MYOFUNCTIONAL

APPLIANCES

FRANKEL APPLIANCE
&
TWIN BLOCK
 CONTENTS
FRANKEL APPLIANCE
 INTRODUCTION
 FRANKEL PHILOSOPHY
 RATIONALE
 EFFECTS OF FR
 MODE OF ACTION
 INDICATIONS & CONTRAINDICATIONS
 ADVANTAGES & DISADVANTAGES
 CLASSIFICATION OF FR
 COMPONENTS OF FR – ACRYLIC COMPONENT
WIRE COMPONENT
 CLINICAL PROCEDURE - VTO
IMPRESSION MAKING
CONSTRUCTION BITE
 MODIFICATIONS
 CONTENTS

TWIN BLOCK
 HISTORY
 PRINCIPAL
 STAGES
 GROWTH STUDIES IN ANIMAL EXPERIMENTS
 RESPONSE TO TWIN BLOCK THERAPY
 CLINICAL DIAGNOSIS AND TREATNMENT PLANNING
 STANDARD TWIN BLOCK
 TREATMENTOF CLASS II DIV1
 TREATMENT OF CLASS II DIV2
 TREATMENT OF CLASS III
 TWINBLOCK TRACTION TECHNIQUE
 MODIFICATIONS OF TWIN BLOCKS
 REFERENCES
FRANKEL FUNCTIONAL
REGULATOR
 INTRODUCTION
FUNCTIONAL APPLIANCES:
 Loose fitting or passive appliance which harness natural
forces of the oro-facial musculature that are transmitted
to the teeth & alveolar bone through the medium of the
appliance.
 Functional appliances are designed to control the forces
applied to the dentition by the surrounding soft tissues
and by the muscles that control the position and
movement of the mandible.
 A new functional behavior pattern is established to
support a new position of equilibrium by eliminating
unfavorable environmental factors in a developing
malocclusion
• Right side of the tongue and the right buccinator muscle
acting in opposite directions at the same time will hold the
denture in place.
• The functioning genioglossus and orbicularis oris muscles
will stabilize a mandibular denture by opposing forces in
the anterior section.
• When the right and left buccinator muscles contract at the
same time an active muscular fixation can be established
even with an inactive tongue.
 FRANKEL’S FUNCTIONAL REGULATOR

Orthodontic device developed by Rolf Frankel (Zwickau) in 1961

in the form of a skeletonized oral shield that, while not in contact
with the underdeveloped parts of the jaw, is intended to bring
about their development.

SYNONYMNS
◂ Encircle device
◂ Functional corrector
◂ Functional regulator
◂ Vestibular appliance
◂ Oral gymnastic appliances
◂ Orofacial orthopedic appliance
 Vestibular
area of
operation

Minimal
maxillary
basal effect
Sagittal
FRANKEL correction via
tooth borne
PHILOSOPHY maxillary
anchorage Periosteal
pull by
buccal
shields and
lip pad
Differentia
l eruption
guidance
 FRANKEL PHILOSOPHY
1. Vestibular area of operation
• Shields of the appliance extend to the vestibular and this
prevents the abnormal muscle function.

VESTIBULAR
SHIELD

2. Sagittal correction via tooth borne maxillary anchorage

• Appliance is fixed on the upper arch by grooves mesial to the
1st permanent molar and distal to the canine in the mixed
dentition period.
• Presence of the lingual pad acts as stimulator and helps in the
forward posturing of the mandible.

GROOVE MESIAL
TO 1ST MOLAR &
DISTAL TO CANINE
3. Differential eruption guidance
• Frankel is placed on the upper teeth. Mandibular posterior
teeth are free to erupt and their unrestricted upward and
forward movement contributes to both vertical as well as
horizontal correction of the malocclusion.
4. Minimal maxillary basal effect
• Downward and forward growth of maxilla seems to be
restricted, even though lateral Maxillary expansion in seen.

5. Periosteal pull by buccal shields and lip pad

• Presence of buccal shields and lip pads exert the periosteal pull
which helps in bone formation and lateral expansion of the
maxillary apical base.
 RATIONALE

• Frankel applied the functional matrix concept and

terminology of Moss (1970) to explain the basis of
design of his appliance.
• When faulty muscle posture is deemed to have
compromised the spatial relationships of the maxilla
and mandible in a growing child, the appliance is
designed to alter the biomechanical conditions in the
periosteal functional matrices of these bones.
 RATIONALE

 In the case of a deficient mandible the cause is considered to

be a postural imbalance between the retractor and protractor
muscles. The FR1 and FR2 appliances are constructed so
that the patient is obliged to posture the mandible forward in
order to achieve a comfortable jaw position. In this way the
periosteal tissues related to the mandibular condyle are
subjected to a biomechanical stimulus which favours an
increased rate of bone deposition until a position of stability
is reached, with the mandible relocated in a more anterior
position.
 RATIONALE

 In the case of a deficient maxilla, the FR3 appliance is

constructed so that periosteal tension is produced at the
superior sulci. The vestibular shields and upper lip pads
counteract the restricting effect of aberrant posture
within the labial muscle groups and normal maxillary
growth is restored.
 RATIONALE

 In skeletal open bite development, clinical relevance is

placed on the poor postural performance of the muscles
forming the external soft tissue capsule and of those
suspending the mandible. Accordingly, therapy with the
FR4 is directed at restoring a competent anterior oral seal
and establishing a more superior postural position of the
tongue and of the mandible.
 EFFECTS OF FRANKEL APPLIANCE
• First, it serves as a template against which the craniofacial muscles
function.
The framework of the appliance provides an artificial balancing of
the environment, thereby promoting more normal patterns of
muscle activity.

• The second effect of the Frankel appliance is its influence on skeletal

and dental development.
The Frankel appliance removes muscle forces in the labial and
buccal areas that restrict skeletal growth, thereby providing an
environment which maximizes skeletal growth.
 MODE OF ACTION OF FR

1. Increase in transverse and sagittal direction

2. Increase in vertical direction

3. Muscle function adaptation - Development of new patterns of

motor function by buccal shields and lip pads of FR leads to:
a) Massaging of soft tissues
b) Loosening of the tight muscles
c) Improving the blood circulation
d) Improving muscle tonicity
e) Providing new functional matrix for peri oral muscle to act upon
it- ‘Ought-to-be matrix’.

