Chapter 8 Treatment of Class Il Division 1 Malocclusion Deep Overbite CLINICAL MANAGEMENT OF TWIN BLOCKS After a century of development of functional techniques {tis surprising thatthe forees of ocelusion have not been used to any significant extent as a functional mechanism. tocorrect malocclusion, Twin Blocks adapt the functional ‘mechanism of the natural dentition, the occlusal inlined plane, to harness the forces of occlusion to correct the ‘malocclusion ‘The Twin Block is a natural progression in the evolu tion of functional appliance therapy. It represents a funda- ‘mental transition from a one-piece appliance that restricts normal funetion to twin appliances that promote normal function ‘Twin Blocks are designed on aesthetic principles 10 {ree the patient of the restrictions imposed by a one-piece appliance made to ft the teeth in both jaws. With Twin Blocks the patient can function quite normally. Eating and speaking can be accomplished without overly restrict normal movements of the tongue, lips and mandible This means that the patient eats with the appliances in the mouth and the forces of mastication are harnessed to maaimize the functional response to treatme Bite Registration The procedure of bite registration for construction of Twin Blocks for a Class If division 1 malocclusion wi deep overbite is described in greater detail, The Exactobite or Projet Bite Gauge is designed to record a protrusive bite for construction of Twin Blocks The blue bite gauge registers 2 mm vertical clearance between the incisal edges ofthe upper and lower incisors, Which is an appropriate interincisal clearance for bite registration in most Class Il division 1 malocclusions with Increased overbite ‘The incisal portion of the bite gauge has three incisal grooves on one side that are designed to be positioned on the incisal edge of the upper incisor and a single groove fon the opposing side that engages the incisal edge of the lower incisor The appropriate groove in the bite gauge for bite registration is selected depending on the ease with ‘hich the patient can posture the mandible forward. In Class Il division 1 malocclusion a protusive bite is registered to reduce the overjet and the distal occlusion ‘on average by 5-10 mm on inital activation, depending, fon the freedom of movement in protrusive function The length ofthe patients protrusive path is determined by recording the overjet in centric occlusion and fully protrusive occlusion. The activation should not exceed 70% of the protrusive path In the growing child with an overjet of up to 10 mm, provided the patient can posture forward comfortably, the bite may be activated edge-to-edge on the incisors with a2.mm interincisal clearance. This allows an overt of up to 10 mm to be corrected on the fist activation, without further activation of the Twin Blocks. Larger ‘overjets invariably require partial correction, followed by reactivation after the initial correction is complet.102 _Twin Block Functional Therapy—Applications in Dentofacial Orthopedics is est fist to rehearse the procedure of bite regs tration, with the patient using a mirror. The patient is instructed to close correctly into the bite gauge before applying the wax or bite registration paste. When the patient understands what is required, softened wax is applied to the bite gauge from a hot water bath. ‘The cli nician then places the bite gauge in the patien’s mouth to register the bite, Alter removing the registration bite from, the mouth, the wax is chilled in cold water and should now be firm and dimensionally stable. In registering the bite the wax is kept clear of the Incisors, so thatthe operator has an unobstructed view (ofthe anterior teeth, This helps the laboratory to position the models correctly in the squash bite (Figs. 8.14 to C). Silicone putty may be used as an alternative to wax to register the bite, but the elasticiy of the material can make it more difficult to locate the models correctly i the construction bite Center lines should be coincident provided no den- tal asymmetry is present. To reduce the overjt when the lower incisors close into the incisal guidance groove on the underside of the bite gauge, the bite gauge Is post- tioned with the upper incisors occluding in the appro- priate groove. It is essential that the patient bites “fully home” into the bite gauge to register the correct vertical ‘opening for the occlusion, Inthe vertical dimension a2 mm interineisalclearan {s equivalent to an approximately 5 or 6 mm clearance Jn the first premolar region. This usually Ieaves 3. mm clearance distally in the molar region, and ensures that space is avallable for vertical development of posterior tecth to reduce the overbite. ts very important to open the bite slighty beyond the clearance ofthe freeway space to encourage the patient 10 close into the appliance rather than alow the mandible to drop out of contact into rest postion (Fig 82), Instructions on Fitting Twin Blocks [At frst the appliance will feel large in the mouth, but ‘within a few days it will be very comfortable and easy to ‘wear Twin Blocks cause much less interference to speech than a one-piece functional appliance. For the frst few days speech will be affected, but will steadily improve land should retum to normal within a week, When the patient has learned to insert and remove the appliance, instruction is given on operating the expansion screw, fone quarter turn per week. The screw should be turned forthe first time after a few days, when the appliances Fig. 8.1: Poe Bte Gauge consucon e brdep ote‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 103 hhave setled in comfortably. As with any new appliance {i