the mandible. The ramal length increased by 5.16 mm in the fixed
appliance group which was significantly larger than the increase
in the Twin block group (3.23 mm). The effect of the molar intrusion
in the Twin block group and the molar extrusion in the fixed
appliance should also be considered. Therefore, the change in
the AFH was insignificantly different between the two groups.
Additionally, the mean pretreatment value of FMA was 23.89 ±
5.58 and 24.47 ± 4.84 in the Twin block and control groups,
respectively indicating horizontally growing patients.
The smaller the cranial base angle, the more forward the
mandibular position, which increases the tendency of a class III

The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022) 1119
 Class II Malocclusion Treatment using Twin Block vs Fixed Orthodontic Appliance
jaw relationship, and the larger the cranial base angle, the more
backward the position of the mandible, which increases the
tendency of a class II jaw relationship. Also, in contrast to the maxilla,
the mandible is affected more by changes in the cranial base
angle.35 Anderson and Popovich36 found more class II occlusions
in large cranial base angle subjects. Kerr and Adams37 concluded
that the size and shape of the cranial base influence mandibular
position by determining the anteroposterior position of the
condyles relative to the facial profile. In the current trial, the anterior
cranial base and posterior cranial base increased significantly in
Twin block group, but the change was insignificant in comparison
to control group. Mills and McCulloch25 reported an insignificant
increase in the posterior cranial base and a significant increase
in the anterior cranial base comparing them with control group.
Almedia et al.38 reported that individuals with class II malocclusion
had greater anterior and posterior lengths of the cranial base and
more obtuse-angular measurements regarding the skull base in
comparison to class I.
Saddle angle showed a significant decrease and gonial angle
showed a significant increase in Twin block group as reported in
a previous study.25 However, the Ar angle significantly decreased
in the current trial, as reported in previous studies,39 but there is
a controversy with Mills and McCulloch. 25 Bhattacharya et al. 35
reported that cranial base angles affect the rotation of the mandible,
saddle angle was correlated with Y-axis and mandibular plane angle
(SN-GoGn). Correlation suggested that increase in the cranial base
flexure can cause a clockwise rotation of the mandible. In the current
trial saddle angle decreased after wearing Twin block appliance and
this lead to a decrease in SN-GoGn. Abdelkarim et al.40 reported that
patients with mandibular retrognathism had the highest values of
saddle angle (123.3°), followed by patients with normal mandibular
posture (122.7°). Thus, after Twin block appliance, the mandible
moved forward attaining less value of saddle angle. The gonial
angle is the representation of the form of the mandible. This angle
has an important role in predicting growth and it also has specific
effects initially on growth, profile changes, and the condition of the
anterior teeth of the lower jaw.41 Sharma et al.42 also reported an
increase in the gonial angle following class II Twinblock treatment
and discussed that this phenomenon may be the result of changing
muscle functions or due to sagittally directing condylar growth,
leading to greater increments in total mandibular length.
Regarding sof t tissue changes, signif icant positive
improvements in the facial profile of the patients were observed.
The soft tissue facial angle (Gl’SnPog’) decreased by 3.73 in Twin
block group. Shahamfar et al.43 reported a significant decrease
in the Gl’SnPog’ after Twin block therapy. Facial convexity was
also evaluated by FH to N’-Pog’ and it increased by 2.5° after
wearing the Twin block appliance, which is in accordance with
Sumitra and Tandur44 who reported a significant change by 2.2 ±
1.3 in FH-N’-Pog. However, in the fixed appliance group, facial
convexity did not increase as much as the Gl’SnPog’ increased
by 1.56°. According to Shahamfar et al.,43 the advancement of the
mandible increased the Z angle by 3.26° in the Twin block group.
However, in the fixed group, the Z angle decreased by 2.99°. The
decrease in SNA and palatal tipping in upper anterior teeth lead
to an increase in Z angle in the Twin block group.
Finally, Twin block appliance is preferable to fixed appliance
in severe class II malocclusion with increased overjet because it
shows a significant and remarkable advancement of the mandible,
whereas fixed appliance is preferable in mild cases, especially if
crowding exists.
1120 The Journal of Contemporary Dental Practice, Volume 23 Issue 11 (November 2022)
L imi tat i o n s
Being a short-term study is a limitation to draw conclusive results
about the difference in the orthopedic effect between two-phase
orthodontic treatment that include a first phase of Twin block
use in comparison to treatment with orthodontic fixed appliance.
Therefore, a long-term follow-up of the patients who participated
in the current study is planned.
C o n c lu s i o n s
The Twin block postured the mandible forward, improving the
maxillomandibular relationship and the facial profile. Mandibular
length increased similarly in both groups, as did the effect on the
maxilla. Dentoalveolar changes contributed to the significant
overjet improvement in the Twin block group. A significant increase
in the PFH parallel to the increase in the AFH, especially in the fixed
group, controlled the deleterious effect on the profile. Finally, the
clinical application of these results may indicate the importance of
functional appliance in treatment of cases with class II malocclusion
due to mandibular retrusion during growth spurt period.
Clinical Significance
Because of its favorable skeletal effect, early treatment of class II
due to mandibular retrusion with Twin block functional appliance is
recommended. Early treatment with fixed appliance affects mainly
the dentoalveolar component. Long-term follow-up is needed for
further insights.
A vai l a b i l i t y of D ata and M at e r ia l s
The datasets generated and/or analyzed during the current study
are available from the corresponding author on reasonable request.
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