4. Mandibular forward positioning - Position of mandible can be

changed by gradual training of the protractor and retractor
muscles followed by condylar adaptation
 INDICATIONS CONTRAINDICATIONS

• Mixed dentition period with • Class I malocclusion with

growth spurts. severe crowding
• Skeletal class II malocclusion • Thumb sucking habit.
with prognathic maxilla and • Severe dentoalveolar problems
retrognathic mandible (Positive in permanent dentition.
VTO) • Uncooperative patients
• Functional class II
malocclusion.
• In a horizontal or neutral
growth vector case.
• Class III malocclusions.
• Bimaxillary protrusion and
open bite problems.
 ADVANTAGES
1. It enables elimination of abnormal muscle function thereby
aiding in normal development.
2. Treatment can be initiated at early age.
3. Less chair side time is spent.
4. The frequency of the patients visit is less.
5. They do not interfere with oral hygiene status.
6. Duration of treatment is comparatively less. they deal with
skeletal as well as dent alveolar problems.
 DISADVANTAGES
1. The appliance is bulky and the cooperation of the patient is
essential.
2. They cannot be used in adult patients were the growth has
ceased.
3. Cannot be used to bring about individual tooth movement
and in cases of crowding.
4. Fixed appliance therapy may be required at the termination
of treatment for final detailing of the treatment.
 TYPES OF FR

FR

FR I FR II FR III FR IV FR V

FR I-a

FR I-b

FR I-c
 CLASSIFICATION INDICATIONS

Frankel’s Regulator 1 To treat class I and II division

malocclusion
FR-Ia To treat Angle’s class I malocclusion with
deep bite
FR-Ib To treat Angle’s class II malocclusion,
overjet not exceed 5mm
FR-Ic To treat Angle’s class II malocclusion,
overjet more than 7mm
FR-II To treat Angle’s class II malocclusion
division I and II malocclusion
FR-III To treat Angle’s class III malocclusion
FR-IV To treat bimaxillary protrusion and open
bite
FR-V Used with headgear
COMPONENTS OF FR
APPLIANCE
 COMPONENTS

WIRE
ACRYLIC

PALATAL BOW
BUCCAL SHIELD
LABIAL BOW
LIP PADS
CANINE EXTENSION
LOWER LINGUAL PAD

UPPER LINGUAL WIRE

LINGUAL CROSSWIRE

SUPPORT WIRE

LOWER LINGUAL SPRINGS

 ACRYLIC
COMPONENT

WIRE
COMPONENT
 FR I

• Used in treatment of class I and Class II division 1

malocclusion .

Indicated in :
• Angle class I and crowding
• Angle class II div 1 (distal occlusion) with normal overbite
• Moderate labial inclination of the upper incisors
• Underdevelopment of the apical bases (primary crowding
symptoms)
TYPES OF FR I

• FR 1a : Used for class I malocclusions where there is minor

to moderate crowding and also in class I deep bite cases.
• FR 1b : Used for class II division 1 malocclusion where
overjet does not exceed 7mm.
• FR 1c : Used for class II division 1 malocclusion in which
the overjet is more than 7mm.
 FR 1a

Components

Acrylic parts
1. Two Vestibular shields
2. Two lip pads

Wire components
1. Palatal bow
2. labial bow
3. Labial support wire
4. Lingual bow
5. Canine loops
6. Lingual wire loop
LINGUAL BOW

• It helps in the forward position of the mandible.

• It extends downward to the floor of the mouth which
fit against the lingual tissue below the incisors

LINGUAL
BOW
 FR Ib

• It has a lingual acrylic pad, instead of the loop in

FR1a.

• Frankel suggested it’s use in Class II deep bite cases,

over jet not exceeding 7mm.
 FR Ic

• Used In more severe CL II DIV 1 malocclusion in which the overjet is

more than 7mm and disto-occlusion exceeds an end to end cusp
relationship.
• The buccal shields are split horizontally and vertically into 2 parts :
i. Anteroinferior portion contains the wires for lingual acrylic pressure
pad or shield and for the lower lip pads.
ii. By opening the vertical cut, the anterior segment with the lip pads and
lingual shield can be moved gradually in an anterior and inferior
direction.
iii. Vertical split is opened to the desired position by a 2 to 3 mm
advancement and is then filled with acrylic.
iv. Thus, a gradual expansion of the capsular matrix and retraining of the
suspending muscles is obtained by altering mandibular postural
position step by step.
The buccal shields are split horizontally and vertically.

By opening the vertical cut, the anterior segment with the lip
pads and lingual shield can be moved in an anterior and
vertical direction step by step.
 FR II

• FR II is the most commonly used Functional Regulator.

• Used in the treatment of Angles’s Class II div 1 and Class
II div 2 malocclusions
The FR -II is composed of

• Acrylic Parts : Buccal Shields,

Lower Labial Pads
Lingual Shield
• Wire parts :
• Palatal bow,
• Canine loops
• Labial bow
• Lower lingual springs
• Lower lingual support wire
• Lower labial wires
 Acrylic parts

1. Buccal shields
• Extend deep into the sulci, particularly in the apical region of
the maxillary first premolar and the maxillary tuberosity.
• The thickness of these acrylic shields should not exceed 2.5
mm. in order to make wearing of the appliance comfortable
for the patient.
Operational purpose
• Physiotherapy: The projecting buccal shields expand the
circumoral capsule in lateral direction, thus forcing the
respective soft tissues to adapt in structure.
• Forced training: The muscles of the cheeks are forced to adapt
their functional performances of the outer surfaces of the buccal
shields.
 2. Labial Pads
• Rhomboid in shape .
• In cross-section, they appear tear-drop shaped which allows a
proper seating of the lip pads in the vestibule without causing
discomfort to the patient.
• The upper edges of the lip pads should have a distance of at least
5 mm from the gingival margin which is important for
preventing stripping of the labial gingiva.
• The distal edge of the pads should not overlap the labial
protuberance of the canine root which would render speaking
difficult and irritate the mucosa of the lower lip.
Operational purpose

• Physiotherapy: The labial pads have a supporting effect on the

lower lip smoothing the mentolabial sulcus and greatly improving
lip posture.
Thus, the adhesive zone of the lower lip can easier find the normal
contact with that of the upper lip which is important for the
establishment of a competent lip seal.
• Forced training: The main purpose of the lip pads is to prevent a
hyperactive mentalis muscle from raising the lower lip. This
inhibitory action is necessary in order to achieve a training effect on
the lip muscles which are destined to bring about the physiological
seal of the oral cavity.
Hard and soft tissue profile before and after insertion of the
FR-1.
The supporting effect of the lower labial pads results in
smoothing the mentolabial sulcus and improving the lip
posture.
• In the presence of mandibular retrusion, the needed expansion of the
inferior part of the oral functioning space requires the combined
action of both the labial pads and the buccal shields.
The structural and postural imbalance between the muscle slings
formed by the superior part of the buccinator and the orbicularis
oris of the lower lip and that formed by the inferior part of the
buccinator and the orbicularis oris of the upper lip can only be
overcome by a concomitant action of the labial pads and the buccal
shields.
3. Lingual shield

The lingual shield lies lingually below the gingival margin of the
mandibular teeth and extends distally to the roots of the lower second
premolars. Its position is secured by two wires connecting it with the
buccal shields of either side.