is normal to expect a litle initial discomfort. But it {s important to encourage the patient to persevere and keep the appliance in the mouth at all times except for hygiene purposes. The patient may be advised to remove the appliance for eating for the first few days. Then it {s important to leam to eat with the appliance in the ‘mouth. The force of biting on the appliance corrects the jaw position, and learning to eat with the appliance in is {important to accelerate treatment. in a few days, patients should be eating with the Twin Blocks and, within a week, should be more comfortable with the appliance in the ‘mouth than they are without it. In this dlagram he incined panei placed too far aly y break of ater emg the unper Bock tis necessary to check the initial activation and con- firm that the patient closes consistently on the inclined. planes with the mandible protruded in its new position. ‘The overt is measured with the mandible fully retruded and this measurement should be recorded in the patient's ‘notes and checked at every visit to monitor progress. FULL-TIME APPLIANCE WEAR ‘Temporary Fixation of Twin Blocks ‘The most crucial time to establish good cooperation With the patient isin the fist few days after fiting the ‘Twin Blocks, when he oF she i learning to adjust to the new appliance. Twin Blocks have the unique advantage compared to other funetional appliances in that they ean be fixed tothe teeth. Such temporary fixation guarantees full-time wear 24 hours per day and excellent cooperation {s established atthe start of treatment. ‘he technique for fixing the appliances in place is simple. the teeth should first be fissure sealed and treated With topical fluoride as a preventive measure prior to fixation. There are two alternative methods of fixation of ‘win Blocks: 1. ‘The appliances may be fixed to the teeth by spreading cement on the tooth-bearing areas of the appliance ‘but not on the gingival areas. The appliance is then inserted and secured in place with cement adhering to the teeth. Zine phosphate or zine oxide cement is suitable for temporary fixation. Alternatively, a small ‘quantity of glass ionomer cement may be used, taking care to ensure that the appliance can be freed easily from the teeth (Fig 8.3). 2. Twin Blocks may also be bonded direety to the teeth by applying composite around the clasps. Tiss a use ful approach in mixed dentition when ball clasps may bbe bonded directly to deciduous molars to improve fixation. Fig. 83: Twin Blocks comentod in poston,104 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics After 10-14 days, when the patient has adapted to the ‘Twin Block and is wearing it comfortably, the appliance can be removed by freeing the clasps witha sickle scaler. ‘Sharp edges of composite can be smoothed over, leaving. some composite attached to the teeth, The altered con- tour of the deciduous teeth will improve the retention (of the appliance. If cooperation is doubsful at any stage of treatment, the operator should not hesitate to fix the appliance in for 10 days to regain control and restore full-time wear. After 10 days full-time wear the patient is. ‘more comfortable with the appliance in the mouth than without ic MANAGEMENT OF DEEP OVERBITE COverbite reduction is achieved by trimming the occlusal blocks on the upper appliance, $0 as to encourage erup- tion of the lower molars. A progressive sequence of trim. ‘ming aims to encourage selective eruption of posterior teeth to increase the vertical dimension. The objective Is. to increase lower facial height and improve facial balance by controlling the vertical dimension (Fig. 8.4). Provided. the correct sequence of trimming is cartied out to con- trol eruption, closure of a posterior open bite is acceler ated in Twin Block treatment compared with a one:plece functional appliance, which is removed for eating, and allows the tongue to spread between the teeth and pre- vent eruption of the posterior teeth, Posterior support {s established as the molars erupt into occlusion before relieving the appliance over the premolars until they also ate free to erupt into occlusion ‘The management of deep overbite begins even before the appliance is fited-by placing elastic separators in the ‘molar region, When the appliance is fite, the separators are removed and the appliance is adjusted to encourage the mola to erupt. In the treatment of deep overbite, itis important to encourage vertical development of the lower molars from, the stat of treatment, by trimming the upper bite block ‘occlusodistally to allow the lower molars to erupt. ‘The upper bite block is progressively wimmed at each visit over several months, leaving only a small vertical clearance of 1 or 2 mm over the lower molas to allow them to erupt into occlusion. The clearance between the upper appliance and the lower molars is checked by inserting a probe (or explorer) between the posterior teeth to establish thatthe lower molars are free to erupt AAC each subsequent visit for appliance adjustment the Fig. 84: Sequence of timming tock 10 reduce overte. The Inclined planes mesa 1 he lower fat molar and tema tac. “This reduces the rk of teakage afer Werming the upper bck. ‘occlusion Is cleared by sequentially trimming the upper block occlusodistally to allow further eruption of the lower molar, again checking thatthe clearance is correct. ‘This sequence of adjustment does not allow the tongue to spread laterally between the teeth to prevent eruption of lower molars, and results in a more rapid development of the vertical dimension. The molars will, erupt into occlusion normally within 6-9 months. Itis important that the mandible continues to be sup- ported ina protruded position throughout the sequence of trimming the blocks. The leading edge of the inclined plane on the upper bite block remains intact, leaving a ‘wiangular wedge in contact with the lower bite block.‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 105 ‘When the molars have erupted into occlusion, a lateral ‘open bite is present in the premolar region because the lower bite block i still ntact. The final adjustment at the fend of the Twin Block stage aims to reduce the lateral ‘open bite by trimming the upper occlusal surface of the lower bite block over the premolars by 2mm. To maintain, adequate inclined planes to support the corrected arch relationships, the lower bite block is shaped into atrian- {gular wedge distally in contact with the upper block. Relieved of occlusal contact, the lower premolars ‘erupt, carrying the lower appliance up ito occlusion. The ‘occlusal height ofthe upper premolars is maintained by Interdental clasps that effectively prevent their eruption ‘The lateral open bite in the premolar region now reduces and the occlusal plane begins to level. ESTABLISHING VERTICAL DIMENSION The Intergingival Height A simple guideline is used to establish the correct vertical dimension during the Twin Block phase of treatment. The intergingival height is measured feom the gingival margin, of the upper incisor to the gingival margin of the lower {incisor when the teeth are in occlusion (Pig. 8). ‘This measurement has proved to be beneficial for temporomandibular joint (TMI) practitioners who use the intergingival height to establish the vertical dimension in a restorative approach to rebuild the occlusion in ‘treatment of patients with TM) dysfunction. ‘The “comfort zone" for intergingival height for adult patients is generally found to be 17-19 mam. This is equ valent to the combined heights of the upper and lover incisors minus an overbite within the range of normal Patients whose intergingival height varies significantly 8: Measuring the internal hight from the “comfort zone" are at greater risk of developing, ‘TM} dysfunction. This applies both to patients with a deep overbite, whose intergingival height i significantly reduced, and to patients with an anterior open bite who have an increased intergingival height. ‘The intergingival height is useful guideline to check progress and to establish the correct vertical dimension during treatment. Measurement of intergingival height {is made by using a millimeter ruler or dividers with a verler scale to measure the distance between the upper and lower gingival margins. To keep track of progress in ‘opening or losing the bite, this measurement should be noted on the record card at every visit. In Twin Block treatment the correct intergingival height is achieved with great consistency. Overcorrection of deep overbite is advisable as a precaution against any tendency to relapse. ‘The intergingival height varies according to the patient’s age and stage of development, and the height fof the incisor crowns. It is smaller in a young patient whose incisors have recently erupted, and larger in an ‘older patient with gingival recession, SOFT TISSUE RESPONSE Rapid changes occur in the craniofacial musculature fn response to the altered muscle function that results from treatment of malocelusion by a full-time functional appliance. As a result of altered muscle balance, signifi ‘ant changes in facial appearance are seen within 2 or ‘3 weeks of starting treatment with Twin Blocks. The rapid {improvement in muscle balance is very consistent and. is observed on photographs as a more relaxed posture Within minutes, hours or days of starting treatment. ‘The Twin Block appliance positions the mandible downward and forward, increasing the intermaxilary space. As a result tis difficult to form an anterior oral seal by contact between the tongue and the lower lip, and. patients adopt anatural lip seal without instruction. As the appliance is worn fll time, even during eating. rapid soft tissue adaptation occurs to assist the primary functions of ‘mastication and swallowing that necessitate an effective anterior orl seal. The patient adopts a lip seal when the ‘overjet is eliminated inthe most natural way possible, by cating and drinking with the appliance in the mouth. This encourages a good lip seal as a functional necessity to prevent food and liquid escaping from the mouth, A good. lip seal is always achieved by normal funetion with Twin Blocks, without the need for lip exercises.106 Twin Block Functional Therapy Applications in Dentofacial Onhopedics Case Report: LJ Aged 10 Years 9 Months ‘This san example of treatment of an uncrowded Class IL division 1 malocclusion with good archform, deep over bite, a fll unit distal occlusion and an 11 mm overjet. The Class Il skeletal discrepancy is measured by a convexity of 7 mm, due to a combination of maxillary protrusion and mandibular retusion. The maxilla is narrow, typical of a distal occlusion and the patient shows only four "upper incisors when she smiles. The upper intereanine distance Is teduced due to lack of support from the lower labial segment. "This is a major etiological factor causing the mandible to be locked in distal occlusion, Maxillary ‘expansion isrequired together with functional mandibular advancement in order to unlock the malocclusion, ‘The facial type is mild brachyfacial, and there is no mally a good prognosis for correction of this type of mal- ‘occlusion provided the unfavorable occlusal factors are climinated to allow the mandible to develop forward into ‘4 norinal relationship with the maxilla. Clinial examina- tion confirms that the profile improves when the patient postures