Presented by-

Anupriya srivastava
Mds III rd year

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 INTRODUCTION
 DEVELOPMENT OF TWIN BLOCK
 PHILOSOPHY BEHIND TWIN BLOCK
 ADVANTAGES
 CASE SELECTION
 APPLIANCE DESIGN
 DIAGNOSIS AND TREATMENT PLANNING
 CLINICAL GUDELINES
 CONSTRUCTION BITE
 PHASES OF TREATMENT

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 MANAGEMENT IN MIXED DENTITION
 MANAGEMENT IN PERMANENT DENTITION
 TWIN BLOCK WITH EXTRA ORAL
TRACTION
 TREATMENT OF REDUCED OVERBITE AND
ANTERIOR OPEN BITE
 MANAGEMENT OF CLASS II DIV2
MALOCCLUSION
 MANAGEMENT OF CLASS III
MALOCCLUSION
 EXTRACTION/NON EXTRACTION THERAPY

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 MAGNETIC TWIN BLOCK
 ADULT TREATMENT
 FIXED TWIN BLOCK
 RESPONSE TO TWIN BLOCK TREATMENT
 GROWTH STUDIES
 CONCLUSION
 REFERENCES

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On 7th September 1977, DR Williams J Clark
developed Twin blocks.
Name :- Colin Gove
Age / Sex :- 7yrs 10 months / Male
Chief Complaint :- Luxated upper central incisor
On Examination :- Class II div 1 malocclusion with
a 9mm overjet and a midline shift to right.

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Treatment :- tooth was re-implanted

mobility and root resorption (class II; lower lip was

trapped lingual)
appliance with a Occlusal plane

place the mandible forward into a edge to edge bite

later a fixed treatment was done.

Later the re-implanted tooth was crowned and a

stable result was obtained at age of 25 years.

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Before Treatment Post Treatment IOPA
IOPA Showing Showing An
Luxated 11 Endodontic Pin To
Stabilize 11

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Different Stages
Of Treatment
Using Twin
Block
Combination
Therapy With
Fixed Appliance
In Later Stage

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Occlusal inclined plane
Use of masticatory forces

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Use of masticatory force :-
twin blocks worn 24 hours,

masticatory force transmitted via the appliance to the

dentition

bony trabeculae (wolfs law)

influencing the rate of growth and the trabeculae

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

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 Clark introduced the Delta Claps in 1985

 enhances appliance fixation

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DESIGN-
 The Delta clasp retains the basic shape of the
Adams clasps with its inter-dental tags, retentive
loops, and buccal bridge.
 difference is in the retentive loops which are
shaped as a closed triangle (from which the name
delta clasp is derived) instead of the open V
shaped loop of the Adams clasp.
 Subsequent modifications has produced circular
loops which are easier to construct.

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Delta clasps are generally constructed from 0.70 to
0.75mm SS wire.

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Advantage:
They do not open with repeated insertion and
removal and therefore give better retention with
less adjustment and hence are less subject to
fatigue.
They give excellent retention on lower premolars and
can be used on most posterior teeth.

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Ball shaped interdental clasps

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 Earlier twin blocks

Bite blocks articulating at a 90 degree angle.

Forced the patient to make a conscious effort to bite

in a forward position.

30% of patients failed

Tend to bite back to their retruded position.

Development of posterior open bites

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 Therefore,
45 degree angulation was used

which was immediately successful.

leads to an equal downward and forward stimulus to

growth.
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Finally designed with 70 degree angulation

Increased horizontal component of force,

more horizontal mandibular growth.

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Comfort
Aesthetics
Function
Patient compliance
Facial appearance
Speech
Clinical management
Arch development

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 Mandibular repositioning
 Vertical control
 Facial asymmetry
 Safety
 Versatility
 Integration with fixed appliance
 Treatment of temporomandibular joint dysfunction

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Ideal requisites for twin block appliance are :
 Class II div 1 with a good arch form.
 Lower arch uncrowded
 Upper arch aligned.
 Overjet 10-12 mm and a deep bite.
 Full unit distal occlusion.
 On models when the lower model is advanced in edge to edge
bite the distal occlusion should get corrected.
 Patient should be growing actively preferably should be in
pubertal growth spurt.
 VTO positive.

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Essential orthodontic records are
 Diagnostic report
 Study models
 X-rays
 Photographs.

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If the facial profile improves when the mandible is
advanced with the lips tightly closed, then
functional mandibular advancement is the
treatment of choice. The change in facial
appearance is a preview of the anticipated result of
functional treatment.

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Profile and frontal photographs with the mandible in
retrusive and advanced position

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The construction bite determines the degree of activation
built into the appliance, aiming to reposition the
mandible to improve jaw relationship.
Activation must be within the physiologic range of
activity of the muscles of mastication and the
ligamentous attachments of the temporomandibular
joint.