Operational purpose
Forced training: The lingual shield is an important part of the exercise
device which is used to overcome the poor postural performance of the
muscles suspending the mandible.
• The lingual shield of the FR permits mandibular advancement
without maintaining the protruded position by a mechanical support
on the mandibular dentition.
• Whenever the mandible tends to slide back to its original retruded
position, a pressure sensation on the lingual aspect of the alveolar
process is provoked.
• This "sensory input" activate the proprioceptors in the gingiva
and the underlying periosteum and, as a result of feedback,
stimulate the protractors to eliminate this disturbing signal.
• However, this mode of action can only be expected to be
established if the anterior displacement of the mandible is
carried out step by step.
• For this reason, the initial construction bite should be taken
with the mandible forward no more than 2 mm or, in a few
instances, 3 mm.
 WIRE COMPONENT

1. PALATAL BOW

• The palatal bow (pabo) crosses the palate with a slight curve in
a distal direction and runs interdentally between the maxillary
first molar and second premolar, makes a loop into the buccal
shield and emerges to form an occlusal rest between the buccal
cusps of the molar.
• Role : connecting and stabilizing action,
intermaxillary anchorage.
 2. CANINE LOOPS / CANINE GAURDS
• Canine loop is embedded in the buccal shield at the level of the
occlusal plane.
• It rises sharply to the gingival margin of maxillary first deciduous
molar, and fits in the embrasure between the deciduous first
molar and the canine to lock the appliance in place on the
maxilla.
• The loop wraps around the lingual surface of the canine and
emerges labially in the canine-lateral incisor embrasure, curving
distally over the canine cusp.
• It helps in canine guidance and proper stabilization of the
appliance.

CANINE
LOOPS
3. LABIAL BOW
• Run in the middle third of the labial surface of the maxillary
incisors .
• The labial wire then turns gingivally at right angle between
the maxillary lateral incisors and canine to form the canine
loops.
• It operates as a “function-activated “ element i.e. it transmit
forces generated by the orofacial muscles on the teeth.

LABIAL
BOW
4. LOWER LINGUAL SPRINGS
• The lower lingual springs are constructed out of 0.028
inch wire and are contoured to the lingual curvature of
the lower incisors at the level of the cingulum.
• These wires are used to
a. prevent extrusion of the lower incisors during treatment.
b. Procline the lower incisors
c. Maintain space by curving the wire around the distal
surface of the lateral incisor.
5. LOWER LINGUAL SUPPORT WIRE
• The wire is fabricated in the general arch configuration of the
future lower lingual pad. It is then curved back on itself and
directed upward and laterally to cross the occlusal surface of the
teeth.
• It is important that the wire pass in the interocclusal area between
the upper and lower arches and not interproximally between the
teeth, or tooth eruption will be inhibited and possible mesial
movement of the lower dentition may occur during treatment.
• The lateral ends of the wire are parallel to the occlusal plane and
parallel to each other because they will be used as guides when
the lower anterior section of the appliance is advanced in future
treatment adjustments.
• The lingual contour of this wire is positioned approximately 1 to 2
mm away from the underlying tissue.
• The wire is positioned approximately 3 to 4 mm below the
gingival margin on the lingual surface of the mandible.
6. LOWER LABIAL WIRES

• The next step in the construction of the appliance is fabrication of

the support wires for the lower labial pads. This assembly can be
constructed either of three individual wires or of one continuous
wire. The 0.036 inch wire should pass from the buccal shield in a
slight anteroinferior direction. Like all wires in this appliance, the
lower labial wires are positioned at least 0.5 to 0.75 mm. away from
the wax relief in order to ensure that the wires will be embedded
completely in acrylic. The ends of the wires which will be
embedded in the future buccal shield are straight and positioned
parallel to each other so that the lip pads can be advanced or
retracted as necessary. The gable bend of the center wire must be
high enough to avoid irritation of the labial frenum.
 FR III

• Frankel III is used during the deciduous, mixed, and early permanent
dentition stages to correct Class III malocclusion characterized by
maxillary skeletal retrusion and not mandibular prognathism.
• According to Frankel, the vestibular shields and upper labial pads
function to counteract the forces of the surrounding muscles that
restrict forward maxillary skeletal development and retrude maxillary
tooth position.
• Frankel also stated that the vestibular shields stand away from the
alveolar process of the maxilla but fit closely in the mandible, thus
stimulating maxillary alveolar development and restricting
mandibular alveolar development.
 PARTS OF THE APPLIANCE

• FR III is composed of – acrylic parts

wire parts
• There are four acrylic parts of the FR-3:
1. two vestibular shields and
2. two upper labial pads .

LABIAL PADS

VESTIBULAR
SHIELD
• The vestibular shields
o Extend from the depth of the mandibular vestibule to the height of
the maxillary vestibule.
o These shields act to remove the restrictive forces created by the
buccinator and associated facial muscles against the lateral surfaces
of the alveoli and the associated buccal dentition.
• The upper labial pads
o Lie in the labial vestibule above the upper incisors.
o Eliminate the restrictive pressure of the upper lip on the
underdeveloped maxilla.
o They are larger and more extended than the corresponding lower
pads of the FR-2’ and are more easily tolerated by the patient despite
this greater extent.
• They provide stretching of the adjacent periosteum, stimulating
bone apposition on the labial alveolar surface.
o They lie in the height of the vestibular sulcus parallel to the contour
of the alveolus.
o The force of the upper lip is transferred by the upper labial pads to
the vestibular shields.
o Since the vestibular shields lie in close approximation to the
mandibular alveolus, the force of the associated soft tissue may be
transmitted through the appliance to the mandible leading to a
significant retardation of mandibular growth.

The distracting forces of the upper lip are removed from the
maxilla by the upper labial pads. The force of the upper lip is
transmitted through the appliance to the mandible because of the
close fit of the appliance to that arch
• The upper lingual wire originates in the vestibular shield,
traverses the interocclusal space, and rests against the cingula of
the upper incisors. In contrast to the FR-2, the upper lingual wire
does not lie between the canine and first deciduous molar (or first
premolar), but rather lies in the interocclusal space between the
upper and lower dental arches .
• The palatal wire originates in the vestibular shields and
traverses the palate. In contrast to the FR-2 in which the palatal
wire lies between the second deciduous molar and the first
permanent molar, the palatal wire crosses the palate behind the
last molar present . Thus, the maxilla and the maxillary dentition
are not restricted in their forward movement by the wires of the
appliance.
• There are two pairs of occlusal rests in the molar region, one of
which is optional.

I. A lower occlusal rest originates in the vestibular shield, makes a

gentle right angle bend along the central groove of the lower first
molar, and then extends again back into the vestibular shield
posteriorly.
• The purpose of this wire is to prevent the eruption of the lower first
molar.
• The mandibular occlusal rest is constructed to cover all erupted or
even partially erupted mandibular molars.
• The maxillary occlusal rest is necessary only in cases of anterior
crossbite.
II. The upper occlusal rest originates in the posterior aspect of the
vestibular shield, traverses the central groove of the upper first
molar, and then recurves back on itself. The upper occlusal rest
is designed in this manner so as not to restrict the forward
movement of the maxilla during functional therapy
 TREATMENT OF CLASS III
MALOCCLUSION

• The FR-3 is constructed without any acrylic part inside the

dentoalveolar arches.
• After insertion of the appliance, the lingual volume is not
diminished, and the tongue is not restricted in movement
function as well as in postural position.
• Thus, the tongue is capable of altering its faulty low posture,
leading to expansion of upper arch.
Construction bite :

• The procedure of taking the construction bite is done by retruding

the mandible as much as possible with the condyle in its most
posterior position. The vertical opening is kept to a minimum to
allow lip closure with minimal stress.
• Wax relief : No wax is applied to the mandibular arch.
 FR IV

● Correction of open bite and bimaxillary protrusion.