the mandible downward and forward to a nor ‘mal overjet with the lips closed (Figs. 8.6 tL). Bite Registration A construction bite registers an exige-to-edge occlusion “with 2 mm interineisl clearance. This results ina vertical clearance in the fist premolar region of 6 mi. Adjustment 4+) When the appliance is fited atthe insertion appoint ‘ment, the patient is instructed to turn the midline screw one quarter turn per week, expanding the upper arch 10 assist in unlocking the mandible from distal ‘occlusion. + Correction of deep overbite is initiated at the stare ‘of treatment by trimming the upper bite block clear of the lower molars, thereby stimulating molar erup- tion, Iti important to leave only 1 or 2 mm occlusal clearance to encourage eruption, so that the tongue cannot spread between the teeth and delay vertical development. The leading edge ofthe inclined plane ‘ofthe upper bite block remains intact to provide con- tact with the lower bite block. This contact isthe key ‘mechanism which provides the functional stimulus to growth by occlusion with the inclined plane on the lower appliance. To avoid gingival irritation in the initial stages of adaptation to the appliance, the fiting surface of the lower appliance is trimmed slightly in the area of the sulcus Lingual to the lower incisors and canines. Alter ‘3 months of treatment the overjet is reduced from 10 mm_ to 3 mm, The posterior teeth are still out of occlusion at this stage. Over the next 3 months the occlusal surface of the upper bite block is trimmed in a sequential fashion at each vist, stil maintaining the leading edge of the Inclined plane intact. This will eventually result in the removal of all the acrylic covering the upper molars. ‘his allows the lower molars freedom to erupt fully into ‘occlusion. The biting surface of the lower Twin Block is then trimmed slightly in the premolar region to allow ceruption of the premolars carrying the lower appliance vertically with them as they erupt. This will then reduce the lateral open bite in the premolar region. The open bite quickly resolves and alter 6 weeks an upper support appliance is fitted with an anterior inclined plane and the lower Twin Block left out. The occlusion setes without further adjustment Full-ime appliance wear continues for 4 months, followed by 4 months of night-time wear to retain the corrected occlusion. Duration of Treatment Active phase: 7 months with Twin Blocks Support phase: 4 months full time with an anterior inclined plane Retention: 4 months anterior inclined plane at night only Total treatment time: 15 months, including retention inal records: 5 years out of retention.‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 107 Case Report: LI Figs. 8A to L: Tresimont: (A) Preles at ages 10 years 9 merihe (Blow westment), 11 yeus 3 months (ater weatmend and 16 yous ‘mente: {8 to 0) Occsn teore veatren 4 harow upper ch wth a 10 mm ove and lower isco bung mo the pe: {€) Atar 6 martha the overt coeste’ and posterior open bie presert nthe et slags of eaten. The upper lock = nme to ercaurago lwer mola oupion. (F) Aer the lower molar Mave upd io tus, the lower eccusal eck Wed alow ‘he intel epen bien fe prema’ tegon to rece. Te lower cecal plane how begins Yo level, wie the upper premalar hag ‘S'masmanse by the upper applance. ‘Aner 9 monde a reament the paler 6 Yeady to proceed to the suppor stage: (G) AN aneror Incined plane ie tits to supper the coreced nose eaters. The lower applarc i leh ot and te lower premel’s nd cannes {re ree to et io ociolon: (H) Appearance before Weatnent at age TO years 9 months: () Appearance afer treatment: 1 L) The ‘eaten 5 years ut tenon,108 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics Case Report: LI cry ne ten a vo | ‘ss 4 y 2} ‘3 Marly plane at ANS (Conus ais at PH Nasionbason anion Basion superimposition Nasion bation at CC‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 109 FUNCTIONAL ORTHOPEDIC THERAPY Case Report: PK Aged 11 Years 4 Months “This young get presents a disfiguring Class It division 1 ‘malocclusion with an overjet of 17 mm and an exces- sive overbte, A combination of maxillary protrusion and. ‘mandibular retrusion has resulted in a severe distal occlu sion, and an equally severe transverse diserepaney with ‘buccal occlusion ofthe upper premolars and a traumatic ‘occlusion ofthe lower incisors in the palate. The maloc ‘clusion is further complicated by the congenital absence fof the second lower premolar on the left side, resulting {in displacement of the lower center line to the left. The ‘dramatic facial and dental changes in tis case illustrate the benefits of a functional orthopedic approach to treat ‘ment compared to a conventional orthodontic approach. Before treatment this patient has the typical listless appearance of many severe Class Il division 1 maloce~ lusions. This has been described as “adenoidal facies” land is evident in the dull appearance of the eyes and ‘poor skin tone. A large overt with a distal occlusion is. frequently associated with a backward tongue position, and a restricted airway. These patients cannot breathe properly and, as a result, are subject to allergies, and. ‘upper respiratory problems due to inefficient respiratory funetion. ‘Alter only 3 months ofteatment the patient undergoes 4 dramatic change in facial appearance, which exceeds the parameters of orthodontic treatment in this time scale. ‘The patient appears more alert and there is a marked Improvement in the eyes and the complexion. This is a fundamental physiological change, extending beyond the limited objective of correcting a malocclusion. he upper pharyngeal space inereased from 5 mm before treatment 10 