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

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 VERTICAL ACTIVATION

Adequate vertical Vertical activation must

clearance must be open the bite beyond the
available between upper freeway space to ensure
and lower teeth to that the patient cannot drop
accommodate blocks of the mandible into rest
sufficient thickness position

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Centric position is checked

Desired degree of activation decided.

patient is trained to bite in the desired position infront

of a mirror.

For accurate control the Exactobite registration device

is recommended.

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 wax is softened and adapted.

The patient is instructed to bite into the desired

position.

wax hardened sufficiently

removed and chilled.

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This gauge allows the clinician
to choose variable amounts of
sagittal activation by selecting
the appropriate groove to
engage the upper incisors
when the mandible closes into
the incisal guidance groove.

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The models with the bite are articulated and the twin
blocks constructed.

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This is indicated in the following conditions:
 Overjet ≥10 mm

 Full correction is not achieved by initial activation.

 Vertical growth pattern
 Adult patients (muscles and ligaments are less responsive to a
sudden, large displacement of the mandible)
 Case of TMJ Dysfunction

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Twin block functional therapy is divided into 3
stages:
1. Active phase 6-9 Months
2. Support phase 3 -6 months
3. Retention. 9 months
Total time Average 18 months

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The objective is to correct to the arch
relationship in the sagittal, vertical and
transverse dimensions.

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The objective of the support phase is to retain the
corrected incisor relationship until the buccal
segment occlusion is fully established.

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Hold the mandible in a forward position and also
help to erupt the bicuspids to complete the
orthopedic correction of the overbite
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The same appliance used during the support phase is
used, where in appliance wear is gradually
reduced to night time wear.

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Though the standard design can be used, retention is
generally limited by deciduous teeth that are
unfavorably shaped.

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 C clasps may be used on deciduous
molars

Retention by bonding composite on tooth

surfaces to create undercuts
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After treatment in the mixed dentition, a final
detailing of the occlusion with fixed appliances
is generally required in the permanent
dentition. So, there is generally a prolonged
phase of support and retention. A night time
functional appliance like Occlusoguide,
resembling a positioner can be used to
overcome the diminished occlusal support that
is normally present during the transition to
permanent dentition.

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An initial phase of functional correction by twin
blocks is generally followed by final detailing of
occlusion with fixed appliances.

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

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 In case of severe maxillary protrusion ( high pull,
cervical pull or combination pull depending on the
individual case.
 To control a vertical growth pattern. High pull
headgear may be used. This restrains vertical
maxillary growth and applies intrusive force on
upper posteriors.
 In adult treatment where mandibular growth
cannot assist the correction of severe
malocclusion.
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Labial hook
soldered to the
conventional face
bow.

Elastics can be given from the labial hook to the ball shaped
interdental clasps or hooks on the anterior part of lower appliance.
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ADVANTAGE:
 If the patient tends to posture out of the
appliance at night, the intermaxillary
traction force would increase and ensure
24 hours effectiveness of the appliance.

 Compared to CI. II elastics, a more

horizontal intermaxillary force is exerted
and extrusive mechanics is avoided.

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DISADVANTAGE:
The headgear effect tends to tip the occlusal and
palatal plane down anteriorly and retrocline the
upper anteriors which may lead to unfavourable
rotation of the mandible

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

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 INTRAORAL TRACTION USING
VERTICAL ELASTICS (MILLS)

They force the patient to bite consistently into the

appliance and hence apply intrusive forces to the
molars (especiaIly upper molars)" thus reducing
anterior open bite.

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d. Magnetic twin blocks are also being
used in anterior openbite problems as
wiIl be discussed later.

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f. Greater interincisal opening (4-5mm)
is required to make it difficult for patient
to disengage from the blocks in openbite
cases.
g. A tongue guard or palatal spinner (lead)
may be added to train the tongue in case
of tongue thrusting habit. Also a labial
bow may be used to retract extremely
proclined incisors and reduce the
anterior openbite.

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Preliminary phase of fixed appliances
therapy may be needed to align the
arches before functional therapy.

2 screws are put in the palate for arch

development in antero posterior
direction.

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Anteriors 75-80% advancement
Posteriors 20-25% distalization.
3D expansion screw- transverse expansion is
required (central sagittal twin block).

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Functional correction of CI.III malocclusion is achieved in twin

block technique by reversing the angulation of the inclined

planes and harnessing occlusal forces as the functional

mechanism to correct arch relationship by maxillary

advancement while using the lower arch as anchorage. The

position of the bite blocks is reversed compared to twin blocks

for class II treatment.

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Bite registration is done with 2 mm interincisal
clearance and mandible in fully retruded position.

Reverse twin blocks can be modified by

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

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Night wear of reverse pull face mask may be used
for 4-6 months to apply orthopedic traction on
upper block and enhance CI. III correction.

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

The Ritcher scale for crowding is as follows:

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

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Non-extraction treatment of irregular dentition is
done in 2 phases depending on the age of the
patient at the start of treatment and the degree of
severity of the skeletal and dental problems.

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Two types of rare earth magnets are used –
 Samarium cobalt
 Neodymium boron (greater force).
Two types of magnetic forces have been proposed.