● Exclusively confined to mixed dentition

● MODE OF ACTION OF FR IV
a. Growth and development pattern of the mandible was altered.
b. The spontaneous downward and backward growth direction of the
mandible was changed to a upward and forward direction by FR-4
therapy, allowing the skeletal anterior open bite to be successfully
corrected through upward and forward mandibular rotation.
Components of FR 4
 FR V

Modification of Frankel by Albert H Owen (1985 –JCO)

• Indicated in Long face syndrome having a high mandibular plane

angle and vertical maxillary excess .

• The appliance consists of addition of posterior acrylic bite blocks to

arrest molar eruption.

• It also has head gear tubes that accept a face bow for an occipital
pull headgear.
 Advantages in combination of frankel with head gear:

1.The vertical dimension can be decreased through intrusion of

the molars.
2.Increased mandibular growth.
3.Significant lateral expansion may reduce the need for
expansion.
 Clinical procedures of FR

Visual Treatment Objective

Impression Making

Construction Bite
 VISUAL TREATMENT OBJECTIVE

• It is a visual plan to forecast the normal growth of the patient

and the anticipated influences of treatment, to establish the
individual objectives we want to achieve for the patient.
• This gives the operator an excellent clue to as to whether the
functional appliance that postures the mandible forward will
improve the facial appearance and profile.
• First the patient is asked to swallow and then lick the lips
and relax.
• Then the patient is instructed to close the teeth in habitual
occlusion, again licking the lips first and then to keep the
teeth tightly together and lips relaxed.
• Patient is then asked to posture the mandible forward into
correct sagittal, reducing the overjet.
Class II Div 1 3mm of mandibular 6 mm of mandibular
malocclusion protraction protraction
 IMPRESSION MAKING
• Two types of trays ,
1. A thermal-sensitive acrylic tray or
2. A custom tray can be used.

A thermal-sensitive acrylic trays are softened in hot

water, placed in the mouth, and molded to the
configuration of the dental arches.
A custom tray, fabricated for the individual case can
also be used.

• Both of these tray types minimize the distortion of the underlying

soft tissue.
 CONSTRUCTION BITE
• A horseshoe wafer of medium hard wax is used to orient the
upper and lower dental arches in all three planes of space
(horizontal, transverse, and vertical).
• In the treatment of Class II cases, Frankel states that the
mandible should not be brought forward more than 2.5 to 3.0
mm., with only enough vertical opening for the cross-over wires
to pass through the interocclusal area.
• If advancement of the mandible 4 to 6 mm, does not provide at
least 2.5 to 3.5 mm. of clearance at the deciduous first molar
area, the construction bite must be opened additionally to provide
this clearance.
PREPARATION OF WORK MODELS

• The first step in trimming the mandibular work model is to

remove the flash with either a laboratory knife or a rotary
instrument until the extensions of the vestibule have been
reached.
• The lower labial region should be carved with a pear-shaped
carbide bur and a laboratory knife.
Work models of a Class II, Division 1 case with red wax
construction bite in place and mounted in a model holder
PRESCRIPTION SHEET
• Usually the standard amount of wax relief for the FR is 3.0
mm in the maxillary vestibular area and 0.5 mm. in the
mandibular vestibular area.

SEATING GROOVES

• In the treatment of the permanent dentition, seating grooves

are cut between the maxillary first molar and the second
premolars, and between the maxillary canines and first
premolars by means of a saw.
 APPLICATION OF WAX
RELIEF
• The outlines of the vestibular shields and labial pads are drawn on the
model with a pencil . These outlines are used as a guide in the
placement of the wax. The models are then separated and wax relief is
applied in the posterior and upper anterior regions of the maxillary
dental cast. Additional wax is then applied in the dental area to
establish a smooth contour on the lingual side of the vestibular shield.
No wax relief is placed on the mandibular cast.
ACRYLIC FABRICATION

• In preparation the upper and lower models are locked

together in the articulator.
• The heels of the models are checked once again to make sure
that the bite is still accurate.
• The acrylic is applied with alternate applications of monomer
and polymer.
• After the acrylic has hardened slightly, the vestibular shields
and the upper labial pads can be trimmed to approximate the
final size and shape; the acrylic is then cured under pressure
for 15 minutes.
• After curing, the appliance is removed from the work models
and placed in an ice bath to harden the wax and facilitate its
removal.
TRIMMING THE APPLIANCE

• After the appliance has been removed from the work model, it
is roughly trimmed with a sandpaper arbor.
• First, the rough outlines of the upper labial pads and the
vestibular shields are formed and smoothed.
• The thickness of the vestibular shields is also reduced to a
uniform 2.0 to 2.5 mm in the same manner.
• A handpiece and a small burr are used to fine-trim around the
wires at the edges of the appliance.
• Then the acrylic parts of the appliance are pumiced and
polished on a rag wheel.
• All edges of the appliance must be smooth to avoid irritation
and gingival stripping.
DELIVERY OF APPLIANCE
• It is a full-time appliance and that will eventually be worn at all
times except during eating, dental hygiene, playing contact sports.
• The patient is instructed to read aloud for one-half hour per day
until normal speech can be accomplished while wearing the
appliance.
• It is usually recommended that the appliance be worn for a few
hours a day for the first few weeks, then gradually increasing wear
time until the patient wears it full time.
ACTIVATING THE APPLIANCE
• After the appliance has been worn on a full-time basis for 3 or 4
months, the distance between the upper labial pads and the
underlying alveolus will decrease. Thus, activation of the appliance
is necessary to continue treatment.
• A crosscut fissure burr is used in a low speed dental handpiece to
free the ends of the labial pad support wires.
• Enough acrylic is removed around the end of this wire to allow
anterior advancement of the wire and maxillary labial pads.
• The lingual surface of the upper labial pads are kept 3 mm away
from the underlying alveolus throughout treatment.
• After the upper labial-pad adjustment has been checked for patient
comfort, the holes in the vestibular shields are refilled with acrylic
to secure the labial-pad support wire.
• In cases of severe maxillary skeletal retrusion, more than one
advancement of the maxillary labial pads may be necessary
 MODIFICATIONS

Modified function regulator S. Haynes, Edinburgh, Great Britain

• Palatal acrylic support and continuous buccolabial acrylic

construction, replaces conventional function regulator with
separate buccal shields and lip pads.
• The appliance is not "locked" into the mesial embrasure of
the maxillary first molars by a cross-palatal bar
 CAPPED FRANKEL APPLIANCE.