20 mm after treatment. Increasing the airway achieves the crucially important benefit of improving respiratory function and may influence basal metabolism as a secondary effect. Increase in the pharyngeal airway is 4 consistent feature of mandibular advancement with a full-time functional appliance. This isthe most significant functional benefit of advancing the mandible, as opposed. to retracting the maxilla in the treatment of Class TL ‘malocclusion. ‘Conventional fixed appliances with brackets cannot produce equivalent physiological changes in the treat- ‘ment of patients with severe malocclusions. A func tional approach achieves a rapid improvement in the facial appearance and can be followed by a simplified ‘orthodontic phase of treatment to detail the occlusion (igs 8.74 10), Treatment Plan ‘To retract the manilla and advance the mandible. ‘The dental asymmetry would be difficult to eliminate in view ‘of the absence of 5. An orthodontic phase of treatment ‘was planned to complete the treatment. Appliances ‘+ Standard Twin Blocks ‘+ Support phase with an anterior inclined plane ‘+ Fixed appliances to complete the treatment. Adjustment ‘The registration bite reduced the overjet from 17 mm to ‘8mm on the initial activation. This correction was achieved. {in 8 weeks, when the inclined planes were reactivated 10 ‘an edge-to-edge incisor occlusion by adding cold cure acrylic to the mesial of the upper inclined plane. The ‘normal adjustments were made to reduce the overbite by ‘wimming the occlusal surface of the upper bite blocks to allow eruption of the lower molars. Twin Blocks were effective in quickly reducing the overjet from 17 mm. to 2 mm in 6 months. After 7 months of treatment the lower appliance was left out and an anterior inclined plane was fitted to retain the position as the remaining posterior open bite resolved and the buccal teeth setled {nto occlusion. The space was closed with a simple fixed appliance, and the slight displacement of the centerline ‘was accepted. This was followed by an orthodontic phase {to complete treatment, Duration of Treatment Active phase: Twin Blocks for 7 months ‘Support phase: 6 months full-time wear ‘Orthodontic phase: 2 months.110 _Twin Block Functional Therapy—Applications in Dentofacial Orthopedics Report: PK 1A) Proce a ages 11 years 4 manthe (olor trainer), 11 years 7 months (3 mons ae treatment) ar 4 merit: (Bt 0) Oucusion bere eamert overt? an (Eo G) Osa change ae 11 months weament tage 11 years 4 mons () Fac change ater 3 ments of weatment showy mated Fiyatiogal improvement, () Fac! change ar 11m o exinan‘Treatment of Class Il Division 1 Malocclusion Deep Overbite_111 Figs. 8.7K to P: Treaimant:(K are M) Facial appearance at 18 years 4 menihs () Upper occuel view ar treatment (N and P) CGochsion at age 18 years 7 month; (0) Lower cocusal view afer teint nate congental auence 0/5 (N and P) Oosison st ape 18 years 7 mens.112_Twin Block Functional Therapy—Applications in Dentofacial Orthopedics Case Report: PK (Corpus ais at PM sion bason at CC‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 113 4 patient who Is growing well and has ftee protrusive movement may be corrected without reactivation of the ‘win Blocks during treatment. If growth i less favorable, ‘or in treatment of larger overjets, ot when the prot sive path of the mandible is restricted, itis necessary 1 reactivate the inclined planes more gradually in pro: _ressive increments duting teatment. Reactivation isa simple procedure that is achieved by ‘extending the anterior incline of the upper Twin Block ‘mesally to increase the forward posture. Cold cure acrylic may be added atthe chairside, inserting the appliance to record a new protrusive bite before the acrylic is fly se. Even in cases with an excessive overet, a single react: vation of Twin Blocks is normally sufficient to correct most malacclusions (Fig. 8. Fig. 88: By ada tthe lower Twin Block ‘Adston of sonic fo te arteor icine of the upper Its important that no acrylic is added to the distal Incline of the lower Twin Block, especially in the teat ment of deep overbite. Extending occlusal acrylic of the lower block distally would prevent eruption ofthe lower first molar. I is necessary to leave the lower first mol free to erupt so thatthe overbite is reduced by increasing the vertical dimension. Ifthe patient’ rate of growth is slow or the direction ‘of growth is vertical rather than horizontal, iti advisable to advance the mandible more gradually over a longer period of ime to allow compensatory mandibular growth, to occur. This can be taken into account by reactivating ‘Twin Blocks progressively to extend the inclined plane of the upperbite block mesilly (Petrov & Stutzman, I Alter extending the upper block forward the contact, ‘of the upper block on the lower molar should be checked. ‘to make any necessary adjustment to clear the occlusion, ‘ith the lower molar for correction of deep overbite. PROGRESSIVE ACTIVATION OF ‘TWIN BLOCKS Progressive activation ofthe inclined planes is indicated 8 follows: ‘Ifthe overjet is more than 10 mm itis advisable to step the mandible forward, usually in two stages. ‘The frst activation is in the range of 7-10 mm. The second activation brings the incisors to an edge-to ‘edge occlusion. 