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(a) Attracting magnets:
This helps in pulling the appliance together and
encourages the patient to occlude actively and
consistently in a forward position. This
increases occlusal contact in both working and
sleeping hours, thus increasing functional
stimulus to growth.

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(b) Repelling magnets:
 Used when less activation is built into twin blocks.
 They induce additional forward mandibular
posturing without reactivation; however, the degree
of activation induced by magnetic forces is not
ascertained.
 Magnetic twin blocks cannot be reactivated by
addition of acrylic to the inclined planes as this
deactivates the magnets

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 1. Rapid correction of CI. II Div I malocclusion with a
large overjet.
2. Resolve mild residual CI. II molar relationship,
especially if it is unilateral.
3.Patients with weak musculature who fail to engage the
appliance consistently.
4. Adult patients with TMJ pain with severe CI II Div 2
malocclusion or unilateral CI. II malocclusion.
5. Severe class III malocclusion.
6. Facial Asymmetry -magnets may be added on inclined
planes on the affected side to increase unilateral
contact.
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Twin blocks can be used in treatment of
adults if the skeletal discrepancy is not
severe. There is generally a
dentoalveolar response with limited
skeletal adaptation.

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2 methods:

a. The clasps can be bonded to the teeth using

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

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Wilson 3D modular
attachments

used as a retentive component on molar

bands and provides a mode of
attachment for occlusal twin block
elements,
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Disadvantages:

1. They can be detached from the teeth, requiring

immediate repair.
2. If lower molars are used for fixations, they cannot
be erupted to correct deepbite.
3. After fitting, adjustment for control of the vertical
dimension is limited.

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

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A series of growth studies have been done on
monkeys and rodents to study the effect of fixed
inclined planes. The results of these studies
indicate that functional mandibular protrusion
with fixed inclined planes has a profound effect on
the whole of the dental arch, the condylar head,
glenoid fossa and muscle attachments.

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

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 Retraction of the condyle

Compression of connective tissue and blood vessels

ischaemia

Pain.

"pterygoid response" (McNamara)

due to altered activity of the medial head of lateral

pterygoid.

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Clark investigated the changes in CI. II Div. I
malocclusion with twin block traction technique in
43 girls and 31 boys aged from 9 years 6 months
to 14 years. He compared it with Michigan growth
studies and Neijmagen growth studies as controls
and found the following changes due to twin block
treatment.

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(i) Maxillary protrusion reduction by retraction of A point.
(ii) Correction of antero posterior skeletal discrepancy by a
combination of maxillary retraction and to a lesser extent,
mandibular advancement.
(iii) Retraction of upper incisors.
(iv) Increase in interincisal angle
(v) Reduction of convexity by retraction of A point relative to
facial plane.
(vi) Advancement of lower incisor tip relative to A- pogonion.
(vii) Retraction of upper molars relative to pterygoid vertical.
(viii) Increase in mandibular length, except in age group
above 13 yrs.
(ix) Increase in ramus height.
(x) Increase in facial height N-Me
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i) Reduction of maxillary protrusion by retraction of A
point.
ii) Reduction of anteroposterior skeletal discrepancy by a
combination of maxillary retraction and to a lesser
degree, mandibular advancement.
iii) Retraction of upper incisors and reduction of the
overjet.
iv) Increase in mandibular length (Ar-Gn) in the age
group 10-12.5 years.
v) Increase in facial height (N-Me)
vi) Increase in gonial angle but not throughout the age
range.

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Mills and Mcculloch (Ajodo, 1998 July) used a
modified twin block with an acrylic labial bow on
lower incisors on 28 CI. II patients and compared
the results with age and sex matched untreated
class II controls. Results indicated that mandibular
growth in the treatment group was on the average
4.2mm greater than the control group over the 14
month treatment period. Some dento alveolar
effects in both arches contributed to the overjet
reduction.

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Lund and Sandler (AJODO 1998 Jan) treated 36 CI II
subjects, mean age 12.4 years with twin blocks and
compared the changes to an appropriate control group.
The data was annualized. In the treatment group, there was
a reduction in ANB by 2 degrees largely due to 1.9
degrees increase in SNB
Treatment resulted in net increase in Ar-Pog by 5.1mm
compared with control group increase of 2. 7mm leading
to a net gain in mandibular length by 2.4mm.

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

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 Spawnil Ghodke 2014 studied the Effect of twin
block appliance on the anatomy of pharyngeal
airway passage(PAP) in class II malocclusion
subject.

 He concluded that correction of mandibular

retrusion by Twin block appliance in class II
malocclusion subject increased the PAP dimension
and maintained the pre-thickness of posterior
pharyngeal wall.

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 SmailieneD. in 2017 studied the Effect of twin
block appliance on body posture in class II
malocclusion subject

 He concluded that the body posture changes during

treatment with twin block appliance were an
expression of the physiological growth, not a
response to improvement in occlusion

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

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

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