◂ Given by Raymond Otto in 1992

◂ Indicated in deep bite cases
◂ Controls labial tipping of mandibular incisors
◂ Disadvantages
1. Need of sufficient posterior separation
2. Capping may impinge on maxillary incisors as treatment progresses
3. Difficult to clean
 Change in angulation of cross over wire- chate 1986

• Strictly horizontal advancement results

in incisal movements of lower wire and
shield.
 HYBRID FUNCTIONAL APPLIANCE (FR 2
and activator combination.

• Given by Dr. Peter Vig and Dr. Katherine Vig in 1986

• Hybrid appliances are specifically and individually tailored for
every patient.
• Instead of using a “named” appliance for the treatment of a class of
malocclusion, various components of different functional
appliances can be used to make a composite appliance.
• So, appliance designs that uniquely match the needs of individual
patients.
 HYBRID FUNCTIONAL
APPLIANCE (FR 2 and activator
combination.
 FR With Continuous Buccolabial Shield And
Palatal Acrylic Support – Hynes 1986

Palatal acrylic support and continuous buccolabial acrylic

construction, which replaces conventional function regulator with
separate buccal shields and lip pads.

The appliance is not “locked” into the mesial embrasure of the

maxillary first molars by a cross-palatal bar.
 TWIN
BLOCK
 HISTORY
• The first Twin Block appliance was fitted on 7 th September,1977 by
WILLIAM CLARK.
• Evolved in response to a clinical problem that presented when a
young patient, aged 8 years 4 months, the son of a dental colleague,
fell and completely luxated an upper central incisor.
• The occlusal relationship was Class II division 1 with an overjet of 9
mm and the lower lip was trapped lingual to the upper incisors.
• Adverse lip action on the reimplanted incisor caused mobility and
root resorption.
• To prevent this an appliance mechanism was designed to harness the
forces of occlusion to correct the distal occlusion and also to reduce
the overjet without applying direct pressure to the upper incisors.
• The upper and lower bite blocks were engaged mesial to the first
permanent molars at 90° to the occlusal plane when the mandible
postured forward.
• This positioned the incisors edge-to-edge with 2 mm vertical
separation to hold the incisors out of occlusion.
• The patient had to make a positive effort to posture his mandible
forward to occlude the bite blocks in a protrusive bite.
• The young patient was successful in doing this consistently to
activate the appliance for functional correction.

Profiles at ages 7 years 10 months (before treatment), 9 years 7

months (after 9 months of treatment) and 24 years
 INTRODUCTION TO TWIN BLOCKS

• The occlusal inclined plane

• The occlusal inclined plane is the fundamental
functional mechanism of the natural dentition.
• If the mandible occludes in a distal relationship to the
maxilla, the occlusal forces acting on the mandibular
teeth in normal function have a distal component of
force that is unfavorable to normal forward mandibular
displacement.
• The inclined planes formed by the cusps of the upper
and lower teeth represent a servo-mechanism that locks
the mandible in a distally occluding functional
position .
The mandible is guided forwards by the occlusal inclined
plane.
 PRINCIPAL

• The goal in developing the Twin Block appliance was to produce

a technique that could maximize the growth response to
functional mandibular protrusion by using an appliance system
that is simple, comfortable and aesthetically acceptable to the
patient.
• Twin Blocks are constructed to a protrusive bite that effectively
modifies the occlusal inclined plane by means of acrylic inclined
planes on occlusal bite blocks.
• The purpose is to promote protrusive mandibular function for
correction of the skeletal Class II malocclusion
 ANGULATION OF OCCLUSAL INCLINED PLANE

• During the evolution of the technique, the angulation of the

inclined plane varied from 90˚ to 45˚ to the occlusal plane before
arriving at the angle of 70˚ as the final compromise angle that
proved most suitable for most cases.

• The initial angulation of 90˚ required the patient to make a

conscious effort to occlude in a forward position..

• An angle of 45˚ applies an equal component of downward and

forward component of force to the lower dentition.

• An angle of 70˚ was finally adopted to apply a more horizontal

vector of force.
The first Twin Blocks were simple bite blocks occluding in
forward posture. The blocks were angled at 90° to the occlusal
plane
 Bite Registration

According to Woodside (1977) mandible should be positioned

protruded approximately 3mm distal to the most protrusive position
that the patient can achieve, while vertically the bite is registered
within the limit of the freeway space.
According to Roccabado normal physiologic TMJ movement as 70%
of the total joint displacement.

There are two types of bite gauges used to register bite for twin block:
1. George bite gauge
2. Exactobite gauge
 George Bite Gauge
• The George bite gauge has a millimetre gauge to measure
the protrusive movement.
• Has a sliding jig attached to a millimetre scale.
• Designed to measure the protrusion path of the mandible
and can record a protrusive bite of no more than 70% of
the total protrusion path.
• Can determine accurately the amount of activation
registered in the construction bite.
 Exacto-bites

• Exacto-bites are horseshoe-shaped jigs with a series of notches,

designed to accurately register the construction bite for
functional or sleep appliances.
• The Exactobite or the project bite gauge is used to record a protrusive
interocclusal record for the construction of twin block.
• Variable amount of sagittal activation can be done by selecting the
appropriate groove to engage the maxillary incisors.
• 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 on 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
which the patient can posture the mandible forward.
STAGES OF TWIN BLOCK TREATMENT

ACTIVE
PHASE

SUPPORT
PHASE

RETENTION
PHASE
 ACTIVE PHASE

• Twin Blocks achieve rapid functional correction of

mandibular position from a skeletally retruded Class II to
Class I occlusion with the aid of the inclined planes.
• Sagittal correction is achieved before vertical development
of the posterior teeth is complete.
• In the treatment of deep overbite, the bite blocks are
trimmed selectively to encourage eruption of lower
posterior teeth to increase the vertical dimension and level
the occlusal plane.
• A minimal clearance between the upper bite block and
lower teeth prevent the tongue from spreading laterally
between the teeth.
 SEQUENCE OF TRIMMING
BLOCKS
• In treatment of deep overbite, the bite blocks are trimmed
selectively to encourage eruption of lower posterior teeth to
increase the vertical dimension and level the occlusal plane .
• The upper block is trimmed occlusodistally to leave the lower
molars 1–2 mm clear of the occlusion to encourage lower molar
eruption and reduce the overbite.
 SUPPORT PHASE

• 4-6 MONTHS.
• The aim of the support phase is to maintain the corrected
incisor relationship until the buccal segment occlusion is fully
interdigitated.
• To achieve this objective an upper removable appliance is
fitted with an anterior inclined plane with a labial bow to
engage the lower incisors and canines .
• The lower Twin Block appliance is left out at this stage and the
removal of posterior bite blocks allows the posterior teeth to
erupt.
• Full-time appliance wear is necessary to allow time for internal
bony remodeling to support the corrected occlusion as the
buccal segments settle fully into occlusion.
Support phase—anterior inclined plane.
 Retentive Phase