1+ In any case where fll correction of arch relationships ‘snot achieved aftr the initial activation, an additional ‘+ Ifthe direction of growth is vertical rather than hot zontal, the mandible may be advanced more gradually to allow adequate ime for compensatory mandibular ‘growth to occur (Figs. 8.94 and B). Fgh. 8.94 and B: Screw acvarcenert mechani for progressive actraton cl Twn Black in veutnent of veal growth and anteer ‘open bef desorbed in Chapters 7 and 12114 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics ‘+ Phased activation is recommended in adult treatment, here the muscles and ligaments are less respon- sive to a sudden large displacement of the mandible (Chapter 20 Adute Treatment). ‘+ In the treatment of TMT dysfunction, care must be ‘exercised so a8 not to introduce activation that is beyond the level of tolerance of injured tissue. It is best to be conservative and advance the mandible slowly toa position that is comfortable and will allow the patient to rest and function without discom- {ort (Chapter 21 Temporomandibular Joint Pain and Dysfunction syndrome). SUMMARY—ADJUSTMENT AND CLINICAL MANAGEMENT Stage 1—Active Phase Appliance Fitting frst necessary to check thatthe patient bites com- fortably fo a protrusive bite with the inclined planes occluding correty. To avoid ieitation as the appliance ‘seven home by the occasion during the fist few days of weat itis important to relieve the lower appliance slighty over the pingivae lingual to the lower incisors ‘he clasps ae adjusted to hold the apliance securely in postion without impinging on the gingival margin. fa labial bow is present, it shouldbe out of contact with the upper incisors. Initial Adjust ment-after 10 Days “The patient should now be wearing the appliances com- fortably and eating with them in position. The initial dis- ‘comfort ofa new appliance should have resolved and the patient should be biting consistently in the protrusive bite. Patient motivation is reinforced by offering encourage- ‘ment for their success on becoming accustomed to the appliance so quickly, and reassurance on any difficulties. “The patient should now be turning the upper midline screw one quarter turn per week. In the treatment of deep ‘overbite the upper bite block should be trimmed clear of the lower molars leaving a clearance of 1-2 mm to allow these to erupt. AL this stage, its important to detect ifthe patient is, {ailing to posture forward consistently to occlude correctly ‘on the inclined planes. This would indicate thatthe appl lance has been activated beyond the level of tolerance of the patient’s musculature. It would then be appropriate to reduce the activation by trimming the inclined planes, to reduce the forward mandibular displacement until the patient closes comfortably on the appliances. The angu- lation of the inclined planes may be reduced to 45° if the patient is failing to posture consistently forward to ‘occlude the blocks correctly. ‘This may be an early sign that progress wil be slower ‘than normal, due to weakness in the patient’s musculature reducing the functional response. This response is more likely in the patient who has a vertical growth pattern ‘Mandibular advancement will then be more gradual, ‘usually requiring incremental activation of the occlusal inclined planes. ‘Adjustment Visit-After 4 Weeks [Atthe first monthly vst postive progres should already bbe evident with respect to better facial balance. Photo- sraphs demonstrate this very clearly, and may be repeated Aa this stage to record progress. Progress can be confirmed also by noting the amount of reduction in overt, as measured intraorally with the ‘mandible fully retracted. To monitor progress, the ovrjet should be measured and noted onthe record card at each ‘isi ‘this allows any lapse in progress or cooperation wo be ‘deected readily. There should bea steady and consistent reduction of overjet and correction of distal occlusion. If ‘cooperation is suspect iti advisable to fix the appliance in place in the mouth to exert immediate control and restore full-time appliance wear Apart from monitoring progres, only minor adjust ‘ment is requited at this stage. Check that the screw is ‘operating correctly, and adjust the clasps if necessary to Improve retention. ithe appliance includes a labial bow, adjust it so as to be out of eontaet with the upper incisors. In the treatment of deep overbite ensure thatthe lower _molars are notin contact with the upper block. The upper block is trimmed occlusodistally to clear the occlusion, using a probe (explorer) to confirm that the lower molars. ‘do not contact the upper block Routine Adjustment-Time Interval 6 Weeks A similar pattern of adjustment continues with steady correction of distal occlusion and reduction of overjet. ‘The upper arch width is checked at each visit, until the ‘expansion is sufficient to accommodate the lower arch in. its corrected position and no further turns of the screw are requited.‘Treatment of Class Il Division 1 Malocclusion Deep Overbite 115 ‘Trimming of the upper block continues until all the ‘occlusal cover is removed from the upper molars to allow the lower molars to erupt completely into occlusion. ‘The overt, overbite and distal occlusion should be fully corected by the end of the Twin Block phase. A slight open bite in the buccal segments should be limited tw the premolar region. It is now appropriate to proceed tw the support phase, ‘Stage 2—Support Phase Anteroposterior and vertical control remains equally ‘important in the support phase to maintain the correc tion achieved in the active phase. ‘The purpose of the support phase is to maintain the corrected incisor relationship until the buccal segment ‘occlusion is fully established. To achieve this objective, an upper removable appliance is fited with an anterior inclined plane to engage the lower incisors and canines ‘The lower appliance is le out at this stage and ‘removal ofthe posterior bite blocks allows the posterior ‘eth to erupt into occlusion. The anterior inclined plane ‘extends distally to engage all si lower anterior teeth