• 9 months
• Treatment is followed by retention with upper anterior
inclined plane appliance.
• Appliance wear is reduced to nightime wear only when
the occlusion is fully established.
 Average Treatment Time

• Active phase: 6-9 months to achieve full reduction of overjet

to a normal incisor relationship and correct the distal
occlusion
• Support phase: 3-6 months for molars to erupt into occlusion
and for premolars to erupt by trimming the blocks. The
objective is to support the corrected mandibular position after
active mandibular translation while the buccal teeth settle
fully into occlusion
• Retention: 9 months, reducing the appliance wear(night wear)
when the position is stabilized.
 Growth Studies in Experimental Animals

● Functional regulation of condylar cartilage growth rate

○ A fundamental study of the relationship between form and
function was carried out on rhesus monkeys at the University
of Michigan(1980).
○ The findings were based on the use of fixed occlusal inclined
planes that were designed to cause a forward postural
displacement of the mandible in all active and passive
muscle activity.
○ The pattern of muscle behavior during the experimental
period showed a cyclic change in response to functional
mandibular propulsion.
 • Initial placement of the appliance produced an increase in
the overall activity of the muscles of mastication
• Decrease in the activity of the posterior head of the
1-7 temporalis muscle
• Increase in activity of the masseter muscle
da • Increase in function of the superior head of the lateral
ys pterygoid muscle

3 • A new plateau of muscle activity was reached at a higher

level of activity than the pretreatment record
we • This level of activity persisted for 4 weeks
eks

• After the 8 week period there was a decline in the muscle

8 activity to level recorded pretreatment
we
eks
 ADAPTIVE RESPONSE IN FUNCTIONAL EXPERIMENTS

NEUROMUSCULAR SKELETAL
ADAPTATIONS ADAPTATIONS

Appliance placement – Results in

immediate change in the stimuli to Structural adaptations are more
the receptors of the orofacial gradual in nature
region

Alteration in stimuli is transmitted Adaptations are not limited to the

to the CNS - mediates change in dentoalveolar area, they occur
muscle activity throughout the craniofacial region

This alteration leads to a forward As structural balance is restored,

positioning of the jaw – muscular the need for altered muscle
changes are rapid and can be activity is lessened. Leads to
measured gradual return to more typical
muscle pattern
 RESPONSE TO TWIN BLOCK TREATMENT

• Harvold ( 1983) demonstrated the tissue changes that occur as a

result of altered occlusal function.
• When the mandible postures downward and forward, there is an
area of intense cellular activity above and behind the condyle
described as a “tension zone” that is quickly invaded by
proliferating connective tissue and capillary blood vessels.
• These changes occur within hours and days of the appliance being
fitted.
• A new pattern of muscle behavior is quickly established,
whereby the patient finds it difficult and later impossible to
retract the mandible into its former retruded position.
• This change in muscle activity has been described by McNamara
as the “pterygoid response” which results from altered activity of
the medial head of the lateral pterygoid muscle in response to
mandibular protrusion.
• Bone remodelling occurs as a secondary response to altered
muscle function.
 DIAGNOSIS & TREATMENT PLANNING

1. Clinical examination
a. Most critical step in diagnosis and treatment planning
2. Photographic records
a. Motivation factor
3. Orthodontic records
a. Photographs
b. Orthodontic models
4. Examination of models
a. Simply sliding the mandibular dentition forwards
helps to observe the articulation expected after
functional therapy
b. Checkpoints – Transverse occlusion, crowding,
incisor eruption levels
 CLINICAL EXAMINATION

• A retrusive mandible can be detected by examining the profile

and the facial contours with the teeth in occlusion.
• Photographic Records: Facial and dental photographs are an
invaluable diagnostic aid to establish the objectives of treatment
and to monitor progress.

EXAMINATION OF MODELS

• To predict occlusal changes by checking the occlusion resulting

when the mandible postures downward and forward to reduce the
overjet. This can be done by sliding the lower model forwards
and observing the articulation of the mandibular dental arch with
that of the upper model.
 THE CLARK CEPHALOMETRIC ANALYSIS

A new approach to cephalometric analysis is derived from

principles expressed in three previous analytical methods

• Ricketts(1960)
• McNamara(1984)
• Bimler(1977)

Having used and studied these analyses the author has

adapted features of these methods to arrive at a system
which aims to simplify and clarify the analytical method for
diagnostic purposes
 McNamara cephalometric analysis in twin block therapy

• Cephalometric analysis of 70 consecutively treated patients

showed highly significant growth changes during the active
phase of treatment, confirming observation by McNamara.

• Followings are angular and linear growth changes are:

1. Increase in effective mandibular length (articulare to gnathion).

2. Increase in length of the facial axis (center of cranium to
gnathion).
3. Increase in facial height.
4. Reduction in the anteroposterior apical base discrepancy on
angular assessment of ANB angle.
5. Reduction in facial convexity ( A point to facial plane).
 Increase in effective mandibular length

Increase in length of the facial axis

Increase in facial height Reduction in facial convexity
PARALLELISM IN DENTOFACIAL DEVELOPMENT

• Bimler (1957) and others have noted the parallel relationship

that often exists between the Frankfort and maxillary planes.
• Ricketts (1960)referred to the parallel development of the
facial axis, the condyle axis and the upper incisor. Ricketts
recommended that the upper incisor should be positioned
parallel to the facial axis for stability and balance after
treatment
 The Facial Rectangle

The facial rectangle is constructed to define the upper, lower,

anterior and posterior limits of the face.

• Nasion horizontal: A line is drawn through nasion parallel to the

Frankfort plane. This defines the upper limit of the face and the
anterior point of union with the cranium.
• Menton horizontal: This is a tangent through menton on the
lower border of the symphysis parallel to the Frankfort plane. It
defines the lower limit of the face.
• Nasion vertical: A perpendicular line is drawn to the Frankfort
plane through nasion. This line defines the anteroposterior
relationship of the maxilla and the mandible relative to the
anterior cranial base.
.
• Basion vertical: A perpendicular through basion defines the
posterior limit of the face..
• Pterygoid vertical: A perpendicular line to the Frankfort plane
through the pterygoid point. This midfacial perpendicular line
was selected by Ricketts because it is in a stable area of growth,
being close to the point of emergence of the trigeminal nerve
from the base of the skull.
The facial rectangle now defines the upper, lower, anterior and
posterior limits of the face, with the addition of a midfacial vertical
line.
This construction facilitates measurement of all factors relative to
vertical and horizontal axes.
 The Facial Rectangle

A facial rectangle is formed to frame the face. The formation of a facial

rectangle helps to define the relative position and angulation of cranial,
maxillary, mandibular and dentoalveolar structures.
 CONTRAINDICATIONS

• Class II skeletal bimaxillary prognathism.