and. the patient must not be able to occlude lingual to the inclined plane. It must be adequate to retain the incisor relationship effectively, but at the same time should be ‘neat and unobtrusive so as not to interfere with speech. Many anterior inclined planes are mistakenly made too large and bulky which causes discomfort for the patient, who may then be discouraged from wearing such an appliance. There is no necessity forthe anterior inclined plane to extend much beyond the level of the {incisal tips ofthe upper incisors, provided it also extends. far enough distally © engage the canines. “The patient must understand the importance of wear: ing the support appliance full time to prevent relapse at this ritical stage of treatment. An appliance that fs com: {ortable and carefully designed is more readily accepted by the patient. ‘Vertical control is essential during the support phase ‘after reduction of overbite. To maintain the corrected ver. tical dimension, a la occlusal stop of acrylic extends for. ‘ward from the inclined plane to engage the lower incisors. “The occlusal stop is an important addition to maintain the corrected intergingval height as the posterior teeth ‘erupt into occlusion. The upper and lower buccal teeth should normally sete into occlusion within 2-6 months, depending on the depth of the overbite. Retention ‘Treatment is followed by @ normal period of retention [As the buccal segments setle in fully, full-time wear fof the support appliance allows time for internal bony remodeling to support the corrected occlusion. A good ‘buccal segment occlusion isthe cornerstone of stability alter correction of arch-to-arch relationships. Appliance ‘wear is reduced to night-time only when the occlusion is fully established. If treatment is carried out in the mixed dentiion, retention may continue with an anterior inclined plane to support the occlusion during the transition to the permanent dentition. In early treatment of severe skel- ‘tal discrepancies a night-time functional appliance of the monobloc type may be used as a retainer. This gives Additional functional support and may be activated to enhance the orthopedic response to treatment during the transitional dentition. An excellent alternative is the ‘occlusoguide, which sa preformed appliance resembling ‘8 mini-posiioner. It is available in a range of sizes and. is designed to retain the corrected incisor relationship ‘with a functional component to retain the correction to 4 Class I occlusion, The management of this appliance is ‘described in Chapter 9 on mixed dentition treatment. Advantages of Twin Blocks ‘he Twin Blockis the most comfortable, the most aesthetic and the most ecient ofall the functional appliances. ‘win Blocks have many advantages compared to other functional appliances: + Comfort—patients wear Twin Blocks 24 hours per day and can eat comfortably with the appliances in place. + Aesthetos—Twin Blocks can be designed with no visble anterior wites without losing’ efficiency in ‘correction of arch reladonshps. + Funtion—the occlusal incined plane isthe most anual of all the functional mechanisms, There is tess inererence with normal function because the mandible can move freely in anterior and lateral terurion without being restricted by a bulky one- piece appliance + Patent compliance—Twin Blocks may be fixed tothe teeth temporary or permanent to guarantce patent compliance. Removable Twin Blocks canbe fed in the mouth forthe frst week or 10 days of treatment to ensure that the patient adap ul to wearing them 24 hours pe day.116 _Twin Block Functional Therapy—Applications in Dentofacial Orthopedics Facial appearance—from the moment Twin Blocks fare fitted the appearance is noticeably improved, “The absence of lp, cheek or tongue pads, a used in some other appliances, places no restriction on nor- ‘mal function, and does not distor the patients facial “appearance during treatment, Improvements in facial balance are seen progressively in the first 3 months ‘of treatment Speech—patients can lear to speak normally with ‘Twin Blocks. In comparison with other funetional appliances, Twin Blocks do not distort speech by res ‘wicting movement of the tongue, lips or mandible. Glnical_ management—adjustment and activation is simple. The appliances are robust and not prone ‘to breakage. Chairside time is reduced in achieving ‘major orthopedic correction, ‘Arch development—Twin Blocks allow independent ‘control of upper and lower arch width. Appliance design is easly modified for transverse and sagittal arch development. Mandibular repositioning—fulltime appliance wear ‘consistently achieves rapid mandibular repositioning ‘that remains stable out of retention, ‘Vertical control—Twin Blocks achieve excellent con: trol of the vertical dimension in treatment of deep ‘ovetbite and anterior open bite, Vertical control is significantly improved by full-time wea Facial asymmetry—asymmetsical activation corrects facial and dental asymmetry in the growing child Safety Twin Blocks can be woen during sports activi ties with the exception of swimming and violent con: ‘tact sports, when they may be removed for safety Efficiency—Twin Blocks achieve more rapid corre: ‘ion of malocclusion compared to one-piece func: tional appliances because they are worn fulltime. This benefits patient in all age groups. Age of teatment—arch relationships can be corrected, {romearly childhood to adulthood. However, treatment {s slower in adults and the response isles predictable. Integration with fixed appliances—integration with ‘conventional fixed appliances s simpler than with any ‘other functional appliance. in combined techniques, ‘Twin Blocks can be used to