• Vertically directed growth.
• Labial tipping of lower incisors.
• Crowding.
 EVOLUTION OF APPLIANCE DESIGN

The earliest Twin Blocks were designed with the following basic
components:
• A midline screw to expand the upper arch
• Occlusal bite blocks
• Clasps on upper molars and premolars
• Clasps on lower premolars and incisors
• A labial bow to retract the upper incisors
• Springs to move individual teeth and to improve the archform
as required
 STANDARD TWIN BLOCK

Standard Twin Blocks are essentially for treatment of an uncrowded

Class II division 1 malocclusion with good arch form and an
overjet large enough to allow unrestricted forward translation of the
mandible to allow full correction of distal occlusion.

Clark’s Twin Block appliance consists of :

• Base Plates.
• Bite Block
• Wire Components : The Delta Clasp
Ball End Clasp
STANDARD TWIN BLOCK APPLIANCE
 WIRE COMPONENTS

DELTA CLASP

• The delta clasp was designed to improve the fixation of Twin

Blocks.
• The delta clasp is similar to the Adams clasp (Adams, 1970) in
principle, but incorporates new features to improve retention, reduce
metal fatigue and minimize the need for adjustment.
• The retentive loops were originally triangular in shape (from which
the name “delta” is derived), or alternatively the loops may be
circular or ovoid, both types having similar retentive properties.

Advantages:
• Clasp does not open with repeated insertion and removal.
• Maintains its shape.
• Requires less adjustment.
• Less prone to breakage.
• Excellent retention on lower premolars.
• Suitable for use on most posterior teeth.
Methods of construction of the delta clasp.

According to the area of best retention:

• Retention loops are angled to follow the curvature of the tooth
into mesial and distal undercuts if the tooth is favourably
shaped with good undercuts mesially and distally.
• Loop is constructed at right angles to the bridge of the clasp
and is directed interdentally to gain retention from adjacent
teeth if the tooth is not favourably shaped.
• Ball End Clasp
Are routinely placed mesial to lower canines and in the upper
premolar or deciduous molar regions for interdental retention
from adjacent teeth.

• C-clasps
are useful in mixed dentition where they can be used for
peripheral clasping on deciduous molars and canines
 THE BASE PLATE
● Appliances may either be made with heat cure or cold cure
acrylic.
● Heat cure acrylic has the advantage of additional strength and
accuracy.
● Cold cure acrylic has the advantage of speed and convenience,
but sacrifices strength and accuracy.
 Treatment of Class II Division 1 Malocclusion

• In Class II division 1 malocclusion a protrusive bite is registered

to reduce the overjet and the distal occlusion on average by 5–10
mm on initial activation, depending on the freedom of movement
in protrusive function.
• The length of the patient’s 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.
 Treatment of Class II Division 1 Malocclusion

The force of biting on the appliance corrects the jaw position,

and learning to eat with the appliance in is important to
accelerate treatment.
 REACTIVATION OF TWIN BLOCK

• Reactivation is a simple procedure that is achieved by

extending the anterior incline of the upper Twin Block mesially
to increase the forward posture.
• Cold cure acrylic may be added at the chairside, inserting the
appliance to record a new protrusive bite before the acrylic is
fully set. Even in cases with an excessive overjet, a single
reactivation of Twin Blocks is normally sufficient to correct
most malocclusions.
 MANAGEMENT OF DEEP BITE CASES

Overbite reduction is achieved by trimming the occlusal

blocks occluso-distally on the upper appliance, so as to
encourage eruption of the lower molars
 TREATMENT OF CLASS II DIV 2 CASES

Bite Registration:

• The construction bite

in Class II division 2
malocclusion is registered
with the incisors in
edge-to-edge occlusion.
• The occlusal bite blocks
tend to be thicker in the
premolar region to allow
clearance of the upper and
lower incisors.
 TREATMENT OF CLASS III MALOCCLUSION

REVERSE TWIN BLOCK

• The position of the bite blocks is reversed compared with that of

Twin Blocks for the treatment of Class II malocclusion.
• The occlusal blocks on the upper appliance are positioned over the
deciduous molars to occlude distally with blocks placed over the
lower first permanent molars .
• The addition of two sagittal screws in the palate provides a means
of activation to advance the upper incisors, and the reciprocal force
on the inclined planes uses anchorage in the lower arch to drive the
upper arch labially.
• Apart from the reverse position of the blocks and inclined planes,
the design of the upper appliance is similar in principle to the
sagittal design used in the treatment of Class II division 2
malocclusion and the same principles apply in relation to
positioning the screws.
 THE BITE GUIDE

• In support phase, when vertical control is necessary during the

transition, in order to maintain the corrected overjet and overbite,
The bite guide acts as a fixed retainer to maintain the corrected
vertical dimension after the molars have erupted into occlusion,
and during the transitional period when the premolars and canines
(or the deciduous teeth in mixed dentition) are erupting to
establish the buccal segment occlusion.
• The inclined plane provided by the Bite Guide is specifically
designed to engage the lower incisors when the overjet is up to 3
mm. If the overjet is more than 3 mm the lower incisors would
then bite lingual to the Bite
 TWIN BLOCK TOOL
• A new Twin Block tool is available to facilitate construction of the
inclined planes to 45° or 70° angles.
• This was designed by Roger.
• A steeper angle of 70° to the occlusal plane may be used when the
patient can posture the mandible forward freely.
• It is common to correct an overjet of up to 10 mm with a single
large activation in patients with deep overbite and a brachyfacial
growth pattern.
• These patients normally can posture forward comfortably and have
good potential for forward mandibular growth.
 The Twin Block Traction Technique
• In cases of severe malocclusion where functional forces alone are
not sufficient, orthopaedic or traction forces are added to achieve
rapid results.
• Indicated :
a. In the treatment of severe maxillary protrusion; to control a vertical
growth pattern by the addition of vertical traction to intrude the
upper posterior teeth;
b. In adult treatment where mandibular growth cannot assist the
correction of a severe malocclusion.
• The Concorde facebow is a new means of applying intermaxillary
and extraoral traction to restrict maxillary growth and, at the same
time, to encourage mandibular growth in combination with
functional mandibular protrusion.
• In this a conventional facebow is adapted by soldering a recurved
labial hook to extend forward to rest outside the lips as an anchor
point to combine intermaxillary and extraoral traction.
• The labial hook is positioned extra orally, 1 cm clear of the lips
in the midline. Hence a horizontal vector of force is formed.
• The traction components are worn at night only to reinforce the
action of the occlusal inclined plane.
• If the patient fails to posture the mandible to the corrected
occlusal position during the night, the intermaxillary traction
force is automatically increased to compensate and to ensure that
favorable intermaxillary forces are applied continuously.
 Modifications Of Twin Blocks

● Invisible Twin Blocks

● Magnetic Twin Blocks
● Fixed Twin Block
● Dr. Gerber’s Neuromuscular Twin Block Design
● A Modified Twin Block Appliance Demonstrating
Incisal Capping
● The Bite Jumping Screw For Modified Tb Treatment
 INVISIBLE TWIN BLOCKS
● Invisible Twin Blocks use preformed occlusal blocks over the
posterior teeth on the models enclosed in pressure molded trays
to fit over the teeth.
● This design may be used to construct simple appliances in
mixed dentition, to be worn full time or part time as a
functional mechanism to advance the mandible.
● This design is excellent for treatment of sleep apnea and may
be worn comfortably during the day.
 Clear Twin Block: A Step Forward in Functional Appliances
- Ahmad Behroozian1, Les Kalman2