maximize the skeletal correction while fixed appliances are used to detail the occlusion. Since Twin Blocks do not need to have anterior wires, brackets can be placed on the anterior teeth to correct tooth alignment simultaneously with ‘correction of arch relationships during the orthopedic phase. During the support phase an easy transition ‘can be made to fixed appliances. ‘+ Treatment of temporomandibular joint dysfunction— the Twin Block may at times also be used as an etlec- tive splint in the treatment of patients who present ‘TMJ dysfunction due to displacement of the condyle distal tothe articular dsc. Full-time wear allows the disk to be recaptured, when disk reduction is pos sible in early stage TM) problems, and at the same time sagittal, vertical and transverse arch develop- ‘ment proceeds to eliminate unfavorable occlusal con- tacts (Chapter 21 Temporomandibular Joint Pain and Dysfunction syndrome). ROBIN’S MONOBLOC: THE ORIGINAL SLEEP APNEA APPLIANCE! Pierre Robin (1902) used the monobloc to treat patients ‘with severe mandibular retrusion, in the condition now defined as the Pierre Robin syndrome. The ortho- dontic aim of correcting Class Il malocclusion was only addressed later when Andresen developed the activa Robin's monobloc was the original sleep apnea appli- ance (Fig. 8.10). We tend to forget that functional therapy developed, not to correct a dental malocclusion, but t0 ‘keep patients alive! Improving the airway delivers holis- tic benefits that profoundly affect a patient's health and. function. Accommodating the tongue in a forward post tion by expanding the maxila and advancing the mandi- ble i fundamental in improving the pharyngeal alway. ‘This remains the baste concept of functional therapy. Fig. 8.10: Robes monctoe.‘Treatment of Class Il Division 1 Malocclusion Deep Overbite_117 ‘Twin Blocks Increase the Airway Recent research supports the view that Twin Blocks Increase the airway [Verma etal. (2012) Vinoth etal (2013) and Temani (2013). A recent ance, “Cephalometric ‘evaluation of hyoid bone postion and pharyngeal spaces following ueatment with TwinBlockappliances” compared wee groups of patents; hypodivergent, normodivergent and hyperdivergen. This study concluded tha the width ‘ofthe upper airway significantly increased (p < 001) and the ANB angle significanty decreased (p < 0.001) in all three groups with forward movement of the mandible. ‘Aer treatment sith Twin Block appliance, signiiant changes occurred in horizontal dimension (anterior displacement) which resulted in significant increase in ‘width of the upper pharynx in all three groups. This is an important finding and it mets repetition that patients ‘with an excessive overjet and overbite before treatment, are typical ofthis effect. Before teatment many patients. with severe Class II division 1 malocelusions have a. typical listless appearance, evident inthe dull appearance Of the eyes and poor skin tone (Figs. 8.114 to F). After ‘only 3 months treatment patients undergo a dramatic ‘change in facial appearance. They appear more alert ‘and there is a marked improvement in the eyes and the ‘complexion. A large overjet with a distal occlusion is, Frequently associated with a backward tongue position, ‘and a restricted airway. These patients cannot breathe properly and, as a result, are subject 10 allergies, and upper respiratory problems due to inefficient respiratory function. Functional therapy to expand the maxilla and ‘advance the mandible increases the airway. This is a fundamental physiological change, extending beyond the limited objective of correcting a malocclusion, Figs 8.118 to F: Facal and arway changes belo and fr Twin Blocks.118 Twin Block Functional Therapy—Applications in Dentofacial Orthopedics Figs 8.128 to F: rv Twin Blocks wih petormed Hock Treatment of Sleep Apnea and Snoring: Invisible Twin Blocks with Preformed Blocks ‘Simple Twin Blocks are prepared by fitting preformed blocks on models and forming clear appliances with [Ess material in a Biostar molding machine (Figs. 8.124, tw E). The appliances prevent sleep apnea by posturing the mandible downward and forward. This advances the ‘tongue and improves the posterior airway. Appliances ike this can be worn by ong distance drives. These appliances. may be used as retainers after treatment of Class 1 ‘malocclusion, or in suitable cases for Class I correction. “This design is suitable for any stage of development, Including mixed or deciduous dentition through to adult, therapy. The preformed blocks simplify the construction, ‘and the appliances may be made in house by placing the blocks on models before forming appliances with Ess material, REFERENCES [ets of Twin Block on Pharyngeal Airway Space in Clas I Division I Cases A 3D CT study. Oral Research presentation ‘Annual Session AAO, 2013 by Dr Paral Tema, research sade in nip Petrovic A Stutzmann (1977) “Further investigations int the functioningofthe “comparator” ofthe servosystem respective postions of the upper and lower dental arches) in the cotrl ofthe condyarcarlage growth ate and ofthe lengthening of the aw in The Biology of Occlusal Development, Monograph [Na-6, Craniofacial Growth series, ed Me Namara JA, Center for Human Growth & Development, University of Michigan, pp. 225-91, Verma et a, (2012). Cephalometic evaluation of hyoid bone Position and pharyageal spaces following, weatment with Twin Block appliances compared 3 groups of patents, Iypodivergent, normodivergent and hiperdivergent. | Orho- dont Sei. 16):77-2 Vinoth SK, Thomas AV, Netravathy R. (2013). Cephalomteric changes in airway dimensions with twin block therapy in ‘growing Class I patents. | Pharm Bialied Se (Suppl 1): S58,