• This study aimed to propose a proof-of-concept modification of the

traditional twin block
• A thermoformable sheet is molded on the maxillary and mandibular
stone models using standard vacuum-forming procedures, similar to
clear retainer fabrication.
• The upper plate should be extended to the most posterior tooth of the
arch.
• At the lower arch the plate usually extends up to the second primary
molar or second premolar. The extension of the appliance can be
determined by the clinician and the patient-specific anatomy.
• Clear retainers are removed from the casts and the casts are mounted
with the use of construction bite, similar to the traditional twin block
procedure.
• After mounting the stone models with construction wax, the
articulator is locked.
• Clear plates are added on the cast .
• a pair of self-cured acrylic bite ramps added on the retainers
similar to the process of twin block fabrication .
• The upper bite block extends from the most posterior tooth to
about second premolar or second primary molar and the lower
bite block is located anteriorly and covers the lower premolars
and canine.
• The inclined planes of the upper and lower blocks are usually 70
degrees, to facilitate forward positioning of the patient’mandible.
 DISCUSSION
• The use of clear aligners is associated with an improved esthetics
and a reduced fabrication time.

• The present modified appliance, called “clear twin block”,

maintains all of the positive properties of the “traditional twin
block” as well as several additional advantages.

• The clear twin block has no wire elements on the labial surface of
the teeth; therefore, its appearance is improved over the
traditional twin block .

• Moreover, wire elements of traditional twin block-like

“arrowheads of Adams’ clasp” and ”the loop of the labial bow”
can irritate the soft tissue of the patient and cause painful ulcers
that inhibit the child to wear the appliance.
 Magnetic Twin Blocks

1. The role of magnets in Twin Block therapy is specifically to

accelerate correction of arch relationships. The purpose of
the magnets is to encourage increased occlusal contact on the
bite blocks to maximize the favorable functional forces
applied to correct the malocclusion.
2. Two types of rare earth magnet used :-
- Samarium-cobalt
- Neodymium-boron
 The author has modified Twin Blocks by the addition of
attracting magnets to occlusal inclined planes, using magnetic
force as an activating mechanism to maximize the orthopedic
response to treatment.

ATTRACTING OR REPELLING MAGNETS

ATTRACTING MAGNETS
 Increased activation can be built into the initial
construction bite for the appliances.
 The attracting magnetic force pulls the appliances
together and encourages the patient to occlude actively
and consistently in a forward position.
 Attracting magnets may accelerate progress by
increasing the frequency and the force of contact on the
inclined planes.
 REPELLING MAGNETS

• Used in Twin Blocks with less mechanical activation built into the
occlusal inclined planes
• The repelling magnetic force is intended to apply additional stimulus
to forward posture as the patient closes into occlusion.

Disadvantage:
1. Amount of activation is not clear.
2. Reactivation of the inclined plane would deactivate the magnets.
3. Produce large open bite in posterior segments.
 Fixed Twin Block
EVOLUTION OF FIXED TWIN BLOCKS

• PHASE 1—2008 (Preformed Occlusal Blocks)

a. In 2008, the first design of preformed blocks was based on
attachment to molar bands using a blade attachment inserted in a
lingual sheath. The blocks covered the occlusal and lingual surfaces
of the teeth, leaving the buccal surfaces free for attachment of
brackets.
b. Preformed blocks are adapted and fitted on models and Essix
material is molded over the blocks to produce individual blocks to
fix in each quadrant. They can then be fitted in the mouth as easily
as cementing a band using a new type of cement that bonds to plastic
and to the tooth surface.
• PHASE 2—2010: ELIMINATES ATTACHMENT TO MOLAR
BANDS
a. Upper and lower blocks are bonded directly to the teeth. The blocks
are designed to cover the lingual and occlusal surfaces of the teeth,
leaving the buccal surfaces clear for attachment of bonded brackets

• PHASE 3—2014: THE ULTIMATE SOLUTION New Designs for

Fixed Twin Blocks
a. Buccal extensions are added to improve stability and fixation of the
preformed blocks. The blocks fit over the teeth and are filled with
Triad material for an accurate fit.
b. Preformed occlusal blocks cover the lingual, occlusal and buccal
surfaces of the upper and lower teeth. They will be available in 3
sizes, large, medium and small, with a simple protocol for clinical
application or by indirect technique in orthodontic laboratories.
 Dr. Gerber’s Neuromuscular twin block design

● Dr.Gerber has modified his twin block design to improve stability

and neuromuscular treatment.
● He has also extended the acrylic and eliminated all sharp edges to
create a tighter fitting appliance.
● The appliances can be modified as the case requires and designs
may be used in any combination.
● For example, upper and lower expansion screws may be used for
lateral development, an upper sagittal type appliance may be used
with basic lower appliance, and face bow, or reverse headgear,
may be incorporated in the case design.
Indications
1. Class ll correction (A-P)
2. Vertical development--to open
3. Vertical correction--to close
4. Arch expansion
5. Arch lengthening
 A Modified Twin Block Appliance Demonstrating Incisal
Capping

● This modification was introduced to reduce the incidence of

midline fracture in the lower block, which was found to be the
most common removable appliance breakage
 The Bite Jumping Screw For Modified Tb Treatment

● The bite jumping screw was developed to simplify

progressive bite advancement with the twin block appliance.
● These screws are incorporated longitudinally in the upper
bite blcks, with the screw heads at 70 degree angles to the
lower bite block. (the system allows a gradual 6mm
anteroposterior correction in either class 2 or class 3 cases).
• Gradual advancement of the bite, produces a more
orthopedic effect and better patient compliance by reducing
tension in the craniomandibular musculature.
• Also gradual bite advancement would improve patient
comfort at rest and during speech, and that it would be more
likely to maintain the correct position of the appliance
during sleep.
 Conclusion

● Facial balance and harmony are of equal importance to

dental occlusal perfection. One cannot ignore the
importance of orthopedic techniques in achieving these
goals by growth guidance during the formative years of
facial and dental development .
● In the new millienium, the integration of orthodontic
and orthopedic techniques offer a new initiative in
restoring facial balance.
 REFRENCES

• Dentofacial orthopedics with functional appliances .Graber, Rakosi,

Petrovic
• Twin Block Functional Therapy, by William J Clark.
• Orthodontics Current Principles & Techniques by Graber , Vanarsdall.
• Removable Orthodontic Appliances by Graber & Neumann.
• McNamara JA, Bookstein FL, Shaughnessy TG. Skeletal and dental
changes following functional regulator therapy on Class II patients.
American journal of orthodontics. 1985 Aug 1;88(2):91-110
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• Clear Twin Block: A Step Forward in Functional Appliances
- Ahmad Behroozian1, Les Kalman2
THANK YOU